Juta's Complete Textbook of Medical Surgical Nursing [2 ed.] 1485121019, 9781485121015

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Juta’s CompleteTextbook of Medical Surgical Nursing

The book is systematically structured, first dealing with the physical needs of a patient, and nursing management principles, then with an introduction to each of the body’s systems and its disorders, followed by the management of specific disorders within that system. Each chapter is organised in general as follows: • • • • • • •

Overview of the system’s normal structure and function Classification of disorders Risk factors Nursing assessment and common findings A general nursing care plan for the disorder Specific disorders Management of disorders.

Key features • Lists of objectives to direct the learner’s focus • Clear medical illustrations of anatomical structures, to introduce each system and its functions • Highlighted medico-legal considerations and hazards related to the management of conditions • Summaries and text boxes which stress important information and nursing practice • General and specific nursing care plans for all major conditions • Common findings, for quick diagnosis and intervention • Learner activities at the end of each chapter, to reinforce learning. Covering the curricula of Fundamentals of Nursing and General Nursing Science, this book is suitable as a prescribed text for nursing students registering in the categories of Auxiliary Nurse, Staff Nurse, or Professional Nurse. It will also be of interest to practitioners of patient advocacy.

Juta’s Complete Textbook of Medical Surgical Nursing

Juta’s Complete Textbook of Medical Surgical Nursing is a valuable, comprehensive textbook for all categories of nurses throughout the years of nurse education and training. Its approach is based on the human body’s needs and systems, which means it can be used anywhere in the world, even though it is written with the southern African nursing student in mind. The text of this second edition is up to date and aligned with the requirements of current nursing programmes.

SECOND EDITION

Juta’s Complete Textbook of Medical Surgical Nursing SECOND EDITION

Sophie Mogotlane Joyce Mokoena Motshedisi Chauke Mokgadi Matlakala Anne Young Bertha Randa

Sophie Mogotlane (general editor) www.juta.co.za

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Joyce Mokoena | Motshedisi Chauke Mokgadi Matlakala | Anne Young Bertha Randa

2017/12/11 10:10 AM

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Juta Support Material To access supplementary student and lecturer resources for this title visit the support material web page at https://juta.co.za/support-material/detail/jutas-complete-textbook-of-medical-surgical-nursing-2e

Student Support This book comes with the following online resources accessible from the resource page on the Juta Academic website: •

Exam and study skills.

Lecturer Support Lecturer resources are available to lecturers who teach courses where the book is prescribed. To access the support material, lecturers register on the Juta Academic website and create a profile. Once registered, log in and click on My Resources. All registrations are verified to confirm that the request comes from a prescribing lecturer. This textbook comes with the following lecturer resources: •

PowerPoint® slides for each chapter

•

Skills videos of selected procedures.

Help and Support For help with accessing support material, email [email protected] For print or electronic desk and inspection copies, email [email protected]

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Juta’s Complete Textbook of Medical Surgical Nursing Second edition Sophie Mogotlane (general editor) Joyce Mokoena Motshedisi Chauke Mokgadi Matlakala Anne Young Bertha Randa

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Disclaimer In the writing of this book, every effort has been made to present accurate and up-to-date information from the best and most reliable sources. However, the results of healthcare professionals depend on a variety of factors that are beyond the control of the authors and publishers. Therefore, neither the authors nor the publishers assume responsibility for, nor make any warranty with regards to, the outcomes achieved from the procedures described in this book. The authors and publisher have exerted every effort to ensure that drug selections and dosages set forth in this text are in accord with current recommendations and practice at the time of publication. However, readers are urged to check the package insert for each drug for any change in indications of dosage and for added warning and precautions. The information in this book is provided in good faith and the authors and publisher cannot be held responsible for errors, individual responses to drugs and other consequences.

Juta’s Complete Textbook of Medical Surgical Nursing First published 2013 Second edition 2018 Juta and Company (Pty) Ltd First floor, Sunclare building, 21 Dreyer street, Claremont 7708 PO Box 14373, Lansdowne 7779, Cape Town, South Africa www.juta.co.za © 2018 Juta and Company (Pty) Ltd ISBN 978 1 48512 101 5 (Print) ISBN 978 1 48511 573 1 (WebPDF) All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage or retrieval system, without prior permission in writing from the publisher. Subject to any applicable licensing terms and conditions in the case of electronically supplied publications, a person may engage in fair dealing with a copy of this publication for his or her personal or private use, or his or her research or private study. See section 12(1)(a) of the Copyright Act 98 of 1978. Project manager: Edith Viljoen Editor: Sarah Koopman and Wendy Priilaid Proofreader: Janine Versfeld and Gabi Solomon Cover designer: Genevieve Simpson Typesetter: Wouter Reinders Indexer: Sanet le Roux Typeset in 9.5pt on 12pt Optima LT Std The author and the publisher believe on the strength of due diligence exercised that this work does not contain any material that is the subject of copyright held by another person. In the alternative, they believe that any protected preexisting material that may be comprised in it has been used with appropriate authority or has been used in circumstances that make such use permissible under the law.

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Contents List of figures......................................................... xiii List of tables........................................................... xvi About the contributors........................................... xxi Preface................................................................... xxii List of abbreviations............................................... xxiii 1  Applicable concepts in nursing practice............. 1 Learning objectives................................................. 1 Introduction............................................................ 1 The meaning of health............................................ 1 The health–ill health continuum and the role of nurses................................................................ 2 Wellness................................................................. 4 Nursing and the nursing profession......................... 5 Practising nursing within the legal, ethical and professional framework...................................... 10 Approaches to healthcare delivery systems in South Africa................................................................. 16 Conclusion............................................................. 17 2 Practising nursing within a culturally diverse society................................................................ 18 Learning objectives................................................. 18 Prerequisite knowledge.......................................... 18 Medico-legal considerations................................... 18 Ethical considerations............................................. 19 Essential health literacy.......................................... 19 Introduction............................................................ 19 The concept of culture............................................ 19 The importance of culture...................................... 20 Cultural issues in healthcare................................... 20 Cultural perspectives on health and illness............. 23 Collaborative, comprehensive and/or alternative healthcare provision........................................... 24 A nurse’s interface with different cultures............... 25 Conclusion............................................................. 27 3  Bio-psychosocial needs...................................... 28 Learning objectives................................................. 28 Prerequisite knowledge.......................................... 28 Ethical–legal considerations.................................... 28 Introduction............................................................ 29 Bio-psychosocial theories....................................... 29 Physical needs........................................................ 29 Psychosocial needs................................................. 31

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Spiritual needs........................................................ 33 Conclusion............................................................. 36 4  Safety in nursing practice................................... 37 Learning objectives................................................. 37 Prerequisite knowledge.......................................... 37 Medico-legal considerations................................... 37 Ethical considerations............................................. 38 Introduction............................................................ 38 Overview of the general aspects of safety............... 38 Safety of patients in the healthcare institution......... 38 Common safety issues in healthcare....................... 42 Identification and management of risks in the healthcare environment..................................... 43 Safety of the person, good name and possessions of patients.............................................................. 49 First aid.................................................................. 51 Conclusion............................................................. 52 5  Hygiene and grooming needs............................. 53 Learning objectives................................................. 53 Prerequisite knowledge.......................................... 53 Medico-legal considerations................................... 53 Ethical considerations............................................. 54 Essential health literacy.......................................... 54 Introduction............................................................ 54 The meaning of hygiene......................................... 54 Factors that influence hygienic practices................. 54 Nursing assessment of hygiene and grooming......... 55 Maintenance of hygiene and grooming in patients unable to help themselves.................................. 57 The maintenance of hygiene in neonates and infants................................................................ 61 Conclusion............................................................. 62 6  Nutrition needs.................................................. 63 Learning objectives................................................. 63 Prerequisite knowledge.......................................... 65 Ethical considerations............................................. 65 Essential health literacy.......................................... 65 Introduction............................................................ 66 What is nutrition?................................................... 66 Macronutrients....................................................... 66 Micronutrients........................................................ 69 Nutrition in relation to health................................. 75 Nutrition through the lifecycle................................ 76

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Nutrition for specific conditions............................. 80 Assessment of nutritional status.............................. 84 Nutritional care plans............................................. 86 Common nutrition-related problems....................... 91 Conclusion............................................................. 95 7  Elimination need................................................ 97 Learning objectives................................................. 97 Prerequisite knowledge.......................................... 99 Medico-legal considerations................................... 99 Ethical considerations............................................. 99 Essential health literacy.......................................... 99 Introduction............................................................ 100 Urinary elimination................................................ 100 Overview of the anatomy and physiology of the renal system....................................................... 100 Micturition ............................................................ 102 Common problems associated with micturition...... 108 Catheterisation....................................................... 114 Elimination of faeces.............................................. 118 Overview of the anatomy and physiology of the gastrointestinal tract........................................... 118 Common problems associated with defecation....... 121 Conclusion............................................................. 131 8  Comfort, rest and sleep needs............................ 132 Learning objectives................................................. 132 Prerequisite knowledge.......................................... 133 Medico-legal considerations................................... 133 Ethical considerations............................................. 133 Essential health literacy.......................................... 133 Introduction............................................................ 134 Sleep: its functions and importance........................ 134 Pain: its functions and importance.......................... 138 Management of specific problems.......................... 140 Conclusion............................................................. 143 9 Homeostasis....................................................... 145 Learning objectives................................................. 145 Prerequisite knowledge.......................................... 147 Medico-legal considerations................................... 147 Ethical considerations............................................. 147 Essential health literacy.......................................... 147 Introduction............................................................ 148 Overview of the body fluids, electrolytes and acid– base balance...................................................... 149 Fluid balance.......................................................... 149 Electrolyte balance................................................. 150 Acid–base balance................................................. 153 Classification of disorders caused by the imbalances of fluid, electrolytes and acid–base...... 155

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Specific disorders related to fluid, electrolytes and acid–base imbalances........................................ 157 Fluid imbalances.................................................... 157 Electrolyte imbalances............................................ 159 Acid–base imbalances............................................ 164 Shock..................................................................... 168 Recording of intake and output............................... 171 Intravenous therapy................................................ 172 Conclusion............................................................. 173 10  Mobility and exercise needs............................. 175 Learning objectives................................................. 175 Prerequisite knowledge.......................................... 175 Types of exercise.................................................... 176 Medico-legal considerations................................... 176 Ethical considerations............................................. 176 Essential health literacy.......................................... 176 Introduction............................................................ 176 Activities of daily living.......................................... 177 Factors affecting mobility........................................ 177 Prescribed limitations............................................. 178 Nursing assessment of mobility............................... 178 Meeting the mobility needs of the patient............... 179 Common clinical problems related to maintenance of mobility......................................................... 182 The collaborative role of the physiotherapist and the nurse............................................................ 189 11  Temperature regulation needs.......................... 190 Learning objectives................................................. 190 Prerequisite knowledge.......................................... 190 Medico-legal considerations................................... 190 Ethical considerations............................................. 190 Essential health literacy.......................................... 190 Introduction............................................................ 191 Overview of regulation of body temperature........... 191 The mechanisms of heat production and heat loss.. 191 Normal variations in body temperature................... 193 Measuring the body temperature............................ 194 Management of common clinical problems related to temperature regulation................................... 195 Conclusion............................................................. 204 12  Competencies of the professional nurse........... 206 Learning objectives................................................. 206 Introduction............................................................ 207 Defining nursing practice....................................... 207 Roles of the nurse................................................... 207 Scope of practice.................................................... 207 Standards of care in nursing.................................... 208

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Contents  v

The basic competencies of the professional nurse... 209 The core competencies in nursing practice and the related competency standards............................ 209 Other competencies............................................... 212 Conclusion............................................................. 212 13  The nursing process.......................................... 214 Learning objectives................................................. 214 Prerequisite knowledge.......................................... 214 Medico-legal considerations................................... 215 Ethical considerations............................................. 215 Essential health literacy.......................................... 215 Introduction............................................................ 215 The nursing process................................................ 215 Application of the nursing process phases/steps...... 216 Steps in the nursing process.................................... 217 Conclusion............................................................. 226 14  Symptoms management................................... 229 Learning objectives................................................. 229 Prerequisite knowledge.......................................... 230 Medico-legal considerations................................... 231 Essential health literacy.......................................... 231 Introduction............................................................ 231 Symptoms management.......................................... 231 General symptoms management............................. 231 Introduction to pain management........................... 238 Nursing interventions for patients in pain............... 247 Pharmacological interventions................................ 248 General principles of treatment for chronic pain..... 249 Morphine............................................................... 250 Non-pharmacological therapy for pain................... 252 Common nursing diagnoses related to pain............ 252 Community care..................................................... 252 Conclusion............................................................. 253 15  Multiple trauma and emergency care............... 255 Learning objectives................................................. 255 Prerequisite knowledge.......................................... 256 Medico-legal considerations................................... 256 Essential health literacy.......................................... 256 Introduction............................................................ 256 An overview of multiple trauma and emergency care.................................................................... 257 Classification of emergency conditions................... 258 Risk factors for emergency conditions..................... 258 Nursing assessment and common findings.............. 258 Specific emergency conditions............................... 264 Respiratory emergencies......................................... 264 Emotional trauma................................................... 275 Conclusion............................................................. 276

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16 Introduction to the disorders associated with cells and tissues................................................ 277 Learning objectives................................................. 277 Prerequisite knowledge.......................................... 279 Medico-legal considerations................................... 279 Ethical considerations............................................. 279 Essential health literacy.......................................... 279 Introduction............................................................ 279 An overview of the anatomy and physiology of the cell..................................................................... 279 Tissues and organs.................................................. 280 Specific disorders associated with cells and tissues. 284 Wounds.................................................................. 284 Assessment of pressure areas.................................. 287 Physiology of wound healing.................................. 288 Tumours................................................................. 293 Conclusion............................................................. 293 17  Oncology nursing care..................................... 294 Learning objectives................................................. 294 Prerequisite knowledge.......................................... 296 Medico-legal considerations................................... 296 Ethical considerations............................................. 296 Essential health literacy.......................................... 296 Introduction............................................................ 297 An overview of the anatomy and physiology of the cell..................................................................... 297 Classification of neoplasms..................................... 297 Staging and grading of tumours.............................. 298 Risk factors............................................................. 300 Pathophysiology of cancer...................................... 303 Nursing assessment and common findings.............. 304 Prevention and early detection of cancer................ 306 Treatment of cancer................................................ 311 Chemotherapy........................................................ 318 Home and community care for cancer patients...... 326 Oncology emergencies........................................... 328 Conclusion............................................................. 330 18 Introduction to specific disorders of the immune system................................................ 332 Learning objectives................................................. 332 Prerequisite knowledge.......................................... 333 Medico-legal considerations................................... 333 Ethical considerations............................................. 333 Essential health literacy.......................................... 333 Introduction............................................................ 333 An overview of the immune system: Structures and functions of the immune system......................... 334 Specific conditions................................................. 341

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Autoimmune diseases............................................. 344 Gammopathies....................................................... 346 Conclusion............................................................. 346

Return to the ward and handover........................... 408 Intraoperative complications................................... 408 Conclusion............................................................. 411

19 Management of patients living with HIV & Aids.................................................................. 349 Learning objectives................................................. 349 Prerequisite knowledge.......................................... 352 Medico-legal considerations................................... 352 ethical and legal considerations.............................. 352 Essential health literacy.......................................... 353 Introduction............................................................ 353 Epidemiology of HIV and Aids................................ 353 Pathophysiology of HIV and Aids............................ 354 Making an HIV diagnosis........................................ 358 HIV Clinical Staging............................................... 365 Common opportunistic infections: HIV co-morbidity...................................................... 374 Prevention of mother-to-child transmission............. 375 HIV/Aids management guidelines in adolescents (10–15 years)..................................................... 375 HIV/Aids management guidelines in children......... 378 Community support for HIV patients...................... 378 Stigma and discrimination...................................... 384 Conclusion............................................................. 384

22  Postoperative nursing....................................... 412 Learning objectives................................................. 412 Prerequisite knowledge.......................................... 412 Medico-legal considerations................................... 412 Ethical considerations............................................. 412 Essential health literacy.......................................... 413 Introduction............................................................ 413 Common responses to surgery................................ 413 Preparation of the environment.............................. 415 Nursing management postoperatively..................... 416 Preparation for discharge and essential health information........................................................ 419 Conclusion............................................................. 421

20  Preoperative nursing........................................ 386 Learning objectives................................................. 386 Prerequisite knowledge.......................................... 386 Medico-legal considerations................................... 386 Ethical considerations............................................. 387 Essential health literacy.......................................... 387 Introduction............................................................ 388 Indications for surgery............................................ 388 Classification and types of surgery.......................... 388 Preoperative care.................................................... 389 Legal and ethical issues in preoperative care.......... 393 Principles of care for preoperative nursing.............. 395 Conclusion............................................................. 400 21  Intraoperative nursing...................................... 401 Learning objectives................................................. 401 Prerequisite knowledge.......................................... 401 Introduction............................................................ 402 The theatre environment......................................... 402 Medico-legal considerations................................... 402 Essential health literacy.......................................... 402 The intraoperative care team.................................. 403 Care of the patient in theatre.................................. 405 Induction of anaesthesia......................................... 406 Recovery room care............................................... 406

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23 Introduction to the disorders of the renal system.............................................................. 426 Learning objectives................................................. 426 Prerequisite knowledge.......................................... 427 Medico-legal considerations................................... 427 Ethical considerations............................................. 427 Essential health literacy.......................................... 427 Introduction............................................................ 428 Overview of the functions of the renal system........ 428 Classification of the disorders of the renal system... 429 Risk factors............................................................. 429 Nursing assessment and common findings.............. 430 Common presentations related to the disorders of the renal system................................................. 434 Conclusion............................................................. 434 24 Management of the disorders of the upper urinary tract..................................................... 438 Learning objectives................................................. 438 Prerequisite knowledge.......................................... 438 Medico-legal considerations................................... 438 Ethical considerations............................................. 438 Essential health literacy.......................................... 439 Introduction............................................................ 439 Risk factors for the disorders of the upper urinary tract................................................................... 439 Pathophysiology..................................................... 440 Signs and symptoms of upper urinary tract infection............................................................. 440 Nursing assessment and common findings.............. 440 Specific disorders of the kidney.............................. 441 Dialysis.................................................................. 452 Specific surgical conditions of the kidney............... 454

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Obstruction of the urinary tract............................... 456 Cancer of the kidneys............................................. 459 Conclusion............................................................. 459

Hysterectomy......................................................... 509 Infertility................................................................. 510 Conclusion............................................................. 513

25 Management of the disorders of the lower urinary tract..................................................... 460 Learning objectives................................................. 460 Prerequisite knowledge.......................................... 461 Essential health literacy.......................................... 461 Introduction............................................................ 461 Risk factors for the disorders of the lower urinary tract................................................................... 461 Pathophysiology of the lower urinary tract infections........................................................... 461 Nursing assessment and common findings.............. 462 Specific conditions of the lower urinary tract.......... 462 Management of bladder dysfunction....................... 464 Specific surgical conditions of the lower urinary tract................................................................... 465 Urinary diversion.................................................... 467 Conclusion............................................................. 469

27  Management of the disorders of the breast...... 515 Learning objectives................................................. 515 Prerequisite knowledge.......................................... 515 Essential health literacy.......................................... 515 Introduction............................................................ 516 Overview of the anatomy and physiology of the breast................................................................. 516 Lactation and breastfeeding.................................... 516 Risk factors for the disorders of the breast............... 517 Specific disorders of the breast............................... 520 Breast cancer.......................................................... 522 Reconstructive breast surgery/mammoplasty........... 525 Conclusion............................................................. 526

26 Management of the disorders of the female reproductive system......................................... 471 Learning objectives................................................. 471 Prerequisite knowledge.......................................... 473 Ethical considerations............................................. 473 Essential health literacy.......................................... 473 Introduction............................................................ 473 Overview of the anatomy and physiology of the female reproductive system................................ 474 The menstrual cycle................................................ 474 Classification of the disorders of the female reproductive system........................................... 475 Specific concerns related to surgical gynaecological conditions.................................. 483 Specific preoperative care for patients with gynaecological conditions.................................. 483 Specific potential postoperative risks...................... 484 Surgical procedures/operations specific to the disorders of the female reproductive system....... 484 Essential health education...................................... 484 Specific disorders of the female reproductive system................................................................ 486 Disorders of the vulva............................................. 491 Disorders of the vagina........................................... 493 Vaginal infections................................................... 495 Disorders of the cervix............................................ 496 Disorders of the uterus............................................ 498 Disorders of the fallopian tubes and ovaries........... 501 Abortion................................................................. 504 Ectopic pregnancy.................................................. 506

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28 Management of the disorders of the male reproductive system......................................... 528 Learning objectives................................................. 528 Ethical and legal considerations.............................. 529 Introduction............................................................ 530 Overview of the anatomy and physiology of the male reproductive system................................... 530 Classification of disorders....................................... 531 Specific disorders of the male reproductive system. 534 Sexually transmitted diseases in males.................... 550 Conclusion............................................................. 550 29 Introduction to the disorders of the respiratory system.............................................................. 552 Learning objectives................................................. 552 Prerequisite knowledge.......................................... 554 Medico-legal considerations................................... 554 Ethical considerations............................................. 555 Essential health literacy.......................................... 555 Prevention of influenza........................................... 555 Introduction............................................................ 556 Overview of the anatomy and physiology of the respiratory system.............................................. 556 Common respiratory problems............................... 563 General treatment of conditions of the respiratory system................................................................ 568 Conclusion............................................................. 574 30 Management of disorders of the respiratory system.............................................................. 576 Learning objectives................................................. 576 Prerequisite knowledge.......................................... 576 Ethical considerations............................................. 576 Essential health literacy.......................................... 577

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Introduction............................................................ 577 Classification of disorders of the respiratory tract.... 577 Specific conditions of the upper respiratory system. 577 Specific conditions of the lower respiratory tract.... 578 Opportunistic infections related to HIV/Aids........... 587 Respiratory disorders in patients with HIV and Aids............................................................. 590 Autoimmune conditions......................................... 591 Cardiogenic conditions........................................... 592 Malignant conditions.............................................. 592 Congenital conditions............................................. 593 Thoracic surgery..................................................... 594 Conclusion............................................................. 594 31 Management of chronic obstructive pulmonary disorders.......................................................... 596 Learning objectives................................................. 596 Prerequisite knowledge.......................................... 597 Ethical considerations............................................. 597 Essential health literacy.......................................... 597 Introduction............................................................ 597 Classification of chronic obstructive pulmonary disorders............................................................ 597 Inflammatory conditions......................................... 601 Obstructive conditions........................................... 604 Infective conditions................................................ 605 Conclusion............................................................. 606 32 Introduction to the disorders of the cardiovascular system...................................... 607 Learning objectives................................................. 607 Prerequisite knowledge.......................................... 608 Medico-legal considerations................................... 609 Essential health literacy.......................................... 609 Introduction............................................................ 609 Overview of the anatomy and physiology of the cardiovascular system........................................ 609 Causes and classification of conditions of the cardiovascular system........................................ 614 Auscultation........................................................... 616 Conclusion............................................................. 619 33 Management of the disorders of the heart and related structures............................................. 624 Learning objectives................................................. 624 Prerequisite knowledge.......................................... 625 Medico-legal considerations................................... 625 Essential health literacy.......................................... 625 Introduction............................................................ 626 Overview of the structure and function of the heart.................................................................. 626

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Classification of cardiac disorders........................... 626 Specific disorders of the heart and related structures........................................................... 627 Infections and inflammatory conditions of the heart and associated structures.................................... 635 Classification of congestive cardiac failure............. 640 Complications of congestive cardiac failure............ 643 Cardiac surgery...................................................... 644 Conclusion............................................................. 646 34  Management of coronary artery disease........... 649 Learning objectives................................................. 649 Introduction............................................................ 650 Overview of the coronary circulation..................... 650 Prerequisite knowledge.......................................... 650 Medico-legal considerations................................... 650 Essential health literacy.......................................... 650 Specific conditions................................................. 652 Conclusion............................................................. 656 35 Management of the disorders of the blood vessels.............................................................. 658 Learning objectives................................................. 658 Prerequisite knowledge.......................................... 659 Medico-legal considerations................................... 659 Essential health literacy.......................................... 659 Introduction............................................................ 660 Overview of the vascular system............................ 660 Structure and function of the blood vessels............. 660 Blood flow through the vascular system.................. 661 Classification of the disorders of the vascular system................................................................ 662 Specific conditions of the arteries........................... 663 Specific conditions of the veins.............................. 668 Specific conditions affecting both the veins and arteries............................................................... 672 Conclusion............................................................. 677 36 Management of the disorders of the haematological system..................................... 679 Learning objectives................................................. 679 Prerequisite knowledge.......................................... 680 Medico-legal considerations................................... 680 Ethical considerations............................................. 681 Essential health literacy.......................................... 681 Introduction............................................................ 681 Overview of the structure and functions of blood... 681 Classification of the disorders of the haematological system....................................... 683 Blood transfusion.................................................... 687 Specific disorders of the haematological system..... 691 Haemorrhagic and coagulation disorders............... 698

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Conclusion............................................................. 701 37 Management of the disorders of the lymphatic system.............................................................. 703 Learning objectives................................................. 703 Introduction............................................................ 704 Overview of the structure and functions of the lymphatic system............................................... 704 Prerequisite knowledge.......................................... 704 Medico-legal considerations................................... 704 Essential health literacy.......................................... 704 Classification of the disorders of the lymphatic system................................................................ 706 Specific conditions................................................. 708 Conclusion............................................................. 710 38 Introduction to the disorders of the gastrointestinal system..................................... 712 Learning objectives................................................. 712 Prerequisite knowledge.......................................... 713 Medico-legal considerations................................... 713 Ethical considerations............................................. 714 Essential health literacy.......................................... 714 Introduction............................................................ 714 Overview of the anatomy and physiology of the gastrointestinal system........................................ 714 The functions of the gastrointestinal system............ 715 Classification of disorders of the gastrointestinal system................................................................ 717 Nutritional disorders and feeding modalities........... 725 Conclusion............................................................. 730 39 Management of disorders of the upper gastrointestinal tract........................................ 731 Learning objectives................................................. 731 Prerequisite knowledge.......................................... 732 Medico-legal considerations................................... 732 Essential health literacy.......................................... 732 Introduction............................................................ 732 Classification of upper gastrointestinal tract disorders............................................................ 732 Disorders of the oesophagus................................... 741 Inflammatory conditions of the oesophagus............ 743 Principles of care for a patient undergoing oesophagectomy................................................ 747 Disorders of the stomach........................................ 749 Inflammatory conditions of the stomach................. 750 Conclusion............................................................. 763 40 Management of disorders of the lower gastrointestinal tract........................................ 764 Learning objectives................................................. 764

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Prerequisite knowledge.......................................... 764 Medico-legal considerations................................... 765 Essential health literacy.......................................... 765 Introduction............................................................ 765 Overview of the anatomy and physiology of intestines, rectum and anus................................ 765 Classification of lower gastrointestinal tract disorders............................................................ 765 Specific disorders of the lower gastrointe stinal tract.......................................................... 765 Anorectal disorders................................................. 776 Conclusion............................................................. 778 41 Management of the disorders of the accessory organs of digestion........................................... 779 Learning objectives................................................. 779 Prerequisite knowledge.......................................... 780 Medico-legal considerations................................... 780 Ethical considerations............................................. 780 Essential health literacy.......................................... 780 Introduction............................................................ 781 Classification of disorders of the accessory organs of digestion........................................................ 781 Specific disorders of the accessory organs of digestion............................................................ 789 Jaundice................................................................. 790 Hepatitis................................................................. 792 Cirrhosis of the liver............................................... 795 Complications of cirrhosis and their management.. 799 Liver failure............................................................ 805 Liver abscess.......................................................... 805 Cancer of the liver.................................................. 806 Liver transplantation............................................... 808 Disorders of the pancreas....................................... 809 Acute pancreatitis................................................... 809 Chronic pancreatitis............................................... 812 Pancreatic cysts...................................................... 813 Carcinoma of the pancreas..................................... 814 Tumours of the pancreatic islets.............................. 815 Disorders of the biliary tract................................... 816 Disorders of the gallbladder.................................... 816 Cholecystitis........................................................... 817 Chronic cholecystitis.............................................. 817 Cholelithiasis.......................................................... 818 Procedures to remove gallbladder stones................ 820 Cancer of the biliary tract....................................... 821 Conclusion............................................................. 822 42 Management of disorders of the endocrine system.............................................................. 823 Learning objectives................................................. 823 Prerequisite knowledge.......................................... 824

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Essential health literacy.......................................... 824 Introduction............................................................ 825 Overview of the anatomy and physiology of the endocrine system............................................... 825 Chemistry of hormones........................................... 825 Classification of disorders of the endocrine system. 826 Specific disorders of the endocrine system.............. 830 Disorders of the parathyroid gland.......................... 832 Disorders of the thyroid gland................................ 835 Disorders of the adrenal gland................................ 839 Adrenal hypofunction............................................. 839 Adrenal hyperfunction............................................ 840 Conclusion............................................................. 842 43  The management of diabetes mellitus............... 843 Learning objectives................................................. 843 Prerequisite knowledge.......................................... 845 Essential health literacy.......................................... 845 Introduction............................................................ 845 Pathophysiology of diabetes mellitus...................... 845 Classification of diabetes mellitus........................... 846 Risk factors for diabetes mellitus............................. 847 Nursing assessment and common findings.............. 847 Specific clinical problems related to diabetes mellitus.............................................................. 851 Chronic complications of diabetes mellitus............ 856 Essential health information for management of specific disorders of diabetes mellitus................ 858 Conclusion............................................................. 858 44 Introduction to disorders of the nervous system.............................................................. 860 Learning objectives................................................. 860 Prerequisite knowledge.......................................... 863 Medico-legal considerations................................... 863 Ethical considerations............................................. 863 Essential health literacy.......................................... 864 Introduction............................................................ 864 Overview of the anatomy and physiology of the nervous system................................................... 864 The neuron............................................................. 864 The brain................................................................ 866 Interpretation of sensory information...................... 867 Control of motor function....................................... 867 Higher cognitive functions...................................... 868 The cranial nerves.................................................. 868 Reflex activity......................................................... 868 The autonomic nervous system............................... 868 Specific clinical problems of the nervous system.... 874 Neurosurgery.......................................................... 875 Pituitary surgery...................................................... 876 Spinal surgery......................................................... 876

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The unconscious patient......................................... 879 Conclusion............................................................. 881 45 Management of disorders of the central and peripheral nervous system................................ 887 Learning objectives................................................. 887 Prerequisite knowledge.......................................... 888 Medico-legal considerations................................... 889 Ethical considerations............................................. 889 Essential health literacy.......................................... 889 Introduction............................................................ 889 Risk factors for disorders of the central and peripheral nervous system.................................. 889 Classification of disorders of the central and peripheral nervous system.................................. 890 Specific disorders of the central nervous system..... 890 Convulsive conditions............................................ 898 Congenital conditions............................................. 900 Infective conditions................................................ 902 NeuroAids.............................................................. 904 Malignant conditions.............................................. 907 Degenerative conditions......................................... 908 Spinal cord disorders.............................................. 909 Other conditions of the peripheral nerves............... 911 Conclusion............................................................. 912 46 Introduction to the disorders of the musculoskeletal system.................................... 913 Learning objectives................................................. 913 Prerequisite knowledge.......................................... 914 Medico-legal considerations................................... 915 Essential health literacy.......................................... 915 Introduction............................................................ 915 Overview of the anatomy and physiology of the musculoskeletal system...................................... 915 Classification of musculoskeletal disorders............. 918 Modalities of care................................................... 921 Conclusion............................................................. 930 47 Management of specific disorders of the musculoskeletal system.................................... 931 Learning objectives................................................. 931 Introduction............................................................ 932 Specific disorders of the musculoskeletal system.... 932 Prerequisite knowledge.......................................... 932 ethical-legal considerations.................................... 932 essential health education...................................... 932 Trauma in the musculoskeletal system.................... 934 Common fractures and their management.............. 940 Infections of the musculoskeletal system................. 946

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Inflammatory and degenerative joint disorders....... 947 Metabolic diseases of the bone............................... 949 Tumours of the musculoskeletal system.................. 950 Work-related disorders of the musculoskeletal system................................................................ 950 Conclusion............................................................. 953 48 Introduction to the disorders of the integumentary system...................................... 955 Learning objectives................................................. 955 Prerequisite knowledge.......................................... 957 Medico-legal considerations................................... 957 Ethical considerations............................................. 957 Essential health literacy.......................................... 957 Introduction............................................................ 957 Overview of the anatomy and physiology of the integumentary system......................................... 958 Appendages of the skin........................................... 958 The functions of the skin......................................... 959 Effects of loss of skin integrity................................. 960 Classification of skin disorders................................ 960 Risk factors related to the disorders of the integumentary system......................................... 960 Nursing assessment and common findings.............. 960 Management of common skin problems................. 966 Diagnostic studies.................................................. 967 Common nursing diagnoses for the disorders of the integumentary system......................................... 970 Conclusion............................................................. 972 49 Management of disorders of the integumentary system.............................................................. 973 Learning objectives................................................. 973 Introduction............................................................ 974 Psychosocial and occupational impact of chronic skin diseases...................................................... 974 Specific conditions of the integumentary system..... 974 Prerequisite knowledge.......................................... 974 Essential health literacy.......................................... 974 Skin disorders in the older patient........................... 984 Conclusion............................................................. 985 50  Management of a burn injury........................... 986 Learning objectives................................................. 986 Prerequisite knowledge.......................................... 987 Medico-legal considerations................................... 987 Ethical considerations............................................. 987 Essential health literacy.......................................... 987 Introduction............................................................ 988 Risk factors............................................................. 988 Types of burn injury................................................ 988 Classification of burn injury.................................... 989

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Management of a patient with burns....................... 993 Principles of wound care in a burn patient............. 994 Complications of burns........................................... 998 Rehabilitation after a burn injury............................ 999 Conclusion............................................................. 1001 51 Management of disorders of the ear, nose and throat........................................................ 1002 Learning objectives................................................. 1002 Prerequisite knowledge.......................................... 1004 Medico-legal considerations................................... 1004 Introduction............................................................ 1004 Classification of the disorders of the ear, nose and throat................................................................. 1004 Risk factors............................................................. 1005 Nursing assessment................................................ 1006 Specific disorders of the ear.................................... 1009 Conditions of the external ear................................. 1014 Conditions of the middle ear.................................. 1016 Mastoid process...................................................... 1018 Conditions of the inner ear..................................... 1019 Specific disorders of the nose................................. 1023 Conditions of the nose............................................ 1023 Specific disorders of the throat................................ 1025 Conditions of the larynx......................................... 1026 Conditions of the pharynx...................................... 1029 Conditions of the tonsils and adenoids................... 1029 Conclusion............................................................. 1031 52 Management of disorders of the eye and vision......................................................... 1032 Learning objectives................................................. 1032 Prerequisite knowledge.......................................... 1035 Medico-legal considerations................................... 1035 Essential health literacy.......................................... 1035 Introduction............................................................ 1035 Overview of the anatomy and physiology of the eye..................................................................... 1036 Classification of eye conditions.............................. 1038 Risk factors............................................................. 1038 Nursing assessment and common findings.............. 1038 Inflammatory conditions of the eye......................... 1046 Specific disorders of the eye................................... 1053 Trauma to the eye................................................... 1053 Loss of an eye......................................................... 1053 Miscellaneous eye conditions................................. 1056 Specific systemic diseases that affect the eye.......... 1060 Nutrition and the disorders of the eye..................... 1061 Refractive errors..................................................... 1061 Prevention of blindness.......................................... 1062 Rehabilitation of the visually impaired.................... 1064 Ethical and legal issues relating to visual

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xii  Juta’s Complete Textbook of Medical Surgical Nursing

impairment and the provision of eye care........... 1064 Conclusion............................................................. 1065 53  Management of elderly patients....................... 1066 Learning objectives................................................. 1066 Prerequisite knowledge.......................................... 1067 Medico-legal considerations................................... 1067 Ethical considerations............................................. 1067 essential health information.................................... 1068 Introduction............................................................ 1068 The demographic impact of ageing......................... 1068 Overview of anatomy and physiology..................... 1068 Community-based nursing...................................... 1071 Hospital-based nursing........................................... 1076 Rehabilitation......................................................... 1078 Chronic and long-term care.................................... 1078 Palliative and terminal care..................................... 1081 Impaired mental functioning care........................... 1082 Care of specific conditions..................................... 1084 Conclusion............................................................. 1092 54 Management of people with disabilities........... 1094 Learning objectives................................................. 1094 Introduction............................................................ 1095 Historical overview................................................ 1095 Rehabilitation......................................................... 1097 Nursing assessment and common findings.............. 1098 Points to consider following disability, trauma and/ or other emergencies.......................................... 1100 Legal protection...................................................... 1100 The rehabilitation process....................................... 1101 Factors influencing rehabilitation............................ 1104 Care and management during rehabilitation........... 1104 Essential approach to goal planning........................ 1107 Preparing to go home............................................. 1108 Essential health information.................................... 1111 Conclusion............................................................. 1112 55 Principles and standards of care of the sick child in hospital................................................ 1113 Learning objectives................................................. 1113 Prerequisite knowledge.......................................... 1113 Introduction............................................................ 1114 Foundations of the child care charter for children in hospital.............................................................. 1114 Medico-legal considerations................................... 1114 Determinants of children’s reactions to hospitalisation.................................................... 1115 Children’s needs during non-threatening and threatening situations......................................... 1115

The role of the nurse in the admission of a child to hospital.............................................................. 1115 Principles and standards of care............................. 1117 Pain in children...................................................... 1120 Conclusion............................................................. 1122 56 Palliative care nursing and end-of-life care...... 1124 Learning objectives................................................. 1124 Prerequisite knowledge.......................................... 1125 Medico-legal hazards............................................. 1125 Ethical considerations............................................. 1125 Essential health literacy.......................................... 1125 Introduction............................................................ 1125 Approach to palliative care..................................... 1126 Attitudes to death and dying................................... 1126 Communication...................................................... 1127 Nursing assessment and common findings.............. 1127 Management of specific symptoms......................... 1131 Respiratory symptoms............................................. 1132 Dermatological symptoms...................................... 1134 Neurological and psychiatric symptoms................. 1135 Generalised symptoms........................................... 1137 End-of-life care....................................................... 1142 Support of the patient and significant others when death is inevitable, including the bereavement period................................................................ 1143 Home care for the terminally ill patient.................. 1146 Conclusion............................................................. 1147 57  Disaster nursing............................................... 1149 Learning objectives................................................. 1149 Prerequisite knowledge.......................................... 1149 Introduction............................................................ 1150 Overview of disasters............................................. 1150 Medico-legal considerations................................... 1150 Ethical considerations............................................. 1150 Essential health literacy.......................................... 1150 Disaster models...................................................... 1151 Classification of disasters........................................ 1152 Causes of disasters.................................................. 1153 Basic principles in disaster management................. 1153 The disaster planning process................................. 1153 Managing the disaster scene................................... 1160 Disaster nursing...................................................... 1162 Nursing in emergency situations............................. 1163 Community health issues in disasters...................... 1167 Psychological consequences of disasters................ 1168 Education............................................................... 1169 Conclusion............................................................. 1169 Bibliography........................................................... 1170 Index...................................................................... 1183

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List of figures Figure 1.1 Figure 1.2 Figure 4.1 Figure 4.2 Figure 4.3 Figure 4.4 Figure 5.1 Figure 5.2 Figure 6.1 Figure 6.2 Figure 7.1 Figure 7.2 Figure 7.3 Figure 7.4 Figure 7.5 Figure 7.6 Figure 7.7 Figure 7.8 Figure 9.1 Figure 9.2 Figure 9.3 Figure 9.4 Figure 9.5 Figure 9.6 Figure 9.7 Figure 9.8 Figure 9.9 Figure 10.1 Figure 10.2 Figure 10.3 Figure 11.1 Figure 11.2 Figure 11.3 Figure 11.4 Figure 11.5 Figure 11.6 Figure 11.7

JCTMSN_BOOK.indb 13

Agent–host–environment model.... 3 Broad framework for ethical decisionmaking.......................................... 13 Restraining sheet............................ 47 Wrist restraint................................ 48 Boxing gloves or mittens................ 48 Finger restraint............................... 48 A bed bath..................................... 57 Washing a patient’s hair................. 59 Visual South African food guide..... 76 WHO weight-for-age chart: boys 0 to 5 years.............................................. 86 The urinary tract............................ 100 Cross-sectional view of the kidney. 100 The structure of the nephron and renal tubules........................................... 101 Types of urethral catheters............. 114 Condom catheters and retracted urine pouch............................................ 117 Supra pubic catheterisation............ 117 The large intestine.......................... 119 Rectal catheter............................... 128 Distribution of body fluids in compartments (70 kg man)............ 149 Pinch test....................................... 155 Pitting oedema............................... 156 Taking the abdominal girth of a patient........................................... 160 Carpo-pedal spasm........................ 164 Types of acid–base imbalances...... 166 Causes of shock............................. 168 Blood pressure............................... 169 Compensated stage of shock.......... 170 Movement of the joints.................. 180 Positions in bed............................. 182 Homen’s sign................................. 185 Mercury thermometer.................... 195 Tympanic thermometer.................. 195 Electronic clinical thermometer..... 195 NexTemp thermometer.................. 195 Tactile/surface thermometer........... 195 Rectal thermometer....................... 195 Immediate management of a hyperthermic patient should include sponging/cold compresses, airconditioning and fluid intake......... 201

Figure 14.1

Covering of the mouth when coughing....................................... 233 Figure 14.2 Visual analogue scale.................... 245 Figure 14.3 Numerical pain rating scale........... 245 Figure 14.4 Body chart to document site of pain............................................... 245 Figure 14.5 WHO 3-step analgesic ladder........ 248 Figure 15.1a Location for chest compressions: two finger breadths above the xiphoid process.......................................... 264 Figure 15.1b Cardiopulmonary resuscitation...... 264 Figure 15.2 Heimlich manoeuvre..................... 265 Figure 15.3 Treatment for open pneumothorax. 270 Figure 16.1 The structure of the cell................. 279 Figure 16.2 Wound healing process................. 288 Figure 16.3 Dehiscence and evisceration in wound healing complications.................... 293 Figure 18.1 Development of cells of the immune system........................................... 335 Figure 18.2 Stages of the immune response...... 337 Figure 18.3 Airway in anaphylaxis.................... 342 Figure 19.1 HIV lifecycle ................................. 355 Figure 19.2 HIV testing algorithm .................... 363 Figure 19.3 Algorithm for testing children younger 18 months of age .......................... 364 Figure 19.4 Algorithm for testing children older than 18 months of age........................... 365 Figure 19.5 Algorithm for testing HIV diagnosis in Adolescents and Adults.................. 366 Figure 19.6 Algorithm for testing HIV diagnosis in pregnant and breastfeeding women.......................................... 367 Figure 19.7 Algorithm for cryptococcal screening and prophylaxis............................. 376 Figure 19.8 Paediatric ART flowchart ............... 379 Figure 20.1 A surgical consent form................. 395 Figure 21.1 The operating theatre..................... 403 Figure 21.2 Scrub nurse.................................... 403 Figure 21.3 Theatre apparel.............................. 403 Figure 21.4 Recovery room.............................. 407 Figure 24.1(a) Paracentesis................................... 445 Figure 24.1(b) Intra-abdominal structures............. 445 Figure 24.2 Peritoneal dialysis.......................... 453 Figure 25.1 Urinary diversion........................... 467 Figure 26.1 External female genitalia (vulva)..... 474 Figure 26.2 Internal female genitalia................ 475

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xiv  Juta’s Complete Textbook of Medical Surgical Nursing

Figure 26.3 Figure 26.4 Figure 26.5 Figure 26.6 Figure 26.7 Figure 27.1 Figure 27.2 Figure 27.3 Figure 27.4 Figure 28.1 Figure 29.1 Figure 29.2 Figure 29.3 Figure 29.4 Figure 29.5 Figure 29.6 Figure 29.7 Figure 29.8 Figure 30.1 Figure 31.1 Figure 31.2 Figure 31.3 Figure 32.1 Figure 32.2 Figure 32.3 Figure 32.4 Figure 32.5 Figure 32.6 Figure 33.1 Figure 33.2 Figure 33.3 Figure 33.4 Figure 33.5 Figure 33.6 Figure 33.7 Figure 33.8 Figure 33.9 Figure 33.10 Figure 33.11 Figure 33.12 Figure 33.13 Figure 33.14

JCTMSN_BOOK.indb 14

Lithotomy position and vaginal examination................................... 479 Sims’ position for a vaginal examination................................... 479 Bimanual palpation of the cervix... 480 Fibroids......................................... 500 Schematic outline of types of abortion......................................... 504 Breastfeeding................................. 517 BSE steps....................................... 518 Lymph nodes................................. 519 Post-mastectomy exercises............. 525 Male reproductive organs.............. 530 The respiratory organs.................... 556 The bronchial tree.......................... 556 Positions for postural drainage....... 564 An oropharyngeal airway............... 572 Commonly available tracheostomy tubes.............................................. 572 A cuffed endotracheal tube............ 572 Patient being ventilated.................. 573 A ventilator.................................... 573 The pathophysiology of ARDS........ 589 The pathophysiology of chronic obstructive pulmonary disease....... 598 An inhaler...................................... 603 A spacer fitted correctly over the nose and mouth............................. 603 The structure of the heart............... 610 Location and position of the heart.. 611 Organs associated with the heart... 611 Blood flow through the heart......... 611 The coronary circulation................ 611 The conducting system of the heart.............................................. 612 Atrial septal defect (ASD)............... 630 Ventricular septal defect (VSD)...... 630 Coarctation of the aorta................. 630 Tetralogy of Fallot.......................... 630 Transposition of great vessels......... 630 Patent ductus arteriosus (PDA)........ 630 Normal sinus rhythm on the ECG... 630 ECG strip of sinus tachycardia........ 632 ECG strip of sinus bradycardia....... 633 ECG strip of atrial ectopic beats..... 633 ECG strip of atrial flutter................ 633 ECG strip of atrial fibrillation......... 633 ECG strip of third-degree AV block............................................. 634 ECG strip of ventricular ectopic beats.............................................. 634

Figure 33.15 Figure 33.16

ECG strip of ventricular tachycardia. 634 ECG strip of ventricular fibrillation...................................... 634 Figure 33.17 ECG strip of ventricular asystole.... 635 Figure 33.18 Pathophysiology of cardiac failure. 641 Figure 34.1 Coronary circulation, obstructed.... 652 Figure 34.2 Pathophysiology and manifestations of CAD.......................................... 652 Figure 35.1 Circulatory system......................... 660 Figure 35.2 Structure of an artery..................... 661 Figure 35.3 Structure of a vein.......................... 661 Figure 35.4 Structure of the veins showing the valve.............................................. 662 Figure 35.5 Normal and abnormal blood flow through the arteries........................ 663 Figure 35.6 Abdominal aortic aneurysm........... 668 Figure 35.7 Varicose veins................................ 671 Figure 37.1 Structures of the lymphatic system. 704 Figure 37.2 Tonsils........................................... 705 Figure 37.3 Lymph nodes................................. 707 Figure 37.4 Lymphoedema............................... 709 Figure 38.1 Organs of the gastrointestinal system........................................... 715 Figure 38.2 The phases of gastric secretion and their regulation....................... 717 Figure 39.1 The structure of the mouth............. 733 Figure 39.2 The structure of the oesophagus..... 742 Figure 39.3 Movement of food through the oesophagus.................................... 742 Figure 39.4 Disorders of the oesophagus.......... 743 Figure 39.5 Types of hiatus hernia.................... 748 Figure 39.6 Structure of the stomach................ 749 Figure 39.7 Peptic ulcer.................................... 752 Figure 39.8 Billroth gastrectomies.................... 759 Figure 39.9 Total gastrectomy with anastomosis of the oesophagus to the jejunum.. 761 Figure 40.1 Structure of the intestines............... 766 Figure 40.2 Intussusception.............................. 767 Figure 40.3 An inflamed appendix................... 770 Figure 40.4 When the appendix is inflamed, tenderness can be noted in the right lower quadrant at McBurney’s point.............................................. 771 Figure 40.5 Haemorrhoids and removal by ligation with a rubber band............ 777 Figure 41.1 The blood supply to the liver.............. 789 Figure 41.2 Anterior view of the liver.................... 790 Figure 41.3 A healthy and a cirrhotic liver............ 795 Figure 41.4 Portal venous systems......................... 804 Figure 41.5 The position of the pancreas.............. 809 Figure 41.6 An inflamed pancreas........................ 809 Figure 41.7 The biliary system.............................. 816

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List of figures  xv

Figure 41.8 The gallbladder.................................. 816 Figure 42.1 Location of the major endocrine glands of the body in females (left) and males (right)....................................... 825 Figure 42.2 Schematic diagram showing the chemistry of hormonal action............. 826 Figure 42.3 Tetany/Carpo-pedal spasm................. 834 Figure 43.1 The pathophysiology of diabetes mellitus.............................................. 846 Figure 43.2 Sites for injection of insulin................ 858 Figure 44.1 Divisions of the nervous system......... 865 Figure 44.2 The structure of a neuron and the pathway for impulse transmission....... 865 Figure 44.3 Longitudinal section through the cerebral hemispheres, cerebellum and brainstem........................................... 866 Figure 44.4 Lateral view of the brain to show the regions of the cerebrum..................... 866 Figure 44.5 The reflex arch................................... 869 Figure 44.6 Schematic diagram to show the effects of raised intracranial pressure............................................. 873 Figure 44.7 Pupil sizes.......................................... 881 Figure 45.1 Pathophysiology of cerebrovascular disease............................................... 895 Figure 46.1 Different types of bones..................... 916 Figure 46.2 Pattern of muscle fibres...................... 917 Figure 46.3 Muscles of different shapes................ 918

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Figure 46.4 An example of a ball and socket joint................................................... 918 Figure 46.5 An example of a hinge joint............... 918 Figure 47.1 Fractures displaying patterns and direction............................................ 937 Figure 48.1 Normal structure of the skin............... 959 Figure 50.1 Rule of nines...................................... 990 Figure 50.2 Types and pathophysiology of major burns.................................................. 992 Figure 51.1 The structure of the ear...................... 1009 Figure 51.2 The paranasal sinuses......................... 1023 Figure 51.3 The pharynx....................................... 1026 Figure 52.1 Horizontal section of the eye............. 1037 Figure 52.2 Visual field defects............................. 1037 Figure 52.3 Snellen chart...................................... 1040 Figure 52.4 Possible eye trauma............................ 1053 Figure 52.5 Squints............................................... 1057 Figure 52.6 Refractive errors................................. 1061 Figure 54.1 The healthcare team........................... 1102 Figure 57.1 Example of a phased response to a notification of a possible disaster........ 1154 Figure 57.2 Cruciform triage tag........................... 1158 Figure 57.3 The triage sieve system....................... 1158 Figure 57.4 The triage sort system......................... 1159 Figure 57.5 Hospital disaster plan......................... 1161 Figure 57.6 Fire tetrahedron.................................. 1163 Figure 57.7 Nurse wearing an evacuation pinafore............................................. 1166

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List of tables Table 1.1 Table 3.1 Table 3.2

Table 4.1

Table 4.2 Table 4.3 Table 6.1

Table 6.2

Table 6.3 Table 6.4 Table 6.5

Table 6.6

Table 6.7 Table 6.8 Table 6.9

Table 7.1 Table 7.2 Table 7.3 Table 7.4 Table 7.5

Table 7.6 Table 7.7

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Stages of growth and development and the associated special needs........ 9 Summary of bio-psychosocial needs... 33 Health-related beliefs and practices of selected religions and implications for health and nursing........................ 35 The seven domains of the National Core Standards for Health Establishments in South Africa (2011)........................ 39 Standards in patient safety, clinical governance and clinical care............. 39 Safety competence............................. 40 Functions, sources and intake guidelines of vitamins, and consequences of deficiencies.................................... 70 Functions, sources and intake guidelines of minerals, and consequences of deficiencies............. 73 Factors causing malnutrition in the elderly................................................ 80 The 10 steps for treatment of severe malnutrition....................................... 82 How to assess risk for disease by using waist circumference measurements.................................... 85 How to classify a child’s growth according to the different growth charts................................................. 85 Classification of weight according to BMI................................................ 87 Special diets, characteristics and indications......................................... 89 Common nutrition-related problems: their causes, interventions and related health promotion aspects................... 91 Measures to facilitate micturition....... 104 The characteristics of normal urine..... 105 Normal variations found in urine....... 105 Abnormalities found in urine.............. 106 Common problems associated with micturition, their causes, presentation and management............................... 109 General nursing care plan for a patient with urinary elimination problems..... 118 Measures to facilitate defecation........ 122

Table 7.8 Table 7.9 Table 7.10 Table 8.1 Table 8.2 Table 9.1 Table 9.2 Table 9.3 Table 9.4 Table 9.5

Table 9.6

Table 9.7 Table 9.8 Table 10.1 Table 10.2 Table 10.3 Table 11.1 Table 11.2 Table 11.3 Table 11.4 Table 11.5 Table 12.1 Table 13.1 Table 13.2 Table 13.3 Table 13.4

Table 14.1 Table 14.2 Table 14.3

 Characteristics of normal and abnormal faeces................................................. 123 Signs of dehydration........................... 128 Nursing care plan for a patient with altered bowel elimination.................. 130 Sleep requirements according to age.. 134 REM and NREM stages of sleep.......... 136 Fluid gain and fluid loss for the average adult in 24 hours................... 150 Electrolyte concentrations in body fluids.................................................. 151 Major electrolytes in the body and their functions............................................ 152 pH of body fluids............................... 153 Classification of disorders related to imbalances of fluid, electrolytes and acid–base........................................... 154 Causes, signs and symptoms and management of major electrolyte imbalances......................................... 160 Important values in a blood gas result 165 Classification of shock........................ 169 Types of exercise................................ 177 Positions which patients can assume in bed................................................ 181 The Norton Scale............................... 186 Sites for body temperature measurement: advantages and disadvantages............ 196 Measuring oral temperature with a mercury thermometer......................... 197 Measuring rectal temperature............. 199 Measuring axillary temperature.......... 200 General nursing care plan of a patient with altered body temperature........... 204 Roles of the nurse............................... 208 Identification of patient’s needs.......... 219 Patients’ needs and related nursing diagnoses........................................... 220 Suggested format for nursing care plan................................................... 225 Example of a care plans to address various needs and documentation thereof............................................... 227 Abnormal characteristics of sputum... 234 Causes of dyspnoea............................ 235 Identifying potential causes of vomiting based on the time of vomiting............ 237

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List of tables  xvii

Table 14.4 General nursing care plan for the symptoms outlined............................. 238 Table 14.5 Factors affecting pain threshold.......... 242 Table 14.6 FLACC scale for assessment of pain in the pre-verbal child........................ 246 Table 14.7 Examples of adjuvant analgesics........ 249 Table 14.8 Analgesics used in children ............... 250 Table 15.1 Revised Trauma Score........................ 257 Table 15.2 Classification of conditions according to the body part affected........................ 258 Table 15.3 General nursing care plan of a trauma/ emergency patient.............................. 262 Table 15.4 Movements and mechanisms of spinal injury................................................. 272 Table 15.5 Types of injuries to the spinal cord..... 273 Table 16.1 Cytoplasmic organelles...................... 280 Table 16.2 General nursing care plan of a patient with disorders of the cells and tissues................................................ 285 Table 16.3 Cell adaptations to injury .................. 286 Table 16.4 Factors that delay wound healing....... 291 Table 17.1 Biologic characteristics of neoplastic and normal cells....................................... 298 Table 17.2 Characteristics of benign and malignant neoplasms.......................................... 298 Table 17.3 Classification of benign and malignant neoplasms according to tissue of origin.................................... 299 Table 17.4 The Tumour, Node, Metastasis staging system................................................ 301 Table 17.5 Usual sites for metastases in common cancers.............................................. 304 Table 17.6 General Nursing Care Plan for the patient with cancer............................ 307 Table 17.7 Warning signs for cancer in various organs................................................ 312 Table 17.8 Safeguards against cancer.................. 312 Table 17.9 Nursing management of the patient on radiotherapy....................................... 316 Table 17.10 Classification of cancer chemotherapeutic drugs............................... 320 Table 18.1 General nursing care plan for patients suffering from immune disorders........ 340 Table 18.2 Common causes of anaphylaxis......... 342 Table 18.3 Classification of autoimmune disorders............................................ 345 Table 18.4 Primary immunodeficiency disorders............................................ 347 Table 19.1 HIV and Aids estimates (2014)........... 354 Table 19.2 Aids-defining conditions.................... 357 Table 19.3 HIV Clinical Staging in Children, Adolescents and Adults...................... 367

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Table 19.4 Comprehensive History and Ongoing Assessment for PLWHA...................... 369 Table 19.5 Physical examination in PLWHA........ 372 Table 19.6 TB treatment in HIV........................... 375 Table 19.7 ART initiation in pregnant and breastfeeding women......................... 376 Table 19.8 ART monitoring in pregnant and breastfeeding women......................... 377 Table 19.9 ART first-line regimen for adolescents 10–15 years....................................... 380 Table 19.10 ART second-line regimen for adolescents 10–15 years.................... 380 Table 19.11 Second-line treatment failure and third-line regimen in adolescents 10–15 years....................................... 380 Table 19.12 ART first-line regimen for adolescents ≥15 years and adults....... 380 Table 19.13 Adult ART Management..................... 381 Table 19.14 Baseline and routine clinical and laboratory assessment for late adolescents and adults....................... 381 Table 19.15 VL monitoring and first-line ARV treatment failure in late adolescents > 15 and adults.................................. 383 Table 19.16 Second-line regimen for late adolescents and adults....................... 383 Table 20.1 Classification of surgery..................... 389 Table 21.1 General nursing care plan of a patient intraoperatively.................................. 409 Table 22.1 General nursing care plan of a patient postoperatively................................... 422 Table 23.1 Fluid and electrolyte disturbances in renal disorders................................... 429 Table 23.2 Classification of the disorders of the renal system according to causative factors................................................ 430 Table 23.3 Classification of the disorders of the renal system according to location..... 430 Table 23.4 General nursing care plan for patients with disorders of the renal system...... 435 Table 24.1 General nursing care plan of a patient with acute glomerulonephritis............ 443 Table 24.2 Causes of acute renal failure.............. 447 Table 24.3 General nursing care plan of a patient with renal failure................................ 451 Table 24.4 Surgical procedures pertaining to the kidney................................................ 454 Table 25.1 Surgical procedures related to the lower urinary tract.............................. 465 Table 26.1 Classification according to events...... 476 Table 26.2 Classification according to structure affected.............................................. 476

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xviii  Juta’s Complete Textbook of Medical Surgical Nursing

Table 26.3 The dos and don’ts of obtaining subjective data................................... 479 Table 26.4 Abnormal vaginal discharge............... 480 Table 26.5 Surgical procedures and their indications......................................... 485 Table 26.6 General nursing care plan for the disorders of the female reproductive system................................................ 487 Table 26.7(a) Presentation of vesico- and rectovaginal fistulae........................... 494 Table 26.7(b) Presentation of cystocele and rectocele............................................ 494 Table 26.8 A summary of the nursing management of the different types of abortion......... 507 Table 26.9 Specific postoperative care plan for hysterectomy...................................... 511 Table 27.1 Tanner staging.................................... 517 Table 27.2 Breast cancer staging.......................... 523 Table 28.1 Classification of the disorders of the male reproductive system................... 531 Table 28.2 General nursing care plan for the disorders of the male reproductive system................................................ 535 Table 28.3 General nursing care plan postprostatectomy.................................... 547 Table 28.4 Sexually transmitted diseases in males................................................. 550 Table 29.1 Normal blood gas values.................... 560 Table 29.2 Radiographic techniques.................... 560 Table 29.3 Endoscopic techniques....................... 561 Table 29.4 Radioisotopic techniques................... 562 Table 29.5 Examination of sputum....................... 562 Table 29.6 Biopsy studies.................................... 563 Table 29.7 General nursing care plan for patients presenting with respiratory disorders.. 569 Table 29.8 Nursing management of the patient with an artificial airway...................... 574 Table 29.9 Drugs used in the respiratory system.. 575 Table 30.1 Causes of disorders of the respiratory tract................................................... 577 Table 30.2 Classification of pneumonia............... 579 Table 30.3 Pharmacological management of pneumonia......................................... 579 Table 30.4 General nursing care plan for the patient suffering from pneumonia....... 580 Table 30.5 First-line drugs in the treatment of pulmonary tuberculosis...................... 584 Table 30.6 Second-line drugs in the treatment of pulmonary tuberculosis...................... 584 Table 30.7 PJP and community-acquired pneumonia in children....................... 588 Table 30.8 Thoracic surgical procedures.............. 594

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Table 31.1 C  lassification of chronic obstructive pulmonary disorders.......................... 597 Table 31.2 General nursing care plan for the patient suffering from chronic obstructive pulmonary disease............................. 599 Table 31.3 Classification of asthma...................... 601 Table 32.1 Haematological laboratory tests in cardiovascular conditions.................. 619 Table 32.2 General nursing care plan for a patient with a disorder of the cardiovascular system................................................ 620 Table 32.3 Types of drugs used to treat cardiovascular conditions.......................................... 622 Table 33.1 Classification of the conditions of the heart and valves................................. 626 Table 33.2 Description of congenital defects ...... 629 Table 33.3 Classification of arrhythmias according to the area of origin ......... 631 Table 33.4 Location of embolus and clinical manifestation thereof.......................... 637 Table 33.5 Left-sided and right-sided cardiac failure................................................ 641 Table 33.6 Left-sided and right-sided cardiac failure: clinical manifestations............ 643 Table 33.7 Drugs used in CCF............................. 643 Table 33.8 Chest trauma...................................... 644 Table 35.1 Common diseases affecting the blood vessels................................................ 662 Table 35.2 Comparison of thoracic and abdominal aortic aneurysm................................. 666 Table 35.3 Pharmacological management in hypertension...................................... 674 Table 36.1 Composition of blood........................ 682 Table 36.2 Classification of disorders of the haematological system according to the causative factors........................... 683 Table 36.3 Normal FBC values............................ 686 Table 36.4 General nursing care plan for patients with disorders of the haematological system....................... 688 Table 36.5 Acute transfusion reactions, aetiolgy and assessment findings of each transfusion reaction ........................... 690 Table 36.6 Classification of anaemia................... 692 Table 37.1 Classification of the disorders of the lymphatic system............................... 706 Table 38.1 Digestion in the gastrointestinal tract.. 716 Table 38.2 Classification of disorders of the gastrointestinal system........................ 717 Table 38.3 The responsibilities of the nurse in diagnostic procedures........................ 720

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List of tables  xix

Table 38.4 General nursing care plan for patients with disorders of the gastrointestinal system................................................ 726 Table 39.1 Conditions of the lips, mouth, teeth, gums and salivary glands................... 734 Table 39.2 Causes of altered gastric motility and secretion............................................ 751 Table 39.3 Comparison of duodenal and gastric ulcers................................................. 754 Table 39.4 Examples of medication commonly used to treat peptic ulcer disease........ 757 Table 40.1 General nursing care plan for a patient after (post) abdominal surgery............................................... 769 Table 41.1 Routine blood tests for hepatobiliary and pancreatic functions.................... 784 Table 41.2 General nursing care plan for patients with disorders of the accessory organs of digestion........................................ 786 Table 41.3 Laboratory findings in jaundice.......... 792 Table 41.4 Major human hepatitis viruses............ 793 Table 41.5 Clinical manifestations of viral hepatitis............................................. 794 Table 41.6 Types of cirrhosis............................... 796 Table 41.7 Clinical manifestations of cirrhosis..... 797 Table 41.8 Stages of hepatic encephalopathy...... 800 Table 41.9 General nursing care plan of a patient with cirrhosis of the liver.................... 800 Table 41.10 Classification of primary tumours of the liver.............................................. 807 Table 42.1 Classification of disorders of the endocrine system............................... 827 Table 42.2 Summary of diagnostic findings in endocrine disorders............................ 829 Table 42.3 Hormones secreted by the anterior and posterior lobes of the pituitary gland.................................................. 830 Table 42.4 Tests for hyper- and hypoparathyroidism.......................................... 833 Table 42.5 Antithyroid drugs and the nurse’s role.................................................... 836 Table 42.6 General nursing care plan for a patient post sub-total thyroidectomy/total thyroidectomy.................................... 837 Table 43.1 Comparison of type I and type II DM.................................................... 847 Table 43.2 General nursing care plan for the patient with diabetes mellitus............. 849 Table 43.3 Classification of insulin according to time of action and duration of action................................................. 852

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Table 43.4 Oral hypoglycaemic medication for type II diabetes................................... 853 Table 44.1 The cranial nerves.............................. 868 Table 44.2 The Glasgow Coma Scale................... 870 Table 44.3 Assessment of cranial nerve function............................................. 871 Table 44.4 Diagnostic procedures for the patient with a neurological disorder............... 872 Table 44.5 Nursing care plan for the patient following craniotomy......................... 877 Table 44.6 Causes of unconsciousness................ 880 Table 44.7 General nursing care plan for the unconscious patient........................... 881 Table 45.1 Classification of disorders of the central nervous system and peripheral nervous system................................... 890 Table 45.2 Diagnostic tests.................................. 891 Table 45.3 General nursing care plan for the patient suffering from a condition of the central nervous system................. 892 Table 46.1 Diagnostic tests for the disorders of the musculoskeletal system...................... 922 Table 46.2 Types of closed casts.......................... 925 Table 46.3 General nursing care plan for patients presenting with disorders of the musculoskeletal system...................... 927 Table 47.1 Types of fractures............................... 936 Table 47.2 Common fractures of the upper limbs and their management....................... 940 Table 47.3 Common fractures of the lower limbs and their management....................... 941 Table 47.4 Fracture of the pelvis.......................... 942 Table 47.5 General nursing care plan of a patient with a fracture of a limb..................... 942 Table 47.6 Comparison of rheumatoid arthritis and osteoarthritis...................................... 947 Table 47.7 Tumours of the musculoskeletal system................................................ 951 Table 47.8 Common work-related musculoskeletal disorders that affect the upper limbs (repetitive strain disorders)................. 953 Table 48.1 Classification of skin disorders........... 961 Table 48.2 Diagnostic studies and the nurse’s responsibilities................................... 967 Table 48.3 Common skin lesions......................... 968 Table 48.4 Nutrition and skin health.................... 970 Table 48.5 General nursing care plan for disorders of the integumentary system............... 971 Table 49.1 Common bacterial skin disorders....... 975 Table 49.2 Viral skin infections............................ 977 Table 49.3 Common fungal infections of the skin.................................................... 978

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Table 49.4 Types of dermatitis, clinical manifestations and nursing interventions...................................... 982 Table 50.1 Assessment and common findings...... 994 Table 50.2 General nursing care plan for a burn injury................................................. 995 Table 50.3 Drug therapy and purposes................ 999 Table 50.4 Topical antibacterial agents used for burns.................................................. 1000 Table 50.5 Therapeutic positioning for the prevention of contractures.................. 1000 Table 51.1 Classification of the disorders of the ear, nose and throat............................ 1005 Table 51.2 General nursing care plan for patients with the disorders of the ear, nose and throat................................................. 1010 Table 51.3 General nursing care plan of a patient intraoperatively.................................. 1021 Table 52.1 General nursing care plan for the conditions of the eye.......................... 1042 Table 52.2 Congenital abnormalities of the eye... 1044 Table 52.3 Degenerative ocular conditions.......... 1045 Table 52.4 Inflammatory conditions of the eye.... 1046 Table 52.5 Eye surgical procedures and their indications......................................... 1054 Table 52.6 Eye swabbing, irrigation and the instillation of medication.................... 1063 Table 53.1 Physiological changes and associated health problems in the elderly............ 1069 Table 53.2 Community resources........................ 1075 Table 53.3 Common causes of postoperative confusion in the elderly patient.......... 1078 Table 53.4 General nursing care plan for the elderly patient.................................... 1079

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Table 53.5 Reversible causes of acute confusion........................................... 1082 Table 53.6 Types of elder abuse........................... 1091 Table 54.1 General nursing care plan for the rehabilitation of a person with a disability............................................ 1109 Table 55.1 Needs during non-threatening and threatening situations while in hospital.............................................. 1116 Table 56.1 General nursing care plan for palliative care in a terminally ill patient............. 1128 Table 56.2 Pharmacological management of symptoms affecting the respiratory tract................................................... 1132 Table 56.3 Pharmacological management to reduce pulmonary secretions............. 1133 Table 56.4 Oral pharmacological agents used for the management of dry skin and pruritus.............................................. 1134 Table 56.5 Pharmacological management of anorexia............................................. 1138 Table 56.6 Oral antiemetics................................. 1139 Table 56.7 Antiemetics administered subcutaneously.................................. 1139 Table 56.8 Pharmacological management of diarrhoea........................................... 1140 Table 56.9 Pain control in mucositis.................... 1142 Table 57.1 Triage according to colour-coded priority classification.......................... 1158 Table 57.2 Extinction media and their advantages and disadvantages.............................. 1164

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About the contributors Sophie Mataniele Mogotlane (General editor) RN, RM, RCHN, RNA, Dipl Nursing Education, Dipl Paediatric Nursing, BA Cur (Unisa), BA Cur (Hons) (Unisa), MA Cur (Unisa,) PhD (Natal) Emeritus Professor and a Research Fellow in the College of Human Sciences at the University of South Africa

Malega Connie Kganakga RN, RM, RCHN, RT, BSc Nursing (UNIN), MA Psychology (UP), MPH (Tulane School of Public Health & Tropical medicine), PhD (Medunsa) Executive Manager & Acting CEO of South African National Aids Council (SANAC)

Motshedisi Eunice Chauke RN, RM, RCHN, RT, Dipl Nursing Education, Dipl Intensive Care Nursing Science, BA Cur (Unisa), MA Health Studies (Specialisation: Critical Care Nursing, Cardiothoracic Nursing) (Unisa), PhD (Unisa) Senior Lecturer, Department of Health Studies, Unisa

Hananja Donald BSc Dietetics (SUN) Lecturer/therapist in the Ukwanda Rural Clinical School, Faculty of Medicine and Health Sciences, Stellenbosch University

Mokgadi Christina Matlakala RN, RM, RNA, RPN, RCHN, RT, Dipl Med-Surg Nursing (Critical Care Nursing), BA Cur (Unisa), M Cur (Medunsa), PhD (Unisa) Professor, Department of Health Studies, Unisa

Moreoagae Bertha Randa RN, RM, RCHN, RPN, RNE, RNA, Dipl Med-Surg Nursing (Critical Care Nursing), B Cur (I et A) (UP), B Tech (OHN) (TUT), MPH (University of Limpopo, Medunsa campus) Lecturer, Nursing Science Department, Sefako Makgatho Health Sciences University

Joyce Desia Mokoena RN, RM, RT, RCHN, Dipl Nursing Education (Medunsa), Dipl Community Nursing (Medunsa), BA Cur (Hons) (Nursing Education) (Unisa), MA Cur (Unisa), PhD (UL) Associate Professor, University of Limpopo, Medunsa campus

Kinna Erasmus RN, RM, RCHN; R Psych, Master (Management) (UP), Honours (Management) (UP), B Cur (Education & Management) (Unisa), Labour Law (RAU) Palliative care Specialist field: Nursing Education

Anne Margaret Young RN, RM, Dipl ICU, Dipl Nursing Education, BA Cur (Unisa) Former Academic Head, Post-Basic Department, Chris Hani Baragwanath Nursing College

Herman B Willemse PhD, MCur, BCur Hon (advance medical and surgical nursing), Dipl Health Science education Registered Nurse, Psychiatric Nurse, Community health nurse, Accoucher Vice Principal, Henrietta Stockdale Nursing College, Head of Academia

Ramokone Mogotlane MBChB (Medunsa), FCOG (SA), MMed (O&G) (UP), MBA (Robert Kennedy College, University of Wales, UK) In private practice (Medi-clinic, Medforum) Helen de Jager MBCHB (UP), Dip Ophth (SA), FC Ophth (SA), MMed Ophth (Medunsa) Ophthalmologist in private practice in Pretoria Theo Ligthelm RN, RA, RPN, RCHN, RNA, Hon B Soc Sc (Nurs) (UFS), Adv Dip Nursing (UNISA), H Dip Ed (PCE), MPA (UFS), RAEA Former Officer Commanding, School for Military Health Training and Senior Staff Officer Operational Planning, SAMHS

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The authors acknowledge the contributions of the following people, who contributed to Juta’s Manual of Nursing Volume 4, on which this book is based. Prof Busisiwe Rosemary Bhengu Prof Karin Enskar Lebo Ziphora Komane Gunilla Lusjegren Isabel Manaka-Mkwanazi Debbie Norval Sefakoane Priscilla Tsebe Nomusa Viola Tshabalala Anna Ruth van Oostveen

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Preface Nursing education and training is at a crossroads, with new programmes and curricula being developed for all categories of nurses. Juta’s Complete Textbook of Medical Surgical Nursing comes at the ideal time to meet the needs of the new curricula, providing a text that is comprehensive yet direct and focused, and covers relevant medical and surgical conditions and nursing care for all the systems of the human body. This book is written specifically to meet the needs of learners undertaking the programmes for a staff nurse or professional nurse and to a limited extent the auxiliary nurse programme. The emphasis is not only on the theory that underpins nursing practice but also on nursing skills that form an integral part of nursing. The book therefore aims to equip the nurse with the knowledge and skills to provide appropriate healthcare services and education to patients and communities in varied locations and circumstances. The language used is simple, clear and easy to understand and where appropriate, line drawings, tables and boxes lend further meaning and clarity to the text. The design of the book is user-friendly with chapters clustered in a manner that enables cross-referencing and avoids unnecessary repetition. Chapters 1 to 22 address general issues in nursing such as applicable concepts, nursing within a culturally diverse society, key competencies and needs, the nursing process, symptoms management, emergency care, cell and tissue injury, oncology, immune disorders, managing a patient with HIV and AIDS and perioperative care.

Chapters 23 to 49 are specific to particular systems. Information is presented systematically, under the following headings: • Learning objectives • Key concepts • Prerequisite knowledge • Medico-legal considerations specific to the system/ condition discussed • Ethical considerations applicable to the system/condi­ tion discussed • Essential health literacy pertaining to the system/condi­tion discussed • Introduction • Overview of anatomy and physiology • Classification of conditions • Risk factors • Pathophysiology • Nursing assessment and common findings • A general nursing care plan • Specific disorders • Essential health information • Conclusion • Suggested activities for learners. Chapters 50 to 57 relate to special aspects such as burn injuries, special senses, the elderly, the disabled, the child in hospital, palliative care and disaster nursing. The book is written by nurses for nurses for use in a variety of settings including the classroom or practice environment. We hope that you, the reader, will derive the same satisfaction from using the book as we, the authors, derived from writing it. The book has afforded us an opportunity to share our experiences with the nursing profession for which we are forever grateful. Sophie Mataniele Mogotlane (General editor) Pretoria August 2017

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List of abbreviations 3TC AA ABC ABG ACCH ACE ACTH ADA ADH ADL AFASS AFB AFP AIDS ALL ALT AML ANS ARDS ARF ART ARVs ASD ASO AST ATP ATV AV AZT BF BIPAP BMI BMT BP BSE BUN CABG CAD CAM cAMP CAT CBO CCF CDC CDCA

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– lamivudine – alcoholics anonymous – abacavir – arterial blood gas – Association for the Care of Children in Hospital – angiotensin converting enzyme – adrenocorticotrophin hormone – adenosine deaminase – anti-diuretic hormone – activities of daily living – affordable, feasible, accessible, safe and sustainable feeding – acid-fast bacilli – alto-feto-protein – Acquired Immunodeficiency Syndrome – acute lymphocytic leukaemia – alanine aminotransferase – acute myelocytic leukaemia – autonomic nervous system – acute respiratory distress syndrome – acute renal failure – antiretroviral therapy – antiretrovirals – atrial septal defect – antistreptolysin O – aspartate aminotransferase – Adenosine triphosphate – atazanavir – atrioventricular – zidovudine – breastfeeding – bi-level positive airway pressure – body mass index – bone marrow transplantation – blood pressure – breast self-examination – blood urea nitrogen – coronary artery bypass graft – coronary artery disease – complementary and alternative medicine – cyclic adenyl monophosphate – computerised axial tomography – community-based organisation – congestive cardiac failure – Centers for Disease Control and Prevention – chenodeoxycholic acid

CEA CIN CKMB CLL CML CMV CNS CO COPD CPD CPK CRT CS CSF CT CTX CVA CVID CVP D4T DCIS DDI DENOSA DHA DIC DKA DM DR TB DRE DVT DXT EACH EBP ECF ECG ECT EDL EDP EEG EFV EMSSA EPS EPTB

– carcinoembryonic antigen – cervical intraepithelial neoplasia – creatine kinase – MB – chronic lymphocytic leukaemia – chronic myelocytic leukaemia – cytomegalovirus – central nervous system – cardiac output – chronic obstructive pulmonary disease – continuing professional development – creatine phosphokinase – capillary refill time – compartment syndrome – cerebrospinal fluid – computed tomography – cotrimoxazole – cerebrovascular accident – common variable immunodeficiency – central venous pressure – stavudine – ductal carcinoma in situ – didanosine – Democratic Nursing Organisation of South Africa – District Health Authority – disseminated intravascular coagulopathy – diabetic ketoacidosis – diabetes mellitus – drug resistant tuberculosis – digital rectal examination – deep vein thrombosis – deep X-ray therapy – European Association for Children in Hospital – evidence-based care – extracellular fluid – electrocardiogram – electroconvulsive therapy – essential drugs list – essential drug programme – electro-encephalography – efavirenz – Emergency Medicine Society of South Africa – electrophysiology study – extra-pulmonary tuberculosis

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xxiv  Juta’s Complete Textbook of Medical Surgical Nursing

ERCP ERV ESR ESRD FBC FBO FDA FDP FF FRC FSH GABA GAG GCS GDM GFR GGTP GI GIT GnRH GORD GPI HAART HCAI HCl HFOV HFV HHNKS HIE HIV HRT HSIL HSV IBD IBS ICD ICF ICN ICP ICU IgA IMCI INR IRIS ISF IVH IVP KS

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– endoscopic retrograde cholangiopancreatography – expiratory reserve volume – erythrocyte sedimentation rate – end-stage renal disease – full blood count – faith-based organisation – Food and Drug Administration – fibrinogen degradation product – formula feeding – functional residual capacity – follicle stimulating hormone – gamma-aminobutyric acid – glycosaminoglycon – Glasgow Coma Scale – gestational diabetes mellitus – glomular filtration rate – gamma glutamyltranspeptide – glycaemic index – gastrointestinal tract – gonadotrophin-releasing hormone – gastro-oesophageal reflux disease – general paralysis of the insane – highly active antiretroviral therapy – healthcare associated infection – hydrochloric acid – high frequency oscillatory ventilation – high frequency ventilation – hyperglycaemic hyperosmolar nonketotic syndrome – hyper immunoglobulinaemia – human immunodeficiency virus – hormonal replacement therapy – high-grade squamous intraepithelial lesion – herpes simplex virus – inflammatory bowel disease – irritable bowel syndrome – implantable cardiac defibrillator – intracellular fluid – International Council of Nurses – integrated care pathways – intensive care unit – immunoglobin A – integrated management of childhood illnesses – international ratio – immune reconstitution inflammatory syndrome – interstitial fluid – intravenous hyperalimentation – intravenous pyelogram – Kaposi’s sarcoma

KUB LABAS LCIS LDH LDOP LEEP LGE LH LIP LLQ LPV/r LSIL LUQ MAC MAC MAMC MAP MAST MCS MDR MDR TB MI MMSE MPQ MRI MS MTBE MTCT MVA NG NGO NMDA NNRTI NPO NREM NRTI NSAID NTM NVP OHL OI ORT OTC PAD PAOD PAS PBP PCA PCM PCP PCR

– kidneys, ureters and bladder – long-acting beta-two agonists – lobar carcinoma in situ – lactate dehydrogenase – low-dose long-term oxygen therapy – loop electrocautery excision procedure – lineal gingival erythema – luteinising hormone – lymphoid interstitial pneumonitis – left lower quadrant – lopinavir/ritonavir – low-grade squamous intraepithelial lesion – left upper quadrant – mid-arm circumference – mycobacterium avum complex – mid-arm muscle circumference – mean arterial pressure – military anti shock trousers – microscopic culture and sensitivity – multiple drug resistance – multiple drug resistant tuberculosis – myocardial infraction – mini-mental state examination – McGill Pain Questionnaire – magnetic resonance imaging – multiple sclerosis – methyltertiary butyl ether – mother-to-child transmission – motor vehicle accidents – nasogastric – non-governmental organisation – N-Methyl-D-aspartate – non-nucleoside reverse transcriptase inhibitor – nil per orem (nothing by mouth) – non-rapid eye movement – nucleoside reverse transcriptase inhibitor – non-steroidal anti-inflammatory drug – non-tuberculous mycobacteria – nevirapine – oral hairy leukoplakia – opportunistic infection – oral rehydration therapy – over-the-counter – peripheral arterial disease – peripheral artery occlusive disease – para-aminosalicylic acid – protocol-based practice – patient-controlled analgesia – protein-calorie malnutrition – Pneumocystis jiroveci pneumonia – polymerase chain reaction

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List of abbreviations 

PDA PDS PEEP PEP PGL PHC PI PLWHA PME PML PMTCT PN PN PNH PPD PPE PT PTC PTCA PTH PTT PVD QSEN RASR RBC RDA REM RF RLQ RNA ROM RTV RUQ SANC SANCA SCID

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– patent ductus arteriosus – prostate-specific antigen – positive end-expiratory pressure – postexposure prophylaxis – persistent generalised lymphadenopathy – primary health care – protease inhibitor – person living with HIV/Aids – patient management executive – progressive multifocal leukoencephalopathy – prevention of mother-to-child transmission – parenteral nutrition – peripheral neuropathy – paroxysmal nocturnal haemoglobinuria – purified protein derivative – papular pruriginous eruption – prothrombin time – percutaneous transhepatic cholangiography – percutaneous transluminal coronary angioplasty – parathormone – partial thromboplastin time – peripheral vascular disease – Quality Safety Education for Nurses – radioallergosorbent test – red blood cell – recommended dietary allowance – rapid eye movement – rheumatoid factor – right lower quadrant – ribonucleic acid – range of movement – ritonavir – right upper quadrant – South African Nursing Council – South African National Council on Alcohol and Drug Dependence – severe combined immunodeficiency disease

SG SGOT SGPT SIADH SLE SNS SPF SSS STD STI SVC SVR T3 T4 TB TBM TBSA TDF TENS TGUGT TIA TLC TNF-ß TPN Trop T TRUS/TUS TSH TST TURP TV UDCA UTI UV VAS VC VDRL VSD WBC WHO WR XDR TB

xxv

– specific gravity – serum glutamic oxalo-acetic transferase – serum glutamate pyruvate transaminase – syndrome of inappropriate ADH secretion – systemic lupus erythematosis – sympathetic nervous system – solar protection factor – sugar and salt solution – sexually transmitted disease – sexually transmitted infection – superior vena cava – strong vascular resistance – triiodothyronine – thyroxine – tuberculosis – tuberculous meningitis – total body surface area – tenofovir – transcutaneous electrical nerve stimulation – Timed Get Up and Go Test – transient ischaemic attack – total lung capacity – tumour necrosis factor – total parenteral nutrition – Troponin T – transrectal ultrasonography – thyroid stimulating hormone – tuberculin skin test – transurethral resection of the prostate – tidal volume – ursodeoxycholic acid – urinary tract infection – ultraviolet rays/light – visual analogue scale – vital capacity – venereal disease research laboratory – ventricular septal defect – white blood cell – World Health Organization – Wasserman reaction – extensively drug-resistant tuberculosis

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1

Applicable concepts in nursing practice

learning objectives

On completion of this Chapter, the learner should be able to: • explain the concepts ‘health’, ‘health promotion’, ‘wellness’ and ‘illness’ • identify national and global initiatives regarding health promotion and wellness • identify the nurse’s role in healthcare, throughout the lifespan, within the multidisciplinary team • explain the healthcare service systems in South Africa, including the approaches used in these systems • identify the factors that influence health • explain the notion of nursing as a profession, functioning within a legal and ethical framework • identify and apply nursing theories and models to improve practice and to provide evidence for research • identify the characteristics for the recognition of nursing as a profession • demonstrate knowledge and understanding of the legal and ethical framework for nursing • explain the need for nursing to organise itself as a professional association or organisation. key concepts and terminology

ethics

Moral principles that govern behaviour.

health

The general condition of a person’s body, mind, emotional, spiritual and social well-being.

health promotion

The behaviour or approach designed to increase the attainment of health of individuals, groups and society.

lifespan

The duration of an individual’s life from before birth (after conception and during intra-uterine life), through infancy, childhood and adolescence, to adulthood and old age, until death at an advanced age.

model

Representations of the interaction among and between concepts showing patterns.

profession

An occupation or vocation requiring specialist knowledge and skills within a legally recognised learning system.

theory

A group of concepts that relate to one another in such a way as to form a lens through which one can perceive a phenomenon.

Introduction The promotion of health as well as the prevention of ill health has always been regarded as one of the fundamental goals of nursing. With an increasing lifespan, there is a growing population of the elderly, and at the same time an increasing burden of chronic illness among middleaged adults. The focus for nursing and nursing practice includes health promotion and well-being, prevention as well as control of chronic conditions. The role of the nurse within a multidisciplinary team takes on new dimensions in a collaborative and inter-professional approach in order to meet the changing needs of the patients and those of society. With the focus on the goal of nursing,

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this Chapter will provide an introduction to the concepts that are applicable to nursing and nursing practice, with specific reference to health and the nurse within a multidisciplinary team, nursing as a profession, including the legal and ethical framework supporting nursing.

The meaning of health The perception of health as a state of being of an individual can be viewed from both a subjective and objective point of view. Health is an elusive process through which one attempts to get a feeling of equilibrium and comfort, based on a person’s perception of well-being. It is dynamic and

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2  Juta’s Complete Textbook of Medical Surgical Nursing

not static, because it can move from perceived optimum levels of well-being to the lowest levels of discomfort and ill health or illness. Human beings are concerned about their state of health every day. Most cultures include an enquiry into one’s health status when greetings are exchanged. Generally speaking, it is easier to determine and measure the attributes of illness than it is to determine and measure those that relate to health. For example, if someone says they are unwell you can ask them what the specific problem is; if someone says they are well, on the other hand, they will find it difficult to answer if you ask what makes them say they are well. Wellness, then, could be defined as an absence of illness.

The WHO definition of health The World Health Organization (WHO) has defined health in their constitution as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. The WHO definition of health is regarded as one that provides an umbrella meaning of health globally. At the individual level, health is a comprehensive concept that impacts on the individual’s life and well-being with respect to: • physical status • mental functioning • emotional well-being • social and interpersonal relationships • spiritual and cultural fulfilment. However, with increasing globalisation, health is also viewed from global perspectives, largely as a result of the impact of the world on local healthcare issues. Global health perspectives are based on the interconnectedness of the world at large as a result of better and conti­nually improving digital communication and telecommuni­ cation, travel, commerce and migration. The impact of communicable diseases poses an even greater risk because of rapid global travel and communication. Furthermore, the impact of global warming and climate change is not confined to one country, but the world at large, and the significant consequences thereof will be experienced by the whole world to a greater or lesser extent. According to Riebeek (2010), as a result of global warming, there will be modifications to the rainfall patterns, resulting in longer growing seasons in some regions and more severe droughts in others. This may impact food production, resulting in malnutrition. More frequent flooding in lowlying areas would also lead to worse and more frequent healthcare crises. Some infectious diseases like malaria

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may manifest in new areas as the tropical temperature zone expand. The role of the nurse in pursuit of health for individuals, families and groups is also influenced by global trends and issues. It is generally recognised that certain behaviours or practices affect health either positively or negatively. In Box 1.1 the outlined aspects relate to behaviours and/or habits which are deemed to help maintain a healthy disposition.

1.1  Habits to form a healthy disposition • Do not smoke. Stop smoking because this will not only benefit the smoker, but also those around them. • Eat a balanced diet with the advocated five food groups, ie carbohydrates, proteins, fats, minerals and vitamins (see Chapter 6). • Exercise and keep physically active. • Manage stress by, for example, talking things through with the relevant people and taking time to relax. • Take alcohol in moderation. • Protect the skin from environmental elements, espe­ cially sunburn, by covering up with long-sleeved cool tops, wearing hats and/or using sun block. • Make use of cancer-screening opportunities, eg Pap smear, mammography, etc. • Practise road safety. • Practise safe sex. • Learn the basics of first aid. (Murdoch, 2014)

The health–ill health continuum and the role of nurses Traditionally, health has always been seen in relation to ill health or disease. The development of the role of the nurse is historically linked with sick or ill people. Therefore, the health status of patients influences the way nurses relate to them and the use of the nursing process. Exploration of the meaning of health, illness and disease promotes understanding of what nurses do and what nursing means. An individual’s perception of health is shaped in various ways and may change according to that individual’s stage of life, level of development, health and ill health experiences, level of physical and psychosocial interaction, and cultural affiliation. In the modern history of nursing, Florence Nightingale is regarded as the person who founded nursing and who helped clarify the role of the nurse in healthcare. From her time onwards nursing scholars have defined health in relation to the role of the nurse, wellness and illness. Some of these scholars are discussed below.

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Chapter 1 – Applicable concepts in nursing practice  3

Virginia Henderson. She emphasised the importance of ensuring that patients’ independence is promoted even after hospitalisation. She said that the unique function of the nurse is to assist an individual (who is either sick or well) to engage in activities that facilitate health if they are willing and strong enough, so that they either retain their health, regain their health or die peacefully as a result of the illness. Martha Rogers. She described nursing practice as the creative and imaginative use of nursing knowledge. Orlin (2011) further states that nursing seeks to promote symphonic interaction between environment and the person to strengthen the integrity of the human being in order to ultimately maximise health potential. Rogers also believed that health and illness are on the same continuum and along the axis, the individual’s interaction with the environment could lead to increased health or to situations that are incompatible with health. Betty Neumann. The systems theory posits that living organisms are open systems in interaction with each other and with the environment. Neumann ascribed to this theory, and attended to both health and illness in her definition of health: • Health as a value between wellness and illness • Wellness as a condition in which all parts and subparts of an individual are in harmony with the whole system, while illness indicates a lack of harmony. Health is therefore visualised as a shifting point on a line (continuum) between wellness and illness. Optimal wellness results when all the needs of a person are met, and unmet needs cause a reduction in wellness. An individual’s state of wellness or illness may alter at any moment; their environment can be assessed to determine which factors increase or decrease their wellness. Various authors have developed other health models in an attempt to clarify the relationships between health and the factors that impact on health. These models include the agent–host–environment model (see Figure  1.1) and the health belief model.

The agent–host–environment model The agent–host–environment model is especially valuable in community healthcare and epidemiology. It identifies risk factors in the interaction between the agent, the host and the environment (see Figure 1.1). Where all three factors are present, illness is more likely to be present. Gulis and Fujino (2014) maintain that disease will occur when an outside agent capable of causing disease or injury meets a host that is susceptible to the agent within an

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environment that is suitable or conducive to the agent and host interacting. This model can be disturbed so that disease does not occur by applying certain interventions that will tackle one of the three elements. For example, boosting the immune system of the host, increasing their knowledge, and motivating them can have a positive impact. If, however, all three factors coincide, the likelihood of illness rises.

host

illness agent

environment

Figure 1.1  Agent–host–environment model

Awareness of such risk factors facilitates the prevention of illness, health promotion and health maintenance.

The health belief model The health belief model, developed in the 1950s by Rosenstock, Hochbaum, Kegeles and Leventhal, describes the health behaviour of people in relation to what they believe about themselves and about health, and in relation to the decision-making process in seeking healthcare services. According to this model, it is believed that individuals will take action to prevent, screen for, or control an ill health condition or situation if they regard themselves as being susceptible to a condition that may have serious consequences, or that will affect their lifestyle. A course of action on their part would benefit them and reduce either their susceptibility to the condition or to its severity. The barriers to taking action, in terms of costs, are outweighed by the benefits of action. The model includes three components, each involving an individual’s perception: 1. Their susceptibility to disease 2. The seriousness of a disease 3. The value of action. The perceived susceptibility to a disease or illness relates to understanding the process of contracting a disease and ranges between being afraid of becoming ill to complete denial that certain behaviour may cause illness. Perceived

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4  Juta’s Complete Textbook of Medical Surgical Nursing

susceptibility depends on people’s belief as to whether they will or will not become ill. The perceived seriousness of a disease concerns the disease itself and the seriousness of its impact on the lifestyle of an individual, such as the possible social consequences impacting on employment, family and social relations. Other consequences of illness include pain, disability and death. The perceived value of action lies in people’s beliefs about how effective preventive measures will be in preventing illness. These beliefs are influenced by the conviction that the disease can be modified or prevented by implementing the recommended behaviour and the belief that it will be cheaper and less unpleasant to take the recommended action. A discussion on health also brings into focus the concepts of wellness and health promotion.

Wellness The perception of wellness is that of an individual reporting to be healthy. Wellness is regarded as an ongoing process that leads an individual to a state of having a perception or feelings of vitality and of being healthy, even in the presence of chronic illness. Wellness is earned. People have to make an effort to attain a state of wellness. Wellness, as a subset of health, consists of four compo­ nents: 1. The capacity to perform to the best of one’s ability 2. The ability to adjust and adapt to varying situations 3. A reported feeling of well-being 4. A feeling of having a balanced and harmonious disposition. Citing the work of Jonas (2005), Foster (2007) points out that wellness differs from health in that health is regarded as a state of being, whereas wellness is a process of being. Foster provides the dimensions of wellness as follows: • Physical wellness, which includes physical activity, nutrition and self-care • Psychological or emotional wellness, which can be expressed as an expectation that positive outcomes will result from events and experiences of life • Social wellness, which includes how well one relates to others; as well as the degree and quality of interactions with others, the community, and nature • Intellectual wellness, which is the degree to which one engages in creative and stimulating activities, and the use of resources to expand knowledge, as well as the development, acquisition, and application of critical thinking • Spiritual wellness, which focuses on the purpose and meaning of life, and the self in relation to others, the community, nature, and/or a higher power.

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However, McMahon and Fleury (2012) observe that while the pursuit of wellness has resulted in extended life expectancy, older adults are not typically valued in our society currently.

Health promotion In order to maintain health, there has to be health promotion and the prevention of disease. Health promotion is a process of creating awareness, shaping attitudes and identifying alternatives so that individuals can be empowered to make informed choices, so that they can change or modify their behaviour in order to achieve physical and mental health, and improve their physical and social environments. Health promotion includes all those activities undertaken by health professionals to promote health, including health education and counselling. Health promotion programmes are designed to improve the health and well-being of individuals and communities through empowerment. Partnerships between nurses and communities enhance this empowerment. Individuals and communities are empowered through the following activities: • Provision of information in order to enhance health literacy • Teaching of skills pertinent to health promotion and disease prevention • Provision of services • Giving of support needed to undertake and maintain positive lifestyle changes.

1.2 WHO Priorities for health promotion in the 21st century 1. 2. 3. 4.

Promote social responsibility for health Increase investment for health development Consolidate and expand partnerships for health Increase community capacity and empower the individual 5. Secure an infrastructure for health promotion Jakarta Declaration on Leading Health Promotion into the 21st Century

Social factors that influence health In order to maintain a positive health status, it is important to understand the social factors that may influence health. These include the following factors: • Socioeconomic inequalities. Different socioeconomic factors have an impact on people’s health. Individuals with a higher socioeconomic level are expected to lead a better and healthier life, but this is not

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always the case. The assumption is that people with a high socioeconomic level will have positive health behaviour. People with a higher socioeconomic status have a potential for a healthier life when compared to their counterparts on lower socioeconomic levels. It is sometimes the case that people from a high socioeconomic level are able to participate in more active health promotion behaviour, such as regular physical examinations, regular visits to the dentist, better access to healthy nutrition, etc. Where people are from a lower socioeconomic level, they may have poorer health due to a lack of access to medical care or health-promoting behaviour. These generalisations are not conclusive and socioeconomic status is not an indication of an individual’s state of health. It is possible for individuals from high socioeconomic situations to have ill health and, similarly, for individuals from low socioeconomic environments to be in perfect health. • Education. This is an important social factor in health. Generally, better-educated individuals have access to information about healthier lifestyle choices and healthy behaviours. Health literacy is an important facet of education. An educated or literate person is more able to acquire the relevant health information needed to lead a healthy life, prevent disease and effectively manage chronic conditions. This is in line with the United Nations International Children’s Fund (UNICEF) GOBI-FFF principle, which includes knowledge about growth monitoring, oral rehydration, breastfeeding, immunisation, food supplementation, family planning and female education. • Social inequalities. Generally, the more affluent an individual or community, the better their health. Poorer members of the community often have to contend with the following issues which might impact negatively on their health: –– A lack of access to healthcare and other facilities such as water, electricity and sanitation –– Unemployment and a lack of resources to pay for visits to doctors or clinics –– A lack of proper housing that can result in over­ crowding, thus promoting the spread of disease –– Undernourishment, which also contributes to poor health and the development of disease –– Little by way of advocacy for change. • Culture. This plays an important role in health. Culture determines the way in which an individual views disease, and how that individual responds when ill (see Chapter 2).

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Nursing and the nursing profession The meaning of nursing The question of what nursing is, and what it is not, has been debated since the time of Florence Nightingale. A single brief definition of nursing has never been standardised. Nursing continually changes to meet the needs and circumstances of particular groups, in particular countries at particular times. Nursing is sensitive to prevailing politics and legislation, national health problems, and economic and educational constraints, and has progressed from nurturing the sick and needy to professionally catering for all the health needs of all people. Its four broad aims are to promote health, prevent ill health, restore health and promote coping (rehabilitating) after radical health changes. The word ‘nurse’ was originally derived from the Latin word nutrix or nutricis, which meant someone who tended or nourished (nutrio) the young, sick, or infirm. Today, any existing definition of nursing is much wider than simply nurturing, although nurturing and caring remain at the core of nursing. Florence Nightingale described nursing as ‘the act of utilising the environment of the patient to assist him in his recovery’ (Nightingale, 1860 in George, 1990). In a 1965 position paper on education, The American Nurses’ Association (ANA) explained nursing as an independent profession and said: ‘Nursing is a helping profession and, as such, provides services which contribute to the health and well-being of people.’ Virginia Henderson, one of the first 20th-century American nursing scholars, defined nursing as ‘primarily assisting the individual (sick or well) in the performance of those activities contributing to health (or its recovery or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge’. Within the self-help context, ‘[it] is likewise the unique contribution of nursing to help the individual to be independent of such assistance as soon as possible.’ The understanding of nursing expanded rapidly as more organisations and authors expressed their views on its nature and functions and the roles of nurses. The central focus of all definitions of nursing remains the person who requires holistic care, taking into consideration their physical, emotional, spiritual and social needs. In most of the modern literature, authors and organisations describe nursing as a profession, a discipline and a science. As a science, nursing is based on a distinct body of knowledge that can be applied in the clinical situation and which is continually being expanded by ongoing research. The South African Nursing Council provides an explanation of nursing science as:

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a clinical health science that constitutes the body of knowledge for the practice of persons, registered or enrolled under the Nursing Act as nurses or midwives. Within the parameters of nursing philosophy and ethics, it is concerned with the development of knowledge for the nursing diagnosis, treatment and personalized healthcare of persons exposed to, suffering, or recovering from physical or mental ill health. It encompasses the knowledge of preventive, promotive, curative and rehabilitative healthcare for individuals, families, groups and communities and covers man’s lifespan from before birth. As a discipline, nursing has the following characteristics: • It is a system comprising a specific, unique body of knowledge. • It uses existing and new knowledge to solve problems and to meet human needs in its own particular and dynamic field. • It requires study and practice separate from other disciplines.

Selected theories of nursing A theory is a set of concepts and propositions that provide a systematic view to a phenomenon. Theories are derived through inductive and deductive reasoning. They are descriptive, explanatory and predictive in nature. The purpose of a theory in nursing is to advance the discipline and practice of nursing.

Characteristics of nursing theory The following list includes the main characteristics of nursing theory: • Clear, logical, sensible description of concepts specific to nursing • Well-explained relationships between concepts • Congruence (agreement, comparability) with the basic assumptions used in its development • Its usefulness and the applicability of its concepts in the clinical situation • Its value in nursing education, research and practice.

The importance of nursing theories Nursing theories are important for the following reasons: • They provide rational, knowledgeable reasons for actions based on organised written descriptions of the reality of nursing. • They provide a knowledge base for acting and responding appropriately in nursing care situations.

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• They generate new knowledge in nursing through research which is used for either testing existing theories or generating new theories. • They provide resolutions on current nursing issues by transforming or informing nursing practice. • They promote problem-solving skills, which knowledgeable nurse practitioners use to undertake organised, considered and purposeful nursing actions. • They prepare the nurse to question assumptions and values, thus leading to other/further definitions of nursing and an increased, dynamic and relevant knowledge base. • Nursing theories guide nurses in providing care to an individual, a family, a group or a community (Meleis, 2011). • Alejandro (2017) adds that nursing theories form the supportive framework on which patient care relies. There are several theories that are used in nursing as no one single theory is applicable to all the diverse needs that nursing has to answer to. This is often regarded as a drawback for the professional status of nursing. However, the advantage of many theories is that they allow nursing phenomena to be examined from many angles and to be viewed from different perspectives. In addition to that, this perspective also allows nursing to use theories from other disciplines, for example from psychology, Maslow’s hierarchy of needs is used extensively in nursing to explain the progression of peoples’ needs. Nursing practice provides specific interventions to meet some of the needs of individuals. Another common theory from other disciplines is the systems theory. In the systems theory, all systems are goal-oriented and are interdependent. Nurses should understand that a change in the patient’s respiratory system, for example, will impact on other systems such as the circulatory and the nervous system, the effects of which can cascade to the rest of the body.

The metaparadigm of nursing Each discipline determines its own way of dealing with phenomena. For example, psychology is concerned with the behaviour of individuals, whereas biology is concerned with living organisms. Nursing, on the other hand, is concerned with the care, well-being and health of individuals throughout the lifespan. The concepts that provide structure to nursing are as follows: • Person. The person, whether described as patient, client, health consumer, human being, individual or other, is the most important reason for the existence of nursing practice. • Health. This is the continuum from wellness to illness.

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• Environment. This relates to the place or community where care is provided, and also describes the world a person lives in and interacts with, including the geography, common resources and culture of the individual. • Nursing. This includes the actions and interactions of the nurse with the individual or person within the environment. These four concepts make up what we call the metaparadigm of nursing. Individual theorists describe the four concepts which make up the metaparadigm and the relationship between them according to their own perspectives, beliefs and experiences.

Florence Nightingale Florence Nightingale’s views are centred on the influence of the environment, and the processes of repair at the patient’s disposal. An analysis of her writings shows that she considered the person to be an individual who desires health and who deals with disease through vital reparative processes, yet does not strive to adapt to the environment or to influence the nurse. Health means being well and having the power to function fully, using environmental factors to maintain health. Disease means that nature initiates a reparative process due to some want of attention. Nursing is an act of providing the optimal environmental conditions to promote and maintain the individual’s own reparative processes. The concept of environment in this theory embraces the physical environmental aspects, which include warmth, diet, cleanliness, ventilation, light and the absence of noise. Nightingale’s beliefs about the influences of environ­ mental factors in health promotion and maintenance, and in caring for the sick remain as important today as when Nightingale first opposed the poor sanitation, living and working conditions and the low quality of nursing in the hospitals of her day. Nightingale also drew a distinction between nursing and medicine and stated that nursing is distinct and separate from medicine. Nursing is achieved through environmental alteration and requires a specific educational base (Pirani, 2016).

Virginia Henderson When Virginia Henderson first formulated a definition of nursing in 1955, it served to establish nursing as a discipline in its own right. Her extensive definition refers to an individual’s needs in relation to health and the role the nurse plays to meet these needs. Henderson’s views

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are briefly summarised under the four components of nursing practice. Person. A person is an independent, whole and complete being with 14 basic needs, which include: 1. Breathing normally 2. Eating and drinking adequately 3. Eliminating (removing toxins from the body) 4. Moving and maintaining posture 5. Sleeping and resting 6. Dressing and undressing 7. Maintaining body temperature 8. Keeping clean and well groomed 9. Avoiding danger and injury to self and to others 10. Communicating to express emotion, needs, fears and opinions 11. Worshiping according to the particular person’s faith 12. Working and experiencing a sense of accomplishment 13. Relaxing through recreation and play 14. Promoting development and health. Health. This is a quality of life achieved by an individual through independent (done alone) or interdependent (done with others) performance of the 14 components of nursing care. In order to work effectively and to reach the highest potential and to attain health, an individual must have the necessary strength, will or knowledge. Environment. The environment is considered as the sum total of internal and/or external influences/conditions affecting the life and development of an organism. Nursing. A unique function of a nurse is to assist individuals, sick or well, in performing those activities contributing to health and its recovery (or a peaceful death) which individuals would perform unaided if they had the necessary strength, will or knowledge; this includes doing the activities in such a way that it may help individuals gain independence as soon as possible.

Dorothea Orem Dorothea Orem first published her self-care deficit theory in 1971. According to this theory, individuals are naturally capable of providing care to self as well as to their dependants. By initiating and performing these

Nursing alert! The self-care deficit concept allows nurses to make a specific nursing diagnosis by identifying the patient’s self-care deficits.

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behaviours, they strive to maintain life, health and wellbeing. The ability to accomplish self-care is an adult activity termed self-care agency. Infants, the aged, and disabled and ill individuals require assistance with their self-care activities. They are said to have a self-care deficit. Self-care requisites (requirements) differ according to the stages of development and health states where different levels of assistance may be needed. Self-care requirements may be: • Universal. These are requirements which are common to all people and necessary for daily living. They include breathing (air), drinking (water), eating (food), eliminating (toxins), social interaction and safety. They are survival needs and everybody regardless of age has a potential to provide for self. For example, a newborn will breathe spontaneously, suck and swallow, pass both urine and stool, will interact by crying or smiling and has a Moro reflex (also known as the startle reflex). • Developmental. Development can be defined as ‘maturity in function’. Developmental requirements arise from developmental processes occurring throughout the life cycle. Therefore, there are activities which can only be undertaken based on maturity and experience. For example, a newborn is not able to feed itself, but this improves with growth and development. • Health-deviation requisites. These are needs that arise from defects and deviations from the normal structure and integrity of the individual and which affect their ability to perform self-care activities. For example, an unconscious patient is not able to change their position in bed and will therefore need someone to care for them, move them and ensure that they do not incur injuries such as falling out of bed. The self-care deficit theory shows that nursing becomes a self-care agency which benefits the individual who, for health reasons, cannot adequately provide self-care, eg feeding an adult patient who may be unable to feed themselves because of illness. The nursing systems theory complements the selfcare deficit theory. Nursing systems develop when nurses prescribe, design and provide nursing to compensate for people’s self-care deficits. Orem identifies three types of nursing system: 1. Wholly compensatory, when a nurse provides for every activity required for daily living as in the care for an unconscious patient 2. Partially compensatory, when a nurse assists an indivi­ dual to perform a function such as in early ambulation, where the nurse supports the individual to walk

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3. Supportive–educative, when an individual can and is capable of self-care, but is unable to carry this out due to a lack of information on how to go about performing the self-care activity, as in a mother with a premature infant. The composition and level of nursing care needed differs from system to system. According to Orem, people have bio-psychosocial and interpersonal components and meet their self-care needs through learned behaviour. Health, when positive, symbolises wellness. The value placed on the term ‘health’ differs between individuals and between cultures. Health is considered to be a behaviour of high value, while illness is of low value. Nursing is a service that focuses on people who are unable to meet their self-care needs. It is a deliberate action aimed at creating such conditions as human beings desire for themselves and in their environment. Nursing education and experience enable nurses to give direct assistance to individuals. Environment, although not dealt with in great detail, is associated with the individual, as well as the values and expectations of the particular society. As such, it is an integrated and interactive system. The nursing community has widely accepted Orem’s theory and applies it in health institutions and community services.

Imogene King Imogene King’s theory was initially published in 1971. It is a theory of goal attainment, based on a conceptual framework of three open systems (personal, interpersonal and social) in dynamic interaction. Specific concepts are identified and interact in each system as follows: • Personal system. This system relates to the individual (eg the nurse and the patient). Applicable concepts are perception, body image, growth and development, self, space and time • Interpersonal system. This system relates to groups (eg peer groups). Applicable concepts are inter­action, communication, transaction, role and stress. • Social system. This system relates to communities (eg Soshanguve, Langa, Richmond), and applicable concepts are organisation, authority, power, status and decision-making. • Communication and interaction (act, react, and interact). When purposeful, this system results in transactions which may lead to goal attainment. According to King, the person as a human being is an open system that is rational and purposeful. A person perceives and controls an action within a timeframe.

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Health is a purposeful, adaptive response to the changing (dynamic) life experience of a human who utilises the available resources optimally to attain their potential in daily life, by continually adapting to the stresses of the external and internal environment. Nursing is a process of human interaction whereby a nurse and a patient, perceiving each other and the situation, set goals together by communicating and agreeing on how to achieve these. Environment is not specifically defined. King’s theory contributes to nursing knowledge regarding interactions between the nurse/patient/group. It emphasises the importance for individuals to participate in mutual goal setting and goal attainment.

Theories and the nursing process The two aims of nursing theory development are as follows: • To increase the body of nursing knowledge

• To facilitate communication on nursing by using a common terminology of defined words and concepts. Nursing theory must be made real by applying its con­ ceptual model in clinical practice. Nursing is there­ fore practised by using a systematic process known as the nursing process. The nursing process consists of assessment, nursing diagnosis, planning, implementation and evaluation and record-keeping, which are integral to the whole process. Assessment usually relates to the component of the person/patient. From the discussion above, Virginia Henderson explains the person as having fourteen basic needs. In assessment, information about the extent to which each need is met or unmet will be collected. A nursing diagnosis will be based on what was discovered in the assessment, stating the individual’s self-care deficits.

Table 1.1  Stages of growth and development and the associated special needs

Stage of growth/ development

Special needs to be met

Prenatal: conception to birth

Need for knowledge and support to create an environment conducive for foetal development

Neonatal: birth to 28 days

Need for bonding (parenting skills), safety, communication, security to build trust, inclusion and cohesion within family needs

Infancy: 1 year

Need for continuous close contact with parent/guardian, nutrition, hygiene and skin care, sleep and rest, skills development, play, infection prevention and treatment

Toddler: 1–3 years

Need for playing, sleep and rest, talking, emotional security, nutrition, safety psychosocial development, hygiene, dental care, infection control, toilet training

Preschool: 3–6 years

Need for basic skill learning (balancing, drawing, throwing, cutting, exercise, counting, imitating), play activity, health maintenance, safety, dental hygiene, emotional, moral, affective, cognitive development (self-esteem), sleep and rest

School age: 6–12 years

Need for sexual awareness, social skills, self-identity, peer and child–adult relationships, perceptual growth, increased interest in and preparation for adult roles; need for physical, cognitive, social, mental and mental development, acceptance, play, communication, mobility, love and friendship, accident and infection prevention

Adolescence: 12–20 years (early, middle, late)

Need for sexual identity and education, becoming less involved in family and more in peers, school and workplace commitment, building a personal philosophy and developing a moral/value system, lasting and quality relationships with adults (parents), need for esteem, value development, coping with stress, appearance, cognitive, sexual, spiritual and communication relationships, health education and maintenance needs (drugs, accidents, food, nutrition), social responsibility

Young adulthood: 20–40 years

Equilibrium in social activities, establishing a career, increased self-identity, achieving intimacy, health education (diet, exercise, rest), attention to incidental health, sexual and reproductive needs, adjustment

Middle adulthood: 40–65 years and above

Need for empowerment in community matters; surgical, medical and chronic health needs; sexual needs: menopause and post-menopause; psychological and spiritual needs: empty-nest syndrome, changed relationship patterns, loss and grief; need for lifestyle changes; ill health recognition, health maintenance, rehabilitation maintenance, rehabilitation needs

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Planning must also be done in relation to the diagnoses, ie the identified needs or self-care deficits. Orem’s theory, for instance, requires the design of care to foster activities that promote self-care. Implementation requires scientific knowledge, which directs the nurse on the care to give and how to do it, based on the nursing diagnosis. Evaluation, according to Henderson’s model, demands continuous reassessment of the extent to which a patient’s needs have been satisfied or met, new needs that may have arisen, and how the patient adjusts or responds to the care given. Evaluation enables nurses to judge the effectiveness of the nursing process. (For a detailed discussion on the nursing process, see Chapter 13.)

The role of the nurse throughout the lifespan Nursing care is needed during all stages of life to promote the quality of a person’s health, to prevent ill health, to care for them during periods of ill health and to optimise well-being within the boundaries set by ill health. The cycle of life is completed in different stages of growth and development. Growth is a physical phenomenon characterised by an increase in height, weight, body size and other physical attri­ butes in the individual’s lifespan. Growth slows down after adolescence and is minimal in adulthood. Development refers to an increase in complexity to function, eg sitting, crawling, walking and running. Development continues with maturity and experience also throughout the lifespan. Genetics and environmental factors influence growth and development. Maturation is a sequence of physical changes influenced by genetics, but indepen­ dent of environment. Environmental factors, eg climate, education and nutrition do, however, impact on maturation. Psychosocial development relates to personality development and includes the development of feelings, temperament, self-esteem, interpersonal skill, adaptability and other related characteristics. Growth and development have been widely studied during this century, resulting in a variety of theories. Freud’s psychoanalytic theory, and Eriksson’s developmental theory – although not included in this Chapter – are but two theories which can, in spite of certain limitations, promote a nurse’s understanding of the stages of human development. Each individual has particular needs during each stage of growth and development. Knowing the needs that are pertinent to each developmental stage facilitates the assessment of needs and how these can be met.

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The role of the nurse within the multidisciplinary team The nurse, as an advocate of the patient, ensures that the patient’s rights in healthcare are met. The role of the nurse includes that of coordinator of the activities of the members of the multidisciplinary team to ensure that the patient gets effective healthcare. The multidisciplinary health team may consist of several healthcare professionals. Naude and Bruwer (2006) lists the following as examples: • Medical practitioner • Registered nurse • Dietician • Physiotherapist • Radiologist • Pathologist • Specialist physician • General surgeon.

Practising nursing within the legal, ethical and professional framework Nursing should be practised within a legal, ethical and professional framework.

Legal framework Compliance with the law is a prerequisite for professions such as nursing. Recognition of professions is based on the law governing healthcare as well as the members of that profession. In South Africa, the supreme law of the country is the Constitution of the Republic of South Africa, 1996. The Constitution lays the foundation for all the other laws in the country. It also contains the Bill of Rights which spells out all the fundamental rights of the citizens of South Africa, including all the health rights. Health professionals have an obligation to uphold, respect and protect those health rights. Other laws pertinent to nursing are the Nursing Act 33 of 2005, as well as the National Health Act 61 of 2003. The Constitution of the Republic of South Africa, 1996 (as amended), as the supreme law of the country, is also important, as it provides for fundamental rights, including the right to healthcare. There are several other Acts which are applicable to nursing and health in general, but the scope of this book does not allow for a discussion of all those other laws.

The Nursing Act 33 of 2005 The Nursing Act 33 of 2005, which repealed the Nursing Act 50 of 1978, provides for the continued legal recognition of nursing as a profession in South Africa. It provides professional regulation of the nursing and midwifery professions in South Africa. The Act provides for

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different aspects of the regulation of nursing with respect to nursing education, nursing practice and research. The Preamble states that the Act has been implemented ‘to regulate the nursing profession; and to provide for matters connected therewith’. Chapter 1: South African Nursing Council. This Chapter provides parliamentary and legal stipulations about the establishment of the South African Nursing Council (SANC) as the governing body for nursing and midwifery in South Africa, its objectives, functions and operations, as well as outlining definitions of terms used. Chapter 2: Education, training, research, regi­stration and practice. This Chapter provides for the following aspects: • Registration of all categories of nurses, including learners, as well as titles to be used • Continuous professional development • Community service • Ethical conduct related to research. Chapter 3: Powers of the Council with regard to unprofes— sional conduct. This Chapter empowers the SANC to: • investigate any complaint of unprofessional miscon­ duct against nurses • investigate incidents of unprofessional con­duct. Provision is also made for impairment of practice. Chapter 4: Offences by persons not registered. This Chapter provides for the protection of the integrity of the nursing and midwifery professions by declaring that a person is guilty of an offence liable for prosecution in the following circumstances: • If a person makes out that they belong to any of the categories of registered persons, or makes use of the titles, badges and distinguishing devices of a registered person, without in fact being registered. • If a person practises nursing or midwifery for gain without being registered as such. • If a person knowingly suggests that someone is a registered person when it is not in fact the case. Chapter 5: General and supplementary provi­sions. This Chapter provides for the following, among others: • The special authorisation and licensing of nurses who are required to assess, diagnose and prescribe treatment for patients in the absence of a medical practitioner or pharmacist (this is done after successful completion of a prescribed course, and such a licence will be valid for three years)

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• That, on the recommendation of the SANC, the Minister of Health may promulgate regulations which relate to all areas of nursing practice • That, without reference or advice from the SANC, the Minister may also promulgate regulations in the public interest • The appeal process against decisions of the SANC (please note: the right to appeal against the decisions of the Professional Conduct Committee is contained in Chapter 1 of the Act).

Nursing alert! Every nurse is expected to acquire the Nursing Act for reference, knowledge and comprehension of the legal aspects pertaining to nursing.

Ethical framework The science of ethics

Ethics can focus on several areas of inquiry. Normative ethics. Normative ethics is the study of human activities in the broad sense in an attempt to determine the standards or norms or criteria for the right or wrong behaviour – it attempts to establish what is right and wrong for the people who we come into contact with through using ethical theories such as utilitarianism, naturalism, formalism and pragmatism. Normative ethics is about the assessment of the moral importance of perceived duties and obligations in human interaction, and theories for moral human conduct are used to support one normative position rather than another. Normative ethics also includes the consideration of the legal implications of practice. For nursing practice, it will consider issues such as what the scope of practice of nurses should be after having completed various education and training programmes, or when a nurse can be legally regarded as having been negligent. Professional ethics is a type of normative ethics which applies ethical principles and rules that will determine which actions are right and which are wrong for the profession. Non-normative ethics. Non-normative ethics includes descriptive ethics and meta-ethics. • Descriptive ethics investigates and explains the phenomena of the moral beliefs and behaviour of different cultural, religious or social groups. This includes, for example, the meaning that these groups attach to illness or suffering. Nurses work with many groups of people who may respond differently to

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illness and suffering. If nurses understand other people’s beliefs of how they should act or what is right for them, it will assist them to make appropriate healthcare decisions. • Meta-ethics analyses the moral language and concepts used in ethics enquiry and the logic of moral justification. It is a secondary level of inquiry that provides theories about ethics rather than theories for ethical conduct. It would typically analyse the connections between human conduct and the logic of moral justification, ethical beliefs (values) and the facts of the real world, and the moral language of the nurse. This does not only investigate what is right or wrong, but it also seeks justification for why something is right or wrong. These forms of ethics are closely related, and their interactions yield a system of applied ethics. Descriptive ethics may first be used to describe a moral phenomenon such as protecting patients from harm, then normative ethics is used to argue for the moral accountability of the nurse in patient care, and finally meta-ethics is used to explain the meaning of accountability within nursing practice. The result of this process can then be applied to the clinical nursing care situation.

Morals Morals and morality include personal values and rules of behaviour. Morality also refers to the rules of conduct that control social interaction. The concept of morality may also embrace the mores of a specific cultural group, based on religion and/or ideology. Ethics and morals are often viewed as being synony­ mous and referred to as having the same meaning. Morals, however, may be described as the ‘must’ and ‘ought to’ of life, whereas ethics are the ‘why’ and the ‘wherefore’ of morals. The moral, for example, will be that all patients must be treated with respect, and the corresponding ethical question might be a theory of equality or dignity and how this relates to specific examples like the healthcare setting. The word ‘moral’ refers to moral principles or morality. In nursing practice, morals are concerned with what the nurse must and ought to do. The duties of the nurse have moral and legal dimensions. The nurse has, for example, a moral and legal obligation to avoid medico-legal risks. Nursing as a moral art means the intelligent and humane application of knowledge and experience.

Ethical principles in nursing The ethical principles of nursing are based on the concept of ‘doing unto others as you would have them do unto you’. This includes such concepts as honesty, telling the truth, self-control, love, responsible action, magnanimity,

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fairness and the alleviation of pain and suffering. The ethical principles on which nursing is based are beneficence, justice, autonomy, veracity and fidelity.

Beneficence and non-maleficence Beneficence is the obligation to do or promote good, while non-maleficence is the duty to avoid harm or not to inflict harm. Nurses help others to gain what is beneficial to them, which promotes well-being and reduces the risk of harm. In nursing, the avoidance of harm is balanced by the provision of benefit. The acceptable ranges of both benefits and risks of harm are established by standards of nursing practice and the professional code of ethics for nurses.

Justice Justice relates to fairness. In healthcare, justice is con­ cerned with the distribution of the benefits and burdens among patient populations. How can available healthcare resources then be distributed fairly and justly among the patients requiring care? Formal justice states that equals should be treated equally and that those who are unequal should be treated differently according to their needs. This means that healthcare resources should be allocated according to needs. While it is not possible to provide equal amounts of healthcare resources to all people, it should be possible to ensure that all people have access to whatever healthcare resources are available, according to individual need. The focus on need allows for ethical distribution of available resources among healthcare patients and forgoes the distribution of these resources outside of need. In a healthcare setting, this implies that all the legal principles and policies will apply equally to all (Moodley, 2010).

Autonomy Nurses should respect people’s autonomy by acknow­ ledging their choices, which are based on their personal values and beliefs. Internal constraints (mental ability or consciousness) and external constraints (hospital environ­ ment, availability of nursing resources or information available to make informed choices) to autonomy may influence the patient’s ability to be autonomous. Rajani (2013) adds that while autonomy means self-rule in that the individual has the freedom of their own choices, they also have to take responsibility for their decisions.

Veracity Veracity refers to the obligation to tell the truth and not to withhold information or lie or deceive others. Truthfulness is regarded as fundamental to the existence of trust among individuals in many cultures. In some cultures, truthfulness in healthcare presumes that the patient has a right not to know, and the leader of the family may first be

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informed of the patient’s condition rather than the patient. This would not be regarded as deception, but rather as supportive to family relationships.

Fidelity Fidelity is the obligation to remain faithful to one’s commitments. These are obligations implicit in a trusting relationship between patient and nurse, such as keeping promises and maintaining confidentiality.

Confidentiality Confidentiality is an ethical duty which requires that all the information regarding a patient is kept secret by health professionals. It is closely related to the ethical principle of fidelity, mentioned above. However, confidentiality is not an absolute principle, as confidences can be broken under certain conditions. For example, the Child Care Act 38 of 2005 requires any form of child abuse to be reported to the authorities.

Privacy Invasion of a person’s privacy occurs when their private affairs are made public without consent. Privacy is guaranteed as a right in the Patients’ Rights Charter. This principle is particularly important in terms of social media: nurses are cautioned to respect the privacy of patients under their care by refraining from posting pictures or events about their patients on social media platforms.

Ethical decision-making Identifying the values in one’s own value system through introspection and self-reflection is the first step in developing the competence to make ethical decisions. The second step is to understand the values that are important to other individuals (patients and other healthcare professionals), and the reasons why these are important. Understanding the value systems of others and acknowledging and respecting that they are equally as

1.3  The Florence Nightingale Pledge The Florence Nightingale Pledge was not drawn up by Florence Nightingale herself. A committee headed by L E Gretter in Detroit, Michigan, drew it up in 1893, and named it in honour of her. It reads as follows: I solemnly pledge myself before God and in the presence of this assembly: • To pass my life in purity and to practise my profession faithfully; • I will abstain from whatever is deleterious and mischievous and will not take or knowingly administer any harmful drug; • I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling; • With loyalty will I endeavour to aid the physician in his work, and devote myself to the welfare of those committed to my care. valid as one’s own value system is essential to making ethical decisions. This introspection is the basis for ethical reasoning which precedes ethical decision-making. During this process, there is due consideration and examination of all the dimensions of the ethical problem. A broad framework for ethical decision-making is highlighted in Figure 1.2.

Codes of ethics in nursing A code of ethics may be defined as a system of principles and moral rules. A professional code may refer to the values and norms of the majority of members of a profession. A professional code is therefore a set of moral principles or rules that regulate the professional conduct of a profession.

What is the problem?

What should be done?

Understand the context.

Develop several options to resolve the values conflict (consult widely – literature and experts).

What are the values involved? What do these values mean to all involved? Where does the conflict lie?

Identify what will be the most appropriate solution. Select an option.

Implement the selected option to resolve the ethical conflict Implement the plan of action considering the legal–ethical framework of healthcare practitioners. Monitor the implementation.

Figure 1.2  Broad framework for ethical decision-making

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A code of ethics in nursing may be viewed as a statement about nursing and the objectives of nursing. In nursing practice, nurses are to follow specific moral guidelines that take patients’ interests and rights into account. The code of ethics holds the nurse responsible for acceptable standards of nursing care. The advantages of a professional code of ethics include the following: • It endorses the professional status of nursing. • It reassures the public. • It provides guidelines for the regulation of the profession and discipline of its members. • It provides a framework within which nurses can formulate their ethical decisions. • It provides guidelines for practice. The following codes of ethics are of importance to the South African nurse: • The Florence Nightingale Pledge • The International Council of Nurses (ICN) Code of Ethics for Nurses (for the full document, search for it on the ICN website (www.icn.ch)). • South African Nurses’ Code of Service (for the full document, search for it on the SANC website (www. sanc.co.za)).

Professional status of nursing Nursing has a proud history of self-regulation as a profession. South Africa was the first country in the world to register its nurses in 1891 – first with the Medical Council, and from 1944 with the South African Nursing Association. A profession is an occupation requiring specialist knowledge and skills within a recognised system of learning authenticated by professional members. A profession functions autonomously and continuously strives to extend its body of knowledge while maintaining and regulating standards. Therefore, a professional is a specialist in a particular occupation or speciality. A profession has a culture of its own; it has definite norms and values and acts as a unifying force to bring together individuals from many diverse backgrounds for a common purpose.

1.4  Characteristics of a profession The criteria for recognition of a profession are as follows: 1. A body of specialised theory with skills based on this theory 2. The development of relevant knowledge drawn from both the arts and the sciences 3. A prescribed period of training and learning prior to qualification 4. The testing of professional competence prior to admission to the ranks of qualified professionals 5. Some form of registration or licensure as a prerequisite for practice 6. Professional autonomy with control of the profession by the profession 7. Ethical control of the profession which is vested in the profession itself and not in an outside agency 8. The ideal of service to the community which is based on the needs of the patient and not on any other consideration 9. Accountability for professional acts 10. Exclusivity, based on the mastery of knowledge and skills and the capacity to internalise and express the norms and values of the profession 11. Legal recognition 12. High social status and social power 13. The application of theory to practice so that the results of actions can be predicted 14. Ongoing critical analysis of its practice and the development of new methods in the light of new knowledge 15. Individuals who practise autonomously, using discretion and judgement based on knowledge and experience, with acceptance of the concept of accountability 16. An overriding concern for the welfare of others 17. An obligation to engage in lifelong learning 18. A constant striving for excellence. Nursing in South Africa complies with the listed characteristics of a profession.

The meaning of professionalism Professionalism and the professionalisation of nurses is a constant growth process. The professionalisation of a nurse is the result of assimilating a variety of influences and experiences through which the culture and value system of the profession becomes part of each practitioner’s identity. This is a process that takes place through contact with and the influence of other practitioners in the health sector. The combined behaviour or conduct of all nurses is referred to as professionhood. To this end every nurse

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has a responsibility to always conduct themselves with professionalism.

Criteria for the professional status of nursing and midwifery in South Africa The professional status of nursing is primarily based on professional solidarity, accountability, proficiency, maintenance of a code of ethics, and the welfare of the public. Midwifery in South Africa has been recognised

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as a profession since 1810, when a training system, code of ethics and professional training requirements were introduced for midwives. Nursing acquired state registration in 1891 and professional status in 1944 with the promulgation of the first Nursing Act 45 of 1944. The fundamental principles on which the professional status of nursing in South Africa is based are as follows: • Peer group control and maintenance of professional discipline by the profession itself through legally constituted institutions or bodies • A specific body of knowledge consisting of specialised skills drawn from the fields of the health, natural and social sciences • An acceptance of the social role and functions of the nurse in the community • The development of specialised knowledge based on research • The preparation of a neophyte to the profession through a specific programme of education and training.

to date with new developments in the profession and related health professions. Examples of such international affiliations are the International Council of Nurses, the International Cancer Association and Public Services International. Often, professional nursing associations or organisa­ tions take on the form of trade unions. That is, in addition to focusing on professional development matters, they also register as a trade union or labour organisation. This is done to ensure that the rights of nurses as employees are respected and upheld. All trade unions must be registered with the South African Department of Labour in terms of the Labour Relations Act 66 of 1995 (as amended). Their primary function is to negotiate favourable conditions of service for their members by means of collective bargaining. Some professional organisations, such as the Democratic Nursing Organisation of South Africa (DENOSA), serve and function as a combination of union and professional organisation.

Organisation of the nursing profession

Functions of a professional association/organisation

The nursing profession organises itself by means of profes­ sional associations and organisations. These are essential for the ongoing growth and development of the professions by which they have been formed. The primary objective of a nursing association/organisation is the promotion of nursing and the development and maintenance of an appropriate professional ethos and culture. The secondary objective of professional associations/organisations, which flows from the primary objective, is the promotion of the health of the population. Generally, the objectives of a nursing association/organisation include: • developing and promoting an efficient and effective nursing and midwifery service in and for the community • enhancing the status of the nursing and midwifery professions, upholding the integrity of these profes­ sions, and promoting their interests • evaluating all matters that affect the nursing profession and taking appropriate action • promoting the rights, interests and socioeconomic status of every member of the profession.

Based on the objectives of professional associations/ organisations, the primary function of such an association/ organisation is the promotion of nursing, which in turn contributes to the welfare of the community. A professional association/organisation: • acts to promote solidarity among its members and to remain in touch with the community and with issues that affect the health of the community • develops a professional identity by restricting membership to members of the nursing profession • increases the service potential of the profession by: –– making educational programmes and ongoing training programmes available to members –– promoting the recruitment of nurses –– conducting research into any factor or issue that may be detrimental to the profession –– keeping abreast of current developments in related professions, such as medicine, pharmacy, general education and law, and analysing the impact of such developments on nursing –– monitoring any factors such as health and illness patterns and socioeconomic issues which may impact on the health of the population and consequently on nursing –– monitoring the quality of nursing education in the country, as well as the accreditation system and the requirements for entry to the registers and rolls –– monitoring the professional conduct system –– evaluating the general socioeconomic status of nurses –– evaluating the delivery of nursing services to the community.

Important aspects of the role of a professional association/ organisation are the development and dissemination of nursing literature. All professional associations/organi­ sations publish professional journals or distribute news­ letters. Many professional associations/organisations will also disseminate other popular international journals. Research is another important aspect of the role of the professional association/organisation. International affiliations may also be entered into to facilitate the exchange of information and to keep up

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• protects the nurse against exploitation and hazard­ ous employment situations by lobbying for the promulgation of appropriate legislation to alleviate or prevent these problems • promotes the objectives of the profession with regard to the social system of the country, and constantly keeps the welfare of the community in mind • negotiates on behalf of its members to secure improved salaries and employment benefits – these negotiations are not solely concerned with salaries but include other benefits such as professional indemnity, group and personal accident insurance, and other similar benefits that may be necessary or advisable • establishes and administers nursing agencies.

Professional indemnity An important benefit arising from membership of a professional association/organisation is professional indemnity. Professional indemnity provides the nurse with legal advice and assistance should they be involved in malpractice or incidents of negligence. Many employers require proof of professional indemnity before they will consider a nurse for employment.

Approaches to healthcare delivery systems in South Africa Modern healthcare is a complex business involving many health professionals, ranging from doctors and nurses to the allied health professions, such as physiotherapists, nutritionists and occupational therapists. Approaches to healthcare vary, and only the most important concepts are dealt with here. The approach to healthcare that is being implemented has an important influence on the way in which nurses practise their profession. • Preventive healthcare is care that seeks to prevent the development of ill health by modifying the factors that contribute to disease, whether these factors are environmental, social or behavioural. • Promotive healthcare seeks to raise the level of health of individuals and communities through education, empowerment and development, both of individuals and of communities. • Curative healthcare provides diagnosis, care and treatment for the individual who has become ill. • Rehabilitative healthcare seeks to return the sick individual to optimum health, and to return the individual to as normal a life as is possible. • Primary healthcare (PHC) involves the delivery of essential, affordable, accessible and acceptable healthcare to a community. Primary healthcare involves the provision of essential basic care at the individual’s point of entry into the healthcare system. It focuses on

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health promotion, disease prevention and management of community diseases, as well as a measure of rehabilitation. The PHC approach is a priority of the National Health System in South Africa and it lies at the base of an integrated district health system.

At provincial level The role of the provincial health authority is to: • develop provincial policies and guidelines based on the national norms, policies and guidelines • plan, monitor and evaluate health services in the province based on the national norms, policies and guidelines • provide hospital and academic health services, which include specialised rehabilitation support centres • approve, within national guidelines, standards and norms, as well as the building and expansion of public and private hospitals and clinics • supply human resource management and development within the province • plan and control the functions of the referral system • provide and coordinate medical emergency services, including ambulance services • provide technical and logistical support to the health districts, as well as coordinating the district health authority (DHA)’s work in the province • provide district-level services where the DHA is unable to do so • plan and manage a provincial health information system • ensure quality control of health services and facilities • effect inter-provincial and inter-sectoral coordination and collaboration • coordinate the budgets of the district health services • provide specific provincial programmes, such as TB prevention and treatment • provide non-personal health services (eg awareness campaigns) • provide and maintain equipment, vehicles and healthcare facilities • consult on health matters at community level • provide occupational health services • undertake research • plan, coordinate, monitor and evaluate provincial services • ensure that functions delegated at national level are carried out.

At district level The DHA is responsible for ensuring that all health services in the district are provided within the norms, policies and guidelines agreed on at national and provincial levels. Its responsibilities include:

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• the promotion of primary healthcare, and the planning, monitoring and evaluation of services • the management and coordination of healthpromotion activities • collaboration with governmental and non-governmental organisations • engagement of communities in their healthcare matters • the provision of PHC and other relevant services within the community, in clinics, community health centres, district hospitals and other facilities • the provision of primary environmental health services, essential medico-legal services and services to prisoners. Administrative, financial and support services, as well as planning and human resources, are provided through negotiated agreements between the province, its districts and municipalities.

The public healthcare system The public or government sector, in the name of the National Department of Health, is the biggest employer of nurses and owns the majority of nurse-training hospitals. In South Africa, the employers of nurses are mainly the Department of Health at national level and the nine provincial health departments. Numerous municipalities in each of the nine provinces have collaborated to establish the district health system.

The private sector healthcare system Private sector healthcare facilities consist of hospitals, clinics and private nursing homes. These may also provide for their own training of nurses. In addition, some physicians, registered nurses and allied health personnel, such as physiotherapists and occupational therapists, run independent private practices. A private sector service functions as a business with a profit motive, and it is subject to the National Health Act 61 of 2003, and must be registered. In private facilities, consumers pay directly or indirectly for services received. This could be in the form of third party payment/medical aid, insurance schemes or

individual payments. Medical aid schemes are regulated by the Medical Schemes Act 131 of 1998. Private health organisations may enter into contractual arrangements with the government to provide specific services to public sector health consumers. In such cases, payment for services is incurred by government with the consumer paying very little, if anything at all.

Voluntary organisations Greater involvement by communities ensures that volun­ tary organisations are allowed the opportunity to initiate and assist government in its primary role of provision of healthcare facilities and services for citizens. These voluntary organisations, which usually start at grassroot level, may include non-governmental organisations (NGOs), community-based organisations and faith-based organisations. They are mainly privately funded by donors and supported by government in the provision of some of the services. The National Department of Health may, however, commission an NGO to perform services on its behalf. In such a case, the department will sign a contract with the donor(s) concerned and take responsibility for expenditure in the provision of the agreed-upon service. NGOs employ nurses of all categories and contribute to nurse training.

Conclusion Nursing is concerned with those who are suffering as a result of ill health and disease. It has developed to a science and an art that, through care and concern, can enhance people’s well-being at any point on the health continuum. Understanding the nurse’s role, the scope of nursing and how it differs from the roles of other health professionals requires an understanding of conceptual models and theories of nursing. Nurses provide care to individuals and families during all stages of life. Effective care considers people’s needs at different stages of the life cycle. Nursing as a profession functions within a legal and ethical framework. It is therefore important for nurses to familiarise themselves with the legal and ethical framework pertinent to the nursing profession in particular and to healthcare in general.

Suggested activities for learners Activity 1.1 Form groups to discuss the following concepts: nursing, health, wellness, health promotion and ill health, and how these concepts apply to nursing in the various stages of life. Activity 1.2 Divide the class into two groups and, in an organised debate, prepare and role-play the benefits of a professional association/organisation when compared with those of a trade union. The debate must be explicit in relation to the governance of the nursing profession, and the legal and ethical implications for the association as well as the trade union in relation to its functioning. One group must argue for a trade union while the other argues against it.

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2

Practising nursing within a culturally diverse society

learning objectives

On completion of this Chapter, the learner should be able to: • describe how a nurse can provide culturally competent nursing care • discuss the development of effective relationships with patients, their families and significant others through culturally appropriate care and communication • plan healthcare taking into account the cultural requirements of patients • explain the principles of patients’ advocacy in respect of cultural needs • discuss the interface between Western medicine and alternative/traditional practitioners • give health information and/or health education that is culturally appropriate and acceptable to patients and their families. key concepts and terminology

acculturation

The paradigm shift that patients must undergo in order to change their culture and adopt the culture of the healthcare provider.

amulet

An object that protects a person from trouble such as ornaments or jewellery worn to chase evil spirits away.

charms

Objects that have power or a spell over evil.

culture

A way of life, which encompasses the ideas, customs, and social behaviour of a particular people or society.

cultural diversity

The variety of human cultures in a specific region.

cultural knowledge

The knowledge the healthcare professional has about specific or diverse groups’ fundamental norms, customs, belief and values.

paradigm

System of understanding and organising knowledge.

supernatural

Something that has a force beyond scientific understanding or the laws of nature.

traditional practitioners

People who practice traditional medicine.

prerequisite knowledge

• Batho-Pele principles • Patients’ rights • Human rights. medico-legal considerations

• The fulfilment of cultural requirements is a patient’s right, and failure on the part of a nurse to meet this need can be interpreted as negligence.

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• Failure to give accurate and adequate information to a patient may also be construed as negligence, particularly if the patient must make major decisions relating to their healthcare, or if the patient is expected to manage their medical condition at home. In order for health information to be acceptable and understood by a patient, the information must be put across in a manner that takes cultural factors into account. Failure to do this is likely to cause a patient to be non-compliant. • Disregard of cultural requirements is an instance of discrimination and may involve the healthcare institution, and the individual nurse, in legal action. ethical considerations

• Nurses have an ethical obligation to –– respect the culture and preserve the dignity of patients at all times –– apply cultural knowledge and sensitivity in order to avoid offending or discriminating against patients based on their cultural backgrounds. • Every patient has a right –– to participate in their own healthcare, including Practice alert! having their cultural needs met –– to health information and health education In situations where patients strongly wish that is accessible, understandable, acceptable, to consult alternative or traditional practitioners, appropriate and congruent with their cultural it is imperative that they are made to understand the requirements full implications of their choice. –– not to be discriminated against because they wish to consult an alternative or traditional practitioner. essential health literacy

Holistic nursing care includes cultural nursing as culture impacts on the patient’s health behaviour. It is essential for the nurse to have a brief background of the patient’s culture and information that will assist to comply with the patient’s wish for alternative treatment. Patients must be encouraged to communicate their wishes and also be given a chance to exercise them if need be. However, possible effects of the alternative medicine on their health and illness must be explained to the patient for them to make informed decisions.

Introduction Nursing is an interpersonal activity, with the goal of restoring or maintaining the health of patients. Inter­ personal activities such as nursing care are, by definition, built on relationships and communication. To be effective in facilitating the healthcare of patients, nurses should develop a good nurse–patient relationship and should be able to communicate effectively with patients. It is essential for nurses to develop insight into the culture of their patients, as well as an understanding of how the individual patient’s culture impacts on health behaviour. Acquiring cultural knowledge assists with the integration of health-related beliefs, practices and cultural values (Campinha-Bacote, 2010). Nurses must be able to gain knowledge about the culture of a patient by asking the right questions and by demonstrating sensitivity towards the patient’s beliefs and culture. Health and illness behaviour must be understood in the light of a patient’s cultural context if a nurse is to fulfil their role in helping the patient to achieve or maintain optimum health.

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In the light of current policy directions in South Africa, a nurse may need to work with indigenous or alternative health practitioners. To do this harmoniously and effectively, nurses must develop an elementary understanding of the basic principles and philosophical outlook of these practitioners. Therefore, the nurse must develop cultural competence in the delivery of healthcare. Cultural competence is a set of congruent behaviours, practices, attitudes and policies that come together in a system or agency or among professionals, enabling effective work to be done in cross-cultural situations. The process of developing cultural competence includes desire, awareness, skill and knowledge (CampinhaBacote, 2010). The aim of this Chapter is to assist you to develop sensitivity towards the traditions and respect for the culture of patients and the community.

The concept of culture Culture is a shared set of norms, values, perceptions and social conventions that give cohesion to a group, race or

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community, enabling them to live together and function effectively and harmoniously. It is a key influence on the way in which an individual perceives and responds to the world. Culture, however, is simply one set of factors among many that mould the individual and their response to the world and to society. Individual behaviour is heavily influenced by culture, but culture is a framework and not a stereotype. Culture consists of the following aspects: • Observable phenomena, such as manner of dress, diet, architecture, language, writing and the arts. • Norms and values, including ideas about how people should behave, about right and wrong, and good and bad. These norms and values are usually taken for granted within a culture; they are universally accepted within that culture, having been absorbed by people at a very early age. Each individual learns about their own culture from an early age, and also learns how to function within that particular worldview. Culture is not inherited; it is acquired during the process of socialisation in childhood. Subgroups or subcultures exist within every society. Organisations, occupations and professions also have their own micro-cultures that individuals accept and adapt to when they join the group. Culture is therefore an integrated pattern of human knowledge, belief, and behaviour that is a result of, and integral to, the human capacity for learning and transmitting knowledge to succeeding generations. It is learned and shared, dynamic and changing. Cultural awareness is thus a deliberate and cognitive process through which sensitivity to a person’s values, beliefs and practices develop.

The importance of culture Culture consists of language, ideas, beliefs, customs, taboos, codes, institutions, tools, techniques, and works of art, rituals, ceremonies, and symbols. It has played an important role in human evolution, allowing human beings to adapt the environment to their own purposes. In a diverse society such as South Africa, cultural differences are very evident; and to be effective in their profession, nurses must be able to work with people whose culture and traditions are different from their own. However, without sufficient knowledge of other people’s culture, it will be difficult to work with or understand people whose culture is different from their own. It is vitally important for the nurse to acquire sufficient knowledge of the cultures they work with in order to avoid offensive stereotyping.

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Cultural insight and knowledge are also essential for nurses given the interpersonal nature of their work. Much of the effectiveness of nursing care is due to interpersonal interactions with patients and the nature of the nurse– patient relationship. There are several nursing theories and models of care that highlight the centrality of culture and trans-cultural nursing, such as: the cultural safety model; Leininger’s theory of Culture Care Diversity and Universality and the Sunrise model; the Giger and Davidhizar Transcultural Assessment Model; and Campinha-Bacote’s cultural competence in healthcare model.

2.1 The acquisition of cultural knowledge and understanding Some suggestions on how to acquire cultural knowledge and understanding: • Nurses should develop an awareness of their own cultural assumptions and prejudices. • Written or visual material on other cultures can be useful to build general knowledge, provided that such material is not biased or prejudiced. • Once a nurse has developed a good relationship with a patient, the nurse can ask questions. If the right questions are asked in a respectful manner and the response is received respectfully, much can be learned. • A nurse should not automatically assume that they know best and that their way of doing things is the only way. Nurses must allow space for the preferences of their patients, which includes cultural and religious preferences.

Cultural issues in healthcare Every human society has its own particular culture. Variation among cultures is attributable to such factors as differing physical habitats and resources, the range of possibilities inherent in areas such as language, ritual, social organisation and historical phenomena such as the development of links with other cultures. An individual’s attitudes, values, ideas and beliefs are greatly influenced by the culture (or cultures) in which they live. Culture change takes place as a result of ecological, socioeconomic, political, religious, or other fundamental factors affecting a society or an individual such as health and illness. There are several cultural factors that act as barriers to effective healthcare. Because South Africa is a diverse society, nurses need to develop an understanding of the cultural dimensions of a number of health-related issues. Many of these issues may be closely allied to religious practices, but all need to be taken into account when

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dealing with patients and the community. Because nursing care is interpersonal and because nursing involves meeting the needs of patients, cultural factors such as modesty, hygiene practices, attitudes to pain and illness, diet and food, as well as death and dying must be understood and taken into account when planning nursing care. These and other issues are discussed below.

Diet Diet is an important cultural characteristic, and it is an area that nurses must find out about during the assessment of their patients. Information should be obtained about, for example, which foods may or may not be eaten, or if there is any special method of preparation. This is important as certain food taboos are based on cultural and religious beliefs. For example, pork is the well-known food taboo of some religions in African and Muslim people. In a hospital setting, efforts should be made to supply the appropriate diet for each patient. If the dietary requirements of the hospital in-patient cannot be met, it may be necessary to approach the family with a view to having them bring in food for the patient, if the condition of the patient allows. A thorough knowledge of the diet of the patient, including the ways in which food is prepared, is essential when giving health education to the patient. Health education should be contextualised according to the patient’s individual lifestyle, and this means taking careful note of specific characteristics, whether cultural or individual. In instances where health education and advice are not appropriate to a patient’s lifestyle and culture, the advice may not be followed and this will be to the detriment of the patient.

Hygiene practices Hygiene practices often differ from culture to culture. Muslim people, for example, always wash their hands as well as the urethral and/or anal area after using the toilet. For some cultural groups, a bath is not regarded as hygienic, and only a shower will suffice. For other groups, specific hygiene measures are taken during menstruation. Nurses should take note of these and any other hygiene requirements that they encounter and try to meet the needs of their patients in the best way possible.

Family hierarchy and lines of communication Culture is instrumental in communication. Language is a powerful instrument that can be used to get to know the other person’s culture. Family hierarchy and lines of communication are sometimes significant when consent has to be obtained for treatment or for a surgical procedure. In South Africa, the current legislation allows people 18 years and older to give consent to medical treatment

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autonomously. However, in many African groups, consent to an operation or other form of treatment is a major decision. Sometimes a patient will ask to go home and consult the elders of the clan, and in some instances the ancestors are consulted. Many African groups require that consent for an operation on a child must be obtained from the child’s family or from the senior male relative, and the mother will feel unable to give consent without consulting the father or a male relative. This can create difficulties where the child is acutely ill and is in need of emergency treatment or surgery and the father is not available. In such a case, it may be necessary for the Medical Superintendent to give consent. In many groups, health matters relating to reproductive health or to sexual matters, such as contraception, must often be discussed with the husband first, before talking to both husband and wife, as it is the husband who takes decisions in the home and nothing will happen if only the wife has received the advice. It is important for the nurse to find out about lines of communication in the various cultural groups because nursing care is based on good communication, and it is essential at all times to make sure that the lines of communication with all stakeholders are appropriate and effective.

Disposal of body parts If an organ has to be removed or a limb amputated, it is essential to find out from the patient or from the relatives whether any special measures are needed for the disposal of the tissue or limb. In many cultural groups, the body parts must be given burial and not simply sent to the incinerator. This requirement is particularly important in the case of amputation. The requirement is often not so stringent in the case of organs and parts of organs or tissues. In South Africa, matters relating to human tissues are legislated in the National Health Act 61 of 2003, which repealed the Human Tissue Act 65 of 1983. Organ donation pratices also vary between different cultures; some groups will not consent because of the belief that the deceased must be buried with all their body parts intact. Organ donation is not universally accepted among African cultures, although there is no specific prohibition in traditional African belief and it may vary depending on the particular group or set of religious beliefs. Orthodox Jewish people and many Muslim people are also likely to refuse organ donation, out of a cultural belief that the body must be buried intact and not necessarily out of any specific religious prohibition. Some groups may refuse permission for post-mortem examination, for example Orthodox Jewish people and Muslim people.

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Death, dying and the disposal of the body As this is the last thing that the family will do for the patient, most families have a strong desire to ensure that things are done in accordance with what the patient would have wanted. It is important to find out, for example, whether the family would like a priest to be called, as would be the case with a Roman Catholic patient. Also important would be to find out whether the family expect to be allowed to stay with the dying person and, if so, which specific family members. In the case of Jewish patients, it is customary for the family to watch at the bedside of a dying relative, but this function is also provided by Jewish community organisations that may be contacted to perform this function if the family is unable to do so. In some cultures, specific rituals are carried out at the bedside of a dying patient. The care of the body after death is also an important cultural aspect. In some African cultures, after the death of a person in hospital, the family may come to collect the spirit of the dead person from the bed where the patient passed on. Nurses should find out whether it is acceptable for the staff to remove tubes and lines and lay the body out, or if there is any specific procedure to be followed before doing the last offices. For example, an individual known as the Wagter, who is sent by the relevant Jewish community organisation, lays out a Jewish patient who has died, although it is usually expected that the nursing staff will remove the tubes and lines. Jewish and Muslim patients are accommodated in their own separate sections of the mortuary and have their own burial organisations.

Amulets and charms Beliefs in charms and amulets are a widespread phe­nome­ non, and are found in many cultures. Amulets and charms are believed to facilitate healing and to protect the patient from harm. The use of charms is not only found among so-called primitive groups but is found in many Western groups. Among Mediterranean groups, for example, belief in the ‘evil eye’ is common and charms are worn to ward off the evil eye. Some amulets are religious in nature, such as holy pictures and holy medals, but their purpose remains the same: to promote healing by supernatural means and to protect the individual from harm. Generally, amulets and charms should not be removed unless it is clearly necessary, eg if the patient is going for operation in the theatre. It may also be necessary to remove amulets in order to facilitate treatment. If it is indeed necessary to remove an amulet, the patient and family should be informed of the need and of the reason for it. Sometimes amulets can be moved to other places on the body, or they can be placed at the bedside, or sent home with the family, but usually the hospitalised patient

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prefers to keep such items with them. Amulets should never simply be discarded, as this can cause great offence to the patient and/or family.

The role of women The role and social position of women varies between societies, and often depends on whether the society is matriarchal or patriarchal. In many cultures, a woman is a perpetual minor, always under the guardianship and supervision of a male relative. Women in such a position usually need to consult with their husbands or senior male relatives before taking decisions, even those relating to health. Among many African groups, it is the male head of the household who must decide if a member of the household can be taken to a hospital or clinic for treatment. This often means that women must wait for absent heads of households to return before a decision can be taken. A great deal of education and empowerment is needed to change these patterns.

Sexuality Sexuality is a universal human trait, but the social regulation and expression of sexuality varies from culture to culture. The area of sexuality covers relations between the sexes, modesty, rituals and practices related to the female menstrual cycle, and, very importantly for nurses, the manner in which intimate matters may be discussed. In many cultures, the frank discussion of sexual matters is regarded as uncouth. It is common to find that it is unacceptable for sexual matters to be discussed between the sexes; women talk to women about sexuality and men talk to men. It follows, therefore, that any discussion on matters related to sexuality, such as contraception or safe sexual practices, must be approached correctly and very carefully. For some, it is necessary to discuss such matters with the head of the household; if they accept, then the family will follow their lead. Depending on the group, it is often prudent to have a male nurse talk to male patients or male family members, and female nurses to talk to female patients or female family members. A young unmarried female is frequently not seen as an appropriate person with whom to discuss intimate matters. The way in which intimate topics and those of a sexual nature are discussed is also important. Frank graphic descriptions are often not acceptable and may cause offence, and the nurse must find ways to get the message across by using terminology that is acceptable to the patients and their families. Other cultural issues related to areas of cultural diversity are family organisation, language, personal space, touching, eye contact, gestures, healthcare beliefs, and spirituality and religion.

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Chapter 2 – Practising nursing within a culturally diverse society  23

Cultural perspectives on health and illness Beliefs on healthcare systems vary among cultures, thus patients regard healthcare differently. Every culture has a system for healthcare based on the values and beliefs that have existed for generations. Nurses have an increased responsibility to meet the needs of an increasingly diverse society in order to reduce health disparities and improve healthcare quality. Beliefs about health and illness are an important cultural factor in healthcare. The challenge for nurses rendering healthcare in a Western-oriented healthcare system, such as the one in South Africa, is to bring the health/illness paradigm of patients into alignment with the system. Health and illness beliefs fall into three major groups, described in the sections that follow.

of ill health thus have a specific cause and can be cured or alleviated by eliminating or neutralising the identified cause. This belief system underpins the practice of modern medicine, but the wholeness of the individual and the relationship with the spiritual dimension are frequently lost sight of. Healthcare within a biomedical paradigm can often be experienced as dehumanising and harsh. Within this system it is the nurse who preserves a holistic approach to the patient. Nurses always strive to meet their patients’ needs and to ensure that all aspects of the patients’ humanity are taken into account. It is easy to become a mere technician in this model and it is important for nurses to guard against this.

The magico-religious paradigm

The holistic paradigm

In this paradigm, illness has a supernatural cause, as opposed to injury, which has a specific and obvious cause. Consequently, the cure for illness lies in the supernatural or spiritual dimension. It is widely believed among African cultures that illness may be brought on by a malicious spell or by the neglect of or a transgression against the ancestors. The cure for illness, while it may involve medication, is spiritual and involves rituals, prayer and possibly some form of sacrifice. Health may be seen as a sign of supernatural favour, and illness as a curse or punishment. In this paradigm, it is also commonly believed that the actions of one individual may affect the health of the community. People who adhere to this belief system do not necessarily reject Western scientific approaches to therapy, but scientific treatment methods are not seen as being the sole agent in effecting a cure. For many African cultures, the two systems exist in parallel, and both are regarded as being effective. For treatment within a modern scientific framework to be successful, however, patients must be allowed expression of the spiritual dimension and access to practitioners who practise within the magico-religious framework. Patient education is an important factor in bringing the two systems into alignment for a patient, and the nurse is a key agent in this process. Accurate health education that takes into account and shows respect for the patient’s health or illness beliefs and behaviours must be offered.

In this paradigm, human beings are seen as a part of nature and as having a need to maintain balance and harmony with the laws that govern the cosmos. Disturbing the cosmic balance causes disharmony, chaos and disease. Explanations for ill health and disease are based on disharmony between the human organism and the forces of the universe. The holistic paradigm is widely held among many cultures, including Western cultures. Many forms of alternative healing in both the East and the West are based on the holistic paradigm, and it is the dominant paradigm among Asian cultures. Florence Nightingale’s philosophy that the role of the nurse and the nursing profession is to provide an environment in which the patient can recover naturally reflects this holistic paradigm. This philosophy forms one of the foundations of the practice of nursing.

The biomedical paradigm This is the dominant belief system among Western cultures, but not necessarily the only one. According to this paradigm, there is a demonstrable cause–effect relationship for all types of illness. These causes may be due to environmental factors, trauma, pathogens, fluid and chemical imbalances or structural changes. All forms

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Integrative and complementary healthcare Integrative therapy includes a more collaborative approach to patient care and encompasses the treatment of patients with both traditional and alternative therapies concurrently. Complementary therapies include a range of philosophies, approaches and therapies that Western medicine does not commonly use, accept, study or understand. The concept of wellness means more than being healthy or without a disease. However, no illness is purely physical. The effects of illness manifest themselves physically, mentally, socially, spiritually and otherwise. Humans are complex beings. The interactions between mind, body, emotions and spirit connect individuals to their environment and other people. Patients from different cultures may have used alternative therapies as their primary approach to health and illness care, and may want to continue the therapies while in hospital. Nurses need to be knowledgeable about the different cultural beliefs and alternative practices. Integrative and

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24  Juta’s Complete Textbook of Medical Surgical Nursing

complementary therapies are holistic and treat the person as a whole. They can be grouped into the therapies as discussed below. Alternative medical systems. These are practices such as homeopathic or naturopathic medicine, and traditional medicine which includes herbal medicine, acupuncture and massage. These therapies are practised by many cultures throughout the world. In South Africa, culture and the law play a pivotal role in herbal medicine, which is regulated under the Traditional Health Practitioners Act 22 of 2007. An example of alternative practice in the South African context is circumcision, which can be done by either traditional groups or dedicated healthcare practitioners, at different cultural circumcision schools or at medical healthcare facilities, respectively. Mind–body interventions. This includes meditation, hypnosis, dance, music and art therapy, and prayer. The therapies enhance the mind’s ability to affect bodily functions. Biologically based treatments. These treatments include products such as herbal medicines, special diets and biological therapies. Manipulative and body-based methods. The therapies include chiropractic and massage therapy. Massage therapy in hospital may also be used in conjunction with physiotherapy. Energy therapies. These therapies include focusing on energy originating from within the body, or from other sources such as therapeutic touch or magnetic fields, and includes reiki, physio acoustics and bio-electromagnetics.

Collaborative, comprehensive and/or alternative healthcare provision Alternative healthcare includes health therapies that are used in place of traditional medicine. Patients are increasingly using alternative therapies from alternative practitioners, and among African cultures the practice of consulting a herbalist, traditional healer or sangoma when ill is common. These kinds of practitioners play a pivotal role in the African community. The importance of indigenous practitioners and the esteem in which they are held in the community are the basis for the frequent calls that are made for these traditional practitioners to be integrated into the health system. Traditional practitioners consult the ancestors regarding the patient’s health by throwing bones or by going into a trance. Following the diagnosis, a remedy will be

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prescribed, again in consultation with the ancestors. These remedies are invariably herbal and are often designed to cleanse, usually by causing purging. Other remedies include tonics and vitamin preparations. Dosage and strength are imprecise and extremely variable, and some concoctions may be highly toxic if too large a dose is taken. The prescription of medication is usually accompanied by some form of ritual and/or prayer designed to enhance the treatment. Sometimes an amulet is given to the patient to complement the treatment and should be worn until the course of treatment has been completed. Both Western and Eastern holistic practitioners may also prescribe medication, again mostly herbal based. Dosages tend to be far more precise, but some herbal preparations can be toxic if taken in too high a dose. In holistic practice, medication is designed to help restore the patient to a state of harmony or balance. Some alternative practitioners such as osteopaths use physical manipulation to achieve a cure by restoring the vertebral column to correct alignment. Traditional, alternative and holistic practitioners enjoy wide respect and are frequently consulted by patients in addition to Western scientific practitioners. The problem is one of identifying a set of principles for a relationship between Western scientific medicine and the various forms of indigenous and alternative medicine. Often this is not a dilemma that the patient will discuss with their Western scientific doctor, because the said doctor is quite likely to disapprove of the patient consulting an alternative practitioner. Nurses are, however, quite often asked to give advice regarding the use of alternative practitioners. It is therefore important for nurses to have a sound knowledge of what treatments the various types of practitioners offer and to be able to identify those that would be harmless and those that might cause the patient harm. Openness should be encouraged, and nurses should find out whether a patient has consulted a traditional or alternative practitioner and, if so, whether any form of medication is being taken. Recent dialogue with African traditional herbalists has led to the establishment of some guidelines. If the patient has consulted a traditional healer and then consulted a Western scientific practitioner, they should return to the herbalist to discuss this. Sometimes traditional medication can be continued, but more often it is advisable to discontinue the traditional medication until the Western medication has been completed. In many areas of South Africa, outreach programmes and training programmes are in place to educate herbalists and sangomas regarding the interaction between traditional medicine and Western medicine. Included in such outreach programmes are principles of referral, particularly in relation to the

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Chapter 2 – Practising nursing within a culturally diverse society  25

nature of conditions that should be referred to a Western practitioner and when to refer. In the area of health education, traditional practitioners play an invaluable role. In the case of conditions such as tuberculosis, it is of paramount importance that the patient continue with the treatment, whether or not traditional medication is taken in addition. Traditional practitioners are also an important link in the campaign against HIV/Aids. It is important to convince a patient not to discontinue Western treatment simply because they are consulting a traditional practitioner. This principle applies particularly where regular forms of treatment such as dialysis are concerned, and where stopping the Western treatment could be life threatening. In the case of a hospitalised patient who is acutely or even critically ill, the use of traditional medication is definitely dubious, if not actually dangerous, and should be discontinued. The problem with the vast majority of traditional herbal remedies is that they have never been scientifically analysed, and they often contain unknown ingredients that may be potentially harmful to an acutely ill patient.

2.2 Practices to be encouraged in cultural exchanges • Being aware of diversity and respecting it, even celebrating it • Recognising that cultural factors are important in the health and illness of patients • Being knowledgeable and respectful about the cultural groups one encounters • Recognising one’s own biases, prejudices and blind spots, and working to overcome these when dealing with patients • Finding ways to care for patients in culturally appropriate and acceptable ways • Striving to give holistic care in all situations.

A nurse’s interface with different cultures A nurse is the patient’s advocate as well as the coordinator of care. It is the nurse who meets the basic needs of the patient, and many of these needs must be met in a culturally appropriate manner, or at least in a way that shows respect for the patient’s culture, norms and values and does not give offence. An example of cultural advocacy could be a patient who refuses hospital treatment due to observation of cultural practices. In South Africa, refusal of hospital treatment and the right to a second opinion or health provider of own choice are included in the Patients’ Rights Charter, which is enshrined in the Constitution

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of the Republic of South Africa, 1996. The nurse should therefore consider the patient’s rights in conjunction with their culture and wishes. Nurses also frequently carry the major responsibility of giving health education and ensuring that patients and their families have understood the information given to them. Nurses are thus the primary caregivers and healthcare practitioners, and they interact with many cultures. Nurses need to develop a broad store of cultural knowledge, and they also need to develop a high degree of cultural sensitivity. Cultural sensitivity embodies the principle of respect and awareness of one’s own norms and values, as well as those of the patient. Culturally sensitive nursing involves caring for a patient in a way that matches the patient’s perceptions of their health problems with their treatment goals.

A nurse’s role within the multidisciplinary team from a cultural perspective It is not possible for the average nurse to undertake an in-depth study of every culture that they encounter. Certain key aspects, however, are important in healthcare

2.3 Pitfalls to be avoided in cultural exchanges • Ignorance and lack of understanding of other cultural groups • Stereotyping, such as assuming that all individuals belonging to a particular cultural group conform to a general pattern or behave in a certain way; it should be considered that all patients are individuals and that their behaviour and reactions are also determined by other factors, such as family, education, and environment • Judging other groups by one’s own norms and values – certain basic principles, such as the concern for hygiene, are practically universal, but may be expressed in different ways • Assigning negative attributes or characteristics to people from another cultural group • Seeing the worldview and experience of other groups as inferior – this leads to prejudice, discrimination and racism • Taking a paternalistic attitude of ‘I know what is good for you’ • Being culturally blind and proceeding as though cultural differences do not exist. The practice of giving dietary advice that is based exclusively on a typical Western diet is such an example.

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26  Juta’s Complete Textbook of Medical Surgical Nursing

and these should be assessed as part of a routine nursing assessment. These key aspects are: • Diet and food habits • Rituals and taboos relating to key events in the lifecycle such as sexuality, birth and death • Health and illness beliefs • Types of practitioner consulted • Health/illness behaviours and decision-making, including family or clan involvement • Relationship with health professionals, as in many cultures the medical practitioner is expected to tell the patient what is wrong, not the other way around • Genetically based biological variations, such as blood values, bone structure and bone density • Practices related to modesty • The discussion of sensitive issues.

Culture and communication The importance of culture in communication cannot be overemphasised. It is essential for nurses to develop a basic insight into the culture of all the patients that they deal with. Failure to develop this insight will hamper health communication and nurses may be seen as being insensitive or even rude as a result of their lack of understanding of the patient’s culture. Where language is a problem, translators may be useful. It is also important for nurses to use the correct channels of communication, such as a senior male relative when necessary.

Communication in a cultural context Cultural context is the care, beliefs, values and practices of a culture that shape a person’s environment. Culture profoundly influences interpersonal commu­ nica­tion, and it is essential for nurses to have a basic under­ standing of the norms and values of the cultural groups with whom they will be working in order to communicate effectively with these groups. Culture determines several key aspects of communication, such as: • How to greet. For example, in African cultures it is not polite to get straight to the matter under discussion without first greeting the other participants and enquiring after their health. Among African cultures it is the older or more senior person who is greeted, and indicates when to speak and when not to speak. In many cultures, a junior person waits to be invited to speak, or waits until the more senior people have had their say and only then may they speak. • Expressing anger and other strong emotions. In most societies, direct physical expressions of anger are not acceptable, as this can be dangerous and lead to injury and even death. Showing grief is another matter. In some cultures, it is a mark of love and esteem for a

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departed relative if those left behind cry and give way to strong overt signs of grief like screaming or tearing at clothes. In other societies, control is expected on the death of a loved one. A controlled reaction does not necessarily mean that the relatives did not care for the person who has died. In other cultures, a man is not supposed to cry, or should cry privately. • Eye contact. In Western societies, looking the other person directly in the eye is taken as a mark of openness and honesty. In other cultures, like African cultures for example, sustained direct eye contact is not polite, particularly from a junior to a senior person, or even female to male. • Gesturing and touching. Generally, areas that may be touched during communication depend on the degree of intimacy of the communicators and the context of the communication. During sexual intercourse, the partners are very intimate and all parts of the body may be touched. In everyday social interaction between work colleagues there is not a high degree of intimacy, and thus only the hands, arms and shoulders may be touched during communication, especially when greeting or congratulating a person. In some cultures, it is the norm to kiss the cheeks of the other person when greeting, irrespective of gender. Cultures can be categorised according to whether they are individualistic or collectivistic, as well as by their communication style. Cultures may have high-context communication styles or low-context communication styles. • Individualistic cultures, such as most Western European cultures, stress individual goals and achievements. These cultures tend to promote competition, and they place great value on achievement. • Collectivistic cultures, such as are found in Africa, stress group activities and group achievements. These place great value on cooperation and group cohesion. • Cultures characterised by a high-context communica­ tion style tend to be indirect or overly polite in com­ munication, having a great concern for perceptions and leaving much to be gleaned from the context and circumstances of the communication, which means that the other person in the communication needs to have a degree of insight into the context and circumstances of the communication in order to be able to fully understand the communication. Many Eastern as well as African cultures have a high-context communication style, and it can be difficult for an individual from a different cultural background to work out the full meaning of the communication unless time has been spent in developing the necessary insight to

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be able to communicate effectively. In African cultures, much communication is implied and the listener must pick this up from the context. Much is left unsaid or is conveyed through nonverbal means, or by riddles and euphemisms, which the listener must understand in order to grasp the full drift of the communication. For example, in the African context the expression ‘izindaba zocansi’ is a term used to cover a multitude of issues related to sex and sexuality. • In contrast, low-context cultures, such as most Western European cultures, have a direct communication style and are much more explicit verbally. The listener will know exactly what is meant, but the style is not always comfortable and can be perceived as rude, especially by someone from a high-context culture.

Essential health information It is especially important to consider the patient’s heritage, education level and language skills when planning patient education. The assistance of an interpreter may be appropriate. The unfamiliar hospital environment may be threatening when language barriers make it difficult to ask questions. Nurses should: • provide information on indications, contraindications, potential benefits and adverse effects of alternative therapies in relation to the present diagnosis

• advise the patient about herb–drug interactions • advise the patient to seek help regarding exploration of therapies that are suitable to them • advise the patient to keep a log of any adverse reactions and report these to the healthcare practitioner • when using oils on the patient, advise the family to be cautious of the risk for toxicity or skin irritation • enquire into allergies when using biologically based therapies • advise the patient to consult safe and competent practitioners.

Conclusion The Nursing and Midwifery Council (NMC) in the United Kingdom states that ‘nurses must practise in a fair and an anti-discriminatory way, acknowledging the differences in beliefs and practices of individuals or groups’ (NMC, 2002). The culture of the patient must be taken into consideration when planning nursing care. Alternative and complementary therapies that will be beneficial for the care of the patient should be assessed. It is not possible for nurses to undertake an in-depth study of every culture that they encounter. Certain key aspects, however, are important in healthcare, and these should be assessed as part of a routine nursing assessment.

Suggested activities for learners Activity 2.1 A male patient is admitted in your unit and the family request to massage him with a body lotion of mixed medicinal herbs which they obtained from a traditional healer. They believe that the lotion will heal the patient of the condition he is suffering from. They have been instructed to put the lotion all over the body and that the patient should not have a bath for 3 days in order for the medicine to work effectively. The family asks you to allow them to put the lotion on the patient and follow the instructions. Debate the following issues: 1. How would you proceed? 2. How does this enhance or inhibit the achievement of the specific outcomes outlined in this Chapter? Activity 2.2 A patient in your unit is confused and refuses oxygen therapy, saying it is disturbing him as he would like to communicate with his ancestors. He is desaturating and becomes violent when you try to put the face mask on him. He then requests you to give him space to discuss the treatment (oxygen therapy) you want to give him with his great-grandmother, who is already dead. Debate how you would proceed in this situation. Activity 2.3 A female patient admitted in your unit with chronic back pain has been scheduled for a spinal operation. Following a visit from relatives she requests to be discharged from the hospital because she is considering acupuncture, and the family has organised an intercessory prayer for her. Explain how you would proceed to deal with this patient.

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3

Bio-psychosocial needs

learning objectives

On completion of this Chapter, the learner should be able to: • apply the nursing process in order to assess, plan and meet the identified needs of the patient appropriately • apply professional, legal and ethical knowledge in order to identify, assess, plan and meet the needs of patients competently • apply nursing theories that are holistic in nature and take all aspects of the patient into account • assess each patient comprehensively and thoroughly in such a way that all needs are evaluated and incorporated into the nursing care of that patient • prioritise needs accurately so that primary needs are addressed before secondary needs. key concepts and terminology

biopsychosocial needs

The totality of factors required for physical survival and optimum physical function, as well as factors necessary for social functioning, psychological well-being and spiritual meaning.

needs

Requirements that must be met in order to ensure the successful achievement of desired goals.

physical needs

The factors which are necessary for the optimum physical and physiological functioning of the body.

psychosocial needs

A variety of cognitive, emotional and interpersonal factors which enable individuals to adapt to the environment, form relationships with others and function successfully within a community.

religion

A spiritual belief system which forms the culture of a person, expressed through rituals, codes and practices shared with others in the belief of a higher power or a deity.

spirituality

An individual’s search for the meaning of life in relation to their own existence in order to understand some of life’s experiences, such as illness.

spiritual needs

Spiritual needs comprise those factors that will enable the individual to find meaning in life and a relationship with a higher power or forces within nature.

prerequisite knowledge

• Sociology: culture and cultural diversity • Religious studies: different types of religions. ethical–legal considerations

According to the Bill of Rights in the Constitution of South Africa, people have a right to their religious beliefs. This implies that patients in healthcare facilities expect this right to be respected and promoted.

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Introduction Nursing involves meeting the needs of those who have self-care deficits in relation to one or more of their needs. Through the nursing process, assessment and identification of these self-care deficits enable a nursing diagnosis to be made, and this serves as the basis for an individual and holistic care plan in order to meet the identified need.

Bio-psychosocial theories People are conscious beings whose existence encompasses the physical as well as the social, psychological and spiritual dimensions. Nursing involves caring and having compassion for others, stemming from the belief that life has an intrinsic value. Caring, compassion and recognition of the value of life are expressed through nursing actions that meet the needs of the patient, and which are aimed at restoring or maintaining an optimum state of physical, mental and social well-being. The basic human needs are the same for every individual, and, although each of us may have additional or special needs, our fundamental needs remain the same, as they constitute our requirements for living. Nursing theorists agree that every individual is a unique being with biological, social, psychological and spiritual dimensions. Nursing theorists also agree that the activity of nursing involves meeting the needs of patients. Below is a summary of the viewpoints of nursing theorists regarding the bio-psychosocial needs of patients. Nancy Roper. (This should be read against Virginia Henderson’s theory and Dorothea Orem’s theory in Chapter 1.) Nancy Roper identifies specific activities of living that are necessary in order to maintain life. Roper’s activities of living are very similar to Henderson’s 14 components for daily living. Roper’s list is given below: 1. Maintaining a safe environment 2. Communication 3. Breathing 4. Eating and drinking 5. Eliminating 6. Personal cleaning and dressing 7. Controlling body temperature 8. Mobilising 9. Working and playing 10. Expressing sexuality 11. Sleeping 12. Dying. Hildegard Peplau. Hildegard Peplau reinforces the concept of nursing as assistance or facilitation in the process of attaining and maintaining optimum health. She views nursing as an applied science and as a

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process that helps patients to meet their own needs. Nursing is an interpersonal process between nurse and patient, and from this we derive the concept of a therapeutic relationship, as well as the concept of the therapeutic use of the self in nursing. Peplau’s approach is particularly valuable in relation to communication and the understanding of interpersonal relationships between patient and caregiver. Maslow’s hierarchy of needs. The psychologist Abraham Maslow developed a theory of needs which places human needs in a hierarchy based on their relative importance for physical survival. These needs are arranged in descending order, from superior to basic, but discussed here in ascending order, where the lower level needs have to be met before those in higher levels can be addressed. According to Maslow’s theory, basic physiological needs such as the need for air, food and water, safety and shelter determine survival, and must be satisfied first before the next levels of need can enjoy attention. Individuals using healthcare facilities generally have one or more unmet basic need/s that the nurse must identify and meet, or help the patient to meet. Although people in general have all of the needs as set out by Maslow, the factors impacting on those needs vary from individual to individual. All patients must be individually assessed and the nature of their needs and the reasons for those needs not being met must be determined. Maslow’s hierarchy of needs has been superseded by other theories in the field of social sciences, but the theory nevertheless remains useful for nurses as it facilitates an understanding of the relative importance of the various human needs, and it enables nurses to assign appropriate priority to the needs of patients.

Physical needs Physical needs are described as the factors required for the optimum physical and physiological functioning of the body. Physical needs include physiological processes, as well as physical activities and adaptation processes, all of which enable an individual to function with optimum efficiency and respond appropriately to the environment.

Need for oxygen The need for oxygen is the most fundamental physiological need. All tissues of the body require oxygen for survival, as oxygen is essential for the final extraction of energy from foodstuff. Oxygenation includes the uptake and utilisation of oxygen by the tissues and the concurrent elimination of carbon dioxide from the tissues. The process of oxygenation includes: • breathing • the exchange of gases in the lungs

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30  Juta’s Complete Textbook of Medical Surgical Nursing

• the transportation of oxygen to the tissues in the blood through circulation • the uptake and utilisation of oxygen by the cells • the transportation of carbon dioxide in the blood • the elimination of carbon dioxide from the body via the lungs. An unmet oxygen need may be due to any factor that interferes with these processes, such as lack of oxygen, inadequate pulmonary ventilation and gas exchange, inadequate circulation, or poor tissue uptake and utilisation.

These waste products are toxic to the body and must therefore be eliminated. Some elimination takes place via the skin (small amounts of urea). The lungs are responsible for the elimination of carbon dioxide. The principal routes of elimination are, however, via the kidneys and the gastrointestinal tract. The processes of elimination include: • defecation • formation of urine by the kidneys • micturition.

Need for temperature regulation

Circulation refers to the movement of blood and plasma through the blood vessels, propelled by the pumping action of the heart. Circulation is the means by which the tissues of the body are supplied with oxygen and nutrients. Adequate circulation is necessary for the proper physiological function of the body. Any factor that interferes with the pumping action of the heart, the volume of blood in the blood vessels, or the patency of the blood vessels will impede circulation.

Humans are mammals, which means that body temperature is maintained within a narrow range irrespective of the temperature of the environment. The physiological functions of the body take place within a narrow temperature range of 36.2 °C to 37.2 °C. When the body temperature leaves this normal range, metabolic processes are altered, which leads to cell and tissue injury and, ultimately, death. Exposure to heat and cold, as well as pyrexial conditions, affects the body’s ability to keep the temperature within the normal range. (Refer to Chapter 11 for more on temperature regulation needs.)

Need for fluids and electrolytes

Need for skin integrity

The body maintains a balance in respect of the uptake and utilisation of water and salts by the body. The correct amounts of fluid and dissolved salts or electrolytes are essential for a variety of chemical and metabolic processes in the body. Maintenance of fluid and electrolyte balance includes: • the intake of fluid and dietary salts • the formation of urine and the elimination of excess fluid and salts • the maintenance of a constant pH in the body fluids.

The skin is the body’s first line of defence. It protects the underlying tissues and organs and prevents the entry of micro-organisms. Sores, burns, wounds, dermatological conditions and skin erosions, as well as skin eruptions, are all forms of skin breakdown that disrupt the integrity of the skin.

Need for circulation

Need for nutrition Nutrients are the raw materials that the body uses for energy, to build and repair tissue, and to synthesise enzymes, hormones and other substances required by the body. Nutrition refers to the taking in, utilisation and storage of foodstuffs. Human nutrition includes the processes of feeding, as well as the processes of digestion, absorption and the metabolism of foodstuffs in the body. Socioeconomic circumstances, as well as the cultural background of a patient, may influence nutrition needs. The culture, as well as the preferences and income of the patient, must be considered when meeting this need.

Need for elimination of waste products Elimination refers to the expulsion of bodily wastes. The body constantly produces waste products, such as urea and carbon dioxide, during the processes of metabolism.

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Need for mobility and exercise Every individual executes a variety of bodily movements in the course of their normal daily activities. In addition, many individuals engage in some form of exercise or sport. The need for purposeful movement and exercise includes not only the capacity for normal bodily movement, but also the capacity for exertion and strenuous physical exercise. The ability to meet this need depends on a variety of factors, such as age, health, physical fitness and strength, neuromuscular function, and musculoskeletal agility.

Need for hygiene The word ‘hygiene’ refers in general to the science of health and its preservation. In particular, the word refers to cleanliness, both of the individual and the environment. Individual hygiene needs relate to the maintenance of personal cleanliness and grooming. Hygiene needs include personal habits and practices regarding personal care and the grooming of the body and practices that are frequently influenced by culture.

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Chapter 3 – Bio-psychosocial needs  31

Environmental hygiene also influences health, and many diseases, such as asthma and other upper respira­ tory problems, can be directly related to pollution and to less-than-ideal environmental conditions. The need to maintain optimal environmental hygiene can also be considered a human need.

Need for comfort and rest The word ‘comfort’ refers to a sense of ease and wellbeing. Physical comfort means not only the absence of pain, but also includes: • the position of the body • the temperature of the environment • the absence of hunger or thirst • the absence of annoying distractions and stressful happenings. Rest is closely tied to comfort and refers to a state of physical inactivity, repose and relaxation. Sleeping and waking, as well as factors that might induce restlessness, must be taken into account. Physical and emotional stress may interfere with an individual’s ability to rest. Rest and sleep are essential for normal physical and psychological functioning in order to replenish energy and repair tissues.

Need for safety The need for safety is multidimensional and includes the following: • Physical safety. In this instance, the need for safety means the avoidance of physical injury and damage to the body. The individual’s level of consciousness and awareness, as well as their level of physical fitness and agility, are relevant to this need. • Psychological safety. This pertains to the feeling of being secure and of knowing what to expect from the people around you, as well as being able to cope with events. It means that individuals understand what is happening and trust that their best interests will be safeguarded.

Need for security Security is based on physical safety, which means adequate food and shelter, as well as freedom from physical harm. Security is all-encompassing and it is a broader concept than physical safety. It relates to: • a state of comfort within one’s environment, and it means that individuals are assured of the means with which to support themselves in society. It implies that an individual is comfortable with their role and satisfied with their position in society. • protection under the law and from violation of one’s

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fundamental human rights. There is obedience to the law and respect for the worth of human dignity in the society and in healthcare facilities in particular. • free access to health facilities and services.

Need for sensation and perception Normal human functioning includes the ability to perceive the environment and respond appropriately to it. Sensation and perception require the ability to see, hear, feel, smell and taste, as well as cognitive abilities that enable an individual to interpret information and to respond appropriately.

Need for sexuality In the physical context, sexual or reproductive needs refer to those actions or processes that are necessary for the reproduction of the species. These include copulation, conception, gestation and parturition. Sexuality needs are assessed throughout the lifespan, from infancy to older adulthood, as these needs relate to a stage in life. Sexuality is influenced by a variety of factors, such as age, sociocultural background, ethics, self-concept and physical fitness. Sexuality is more than a physical need because of the psychological and cultural dimensions which must be taken into account when dealing with patients. The sociocultural aspects of sexuality for females include: • menstruation • pregnancy • abortion • contraception. Assessment regarding sexuality needs should take cognisance of the fact that sexual dysfunction (challenges regarding the desire or actual performance of sexual activity) may be as a result of illness, disability, drugs, stress, or other physiological changes like menopause. Nurses must also be aware of patients’ need for information about sexual activity and ways in which sexual activity is altered according to the health status of the patient. Comprehensive history taking on the first visit to a health facility regarding sexuality should include: • a history of sexually transmitted diseases (STD) • sexual activity or practice • sexual orientation • sexual dysfunction.

Psychosocial needs Psychosocial needs refer to a variety of cognitive, emotional and interpersonal factors that enable individuals to adapt to the environment, form relationships with others, and function successfully within a community.

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Need for cognition

Need for autonomy

The word cognition comes from Latin cognoscere, to know. In order for an individual to function adequately in relation to the environment, other individuals and the community, effective thought processes must be developed. Effective thought processes include orientation to the environment and the people in the environment, as well as problem-solving skills and the ability to form concepts and organise thoughts in a logical manner. Memory and the ability to understand and learn are also necessary for adequate cognition.

Autonomy implies independence, control and the competent management of the cognitive, perceptual and behavioural processes of an individual, within societal definitions of ‘normality’ or ‘mental health’, and conforming to accepted social norms. Autonomy also includes the facility of choice, or the ability to make an informed decision between several alternatives, based on personal beliefs and preferences. The ability to exercise choice also implies the right to have those choices respected.

Need for adaptation

Need for relatedness

In order to be able to deal with stress and life events effectively, individuals must develop a variety of conscious coping skills. Coping behaviours involve the use of problem-solving techniques and relaxation, as well as the avoidance of stressful situations. Healthy coping implies adaptability and the capacity to deal with change rationally and appropriately. Less healthy coping mechanisms include aggression, withdrawal and substance abuse. Unconscious coping behaviours include defence mechanisms such as denial, projection, repression and regression. Coping skills are more difficult to assess in children, but children who are able to make their needs known and who are confident of having these needs met are coping effectively. Severe stress in a child may bring out primitive defence mechanisms such as temper tantrums, withdrawal and regression.

Humans are social beings and need the esteem and cooperation of their fellow human beings. We also have a need to form close associations with others, as the fullest expression of the personality is attained within reciprocal human relationships. Different types of relationships are characterised by different degrees of self-disclosure. Close, intimate relationships demonstrate mutual trust and support, as well as mutual esteem building. These relationships include the following: • The nurse–patient relationship. This is a special type of relationship in that it is intimate and caring without being too close. The nurse knows and cares for their patients, but does not become emotionally involved with them. Nurse–patient relationships are also characterised by empathy and a ‘disinterested’ concern for the patient’s best interests. • Family relationships. Usually influenced by one’s role in the family, eg father, mother, daughter, son, etc. The presence or lack of family support is also crucial for dealing with illness. • Significant other relationships. Characterised by emotional ties with one another or other factors.

Need for self-esteem and self-concept Self-esteem implies that one has confidence in one’s abilities. Adequate self-esteem requires acceptance of the self and feeling good about the self. This includes acceptance of bodily appearance and characteristics. Good bonding in an infant is a prerequisite for the development of self-esteem. A child with good self-esteem will show confidence and be outgoing. Adequate role performance is related to self-esteem needs, as every individual has a need to fulfil their various life roles effectively. Self-concept relates to how one feels or thinks about oneself. The components of self-concept include identification, body image, role performance and selfesteem. A healthy self-concept requires acceptance of one’s personality traits, as well as a realistic perception and acknowledgement of one’s faults. Self-confidence is based on a healthy self-concept and self-esteem which are the basis of sound interpersonal relationships and mental health.

Need for stimulation Curiosity is one of the most striking features of human nature. People have an innate need to explore, to develop their potential, to respond to challenges and to achieve. Stimulation is essential for the development of human potential. The environment, education and interaction with other people are all crucial for development. Stimulation also includes the need for leisure time activities, during which individuals express themselves in an informal and pleasurable way. Meaningful work, on the other hand, is an important source of stimulation as it enhances self-esteem.

Need for communication Communication with others is a natural human activity that is essential for survival and for the formation of

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Chapter 3 – Bio-psychosocial needs  33

meaningful relationships. Communication is the process of giving and receiving information, and of attaching meaning to information and making use of that meaning. It is a major factor in determining the relationships that people have with others and what happens to them in the world. Table 3.1  Summary of bio-psychosocial needs

Physical needs

Psychosocial needs

Spiritual needs

Oxygen

Cognition

Meaningfulness

Circulation

Adaptation

Religious expression

Fluids and electrolytes

Self-esteem and self-concept

Nutrition

Autonomy

Elimination

Relatedness

Temperature regulation

Stimulation

Skin integrity

Communication

Mobility and exercise Hygiene Comfort and rest Safety Security Sensation and perception Sexuality

Need for meaningfulness (existentialism) Meaningfulness implies the need for meaning and purpose in an individual’s life in order to cope with life’s challenges, for example illness or even death. Finding meaning in life requires the development of a personal philosophy and ideology to facilitate the process of finding meaning. Grieving is an essential part of finding meaning in pain, suffering and death. Both patient and family may need to grieve in order to accept and work through the diagnosis of illness or the death of a loved one.

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Meaning in life is frequently connected to self-esteem and relatedness, as many people find meaning and selfexpression in their relationships with others, and with a higher or divine power.

Spiritual needs Human nature has a spiritual dimension, which encompasses the need to find meaning in life and a relationship with a higher or divine power. Human spirituality also means defining life values and belief systems, and relating to the self and to others within the framework of those life values and belief systems or philosophies. Spiritual needs are dynamic as they change with time and circumstances, for example life events such as the illness or death of a loved one. The terms spirituality and religion are often used syno­ nymously, although the two are not necessarily the same. Spirituality is a broader concept than religion. However, most religious people are spiritual as well. The spiritual needs of the patient include the need for meaningfulness (existentialism) and the need for the expression of religion. Holistic care in nursing includes giving spiritual care, which includes reason, reflection, religion, relationships and restoration. Assessments of patients on admission should include a comprehensive history taking regarding the patient’s religious beliefs with regard to health and illness. This is to ensure that these beliefs and practices are taken into consideration when planning nursing care, as well as their impact on medical treatment and procedures. Very often, nurses will only ask about religious affiliation and not delve into the specific health beliefs or practices that may impact on healthcare.

Meeting the spiritual needs of the patient Principles of spiritual care

Some principles include: • recognition and acceptance of the spiritual dimension of human beings (self-awareness) • comprehensive assessment to determine the patient’s spiritual and religious needs • good communication; the need to listen in an authentic manner • empathy and the ability to accept what the patient says • sympathy to enhance a trusting relationship to allow the patient to feel safe • use of judicious self-disclosure • referral to professionals more qualified in spiritual care, eg a hospital chaplain or the religious leader of the patient.

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Need for religious expression For most human beings, spiritual needs are fulfilled within an organised system of belief and worship, whether formal or informal. The religious beliefs and practices of an individual form an important part of that individual’s life, particularly in relation to beliefs and practices about birth, death, health and illness. Religious practices and rituals play an important part in enabling individuals to weather life’s crises, including ill health. Regarding praying with the patient, the nurse should make sure that this practice is not in conflict with the policies of the institution. French and Naraynasmy caution that ethical issues arise when praying with patients, and advise that informed consent should be obtained from the patient first. Poole and Cook maintain that praying with a patient may constitute breach of professional boundaries. In a multicultural society such as South Africa, nurses need to be familiar with the major religious practices common among the population. All cultural and religious affiliations are recognised in the Constitution.

Religious beliefs and practices regarding health There is growing evidence in literature that there is a connection between spirituality, religion and health. Research indicates that religion strengthens people’s ability to cope with life-threatening disease. Some of the major religions’ beliefs and practices, and the implica­ tions of these for health and nursing, are summarised in Table 3.2.

Integrative healthcare This approach to health includes the use of complementary and alternative healthcare practices, and may sometimes include conventional medicine, albeit for a brief period. The central belief of this modality of healthcare is that the human body has the capacity to heal itself. As a result, healthcare is geared towards changes in lifestyle and involves the use of natural and manual healing therapies. Complementary and alternative therapies include acupuncture, chiropractic practice, herbal medicine, homeopathy, osteopathy, aromatherapy and hypnotherapy. African traditional medicine is also regarded as a comple­ mentary and alternative therapy.

The traditional health practitioner According to the World Health Organization, traditional practitioners are those who are recognised by their communities as being capable and competent to provide healthcare services, using methods which are cultural, traditional, spiritual, and religious.

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Traditional medicine is widely used in many parts of Africa, including South Africa. There is a belief that conventional medicine may not provide all the answers regarding ill health. South Africa is a multicultural society and many cultural groups use traditional medicine alongside conventional Western medicine. Muslim people and adherents of Hinduism often approach traditional healers. In South Africa, traditional health practitioners are recognised and regulated under the Traditional Health Practitioners Act 22 of 2007. Traditional health practitioners include diviners, traditional doctors, spiritual healers, traditional surgeons and traditional birth attendants. Diviners. Diviners are traditional health practitioners who often diagnose ill health by means of casting a specific set of bones on the floor. This is their way of communicating with the ancestors to guide them through the patient– practitioner interface. The bones provide information and messages which are interpreted to facilitate a diagnosis, or an explanation to an individual’s problem. The diviners are holistic practitioners who not only attend to physical problems but adopt a more psychosocial perspective. Prescription for treatment is by means of herbs and very often the performance of some rituals. Traditional doctor, inyanga, herbalist. Traditional doctors use medicinal herbs in the treatment of patients. They usually acquire the skills through an apprenticeship system, where they are taught by an expert. They provide preventive, promotive and curative healthcare. Spiritual healers. They are often referred to as ‘faith-based healers’, because they use religion, especially Christianity, as the medium for the healing. Spiritual healers use verses from the Bible as the foundation for diagnosis and healing. They also use holy water, ash and colourful ropes to cast out evil spirits. Healing baths are often used to cleanse the body. Traditional surgeons. A traditional surgeon is one who performs circumcision as part of a cultural initiation process. This practice is very common among Xhosa people in South Africa and the vhaVenda people in the Limpopo province. Other ethnic groups also participate in this traditional practice in the urban areas of Gauteng. These groups include the Ndebele, Basotho and Zulu people. Other ethnic groups mostly opt for the conventional hospital-based circumcision. (See also Chapter 2 on cultural diversity in healthcare.)

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Chapter 3 – Bio-psychosocial needs  35 Table 3.2  Health-related beliefs and practices of selected religions and implications for health and nursing

Religion

Health-related beliefs and practices

Implications for health and nursing and handling of the situation

African Religions, eg Z.C.C.

• Eating pork is prohibited • Alcoholic beverages are forbidden • Drink special tea or coffee supplied by the church outlets • Priest may anoint the patient with holy water

• Do not give the patient any food with pork, including processed meat • Allow time for the priest to visit, pray with the patient and to anoint with holy water • Patient may request early discharge in order to consult with the church elders for major decisions like consent for operation

Buddhism

• Accepts modern medical science

• May refuse medication in order to protect the body from the effects of chemicals

Hinduism

• Eating meat involves harming a living creature • Cremation is the most common form of body disposal

• Engage with the hospital dietician to provide a vegetarian diet

Islam

• Eating pork or pork-derivative medication is prohibited • No alcohol is allowed • Ritual cleansing before eating and prayer is practised • Fasting during daytime during the month of Ramadan • Uses faith healing, including group prayers • After the death of a patient, a family member may wish to wash the body and position the bed to face Mecca; the head should rest on a pillow • Burial usually takes place as soon as possible within 24 hours

• Cannot eat until the sun has set during the month of Ramadan • May refuse medication if it is porcinederived • Some female patients prefer female healthcare professionals • Food should be Halaal only • Family to be consulted if a delay to the release of the body is anticipated (in cases where there is a need for a postmortem) so that the family can make other arrangements

Judaism

• Believes in the sanctity of life • Observance of the day of Sabbath

• Visitation from the rabbi is part of support during illness • May refuse treatment on the Sabbath day • Life support is discouraged • Food should be kosher only • After post-mortem, all body parts to be returned for burial

Christians (Catholics and Protestants)

• Accepts modern medical science • Use prayer and faith healing • Visits from clergy may include holy communion (Sacrament of the Sick) • Patients may request ‘non-meat’ diets during Lent (the 40 days before and during the Easter period) • Patient may want to keep a religious object such as a rosary with a crucifix

• Allow time for prayer by family, friends and clergy • Are in favour of organ donation • Provide the requested diet unless contraindicated • Allow patient to keep, but may have to remove when patient goes for X-rays or surgery

Jehovah’s Witness

• Blood in any form is not accepted • Blood volume expanders are acceptable if they are not derived from blood

• Will not accept any blood transfusion, even in a life-threatening situation • The health condition of the patient may deteriorate with fatal consequences

Seventh-Day Adventist

• Fasting is practised • Vegetarian diet is encouraged

• Provide vegetarian diet • Meat diet should exclude pork

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Traditional birth attendants. A traditional birth attendant is a health practitioner who assists a mother during childbirth and has acquired skills through delivering babies or through apprenticeship. Traditional birth attendants (TBAs) typically also provide care during pregnancy, childbirth, and the post-partum period. They render this service to women in their community and are often paid in kind. In developing countries, traditional birth attendants play a significant role in areas where midwives and doctors are scarce. Lane and Garod (2016) add that TBAs act as cultural brokers between Western and traditional practices in childbearing and provide women with continuity of care from a known carer. TBAs in South Africa are recognised

legally in the Traditional Health Practitioners Act 22 of 2007. They work in collaboration with the health system as per the guidelines of the World Health Organization.

Conclusion In this Chapter, the bio-psychosocial needs presented correspond to Maslow’s needs for survival and provides the foundations for nursing diagnosis and basic nursing. The Chapter forms the basis for the content of the Chapters to follow, where needs including those relating to safety; hygiene and grooming; nutrition; elimination; homeostasis; modality; exercise; and temperature regulation are dealt with. Other needs are covered in Chapters dealing with the respective relevant systems of the body.

Suggested activities for learners Activity 3.1 A baby is admitted to your ward. On history taking you find that its parents are Jehovah’s Witnesses. The medical diagnosis is such that the baby needs urgent corrective abdominal surgery. The parents, bound by their religion, will not give consent for surgery and possible blood transfusion. In a discussion with colleagues, state how you are going to manage this problem, taking into consideration: • the theorists’ stipulations • ethical and legal implications • patients’ rights • the patient’s and the family’s spiritual needs • the role of the nurse. Activity 3.2 A devout Muslim patient dies in your care. A post-mortem has to be done, and this can only be done after a 24-hour period. Describe how you will manage this situation.

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4

Safety in nursing practice

learning objectives

On completion of this Chapter, the learner should be able to: • demonstrate insight into the need to promote a culture of safety in the healthcare setting • discuss the nursing competencies required to promote safety and prevent medico-legal risks • identify incidents affecting the safety of the nurse, other healthcare workers, patients and families • identify potential safety hazards in a clinical area and apply appropriate measures to correct the situation • correctly apply institutional policies regarding identification of patients • correctly apply institutional policies regarding the protection of patients’ property • correctly apply the National Core Standards of quality care to ensure patients’ safety in the clinical area • correctly deal with accidents and incidents in the clinical situation • describe the principles of first aid in handling burns, poisoning, and other injuries at work or home • indicate the current legislation regarding the prevention of accidents and maintenance of safety at an institutional level • describe the components of patient safety in hospital. key concepts and terminology

adverse event

An unfavourable occurrence that happens while one is undergoing medical care.

error

An unplanned situation where a mistake occurs and the goal of the care is not achieved.

medico-legal hazard

A threat to the safety of all people within a healthcare setting, including patients, personnel and visitors; it involves both medical and legal aspects.

restraint

A restrictive device used to subdue and limit the physical activity of a patient.

safety

Efforts made by healthcare professionals to prevent harm to patients.

prerequisite knowledge

• First aid or primary emergency care • Microbiology, parasitology and pharmacology • Government and institutional policies on safety. medico-legal considerations

In terms of the law in South Africa, all people have a Constitutional right to the safety of their person, name and property, and, while a patient is under the direct care of a nurse, the nurse is accountable for the safety of that patient. Nurses are also an important source of health and safety advice in the community, and they therefore have a professional obligation to be involved in issues concerning safety in the home and in the community, as well as in the healthcare institution.

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ethical considerations

Patient safety includes the protection and security of the good name of the patient, thus making it an ethical duty of the nurse to protect the confidentiality and privacy of a patient. This ethical responsibility is provided for in the Code of Ethics for nurse practitioners in South Africa (SANC 2013). The ethical principles of beneficence and non-maleficence enjoin the nurse to promote good and prevent harm in nursing care.

Introduction

Safety of patients in the healthcare institution

Epidemiological studies indicate that patient safety is a global concern. Patients in healthcare settings place their trust in the healthcare providers regarding their safety. Nurses share this responsibility with other healthcare providers. Nurses, who spend the most time with patients, should regard patient safety as one of their primary responsibilities. They also play a significant role in detecting certain safety risks in healthcare. The primary function of the nurse is to promote health, prevent disease, provide care and detect illness early, and treat illness to prevent complications for the sick. If death ensues, the nurse must be caring and should facilitate a peaceful and dignified death, as well as comfort the bereaved family. The environment within which this mandate is carried out is expected to be safe for the nurse, the patient and the patient’s family.

In order to promote and maintain a culture of safety, nurses need to focus consciously on the reduction of risk, injury, infection, and the adverse effects of all medical and therapeutic interventions in any form, including medication. Provision of a safe environment for patients is a core value in nursing practice. Safe behaviours can be learnt and integrated into nursing practice. Accountability for safe, effective and competent care should be acknow­ ledged as an acceptable standard of care. The nurse is in a key position to ensure that this standard of safe patient care is maintained and upheld.

Overview of the general aspects of safety Safety in an institution is an essential consideration in every aspect of nursing care. Safety means a safe clinical environment for all healthcare workers, other personnel in an institution, patients, their property, and visitors. According to Swart, Pretorius and Klopper (2015), patient safety is the prevention of errors and adverse events associated with healthcare.

Medical waste Medical waste should be disposed of safely and responsibly, taking into account the potential hazards thereof when disposed of incorrectly.

Violence Violence in the workplace is an issue that employers must be aware of, and they must ensure the safety of healthcare workers and patients at all times. Unacceptable behaviour includes verbal, emotional and physical violence, as well as sexual violence, directed towards either patients, their visitors, or healthcare workers. Violence can also be in the form of unsafe environments for healthcare workers and patients, such as unprotected premises, dirty slippery floors, broken windows, poor ventilation, poor sanitation, noise, poorly controlled temperatures, crowded wards, etc.

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Nursing and safety Traditionally, patient safety in nursing focused mainly on: • using the bedrails properly to ensure that the patient did not fall out of bed • preventing medication errors by using the five Rs of medication (see the Clinical alert! box further on in this Chapter). However, patient safety also involves preventing violence from nurse to patient or vice versa, from patient to patient and from the public to the patient. Sustained research on patient safety indicates the close relationship between quality care and patient safety. In providing a safe environment in patient care, nurses have to consider both the national and international standards which highlight best practices in patient safety.

National standards of patient safety The South African Department of Health published the National Core Standards for Health Establishments in South Africa in 2011. The purpose of these standards, among others, is to ensure the provision of quality and safe care for patients. The core standards are developed into seven cross-cutting areas or domains where service, quality and safety may be at risk. These standards are based on the key priority areas which have been identified through surveys as well as through media reports. Compliance with the standards is deemed critical in improving the quality of healthcare services and reducing the risks associated with poor care and inadequate management.

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The key priorities are: • improving staff values and attitudes • waiting times • cleanliness • patient safety and security • infection prevention and control • availability of medicines and supplies. Table 4.1 indicates the seven domains of the National Core Standards. The first three domains are the core business of the health delivery system. The remaining four domains pertain to the support system that ensures that the core business is achieved by the staff. Delivery of quality care will be measured against the implementation of these standards. Domain 2 encompasses the standards to be maintained to provide patient safety. Table 4.2 provides a summary.

Table 4.1 The seven domains of the National Core Standards for Health Establishments in South Africa (2011)

Domain 1

Patient rights

Domain 2

Patient safety, clinical governance and care

Domain 3

Clinical support services

Domain 4

Public health

Domain 5

Leadership and corporate governance

Domain 6

Operational management

Domain 7

Facilities and infrastructure

Source: South African Department of Health

Table 4.2  Standards in patient safety, clinical governance and clinical care

Sub-domain

Standard

Patient care

• Patients’ recovery, care and treatment that follow nursing protocols, meet their basic needs, and contribute to their recovery

Clinical management of priority health conditions

• Care provided contributes positively to national priorities, including the United Nations Millennium Development Goals for maternal and child health, HIV and tuberculosis

Clinical leadership

• Doctors and nurses and other health professionals constantly work to improve the care they provide through proper support systems

Clinical risk

• Clinical risk identification and analysis take place in every ward to prevent incidents that compromise patient safety • Patients with special needs or at high risk, such as pregnant mothers, children, the mentally ill or the elderly, receive special attention • Safety protocols are in place to protect patients undergoing high-risk procedures such as surgery, blood transfusion and resuscitation

Adverse events

• Adverse events or patient safety incidents are promptly identified and managed to minimise patient harm and suffering • Adverse events are routinely analysed and managed to prevent recurrence and learn from mistakes

Infection prevention and control

• An infection prevention and control programme is in place to reduce healthcareassociated infections • Specific precautions are taken to prevent the spread of respiratory infections, like wearing masks and isolating infectious patients • Standard precautions are applied to prevent healthcare-associated infections • Strict infection control practices are observed in the designated infant feed preparation areas

Source: South African Department of Health

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Patient safety, clinical governance and clinical care This domain relates to how to: • ensure quality nursing and clinical care and ethical practice • reduce unintended harm to healthcare users or patients in identified cases of greater clinical risk • prevent or manage problems or adverse events, including healthcare-associated infections • support any affected patients.

International standards of patient safety in nursing practice As patient safety is a global concern, it has received attention internationally over the years, and nurses are regarded as the key role-players in enhancing patient safety. The International Council of Nurses (ICN) adopted a position statement on safety in 2002 which states the following: The ICN believes nurses and national nurses’ associations have a responsibility to: • inform patients and families of potential risks • report adverse events to the appropriate authorities promptly • take an active role in assessing the safety and quality of care • improve communication with patients and other healthcare professionals • lobby for adequate staffing levels • support measures that improve patient safety • promote rigorous infection control programmes • lobby for standardised treatment policies and protocols that minimise errors

• liaise with the professional bodies representing pharmacists, physicians and others to improve packaging and labelling of medication • collaborate with national reporting systems to record, analyse and learn from adverse events • develop mechanisms, for example through accreditation, to recognise the characteristics of healthcare providers that offer a benchmark for excellence in patient safety. International literature also reports on research studies and best practices regarding patient safety. Of importance is the challenge faced by nursing education to teach learners about patient safety early in their training, so as to successfully develop a culture of patient safety. One of the competencies that have been identified for a nurse practitioner nationally and internationally is that of patient safety. (Other competencies are discussed in Chapter 12.) Nursing educators and unit managers have a responsibility to ensure that learner nurses acquire the basic competencies in patient safety by reducing the chances of mistakes that occur as a result of gaps in the systems by ensuring that there are guidelines and protocols in the units to prevent or at least minimise the occurrence of such, for example instituting a system of checking one another when calculating the correct dosage of a drug as a fraction from a large ampoule or vial for injection. Related to this competence, the learner needs to demonstrate the appropriate knowledge, attitudes or behaviour as well as the skills. An example is provided in Table 4.3.

Table 4.3  Safety competence

Knowledge

Attitudes and behaviour

Skills

• Describes factors that create a culture of safety • Delineates general categories of errors and hazards in healthcare • Identifies human factors and basic safety design principles that affect unsafe practices

• Recognises the importance of communication with the patient, family and healthcare team members regarding safety and adverse events • Appreciates the cognitive and physical limitations of human performance

• Participates in data collection to facilitate effective transfer of patient care responsibility • Uses the organisational error reporting system successfully • Communicates observations or concerns related to hazards and errors to patients, families and/ or health team members • Demonstrates the effective use of technology and standardised practices and protocols that support safe practice

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Chapter 4 – Safety in nursing practice  41

International nursing education provides competencybased nursing curricular models in pre-registration nursing programmes. In addition to the core competencies identified for the nurse practitioner, there is a specific initiative in the United States, referred to as Quality Safety Education for Nurses (QSEN). The following competencies have been identified in the preparation of professional nurses: • Patient-centred care • Teamwork and collaboration • Evidence-based practice • Quality improvement • Safety • Informatics.

2.

3.

Evidence-based practice Evidence-based practice (EBP) is integral to healthcare, and nurses have an obligation to identify and use the best available and most up-to-date evidence to deliver high-quality and safe nursing care. This means that practitioners must be able to analyse the strength of the evidence available to determine not only its value but also its appropriateness for patient care in their institution. In addition, having identified the appropriate evidence, the practitioner must ensure that individual patient preferences and values are accommodated to ensure patient-centred care. Internal evidence, such as the practitioner’s expertise, is therefore just as important as the external evidence used to provide quality care. The motivation for using EBP, according to Melnyk and Fineout-Overholt (2011: 7–9), includes that it: • leads to highest quality care and patient outcomes • reduces healthcare costs • increases reimbursement and decreases denials • reduces geographic variations in the delivery of care • increases clinician empowerment and role satisfaction • reduces healthcare provider turnover rate • meets the expectations of an informed public. The implementation of EBP requires a culture change so that management supports the concept of EBP. The in­ stitutional infrastructure has to provide sufficient re­ sources to change practice, including identifying mentors to drive the process. EBP can be broken down into five key stages: 1. The question. The first step in EBP is recognising that there is a need for new information. This information need has to be converted into an answerable question. The right clinical question has to be asked to address

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4.

5.

the need identified. mnemonic PICOT can assist in doing this: P Patient population I Intervention C Comparison intervention O Outcome T Time. Finding the evidence. Choosing the right evidence is of fundamental importance. When using external evidence, keep in mind that not all evidence is of equal value and that there are several grading systems to grade the evidence available. Appraisal. The evidence must be critically appraised to determine its validity and potential usefulness. A valid appraisal tool should be used, for example: considering validity in terms of cases obtained and data collection methods; the possibility to replicate results; and, as indicated earlier, the suitability to clinical practice. It is also important to compare the results with other studies. Acting on evidence. Once it has been concluded that the evidence is of sound quality, a decision will have to be taken about whether the evidence should be incorporated into clinical practice. Before incorporating new evidence, an education plan must be developed to ensure that all relevant practitioners are involved in the practice change. In addition, measurement criteria must be developed to evaluate the success of implementation. Evaluation and reflection. Evaluation and reflection are necessary to determine whether the action you have taken has achieved the desired results. Communicate the changes to ensure that everyone remains informed about the expected behaviour.

To ensure that nursing practice is based on evidence, continuous research is required to find better ways to improve practice. Traditionally, nurses have tended to depend on their own experience as well as that of their colleagues and other members of the multi-disciplinary team. It is important for healthcare facilities to devise ways in which EBP can be implemented in order to facilitate patient safety. Debourgh (2011) adds that there should be partnerships between academic and service to enhance patient safety and quality. Barriers to the implementation of EBP (Lyle-Edrosolo & Waxman, 2016) include: • the belief that the ‘old way’ is the ‘best way’ • a lack of knowledge and experience of EBP • misperceptions or negative attitudes about research and EBP

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• a lack of belief that EBP improves outcomes • too much information in journals, leading to an information overload • a lack of time and resources to search for and appraise evidence • overwhelming patient loads.

Common safety issues in healthcare Several safety-related risk factors are identified for both the patient and the care provider. Some patients are more vulnerable than others, and nurses are invariably at risk, as nursing is a risk-laden occupation. Let us discuss the factors affecting patients’ potential for accidents first.

Factors affecting patients’ potential for accidents Altered sensory perception

Any decrease in or loss of sensory faculties (such as hearing, sight, smell or touch) reduces a patient’s awareness of the environment and increases the safety risk to which that patient is exposed. The following factors should be taken into account: • Hearing. A patient who cannot hear may be unable to understand what is happening around them and will be unable to hear people approach, which may expose them to hazards. • Sight. If a patient’s sight is severely diminished or they are blind, that patient may have difficulty in coping in a new or strange environment. A patient who is visually impaired may bump into objects, trip or fall in unfamiliar places or areas. • Smell. Without a sense of smell, a patient might not be able to smell toxic gases or smoke from smouldering fires. • Touch. A patient whose nervous system has been compromised and whose sense of touch is diminished is more prone to injury. Tissue damage through pressure has the potential for necrosis and contractures, as the feeling of pain and discomfort (which normally acts as a warning of impending tissue damage) is absent or blunted in such patients. • Taste. Taste is very important in protecting the patient from ingesting poisonous substances or food that is stale.

Impairment of awareness The following patients with impairment in their awareness also require special attention: • Disorientation. A patient may not be fully aware of their surroundings because they are semi-conscious, unconscious or confused. An unconscious person is more vulnerable to safety risks and injuries. This change in perception may adversely alter the

JCTMSN_BOOK.indb 42

judgement of the patient regarding safety measures, and expose the patient to risks and accidents. • Age. Infants, toddlers and young children are at risk because they are active and adventurous, but too young to understand the dangers that surround them. Most home accidents occur in this age group, for example falls from beds or stairs, burns and scalding, electrical hazards, drowning, and choking on small objects. Adult supervision is important in preventing these accidents. The elderly are more vulnerable to accidents because of diminished function, poor vision and impaired mobility. Common safety risks include falls on slippery or uneven floors. • Emotional state. Anger, anxiety, depression and shock are all emotions that can unsettle patients, causing them to behave irrationally and thus make them vul­ nerable to accidents; for example, trying to get out of bed unassisted even if they know they are too weak.

Mobility Patients whose balance or coordination is affected by disease, muscle weakness or paralysis may need the assistance of crutches, a walker or a walking stick; they may also need help to carry out normal activities. Such patients are prone to falls, whereas patients who are completely immobile are prone to bedsores or decubitus ulcers (see Chapter 10).

Lifestyle Lifestyle practice can increase a person’s risk for injury. Alcohol and drug use may enhance reckless and unsafe behaviours, leading to various safety risks or injuries. Patients may be used to an independent lifestyle and, because they resent being dependent on others, may attempt things that they cannot manage, eg risking a fall by getting out of bed unaided.

Communication Inability to communicate clearly with one another may place patients at risk simply because they don’t understand the nurse’s instructions. A patient may be illiterate and unable to read signs, eg nil per mouth. A language barrier may exist, either because the nurse and the patient speak different languages, because the terms used by the nurse are unfamiliar, or because the nurse is too technical and cannot be understood by the patient. A patient may be aphasic and unable to communicate verbally.

Factors affecting care providers’ potential for accidents According to Armstrong and Laschinger (2006), research has shown that nurses who work in empowering environments

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are satisfied with their work, and their performance ensures good patient outcomes. On the contrary, nurses working in poor work environments are prone to burn­ out and stress, and have an increased potential for errors, which undermines quality care and patient safety (Laschinger and Leiter, 2006). Furthermore, Armstrong and Laschinger (2006) highlight some characteristics of work environments where patient safety is good. They include: • Work environment where nurses participate in hospital affairs • Nursing foundations for quality of care • Nurse manager ability and leadership • Support of nurses; staffing and resource adequacy • Collegial nurse-physician relations.

Identification and management of risks in the healthcare environment As indicated earlier, incidents in a healthcare environment can compromise the safety of patients and nurses. It is therefore important for nurses to plan the care of patients in such a way that those incidents are prevented or at least minimised. Risks in healthcare are categorised according to their causative agents: patients, therapeutic procedures, or equipment. Patient-driven incidents occur as a result of the behaviour of the patient, eg self-inflicted injuries, cuts and bruises, poisoning, burns, etc. Therapeutic procedure incidents occur while therapy or care is being given, eg falls while transferring the patient, medication errors, contamination of sterile fields, and incompetent or unsafe performance procedures. Equipment incidents occur because of the malfunction or improper use of medical equipment. Electrical power failure can also be a risk factor, eg for infant incubators.

Existing safety knowledge Most patients are knowledgeable about common safety measures. Thorough assessment should enable the nurse to identify knowledge deficits and plan interventions accordingly. The general principles of planning for safe patient care are outlined in Box 4.1.

Infections

Infection control and standard precautions Prevention and control of infection is one of the most important nursing roles regarding the safety of the patient. The transmission of infection from patient to patient or from nurse to patient or vice versa in healthcare institutions is a serious problem, as it is a medico-legal risk. Healthcare institutions are places where sick people congregate, and infections are easily passed from one patient to the next. Hospital-acquired, or nosocomial infection causes

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4.1  General principles for patient safety • Be aware of medico-legal hazards in the environment at all times • Apply general safety precautions and measures to prevent accidents or adverse incidents • Ensure prompt and complete reporting of all accidents or breaches of safety in a nursing unit • Apply appropriate measures to rescue patients from hazardous situations, eg fire • Ensure that there is an appropriate disaster plan in the unit or institution and that it is known to all members, and that periodic drills are undertaken to ensure a state of preparedness among members of staff • Ensure that patients are well informed about their treatment, in particular regarding related effects and potential accidents, and how to prevent or avoid these • Ensure that patient safety is taken into account in all the individual nursing care plans • Assess and maintain the general safety of the environment at all times • Ensure proper maintenance of equipment increased morbidity and mortality among patients, and can also impact on the length and cost of their stay. The fact is that the environment of the healthcare institution is colonised by the multiple organisms carried by patients, and these organisms may easily be transmitted to newly admitted patients. Many of these hospital-based organisms are resistant to ordinary anti-microbial therapy and can cause serious and life-threatening infections in susceptible patients. Therefore, infection control refers to all the measures applied in a nursing unit to prevent infections from occurring by removing the source or destroying it.

Hospitalised patients are more vulnerable to infections When admitted to hospital, patients become more susceptible to nosocomial infections. This is due to the following reasons: • A sick patient has a lowered resistance and is more vulnerable to infection, especially where the primary defences are inadequate, for example a break in the continuity of the skin, trauma, stasis of body fluids, change in the pH of body secretions, and altered peristalsis. • A patient may present with a lowered resistance to other infections, for example in cases where the immunity of a patient to opportunistic infections is suppressed

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• •

• •

due to the disease condition or the consumption of certain medication such as corticosteroids. A patient may be nutritionally compromised due to their illness. The very elderly and the very young are more susceptible to infection, because an infant’s immune system is immature, while the elderly have a diminished immune response as a result of the ageing process. Invasive procedures and some pharmaceutical agents. Patients come into close proximity with a large variety of other sick people who may be carrying a variety of micro-organisms.

Nurses must therefore be thoroughly conversant with the principles of prevention in relation to cross-infection and they must apply these principles diligently when working with patients.

Routes of transmission There are several ways in which pathogenic organisms can be transmitted. The four most common routes are: 1. Contact transmission. This is the most frequent means of transmission and, therefore, the most important to consider when preventing infection. Contact trans­ mission includes direct, indirect and droplet contact. 2. Vehicle transmission. A vehicle is an agent or a medium that carries the pathogen, eg blood, water or food. Viruses such as HIV and Hepatitis B can be transported by blood. 3. Airborne transmission. Micro-organisms may float free in the atmosphere or attach to dust particles and are inhaled by or deposited on a susceptible host and an infection results. 4. Vector transmission. Animals or insects may carry the pathogen from one host to another or to another transport medium, eg mosquitoes, rats.

Principles of infection control In order to prevent infection as far as possible, these are some important principles of infection control to remember: • Remove the source of infection by establishing and maintaining a hygienic environment (good house­ keeping), and by sterilising, disinfecting, cleaning and treating the infected patient. • Block the routes of transfer of micro-organisms by applying barrier nursing measures, ie isolate the infected, susceptible patients and staff; practise aseptic techniques; and ensure high standards of personal hygiene of staff. • Increase the patient’s resistance by improving nutrition, rest and exercise.

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Standard precautions The standard precautions, previously referred to as the Universal Precautions of Infection Control, are measures designed to reduce the risk of transmitting blood-borne viruses to healthcare workers. The guidelines are intended to minimise the risk of coming into contact with body fluids such as blood, urine, faeces and other body secretions. Precautions are applied when coming into contact with every patient, in all settings, regardless of the diagnosis. The most effective method of preventing and reducing infection is hand washing (see Box 4.2).

4.2  Hand washing or alcohol rubs • Before direct contact with patients or their records • Before putting on sterile gloves and before doing any invasive procedures, eg inserting an indwelling urinary catheter or peripheral vascular catheters, and after contact with a patient’s intact skin, eg taking pulse or blood pressure, or when lifting a patient • After contact with body fluids or excretions or mucous membrane, etc, even when hands are not visibly soiled • When moving from a contaminated body site to a clean body site during care of a patient • After contact with inanimate objects (including medical equipment) in the vicinity of the patient • After removing gloves (WHO, 2009)

Minimising cross-infection In order to reduce the risk of cross-infection between patients and staff, ensure the following procedures are adhered to (Geyer et al, 2016): 1. Perform hand hygiene between hand contacts, after contact with blood, body fluids, secretions, excretions, non-intact skin, mucous membranes or contaminated items. 2. Wear gloves when touching blood, body fluids, secretions, excretions, non-intact skin, mucous membranes or contaminated items. 3. Remove gloves and perform hand hygiene between patient care. 4. Wear masks, eye protection or face shields in case of secretions generating splashes or sprays of blood or body fluids. 5. Cover all wounds with a waterproof dressing. 6. Clean and reprocess patient care equipment properly, and discard single-use items, eg disposable syringes, towels, and underwear.

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7. Place contaminated linen in a leak-proof bag to prevent skin and mucous membrane exposure and contact. 8. Discard all sharp instruments and needles in a puncture-resistant container (needles should be discarded uncapped, or use a mechanical device for recapping). 9. Provide a private room if the patient’s hygiene places other patients at risk of infection. 10. Ensure that patients cover nose/mouth when coughing or sneezing; use disposable tissues to remove respiratory secretions. The tissues should be incinerated safely.

Principles of wearing gowns, masks and gloves The correct use of gowns, masks and gloves is essential for preventing the spread of infection. All staff, including doctors, paramedical staff, and cleaners, must be taught the correct method of using gowns, masks and gloves: this includes how to wear/put on and how to take off. It is very important to explain to patients the reason for isolation and to ensure good communication with them at all times, as this secures their cooperation. Gowns. The principles of wearing gowns include the following: • Handle on the inside only – the outside is contaminated by contact with the patient. • The gown must cover the nurse’s uniform. • The gown must be properly secured/fastened.When removing the gown, only the inside should be touched. • Wet or soiled gowns should be changed. • Always wash hands before and after removing the gown. Masks. The principles of wearing masks include the following: • Hands should be washed before donning the mask and before removing it. • The mask should fit properly over the nose; spectacles may be allowed to rest over the nose piece of the mask to prevent misting. • The mask should not be touched while it is worn. • The mask should be changed if it becomes soiled or wet. • Once masks have been removed, they must be properly disposed of. • The same mask should not be worn twice. Once taken off, it must be discarded.

JCTMSN_BOOK.indb 45

Gloves. The principles of wearing gloves include the following: • Only the inside of the glove should be handled – the outside of the glove is regarded as contaminated when gloves are worn as part of isolation precautions. • Gloves should be donned last, after the gown and mask have been put on. • A new pair of gloves should be put on if the first pair is punctured or torn. • When removing gloves, pull them off inside out so that the outside is not touched.

Safe administration of medicines Safe administration of medication begins with a legally valid prescription by a doctor or other registered person. The accurate interpretation of the prescription and the safe administration of the medication are also very important.

Principles of safe administration of medicines The legal validity of a prescription is ensured by the presence of the following: • The full name of the patient • The date and time of administration • The frequency and duration of administration • The generic name of the drug • The dosage to be given • The route of administration • The signature and designation of the doctor or prescribing person on the script; the entire prescription must be legible. A nurse should always be certain that they understand the prescription and the method and route by which the medication is to be given. A nurse should never give any medication to a patient if they are unsure of the order. Nurses have the right to question any order that they cannot read or understand or which they consider to be incorrect. The accountability for the execution of the prescription rests with the nurse. Type of order. The type of order is often indicated in abbreviations. Some of the commonly used abbreviations include the following: • ac (ante cibum) – before food • ad lib – as much as desired • bd – twice a day • c (cum) – with • c.m. (cres mane) – tomorrow morning • ex aqua – with water • mane – in the morning • o.m. (omne mane) – every morning • per os – orally (by mouth)

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• • • • • • •

p.c. (post cibum) – after food p.r.n. (pro re nata) – when necessary q.h. – every hour (hourly) q.i.d. or q4h – four-hourly stat (statim) – immediately t.i.d. – three times a day t.d.s. – three times a day by mouth

Medication must be given within 30 minutes of the time specified on the prescription. The exception to this is preoperative medication, which must be given exactly as prescribed. Dosages. It is essential for nurses to understand the dosages of the drugs that they administer to patients and how these dosages are calculated. Some drugs require the use of a protocol. Because of the dangers inherent in the administration of medication and the high probability of mistakes occurring, nurses should always check the dosage, route of administration and manner of administration with another colleague. If a nurse is at all unsure of a calculation, the calculation should be checked with the charge nurse or a competent colleague. The following is the principle of calculation of dosages: • Knowledge of the drug administered. In order to be able to monitor a patient’s response to the medication, the nurse must be aware of the expected beneficial effects of the medication as well as possible side effects and adverse reactions. Ensure that the route used is correct for the drug, eg pessaries are not given orally. It is for this reason that nurses are required to complete a course or module in pharmacology before they can be allocated the responsibility of administering medication. • Allergies, side effects and adverse reactions. Before giving any new drug to a patient, nurses should check the assessment record for any allergies, side effects or adverse reactions that have occurred in the past. The nurse should recheck with the patient before administering the medication to confirm the identity and any allergies of the patient.

Other safety precautions • Do not use medicines from unmarked or illegally marked containers. Do not use medicines that are discoloured or cloudy. Medicines that have formed sediment should also not be used, unless the medicine requires shaking before administration. Do not administer expired drugs to patients. • Medicines must not be left at the bedside of patients. The exception to this rule is patients who take medication p.r.n. (when necessary), eg nitroglycerin

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Clinical alert! Nurses should consider the five Rs when administering medication. These are the: 1. Right dose 2. Right drug 3. Right route 4. Right time 5. Right patient (Jones and Treiber, 2010) preparations or antacids, or patients who are on medication for their own specific use, eg eye ointment, inhalant or lotion. Check the hospital/provincial policy regarding this practice. • Although patients may be encouraged, in some institutions, to be responsible for their own medication administration, the nurse remains responsible for the safety of the patient and for whether that medication has been taken. The nurse must, therefore, be satisfied that the patient is able to cope with this responsibility. • Medicines must be kept out of reach of children and other patients, especially when patients are responsible for their own medication. • Special precautions must be taken for some drugs, eg checking and recording the pulse before giving digitalis.

Safe storage and control of medication • Keep all medication in locked cupboards or medicine trolleys – never leave an open medicine trolley unattended. • Medicines for external use must be kept separate from those for internal use. • Medicines should be stored at the temperature recommended by the manufacturer. • Never decant medicines from one container into another. • Labels indicating the name of the drug and instructions for administration must be clear and not stained. These labels usually denote the medicine mixture, eg ferrous sulphate. • In terms of the Medicines and Related Substances Control Act 14 of 2015, special controls are required for Schedule 5, 6 and 7 drugs, which must be adhered to.

Poisons Apart from medicines, many of the substances used in a healthcare institution are poisonous. The list below applies to all poisonous substances, including substances used for cleaning and disinfection. Safety measures that

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should be adhered to for the prevention of poisoning are the following: • Keep all poisonous substances locked away, out of reach of children. • All chemicals must be stored in bottles that are clearly labelled with the name of the chemical and the strength of the solution. • The bottles should be clearly marked ‘POISON’, with a lid that is tightly closed when not in use. • Poisons must never be decanted into other bottles. Chemicals for use in healthcare institutions, eg Savlon, should be mixed and dispensed by the pharmacist ready for use. This prevents damage to a patient’s skin by high-strength/concentrated solutions that have been incorrectly mixed. If solutions have to be mixed by a nurse, they should read the instructions carefully, wear gloves while mixing, and check calculations for dilution with a colleague. (See the first aid management of poisoning later in this Chapter.)

Falls Falls are a common cause of injury to patients in healthcare institutions, and frequently result in legal action being taken against the healthcare institution. The risk for falls increases with advancing age, confused and disoriented patients, those that are attached to equipment (such as intravenous therapy) or taking medication that causes cognitive alteration, or those who fail the ‘timed get up and go’ test. (See Box 4.3 for the TGUGT.) The risks for falls are reduced by the following factors: • Adequate supervision of all patients • Effective orientation of all patients to the environment, a call system, adequate lighting • Cot sides used to prevent restless or confused patients from falling out of bed (in some institutions it is policy that any patient over 70 years of age should sleep in a cot bed with the cot sides up, particularly at night)

• Frail, weak or elderly patients not allowed to get out of bed without assistance (beds in healthcare institutions are high, and it is very easy for a patient to hurt themselves if falling from a high bed) • Proper use of sedation and/or prescribed restraint for restless patients who may be inclined to try to get up and wander about if not sedated or restrained • Weak and ill patients always assisted when ambulating or moving from bed to chair or back again • Loose rugs and slippery or highly polished floors avoided; any spills on the floor wiped dry immediately • No moving of patients unaided if at all possible (this may result in patients falling to the floor and hurting themselves) • Provide ambulatory aids, eg walkers or wheelchairs • Adequate lighting, especially at night • Adequate opportunities for toileting.

Restraints Restraints are protective devices that are used to limit the physical activity of a patient or to immobilise an extremity. Restraints may either be physical or chemical. Physical restraints reduce the patient’s movement through the application of a device, for example a padded belt that can be used to tie down a patient and restrict movement. A doctor’s prescription is usually required for the application of a physical restraint, followed by meticulous monitoring and documentation by the nurse. Chemical restraints are drugs used to control the patient’s behaviour. Commonly used chemical restraints include anxiolytics and sedatives. A mild sedative may be prescribed to calm the patient. However, there may be times when sedation is contra-indicated, and the only way to protect a patient is to use physical restraints. Most people naturally resist restraint of any kind. It interferes with their ability to move about freely. For this reason, restraint is used, especially in adults, as a last resort and with great circumspection. In all cases, the nurse should first try to calmly explain the reasons for the restraint, irrespective of the mental state of the patient. This section will focus on the common types of physical restraints.

4.3  The TGUGT The ‘timed get up and go’ test (TGUGT) is used to assess functional mobility. The patient is timed while moving from a seated position to a standing position, walking 3 m, returning to the chair and sitting. Patients should be able to perform this test in 10 seconds or less. Those who require 20 seconds or more are considered to have mobility deficits and should be closely monitored for falls.

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Figure 4.1  Restraining sheet

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Restraints are used to: • protect the patient, eg to prevent a patient from falling out of a bed or chair • allow for treatment in a safe environment, eg while intravenous therapy is running • reduce the risk of injury to others, eg when confused and hitting nursing staff or other patients.

Medico-legal implications of restraints Mechanical means of bodily restraint may only be used for the purposes of surgical or medical treatment or to prevent patients from injuring themselves or others. The doctor must prescribe the type of restraint and state the reasons for using it. If, however, there is any chance that a patient may remove essential items such as a central line or an endotracheal tube, thereby creating a potentially life-threatening situation, the nurse should not hesitate to use restraints and obtain the prescription at a later time. If a patient is in full possession of their faculties, restraint may be viewed as assault and a charge may be laid against the hospital personnel. Restrained patients often become more confused, restless and anxious than before and they are more depen­ dent on nursing care. It is therefore important to assess the patient thoroughly and carefully before using restraints.

Figure 4.2  Wrist restraint

They may also be used to prevent such patients from scratching or picking at wounds. The restraint may consist of crêpe bandages, or ready-made wrist straps may be used. Boxing gloves or mittens. These restraints are applied for the same reasons as wrist restraints, but they are less restrictive. A very restless patient may still be able to remove lines and tubes. Boxing gloves must be firmly applied but must not be too tight, or circulation to the fingers may be compromised. Digits may also be injured if the patient is able to poke a finger through the boxing glove. Boxing gloves should be taken off and re-applied every 4–6 hours to allow the hands and fingers to be cleaned and exercised.

Common types of restraint The types of restraints that may be used are discussed below. Belt restraints. These restraints are applied to prevent patients from falling off a narrow trolley, X-ray table or theatre table. They may also be used to keep very weak, elderly or frail patients from falling out of a chair. The body of the patient is usually strapped onto the bed or stretcher with a belt. An alternative to belt restraints is a restraining sheet (see Figure 4.1). Wrist restraints. These restraints are applied to prevent confused patients, infants and children from removing essential lines, tubes, wires or dressings.

Figure 4.3  Boxing gloves or mittens

Finger restraints. These restraints are applied for the same reasons as wrist restraints or boxing gloves, but they are more comfortable for patients. It is quite easy for a patient to remove finger restraints, so the nurse needs to be vigilant and provide an explanation for the use of restraints. They may also be used as splints when fingers need to be immobilised. Mummy. A blanket or sheet that is folded around the child to limit movement. Mummy restraints are used to perform procedures on children.

Clinical alert! Restraints MUST be prescribed by the doctor.

Principles of using restraints Figure 4.4  Finger restraint

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• Explain the reason for using a restraint to the patient even if the patient does not appear to understand

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•

• • • •

•

•

• • • •

•

you. Reassure the patient frequently, as well as the significant others. Choose the restraint to suit the age and the condition of the patient. Allow them as much movement as possible. If the patient is restless, confused or aggressive, ask for help to apply the restraint. Apply the restraint securely but don’t cut off the blood supply. Pad bony prominences before applying the restraint to prevent friction to the underlying skin. Use knots that can be released quickly in an emer­ gency. Don’t use knots that will pull and tighten the restraint. The best knot to use is the clove hitch. Remove limb restraints every 2  to 4  hours. Provide skin care and put the restricted limbs through a full range of movements. Reposition the patient. Perform skin assessment, circulation and neurological tests every 2 hours, checking the skin colour, sensation, temperature, motion and capillary refill in the area distal to the restraint. Do not leave the patient unattended while the restraint is temporarily removed. Report any change in skin colour or condition, eg blue or white skin. Record and report any break in the skin. While the restraint is on, keep the patient’s limbs in a position of normal function. A daily record of restraints must be kept. The type of restraint used, the reasons for use, and the name of the consenting doctor must be recorded in the patient’s notes. In units where it is frequently necessary to restrain patients, such as intensive care units, a protocol which has been drawn up by the medical practitioner in charge of the unit may be used.

Clinical alert! Always remove the restraint at the earliest possible opportunity.

Safety of the person, good name and possessions of patients Ensuring the safety of the person, good name and possessions of patients is a major professional obligation of nurses in terms of professional legislation and ethical codes. The safety of a patient’s name should be ensured by protecting their privacy and and maintaining confidentiality of their affairs, as provided for in terms of ‘professional secrecy’, as defined in Regulation 767 (SANC, 2014). The safety of patients’ possessions,

JCTMSN_BOOK.indb 49

however, is an aspect of patient safety that is frequently overlooked. Civil liability suits against healthcare institutions due to patients’ possessions having been lost or stolen are avoidable if safety measures are followed. While a patient is in the care of the nurse in a health institution, the nurse is responsible for ensuring the safekeeping of the patient’s property as far as possible. Patients have the right to claim compensation from hospital/clinic authorities if they can prove that their property was lost as a result of negligence by the staff of the healthcare institution. Each healthcare institution will have its own policy regarding care of patients’ possessions, and nurses must function within the policies of their employing institutions. Many healthcare institutions will not accept responsibility for patients’ possessions if they believe this to be too risky or too costly. When such an exercise is undertaken, patients are asked to sign an indemnity form releasing the healthcare institution from this responsibility.

On admission Patients may keep personal items in their bedside locker, such as toiletries, spare night clothes, underwear, dressing gown and slippers, tissues, reading material, sweets and fruit, if allowed. Nurses must explain to patients, however, that the healthcare institution cannot accept responsibility for these items and that they are kept at the patient’s own risk. The rest of a patient’s clothing should be taken home. If the clothing is taken home, this must be recorded in the admission book or in a separate ‘kit’ book, and the name of the person taking the clothes and valuables should be noted. In some institutions, however, clothing may be stored in a locked cupboard or in the patient’s bedside locker under their own care (and at their own risk). Clothing may also be stored in a ‘kit’ room or cupboard set aside for that purpose and kept locked.

Kitting of clothes to be locked in a ‘kit’ cupboard/room Each item of clothing is carefully described and listed in a kit book. Do not use evaluative descriptions of clothing, eg an expensive leather jacket is simply described as a ‘brown jacket’. The patient signs to verify the accuracy of the inventory. The nurse witnesses the signature. All the items of clothing are carefully labelled, hung on hangers or placed in the patient’s bag or suitcase, or into labelled bags, and kept locked in the kit room.

Care of money and valuables The following are a few general principles relating to the care of money and valuables in a healthcare institution: • Valuables and money, other than some small change,

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should never be kept at the bedside, but should preferably be sent home with the patient’s relatives. If the valuables cannot be sent home, the following guidelines can be followed: –– Amounts larger than R20, cheque books, bank cards and credit cards are removed to a central safe in the hospital. A receipt is given to the patient. –– All other valuables are listed in a valuables book, eg rings, necklaces, earrings. Evaluative descriptions are avoided, eg a gold necklace is described as ‘a gold-coloured’ necklace. This is done to avoid an unscrupulous claim that an item returned is not the genuine article. The items are placed in a special envelope that is sealed in front of the patient. The valuables book is signed by the patient and witnessed by a registered nurse and one other person. The sealed envelope containing the valuables is then locked up in a valuables cupboard. • If a patient is admitted with no valuables, this fact is recorded in the book and the patient confirms this by signing. • A patient may choose to keep certain valuables at their bedside, eg spectacles, a watch, a wedding ring and small change. This must also be recorded. • Weapons of any description are removed on admission and locked away in a central safe. The patient is given a receipt. These include firearms, knives and cultural weapons.

Unconscious or disoriented patients All possessions for unconscious or disoriented patients, except necessary toiletries and sleepwear, are kitted or locked in the safe and/or valuables cupboard. It is essential that witnesses be present and that they sign the property books. The reason for the absence of the patient’s signature must be recorded. The patient’s possessions may be sent home, in which case the family must check the clothing and valuables and sign for them.

Patients going to theatre Remove spectacles, contact lenses, wigs, hairpieces, artificial limbs and dentures. (Some anaesthetists prefer that dentures be left in position. Check instructions, if any, from the anaesthetist or surgeon.) These items are removed immediately before going to theatre. Dentures are cleaned and placed in a clean bowl in the bedside locker. All valuables are removed, itemised and signed for in the valuables book. They are placed in an envelope and locked away. The valuables are returned to the patient on their return from theatre. If rings cannot be removed,

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they are covered with tape and the fact is recorded in the patient’s file and on the theatre forms. Valuables are returned to the patient when they have returned from theatre and are in an alert state and able to check and sign for them.

On discharge On discharge, a patient’s possessions are all checked and signed for in the property books. The patient is given a copy, the other copy stays in the book and the third goes into the patient’s file. Weapons, money and bank cards, etc, may be collected from the central safe on presentation of the receipt given to the patient or family on admission.

Death of a patient Toiletries and clothing are handed to the family after they have checked and signed for them. Valuables should be sent to a central safe for safe-keeping. They may only be handed over to a family member or to an executor appointed to handle the deceased patient’s estate. If rings cannot be removed from the body, they are left on and this fact is recorded in the patient’s file and on the paperwork that is sent to the undertaker. Later, the undertaker may be able to remove such rings and give them to the family.

Refusal of hospital treatment Although a patient does have the right to refuse treatment in a healthcare institution, safety guidelines still apply, and the staff should do their best to ensure that the patient will not be harming themselves by leaving the healthcare institution prematurely. Hospital authorities are entitled to insist that the attending doctor or other staff members discharge the patient between certain specified hours, eg 07:00 and 18:00. If a patient refuses to comply, hospital staff may not prevent the patient from leaving unless they are not mentally competent. Should the patient refuse hospital treatment, the National Health Act 61 of 2003 determines that the patient must sign a discharge certificate or release of liability if they refuse to accept the recommended treatment. Nurses should therefore: • inform the patient of any medical risks to which they may be exposed by refusing further treatment • record clearly in the patient’s notes the fact that the patient has refused hospital treatment and their reasons for doing so.

Identification of patients Correct identification of patients is vitally important in healthcare institutions to ensure that staff know who a patient is at all times, and that treatments and procedures are carried out on the correct patient. In most healthcare institutions, each patient is allocated an identification

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number, usually comprising their birth date in some form. A label or disc with the patient’s name and number must be attached to the patient as soon as possible after admission, usually on the wrist but sometimes on the ankle. The patient must be unable to pull it off. If an unidentified person is admitted, the label must record their hospital identification number. The name can be added later when they have been identified. Before carrying out any procedure or treatment, or before giving medication, the patient’s identity must be checked against their identification label. In many healthcare institutions, identification bracelets are frequently removed to allow for venepuncture and the setting up of intravenous access lines. It is vitally important, therefore, that identity bracelets be checked on a daily basis. If a bracelet has been removed, it should be renewed promptly. Identification bracelets also become illegible through wear and tear or wetting during bathing of patients. All illegible identity bracelets should be renewed.

First aid First aid is the initial treatment and assistance given to an injured or sick person before being attended to by a qualified healthcare professional. The aims of first aid are to: • provide initial care until definitive medical treatment can be accessed • prevent the condition from worsening • promote recovery (Elmagrabi, ElwardanAly & Khalaf, 2017). Common conditions requiring first aid include injuries, burns or scalds, suspected poisoning, snake bite, and near drowning. Only a limited scope of first aid measures will be discussed in this book.

Burns and scalds Burns are commonly caused by dry heat, eg open fires, or moist heat, eg steam and hot liquids. Burns can also occur as a result of chemical agents and electrical sources, including lightning. Radiation, eg sunburn and X-rays, can cause burns. Extreme cold, eg frostbite, can also cause burns.

Prevention of fires, burns and scalds The following preventative measures are applicable to both children and adults in the prevention of fires and burns: • Keep matches and lighters out of reach of children. • Candles and oil lamps should be secured and not left unattended.

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• Children, the elderly and people with epilepsy should be under adult supervision when near open fires. • All homes should have a fire extinguisher which is tested regularly. A bucket of sand is a cost-effective solution if a fire extinguisher is unaffordable. • As a precautionary measure, all homes should have smoke detectors, if possible. • Inflammable liquids, eg enamel paint, glue, paraffin, etc, should not be stored near a fire source. • Bath water for children and the elderly should always be tested for the correct temperature before bathing. • Smoking should be prohibited, with visible signage, next to inflammable objects or liquids, eg oxygen. • Electrical appliances should be properly maintained, and electrical equipment with cords that are frayed and exposed should not be used.

First aid management Burns and scalds • Apply cold or tepid water to the burnt area. • Do not puncture or cut the blisters. • Do not remove any adherent clothes. • Cover the burnt area with a clean sheet or blanket and transport the casualty to hospital. • Lay the casualty flat during transportation and reassure to allay anxiety. Electrical burns • Ensure that the casualty is no longer in contact with the electrical source, and discontinue the current by switching off the plug. • Seek medical attention. Chemical burns • If eyes are involved, flush the eyes with water. • Remove contaminated clothing. • Use protective gloves and clothing to protect yourself as a first aider. • Inform the paramedic or doctor about the nature of the chemical. Frostbite • Remove the casualty to a warm area and keep warm – the first aider’s body heat may also be used to keep the casualty warm. • Give a warm bath (not hot!). • Do not rub the affected area. • Give paracetamol to reduce or alleviate pain.

Poisoning Poisoning occurs when any poisonous substance enters the body through ingestion, by injection, through the

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skin, inhalation, etc, in sufficient amounts to cause harm to the body.

Assessment findings of poisoning The following factors can be taken into account in assessing whether the patient was poisoned: • History of accidental or intentional poisoning • Evidence of objects pertaining to the poison, eg container or bottle • Dizziness, drowsiness, disorientation, stupor or loss of consciousness • Dry mouth, nausea or vomiting when poison is ingested.

First aid management of poisoning • Identify the poison by asking the casualty or look for evidence. • If unconscious, place in the recovery position. • Establish or maintain an open airway. • Assess for signs of breathing, ie chest rising; listen to kind of breathing, eg stertorous (noisy or laboured) or stridor (wheezing); or place back of hand next to the mouth to feel for the movement of air in and out of the mouth if in doubt. • Check for the pulse and note the colour of the skin and mucous membrane. • Call for help. • Transport to the hospital, taking the evidence of the poisoning along. First aid management of ingested poisons • Vomiting may occur – ensure a clear airway in case, but do not induce vomiting. • Seek medical opinion. • Transport to hospital.

First aid management of inhaled poisons • Remove to a safe area with adequate ventilation. • Wear a mask to prevent inhaling the poisonous substances as well. • Call for medical assistance. • Transport to the hospital.

Conclusion Patient safety in a healthcare facility includes the safety of the person and their good name or reputation, as well as their belongings. Provision of safe patient care is a professional obligation for nurses in the healthcare setting. Patients become vulnerable to risks in the healthcare setting as a result of various factors that include patient age, level of consciousness, vulnerability to a disease, certain therapies or treatments, and human error. Patient safety is one of the key competencies of nurses. Therefore, nurses need to be aware that the clinical area is risk-laden and might compromise the safety of the patient. Patient safety issues are responsible for some of the litigation against nurses and healthcare facilities. Some inherent risks in the clinical area include injuries from falls, burns and scalds, infections, etc. Vigilance and adequate supervision are important in mitigating the ever-present threat to patient safety in the clinical area. Adherence to safety protocols and policies helps to promote the safety of patients. Observing the ethical and human rights dictates of patients also facilitates their safety. First aid measures are important in saving lives and reducing the degree of harm to the patient by the initial injury.

Suggested activities for learners Activity 4.1 Identify potentially hazardous aspects in your ward. Classify them under the following headings: • Patient-driven incidents • Therapeutic procedure incidents • Equipment-related incidents. Activity 4.2 Explain why the application of a restraint to a restless patient (who is at risk of injuring themselves or others) requires the doctor’s prescription. Activity 4.3 Describe the ‘timed get up and go’ test. Activity 4.4 Design a profile of patients who are at the greatest risk of falls in a hospital and suggest strategies to improve their safety.

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5

Hygiene and grooming needs

learning objectives

On completion of this Chapter, the learner should be able to: • demonstrate competency in providing for the hygiene and grooming needs of patients under your care • describe factors that influence hygienic practices amongst patients in a healthcare setting • interpret nursing assessment findings from –– history taking regarding personal and cultural hygiene practices –– examination of the skin surface, mouth, eyes, nostrils, ears, nails, hair, genitalia, perineal and anal areas • perform a complete examination and bathing of the neonate • implement nursing interventions designed to maintain hygiene in dependent adults and babies, eg bed baths, tub baths, showers and baby baths • record and report any abnormalities, eg bruises, jaundice, cyanosis, skin discolouration, oedema, etc, identified while providing for the hygiene and grooming needs of patients. key concepts and terminology

cerumen

Earwax.

dental caries

Rotten teeth.

dentures

Dental restorations.

halitosis

An unpleasant odour from the mouth, commonly referred to as bad breath.

hand hygiene

A general term that applies to hand washing, antiseptic hand washing, waterless hand sanitising or surgical hand scrub.

hygiene

The science of health and its maintenance.

sordes

Dry cracked dirt round the mouth composed of saliva, serum from sores and epithelial cells.

talons

Hard, long claw-like nails.

unkempt

Not groomed, untidy appearance.

prerequisite knowledge

• Anatomy and physiology of the skin • Microbiology and parasitology • Biochemistry and biophysics. medico-legal considerations

Patients who present with hygienic and grooming needs are usually dependent on healthcare workers to help them with activities for daily living and may be debilitated by ill health. They may therefore sustain a variety of injuries in the process of receiving care, such as burns from hot water used to wash them in a bath, shower or basin; fractures from falls if the cot bed is left open during bed baths or other forms of grooming; and abrasion

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and chafing from friction against wet or rough linen during position changes while giving a bed bath. The nurse must therefore keep these medico-legal hazards in mind and ensure that the water used for bathing is at a correct temperature, that the cot bed rails are closed when not in attendance, that the patient is kept dry, and that immobile patients are not dragged on the bed linen to change position. ethical considerations

The nurse must ensure privacy while providing hygiene and grooming care to the patient. The patient’s preferences should be taken into consideration, for example by enquiring about their preferred bathing times. The nurse must show respect and avoid unnecessary physical exposure of the patient to preserve the patient’s dignity and privacy. It has been noted that cultural differences in grooming behaviours are apparent early in life and maintained across a significant span of development. The patient must be kept clean and dry to promote selfimage. Basic hygienic practices should be practised for bedridden patients after using the bedpans. Use of hand wipes can be vital to prevent contamination of hands by micro-organisms. Aseptic techniques must be employed when invasive procedures such as catheterisation are done so that nosocomial infection is prevented at all times. essential health literacy

Body cleanliness is an activity for daily living. Keeping the skin clean is necessary to keep the skin healthy, and keeping clean and well groomed improves one’s image. People in the community must know that it is important to care for the skin and must therefore wash daily with a mild detergent, brush teeth and wear clean clothes for health reasons, and also for confidence in the company of other people. People must know that washing one’s body and changing into clean clothing will make one fresh with no untoward body odours. Taking a bath is also a form of therapy in that it is a form of exercise that freshens one and enhances rest and relaxation. Following a bath, skin should be kept soft and supple with correct lubricants and moisturisers. Hand hygiene should also be included in the personal hygiene of the patient and family members. Hands touch everything and they are a portal for infection. Therefore, to keep healthy, hands must be washed every morning and every time before touching food to eat or prepare and after using the toilet. Teeth must be brushed every day to prevent dental caries and to improve appetite.

Introduction Hygiene is the proper care of the whole body, the skin, hair, eyes, ears, nose, teeth, nails and hands to promote good health by protecting the body from infection and disease and to provide a sense of well-being. Hygienic care promotes cleanliness, provides comfort and relaxation, and improves self-image and a healthy skin. Patient hygiene also assists in providing for the safety of the patient and promoting the patient’s defence mechanism. When an individual is unwell, either physically or mentally, they are often unable to meet their own hygienic needs, and the nurse has to step in and assist. This is in line with the scope of practice of the nurse, ie to promote and maintain the hygiene and comfort of the patient. The nurse is responsible for maintaining safety, privacy and warmth when providing hygienic care or assisting patients in hygienic practices.

The meaning of hygiene Hygiene in general refers to the cleanliness of the body and the environment. Personal hygiene is determined by

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individual values and practices, and is therefore unique to each individual. Individualised care is often based on these practices and needs. Hygiene and grooming are influenced by a number of environmental and cultural factors. Personal hygiene includes bathing, skin care, hand washing, perineal care, foot and nail care, mouth or oral care, hair care, and eye, ear and nose care.

Factors that influence hygienic practices Hygienic practices are influenced by a number of factors, including developmental stage, body image, religion, social and cultural practices, personal preferences, physical factors, socioeconomic status and knowledge.

Developmental stage Children learn most of their hygiene practices at home and in their personal environment. They modify their behaviour as they grow up, imitating family members. Many of these behaviours stick with them throughout life. With advancing age, hormonal levels and changes in the integumentary system often require hygienic practices.

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Body image As body image is a subjective belief about a person’s own physical appearance, it may be distorted due to illness or a surgical procedure. The nurse should assist the patient to maintain hygienic practices in accordance with the patient’s belief about themselves prior to the illness, and assist the patient to adapt to the current situation as well.

Religion Each religion observes specific rules related to personal hygiene. Most religions subscribe to cleanliness of the body, clean clothes and hand washing.

Social and cultural practices Norms related to hygiene practices differ between cultures. Cultural competency should be cultivated by the nurse in order to provide culture-congruent care to each patient. Patients are educated by family members during childhood regarding hygiene. Older adults are often influenced by a wider network of people in society, eg co-workers, friends, etc. Daily bathing routines and measures of hygiene may differ depending on individual cultural preferences. The nurse should not be judgemental about individuals and should provide appropriate care to each individual.

Personal preferences Some patients may prefer to take a bath in the morning, some may prefer it in the evening as it facilitates relaxa­ tion and sound sleep, and others may prefer to bath every 2 days.

Physical factors People may be prevented from attending to personal hygiene by circumstances that make them unable to accomplish the mechanisms of bathing. Unconscious patients, amputees, paraplegic people, babies and children usually require assistance with hygiene from nurses, caregivers and family members. Other factors may be postoperative incisions or plaster casts as a form of treatment.

Socioeconomic status Financial status often affects a person’s ability to purchase hygiene products. Toothpaste, deodorants and other toiletries may be very expensive for some individuals. Patient advocacy by the nurse is required to provide the patient with such basic needs.

Knowledge An understanding of the relationship between hygiene and health is vital. Illness or surgery may result in changes

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to basic hygiene practices. Some patients may lack knowledge of hygiene and must be encouraged to function at their highest level of independence, especially with regard to self-care, and must appreciate that keeping their bodies clean is a habit to be practised daily.

Nursing assessment of hygiene and grooming A systematic head-to-toe assessment is necessary in respect of a patient’s general state of hygiene and grooming. During the assessment, the nurse should note all aspects pertaining to the hygiene and grooming of the patient. In addition, the nurse should be aware of the patient’s attitude toward their own cleanliness and their own individual hygiene and grooming habits. The purpose of the assessment is also to collect information about a person’s ability to maintain their own personal hygiene. Factors to keep in mind and which may influence an individual’s personal hygiene regime are described below.

Skin Assess the patient’s skin in the following manner: • Assessment of the skin should be performed on admission to assess the risk for pressure ulcers. • Note the general condition and cleanliness of the skin. Ingrained dirt on the exposed areas of the body may indicate an outdoor occupation or homelessness. Skin folds such as the groin and under the breasts should be inspected. Excoriation – scratch marks – in these parts may indicate long-standing dirt and irritation from sweat. Skin fold areas should also be inspected for parasites such as lice, which like to congregate in warm areas of the body. The underlying skin should also be examined in patients who are wearing corsets or braces. • Note lesions and whether the skin is moist or dry.

Hands and nails Perform the following assessment of the patient’s hand and nails: • Ascertain the cleanliness of both hands and nails. Dirt under the fingernails may be due to a patient’s occupation and is not necessarily an indication of poor hygiene. Many smokers develop a yellow nicotine stain between the index finger and the middle finger, and the presence of such a stain is a strong indication to the nurse that the person smokes. • Examine the condition of the nails. Nails that are bitten may indicate anxiety, or nail biting may simply be a bad habit. Ragged, poorly trimmed toenails can be a hazard as they may catch on socks and stockings, and may also press against other toes, causing ulcers.

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Clubbed nails are associated with a number of diseases mostly of the heart and the lungs. • Thickened, horny toenails of old age can be very difficult for the patient to trim unaided. When such toenails are left to grow, they easily become long clawlike talons that twist and wrap themselves around the toes. Once this has happened, the offending toenails are extremely difficult to trim. • Try to determine the patient’s hand-washing routine.

Hair The condition of the hair usually contributes to the morale, appearance and body image of an individual. Hair care, including beards in men, consists of shampooing, brushing, combing, braiding and shaving. Hair is assessed in the following manner: • Observe the style and length of the hair as this gives an indication of the care the patient takes with their appearance. • Examine the condition of the hair. Dry and fluffy hair may indicate a lack of attention to conditioning and general care of the hair, and may also indicate poor nutrition. Hair that is greasy and smelly indicates poor care, ie hair is not being washed often enough. Inspect the hair for dandruff, as well as for the presence of head lice. Note areas of baldness. In men above the age of 40 baldness is usually normal, and bald patches may also sometimes be seen in elderly women. • Ask the patient about their hair-washing routine.

Mouth and teeth Mouth care includes the removal of food particles and secretions by brushing and rinsing the mouth and teeth to prevent bad breath (halitosis), feelings of uncleanliness and dental caries. Oral hygiene promotes a better appetite and maintains a healthy state of the mouth, gums, teeth and lips. Oral hygiene is a very important aspect of general hygiene and basic care. Most individuals maintain adequate oral hygiene through brushing their teeth and rinsing their mouth twice a day. However, the presence of dental caries, as well as excessive plaque around the teeth, indicates poor oral hygiene. Swollen red gums indicate gingivitis which accompanies poor dental hygiene. In a hospitalised patient or an ill patient being cared for at home, oral hygiene can become a problem and a source of complications. With unconscious patients, mouth care should be provided at least every 8 hours. If the patient is mouth breathing, perform mouth care every 4 hours, as mouth breathing causes the tongue to be dry and become crusty. • In the mouth, assess for dryness of the mucous membrane and examine for the general condition of

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the teeth. Normally the mouth should be moist and the tongue should not be furred but should have a bright pink colour. A furred tongue is frequently seen in ill patients who are not eating and/or drinking adequately. White plaque may be patches of oral thrush, which is often seen in immune-compromised patients, and those on steroids. • The odour of the breath, if any, should be noted: –– Halitosis is detected where oral hygiene is poor. Halitosis may also assist in the diagnosis thereof. –– A ‘dead mouse’ smell is detected in liver disease. –– A sweet smell or an odour of apples or nail varnish remover indicates the presence of ketones and suggests poorly controlled diabetes mellitus. • Patients with dentures or bridges who are bed-bound, comatose or weak, or who have trouble with hand and finger dexterity, may need assistance to care for their dentures.

5.1  Predisposing factors to oral problems • Disease conditions –– Diabetes mellitus –– HIV and Aids • Treatments or therapies –– Some antibiotic (cause oral thrush) –– Steroids –– Medication like phenytoin –– Chemotherapy (may also cause oral thrush) –– Radiotherapy –– Oxygen therapy • Other factors –– Inability to care for oneself due to illness, eg unconsciousness –– Limited fluid intake –– Dehydration –– Inadequate intake of food or malnutrition –– Mouth breathing (as in blocked nose due to colds and flu).

Eyes In a healthy individual hygiene of the eye is seldom a problem, and individuals do not normally have a specific routine for eye care. Frequent eye care is necessary for unconscious patients, ie eye-swabbing and installation of artificial tears to prevent drying. The eyes normally take care of themselves. The lacrimal gland produces lacrimal fluid (tears), which moisten the surface of the eye, lubricate eyelids and wash away foreign bodies. Tears contain lysosomes, which are capable of breaking up bacteria and foreign bodies.

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Through this process, the eyes are able to take care of themselves. However, in poverty-stricken communities where environmental hygiene and the nutritional status of the community are poor, children may develop matted sticky eyes. This can lead to chronic irritation of the eyes, leading to visual problems later in life. During assessment, the nurse should look at the condition of the eyes, eyelids and eyelashes, noting any encrustations, drainage problems or redness of the eyes. Styes or small abscesses of the eyelashes are frequently seen in poorly nourished or immuno-compromised patients. Chronically red eyes are often an indication of eye strain, and the patient should be advised to have their eyes tested.

Ears Hearing acuity may be affected if cerumen or foreign material collects in the external ear canal. Remove these materials by gently washing the external ear canal with a warm wash cloth. No object, including cotton-tipped applicators, should be inserted into the ear canal. For patients who use hearing aids, the earpieces must be cleaned with soap and water daily.

Genitalia When assessing hygiene, it is essential to examine the genitalia as that assists in detecting clinical problems before they complicate. • Examine the general state of the cleanliness of the genitalia. The skin should be pink and moist and should appear clean. A faint musky odour may be detectable, which is normal. Excessive secretions caked in the skin folds should be noted, as this indicates inadequate hygiene. • Note any offensive odour or discharge from the urethral meatus or the vagina in women, as these usually indicate infection. • Note any white patches on the labia or under the foreskin, which may be due to thrush. Thrush may be due to diabetes mellitus or it may indicate candidiasis and moniliasis common in patients with HIV/Aids. • Note a red excoriated groin and vulva. This may be seen in elderly women who are diabetic. The irritation is due to the presence of glucose in the urine. Meticulous hygiene of the area as well as control of the diabetes is required to resolve the problem. • Note any lesion or sores and report these promptly. Sores and lesions on the genitals are invariably an indication of the presence of sexually transmitted infection or diseases. The patient and their sexual partner(s) should be treated as soon as possible.

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Maintenance of hygiene and grooming in patients unable to help themselves Daily hygiene and bathing is an important aspect of basic nursing care. Bathing the patient removes perspiration (which may increase in some illnesses), accumulated oil, dead skin cells and some bacteria. A warm bath also stimulates the circulation and is soothing and relaxing for the patient. A daily bath further affords the nurse an excellent opportunity to assess the patient. During the daily bath, the nurse should not only bathe the patient, but also carry out basic grooming tasks such as brushing of hair, shaving in men and applying deodorant or aftershave lotion. These actions will make the bath refreshing for the patient and improve their morale, appearance and selfrespect. Patients who are unable to help themselves need to be bathed by the nurse; if the patient is able, they should be assisted by the nurse. The dignity of the patient must always be maintained, and exposure of their body must be minimised. While protecting the bedclothes with towels, the nurse exposes and washes each limb or area of the body separately, beginning with the face and ending with the genitalia and the anal area. If the patient is able, they may prefer to wash the genitalia unaided.

Clinical alert! For a female patient, cleanse the perineal area from front to back. For a male patient, cleanse the urinary meatus by moving in a circular motion from front backwards around the glans.

Figure 5.1  A bed bath

The nurse should, as far as possible, follow the patient’s own practices and preferences, for example using soap on the face or not, or using separate washcloths for face and body. During the bath, skin fold areas should receive special attention and should be dried well, as these areas become irritated if left damp. The nurse should also pay

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particular attention to the area under the breast in women who are obese or who have large breasts. After washing the patient, the nurse should also take the opportunity to apply face and body creams, deodorant, aftershave or talcum powder, taking care not to apply too much talcum powder as the powder may become caked in skin fold areas and cause irritation.

Clinical alert! A beard or moustache should not be shaved off without the patient’s consent. Men who are normally clean-shaven should be shaved at least every other day. When using a razor to shave a patient’s beard, apply shaving cream or shaving soap and water first to soften the bristles and make the skin more pliable. Hold the blade at a 45-degree angle to the skin and shave in short, firm strokes in the direction of the hair growth. Hold the skin taut, particularly around creases, to prevent cutting the skin. After shaving the entire area, wipe and wash the patient’s face with a wet face cloth to remove any remaining shaving cream and hair. Dry the skin well, then pat aftershave lotion on with the fingertips or apply powder in accordance with the patient’s preference. The beard of those men who do not shave should be kept trimmed and clean. A beard or moustache may not be shaved off without the patient’s consent, unless removal of the beard is essential for treatment and care, eg if a tracheotomy tube is in situ. During the daily bath, the nurse should clean under the patient’s nails or cut and trim the nails if necessary. To do this, a kidney bowl or bath towel is placed under the hand. The nail is cut or filed straight across beyond the end of the finger or toe. Avoid trimming or digging into nails at the lateral corners, as this predisposes the patient to ingrown toenails if done on the foot. Patients who have diabetes or circulatory problems should have their nails filed rather than cut. The daily bath is an ideal opportunity for the nurse to give individual attention to the patient, to talk to them, and to develop a good nurse–patient relationship. To maintain the condition of the hair, it should be brushed daily, particularly if the hair is long, as long hair mats and tangles easily if the patient is confined to bed. Dry shampoo can be used to reduce greasiness in the hair of the patient who is confined to bed, but it is usually preferable to actually wash the hair. After bathing the patient, it is usual for the nurse to refresh the patient’s bed linen, or to change the bed linen entirely. If the patient is bedridden, the nurse moves them from side to side or up and down in order to change the

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bottom sheet and draw sheet. Depending on the condition of the patient, they may be seated out of bed while the nurse changes the bed.

Hand hygiene by patients Patients and their families should be encouraged to practise hand hygiene while in hospital. Patients are encouraged to wash their hands after using the toilet, commode, urinal, or bedpan. This is to prevent the risk of their hands becoming contaminated with faecal organisms, eg E. coli. Patient hand wipes should especially be provided to bedridden patients. Nurses should ensure that soap and towels are always available for use at the sinks for ambulant patients.

Research alert! In a hospital in Dundee, Scotland, a study was undertaken to explore nurses’ and patients’ perceptions towards hand hygiene and determine whether patients who required assistance with their hand hygiene were encouraged and offered appropriate facilities at appropriate times. It was found that although 100% of nurses and 95% of patients believed that hand hygiene was an important part of controlling and preventing the spread of infections, only 64% of nurses reported having offered patients the opportunity to practise hand hygiene (Burnett, 2008). Hand hygiene should also be practised meticulously by nurses. Artificial nails should not be worn when handling patients. There is documented proof of outbreaks of infection due to Gram-negative bacteria and fungi, which is associated with artificial nails (Burnett, 2008).

Hair washing Washing the hair of a patient in bed can be quite an undertaking. A fairly easy way to do this is to follow the procedure below (see Figure 5.2): • Pull the bed away from the wall. • Pull the mattress down to expose enough of the spring to rest a basin on. • Where possible, shift the patient up in the bed until the head is at the top edge of the mattress, with the hair hanging over the edge. • With the patient thus positioned, a basin can be placed on the exposed spring to make a backwash, and the hair is then washed using a jug and basin. The bedclothes must be protected with towels or with a plastic sheet while the hair is being washed.

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African hair that has not been straightened or styled in any way will normally remain tightly curled and close to the head, but the hair does occasionally need to be conditioned, as it tends to be dry and brittle. African hair should be gently combed every day using a wide-toothed ‘Afro’ comb. Braided hairstyles should simply be left in place and can be washed as is. Do not undo braided hair without the patient’s permission. After washing the hair, it should be dried well, using a towel and a hairdryer if available.

Clinical alert! • Avoid home remedies for eye problems, such as rinsing the eyes with urine to treat a stye, for example • A patient should not try to remove a foreign body at home • If dirt or dust gets into the eyes, clean with plenty of clean, tepid water or saline • If the irritation continues, consult the professionals

lenses re-inserted until they have recovered. If the patient is unconscious and is known to have contact lenses in, these should be removed. If the nurse is unable to remove them, an ophthalmologist should be called in. Once removed, the lenses should be kept safely or sent home with the patient’s family.

Figure 5.2  Washing a patient’s hair

Hygiene of the eyes, ears and nose General eye care

Eyes are very delicate and should be treated with care. If irritated with particles of dust or any other foreign body, rinse with plenty of clean water. If the irritation persists, a medical practitioner should be consulted. Dried secretions that have accumulated on the eyelashes need to be softened and wiped away as follows: • Place a sterile cotton wool ball moistened with sterile water or normal saline over the lid margins. • Wipe the loosened secretions from the inner canthus of the eye to the outer canthus to prevent the particles and fluid from draining into the lacrimal sac and nasolacrimal duct. • If the patient is unconscious and lacks a blink reflex or cannot close the eyelids completely, drying and irritation of the cornea must be prevented. Lubricating eye drops may be administered if ordered by a physician. The eyes of an unconscious patient should be kept closed to protect the cornea: this can be done by means of eye pads, or by holding the edges of the eyelids together with a non-irritant tape. Contact lens care. Contact lenses should be stored in a case when not in use. Contact lenses may be hard, soft or gas-permeable. Most patients normally care for their own lenses. They learn a care method that best suits them from their eye specialist. Seriously ill patients whose contact lenses have been removed will not need the

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Artificial eyes. Patients may have an artificial eye that is either permanently implanted or removable. Artificial eyes are usually made of glass or plastic. An eye that is not implanted needs to be removed daily for cleaning. Most patients who wear a removable artificial eye follow their own care regimen. For an unconscious patient, daily removal and cleaning is not necessary. If the nurse notices problems (eg redness of the surrounding tissues, drainage from the eye socket or crusting on the eyelashes) or if the patient is scheduled for surgery, the nurse must remove the eye from the socket; clean the eye with normal saline, and the socket and surrounding tissues with warm tap water or saline; and then re-insert the eye. Patients whose mobility is impaired by injury or paralysis may also require assistance. In addition, the nurse must determine the patient’s routine eye care practices so that these can be followed.

Ear care Normal ears require minimal hygiene. Patients who have excessive cerumen (earwax) and dependent patients who have hearing aids may require assistance from the nurse. The auricles of the ear are cleaned during the daily bath. The nurse or patient must remove excessive cerumen that is visible or that causes discomfort or hearing difficulty. Visible cerumen may be loosened and removed by retracting the auricle downward and outward and the cerumen extracted with a dissecting forceps. Patients need to be advised never to use matches, bobby pins, tooth picks or cotton-tipped applicators to remove cerumen. Bobby pins and toothpicks can injure the ear canal and rupture the tympanic membrane; cotton-tipped applicators can cause wax to become impacted within the canal.

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Hearing aids. Hearing aids amplify sound and must be cleaned daily. Hearing aids must be removed before surgery. To ensure proper functioning, hearing aids must be handled appropriately during insertion and removal. Do not drop or bump hearing aids because this can cause damage. Hearing aids should be stored in their case to prevent damage and accumulation of dust and dirt when not in use. Clean the earpiece with soap and water daily to prevent build-up of wax and debris. If not in use, the battery cover should be opened so that the battery disengages.

Nasal care Excessive nasal secretions can be removed by inserting a cotton-tipped applicator moistened with water or normal saline, or by applying suction. A cotton-tipped applicator should not be inserted beyond the length of the cotton tip. The nares of patients with nasal tubes should be cleaned with a moistened cotton-tipped applicator to prevent the accumulation of secretions around the tubing.

Oral hygiene and mouth care Normal care

Oral health is essential to general health and well-being at every stage of life. Where possible, maintain a normal oral care routine and ensure that the patient’s teeth and mouth are kept clean by means of brushing and rinsing. Commercially available toothpaste can be used, or an effective dentifrice can be made by combining two parts of table salt to one part of baking soda. When cleaning the teeth, the sulcular technique should be used, as this is the most effective way to clean the teeth and remove plaque. See Box 5.2 on this method. Flossing of teeth is especially beneficial in preventing the formation of plaque and removing it from the teeth, particularly at the gum line.

Care of dentures If a patient is incapacitated, elderly, confused, or confined to bed, care of dentures becomes the nurse’s responsibility. To remove dentures: • Wear gloves and, using a piece of tissue or gauze to prevent slipping, grasp the dentures at the front with the thumb and index finger and slide them out of the mouth. • To remove lower dentures, turn the denture slightly and remove by pulling the denture out between the lips, one side at a time. Partial plates and removable bridges may also need to be taken out by the nurse. • Clean dentures with a toothbrush, a dentifrice and tepid water. Please note that dentists discourage the use of toothpaste on dentures, because it is corrosive

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on the dentures and causes scratches, which are good hiding places for micro-organisms.

5.2 The sulcular method of how to brush teeth • Moisten the bristles of a soft toothbrush with tepid water, and apply the toothpaste or dentifrice. • Hold the brush against the teeth with the bristles at a 45-degree angle. The tips of the outer bristles should rest against and penetrate the gingival sulcus. Then brush with clean strokes under the sulcus of two or three teeth at one time. • Move the bristles back and forth, using a vibrating or jiggling motion, from the sulcus to the crowns of the teeth. • Repeat until all outer and inner surfaces and sulci of the gums are cleaned.

Unconscious and seriously ill patients Mouth care for unconscious or very ill patients is very important, since their mouths tend to become dry, and the lips, gums and tongue become coated with a combination of saliva, micro-organisms and epithelial cells known as sordes. A dirty or dry mouth is predisposed to infection. Dryness in the mouth occurs when the patient cannot take fluids by mouth or is breathing through the mouth or is on oxygen therapy, which tends to dry the mucous membranes. The mouth of an unconscious or helpless patient is cleaned using gauze swabs, or commercially prepared applicators. All the surfaces of the mouth are wiped clean, and any solids are gently removed. Some nurses advocate cleaning the mouth using a toothbrush and toothpaste and then rinsing with a mouthwash, which is then removed using a suctioning apparatus. Other preparations that may be used to clean the mouth include lemon juice mixed with oil, sodium bicarbonate and plain mouthwash.

Genital hygiene The genital area is a moist dark place where bacteria may thrive if proper hygiene of the area is not maintained. Although it is a vital task, a nurse may find this task embar­ rassing, especially if the patient is not able to maintain adequate hygiene of the area and is of the opposite sex. The genitalia should be washed with soap and water, and then dried thoroughly. In a female patient, the vulval area and the labia majora should be cleaned first, then the labia are spread to wash the folds between the labia majora and the labia minora. For menstruating women and patients with indwelling

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catheters, use cotton wool balls or gauze squares (use a clean cotton wool ball or gauze square for each stroke). In a male patient, the penis should be washed well and dried. If the patient is uncircumcised, pull back the prepuce (foreskin) to expose the glans penis for cleaning. Replace the foreskin after cleaning the glans penis. The scrotum should also be washed and dried. The nurse should carefully inspect the area around the urethra in patients who are catheterised to check for intactness of the urethral orifice. Protective ointments can be applied to the urethral area if necessary.

The maintenance of hygiene in neonates and infants Daily bathing of a neonate/infant A daily bath is important for both the caregiver and the baby, as it is an occasion for touching, cuddling and communicating, all of which play an important role in the baby’s development. The daily bath is also an excellent opportunity for the nurse to assess the baby: • The infant’s overall size and shape are immediately apparent, as is the relative size of the head, extremities and trunk. Microcephaly or cranial enlargement is obvious. If hydrocephalus is present, the forehead is often very prominent. • The baby’s posture and the posture of the limbs should be examined. Normal flexion of the extremities indicates good muscle tone. Lack of flexion is associated with flaccidity, whereas excessive flexion usually suggests hyper tonicity (spasticity). • Skin colour and condition are observed. Jaundice, pallor, rash, cyanosis and evidence of trauma must be reported and recorded. • The facial expression should be noted. • Evaluation of respiration should be part of the nurse’s overall inspection: at rest, a normal neonate breathes at a rate of 30 to 40 breaths per minute, with no rib retraction or flaring of the nostrils. Following the initial observation, the baby is taken out of the bath to be dried on the table or bed. During this period, the following is done: • The abdomen is palpated gently to detect distension or any obvious masses. • The major pulses and the apical pulse are palpated by placing the hand over the baby’s heart. • The vertebral column is palpated to feel for any obvious abnormalities. • The genitalia are dried and examined to detect any obvious abnormalities.

The normal umbilical cord is bluish and moist at birth. Within 24 hours it begins to dry and becomes dull and yellowish-brown. Later it turns black and shrivels considerably. After birth, the cut section of the cord reveals three blood vessels (two arteries and one vein). A single umbilical artery could be a reason for other congenital malformations of any type. If meconium has not been passed by the end of the first day of life, patency of the anus should be ascertained by inserting the tip of a thermometer or thin catheter for a distance not in excess of 1 cm (this is routinely done with the first bath).

5.3  General principles of a baby bath • Prevent cross-infection between babies, and between the nurse and the baby. • Prevent physical injury to the baby, through falling or having the bath water too hot, which will burn the baby. The temperature of the water should always be tested before bathing the baby. A simple way to do this is to use the elbow. The baby must be securely held at all times during the baby bath – a healthy baby can roll off a counter top in no time if left unattended. • Prevent excessive cooling of the baby. • Stimulate the baby by touching and communicating with the baby.

5.4  How to perform a baby bath 1. Undress the baby but leave the nappy on. 2. Spread two towels on a countertop or bed. 3. Securely wrap the baby in the first towel to prevent kicking and struggling. 4. Pick up the baby and tuck them under the arm. 5. Place your thumb and middle finger over the baby’s ears. 6. Keep the baby’s head over the edge of the washbasin and wet the head and hair with the right hand. 7. Apply baby shampoo to the head. Massage the head gently with the fingertips. 8. Rinse the head thoroughly. 9. Place the baby on the work surface and dry the hair. Give special attention to the neck and behind the ears. 10. Next, loosen the towel, without overexposing the baby. 11. Remove the nappy. ❱❱

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12. Use the washcloth or hands to lather the body with soap in the following order: • Anterior neck area, chest and abdomen • Arms from the pulse joint to the axilla • Feet and legs, while washing in the direction of the groin • Turn the baby to the side and lather the back from top to bottom • Lather the genitalia and buttocks last. 13. Lift the baby by placing your left hand under the axilla furthest away. The head and neck of the baby must rest on your left lower arm. Place your right hand on the baby’s thighs and lift the legs. 14. Lower the baby into the washbasin. 15. Wash the baby’s hands (one at a time) with soap and rinse. 16. Allow the baby time in the water to play and kick while washing the soap off. 17. Remove the first towel and rearrange the second towel in readiness to receive the wet baby. 18. Lift the baby out of the water in the same manner the baby was placed in the water. 19. Place the baby on the towel and gently dry the baby. Place on its side and dry the back. 20. Give special attention to the axilla and groins. 21. Place a nappy under the buttocks. 22. Dress the baby quickly to avoid exposure. 23. Apply petroleum jelly to the buttocks to prevent ammoniac dermatitis before securing the nappy. 24. Communicate and talk with the baby during the entire bathing procedure. This will make you and the baby feel more relaxed and will enhance a feeling of security in the baby.

Changing of nappies Babies and infants are incontinent until control is esta­ blished over bowels and bladder by ±2 years of age. Until

then, the baby needs to be kept clean and dry by the parents or caregivers after bowel or urine elimination. When the nappy is wet or dirty, it should be changed and the buttocks and perineum cleaned as follows: • First, the nappy is removed and discarded appropriately. • The perineum and buttocks are thoroughly cleaned using a soft wet cloth (warmed if necessary), tissues or wet wipes. • Barrier cream or Vaseline can be applied to the buttocks and perineum to prevent nappy rash. • Once the baby is clean and comfortable, a fresh clean nappy is put on.

Conclusion Good hygiene or personal cleanliness not only helps maintain a healthy self-image but is also important in preventing the spread of infections and disease. Hygienic care promotes cleanliness, provides comfort and relaxation, improves self-image, and promotes healthy skin. Personal hygiene, throughout the lifespan, includes bathing, skin care, perineal and genital care, foot and nail care, mouth or oral care, hair care, and eye, ear and nose care. Hand hygiene should also be encouraged as part of the hygiene of the patient and the family when visiting a health facility. Hand hygiene is the most effective way of minimising healthcare-associated infections. Attending to the hygiene of a patient also affords the nurse an opportunity to observe the patient and to detect abnormalities. The patient and their environment, including the bed they lie on, comprises a unit, which needs to be maintained in a hygienic manner. Hygienic practices are influenced by body image, developmental stage, social and cultural practices, personal preference, socioeconomic status and knowledge. Individualised personal hygiene and grooming may be necessary in order to address the needs of the patient adequately.

Suggested activities for learners Activity 5.1 Describe the three things you would do to promote your patient’s comfort during a complete bed bath. Activity 5.2 Outline the importance of hygiene. Activity 5.3 Give an outline of a talk you will give to a young parent regarding the principles of a baby bath. Activity 5.4 Outline the factors that influence individual hygienic practices.

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6

Nutrition needs

learning objectives

On completion of this Chapter, the learner should be able to: • describe the characteristics, functions and sources of nutrients • describe the nutritional requirements during each phase of the lifecycle • describe nutritional needs related to specific conditions • assess a patient’s nutritional status • prepare, implement and evaluate a care plan related to specific diets • describe the health education related to specific conditions. key concepts and terminology

anaemia

A condition characterised by low levels of haemoglobin in red blood cells, caused by a deficiency of iron, vitamin B12 or folate, or chronic disease.

anthropometry

The use of body measurements (such as weight, height, mid-upper arm circumference, etc) to assess the nutritional status of a person.

body mass index

A formula that compares weight with height, indicating whether a person is underweight, a healthy weight or overweight, and the degree thereof.

breast milk substitute

Any food or drink marketed as a partial or complete replacement of breast milk, whether suitable for that purpose or not (including infant formula, tea, juice, cereal, etc).

cautious feeding

The careful introduction of special formula feeds immediately after a child with severe acute malnutrition has been stabilised. Due to the child’s fragile physiology, the diet is low in protein, fat and sodium but high in carbohydrates so that it provides just enough nutrients for physiologic processes.

catch-up growth

A phase of rapid weight gain during the rehabilitation of a child with severe acute malnutrition. This is achieved by providing a high intake of nutrients once the stabilisation phase is complete and the child’s appetite has returned.

cholesterol

A fat-like substance that is both produced by the body and found in foods of animal origin.

complete proteins

Foods that contain all the essential amino acids in the correct amounts to meet the body’s needs.

complementary foods

Any food (liquid, semi-solid or solid) given to children in addition to breast milk or replacement feeding to meet their nutrient needs from the age of six months onwards.

diet history

Information on regular eating patterns, including food likes and dislikes, portion sizes, meal patterns, frequency with which foods are eaten and food availability.

enteral nutrition

Providing nutrients into the gastrointestinal tract through a tube when oral intake is insufficient to meet nutritional needs.

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enzymes

Chemical substances that regulate chemical reactions in the body.

essential amino acids

The building blocks of proteins that cannot be made by the body and need to be consumed through food.

exclusive breastfeeding

Feeding only breast milk and no other foods or fluids, including water, with the exception of drops or syrup consisting of vitamins, mineral supplements or medicines as prescribed by a doctor or nurse.

food security

A situation where all people at all times have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life.

growth faltering

When a child does not gain adequate weight according to the growth curve over 3 consecutive months.

growth monitoring and promotion

Regularly measuring, recording and interpreting a child’s growth to counsel, take action and follow up results with the purpose of promoting that child’s health, development and quality of life.

hyperemesis gravidarum

Nausea and vomiting that continue throughout pregnancy, causing dehydration, electrolyte imbalance and an inadequate intake of nutrients.

incomplete proteins

Food sources that are deficient in (or have limited amounts of) one or more essential amino acid(s).

kilojoule

Unit to measure the amount of energy in foods.

low birth weight

A birth weight less than 2 500 g.

macronutrients

Nutrients needed by the body in large amounts, classified as carbohydrates, proteins and lipids (fats and oils).

malnutrition

Impaired health due to a deficiency, excess or imbalance of nutrients, including overnutrition (excess energy and/or nutrients) or under-nutrition (deficiency of energy and/or essential nutrients).

metabolism

All chemical processes involved in the breaking down and utilisation of nutrients by the body.

micronutrients

Nutrients that are needed by the body in small amounts for tissue growth and maintenance, classified as vitamins or minerals.

mixed feeding

Giving breast milk as well as other milks (like commercial formula or home-prepared milk), foods or liquids (like water, tea, juice, etc) to a child younger than six months.

nasogastric tube

A feeding tube that is passed into the stomach via the nose, pharynx and oesophagus.

noncommunicable disease

A condition that is not infectious but chronic in nature, progressing slowly and needing long term treatment.

non-essential amino acids

Amino acids that can be made in the liver.

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nutrients

Chemical substances contained in food and needed by the body for growth, maintenance and repair of tissues.

nutrition

The processes by which a living organism ingests, digests, absorbs, transports, metabolises, stores and excretes/eliminates food.

obesity

An excess accumulation of body fat, often causing impaired health, indicated by body mass index of more than 30 in adults and by a weight-for-height above +3 standard deviations of the reference population in children.

over-nutrition

Nutrition that exceeds physiological needs.

overweight

An excess accumulation of body fat, often causing impaired health, indicated by a body mass index of 26–30 in adults and by a weight-for-height above +2 standard deviations of the reference population in children.

parenteral

Feeding and/or giving fluid directly into the bloodstream, bypassing the digestive tract.

pica

An eating disorder characterised by eating substances that contain little or no nutrients such as ice, soil, charcoal or clay.

stunting

A height-for-age z-score of below –2, an indicator of long-term under-nutrition.

under-nutrition

Nutrition that does not meet physiological needs.

underweight

A weight-for-age z-score of below –2, an indicator of short-term under-nutrition.

wasting

A weight-for-height z-score of below –2, an indicator of acute, short-term under-nutrition.

prerequisite knowledge

• Familiarity with human anatomy and physiology, especially that of the gastrointestinal tract • Understanding the different stages of the life cycle • Awareness of common communicable and non-communicable diseases. ethical considerations

Promoting any breast milk substitutes among mothers/caregivers is a serious violation of the international code of marketing of breast milk substitutes as well as the regulations relating to foodstuffs for infants and young children. Marketing or recommending any nutritional products for personal gain is considered to be a conflict of interest as it affects your ability to recommend what is best for the patient instead of that which is best for your sales. In spite of policies and criteria, it can be challenging to ensure a fair distribution of nutritional supplements from a facility in the context of poor socioeconomic circumstances as it hinders the promotion, protection and support of breastfeeding. Access to food is considered a basic physical need and a human right that should be fulfilled. Sometimes the decision of whether or not to continue aggressive nutrition support for people who are unconscious, incurably brain damaged or receiving palliative care can be controversial. essential health literacy

Food is one of the basic needs for survival and must be given the importance it deserves. Nutrition is the cornerstone of health and people should strive to eat a balanced diet that is adequate in quantity and contains all the required nutrients, such as carbohydrates, proteins, fats, vitamins and minerals.

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For the majority of South Africans, staple foods consist of maize meal in its various forms, bread, rice and pasta, as these foods are usually accessible and affordable. These foods contain mainly carbohydrates that provide the body with energy but does not build the body or protect it against disease. Protein is needed to build and repair the body and can be found in all forms of meat, chicken, fish, legumes (dry beans, peas, lentils and soy), eggs, milk, cheese and nuts. These foods are usually more expensive than the starchy foods mentioned above, and South Africans living in poor socioeconomic circumstances may struggle to eat adequate quantities or rely on poor quality proteins that do not help to promote their health. Some South Africans tend to eat too much of these foods, which can also be harmful to their health. Fats are commonly found in cooking oils, margarine and mayonnaise, while vitamins and minerals are found in a wide variety of foods, including fruits and vegetables. While people are encouraged to enjoy a variety of foods in adequate amounts, there are many people who struggle to eat balanced meals. This occurs in both poverty and affluence, health and disease, and in both childhood and old age. Sometimes it is due to circumstance and other times it is due to the choices people make. Whatever the reason, you can have an important influence in helping people to see the value of eating well so that they may enjoy good health and an optimal quality of life.

Introduction Nutrition and health are inseparable. Good nutrition is essential to attain health and prevent disease while poor nutrition leads to morbidity and mortality. The food a person eats regulates how their body functions. Therefore, adequate and appropriate nutrition can prevent diseases, speed the rate of recovery after surgery or illness and even treat certain diseases like diarrhoea, diabetes, heart diseases, and many others. Poor nutrition will have the opposite effect. For this reason, any person involved in healthcare needs knowledge of nutrients, nutrition through the life cycle and the influence of nutrition on the management of disease. As a nurse, you will assess nutritional status and then respond appropriately. Thereby, you will not only help people to eat well during illness but will also play an important part in educating them about continued good nutrition.

What is nutrition? Nutrients are chemical substances contained in food and are the building blocks needed for growth, maintenance and functioning of the body. Nutrition refers to the proces­ ses by which a living organism ingests, digests, absorbs, transports, metabolises, stores and excretes/eliminates these nutrients. Nutrition as a clinical area is mainly focused on the properties of food that promote health. Nutrients can be classified as either macronutrients or micronutrients. Macronutrients refer to those nutrients required by the body in large amounts. They are carbo­ hydrates, proteins and lipids (fats and oils). Micro­nutrients are required by the body in small amounts for tissue growth and maintenance. They are vitamins and minerals.

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Each nutrient has different functions so it is important to regularly provide the body with all the nutrients and not exclude any particular one from an eating plan.

Macronutrients Carbohydrates Carbohydrates provide the body with energy when eaten but can also be stored in muscles and in the liver to be converted quickly when the body needs energy. They can be classified as simple carbohydrates (sugars) or complex carbohydrates (starches and fibre).

Functions of carbohydrates • Provide energy by breaking down sugars and starches into glucose. Each gram of carbohydrate (except fibre) produces 17 kJ of energy. • Spare protein. If glucose is available, body protein is conserved and not broken down for energy. • Prevent ketosis. This occurs when body fat and protein are being broken down for energy. About 100 g of carbohydrate daily is enough to prevent ketosis. • Provide basic molecules needed by the liver to synthesise non-essential amino acids. • Provide chemical precursors to synthesise essential substances such as bone, connective tissue, cartilage and nervous tissue. • Lactose helps the body absorb calcium and phosphorus. It also promotes the growth of intestinal bacteria that manufacture certain B-complex vitamins. • Provide the body with vitamins B1, B2, B3, iron and folate. Whole grains are rich in magnesium, zinc and fibre.

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6.1 Essential health information about fibre

6.2 Essential health information about sugar

Fibre cannot be digested by the human body for energy but rather supplies roughage or bulk to the diet.

Even though sugar is not an independent risk factor for any particular disease, some problems associated with too much sugar intake include dental caries, obesity and possibly diabetes mellitus. It is recommended to use sugar, foods and drinks high in sugar content sparingly.

The health benefits of fibre in carbohydrates are that it: • promotes digestion • prevents/relieves constipation • protects against colon and rectal cancers • prevents diverticulitis • reduces serum cholesterol (this decreases the risk for non-communicable diseases) • satisfies the appetite (this reduces the intake of food and helps to achieve/maintain a healthy body weight) • slows glucose absorption in the small intestine (this decreases blood glucose levels). Most people need 25–30 g of any type of fibre per day. The following are ways in which daily fibre intake can be increased: • Eat plenty of vegetables and fruit every day. • Choose whole vegetables and fruits rather than juice. • Eat foods with whole grains instead of refined grains. • Eat cooked dry beans, split peas, lentils and soya regularly.

Sources of carbohydrates • Starchy foods like maize meal, cereal, rice, bread, samp, pasta, potatoes and sweet potatoes • Fruit and some vegetables • Dry beans, split peas, lentils (they are also high in protein) • Milk and milk products (they are also high in protein) • Sugar (although this is not a nutritious source of carbohydrates).

Proteins Protein is required for growth, repair and maintenance of the body structures. It is stored in muscle, bone, blood, skin, cartilage and lymph. When the supply of carbohydrates and fats is inadequate for the body’s needs, protein (from food or from the body’s storage) can be broken down as a source of energy. The building blocks of proteins are known as amino acids. Essential amino acids cannot be made by the body

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The following can be done to decrease a person’s daily intake of sugar: • Drink fewer fizzy drinks and cool drinks. Rather have water, milk, diluted fruit juice or tea/coffee without sugar. • Enjoy fruits (including dried fruit) instead of sweets, chocolates, cakes and cookies. • Plan or prepare meals and snacks ahead of time so there is no need to buy sugary foods from shops, kiosks or vending machines. • Consider using sugar substitutes (sweeteners), especially in the case of obesity or diabetes mellitus.

6.3 Essential health information about starches Processing starches can be good when this makes the nutrients in the food more available to the body, but most of the time starches are processed so much that they lose many of their nutrients. The staple foods of many South Africans include maize porridge and bread (both refined/processed carbohydrates that do not contain many nutrients anymore). To help prevent and address micronutrient deficiencies in the population, all bread flour and maize meal in South Africa must be fortified (or strengthened) with a specific vitamin and mineral mix (containing vitamins A, B1, B2, B3, B6, folate, iron and zinc). This regulation has been mandatory since 2003 and helps people take in more nutrients even if they do not have access to a variety of foods. and need to be consumed through food. Non-essential amino acids can be synthesised in the liver if nitrogen and other precursors are available. Food proteins are classified as complete or incomplete depending on which amino acids they contain. • Complete proteins are foods that contain all of the essential amino acids needed to meet the body’s

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needs. Examples are meat, milk, cheese, eggs and soy (the only plant source that is considered a complete protein). • Incomplete proteins are food sources that are deficient in or have limited amounts of one or more of the essential amino acids. With the exception of soybeans, all plant proteins are incomplete. Examples are legumes (dry beans, peas and lentils), nuts and seeds.

6.4 Essential health information about proteins It is possible to combine two different incomplete proteins to make a complete protein. One source may lack a certain amino acid, but if that amino acid is found in another source they can create a complete protein when taken together. This is very important for people who have low-protein diets or lack the finances to buy animal foods often. The following, when combined, make complete proteins: • Grains and legumes, eg samp and beans, lentils and rice, beans on toast, pea soup and bread • Grains and milk products, eg macaroni and cheese, maize porridge and amazi, bread and cheese • Legumes and seeds, eg lentil salad with sunflower seeds, hummus (a spread made from chickpeas and sesame seed paste).

Functions of proteins • The regeneration or growth of new tissue and maintenance or repair of damaged or old tissue. Protein forms the basis of the structure of all the cells and tissues of the body, including bone, muscle and cartilage. • Provide energy if carbohydrates are insufficient. Each gram of protein provides 17 kJ of energy (the same as carbohydrates), but it requires many enzymes and extra energy to make the protein’s energy available. • All the regulatory substances in the body consist of protein, such as enzymes, hormones, neurotrans­ mitters, RNA and DNA. • Blood proteins have specific functions. Haemoglobin is required for oxygen transport; fibrinogen for the clotting of blood; albumin for the regulation of fluid balance in the intravascular fluid compartment; and transferrin for the transport of iron. • Proteins bind with substances to transport them to where they will be utilised, eg triglycerides, cholesterol, phospholipids, minerals, vitamins and certain drugs. • Creating lymphocytes and antibodies that help with normal functioning of the immune system.

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• Regulate osmotic pressure in the plasma (albumin and globulin). • Assist with the maintenance of acid–base balance in the body as amino acids bind with both acid and alkaline substances. • Normal vision as the retina of the eye contains a lightsensitive protein (rhodopsin) that is bound to vitamin A. • Provide the body with vitamins B1, B3, B12, D, phos­ phorous, iron, zinc, and iodine.

Sources of proteins Animal sources are fish, chicken, lean meat, eggs, milk and milk products. The best plant sources are legumes (dry beans, peas, lentils and soya), nuts and seeds. It is recommended that proteins make up to 15–20% of a person’s diet or 0.8 g of protein for every kilogram of body weight in healthy people. Some conditions require more protein, such as: • emotional or physical stress, infection and high envi­ ronmental temperatures • times when the body must heal itself, eg after surgery, trauma or burn injuries • people with large muscle mass (as muscle tissue requires protein to maintain itself) • catabolic conditions, eg HIV, Aids, TB or cancer. Some people believe that a diet high in protein is beneficial for their health. Although this can help people to achieve a healthy body weight, the long-term safety of a high-protein diet has not been established. Protein sources are more expensive than other foods, and high protein intake increases the excretion of calcium (which may increase the risk of osteoporosis) and nitrogen (which may play a role in poor renal function). It also increases the risk of atherosclerosis and colon and prostate cancers.

Lipids (fats and oils) Lipids are a concentrated source of energy. They are classified as fats (lipids that are solid at room temperature) or oils (lipids that are liquid at room temperature). Cholesterol is a fatlike substance that is both produced by the body and found in foods of animal origin. Most of the body’s cholesterol is synthesised in the liver and some is absorbed from foods such as milk, egg yolk and organ meats. It is needed to create bile acids, synthesise steroid hormones and form an important part of cell membranes. Too much cholesterol can increase a person’s risk for developing heart disease.

Functions of lipids • Provide energy. Each gram of fat will produce 38 kJ of energy. Extra energy not needed by the body

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• • • • • • • • •

will be stored in the fat cells (adipose tissues) for later use. Transport fat-soluble substances in and out of cells. Form part of bile, steroid hormones and vitamin D. Needed for healthy skin, normal growth in children and form part of retinal and brain tissue. Are needed for the absorption of the fat-soluble vitamins A, D, E and K. Slow down the emptying of the stomach thereby contributing to a feeling of fullness. Enhances the flavour and texture of food. The fat layer under the skin helps to maintain a constant body temperature. Lipids in the skin act as natural lubricants to protect and maintain the condition of the skin and hair. Body fat around the internal organs acts as a protective cushion, especially for the kidneys, intestines and mammary glands.

Sources of lipids • Saturated: butter, cream, fat on meat, chicken skin, pro­ ces­sed meats, cheese, full cream milk and milk products • Mono-unsaturated: oils (sunflower, canola, olive), nuts, peanut butter, avocado, mayonnaise, margarine • Poly-unsaturated: seeds (pumpkin, sunflower, flax), fish (sardines, mackerel, salmon) • Trans fat: processed foods, eg biscuits, pies, pastries.

Micronutrients Vitamins Vitamins are necessary for many important physiological functions such as the formation of red blood cells, hormones and genetic material, and to maintain proper functioning of the nervous system. With few exceptions, the body cannot produce vitamins, so even though only small amounts are needed, the body must get vitamins from food every day. See Table 6.1 for the major functions and food sources of vitamins. Vitamins are classified as water soluble or fat soluble: • Water-soluble vitamins are found in the watery portions of foods. They are absorbed into the bloodstream directly and move freely within cells. They are not stored in the body and need to be taken in daily through food. If excess amounts are consumed, they are excreted in the urine. They can be affected by food processing, storage and preparation. • Fat-soluble vitamins are absorbed with lipids into the lymphatic system and the bloodstream. In the bloodstream they attach to lipoproteins for transport. Excess amounts of fat-soluble vitamins are stored in the liver and adipose tissue, and thus do not need to be consumed with the food daily.

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6.5 Essential health information about lipids Guidelines to use fat sparingly and choose vegetable oils, rather than hard fats: • Choose vegetable oil and soft margarines rather than brick margarine, butter, lard or ghee. • Use a small amount of oil when cooking. • Choose low-fat sauces with pasta, rice and potatoes. • Add flavour to foods by using herbs, spices, lemon juice and garlic instead of fats, oils and rich sauces. • Cut visible fat from meat and remove the skin of chicken before cooking it. Choose meats labelled ‘lean’. • Enjoy healthy fats by eating fish every week. • Limit intake of organ meats, eg livers and kidneys. • Use low-fat or fat-free milk and milk products rather than full-cream. • Be careful of ‘hidden fats’ in processed meats, biscuits, condiments, sauces and convenience foods.

6.6 Essential health information about vitamins • The best way to get vitamins is through fresh food and not through supplements, but vitamin supplements can prevent deficiency diseases when dietary intake is inadequate. • Special populations may benefit from vitamin supplements, for example children, pregnant women, people with chronic disease, elderly people and alcohol addicts. In South Africa, children receive routine high dose vitamin A drops every 6 months from the age of 6 months. Pregnant women receive Folate, Iron and Calcium supplementation during antenatal care. • Vegans (vegetarians who exclude all animal products such as eggs and milk products from their diet) need to obtain vitamin B12 from brewer’s yeast, food fortified with vitamin B12 or a vitamin supplement. • Stress, smoking, infections and burns deplete vitamin C reserves and therefore higher doses of this vitamin are needed. Vitamin C is not stored in the body; thus it has to be taken regularly through the diet or supplements to maintain sufficient levels.

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70  Juta’s Complete Textbook of Medical Surgical Nursing Table 6.1  Functions, sources and intake guidelines of vitamins, and consequences of deficiencies

Vitamin

Functions

Sources

Intake guidelines*

Consequences of deficiency

Water-soluble vitamins B1 (thiamine)

Appetite stimulation, blood building, improves circulation, digestion, growth and learning ability

Whole grains, oats, lean meat, liver, yeast

Males: 1.2 mg/day Females: 1.1 mg/day

Beriberi, affecting the neuromuscular and circulatory systems

B2 (riboflavin)

Antibody and red blood cell formation, energy metabolism, cell respiration, maintenance of healthy skin, mucous membranes, cornea and vision

Lean meat, poultry, fish, liver, milk and milk products, eggs, green leafy vegetables, whole grains

Males: 1.3 mg/day Females: 1.1 mg/day

Ariboflavinosis (dermatitis, glossitis, photophobia)

B3 (niacin)

Improved circulation, cholesterol reduction, growth, hydrochloric acid production, metabolism, sex hormone production, maintenance of normal skin, mucous membranes and nerve integrity

Lean meat, poultry, fish, yeast, peanuts

Males: 16 mg/day Females: 14 mg/day

Pellagra (a photosensitive, scaly, pigmented dermatitis on areas exposed to sunlight which can be accompanied by dementia and diarrhoea in severe cases)

B5 (pantothenic acid)

Antibody formation, cortisone production, growth stimulation, stress tolerance, vitamin utilisation, conversion of carbohydrates, fats and protein

Organ meats, mushrooms, avocados, eggs, yeast, milk, sweet potatoes

Males: 5 mg/day (AI) Females: 5 mg/day (AI)

General failure of all body systems

B6 (pyridoxine)

Antibody formation, digestion, deoxyribonucleic acid and ribonucleic acid synthesis, fat and protein utilisation, amino acid metabolism, haemoglobin production

Meat, poultry, fish, vegetables, nuts, whole grains (especially wheat)

Males: 1.3 mg/day Females: 1.3 mg/day

Dermatitis, glossitis, seizures, anaemia

❱❱

*Recommended Daily Allowance (RDA) for people older than 14 years, unless indicated otherwise, eg Adequate Intake (AI)

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Vitamin

Functions

Sources

Intake guidelines*

Consequences of deficiency

B12 (cobalamin)

Blood cell formation, cellular and nutrient metabolism, iron absorption, tissue growth, maintenance and function of bone marrow, gastrointestinal system and nerve cells

Organ meats, meat, milk, eggs, fish, cheese

Males: 2.4 µg/day Females: 2.4 µg/day

Pernicious anaemia

C (ascorbic acid)

Collagen production, digestion, fine bone and tooth formation, iodine conservation, healing promotion, red blood cell formation, infection resistance

Guavas, citrus fruits, paw-paw, tomatoes, sweet peppers, potatoes, cabbage Exposure of cut surfaces to air, prolonged soaking and overcooking will decrease the vitamin C content dramatically

Males: 90 mg/day Females: 75 mg/day

Scurvy

Biotin

Cell growth, fatty acid production, metabolism, vitamin B utilisation, maintenance of skin, hair, nerve and bone

Eggs, organ meats, legumes, yeast, milk and nuts

Males: 30 µg/day (AI) Females: 30 µg/day (AI)

Loss of appetite, fatigue, depression, dry skin, heart abnormalities

Folate

Red blood cell formation, nucleic acid formation, cell growth and reproduction, hydrochloric acid production, liver function, protein metabolism

Liver, mushrooms, green leafy vegetables, lean beef, potatoes, whole grains, legumes, citrus fruits

Males: 400 µg/day Females: 400 µg/day

Megaloblastic macrocytic anaemia, fatigue, depression, neural tube defects, homocystenaemia

Green leafy vegetables, yellow/ red/orange vegetables, edible yellow and orange parts of fruits, milk products, organ meats, egg yolk, fish, enriched margarine Vitamin A in excess can be toxic, so do not overdo supplements

Males: 900 µg/day Females: 700 µg/day

Hyperkeratosis, decreased immunity, night blindness, keratomalacia and xeropthalmia

Fat-soluble vitamins A (retinol)

Body tissue repair and maintenance, infection resistance, bone growth, nervous system development, cell membrane metabolism and structure

❱❱

*Recommended Daily Allowance (RDA) for people older than 14 years, unless indicated otherwise, eg Adequate Intake (AI)

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Vitamin

Functions

Sources

Intake guidelines*

Consequences of deficiency

D (calciferol)

Calcium and phosphorus metabolism (bone formation), myocardial function, nervous system maintenance, normal blood clotting

Exposure of skin to the ultraviolet rays of the sun, fish liver oil, fatty fish, bone meal, egg yolks, organ meat, butter, enriched margarine

Males: 5 µg/day (AI) Females: 5 µg/day (AI)

Rickets

E (tocopherol)

Aging retardation, anticlotting factor, diuresis, lung protection (antipollution), male potency, muscle and nerve cell membrane maintenance, myocardial perfusion, serum cholesterol reduction

Dark green vegetables, fruits, nuts, organ meat, eggs, vegetable oils, wheat germ, maize, legumes, unrefined cereal products, butter

Males: 15 mg/day Females: 15 mg/day

Red blood cell haemolysis, oedema, skin lesions

K (menadione)

Liver synthesis of prothrombin and other blood-clotting factors, participates with vitamin D in the synthesis of bone protein

Green leafy vegetables, sunflower oils, yoghurt, liver, molasses, broccoli, brussels sprouts, dairy products

Males: 120 µg/day (AI) Females: 90 µg/day (AI)

Haemorrhaging

*Recommended Daily Allowance (RDA) for people older than 14 years, unless indicated otherwise, eg Adequate Intake (AI)

Minerals Minerals play an important role in promoting growth and maintaining health by providing structure to body tissues and regulating body processes. A disruption of the body’s balance in any one of these minerals can be life threatening. Macrominerals are needed by the body in large amounts while microminerals are needed by the body in small amounts. They are present in foods and are not sensitive to heat in cooking but some may be lost in the cooking water as they are water soluble. See Table 6.2 for the major functions and food sources of minerals.

Water/fluid A continuous supply of clean, safe water is one of our most basic nutritional needs, as a person can survive no longer than a few days without water. Water makes

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up about 50–80% of a person’s total body weight and is essential in ensuring a balanced distribution of fluids to all body cells. Body water contains dissolved substances such as electrolytes, glucose, amino acids and other nutrients that are necessary for physiological functioning.

Functions of water/fluid in the body • Serves as a medium for all biochemical reactions in the body. • Lubrication, for example within the eyes and joints. • Solvent for minerals, vitamins, glucose and other small molecules. • Gives structure and shape to cells, and helps form the structure of large molecules, for example protein and glycogen.

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Chapter 6 – Nutrition needs  73 Table 6.2  Functions, sources and intake guidelines of minerals, and consequences of deficiencies

Mineral

Functions

Sources

Intake guidelines*

Consequences of deficiency

Macrominerals Calcium

Blood clotting, bone and tooth formation, cardiac rhythm maintenance, cell membrane permeability, muscle growth and contraction, nerve impulse transmission

Milk and milk products, green leafy vegetables, legumes, tinned fish (eaten with the bones)

Males: 1 000 mg/day (AI) Females: 1 000 mg/day (AI)

Osteoporosis, stunted growth in children, brittle fingernails, palpitations, insomnia, muscle cramps, hypertension

Chloride

Fluid, electrolyte, acid–base and osmotic pressure balance, component of HCl in the stomach (digestion)

Salt

Males: 2.3 g/day (AI) Females: 2.3 g/day (AI)

Disturbance in acid–base balance

Magnesium

Acid–base balance, metabolism, protein synthesis, muscle relaxation, cellular respiration, nerve impulse transmission

Green leafy vegetables, nuts and seeds, seafood, cocoa, whole grains, legumes, unrefined cereals (eg oats)

Males: 400 mg/day Females: 310 mg/day

Confusion, disorientation, nervousness, irritability, tremors, muscle spasms, rapid pulse, neuromuscular dysfunction

Phosphorus

Bone and tooth formation, cell growth and repair

Eggs, fish, whole grains, meats, poultry, milk and milk products, nuts and seeds Absorption is dependent on vitamin D

Males: 700 mg/day Females: 700 mg/day

Appetite loss, fatigue, irregular breathing, nervous disorders, muscle weakness

Potassium

Muscle contraction, nerve impulse transmission, rapid growth, acid–base balance, osmotic pressure balance

Meat, poultry, fish, potatoes, sweet potatoes, tomatoes, spinach, mangoes, bananas, citrus fruit

Males: 2 000 mg/day Females: 2 000 mg/day

Muscle weakness, paralysis, loss of appetite, confusion, weak reflexes, slow irregular heartbeat

Sulphur

Collagen synthesis, vitamin B formation, enzyme and energy metabolism, blood clotting

Meat, poultry, fish, eggs, dried beans, broccoli, cauliflower

Males: none Females: none

None

❱❱

*Recommended Daily Allowance (RDA) for people older than 14 years, unless indicated otherwise, eg Adequate Intake (AI)

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74  Juta’s Complete Textbook of Medical Surgical Nursing

Mineral

Functions

Sources

Intake guidelines*

Consequences of deficiency

Iron

Growth (in children), haemoglobin production, immune function, cellular respiration, oxygen transport

Liver, seafood, red meat, poultry, fortified maize meal and bread, enriched breakfast cereals, green leafy vegetables, dried fruit, eggs, legumes, nuts

Males: 8 mg/day Females: 18 mg/day

Hypochromic microcytic anaemia, fatigue, koilonychia (brittle, concaveshaped nails), constipation, respiratory problems

Zinc

Wound healing, immune function, carbohydrate digestion, metabolism, transport of vitamin A, reproductive organ growth and development

Liver, meat, seafood, poultry

Males: 11 mg/day Females: 8 mg/day

Growth retardation, delayed sexual maturation, poor wound healing, skin disorders, immune deficiency, fatigue, taste loss, poor appetite

Fluoride

Bone and teeth formation (tooth enamel)

Fluoridated drinking water, seafood

Males: 3.8 mg/day (AI) Females: 3.1 mg/day (AI)

Dental caries

Copper

Bone formation, melonin synthesis, healing processes, haemoglobin and red blood cell formation, mental processes, iron metabolism

Organ meats, seafood, nuts, legumes, dried fruit

Males: 900 µg/day Females: 900 µg/day

General weakness, impaired respiration, skin sores, bone disease

Iodine

Energy production, metabolism, physical and mental development, thyroid hormone production

Salt (iodised), seafood

Males: 150 µg/day Females: 150 µg/day

Poor cognition, endemic goitre (enlarged thyroid gland), mental retardation and cretinism, both from an in utero iodine deficiency

Selenium

Immune mechanisms, cellular protection, fat metabolism

Seafood, organ meat, meat, poultry, eggs, whole grains

Males: 55 µg/day Females: 55 µg/day

Deficiencies rarely occur

Microminerals

❱❱

*Recommended Daily Allowance (RDA) for people older than 14 years, unless indicated otherwise, eg Adequate Intake (AI)

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Mineral

Functions

Sources

Intake guidelines*

Consequences of deficiency

Manganese

Enzyme activation, carbohydrate and lipid metabolism, growth and reproduction, formation of connective and skeletal tissue, vitamin B1 metabolism, vitamin E utilisation

Whole grains, legumes, nuts, coffee, tea, bananas, egg yolks, green leafy vegetables, liver, soybeans

Males: 2.3 mg/day (AI) Females: 1.8 mg/day (AI)

Ataxia, dizziness, hearing disturbance/ loss, skeletal abnormalities, sterility

Chromium

Carbohydrate lipid and protein metabolism, serum glucose maintenance

Liver, brewer’s yeast, potatoes, seafood, whole grains, meat, poultry, cheese

Males: 35 µg/day (AI) Females: 25 µg/day (AI)

Insulin resistance

*Recommended Daily Allowance (RDA) for people older than 14 years, unless indicated otherwise, eg Adequate Intake (AI)

• Regulates body temperature (eg evaporation of sweat from the skin surface). • Helps with nutrient digestion and absorption. • Transports nutrients to cells, and carries waste products away from them through urine, faeces and exhalation.

people. Values for RDAs vary for different age groups and genders. On a food label, the RDA tells you the percentage of a person’s daily nutritional requirements that a specific food contains.

Sources of water/fluid

The South African Food-Based Dietary Guidelines are short, positive messages that aim to teach the population how to make food and beverage choices that will meet their nutrient needs and lower their risk for developing noncommunicable diseases. These messages are used by the South African Department of Health for nutrition education materials and used by healthcare workers to educate patients. The value of these messages is that they were designed specifically for South Africans by the Department of Health so they take into account the dietary patterns of the local populations and aim to address relevant public health concerns of both over – and undernutrition. These guidelines are also food-based and not nutrient-based, so that it is easier for the general population to understand and apply the content of the message. The South African Department of Health has also designed a visual South African Food Guide. It illustrates the different food groups that should be eaten regularly in various circles. The size of each circle shows the proportion that each group should contribute to a person’s diet. Unlike many other visual food guides, it does not include items like sugar, sweetened food or drinks, or salt, as it only includes foods that are essential for health (see Figure 6.1).

Liquids are the only water sources that meet the body’s fluid needs but solid foods and metabolic water also contribute to total fluid intake. In an average diet, solid foods supply about 700 ml of water per day. The metabolism of carbohydrates, fats and proteins produces about 240 ml of water per day. To maintain fluid balance, a person’s fluid intake should equal their fluid output. On average, an adult loses about 2 300 ml of water daily through sweating, breathing and urinating. These losses should be replenished by drinking 6–8 glasses of clean, safe water every day. The body needs extra water when sweating a lot (during strenuous activity or hot weather) and with fever, diarrhoea or vomiting.

Nutrition in relation to health Most countries establish nutrition standards or guidelines for major nutrients in order to maintain healthy populations. South Africa uses the recommended dietary allowance (RDA) when referring to nutrients and the South African Food-Based Dietary Guidelines when referring to foods.

Recommended dietary allowance (RDA) RDAs refer to the amounts of different nutrients that are sufficient to meet the needs of the majority of healthy

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South African Food-Based Dietary Guidelines

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76  Juta’s Complete Textbook of Medical Surgical Nursing

6.7 Essential health information about minerals Calcium and sodium are the minerals that cause the most health concerns. Less than optimal amounts of calcium increase the risk of osteoporosis, and excess sodium intake can increase the risk for hypertension. People who take calcium supplements should remember the following: • Do so in moderation – if doses higher than 500 mg are needed, the supplement should be spread throughout the day. • Calcium carbonate is best absorbed with food. • Calcium citrate is best absorbed on an empty stomach. Avoid taking calcium citrate with iron as calcium can interfere with iron absorption. • Constipation is a common adverse effect of calcium supplements – drink adequate fluids to reduce this risk. • Calcium supplements should not be taken to replace dietary intake of calcium. To limit the intake of sodium, use salt and foods high in salt sparingly: • Choose fresh foods rather than processed foods (eg fresh or frozen vegetables/fish rather than tinned). • Read food labels to avoid or limit foods that contain too much sodium. Compare labels of different brands of similar items to find the product with the lowest sodium content. • Limit the intake of processed foods such as sausages, viennas, polony, bacon, biltong (dried meat) and dried sausage, chips, savoury biscuits and tinned foods. • Limit the use of seasoning salt, stock cubes and soup powders, sauces and salad dressings. Rather use herbs, spices, garlic, chili, curry powders, lemon juice or vinegar to flavour food. • Taste food before adding salt. • Be aware that high-sodium foods do not always taste salty. • Limit intake to 2 g sodium, as seen on labels, or 5 g salt, as added to food, per day.

Nutrition through the lifecycle Nutrition plays a major role throughout life. Each stage of life has specific nutritional needs to ensure optimum functioning of the body.

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Figure 6.1  Visual South African food guide

Source: South African Department of Health

6.8 Essential health Information about dehydration Diarrhoea and vomiting can cause the body to become dehydrated when too much fluid is lost. This dehydration is dangerous and can be life-threatening in young children. Teach caregivers how to treat dehydration at home by preparing a sugar–salt solution. Take 1 ℓ of boiled, cooled water; add 8 teaspoons of sugar and ½ teaspoon of salt. Give the child sugar– salt solution after every loose stool, half a cup for children under 2 years and a cup for children aged 2–5 years. The child is unlikely to drink it all at once so offer small, frequent sips. If vomiting occurs, wait 10 minutes and then start again, but more slowly.

Nutrition during pregnancy and lactation A pregnant woman has increased nutritional needs because of her increased body weight and the growth of her foetus. The amount of extra nutrition required varies depending on each woman’s health and nutritional status before pregnancy; her level of activity; and her general living conditions. Weight gain should range from 0.3 kg (for overweight women) to 0.5 kg or more (for underweight women) per week during the second trimester. The health of a pregnant woman has a great impact on the health of the child, not only for the time of gestation but also for the rest of the child’s life. If a mother has a poor nutritional status and gains too little weight, the child will not receive enough nutrients. Gaining too little

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6.9  Essential health information about the South African Food-based Dietary Guidelines

6.10  Essential health information about avoiding harmful substances during pregnancy and lactation

• Enjoy a variety of foods. • Be active! • Make starchy foods part of most meals. • Eat plenty of vegetables and fruit every day. • Eat dry beans, split peas, lentils and soya regularly. • Have milk, maas or yoghurt every day. • Fish, chicken, lean meat or eggs can be eaten daily. • Drink lots of clean, safe water. • Use fats sparingly. Choose vegetable oils rather than hard fats. • Use salt and foods high in salt sparingly. • Use sugar and foods and drinks high in sugar sparingly.

Alcohol All types of alcohol should be avoided during pregnancy because it can cross the placental membrane and affect the developing foetus. If a pregnant woman drinks alcohol during pregnancy, the child can be affected by foetal alcohol spectrum disorders which include abnormalities in body structure, behaviour and cognitive function. When children are severely affected, they are referred to as having foetal alcohol syndrome (FAS). Alcohol can also be passed through the breast milk, where it can interfere with the child’s brain development. It is essential to emphasise the irreversible damage caused by alcohol intake during pregnancy to all community members.

weight during pregnancy can also increase the child’s risk of developing non-communicable diseases such as heart disease, type 2 diabetes and hypertension later in life. Being overweight or obese also has risks such as gestational diabetes, pregnancy-induced hypertension, premature birth, increased rates for caesarean section and a birth weight of more than 4 000 g with its problems such as obstructed labour. Some of the nutrition-related problems during preg­ nan­ cy are anaemia, nausea and vomiting/hyperemesis gravi­ darum, heartburn, constipation, Pica, gestational diabetes and pregnancy-induced hypertension.

Anaemia during pregnancy In South Africa, 16–26% of pregnant women have anaemia (Du Plessis, Labuschagne & Naude, 2008) due to deficiencies of iron, vitamin B12 and/or folate, genetics and infections. Iron deficiency is a risk factor for maternal mortality, and is responsible for 20% of maternal deaths globally per year (South African Department of Health, 2013). Folate deficiency can also lead to neural tube defects and reduced growth in the foetus. In South Africa, pregnant women routinely receive both iron and folate supplements from their local clinics.

Pregnancy-induced hypertension Pregnancy-induced hypertension can be caused by obesity, excessive weight gain during pregnancy, genetics, age and chronic hypertension in previous pregnancies. Severe forms of pregnancy-induced hypertension are a serious threat to the survival of both the mother and

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Smoking Smoking during pregnancy reduces the amount of oxygen supplied to the foetus. The negative effects are dose-dependent, and include reduced birth weight, increased risk of preterm delivery, impaired intellectual development and foetal nicotine addiction. Smoking is also harmful after birth because the child will be exposed to the cigarette smoke in the environment (causing respiratory problems) and nicotine in the breast milk. Caffeine Consuming too much caffeine can possibly cause miscarriages in the first trimester (Shabert, 2004). The current recommendation is that pregnant women have no more than four 150 ml caffeine-containing drinks (such as coffee, tea, soft drinks and energy drinks) per day, but there is not enough research to make a specific recommendation. Chocolate, some energy bars and some medication also contain caffeine and should be used with caution. Food safety Increased progesterone levels during pregnancy decrease a woman’s ability to resist infectious diseases, making her more prone to food-borne infections. These can have serious consequences, including spontaneous abortion, stillbirth, mental retardation, blindness, seizures and death. Pregnant women should avoid raw or undercooked fish and meat, unpasteurised milk and milk products and should take care to wash all vegetables and fruit.

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foetus, and the only treatment is immediate delivery. Hypertension contributes to 15.6% of maternal deaths in South Africa. Although all the risk factors cannot be controlled, promoting a healthy pre-pregnancy weight and healthy weight gain during pregnancy could prevent the onset of this problem. All pregnant women should also receive routine calcium supplementation to prevent pregnancy-induced hypertension.

Infant nutrition The first 1 000 days of life, from conception to the age of 2 years, represent a unique window of opportunity to invest in the health of a human being. Appropriate feeding practices are essential for the survival, optimal nutritional status, growth and development of infants and young children. Appropriate feeding practices include starting breastfeeding within one hour after birth, breastfeeding exclusively for the first six months of life and introducing nutritionally adequate and safe complementary foods at six months while continuing with breastfeeding for two years and beyond (South African Department of Health, 2013: 39). Exclusive breastfeeding for 6 months and continued breastfeeding up to 1 year may prevent 13% of all deaths in children younger than 5 years in countries with a high under-5 mortality rate, far outweighing the number of deaths that can be prevented by any other single preventive measure. This is why the protection, promotion and support of breastfeeding is globally considered to be a key child survival strategy (South African Department of Health, 2013). Although breastfeeding is a common practice throughout the developing world, exclusive breastfeeding is rare. In South Africa, mixed feeding of children under 6 months is a common practice even though there is extensive evidence that exclusive breastfeeding for 6 months provides many benefits over mixed feeding (see Box 6.11). There are various reasons why mothers struggle with exclusive and ongoing breastfeeding. These include the perception of insufficient milk, misinformation, fear of HIV transmission, marketing of breast milk substitutes, returning to work, pressure from family members and cultural practices. Mothers need knowledge and much support to continue breastfeeding in spite of these challenges. Healthcare workers should do their best to protect, promote and support breastfeeding in South Africa.

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6.11  Benefits of exclusive breastfeeding For the mother • Helps to lose weight gained during pregnancy • Strengthens bonding with the infant • Can act to potentially prevent post-partum depression • Can act to potentially prevent the development of breast and ovarian cancer in later life • Can prolong birth intervals by delaying the return of menstruation • A more economical option given that one does not have to buy baby food. For the child • Provides all the nutrients a baby needs • Strengthens immunity and resistance to disease • Prevents infections and, as a result, the potential deaths caused by these infections • Strengthens bonding with the mother • Improves cognitive function and development • Reduces risk of developing obesity and chronic diseases later in life.

Breastfeeding in the context of HIV In 2011, Dr. Aaron Motsoaledi, the then-National Minister of Health, declared that South Africa had adopted the 2010 WHO Guidelines on HIV and Infant Feeding, and recommended that all HIV-infected mothers should breastfeed their infants and receive antiretroviral treatment (ART) to prevent transmission (Tshwane Declaration, 2011). The availability of lifelong ART for pregnant women and low-dose Nevirapine for HIV-exposed infants reduces the risk of transmitting HIV through breast milk and therefore strengthens arguments for promoting exclusive breast­feeding as the best choice for South African women. Exclusive breastfeeding protects the intestinal lining of the stomach of the child from irritations that may facilitate the infection with the HI virus.

Complementary feeding (6–12 months) Nutritionally adequate and safe complementary foods should be introduced at 6 months of age, accompanied by the continuation of breastfeeding until the age of 2 years or beyond. If complementary foods are introduced too early, when the digestive tract is immature, there is the risk of diarrhoea and allergies. Introducing complementary foods too late could lead to undernutrition, decreased immunity and a reluctance to try new flavours and textures. Soft porridge is often the first food to be introduced, followed by vegetables and fruit. Allow the child to get

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used to the taste and texture of one new food at a time and look out for any allergies or intolerances should these occur. It is not necessary for caregivers to buy commercial infant foods as it is much more economical and healthier to prepare the food at home. Caregivers should not add sugar, salt or spices to infant food. Egg yolk, minced meat, soft chicken, chicken livers, etc should be given to infants to supplement the iron in breast milk. Young children should also be offered clean, safe water to drink regularly.

Nutrition during childhood Undernutrition in children is a complex problem and often related to poverty. While there are various policies and programmes in place, such as the national school feeding programme or routine vitamin A supplementation, some of these are poorly implemented or may have inadequate coverage. When providing nutrition education, one should encourage caregivers to let their children enjoy a variety of foods. Remember that children have small stomachs, so feed them five small meals per day and avoid giving drinks 30–60 minutes before meals as it tends to spoil their appetite. Make starchy foods part of most meals and give 4–5 portions of vegetables and fruit every day. Feed children foods rich in iron, vitamin A and vitamin C. Children can eat chicken, fish, eggs, beans, soya or peanut butter every day, but they need to drink milk every day as a source of calcium. This can be breast milk, full-cream cow’s milk or sour milk (500 ml per day). If children have sweet treats or drinks, offer small amounts with meals and remember to regularly offer clean, safe water. Also encourage children to play and be active every day (Voster, Badham & Venter, 2013).

6.12 Essential health information about oral health According to the 2003 National Children’s Oral Health Survey, only 39.7% of South African children in the 6-year age group is caries free (Singh S, 2011). This is caused by poor oral hygiene, vitamin and mineral deficiencies during the time of tooth formation (even as early as 6 weeks’ gestation, when tooth development begins) and inappropriate use of feeding bottles. If children are put to bed with a feeding bottle, their teeth bathe in the liquid for a long period and the sugar in the liquid (whether it be milk, fruit juice or sweetened tea) causes damage to the teeth. Children should not receive fruit juice and soft drinks often; if given, these should be diluted with water and given in a cup rather than a bottle.

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Nutrition during adolescence The need for nutrients and energy increases during the growth spurt of adolescence, but specific needs differ depending on nutritional status, activity, lifestyle, health status and living conditions. Important nutrients needed during adolescence for growth, skeletal development and optimal cognitive development include protein, iron, zinc and iodine, while calcium is necessary for increased bone growth during this life phase (Wenhold, Kruger & Meuhlhoff, 2008). Adolescents are especially vulnerable to poor nutrition, as they have increased nutrient needs but also tend to have poor eating habits, engage in risky behaviours (such as smoking, alcohol and substance abuse, and unprotected sexual activities), may be affected by HIV/Aids, and can be easily influenced by their environment and/or peers (Wenhold, Kruger & Meuhlhoff, 2008). These behaviours directly impact their health, so adolescence provides a unique opportunity for health promotion before poor habits become fixed and difficult to change.

Nutrition during adulthood Nutritional needs vary among adults, depending on age, gender, nutritional status, physical activity, health status and living conditions. A healthy body is maintained by learning to balance the intake of energy from food with the energy that is used by the body. The most appropriate tool to guide the eating habits of adults is the South African Food-based Dietary Guidelines (see Box. 6.9), as it aims to address and prevent both under- and over-nutrition, thereby promoting optimal quality of life.

Nutrition for older people Good nutrition is essential for the independence and quality of life of older people. Although the elderly need less energy (due to the decline in metabolic rate and decreased physical activity), they have increased nutrient needs and at the same time face many barriers to meeting those needs. Factors that lead to malnutrition in the elderly can generally be grouped into three categories: social, physical/ medical, and psychological/emotional (see Table 6.3). Due to reduced physical activity, overweight and obesity can also affect the elderly. Changes in body composition (decreased skeletal muscle mass and increased body fat), along with reduced function in certain organs (such as the pancreas, kidneys or heart), can increase the risk of developing many chronic diseases such as hypercholesterolaemia, atherosclerosis, insulin resis­ tance, hypertension and type 2 diabetes mellitus. Being over­weight also worsens arthritis and can impair physical mobility and respiratory function.

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80  Juta’s Complete Textbook of Medical Surgical Nursing Table 6.3  Factors causing malnutrition in the elderly

Social

Physical/medical

Psychological/emotional

Poverty Isolation Difficulty buying food Difficulty preparing meals Abuse/neglect by caregivers

Decreased appetite Chewing difficulties Swallowing difficulties Dry mouth Decreased smell or taste Poor eyesight Physical disabilities Weakness Chronic diseases or infections

Loneliness Depression Bereavement Cognitive impairment Mental illness Alcoholism

Weight management in older people should focus mainly on increased physical activity and increased intake of nutrient-dense foods. Restricting food too much in this age group could compromise the intake of important nutrients and negatively influence the enjoyment of social aspects surrounding food.

Nutrition for specific conditions Nutrition for people living with HIV/Aids and/or TB HIV/Aids is the largest single cause of death in South Africa, and the burden of TB is equally disturbing (Naude, Labuschagne & Labadarios, 2008). Although there are drugs that effectively control HIV/Aids and cure TB, the importance of good nutrition to improve the health and quality of life of people living with HIV, Aids and/or TB cannot be ignored. An optimal nutritional status causes the immune system to function well, which is why nutritional deficiencies reduce the ability of the immune system to defend the body against infections. When a person is malnourished, they are at greater risk of getting an infection, such as TB or HIV. On the other hand, having an infection can directly or indirectly lead to malnutrition, so malnutrition and infection exist in a vicious cycle, each making people more vulnerable to the other (National Department of Health: Directorate: Nutrition, 2007). There are many factors contributing to malnutrition in people infected with HIV, Aids and/or TB. They have increased energy needs due to the primary infection, secondary opportunistic infections and fever. They have decreased energy intake due to symptoms such as poor appetite, nausea or malabsorption. They can also have in­creased nutrient losses due to diarrhoea or vomiting. This can lead to weight loss and/or deficiencies in micronutrients, which can accelerate disease progression and mortality, and influence the effectivity of treatment. Unfortunately, many people living with HIV are also more at risk of developing

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non-communicable diseases due to lipodystrophy (a side effect of ART) and/or poor lifestyles (National Department of Health: Directorate: Nutrition, 2007). Good nutrition cannot directly prevent the spread of these infections or cure them, but it can improve the individual’s health, quality of life and response to drug treatment. There is no single food or nutrient that can alter the course of these diseases or cure malnutrition, so people are encouraged to enjoy a variety of foods including locally available, affordable and traditional foods. They should also receive fortified foods as well as macro- and micronutrient supplements at safe levels (Academy of Science of SA, 2007). People infected with HIV/Aids and/or TB are specific target groups of the South African Department of Health’s Nutrition Therapeutic Programme. If their BMI is below 18.5kg/m2 or they have experienced unintentional weight loss of 5% over 1 month or 10% over 6 months, they will receive monthly nutritional supplements in the form of enriched porridge and/or energy drinks from their primary healthcare facility (Western Cape Department of Health: Sub-Directorate: Nutrition, 2011).

Micronutrient supplementation A good multivitamin and mineral supplement (that provides 50–150% of recommended daily intake) is advisable, especially because it is unlikely that an infected person will be able to meet the increased requirements for vitamins and minerals with food intake alone. It is important to remember, though, that micronutrient supplementation is only useful in combination with an adequate and well-balanced diet and can never replace the need for adequate food intake. Supplements should be taken with caution and only after consulting an expert health professional. Patients receiving Isoniazid as part of their TB treat­ ment should also receive 25 mg pyridoxine (vitamin B6) supplements per day, because Isoniazid is an antagonist

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6.13 Essential health information about food safety and hygiene Due to weakened immunity, people living with HIV, Aids and/or TB are usually more vulnerable to contracting food-borne illnesses. It is therefore important for them to follow basic food safety guidelines. Practice good personal hygiene. Always wash hands thoroughly with soap and warm water before touching food, between touching raw and cooked food, after touching animals, after visiting the toilet and after sneezing or blowing the nose. Cover all wounds when working with food. Use clean, safe water. In South Africa, it is generally safe to drink water from a tap. If water is sourced from a river or well, boil it before use. If this is not possible, add 1 teaspoon (5 ml) of bleach to 25 ℓ of water. Mix well and let it stand for 2 hours (or preferably overnight) before using it. Store it in a clean container with a lid or covered with a cloth. Keep a clean kitchen. Wash all work surfaces and dishes/utensils with soap and water. Use kitchen cloths in the kitchen only. Disinfect cloths, sponges and scourers with bleach. Replace cracked crockery and scratched plastic containers/boards as they are ideal hiding places for germs and are difficult to clean properly. Shop safely. Buy food from a reliable person/place with good food-handling practices. Buy food in amounts that can be used before it spoils. Check the quality of foods and avoid dented/bulging cans, cracked eggs, and products that have passed their ‘sell by’, ‘best before’ or ‘use by’ dates, even if they still look good or the price has been marked down. Enjoy safe foods. If unsure of where food comes from or how it has been prepared, it is safer not to eat it. Avoid products containing raw or undercooked meat or eggs, even in small amounts, including biltong (dried meat) and dried sausage. Always cook meat, chicken, fish and eggs very well to kill bacteria. Only use pasteurised milk. If unpasturised milk unavailable it is possible to boil the milk at home. Wash vegetables, fruit and eggs before use. Avoid mouldy fruit and cheese.

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Handle and store food safely. Uncooked food should be kept separate from cooked food to avoid crosscontamination. Store cold foods in a fridge or freezer. Defrost foods carefully (in a fridge, microwave or a cool place away from direct sunlight) and not at room temperature as this allows for bacterial growth. Always keep food well covered to prevent flies and other insects from reaching it. Reheat left-over foods at a high temperature to destroy any bacteria. Another good resource for useful information is the South African National Guidelines on Nutrition for People Living with HIV, Aids, TB and other chronic debilitating conditions. of pyridoxine and can cause a deficiency in the body. Children are not routinely supplemented unless they are receiving large doses of Isoniazid (more than 10 mg per day). In this case they too should receive 25 mg of pyridoxine supplements per day.

Complementary and alternative therapies Some people living with chronic diseases such as HIV/ Aids may want to use complementary and/or alternative therapies (eg St John’s Wort, garlic, African wild potato) in the hope of improving or curing their condition. Although some substances may be harmless and even offer some benefit, others can be harmful and interfere with the effective working of ART. Nurses should be well informed of the benefits and risks of local therapies in order to provide sound advice.

Nutrition for people living with noncommunicable disease According to the WHO, 70% of deaths in the world are due to non-communicable diseases such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes (WHO, 2017). The global burden of non-communicable diseases is enormous, but the common risk factors are largely modifiable, therefore action can be taken to reduce related morbidity and mortality. The most important goal for people living with noncommunicable diseases is achieving and maintaining a healthy body weight. Moderate weight loss of 5–10% of body weight in people who are overweight is associated with an improvement in blood glucose control, dyslipidaemia and blood pressure (Dansinger et al, 2005). In spite of many products or programmes that offer a quick solution to achieving a healthy body weight, nurses should be well informed to give appropriate advice. Achieving a healthy body weight depends on the amount and type of

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food that is eaten, the way that food is prepared as well as the level of a person’s physical activity. Most patients will benefit from consulting a dietitian at their local primary healthcare facility so that they can receive advice suited to their circumstances but this service may not always be available. The South African Food-Based Dietary Guidelines and the South African Food Guide can be used as nutrition education tools while emphasising the most relevant messages for the person’s condition. People should be empowered with knowledge and skills to take responsibility for their health and be supported in their efforts to make lifestyle changes that will improve their health and quality of life.

the treatment of severe malnutrition to improve case outcome. There are 10 steps that occur in two phases: the initial stabilisation phase, where the critical medical conditions are managed, followed by the rehabilitation phase (see Table 6.4). The successful management of severe malnutrition requires each caregiver to treat each child with affection and carefully complete each specific step. In this way the risk of death is decreased and the chance of full recovery is greatly increased. While each step is very important, this section will only focus on steps 6 to 8. For a detailed discussion of each step you can refer to the Guidelines for the inpatient treatment of severely malnourished children (WHO, 2003).

Nutrition for children with severe acute malnutrition

Correcting micronutrient deficiencies

Severe acute malnutrition in children is diagnosed by the presence of severe wasting (weight-for-height z-score of below −3 on the WHO growth chart) and/or bilateral nutritional oedema and/or an arm circumference less than 115 mm (for children aged 1–5 years). Severe acute malnutrition causes major changes in a child’s physiology and metabolism, which makes them respond very differently to medical treatment. If treated incorrectly, these patients recover slowly and face a very high mortality rate. The WHO has established specific guidelines for

All malnourished children have vitamin and mineral deficiencies. Give the child 5 mg of folate and a high dose of vitamin A (50 000 IU for 0–5 months; 100 000 for 6–12 months; 200 000 for 12 months and older) immediately, unless you are sure that the child has received vitamin A within the previous month. Then provide daily multivitamins, folate, zinc and copper supplementation. Anaemia is common in children with severe acute mal­nu­trition, but don’t give them iron in the stabilisation phase, as this worsens infections. By the second week (or when the child’s appetite has returned) you can start iron

Table 6.4  The 10 steps for treatment of severe malnutrition

Steps

Stabilisation phase Days 1–2

Days 3–7

Rehabilitation phase Weeks 2–6

1. Treat/prevent hypoglycaemia 2. Treat/prevent hypothermia 3. Treat/prevent dehydration 4. Correct electrolyte imbalance 5. Treat/prevent infection 6. Correct micronutrient deficiencies

(without iron)

(with iron)

7. Start cautious feeding 8. Achieve catch-up growth 9. Provide sensory stimulation 10. Prepare for follow-up Source: Ashworth et al, 2003

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supplementation, and a combined electrolyte/mineral solution can be added to the child’s feed or rehydration solution.

Start cautious feeding As soon as the child has received the necessary emergency treatment (for hypothermia, dehydration, septic shock, etc), start with cautious feeding immediately. Although you may want to provide the child with large amounts of food to help the body recover from the severe acute malnutrition, this will be harmful and may even be fatal. Due to infections, impaired digestive function and imbalanced electrolytes they cannot tolerate the usual amounts of protein, fat and sodium. For this reason, the diet given at first should be low in protein, fat and sodium but high in carbohydrates. F-75 (containing 75 kcal/100 ml) is the formula used during the stabilisation phase. The formula can be easily prepared using basic ingredients (such as dried skimmed milk, sugar, cereal flour, oil, mineral mix and vitamin mix) and, where necessary, will be prepared in the facility. F-75 is mostly available commercially as a powdered formula (to mix with water) or a ready-to-use product, both of which are safer to use. The amount of formula to be given is calculated according to the child’s weight and feeds are given frequently (day and night) in small amounts. Encourage the mother to continue breastfeeding in addition to the F-75 feeds. Most children admitted to a facility for severe acute malnutrition have poor appetites, so healthcare workers and/or caregivers who are responsible for feeding the child will need a lot of patience and commitment. Feeds should be given from a cup, but weak children may need to be fed with a dropper, syringe or spoon. If the child is unable to take in at least 80% of the required amount, a nasogastric tube should be inserted. First encourage the child to take the feed orally and then give the remaining amount via nasogastric tube, but do not use intravenous feeds. Keep record of the amount of feed offered and how much was taken. Carefully record any vomiting, the frequency of watery stools and the child’s daily weight. Diarrhoea should improve and oedematous children should lose weight during the stabilisation phase.

Achieve catch-up growth When the child’s appetite has improved, the initial phase of treatment has been successful and the rehabilitation phase can begin. When the child becomes hungry it shows that the infections are coming under control and metabolic abnormalities are improving. F-75 is replaced with F-100 (containing 100 kcal/100 ml), but the change

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should be gradual as there is a risk of heart failure if the child should suddenly consume large amounts of feed. (Ashworth et al, 2003.) Replace the F-75 with the same amount of F-100 for 2 days before increasing the amount of feed. Then increase each feed until some of the feed is left by the child. Keep record of the amount of feed offered and taken, and be sure to discard any left-over feed (do not re-use it for the following feed). If the child is being breastfed, encourage the mother to continue, but it is important to note that breast milk does not contain enough nutrients to cause the child to achieve catch-up growth, so the child should still receive all of their F-100 feeds. The child should not be left to eat alone but should actively be encouraged to eat. Although it is not necessary to use any other diet besides F-100, children who are older than 24 months may want a mixed diet including solid food. As most traditional diets contain less energy and nutrients than F-100, local foods should be enriched. Oil (eg sunflower) can be added to increase the amount of energy, dried skimmed milk powder can increase the amount of protein and peanut butter can be added for extra protein and fat. Weigh the child daily and keep a record of the weight. The child should reach its target weight within 2–4 weeks, but continue giving F-100 until the child’s weight increases from below the –3 z-score to the −1 z-score on the weight-for-height growth chart. See the section titled ‘Interpreting weight and length/height in children’ below. Before discharge from the facility it is important that the child’s mother or caregiver has come to understand the cause of malnutrition, and knows how to prevent it from reoccurring. Involve the mother or caregiver in caring for the child during their time in the facility so that they can be empowered with the necessary skills. Teach them how to continue with good feeding practices at home and how to provide appropriate sensory stimulation for the child. The child should receive proper meals that contain enough energy and nutrients at least 5 times per day. Snacks (such as milk, banana, peanut butter and bread) should be given between meals and the child should be encouraged to complete every meal. The mother can still continue to breastfeed on demand. Regular follow-up of the child is very important and is normally scheduled at 1 week, 2 weeks, 1 month, 3 months and 6 months. Ask the parent or caregiver about the child’s health, feeding practices and play activities and do a thorough assessment of the child’s nutritional status and developmental milestones. Remember to praise and encourage the parent or caregiver when they are taking good care of the child and continue teaching them about appropriate childcare practices.

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Assessment of nutritional status

Mid-upper arm circumference

Nutrition assessment is the process used to evaluate nutritional status, identify malnutrition and determine which individuals need nutritional support. Assessment will help to plan appropriate interventions for the patient and monitor results of the intervention to determine whether it is effective or not. There are four major practicebased assessment areas to determine a person’s nutritional status: A Anthropometric measurements B Biochemical or laboratory analysis C Clinical evaluation D Diet history.

The mid-upper arm circumference is a quick, easy, non-invasive tool to assess nutritional status. The measurement can help to evaluate patients who cannot be weighed easily (eg a child with cerebral palsy who is confined to a wheelchair) or someone whose weight is an inaccurate picture of nutritional status (eg a pregnant woman). A pregnant woman’s weight is changing due to her pregnancy, so her BMI is not a good indicator of her nutritional status. It is advisable to use a more stable measurement like her mid-upper arm circumference.

Anthropometric measurements There are various measurements that can be done to determine the shape and size of a patient’s body. More than one measurement is necessary in order to do a proper assessment, eg comparing a person’s weight with their height will provide much more information than taking only their weight. This information is most valuable when the measurements are accurate and are recorded over a period of time.

Weight Children aged 0–2 years should be weighed without clothing or nappies, sitting or lying down on a paediatric pan scale. Children older than 2 years and adults should be weighed in light clothing (removing jackets or jerseys) and without shoes.

Length or height Children aged 0–2 years who cannot yet stand are measured without shoes and head coverings, lying down, by using a length board or mat. Children older than 2 years and adults are measured while standing without shoes or head coverings using a stadiometer or measuring rod. If they are unable to stand, an indirect method such as arm span, recumbent length or knee height can be used to determine their length by using specific calculations.

Head circumference Head circumference is useful in assessing severe growth disorders and intracerebral abnormalities in children. These measurements are only taken at 14 weeks and 12 months and compared to expected values, which are 37–42 cm and 42–47.5 cm respectively. (Western Cape Department of Health, 2001.)

Clinical alert! Remove any sleeves and let the patient stand with their arm relaxed at their side with the palm facing inwards. Then wrap the tape gently but firmly around the arm at the midpoint and measure to the nearest mm. If the measurement falls below a specified value, the patient is classified as malnourished and nutritional intervention is required. For children aged 1–5 years a value below 125 mm indicates moderate malnutrition, while a value below 115 mm indicates severe acute malnutrition. For pregnant women, a value below 220 mm is an indication of malnutrition.

Waist circumference This measurement is a good indicator of intra-abdominal fat mass, and is a better predictor of risk for chronic noncommunicable diseases than the body mass index (BMI). The measurement is taken while a patient is standing by placing the measuring tape around their waist (parallel to the floor) at the mid-point between the lowest (floating) rib and the iliac crest of their hip bone. The measurement is then compared to certain values that indicate the risk for chronic disease (see Table 6.5).

Interpreting the measurements Interpretation of the measurements is very important. If a measurement is simply taken but not interpreted, it will not show much about the nutritional status of the patient. Nurses who become familiar with interpreting the measurements will find them to be a valuable tool in assessing and monitoring patients’ progress. It is important to give feedback to patients or their caregivers, and to counsel them on the necessary corrective action(s).

Interpreting weight and length/height in children Growth charts are most commonly used to interpret the growth of children. The new Road to Health booklet that

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Table 6.5  How to assess risk for disease by using waist circumference measurements

Ideal

Increased risk

Substantial risk

Men

< 94 cm

94.0–101.9 cm

≥ 102 cm

Women

< 80 cm

80.0–87.9 cm

≥ 88 cm

Source: World Health Organization Table 6.6  How to classify a child’s growth according to the different growth charts

Z-score

Growth indicators Length/height for age

Weight for age

Weight for length/ height

Above +3

Child very tall; rarely seen Endocrine disorder

May be growth problems; assess weight for length/ height

Obese

Above +2

—

—

Overweight

Above +1

—

—

Possible risk of overweight

0 (median)

—

—

—

Below −1

—

—

—

Below −2

Stunted

Underweight

Wasted

Below −3

Severely stunted

Severely underweight

Severely wasted

Source: Western Cape Department of Health

each child receives from the National Department of Health contains three different growth charts, namely weight-forage, height-for-age and weight-for-height. Each of these growth charts assesses different aspects of growth in the child and has z-scores which help classify the child’s growth. Children’s growth is monitored over time, and any special circumstances (such a low birth weight) must be considered when interpreting a child’s growth pattern. The nurse should always give the parent or caregiver feedback about the growth of the child. Praise them if the child is growing well, and offer advice or intervention if the child is not growing according to the expected rate.

Interpreting weight and height in adults using the BMI For people older than 18 years, the BMI indicates whether their weight is appropriate for their height and may provide a useful estimate of malnutrition. Keep in mind, however, that because the BMI cannot show a person’s body composition (ie how much muscle, fat or fluid makes up the body) the results should be used with caution in people who have fluid retention or are very muscular (eg athletes).

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To calculate the BMI, take the person’s weight (in kg), divide it by their height (in m) and divide it by their height (in m) again.

Interpreting weight in adults according to percentage of body weight lost Percentage of body weight lost is normally used to assess the severity of malnutrition in people with HIV, Aids or TB. However, achieving a certain percentage weight loss in overweight patients who have non-communicable diseases can help in the management of their condition. Percentage weight lost can be calculated from a previous weight that was recorded or from the person’s memory (although memory is, of course, not as reliable as a measured weight). To calculate the percentage weight lost, take the original weight and subtract the current weight to determine the difference. Then divide the difference by the original weight and multiply by 100.

Biochemical or laboratory analysis Biochemical tests (analysis of blood, urine and other body tissues) are the most objective and sensitive indicators of

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28

3

26 24

2

Weight (kg)

26 24

22

22

20

20

18

0

18 16

16 14

-2

14

12

-3

12 10

10

Months

28

8

8

6

6

4

4

2

2

2 4 6 8 10 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10 Birth 1 year 2 years 3 years 4 years 5 years Age (completed months and years)

Figure 6.2  WHO weight-for-age chart: boys 0 to 5 years Source: World Health Organization

nutritional status. These tests range from the quick fingerprick to check a diabetic patient’s blood glucose to the blood that needs to be sent to a laboratory to determine the viral load of a patient with HIV infection. Results can provide valuable information regarding the patient’s health and nutritional status, but should be interpreted carefully as the results can be influenced by disease and treatment.

Clinical examination A thorough clinical assessment involves a systematic head-to-toe examination of the patient, looking at both their general condition and specific parts of the body. It’s an important part of the nutritional assessment because certain nutrient imbalances may be detected that cannot be identified with the other assessment methods. Signs to look out for include muscle wasting, hydration status (eg dehydration or oedema), pallor and poor wound healing. Give special attention to the areas where nutritional deficiencies often appear, for example the skin, hair, nails, eyes, lips, gums, teeth and tongue. Many of these signs will indicate a lack of several nutrients but nurses should be aware that some signs are

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not necessarily related to nutrition, and could be due to old age or other factors.

Diet history The goal of taking a diet history is to determine the nutrient content of the food consumed and to evaluate how appropriate it is for the particular patient. It can provide valuable information about the patient’s eating habits, appetite, lifestyle, preferences and dislikes, portion sizes, eating problems, use of complementary or alternative therapies, food availability, etc.

Nutritional care plans Preparing a nutritional care plan A nutritional care plan is aimed at achieving and maintaining optimal nutritional status within the context of the patient’s condition and environment, while helping to alleviate pain, discomfort and any other effects of the condition. Once a complete picture of the patient’s nutritional status has been assembled, a nutritional care plan can be prepared for the patient. The objective of such a plan

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6.14  Working out BMI BMI = weight (in kg) ÷ height (in m) ÷ height (in m) For example: A person weighs 70 kg and has a height of 168 cm. What is their BMI? BMI = 70 ÷ 1.68 ÷ 1.68 = 24.8 Then use Table 6.7 to classify the patient’s weight according to their BMI. Table 6.7  Classification of weight according to BMI

BMI

Interpretation

< 16

Severely underweight

16–16.9

Moderately underweight

17–18.4

Mildly underweight

18.5–24.9

Healthy weight

25–29.9

Overweight

30–34.9

Mildly obese

35–39.9

Moderately obese

> 40

Severely obese

Source: World Health Organization

It is clear that the person in the example has a healthy weight for their height. It is important to understand that both a low BMI (being underweight) and a high BMI (being overweight) are associated with increased risk of disease.

6.15 Calculating percentage of weight lost Difference in weight = original weight (in kg) – current weight (in kg) Percentage weight lost = difference in weight (in kg) ÷ original weight (in kg) × 100 For example: A patient weighed 84 kg in March and now weighs 72 kg in September. What is their percentage weight loss? Difference in weight = 84 kg – 72 kg = 12 kg Percentage weight lost = 12 kg ÷ 84 kg × 100 = 14.3% over 6 months Unintentional weight loss of 5% in 1 month or 10% in 6 months is considered to be a serious problem, especially in people who are living with HIV, Aids or TB, and will require nutritional support.

To provide for continuity of care, you should consider the patient’s need for assistance with nutrition after discharge from the facility. Some patients may need to see a dietitian for nutrition education or support, whereas others may need to be referred to a nutrition programme at their primary healthcare facility. Some patients may need social services to assist them with food parcels or grant applications, and others may need community-based carers to provide home care. Remember to refer patients to the relevant people so that they can receive continued care and achieve an optimal nutritional status even when they are no longer under your care.

Implementing a nutritional care plan may be relatively simple and easy to achieve, such as re-establishing fluid balance after dehydration (by providing fluid either orally, via a feeding tube or intravenously) or it could be complex, needing long-term intervention, such as rehabilitating a severely malnourished child (that will require interventions by different members of the healthcare team over several months). Determining nutritional goals or outcomes is a mutual effort between the nurse, the patient (or caregiver), other members of the healthcare team, the family and in some cases the community as well. These outcomes should include achieving and maintaining optimal nutritional status, preventing complications associated with malnu­ trition, and promoting optimal nutritional practices and a healthy lifestyle.

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Implementation of a nutritional care plan in the clinical area involves three major interventions, namely collaborating, educating and monitoring. In the hospital setting the nurse may collaborate with the doctor, the dietitian and the food service manager regarding the nursing interventions needed to promote optimal nutrition for patients. This could include ordering a special diet from the kitchen, giving nutrition supplements, etc. In the community setting, a nurse’s role will be largely educational. Nutrition counselling involves more than just providing information, and you should assist patients to integrate diet changes into their lifestyle and provide strategies to motivate them to change their eating habits in a way that is sustainable.

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6.16 Essential health information about religion An important aspect to discuss is how the patient’s religion, culture or beliefs may influence the types of food they choose to include in or exclude from their diet. Common practices you may encounter include the following: • Muslim people eat Halaal meat (that has been slaughtered according to specific religious laws). They avoid pork and alcohol, and fast from food and drink on certain holy days, especially during the month of Ramadan. • Jewish people eat Kosher food (including meat that has been slaughtered and prepared according to specific religious laws). They also avoid pork and sometimes alcohol, and fast from food and drink on certain holy days. • Rastafarian people mostly follow strict vegetarian or vegan diets. Vegetarian people eat mostly food from plant sources (eg vegetables, fruit, starches/ grains, nuts/seeds and legumes) while avoiding some or all foods from animal sources. Vegans eat only food from plant sources, but lacto-vegetarians include milk products in their diet and lacto-ovo vegetarians include both milk products and eggs.

Monitoring will determine whether there is improve­ ment or deterioration in nutritional status and will allow modifications to be made in the care plan.

Diets used in hospital/care facilities Diets can be modified in different ways by altering either the nutrients or the consistency of the meals. Providing a special diet will help provide for patients’ specific needs and help them achieve/maintain a good nutritional status. The variety of special diets that are available will differ between facilities depending on factors such as the level of healthcare provided, the training of staff and the available facilities in the food service unit. Special diets will mostly be requested/prescribed by the dietitian or doctor but it would be valuable for nurses to know the characteristics and indications of each one.

Ensuring adequate food intake Patients’ appetites may be decreased by factors such as illness, physical discomfort or pain, unfamiliar food, and environmental and psychological factors. Some patients may need to be assisted during meals (eg help with positioning or cutting food into smaller pieces), while others may need to be fed.

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If feeding a patient, position them in a way that is comfortable and safe (an upright position decreases the risk of aspiration). Ask them in which order they would like to eat the food and if they cannot see, tell them which food is being given. Always allow time for chewing and swallowing before offering more food. Although feeding a patient is time consuming, be patient and unhurried and convey that there is ample time. Make the time pleasant by, if possible, conversing with the patient throughout the meal. Normal utensils should be used whenever possible. Patients who have difficulty drinking from a cup or glass may be offered a straw or a special cup with a spout and those who have difficulty handling normal utensils can be given assistive devices to help them maintain their independence. In these cases, an occupational therapist can assess the need and provide the best recommendations and/or devices.

Enteral nutrition When a patient is unable to ingest sufficient foods orally or the upper gastrointestinal tract is impaired and the transport of food to the small intestine is interrupted, enteral nutrition should be provided. Nutrients are administered into the gastrointestinal tract through a tube, directly into the stomach (nasogastric) or the small bowel (nasoenteric). Patients who require long-term enteral feeds may receive a percutaneous endoscopic gastroscopy where a tube is surgically placed directly into the stomach through the abdominal wall. The decision on where to place the tube depends on various factors such as how long the patient will need enteral feeds, the risk of aspiration or displacement, the patient’s digestive or absorption capacity, and the volume of feed that needs to be administered. Selecting an appropriate enteral formula depends on the patient’s diagnosis and nutritional needs as well as practical factors such as budget, convenience and available facilities. Standard (or polymeric) feeds are nutritionally balanced with an acceptable taste and a reasonable price, but require normal digestive and absorptive function. A patient with compromised gastrointestinal function will most likely receive a semi-elemental (or partially digested) feed which is less palatable and more expensive, but allows for better absorption of nutrients. Some patients may also require feeds that are specially designed for certain conditions, such as diabetes mellitus or renal impairment. The frequency and amount of feeds will be calculated by a dietitian or doctor according to the patient’s nutritional requirements. With bolus or an intermittent drip, feeds are administered several times per day by a syringe, gravity drip or infusion pump. These feedings should be given

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Chapter 6 – Nutrition needs  89 Table 6.8  Special diets, characteristics and indications

Diet

Characteristics

Indications

Full

• Contains a variety of foods prepared using any cooking method

• No special dietary needs

Light

• Foods that are easy to digest • Mechanical: avoid pips, seeds, whole grains, fried foods, and anything hard, dry or tough • Chemical: avoid spices, acidic foods (eg vinegar, lemon) and gas-forming foods (eg cabbage, cucumber, beans) • Temperature: avoid food that is too hot or cold

• Transition from fluid to full diet • Following surgery

Soft

• Foods that are easy to chew or can be pressed against the palate with the tongue • Sauces are often added to make foods easier to swallow

• Chewing or swallowing difficulties* • Painful mouth

Puree

• Foods from the light and/or soft diet are mashed or pureed in a food processor

• Chewing or swallowing difficulties* • Painful mouth

Clear fluid

• Limited to clear fluids, for example water, clear juices (apple, grape, berry), clear soups, tea (without milk) and jelly • Aim is to relieve thirst, prevent dehydration and minimise stimulation of the gastrointestinal tract

• Preparation for gastrointestinal surgery • Following gastrointestinal surgery • Severe nausea, vomiting or diarrhoea

Full fluid

• Contains only liquids or foods that become liquid at room temperature • It is low in fibre, protein and iron, and can be high in saturated fat (especially when a lot of milk products are given) • It is not nutritionally adequate for long-term use unless patients are receiving supplemental drinks

• Transition from clear fluid to full diet • Chewing or swallowing difficulties* • Painful mouth

Diabetic

• Contains no sugar or sweet foods, and is high in fibre and low in fat • Portion sizes are measured • Meals are distributed through the day to ensure better blood glucose control, for example by providing snacks between meals

• Diabetes mellitus • Sometimes also indicated for obesity or cardiovascular disease

High protein

• A full diet supplemented with extra protein and energy in the form of nutritious foods (eg an extra egg with breakfast) and/or supplemental drinks

• Malnourished patients • Increased energy requirements (eg HIV, TB or cancer)

Low protein

• Protein sources (meat, chicken, fish, eggs and milk products) are restricted by providing smaller portions that are measured/strictly controlled • Sodium, potassium, phosphate and fluid may also be restricted in this diet

• Renal impairment

Low salt

• Contains no added salt and limits foods containing sodium (eg processed foods, processed meats, tinned products, stock and soup powders)

• Hypertension • Congestive heart failure • Renal impairment • Liver disease with ascites

*R  emember to consult with the speech therapist to determine which textures will be most appropriate for the patient who has swallowing difficulties.

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6.17 Essential health information about providing meals to patients • Provide a clean environment free of unpleasant sights and odours (remove urinals/bedpans and close doors to the toilet). • Allow/assist patients to wash their hands before meals. • Encourage/provide oral hygiene (such as rinsing the mouth or brushing the teeth if necessary) before meals as it improves the patient’s ability to taste. • Avoid unpleasant/uncomfortable treatments or procedures before/after meals. • Relieve symptoms that may decrease appetite before meals, such as giving an analgesic for pain or an antipyretic for fever. • Assist the patient to sit in a chair or a comfortable position in bed, whichever is permitted and appropriate. • Clear the over-bed table to make space for the tray and make sure it is clean and hygienic. • Arrange the over-bed table close to the bedside so that the patient can reach and see the food. • Always check to ensure that the patient has the correct special diet. • Provide familiar, culturally appropriate food when possible. • Assist the patient if needed in spreading bread, cutting meat, etc. • If the patient is blind, identify the placement of the food. • On completion of the meal, observe how much and what was eaten and the amount of fluid taken, and record this on the appropriate documents. • Following the meal, offer patients a mouth rinse or attend to their oral hygiene in order to prevent dental caries and halitosis. • Always check for any problems during or after meals, eg if the patient does not eat, experiences nausea and/or vomiting, chewing and/or swallowing difficulties, or pain. Report these observations to the relevant person and record it on the appropriate documents.

only into the stomach and the patient must be monitored closely for distension and aspiration. Continuous feedings are usually administered over 24 hours using an infusion pump that ensures a constant flow rate. These are used for patients who do not tolerate large volumes of feed at once, and are essential when feedings are administered into the small bowel.

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Common complications in patients receiving enteral feeds are aspiration and diarrhoea. The risk of aspiration can be reduced by giving feeds slowly and raising the patient’s head and shoulders above the chest during and after feeding. Diarrhoea can be prevented by giving feeds slowly, ensuring correct concentration and preparing feeds hygienically. Remember that diarrhoea can also be caused by various other factors such as bacterial overgrowth, medication or illness, and the actual cause should be identified and addressed before adjusting or withholding feeds. (Mahan & Excott-Stumo, 2004.)

Parenteral nutrition When the gastrointestinal tract is non-functional, feeds are administered intravenously to bypass the digestive tract. Parenteral nutrition would be indicated in patients with severe malnutrition (with a non-functioning gastrointestinal tract), severe burns, bowel disease disorders (eg obstruction or resection), moderate to severe acute pancreatitis, those who have undergone major surgery, or any condition where the gastrointestinal tract would be inaccessible for 3–5 days. Total parenteral nutrition aims to provide all the patient’s nutritional requirements in a volume that is well tolerated. A central venous catheter is inserted into the superior vena cava, which allows concentrated feeds to be administered to the patient long term. Peripheral parenteral nutrition refers to feeding through a catheter that is inserted into a small vein (usually in the arm). It is a short-term method to provide supplemental feeds or to help with the transition from parenteral to enteral feeds. Parenteral solutions are high in glucose so infusions are started gradually over 2–3 days to prevent hyper­ glycaemia. Feeds can then be administered by continuous infusion (over 24 hours) or cyclic infusion (over 8–12 hours, usually at night). When parenteral feeds are dis­continued, this should also be done gradually to prevent hypoglycaemia. Monitoring patients for potential complications is of great importance. Complications can be mechanical, such as an air embolism, or metabolic, such as electrolyte abnormalities, but the greatest risk remains the potential for infection. Be sure to monitor patients closely for any signs of infection and always observe surgical aseptic technique when changing solutions, tubing, dressings and filters.

Special community-based nutritional services There are various community-based programmes that can assist in the nutrition support of people who are at risk of malnutrition and it is helpful to be aware of the different options for your patient following discharge from the hospital.

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The Nutrition Therapeutic Programme is an initiative by the South African Department of Health, and operates in South African primary healthcare facilities. (Naude, Labuschange & Labaderios, 2008.) The main target groups are children; pregnant and lactating women; and malnourished people living with HIV, Aids and/or TB. There are specific criteria for each group, and patients on the programme receive enriched porridge, energy drinks and/or ready-to-use therapeutic food for six months. Food parcels are provided to some people who are at risk by the South African Department of Social Development or local NGOs. The National School Nutrition Programme of the South African Department of Education provides meals to children attending schools in communities affected by poverty. The main aim is to improve the education of learners by relieving hunger and the effects of malnutrition on their learning abilities. Many communities also have charity or faith-based organisations that provide cooked meals to vulnerable people such as the homeless, the elderly and people living with HIV, Aids and/or TB. As these people are usually identified and referred by a healthcare facility, it is important for you to know which organisations are actively at work in their community so that you can work with them.

Evaluation of nutritional outcomes Ongoing evaluation from the onset is vital in order to provide a patient with cost-effective treatment and results.

In a hospital/care facility, nurses need to monitor how well patients tolerate their meals. The reason for meals not being eaten needs to be investigated as this may affect a patient’s nutritional status and progress. Meals that are not tolerated may need to be adapted to assist the patient in recovery. At primary healthcare level, evaluation may include growth monitoring and promotion of a malnourished child on the Nutrition Therapeutic Programme, or monitoring the weight of a person with diabetes mellitus. In each case, the goals that were established during the planning phase should be evaluated according to specific desired outcomes so that interventions can be continued, adapted or stopped if the goals have been achieved.

Common nutrition-related problems There are various problems that can affect a person’s ability to maintain an optimal nutritional status. This can be caused by an inability to take in adequate nutrients (eg poor appetite, sore mouth, increased nutritional needs) or the loss of valuable nutrients (eg through vomiting or diarrhoea). Being informed about the interventions and medical management of these problems is only a part of the care process. There is much advice you can offer patients in addition to (or sometimes instead of) conventional therapy that should help to relieve some of the symptoms and help them to attain a good nutritional status. See Table 6.9 for common nutrition-related problems and advice you can offer.

Table 6.9  Common nutrition-related problems: their causes, interventions and related health promotion aspects

Causes

Interventions to address cause and/or symptoms

Health promotion/home care to ensure adequate intake

Pain and difficulty with chewing or swallowing • Poor oral hygiene • Vitamin B deficiency • Poorly fitting dentures • Immunosuppression leading to opportunistic infection • Long-term use of broad spectrum antibiotics/ corticosteroids • Stroke (causing dysphagia) • Poor hygiene of feeding bottles causing infection • Dental/facial surgery

• Pain relief • Oral care • Correct nutrient deficiencies • Ensure proper fitting dentures • Test for HIV if status is unknown • Appropriate medication –– Antibiotics –– Local/systemic antiviral agents –– Antifungal agents • Refer to speech therapy to assist with swallowing difficulties

• Good oral hygiene (regular brushing and rinsing with salt-water mouthwash) • Maintain adequate hydration • Take sips of fluids with meals to make swallowing easier • Adjust consistency of food to make it easier to chew and/or swallow • Encourage soft, bland foods • Avoid hard/crunchy/spicy/acidic foods for sore mouth • Avoid sticky/dry foods for swallowing difficulties • Cold foods and drinks or ice may relieve discomfort and pain • Use a straw for liquids or soups • Encourage mothers to cup feed instead of using bottles and educate on good hygiene

❱❱

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Causes

Interventions to address cause and/or symptoms

Health promotion/home care to ensure adequate intake

• Treat illness • Revise and modify medication • Correct nutrient deficiencies • Refer to psychologist or counsellor to assist with depression/anxiety

• Eat small, frequent meals • Ensure meals are nutritious • Eat in a relaxing environment with friends or family, and make mealtimes enjoyable • Present meals so they are attractive and appetising • Try to stimulate appetite by eating favourite foods • Avoid drinking fluids before or during meals as this can fill the stomach • Enrich foods by using products such as margarine, oil, peanut butter, milk, eggs and sugar to increase the energy and/or protein content of the meal. Stir margarine or peanut butter into porridge, sweeten vegetables or make scrambled eggs

• Screen for possible disease • Deworm • Investigate social circumstances • Refer to social worker • Refer for Nutrition Therapeutic Programme

• Counsel according to the cause (ie if due to poor appetite, see the appropriate section) • If due to social circumstances, counsel on economical meals

• Oral rehydration solution • Intravenous therapy if unable to keep fluids down • Refer if: –– dehydrated –– shocked –– known diabetic –– jaundiced –– showing signs of intestinal obstruction (no stools/flatus) –– presenting with abdominal pain/tenderness with guarding and rigidity

• Eat small, frequent meals and chew food slowly • Maintain adequate hydration with clear fluids • Drink fluids between meals instead of with meals • Eat lightly salted and dry foods (such as salty crackers or toast) • Avoid fatty or oily and spicy foods • Eat simple foods (such as rice, mashed potato, toast, noodles, scrambled eggs, banana or custard) • Remain upright for about 20 minutes after eating before lying down

Poor appetite • Illness • Medication • Depression • Anxiety • Micronutrient deficiency

Weight loss • Disease: –– TB infection –– HIV infection –– Diabetes –– Cancer –– Thyroid dysfunction • Inadequate food intake: –– Poor appetite –– Sore mouth/swallowing problem –– Nausea/vomiting –– Stress –– Poor food security • Worm infestation Nausea and vomiting • Viral infection • Motion sickness/dizziness • Early pregnancy • Medication • Alcohol abuse

❱❱

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Causes

Interventions to address cause and/or symptoms

Health promotion/home care to ensure adequate intake

–– infants have projectile vomiting –– vomit contains blood, is dark green, brown or smells like faeces –– regular vomiting lasts more than 24 hours, especially if accompanied by abdominal pain

• Cold foods/drinks are usually better tolerated than hot foods/drinks. This also prevents the odour of the hot food worsening the nausea • Open windows to allow for good ventilation of the room/house • Maintain good oral hygiene • Apply a cool compress to the forehead to assist the patient to relax

• Oral rehydration solution • IV fluids if unable to keep fluids down • Appropriate medication –– Ciprofloxacin –– Loperamide –– Corimoxazole –– Metronidazole • Test for HIV if status is unknown

• Drink plenty of fluids (water and oral rehydration solution) to prevent dehydration • Eat small, frequent meals • Eat foods containing soluble fibre (eg oats, legumes and apples without the skin) • Avoid foods containing insoluble fibre (eg whole-wheat bread, bran, nuts and seeds) as these can irritate the gut • Eat foods containing potassium (eg bananas and potatoes) to replace losses in the stools • Avoid fatty or oily foods • Avoid foods or drinks containing caffeine (eg coffee, Ceylon tea, cola and chocolates) as these can stimulate the gut and worsen symptoms • If milk and milk products worsen the symptoms, avoid them, although fermented milk products (eg yoghurt and maas) may still be tolerated • Ensure good personal hygiene, especially hand washing

• Education on non-drug approaches • Appropriate medication –– Sennosides • Refer if: –– no stools or wind in past 24 hours with abdominal pain and vomiting

• Drink more fluids, especially water • Eat more foods that contain fibre such as whole-wheat bread, oats, vegetables, fruits, dry beans, peas and lentils • Be more active and take part in exercise according to ability (aim for 20 min per day) • Avoid chronic laxative use or enemas

Diarrhoea • Infection –– Poor hygiene –– Immunosuppression –– Worm infestation • Lactose intolerance • Osmotic diarrhoea (too much sugar, often from dried fruit)

Constipation • Diet/lifestyle • Medication –– Amitriptyline –– Codeine/morphine –– Antacids –– Iron supplements • Pregnancy

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Causes

Interventions to address cause and/or symptoms

Health promotion/home care to ensure adequate intake

• Assess risk for endiovascular disease • Stop NSAID/aspiria • Appropriate medication –– Magnesium trisilicate suspensions

• Eat small, frequent meals • Eat slowly and chew food well • Avoid large meals containing lots of fat at least 3–4 hours before lying down • Avoid rigorous exercise soon after eating • Stop/avoid smoking • Avoid alcohol and foods or drinks containing caffeine (eg coffee, cola and chocolates) • Avoid spearmint and peppermint • Avoid spicy, acidic or gas-forming foods and carbonated drinks • Wear loose-fitting clothing, and avoid tight belts or clothing that can increase pressure on the stomach

• Pain relief • Appropriate medication: –– Paracetamol –– Magnesium tricilicate suspension • Deworm • Stop NSAIDS/aspirin • Refer if: –– peritonitis –– jaundiced –– fever –– no stools or wind in past 24 hours and vomiting –– no urine passed for last 12 hours and swelling of abdomen –– pregnant with BP > 140/90 –– associated with chest pain –– recurrent with constipation and/or diarrhoea and bloating –– loss of weight/appetite –– blood in stools –– persistent vomiting/vomiting blood

• Advise as for a patient with heartburn • Discuss normal bowel functions and frequency

Heartburn/indigestion • Relaxed gastro-oesophageal sphincter pressure due to: –– Spicy food –– Peppermint –– Alcohol –– Fatty foods –– Smoking –– Non-steroidal antiinflammatory drugs (NSAIDs)/aspirin

Abdominal pain • Pelvic infection • Constipation • Abdominal mass • TB • Cancer • Worm infestation • Irritable bowel syndrome

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Conclusion Malnutrition affects the South African population in the form of undernutrition, over-nutrition and various micronutrient deficiencies. Through this Chapter, you should have a greater awareness of the main nutritionrelated challenges in South Africa. The characteristics of nutrients, the importance of nutrition through each phase of the lifecycle and the value of nutrition in the prevention and/or management of

certain conditions have been briefly described. This will equip you in assessing the nutritional status of patients, as well as preparing, implementing and evaluating nutritional care plans for them. You should also be able to offer appropriate advice to patients. By using this knowledge, you can play a key part in helping to achieve optimal nutrition for all people in your care.

Suggested activities for learners Activity 6.1 A mother with a 4-month-old child comes to you for advice on complimentary feeding. Discuss the following: • The best time to start complimentary feeding and why • What foods would be considered appropriate and safe • Good sources of vitamin A • The functions of vitamin A. Activity 6.2 Practice measuring your weight and height in the correct way. Write it down. • Calculate your body mass index (BMI). • Classify your weight accordingly. • Do you have reason to be concerned? • What factors do you think are contributing to your current BMI? • What eating patterns or lifestyle habits do you think you could improve? Activity 6.3 Adapt the following menu for an elderly person who does not have teeth or dentures. Breakfast Oats porridge with milk and sugar Apple Lunch Chicken pieces Samp Green beans Beetroot salad Supper Fried egg Whole-wheat bread Sliced tomato ❱❱

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Activity 6.4 You are working as a nurse at a primary healthcare facility. Mr Dube, one of your patients who has TB, weighs 52 kg today. His usual weight is 58 kg. He recently lost his job as he is too weak to work and complains of a decreased appetite. • Calculate Mr Dube’s percentage weight loss. Are you concerned? • List all the possible reasons for his decreased appetite. What advice would you offer him? • Compile a brief nutritional care plan including your goals and possible interventions to help Mr Dube achieve an optimal nutritional status.

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7

Elimination need

learning objectives

On completion of this Chapter, the learner should be able to: • explain how to assess common problems associated with elimination as it applies to both the urinary tract and gastrointestinal tract across the lifespan • discuss the common causes and effects of selected elimination problems • discuss the nursing history to be obtained from a patient with an alteration in urination and defecation • collect specimens of urine and faeces for both routine ward and laboratory tests • accurately monitor techniques and interpret assessment findings related to elimination, eg testing of urine and interpretation of findings thereof • identify measures that maintain normal elimination patterns • design a nursing care plan for a patient with altered elimination patterns. key concepts and terminology

afferent arterioles

Smaller arteries that form from the renal artery and form a tuft of arteries in the Bowman’s Capsule, known as the ‘glomerulus’.

aldosterone

A renal hormone secreted by the adrenal cortex; that regulates the reabsorption of sodium and the excretion of potassium in the renal tubules.

anti-diuretic hormone

A renal hormone that regulates water reabsorption from the renal tubules.

anuria

Absence of urine/urinary output that is less than 100 ml/day.

catheterisation

Passage of a catheter into the urinary bladder with the aim of emptying the bladder.

chyme

Digested food mixed with gastric juices and enzymes in the small intestines ready for absorption into the circulatory system.

constipation

Difficulty in passing a stool which is usually hard.

cortex

Outer layer of the kidney tissue where nephrons are found.

defecation

An act of expelling faeces through the anus in response to an urge.

diuresis

Increased formation or secretion of urine.

diurnal enuresis

Uncontrollable passage of urine both in the day and night.

dysuria

Painful or difficult urination.

efferent arterioles

Smaller arteries that leave the Bowman’s Capsule, to form peritubular capillaries in the medulla of the kidney.

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elimination

Removal of waste products from the body.

encrustation

The blockage of a urinary catheter by mineral salts due to prolonged catheterisation.

enuresis

Involuntary passage of urine, thus wetting of clothes.

glomerular filtrate

An exudate that sips through the capillary walls of the glomerulus in the Bowman’s Capsule.

glomerulus

A tuft of capillaries in the Bowman’s Capsule formed from the afferent arterioles through which filtration occurs.

haematuria

The presence of blood in urine.

hilum

The hollow area on the concave side of the kidney where renal blood vessels enter and leave the kidney.

homeostasis

A term used to describe regulatory mechanisms which maintain a chemical balance between electrolytes and water within the intra- and extracellular compartments in the body.

hypocalcaemia

Low concentration of calcium in the body fluids.

hypoxia

Low oxygen concentration in the blood.

incontinence

Inability to control passage of urine or faeces or both.

encopresis

Inability to control faeces/stool.

large intestine

The portion of the gastrointestinal tract through which waste material, including undigested substances from the small intestine, passes. It consists of the following segments: ascending, transverse, descending, sigmoid colon and rectum.

medulla

Inner layer of the kidney tissue where renal tubules are found.

megacolon

Dilated and atonic colon caused by faecal mass and gas that may obstruct the passage of colon contents or lead to perforation of the bowel.

melaena

Blood in the stool.

micturition

The act of passing urine (same as ‘urination’ and ‘voiding’).

mobility

Movement.

nocturia

Excessive urination at night.

oliguria

Decreased urinary output of less than 400 ml/day.

peristalsis

Rhythmic wave-like contractions and dilatations in the lumen to push the contents of the lumen forward.

polyuria

Increased amounts of urinary output of more than 3 000 ml/day.

proteinuria

Presence of abnormal amounts of protein in urine.

pyuria

Pus in the urine.

rectal prolapse

A condition in which the rectum (the last part of the large intestine before it exits the anus) loses its normal attachments inside the body, allowing it to slip outside the anus.

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residual urine

Volume of urine remaining in the bladder after voiding.

retention

Inability of the bladder to empty completely during micturition.

specific gravity

The weight of a given volume of urine compared to the weight of an equal amount of water.

sphincter

Circular muscles found around an opening and which on contraction will cause closure of the opening and on relaxation will open the outlet.

tenesmus

Straining at defecation which can lead to rectal prolapse.

urinary tract infection (UTI)

An infection in any part of your urinary system, ie kidneys, ureters, bladder and urethra.

urinometer

An instrument used to measure the specific gravity of urine.

prerequisite knowledge

• Anatomy and physiology of the urinary tract and that of the gastrointestinal tract • Chemistry and microbiology. medico-legal considerations

Catheterisation is a sterile procedure which is done to drain urine from the bladder. Introduction of the catheter into the urinary tract may introduce ascending infection if the principles of asepsis are not observed. The Foley’s catheter must never be pulled out forcefully without deflating the bulb that holds it in place as this may cause damage to the urethra. For faecal elimination, enema solutions, enema tubes, flatus tubes, and suppositories must be introduced gently into the rectum to avoid irritation of the rectal mucosa. ethical considerations

• Always ensure privacy when carrying out procedures relating to elimination and do not expose the patient unnecessarily. Patients must always be treated with dignity and respect. • Principles of care for patients who cannot eliminate normally must be observed. After cleaning an incontinent patient, ensure that the patient is comfortable. essential health literacy

It is important for both patients and non-patients to be educated on how to promote regular urinary and bowel elimination through sufficient fluid intake (drink 2–3 ℓ of water daily), regular exercise, and a diet rich in fibre. Patients should pay attention to the urge of urination or defecation. Patients should be advised to defecate when the gastrocolic reflex is strongest (after breakfast) and try to establish a pattern by defecating at the same time each day (after breakfast). Patients and the general community need to know the importance of exercise as a means to regulate elimination and be made aware of the dangers inherent in the overuse and abuse of laxatives.

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Introduction

Adrenal glands

Elimination is an important bodily function: the human body rids itself of waste products to maintain effective functioning. The four mechanisms of elimination are: 1. The formation of urine by the kidneys and the excre­ tion of urine via the urinary tract 2. The expulsion of faeces (defecation) from the gastro­ intestinal tract after digestion and absorp­ tion have been completed 3. The excretion of some waste products in the form of sweat from the skin 4. The removal of carbon dioxide and water via the lungs during expiration. In this Chapter, elimination will be discussed under the urinary tract and the gastrointestinal tract. Sweat and sweating will be discussed under the integumentary system in Chapter 48, while removal of carbon dioxide will be discussed under the respiratory system in Chapter 29. In the discussion of elimination, nurses will be assisted to develop an understanding of the regulation and control of the bladder and bowel function. They will be encouraged to become proficient in the assessment of bladder and bowel function, and be assisted to develop competence in the prevention and nursing management of common problems associated with elimination, such as dysuria, frequency, retention, diarrhoea, constipation and incontinence of both urine and faeces. Emphasis will also be placed on the control of elimination of both urine and faeces as a measure of maturity in the assessment of milestones in child development.

Kidneys

Ureters

Urinary bladder

Urethra Figure 7.1  The urinary tract

Medulla (pyramids)

Lesser calcyces

Cortex Capsule

Urinary elimination Urinary elimination is a product of the renal system whereby excess water and waste products of metabolism are removed from the body through the act of micturition, voiding or urination.

Renal column of medula

Renal artery

Overview of the anatomy and physiology of the renal system The renal system consists of two kidneys, two ureters, the urinary bladder and the urethra as illustrated in Figure 7.1.

Renal vein

The kidneys he kidneys are a pair of brownish-red bean-shaped organs that are situated retro-peritoneally on the posterior abdominal wall on either side of the aorta and the inferior vena cava. They extend from the 12th thoracic vertebra to the 3rd lumbar vertebra. They have posterior and anterior surfaces. Each kidney is composed of the renal parenchyma and the pelvis. The renal parenchyma is

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Papilla of medula

Ureter Greater calcyx Figure 7.2 Cross-sectional view of the kidney

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covered by a fibrous capsule which continues over the pelvis. The renal parenchyma presents with two distinct parts, the cortex and the medulla (see Figure 7.2). The cortex is the outer layer of the parenchyma which contains over a million nephrons. Nephrons are functional units of a kidney. The medulla is the inner layer of the parenchyma. It is made up of renal pyramids, and conducting tubules are in this part of the kidney as well. These finally unite to form the pelvis of the kidney. The hilum is the hollowed area on the anterior surface of the kidney where the renal artery, which originates from the abdominal aorta, enters the kidney and the renal vein leaves the kidney (see Figure 7.2). In the kidney, the renal artery divides into smaller arterioles that eventually form afferent arterioles. Each afferent arteriole further divides into smaller branches that form a knot/tuft of capillaries, known as a ‘glomerulus’ and it is contained in the Bowman’s Capsule. This tuft of capillaries is responsible for the ‘glomerular filtrate’. The efferent arteriole leaves the Bowman’s capsule to form smaller peritubular capillaries which finally form the renal vein. The renal vein extends from the hilum to join the inferior vena cava. It is estimated that 1 200 ml of blood passes through the kidneys every minute in the average adult (± 21% of cardiac output).

Structure and function of the nephron A nephron is made up of a glomerulus, ie a tuft or cluster of blood vessels that are contained in the Bowman’s capsule. The capsule continues as renal tubules, ie the proximal renal tubule, the Loop of Henle, the distal tubule and the collecting duct (see Figure 7.3). The capsule has pores large enough to let water and some small particles of solutes to pass through, but do not allow large protein and glucose molecules to filter through, which means that the blood retains the essential elements needed by the body through selective reabsorption. The fluid that filters through the Bowman’s capsule is known as the ‘glomerular filtrate’ (± 120 ml/minute). The glomerular filtrate is chemically almost the same as plasma, but only has very small quantities of protein and consists of sodium, chloride, potassium, creatinine, urea, amino acids, glucose, uric acid, bicarbonate and other electrolytes and large amounts of water. The glomerular filtrate passes along the nephron’s tubules where about 99% of water and essential solutes are reabsorbed into the bloodstream. The tubules also secrete substances such as drugs into the urine. The 1% of water that is left forms the urine that is excreted.

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Capsular space Efferent arteriole

Renal tubule

Glomerulus Renal corpuscle

Afferent arteriole

Collecting duct

Descending limb Papillary duct

Loop of Henle

Ascending limb

Figure 7.3 The structure of the nephron and renal tubules

Hormonal control of the kidney The anti-diuretic hormone (ADH) and aldosterone are important regulators of renal function. ADH is produced in the hypothalam us, stored and released by the posterior lobe of the pituitary and regulates the amount of water that is reabsorbed by the renal tubules in response to fluctuations in the osmotic pressure in the blood. Water, sodium and other ions are reabsorbed into the bloodstream, making the urine more concentrated. In the absence of ADH, only sodium and other ions are reabsorbed, leaving water in the urine and diluting it. Aldosterone is a hormone that is secreted by the adrenal cortex, and acts on the distal tubule, where it increases the reabsorption of sodium and excretion of potassium. The reabsorption of sodium results in an increase in osmotic pressure followed by the release of ADH, which increases the reabsorption of water. Once the urine has been formed in the kidneys, it enters the ureters via the collecting ducts in the kidney, and it is propelled by peristalsis through the ureters to the urinary bladder.

The ureters The ureters are two hollow tubes that convey urine from each of the renal pelvis to the urinary bladder (see Figure 7.1). In adults, they are approximately 30 cm in length. Urine moves down the ureters by peristalsis.

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The urinary bladder The urinary bladder is a hollow, pear-shaped muscular organ that serves as a reservoir for urine. It has two inlets at the top which are the points of entry for the ureters, and one outlet at the bladder neck which continues as the urethra (see Figure 7.1). The wall of the bladder is made up of four layers. The outer layer is the adventitia, which is made up of connective tissue. This layer is followed by the smooth muscle layer known as the detrusor. Beneath the detrusor is another smooth muscle, the lamina propia, which separates the detrusor from the innermost layer, the urothelium. The urothelium is specialised in that it is impermeable to water and therefore allows the bladder to retain urine for long periods of time without it being reabsorbed. Because of its musculature, the bladder is considerably elastic and is capable of great distension. The outlet at the bladder neck has a sphincter mechanism that is formed by involuntary smooth muscles for the internal sphincter, while the external portion of the sphincter, which is at the anterior aspect of the urethra, is under voluntary control. The bladder is emptied by the contraction of its muscles. The desire to urinate is caused by sensory stimulation in the bladder as a result of the pressure of urine, the chemical composition of urine or reflex stimulation.

The urethra The urethra is a passage for micturition (see Figure 7.1). It has internal and external sphincters that keep the urethra closed so that urine does not leak from the bladder. The external sphincter is under voluntary control and its control is dependent on growth and development from childhood. In males, the urethra is 20–25 cm long. It traverses through the prostate gland and in addition to carrying urine, it also carries semen for reproduction. The female urethra is approximately 5–10 cm in length. It is straight and although not involved with reproduction, it opens into the area of the female external genitalia above the vaginal opening.

The functions of the kidney The main functions of the kidneys are as follows: Waste excretion. The kidneys filter all the waste products of metabolism in the form of excess water, urea, creatinine, ammonia, uric acid, drugs, toxins and solutes such as sodium chloride. These are removed from the body in the process of urine formation. Urine formation. Urine is a product of the nephron and renal tubules. The nephron is the functional unit of the kidney and each kidney has approximately 1 million nephrons.

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Homeostasis. This term describes regulatory mechanisms that maintain a balance in electrolytes and water in the extracellular and intracellular compartments in the body. The intricate structure and functioning of the kidney maintain the constant composition and volume of body fluids so as to ensure intra- and extracellular homeostasis. The rates of filtration, secretion and reabsorption are under the control of many hormones and haemodynamic signals present in the kidney. Control of blood pressure. This happens in the distal convoluted tubule, under the influence of aldosterone and the renin-angiotensin hormones. Whereas aldoste­ rone is responsible for the reabsorption of sodium, reninangiotensin reacts to the volumes of blood contained in blood vessels and causes vasoconstriction or vasodi­ latation, thus regulating blood pressure. Vitamin D metabolism. The kidney is also essential for vitamin D metabolism, where the inactive 25-hydroxycholecalciferol is hydrolysed to form the active 1.25-dihydroxycholecalciferol. Failure of this process contributes to hypocalcaemia and poor bone formation. The main source of erythropoietin. The kidney is the main source of erythropoietin necessary for the generation of red blood cells for oxygen uptake, especially in response to hypoxia.

Congenital abnormalities in the renal system Pathology in the renal system may be as a result of congenital abnormalities. There may be a fusion of the kidneys that takes place during development in the embryonic stage. In such cases the child will be born with one kidney which is usually horseshoe-shaped. One kidney may be smaller in size. In such cases the kidney may also be non-functional. There may be cases where there is a double ureter or strictures in the length of the ureter.

Practice alert! Whatever the abnormality, treatment is only advised if there are untoward symptoms.

Micturition An amount of 200–300 ml of urine in the urinary bladder is required to stimulate the urge to void. The collected urine stretches the walls of the bladder, causing the baroreceptors to stimulate the parasympathetic nervous system. This stimulation causes urinary bladder contraction. When the motor nerves are inhibited, muscles

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relax and the sphincter opens, and conversely, when these are not stimulated, the muscles remain contracted and the sphincter remains closed. This allows for voluntary control of micturition. After 3 years of age, the urethral external sphincter is normally under voluntary control and micturition can therefore be delayed by contraction of this sphincter. Micturition can only be postponed temporarily. After a while the urge will become irresistible, and the individual may experience incontinence if they delay for too long. When the bladder becomes distended to 1 000 ml or more, bladder tone may be lost and tissue damage can occur.

Mental state. People’s normal micturition habits may be altered by stress or anxiety due to or following illness, surgery or emotional issues. Anxiety can prevent complete urination and tension makes it difficult to relax abdominal muscles.

Factors affecting micturition

Medication. Medication like diuretics prevent reabsorption of water and certain electrolytes, and urinary out­ put increases. Analgesics may cause confusion and disorientation, with effects on the bladder and urethral musculature.

The factors that affect how and when micturition takes place are as follows: Age. Micturition is usually under a degree of conscious control. Adults and older children are able to control micturition, while children younger than 3 years may not be able to control the act voluntarily. Elderly individuals, due to lax muscle tone including sphincter muscles, may be incontinent of urine. Privacy. Individuals who are able to control micturition, may determine surroundings in which to pass urine. The surroundings are usually comfortable, secure, private, and where possible, known to them. Hospitalisation may contribute to difficulty in micturition as the surroundings are strange, shared by many people and worse still, if micturition has to be made in a urinal or bedpan, in a public ward. Position. Micturition is usually done sitting or standing, depending on the gender. In hospital, it may be required that urine is passed lying down or sitting in bed. The unusual and unnatural position may contribute to the difficulty in passing urine. Surgical procedures. The stress response to surgery reduces the amount of urinary output to increase circulatory fluid volume. Anaesthetics and pain-killing drugs cause reduced intra-bladder pressure and inhibition of the micturition reflex, resulting in development of urinary retention. The nature of the facility. Micturition is best done in a comfortable and clean toilet, and best still, in known surroundings. Dirty, smelly toilets with broken seats, cracks in the walls, and open roofs may contribute to individuals holding the urine and distending the bladder to dangerous levels.

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Health status. Ill health with debilitating effects may affect the tone of muscles, the mental and psychological state enhancing anxiety. This may result in incontinence or retention. Acute renal diseases reduce urine volume, while spinal cord injuries interrupt voluntary bladder emptying.

Fluid intake. Increased intake of fluids may also result in increased urine volumes and frequency of micturition. Alcohol stops the release of anti-diuretic hormones, thus promoting urine production. Mobility. Immobility may result in stagnation of urine in the urinary bladder that distends to contain large volumes of urine.

Facilitating micturition Hospitalisation and illness, as well as prescribed medical therapies, may interfere with a patient’s normal voiding habits. The facilitation of micturition is an important part of a nurse’s role, and several factors should be taken into consideration. Based on the factors that influence micturition, Table 7.1 indicates measures to facilitate micturition.

Characteristics of normal urine Urine is a complex watery solution with organic and inorganic substances of which most are waste products from metabolism of food and body cells. The normal characteristics of urine are summarised in Table 7.2. Some of the normal variations that may be found in urine are indicated in Table 7.3. Some of the abnormalities that may be found in urine are indicated in Table 7.4.

Assessment of urine The observation and testing of urine is one of the first procedures that a nurse learns to do. It is also one of the most important screening procedures done during the assessment of a patient, be it in the primary healthcare

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104  Juta’s Complete Textbook of Medical Surgical Nursing Table 7.1 Measures to facilitate micturition

Scenario

Measures

The patient is struggling to relax

• Ensure privacy and comfort • Allow sufficient time to void • Suggest reading or listening to music while passing urine • Sensory stimuli that may promote muscle relaxation include: –– applying warmth over the perineum in female patients –– sitting in a warm bath –– applying a hot water bottle to the lower abdomen for both males and females –– turning on a tap of running water within hearing distance – this is also to mask any sounds for those who find it embarrassing –– relieving physical and emotional discomfort to decrease muscle tension –– providing analgesics for pain as prescribed

Positioning

• Assume a normal position, ie standing position for males, and sitting or squatting for females • Use bedside commodes, bedpans or urinals for bedridden patients • Suggest the use of hands to push on the lower abdominal area, and lean forward to increase the intra-abdominal pressure

Timing

• Never ignore the urge to void • Offer assistance to eliminate at regular intervals, eg on awakening, before and after meals or beverages, and at bedtime

During bed rest

• Warm the bedpan to prevent contraction of perineal muscles which may inhibit voiding • Simulate the normal voiding position by elevating the head of the bed to Fowler’s position (an inclined position obtained by raising the head of the bed about 45–60 degrees) and have the patient flex the hips and knees; a small pillow or rolled towel positioned at the small of the back may increase physical support and comfort • If confined to bed, assist female patients into an upright position on the bedpan with legs hanging down (if allowed) at the edge of the bed, feet resting on a chair; a male patient can lie on the side if confined to bed to enable him to use the urinal

Nutrition and fluids

• Adequate fluid intake is necessary to ensure output, even if the patient avoids passing urine due to dysuria • Adequate intake of fluids is important to prevent some of the complications of bed rest, such as infection and the formation of calculi

Exercise

• Important for the prevention of some of the complications of bed rest, such as cystitis

clinic or hospital situation. This screening will consist of a subjective and an objective assessment.

Subjective data This relates to information as provided by the patient about: • The act of micturition. Is there pain, burning and/or straining on micturition? • The nature of the urine stream. Is it strong or weak? • The urine itself. Type of smell if any, colour, amount, and any deposits? • The effect of urine on and around the genital area. Is there skin irritation or not? Is there staining of the person’s underwear?

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Objective data This data is used to: • Determine colour and odour • Determine clarity and the presence of deposits after the urine has stood for a while • Determine specific gravity (SG) – this is the weight of a given volume of urine as compared to the weight of an equal amount of water, and is measured with a urinometer.

Biochemical tests There are various makes of test strips that are available in the market. Each test strip has coloured pads that contain enzymes or reagents that will react and change colour when dipped into the urine to detect substances dissolved

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Chapter 7 – Elimination need  105 Table 7.2 The characteristics of normal urine

Characteristics Physical properties: Colour and transparency Clarity Reaction Specific gravity (SG) Deposits Odour pH Daily amount Chemical constituents: Water Solids Inorganic salts

Observation Clear, straw coloured Transparent Slightly acid on a mixed diet 1 010–1 030 (on a moderate fluid intake according to the amount of solids in it) None present in warm acid normal urine. If clear when passed, deposits that appear later will not be of pathological significance Characteristic (described as aromatic) but not offensive The pH of normal urine is slightly acid, ranging from 5.5 to 7.0 Adults 1 000–1 500 ml; children (10 years) 600 ml; babies 180 ml (the amount of urine passed is in direct relation to fluid intake) 96% 3.7%; dissolved in water and thus cause urine to be heavier than water. This includes nitrogenous substances (urea, creatinine, uric acid, urates and ammonia) Chlorides, phosphates, sulphates, oxalates of sodium, potassium and calcium and the pigment urochrome

Table 7.3 Normal variations found in urine

Characteristic

Observation

Rationale

Colour and transparency

Amber to straw coloured Light straw to colourless

Concentrated urine with high SG due to dehydration Dilute urine with low SG, means that little fluid has been lost from the body, as on cold days; can also mean that the individual is taking in large volumes of fluid which is making the urine dilute. Dilute urine may also be seen in individuals who are on diuretic therapy Large quantities of reddish-coloured foods such as beetroot, senna and rhubarb taken in the diet Cakes and sweets containing food dyes Infection of the urinary tract Some medication which may colour the urine blue, eg warfarin and rifampicin turn it orange

Reddish colour Orange and/or green colour Dirty cloudy colour Blue colour Reaction

Alkaline reaction

Acidic reaction

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Medication or diet containing a lot of vegetables and fruit Urine that has been left standing for 2–4 hours will become alkaline due to the decomposition of urea to ammonia by urea-splitting organisms Alkaline medication, eg potassium citrate or bicarbonate of soda

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106  Juta’s Complete Textbook of Medical Surgical Nursing Table 7.4 Abnormalities found in urine

Abnormality Colour: Smoky Red Port-wine (dark red) Yellow-brown/brown-green with a yellow froth Opalescent/milky Reaction: Alkaline Odour: Ammonia Fishy Sweet (like acetone)

Deposits: Yellow Thick yellow and wavy Red/chocolate coloured Volume: Polyuria, meaning an increased amount of more than 3 000 ml/day with a low SG ( 1 025) Biochemistry: Sugar in the urine (glycosuria)

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Cause Small amount of blood Large amount of blood (haematuria) or haemoglobin as a result of haemolysis; or presence of acute infection, eg cystitis, urethritis, renal calculi, neoplasm Porphyrins due to faulty metabolism of haemoglobin in the liver (The urine turns red after it has been standing for a while) Presence of bilirubin Bile, bacteriuria with pus and an infecting organism such as E. coli Urinary tract infection Bladder infection as may be indicated by a persistent alkaline reaction (pH 7–8) in a fresh specimen of urine Urinary bladder infection Urinary bladder infection caused by E. coli Starvation and/or diabetes mellitus; the odour is caused by the presence of ketones, which are formed when the body fat is broken down to provide nourishment to the tissues Bile Pus Blood Diabetes mellitus, chronic nephritis, diabetes insipidus, use of diuretics Renal failure Renal failure

Dilute urine due to polyuria, high water intake, diuretics Serious degree of renal failure Concentrated urine due to insufficient water intake, dehydration Renal excretion of excess sugar due to: • Raised blood sugar (hyperglycaemia) • Diabetes mellitus • Pregnancy and lactation • Excitement, shock, thyrotoxicosis • Cortisone therapy, Cushing’s syndrome

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Abnormality

Cause

Ketone bodies in the urine

Ketosis as a result of abnormal fat metabolism due to: • Starvation • Diabetes mellitus • High protein, high fat and low carbohydrate diet Nephritis and nephrosis, toxaemias of pregnancy Strenuous exercise, nervous tension, febrile diseases, congestive cardiac failure Acute infection (nephritis, pyelitis, cystitis), hypertension, tumours or tuberculosis of the urinary tract, trauma, bilharzias Altered bile pigments absorbed from the gut and excreted by the liver with the bile. With the large amounts or the inability of the liver to secrete it, it accumulates in the blood and is metabolised and excreted via the kidney in the urine Toxic obstructive and infective jaundice and cirrhosis of the liver Urinary tract infection as a result of bacteria

Albumin or globulin in urine Protein in the urine (proteinuria) Blood in the urine (haematuria) Urobilinogen in the urine

Bile in the urine (choluria) Pus in the urine (pyuria)

or suspended in the urine. Every container has a colourcoded chart that is pasted around it, with which the test strip is compared to determine the result. The timing that is specified on the container must be adhered to in order for the test to be accurate. The test strip will evaluate the following: • The presence or absence of sugar (glucose) in urine. If present, the strip will change colour according to the amount of sugar. • Ketones in the urine will turn the pad on the test strip to the designated colour. • Nitrates in the urine can be detected with a test strip and are the result of nitrate-forming organisms that cause infection of the urinary tract (causing 90% of infections, eg E. coli, Salmonella, Staphylococci, Proteus, Klebsiella). A negative result does not exclude urinary tract infection by other non-nitrate producing organisms. An early morning, fresh specimen is the best to detect asymptomatic bacteriuria, eg in early preg­nancy and early childhood. In case a urinary tract infection is diagnosed, that can be treated promptly to avoid complications like pyelonephritis and renal failure. • Leucocytes (intact or lysed, ie pus cells) can be detected with a test strip. Elevated excretion of leucocytes indicates inflammation and infection of the kidneys and lower urinary tract. An early morning sample will provide the best indication. • Blood not visible to the naked eye (occult blood) can be detected by the sensitive chemical test incorporated in the test strip. Gross haematuria will be visible as a red discoloration of the urine. Discoloration will start when there is more than 0.5 ml blood in 1 ℓ of urine. • Proteins commonly found in abnormal urine are serum albumin and serum globulin – albumin being

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by far the most common of proteins. The reagent strip will determine the presence of protein in the urine. In some instances, the reagent strip provides the type of protein present. • pH can be numerically read on the colour chart according to the colour change on the test strip. A pH of 7 is neutral, a higher pH indicates alkaline urine, and a lower pH indicates acid urine. • Specific gravity (SG) can also be numerically read on the colour chart according to the reaction on the strip. • Bilirubin and urobilinogen are the catabolic products of spent erythrocytes – none or very small amounts are normally excreted through the kidneys.

Laboratory tests Urine samples can be sent to a laboratory for special tests, eg: • Microscopic evaluation for blood cells, casts, bacteria, parasites • Culturing of microbes and determining the sensitivity of microbes to antibiotics • 24-hour specimens to determine daily excretion of various substances such as waste products, hormones or drugs.

Obtaining a sample of urine for analysis It is a nurse’s responsibility to obtain and dispatch (where indicated) a sample of urine in such a way that the reliability of the results will be ensured. Urine specimens should ideally be obtained early in the morning. Great care must be taken when obtaining a urine specimen for analysis. To prevent contamination with blood, for example in the menstruating woman, a vaginal tampon can be used, otherwise a midstream specimen of urine (a urine sample collected during the middle of a flow

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of urine) is collected. For a microscopy, culture and sensitivity test, a midstream specimen should always be obtained. Catheterisation to obtain a specimen is not advisable, as this creates a route for the introduction of bacteria into the urinary tract. In males a Paul’s tubing (external catheter used in males for management of urinary incontinence) may be used to collect a specimen of urine.

Common problems associated with micturition Normal urinary elimination can be affected by physiological factors, psychosocial conditions, and diagnostic or treatment-induced factors. Knowledge of these factors enables the nurse to anticipate possible elimination problems. Risk factors related to micturition include the following: • Age. Children cannot control urination voluntarily until 18–24 months. The child must be able to recognise the feeling of bladder fullness, to hold urine for some time, and to communicate the sense of urgency to the parent. The process of ageing may impair micturition. Problems of mobility may make it difficult for older adults to reach the toilet or bedside commode in time. • Urinary Tract Infection (UTI). Signs and symptoms of UTI include pain or burning urination, frequent and urgent sensation of the need to void. The patient may ignore the urge to void, fearing the burning sensation and pain to be experienced. • Instrumentation/diagnostic procedures. Cystoscopy may cause localised oedema of the urethra and bladder sphincter spasm, resulting in urinary retention. • Surgery (gynaecological and rectal). The stress response to surgery reduces the amount of urinary output to increase circulatory fluid volume. • Trauma. Trauma decreases muscle tone. It includes the following: –– Blunt blow on the genitals –– Cuts, stab or gunshot wounds on the genitals –– Bad falls on the genitals. • Medication. Anaesthesia and painkillers slow the filtration rate and reduce urine output. Diuretics prevent reabsorption of water and electrolytes, and urinary output increases. • Dehydration. More fluid intake increases urine production. Alcohol stops the release of the antidiuretic hormone (ADH), thus promoting urine production. Fluids containing caffeine increase frequency of micturition.

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Clinical alert! The insertion of urinary catheter is one of the most common causes of hospital-acquired (nosocomial) infections.

7.1  Paediatric urine sampling Paediatric urine-collecting bags are available to obtain urine samples from infants. The bag has an adhesive disc around the inlet opening that can be affixed around the genitalia of the infant (male or female). On removal of the bag, the adhesive disc can be folded over to seal the bag and prevent the contents from spilling out during transportation. The bag can be clearly marked (before application) and used for either ward testing or laboratory testing. The contents can also be poured into a sterile container for dispatch to a laboratory. Suprapubic aspiration, using a needle and syringe to obtain a specimen of urine, is sometimes done in infants. • Emotional instability. Anxiety and stress may affect a sense of urgency and increase the frequency of urination. Anxiety may prevent complete urination because of tension.

Urinary incontinence The flow of urine out of the urinary bladder is controlled by sphincter muscles surrounding the urethra. The sphincter muscles relax when the urinary bladder contracts and voiding takes place. The muscles therefore prevent continuous flow of urine from the bladder and makes voluntary control of urination possible. Urinary incontinence refers to the inability of a person to control their bladder. There are many reasons for this, and a proper assessment must be done before any treatment or care can be planned. Urinary incontinence is often under-reported, as many people regard urinary incontinence as being part of the normal process of ageing. People find it embarrassing to admit that they sometimes wet themselves, and the socially unacceptable nature of the problem also contributes to the fact that patients keep the problem to themselves. Socially, lack of control over elimination is associated with an infantile state.

Types and causes of incontinence Urinary incontinence may be temporary as a result of acute illness, or it can be permanent. It is caused by many factors.

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Chapter 7 – Elimination need  109 Table 7.5 Common problems associated with micturition, their causes, presentation and management

Frequency Causes

• Related to the reduced bladder capacity in cases of enlarged prostate in men pressing on the bladder • Irritation in the bladder, eg cystitis; other infections in the urinary tract, eg urethritis, prostatitis • Can also be associated with dysuria in urinary tract infections • Can be a result of polyuria in diabetes mellitus or in diuretic therapy

Presentation

• The patient passes small amounts of urine more often than usual • At night, sleep may be disturbed • There may be dysuria and burning on micturition

Management

• Frequency is a symptom of a disease, so a medical diagnosis must be made and the patient treated • Provide plenty of fluids if permitted • Keep a record for fluid intake and output

Burning on micturition Causes

• Irritation due to urinary tract infection, acute prostatitis, tumours in the bladder

Presentation

• There may be pain or difficulty in micturition • There may be retention or even dribbling

Management

• Find the cause and manage accordingly, increase fluid intake if permitted • Ward and laboratory urinalysis to exclude UTI • Administer medication as prescribed

Hesitancy Causes

• Benign prostatic hyperplasia, compression on the urethra, neurogenic bladder

Presentation

• There is a delay in starting to pass urine

Management

• Find the cause and manage accordingly • Increase fluid intake if permitted • Respond to the urge to void

Dribbling Causes

• In women this could be a result of a weak pelvic floor following childbirth; in men the cause could be a benign prostatic enlargement

Presentation

• This may be described as a form of urinary incontinence associated with poor tonus of pelvic floor muscles, retention with overflow and advanced age • There is a constant leak of a few drops of urine every time the intra-abdominal pressure is raised as is the case with sneezing, coughing • The patient may be shrouded with a smell of urine

Management

• Find the cause and manage accordingly • Provide absorbent pads and change these frequently • Teach the patient Kegel exercises • Encourage the patient to respond to the urge to void and provide privacy • Allow for adequate time to empty the bladder completely • Provide emotional support

Urgency Causes

• Associated with urinary tract infection, chronic prostatitis, urethral stricture, urethritis, benign prostatic hyperplasia, diuretics, diabetes mellitus

Presentation

• Strong desire to pass urine which if not acted on immediately may lead to incontinence

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110  Juta’s Complete Textbook of Medical Surgical Nursing

Management

• Identify the cause and manage accordingly, • Increase fluid intake if permitted • Conduct urine studies both in the ward and in the laboratory • Administer medication as prescribed • Provide protective pads until condition is brought under control

Enuresis Causes

• Associated with emotional stress in cases of separation in children or arrival of a new sibling • In adults, it may be associated with tensions in the family • Diurnal enuresis or day and night wetting is due to lack of attention to the sensation to void or attention seeking • Nocturnal enuresis or night-time bedwetting is due to unusual deep sleep, urinary tract infection, failure of the kidney to concentrate urine resulting in diuresis as could be the case in diabetes mellitus • Other factors may be congenital abnormalities in the structure and functioning of the bladder or presence of spina bifida

Presentation

• Diurnal enuresis, ie wetting of clothes in the day and bed linen in the night • Poor sleep, and therefore the patient may be constantly tired

Management

• Find the cause and manage accordingly • Provide emotional and psychological support to enhance self-esteem • Provide a restful environment to promote sleep • Pay adequate attention to the child such that the arrival of the new sibling is not a threat • Programme the patient to void frequently at regular intervals • For bedwetting: limit fluid intake in the evening, wake the patient up at frequent intervals to void • Conduct urine studies in the ward and at the laboratory to exclude infection; and if infection is present, administer medication as prescribed

Nocturia Causes

• Decreased renal concentrating ability • Diabetes mellitus

Presentation

• Excessive urination at night

Management

• Find the cause and manage accordingly • Reduce fluid intake in the evening

Polyuria Causes

• Diabetes mellitus, diabetes insipidus, diuretics • Excessive fluid intake

Presentation

• Increased volume of urine passed

Management

• Find the cause and manage accordingly • Reduce fluid intake especially in the night

Oliguria Causes

• Inadequate fluid intake • Acute or chronic renal failure

Presentation

• Urine output less than 400 ml/day

Management

• Find the cause and manage accordingly • Increase fluid intake if permitted

Anuria Causes

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• Acute or chronic renal failure

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Presentation

• Urine output less than 100 ml/day

Management

• Find the cause and treat. • Increase fluid intake if permitted

Haematuria Causes

• Acute glomerulonephritis, renal stones, trauma, haemophilia, cancer of the genitourinary tract

Presentation

• Presence of blood in the urine

Management

• Find cause and manage accordingly

Proteinuria Causes

• Acute and chronic renal disease, nephritic syndrome, glomerulonephritis, heart failure

Presentation

• Abnormal amounts of protein in the urine

Management

• Find cause and manage accordingly

Stress incontinence. This occurs as a result of a sudden increase in the abdominal pressure during sneezing, coughing, aerobic exercise or change of position. It is as a result of: • Laxity of the muscles of the pelvic floor and is common in women after childbirth • In men this becomes a complication of radical prostatectomy • It is also a common complaint among the elderly and it is associated with dribbling. Urge incontinence. Involuntary passage of urine in response to a strong desire to void. It is associated with neurologic dysfunction that inhibits the contraction of the smooth muscle of the bladder. Incontinence with overflow. This is associated with over distention of the bladder, where small amounts of urine that the urinary bladder can no longer hold are involuntarily released. This is usually associated with retention. It is caused by the inability of the bladder to empty completely as a result of tumours, strictures, prostatic hyperplasia. Functional incontinence. This is where the patient fails to recognise the urge to void, eg in cases of Alzheimer’s disease. Reflex incontinence. Caused by disorders of the neurologic system such as multiple sclerosis, spinal cord injuries or stroke. Overactive bladder. There is frequency and urgency, but the urge to void may or may not be there.

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Transient incontinence. This is temporary involuntary urinary loss caused by a condition that is likely to resolve, such as taking a new medication or coughing because of a cold. Mixed incontinence. This occurs when there is a combination of different types of incontinence. Other causes of incontinence include: • Spinal injuries and brain lesions such as cerebrovascular accident • Inadequate sphincter control and dribbling following direct trauma • Nocturnal enuresis, or bedwetting, that is usually associated with emotional problems in children – sometimes the bed wetter is simply a late developer • Sedatives may cause bedwetting in the elderly • Instability of the muscle of the pelvic floor.

Nursing alert! It is quite common for a patient to present with a combination of two or three types of incontinence.

Assessment and common findings The findings may be as follows: • There may be a history or evidence of involuntary voiding associated with increased abdominal pressure or a strong urge to void. • Reports of lower back or flank pain, dysuria with urinalysis, and a urine culture that provides data regarding the presence of infection.

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Urodynamic studies done include: • Uroflowmetry to assess bladder strength and ability of the urethral sphincter to open and/or close • Cystometry to give information about the patient’s bladder capacity and its ability to sense bladder filling • Urethral pressure profile, post-void residual testing and blood urea nitrogen (BUN).

Care of a patient with incontinence Every effort should be made to maintain the dignity and privacy of the patient. Nurses should treat patients who are incontinent with patience. The patient will need a lot of emotional support until a satisfactory solution to the problem has been reached. It is extremely important for a full assessment to be done to identify possible causes that can be treated or eliminated, including: • obtaining the patient’s urinary history and document voiding patterns • obtaining residual urine specimens that may help in the determination of the type of incontinence • performing routine urine tests and culture and biochemical tests to exclude infection and other systemic diseases, such as diabetes, that may be required • monitoring fluid intake, and if unrestricted, increasing it to at least 2–3 ℓ per day • looking at medication that can be prescribed, such as anticholinergics and smooth muscle relaxants to inhibit uncontrolled bladder contractions and enhance functional bladder capacity – beta-adrenergic drugs may be prescribed to improve smooth muscle contraction of the neck of the bladder • instituting, where indicated, a bladder retraining programme to improve the patient’s bladder control. This is usually an important aspect of the rehabilitation process following spinal injury • performing surgery, which includes urethral suspen­ sion, pubovaginal sling, urethropexy and insertion of an artificial sphincter to increase urethral resistance.

Care of the skin of an incontinent patient Skin care is a major problem when a patient becomes incontinent. The patient should be kept meticulously clean and dry to avoid severe skin rashes and ulcerations that may occur as a result of the accumulation of urine, which is converted into ammonia, on the skin. The patient’s perineal area should be washed with soap and water and dried thoroughly with a soft cloth. Clean, dry clothing and bed linen must be provided as frequently as is required. Barrier creams, such as zinc oxide, can be applied to

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7.2  Strengthening the bladder Some suggestions for bladder training are: • Set time intervals for voiding • Encourage patient to adhere to the set times to void • Begin with short intervals between voiding and increase the intervals as the bladder becomes strong. • Kegel exercises to be done three times a day to improve pelvic floor muscle tone.

7.3  Improving pelvic floor muscle tone Kegel exercises involve the tightening of paravaginal muscles and anal sphincter to control urination and defecation. In female patients, vaginal cones of varying weights may be used intra-vaginally and retained for about 15 minutes at a time to strengthen and improve pelvic floor muscle tone. Pelvic floor exercises can also help men suffering from incontinence and impotence. irritated skin to protect it from contact with urine. There are various products on the market that will absorb the wetness and leave a dry surface. Such as incontinence briefs that can be used for females during the night. Absorbent pads similar to sanitary pads can be used for either sex. For males with urinary incontinence, a urinary sheath (condom) can be applied. The end is then attached to a urinary drainage bag. This system is preferable to the insertion of a retention catheter as the possibility of infection is minimised. The application of the condom drainage system should be done carefully in order to protect the skin. If worn for short periods, application can be done with an elastic tape only: some patients only require a condom appliance at night. If the condom is to be worn for extended periods, additional methods may be needed to secure the appliance. The manufacturer’s instructions should be consulted and followed when applying a condom drainage system, as these drainage systems can be difficult to keep in place. A condom drainage system should also be changed frequently and kept scrupulously clean to avoid infections. Only where there is no other solution should the patient be catheterised for urinary incontinence.

Essential health information • Teach the patient about Kegel (perineal) exercises, to strengthen the muscles. • Explain the rationale for bladder training.

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• Educate the patient on signs and symptoms of urinary tract infection that need to be reported. • Emphasise the importance of adequate fluid intake and rest. • Ensure that patient understands the importance of skin care and personal hygiene.

Urinary retention Urinary retention is the inability to completely empty the urinary bladder during micturition. Any residual urine left for long periods stagnates and can predispose the patient to bladder infection (cystitis). In some instances, the urine accumulates and results in incontinence with overflow. The causes of urinary retention include the following: • Prescribed medication, eg sedatives, anaesthetics, analgesics and antidepressants, which interfere with normal voiding • Inadequate or restricted fluid intake • Anxiety, especially in unfamiliar environment and situations, eg hospitalisation • Lack of privacy • Dirty and cracked toilet seats, which may cause the person to void as quickly as possible • Unnatural position assumed to void • Urinary tract infection • May be a complication following the administration of general or spinal anaesthesia and pain following genital, abdominal, pelvic or rectal and/or anal surgery or childbirth in females • Decreased contractility of the detrusor (smooth muscle of the bladder) • There may be narrowing or obstruction of the neck of the bladder due to: benign or malignant prostatic hypertrophy, malignancy of the bladder mucosa, foreign body (blood clot, calculus or a foreign body introduced from outside), congenital abnormalities, urethral valves, local metastatic invasion from vaginal, vulval or cervical cancer in women, muscle spasm following surgery, or pain • There may be obstruction of urinary flow following brain and spinal injury and also as a result of ignoring the urge to void • There may be a urethral stricture, eg post-gonococcal urethritis; post-trauma, eg traumatic introduction of foreign bodies or trauma from outside the bladder (blow, gunshot or stab wound); genital trauma in women, eg birth trauma, trauma during rape or rough sex during vaginal intercourse.

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Assessment and common findings There may be a history of inability to pass urine even though the urge is strong, indicating an obstruction that would usually be in the urethra. The urge may be accompanied by supra-pubic pain or burning on micturition. There may be an urge to continue to pass urine even when the stream has stopped, indicating a failure of the bladder to empty completely resulting in straining at the end of the urinary flow. On physical examination, assess for urine colour, clarity and odour. A diagnosis can be made on the history given by the patient and the findings of urine tests (both in the ward and in the laboratory), which may suggest the presence of infection. The causes of the retention may be identified by means of cystoscopy; cystogram; kidney, ureters/urethra and bladder X-rays; and intravenous pyelogram (IVP).

Care of the patient with urinary retention Re-establishing urine flow is an immediate treatment goal for obstruction. The urine flow can be re-established in the following ways: • The cause must be identified and treated • Assist the patient to void by assuming a position that facilitates voiding, for example female sitting upright and male standing upright. Other measures that could help include: –– Sitting in lukewarm water may help to relax the urinary sphincters –– Auditory stimuli such as running water from a tap within hearing distance of the patient –– Provide privacy and adequate time for voiding – the patient should not be rushed –– Encourage the use of a relaxation technique, such as deep breathing –– Early ambulation of the patients post-surgery –– Administer adequate amounts of fluid if permitted • Medication such as cholinergics (stimulate bladder contractions), analgesics and antibiotics may be prescribed • In order to facilitate urinary drainage and to re-esta­blish urinary flow, catheterisation may be done. The location of the obstruction will determine the type of catherisation. The different types of catheterisation include urethral, suprapubic, intermittent and continuous. • Intermittent catheterisation is used in urinary retention due to spinal cord injury and neurogenic bladder dysfunction. Urine is emptied periodically usually every 4–6 hours. Continuous catheterisation refers to a situation where the catheter is left draining for long periods, even months. In such cases, patients have to be taught self-catheterisation.

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Practice alert!

7.4  Different types of catheters

Where there is a need for catheterisation, fluid intake and output should be strictly monitored.

There are different types of catheters available today. Selecting the right catheter will depend on what it is needed for and for how long catheterisation will be required. Catheter selection is done according to the following three criteria: 1. Expected duration in situ. Although a lot has been written about latex allergies, latex catheters remain a suitable choice for catheterisation of between 7 and 10 days. For intermediate use (3 to 4 weeks), catheters made of latex with silicone coating can be used. Silicone or hydrogel catheter should be used for long-term catheterisation (3 weeks to 6 months). 2. Consistency of urine. The smallest catheter size possible should always be used. 3. Bulb size required. A standard size bulb should be 5–10 ml. The 30 ml bulb is usually only indicated after urological procedures. The 30 ml bulb has a greater intravesicular displacement, thereby resulting in greater bladder irritation and discomfort. The ideal size bulb for adults is 5–10 ml: 8–10 ml of sterile water is used in a catheter marked for 5–10 ml, as 3–4 ml remains in the channel. Inadequate inflation of the bulbs results in a lopsided bulb that kinks the catheter, causing blocking, and the catheter may slip out easily during coughing or bladder spasm.

Catheterisation Catheterisation is the passage of a sterile catheter into the urinary bladder, either through the urethra (urethral catheterisation) or above the symphysis pubis (suprapubic catheterisation) for the purposes of: • draining urine to empty the bladder when urine is not eliminated naturally • instilling medication. Catheterisation can be intermittent, short term, long term, or continuous.

Indications for urethral catheterisation A distinction should be made between patients who require short-term catheterisation (eg the surgical patient) and long-term (permanent) catheterisation. Questions to be asked are: • Why must the catheter be inserted? • For how long should it remain in situ? Intermittent catheterisation. This is mostly used for collection of sterile urine sample, to provide relief from bladder distention, to measure residual urine and for management of patients with spinal cord injury, neuromuscular degeneration, or incompetent bladders. A new sterile catheter is normally used each time. Short-term catheterisation. This is used mostly for the surgical patient (pre- or post-surgery/hospitalisation) and critically ill patients to empty the bladder, monitor urinary output and to ensure continuous drainage without the sick/ sedated patient having to use a toilet or bedpan. It can

also be used for surgical procedures involving pelvic or abdominal surgery for repair of the bladder, urethra, and surrounding structures; urinary obstruction (eg enlarged prostate); and acute urinary retention as well as prevention of urethral obstruction from blood clots. As soon as the patient is stable, awake and ambulatory, the catheter should

Figure 7.4 Types of urethral catheters

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be removed. It remains the responsibility of the nurse to advocate for the patient for the removal of the catheter and the patient’s physician to order removal of the catheter. Long-term/permanent catheterisation. This is for patients who need the most care and can develop the complications mentioned below. Patients who are bedridden due to chronic illness, old age or neurological problems (cerebrovascular accidents, quadriplegia, etc) make up most of these cases. It is also to promote healing of perineal ulcers where urine may cause further skin breakdown.

•

•

Care of catheterised patients and prevention of complications Adequate hydration of the patient ensures a large volume of dilute urine. This will limit encrustation/gravel formation and it will flush out bacteria. The oral fluid intake must be at least 2–3 ℓ per day provided that the patient has no systemic (cardiovascular or renal) contraindications. The most common uro-pathogen is E. coli, and it prefers alkaline urine. Acidifying the patient’s urine may prevent urinary tract infection. Dietary measures can also help urinary acidification. Most vegetables and some fruits (not citrus products) yield alkaline urine, whereas meat, fish, poultry, eggs and cereal acidify the urine.

Catheter and genital care An indwelling urethral catheter is a foreign object to the body and will therefore be associated with problems of ascending infection if left in situ for long periods. The nursing care must be aimed at optimising patient comfort, as well as limiting infection by the catheter. The nursing responsibilities with regards to patients with catheters who require genital care are as follows: • Ensure free drainage of the urine by avoiding twisting/ kinking of the catheter or drainage bag tube. It is preferable to fix the catheter on the upper thigh. • In male patients, fix the catheter on the suprapubic area to avoid tugging or pulling. • The urine bag must always be lower than the pelvis of the patient to ensure adequate drainage by way of gravity. If it is necessary to raise the drainage bag, eg with a bedridden patient who must be turned onto the other side, be sure to clamp the tube high up before raising the bag to prevent backflow of urine into the bladder. Keep the tube clamped until the drainage bag is below the level of the bladder on the other side again. Check that the flow of urine is no longer obstructed before leaving the patient. • Take extra care when moving or ambulating a patient.

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•

•

• • • •

•

•

•

Watch the position of the tubing and bag at all times to prevent pulling on the catheter. To prevent injury to the urethral lumen or bladder wall, always disconnect the drainage bag and tubing from the bed frame before helping a patient out of bed. When possible, attach a leg bag to allow the patient greater mobility. Perineal–genital care should be done at least twice daily. This is considered to be one of the most significant measures for reducing the incidence of infection. Secretions and encrustations may accumulate at the urethral orifice and it presents an ideal medium for pathogens that can then ascend the tract. The basic care is thorough washing of the area with soap and water. For the uncircumcised male patient, the foreskin must be retracted to clean well under it. Special catheter care in addition to perineal-genital care may also be required, and it basically includes cleansing of the urethral meatus and catheter with an antiseptic solution and the application of an antimicrobial ointment at the urethral meatus. Unless specifically prescribed, no dressing is applied. Check the catheter care prescribed by your institution. Always maintain a closed drainage system. Unneces­ sary disconnection of the urine bag must be avoided in order to limit contamination of this system. Check that there are no leaks at the connection sites. Keep the drainage bag off the floor by securing it to a hook or the bed frame. Ensure that there are no loops in the tubing that hang below its entry into the drainage bag. Utilise the surgically aseptic technique when emptying the drainage bag. The tube or connection used to drain the bag should not be contaminated and should be reattached appropriately when the bag has been emptied. Empty the drainage bag at regular intervals so that it does not overfill and cause urine backup in the tubing, thus creating a reservoir for microbes. Irrigation of the catheter may be useful to rid the system of debris (mucus, blood, gravel) that causes blockage of the catheter. This must also be done in an aseptic manner. Routine washouts are avoided, as they increase the risk of infection. If there are systemic manifestations of an ascending urinary tract infection (rigors, fever), urine can be sampled by aspiration through a special port in the tubing that now is part of most drainage bags. This will allow isolation of the specific bacteria involved, as well as determining the antibiotics that will be effective in fighting the identified bacteria.

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• Replacement of long-term indwelling catheters must be done at regular intervals. This will depend on: –– The type of catheter used –– The patient’s response to the catheter –– The specific requirements of the relevant institution. • Removal of a catheter is done as soon as its purpose has been achieved (always on the order of the physician). If the catheter has been in situ for a long time, bladder training may be necessary. On removal of a long-term catheter, the patient will experience frequent urination until their bladder has regained its muscle tone. Taking increased quantities of fluid and initially trying to keep urine in the bladder for as long as possible, may assist in regaining bladder tonus. Most patients will experience a burning sensation in the urethra as a result of irritation by the catheter. Increased quantities of fluid will minimise the burning by diluting the urine. • Assess and record fluid intake and output.

•

•

•

•

Practice alert! Silastic urinary catheters should last for an average of 3 months. Sometimes temporary removal of the catheter is required to treat persistent/severe complications. Further urological assessment by the physician will be necessary if this happens.

Practice alert! It is vitally important that the nurse check that the patient passes urine within 8 hours of catheter removal – if not, the catheter may need to be replaced.

Complications of urethral catheters Complications may arise during the use of urethral catheters. Short-term complications are as follows: • Urethral trauma. During insertion the balloon can be inflated when it is still in the prostatic urethra. Long-term complications can occur as well. All of the short-term complications can also occur at a later stage. Long-term complications are as follows: • Infection. Anything from haemorrhagic cystitis (macroscopic haematuria) to urethritis (purulent discharge around the catheter) or urethral abscess is possible. If left untreated, an infection may ascend to cause acute pyelonephritis and subsequently renal

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•

scarring. This can eventually lead to renal failure. A peri-urethral abscess can break through the perineal skin causing a urethra-cutaneous fistula. Calcification. Because the catheter is a foreign object in the urinary tract, it invites the formation of encrustations (so-called eggshell calcifications) that can lead to bladder stone formation. More often, however, it causes gravel that can block the catheter. Urethral dilatation. This is a procedure whereby a thin instrument is inserted into the urethra to stretch it. It can be an annoying problem in female patients with a chronic indwelling catheter. It causes urine to leak past the catheter and eventually the catheter can be expelled, even with a 30 ml balloon. Inadvertent traction. Pulling on the catheter for some reason can also traumatise the bladder neck/urethra. Small (5 ml) balloons can be pulled out completely followed by quite severe urethral bleeding afterwards. Infection. If a catheter is in situ for more than a week it will be associated with urinary tract infection, even if it is only sub-clinical (bacteriuria). Mechanical blockage. Catheters can be blocked with debris (blood, mucus, sediment, gravel) or due to kinking.

Practice alert! It is essential that drainage of urine be seen on insertion before inflating the catheter balloon.

Practice alert! The catheter needs to be checked regularly to ensure free drainage.

Suprapubic catheterisation In suprapubic catheterisation the catheter is inserted directly into the bladder through a suprapubic insertion or puncture. The purpose of suprapubic catheterisation is to divert the flow of urine in cases of urethral strictures, trauma and prostatic hypertrophy or other related tumours. Following gynaecologic and other abdominal surgery when bladder dysfunction is likely, suprapubic catheterisation is usually performed by the doctor. The responsibilities of the nurse in cases of suprapubic catheterisation include: • Preparation of the patient –– In many instances, the bladder is distended by increasing fluid intake if allowed, or instilling

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Condom catheter

Figure 7.5 Condom catheters and retracted urine pouch Female urinary tract

Male urinary tract Catheter with retention balloon in bladder

Catheter with retention balloon in bladder

Catheter

Catheter in urethra

Urine leg bag with supporting straps Urine leg bag with supporting straps

Figure 7.6 Supra pubic catheterisation

sterile saline solution through the urethral catheter. This measure ensures easy location of the bladder during the procedure. –– Place the patient in a supine position (lying horizontally with the face and torso facing up). –– Clean the suprapubic area with a disinfectant. –– The bladder is entered through an incision or puncture made by a small trocar where a catheter is inserted into the bladder. The catheter is then secured with two or three sutures to prevent tension and a sterile dressing is applied. • Post-insertion –– A strict intake and output record is maintained to ensure that the catheter is draining correctly as bleeding may occur and clots may block the catheter.

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–– Administer plenty of fluids to keep the catheter patent. –– The insertion area must be kept clean. Dressings are to be changed whenever soiled. –– Observe for urine leakage and report if present. –– For long-term suprapubic catheterisation, the catheter is changed regularly at 6–12 week intervals. • Removal of the catheter –– This usually follows a test on the ability of the patient to void. For the test, the catheter is clamped to allow the patient to pass urine through the urethra. After the patient has passed urine through the urethra, the catheter is unclamped, and the urine that drains through the catheter is referred to as the residual urine. If the amount of the residual urine is less than 100 ml on two separate occasions, then the catheter is removed, because

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this is an indication that the patient is ready to void normally.

Essential health information for the patient and family Many patients with chronic urinary incontinence can be taught intermittent self-catheterisation. • Educate the patient with regard to the underlying principles of self-catheterisation and the importance of observing these principles. • The patient is shown how to insert a Jacques catheter (one without a bulb) into the bladder at regular intervals and drain the bladder, using all the necessary sterile precautions. As all individuals have a reasonably high degree of resistance to their own commensal organisms (normal flora) when in good health, the risk of urinary tract infections is considerably reduced if self-catheterisation is carried out. • If the patient is being cared for at home, the carers can also be taught how to carry out intermittent catheterisation at home, to reduce the incidence of urinary retention and over-distension of the bladder. • Provide adequate information regarding the condition and indicators of UTI. • Explain the need for regular, periodic, complete emptying of the bladder. • Emphasise the importance of adequate fluid intake and the importance of responding promptly to the urge to urinate.

Elimination of faeces Faecal elimination (defecation) is the function of the gastrointestinal tract (GIT) where undigested fibre, residue and mucus are removed from the body.

Overview of the anatomy and physiology of the gastrointestinal tract The gastrointestinal tract and formation of faeces The GIT is a hollow muscular tube that extends from the mouth to the anus. It includes the mouth, pharynx, oesophagus, stomach, small intestine and the large intestine. Its principal functions are to: • provide the body with fluids, nutrients and electrolytes as digestion and absorption take place in the GIT • dispose of the waste residue from the digestive process. Only undigested waste products from the tract are eliminated as faeces or stools. Other routes such as the lungs, kidneys and skin excrete wastes from body metabolites. For a detailed discussion on the anatomy and physiology of the GIT, see Chapter 38. The large intestine is the functional part of the GIT that facilitates the elimination of faeces.

The anatomy and physiology of the large intestine The large intestine is also known as the bowel or the colon. It plays a major role in the elimination of solid waste, because most of the chyme (liquefied food and digestive

Table 7.6 General nursing care plan for a patient with urinary elimination problems

Problem

Nursing diagnosis

Expected outcome

Nursing intervention and rationale

Evaluation

Stress/Functional urinary incontinence

Impaired urinary elimination (incontinence/ retention) related to mechanical obstruction evidenced by dribbling/bladder distention

Patient to establish a regular voiding pattern

Monitor and record the time and amount of urination to determine kidney function. Instruct the patient to urinate every 2–4 hours to assess renal function. Encourage the patient to increase fluid intake to 2 000 ml per day when not contraindicated to maintain kidney function.

Patient to report smooth passing of urine

Source: adapted from Gulanick & Myers, 2011

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juices) is absorbed in the small intestine. In an adult, the large intestine is about 1.5 m in length. It extends from the caecum to the anus. It therefore consists of four main portions: the ascending colon, transverse colon, descending colon and, sigmoid colon. The rectum (distal portion of the large intestine where faeces are stored) connects to the anus (opening of the rectum at the skin). The large intestine has a muscular layer with longitudinal and circular fibres that permit it to enlarge and contract in width and length. The circular fibres are concentrated in the sphincters of the ileo-caecal valve at the beginning of the large intestine and anus at the end of the large intestine. Then there is the submucosal layer which contains lymphoid tissue to provide defence from invading microbes and the mucosal lining with mucus-secreting cells. The caecum is the dilated first part of the large intestine. It has a worm-like extension, called the appendix that contains lymphoid tissue. The ascending colon extends from the caecum, up the right side of the abdominal cavity. When it reaches just below the liver, it makes a 90° turn to form the hepatic flexure. It then continues as the transverse colon, running below the stomach until it reaches the spleen. At this juncture it turns down to form the splenic flexure and becomes the descending colon, as it passes down the left side of the abdominal cavity. As the descending colon enters the pelvis, it becomes the sigmoid colon, and then the rectum. The rectum is a dilated section of the colon that terminates at the anus. The anus leads from the rectum to the exterior (see Figure 7.7). Transverse colon

The major function of the colon is to absorb water and electrolytes in the proximal half and to store faeces in the distal half until defecation occurs. The contents of the colon usually represent food ingested over the previous 4 days, although most of the waste products are excreted within 48 hours of ingestion. The contents of the GIT (called chyme) are propelled along the tract by peristalsis. As much as 500 ml of chyme passes into the colon daily: most of this is absorbed by the colon, except approximately 100 ml that is excreted in the faeces. The colon also secretes mucus that contains large amounts of bicarbonate ions. The mucus lubricates faeces, facilitating evacuation. The mucosa is protected from mechanical and chemical injury by the mucus secretions. Bacterial acids are neutralised in the alkaline secretion, allowing constant putrefaction of whatever proteins were not digested and absorbed in the small intestine. Irritation of the mucosa results in an increased output of mucus in an attempt to dilute and remove the irritant. The result is frequent stringy loose stools.

Normal characteristics of stools Normal stool is light to dark brown, soft and formed in children and adults. The light to dark brown colour is caused by bile (orange or yellow digestive fluid produced by the liver). Depending on the type of feedings, infant stools may be dark yellow and unformed. Certain vita­ mins, drugs or diet change the colour of the stools.

Composition of faeces Faeces consists of 75% water and 25% solid matter. The organic components consist of undigested food residue, digestive secretions and enzymes, dead cells, bile pigments and mucus. Thirty per cent (30%) of this mass is bacteria and 30% is fat.

Normal process of defecation Ascending colon

Descending colon

Caecum Appendix

Rectum

Figure 7.7 The large intestine

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Two defecation reflexes normally stimulate defecation. The intrinsic defecation reflex is stimulated by distension of the rectum. This happens when faeces and gas are propelled by peristalsis into the rectum from the descending colon. The second reflex, parasympathetic defecation reflex, is involved when nerve fibres in the rectum are stimulated. Parasympathetic signals are transmitted to the spinal cord and then back to the sigmoid colon and rectum. These signals intensify peristaltic waves, relax the internal anal sphincter and intensify the intrinsic defecation reflex. The external anal sphincter is under voluntary control after the age of about 3 years. When the urge to defecate is felt, the individual may suppress the urge until the time is more convenient for them to go to the toilet and defecate.

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The ability to suppress the urge, however, only operates within certain limits. After a time the urge may become so powerful that it is irresistible and defecation is involuntary.

Physical activity. Regular exercise promotes peristalsis. Lack of mobility may result in poor muscle tone, slow peristalsis and constipation.

Factors that influence defecation along

Medication. Most drugs have side effects that influence normal elimination. Some can cause diarrhoea (eg antibiotics) and others constipation (eg morphine, codeine and other analgesics, large doses of certain tranquillisers, diuretics and anti-depressants). Some medicines are given because they directly affect elimination. Laxatives stimulate bowel activity and promote faecal elimination. Medication can be given to treat diarrhoea. Iron medication can cause either diarrhoea or constipation and can also change the colour to much darker colours.

Changes in bowel elimination is altered by many factors. Below are some of the common factors: Diet. Faecal volume is determined by adequate intake of bulk (cellulose, fibre). Irregular eating habits will impair regular defecation. Low fibre foods (pasta, lean meats, milk) slow peristalsis. People who eat at regular times usually have a regularly timed, physiologic response to food intake and a regular pattern of peristaltic activity in the colon. Inability to digest certain foods or individual allergies may cause watery stools. Certain gas-forming foods (cabbage, broccoli, onions and beans) stimulate peristalsis. Fluid intake. High intake of roughage (bulk) without sufficient intake of fluids will cause constipation. With inadequate intake or excessive fluid losses, the body has to reabsorb fluid from the chyme as it passes along the colon. The chyme becomes drier than normal and the result is hard faeces. Reduced intake of fluids will slow the passage of chyme along the intestines during which reabsorption of fluid will also be increased. Lifestyle. Early bowel training plays an important role in the habits of defecation in later life. The availability of toilet facilities, embarrassment about odours and the need for privacy also affect faecal elimination patterns. Age. Age affects the character of faecal elimination and its control. The very young cannot control elimination until the neuromuscular system is developed (usually 2 to 3 years of age). The elderly experience changes that will influence evacuation of the bowel such as: • atony (loss of tone) of the smooth muscle of the colon, which results in slower peristalsis and constipation • decreased tone of the abdominal muscles, which results in less pressure being exerted during bowel evacuation • lessened control of anal sphincter muscles, which may result in an urge to defecate. Muscle tone. Muscular activity stimulates peristalsis and therefore facilitates the movement of chyme along the colon. Weak abdominal muscles will make it difficult to increase the intra-abdominal pressure during defecation or to control defecation.

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Psychological factors. Stress, anxiety, or fear initiates parasympathetic impulses, causing acceleration of digestion and peristalsis. In contrast, depressed people may experience slower intestinal motility, which results in constipation. Facility and environment. An environment that is dirty, cold, dark, far away or too near people and has no privacy influences defecation. Admission into hospital and the use of a bedpan may also affect faecal elimination. Pain. Rectal surgery, haemorrhoids and abdominal surgery may cause the patient to suppress the urge to defecate because of pain, and the consequence is constipation. Diagnostic procedures. Certain examinations involving visualisation of the gastrointestinal structures may require an empty bowel. This necessitates that before the tests patients are given bowel evacuants or an enema to cleanse the bowel. In these instances, the person will not defecate normally until they have resumed eating. If barium was used during a radiological examination, it will harden if left in the colon and may lead to constipation or even faecal impaction. Pregnancy. As pregnancy advances and the foetus grows bigger, pressure is exerted on the rectum and this can lead to constipation. Anaesthesia and surgery. The normal movement of the colon is stopped or slowed down by agents used for general anaesthesia which block parasympathetic stimulation of the muscles of the colon. People who have regional or spinal anaesthesia are less likely to develop this problem. Direct handling of the intestines during

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surgery will cause temporary cessation (24–48 hours) of intestinal movement, namely paralytic ileus.

elimination patterns and the characteristics of stools. A normal stool has the characteristics in described Table 7.8.

Pain. Pain or discomfort during defecation as would be the case with a fissure-in-ano, will often be the reason why someone suppresses the urge to defecate in order to avoid the pain. The consequence is constipation.

Obtaining a stool specimen

Position during defecation. Squatting allows a person to lean forward, exert intra-abdominal pressure and contract thigh muscles and defecate normally. Immobile patients require a bedpan to use while in bed and cannot contract muscles to defecate. Irritants. Various substances such as spicy food, bacterial toxins or poisons can irritate the GIT. These produce diarrhoea, and large amounts of flatus. Sensory and motor disturbances. Head and spinal cord injuries can decrease the stimulation for defecation due to impaired mobility. Impaired mobility will limit a person’s ability to respond to the urge to defecate when they are unable to reach a toilet or summon assistance. Poor functioning of sphincters may result in faecal incontinence. Systemic conditions. Conditions such as those of the thyroid gland where overactivity will result in diarrhoea and underactivity in constipation; acute infections may result in diarrhoea and chronic infections may result in constipation; food sensitivities usually result in diarrhoea and systemic conditions related to electrolyte imbalances such as hypokalaemia may result in constipation. Condition of the large intestine. Conditions such as in­ flam­ matory bowel disease causes diarrhoea; while intestinal obstruction, diverticular disease, and haemor­ rhoids cause constipation, and colorectal cancer causes diarrhoea alternating with constipation.

Facilitating regular defecation Hospitalisation and illness, as well as prescribed medical therapies, may interfere with a patient’s normal habits of defecation. The facilitation of regular defecation remains an important part of a nurse’s role, and several factors should be taken into consideration (see Table 7.7).

Characteristics of normal and abnormal faeces Inspection of faecal characteristics yields information relating to alterations in the nature of elimination. Various factors including information obtained from the patient can have an influence on the diagnosis in relation to

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A stool specimen for assessment in the ward or clinic can be saved in the bedpan in which it has been passed.

Common problems associated with defecation Risk factors Some risk factors associated with irregular defecation are: • Diet • Mobility • Gastrointestinal infection.

Constipation Constipation is the infrequent and difficult passage of hardened stool. The water in its composition gets reabsorbed and the stool passed is small, dry and hard. In some instances there is no stool passed for days.

The common causes of constipation The following causes might contribute to constipation: • Irregular defecation habits, and change in daily routine may interfere with the routine for defecation.

Clinical alert! Prevent cross-infection by washing hands after defecating, before handling food, and before and after attending to other patients.

7.5  Collection of a stool specimen Collection of a stool specimen for ward inspection can be done from the bedpan. Using a wooden speculum: • Determine the stool’s characteristics, ie shape, colour, odour and sometimes constituents • Examine the stool by separating it to exclude foreign bodies such as worms and undigested food which could not be identified from mere observation. In preparing for laboratory tests: • Ensure that the specimen is not contaminated • Scoop a sufficient amount of stool using a spatula into a labelled specimen bottle • Close the bottle tightly and wipe the bottle to remove any spillage • Wash and dry hands • Transport to laboratory with a correctly completed laboratory form.

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122  Juta’s Complete Textbook of Medical Surgical Nursing Table 7.7 Measures to facilitate defecation

Situation

Measures

Relaxation

• Present a bedpan at regular intervals • Ensure privacy • Allow sufficient time • Suggest reading or listening to music while defecating • Relieve physical and emotional discomfort to decrease muscle tension

Positioning

• Assume a normal sitting position whenever possible • Use bedside commodes or bedpans for bedridden patients

Timing

• Never ignore the urge to defecate and encourage defecation when the urge is recognised • Establish a regular bowel elimination pattern • Stimulate mass peristalsis, eg with a hot drink or a light snack at regular intervals in line with the established elimination pattern • Help patients who already have an established routine to maintain it

During bed rest

• Warm the bedpan • Simulate the normal position as closely as possible. If confined to bed, assist patients in an upright position on the bedpan with legs hanging down (if allowed) at the edge of the bed, feet resting on a chair

Nutrition and fluids

For constipation: • Increase daily fluid intake – both hand and cold drinks – unless contra-indicated • Increase intake of fibre in the diet, eg fruit, prunes, raw vegetables, bran products and wholegrain cereals and bread • Stool softeners and laxatives should be taken as a last resort • For diarrhoea: –– Eat small amounts of bland foods (the patient needs to be encouraged to eat even if they may reluctant to eat or drink for fear of stimulating the gastrocolonic and duodenal reflexes which may induce more stool) –– Increase potassium intake to compensate for losses –– Avoid very hot or cold fluids as well as spicy and high fibre foods as these stimulate peristalsis • For flatulence: –– Decrease the intake of carbonated beverages; the use of straws to drink; and chewing gum, as all of these increase swallowing of air –– Avoid gas-forming foods, eg cabbage, beans, onions

Exercise

• Early ambulation post-surgery • Encourage isometric exercises (a type of strength training in which the joint angle and muscle length do not change during contraction) to strengthen abdominal and pelvic muscles

• Ignoring or inhibiting normal defecation reflexes tends to progressively weaken these conditioned reflexes. When habitually ignored, the urge to defecate is ultimately lost. • Overuse of laxatives also inhibits natural defecation reflexes. The habitual user eventually requires larger or stronger doses of laxatives as they have a progressively reduced effect with continual use. • Inappropriate diets such as bland diets that are low in roughage or diets that lack bulk and will not provide sufficient residue of waste products to stimulate the reflex for defecation. Low-residue foods (eg rice,

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eggs, lean meat) move more slowly through the GIT. Increasing fluid intake with such foods increases their rate of movement. A change in diet and meal times may also predispose people to constipation, as this is a change in habit. • Diseases of the anus, rectum and colon, eg bowel obstruction, carcinoma of the colon, diverticular disease of the colon, painful lesions of the anus. • Insufficient exercise, such as patients on prolonged bed rest. Lack of exercise is usually associated with lack of appetite.

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Characteristic

Normal

Abnormal

Cause/s

Colour

For infant: yellow For adult: brown

White or clay Black or tarry (melena) Red Pale with fat (steatorrhoea) Translucent mucus Bloody mucus

Absence of bile pigment Iron ingestion or bleeding from upper GIT (stomach) Bleeding from lower GIT (rectum) Bleeding haemorrhoids Malabsorption of fats, diet high in milk Spastic constipation, colitis Blood in faeces or infection

Odour

Pungent : affected by ingested food

Offensive if pus or blood present

Infection or haemorrhage in the GIT

Consistency

Soft, semi-formed, formed, moist

Liquid (diarrhoea) Hard, dry

Increased intestinal motility (irritation of the colon by bacteria) Dehydration, constipation, laxative abuse

Frequency

Infants: 4–6/day if breastfed infant; 1–3/day if bottle fed Adult: daily or 2–3 times/ week, depending on the diet

Infant: > 6/day or < than once every 1–2 days Adult more than 3 times a day or less than once a week

Hypomotility (decreased motility of the GIT) or hypermotility (increased motility of the GIT)

Shape

Cylindrical and resembles the diameter of the rectum in adults

Narrow, pencil-shaped or flat ribbon-like Pellet-like

Obstruction Rapid peristalsis Hirschsprung’s disease Severe constipation

Constituents

Undigested food, bile pigments, fat, protein

Pus Blood Foreign body Mucus and worms

Infection Bleeding in the GIT Swallowed objects Worm infestation Malabsorption

• Psychological causes, such as emotional upheavals, may result in constipation by inhibiting intestinal peristalsis through the action of epinephrine and the sympathetic nervous system. • Neurological disorders that block nerve impulses to the colon such as Parkinson’s disease, multiple sclerosis, stroke and spinal injuries. • Metabolic and endocrine disorders such as diabetes mellitus, hyper- and hypothyroidism and hypercal­ caemia. • Other systemic disorders include lupus, amyloidosis, and scleroderma. • Medication and chemical agents such as calciumcontaining antacids, antidepressants, anticonvulsants, iron medication and opioids cause constipation. • Age is also a factor in constipation, as activity and muscle tone are reduced.

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• Pressure from outside the colon (eg gravid uterus, ovarian cysts) is also a factor. • Undergoing general anaesthesia for surgery is another cause of constipation. • Dirty, poorly lit toilets with cracked toilet seats, doors that do not close can also cause constipation due to patients not wanting to use these types of facilities.

Pathophysiology of constipation Constipation is a sign of a disorder which may be systemic or localised in the GIT. Constipation results from decreased motility of the colon. When faeces remain long in the colon, the water gets reabsorbed and the stool becomes dry, hard and difficult to expel. The urge to pass a stool is stimulated by the distension of the rectum which initiates a series of actions such as the stimulation of the retroanal reflex of the anal sphincter muscle, relaxation of the external anal

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sphincter muscle and muscles of the pelvic floor and an increase in the intra-abdominal pressure. Interference with any of the processes can lead to constipation.

Assessment and common findings Careful assessment of a person’s bowel habits and history are essential before a diagnosis of constipation is made. • Defecation pattern. Determine the person’s normal bowel habit. A person’s regular defecation pattern may be that it only takes place a few times a week and the person therefore is not necessarily constipated if they miss a day or two. • Ease of evacuation. Determine the degree of difficulty with evacuation of stool and increased effort or straining of the voluntary muscles of defecation associated with constipation. Straining during defecation places stress on abdominal and perineal sutures if any and rupture under sufficient pressure. • Use of elimination aids. Establish the use of laxatives and purgatives. • Diet. Establish the patient’s typical diet including foods they eat and avoid as well as how frequently they eat throughout the day. It is important to determine how much fibre the patient consumes and how often. • Fluid. Establish the amount of fluid intake per day (2–3 ℓ of water per day). • Stress. Determine if the patient experiences stress as well as the source of their stress. • Exercise. Establish the exercise pattern followed. • History. Find out if there has been a previous episode and how it was managed. Subjective data gathered from the patient may also include: • A report of a decrease in the frequency of defecation • Passage of hard, dry stool associated with straining • Flatulence • Abdominal distension/bloating with nausea and vomiting • There may be abdominal pain/cramps with tenesmus. A physical assessment of the patient should include the following: • An abdominal palpation, which may reveal the presence of a faecal mass. • A digital rectal examination. This involves the insertion of a gloved and lubricated finger into the rectum. It can be done to assess the tone of the anal sphincter and the contents of the rectum. • Blood or mucus can be observed on the hard stool as an indication of anal bleeding, as the hard stool tears through the anus.

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Diagnostic studies include: • Blood and thyroid tests to detect infection, other systemic diseases and thyroid diseases • Blood tests to assess the levels of amylase, which is usually elevated in conditions of the pancreas; and bilirubin which is elevated in hepatobiliary diseases. • Colorectal transit study or anorectal function tests • Colonoscopy and/or sigmoidoscopy to view structural changes that may contribute to constipation and exclude colon or rectal cancer • Barium enema.

Effects of constipation These may include the following: • Bloating • Flatulence • Abdominal colic • Excessive straining during defecation • Anal fissure • Faecal impaction with overflow diarrhoea • Poor appetite • Headache, lethargy and malaise • Halitosis • An abdominal mass • May worsen urinary incontinence due to the hard faeces pressing on the bladder • In children it may cause irritability and fretfulness. Other serious effects include: • Intestinal obstruction • Haemorrhoids • Rectal prolapse • Megacolon • Hypertension.

Care of a patient with constipation Constipation is often a sign of a disorder, therefore, the cause must be found and treated. The nursing measures are usually in line with the nature, severity, duration and associated problems. Cleansing of the bowels can be obtained in the ways described below. Increasing faecal mass. Various substances can be taken orally to increase the bulk of the stool. Bran will increase fibre in the stool, thereby increasing water absorption in the stool. Agar (from seaweed) becomes jellylike when mixed with fluid in the GIT (eg Agarol). Seeds from various plant species absorb water in the GIT to form a viscous substance (eg Agiolax granules, Metamucil). These agents can be used to correct both dry and loose stools. For patients with ileostomy, bulking agents are often used to thicken the drainage and to prevent the leaking of watery

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faeces. Bulking agents must never be used in the patient with impacted faeces. Faecal softeners and lubricants. These agents are used to soften a hard, shrunken stool. Liquid paraffin is a mineral oil that is not absorbed, so it acts as a lubricant and softens the faeces in the colon. It is considered a mild laxative, but continued use may be harmful. It may interfere with digestion and absorption from the small intestine with resultant deficiency of fat-soluble vitamins. Non-irritating faecal emulsifying agents (eg dioctyl sodium sulphosuccinate) lower the surface tension in the faeces and thus increase fluid penetration. Combined with bowel stimulants, they form effective purgatives for use in cases of constipation. Colonic stimulants and cathartic therapy. Cathartics are substances that stimulate evacuation of the bowel, such as laxatives and purgatives. Laxatives have a mild effect which loosens the bowels without causing abdominal cramps and watery stools. Purgatives have a stronger effect than laxatives and are often accompanied by abdominal cramps and dehydration. Prolonged use of purgatives may cause hypokalaemia and inflammation of the bowel. A large dose of a cathartic may have a purgative effect, whereas a small dose of the same cathartic may have a laxative effect and produce a normal bowel movement. Cathartic therapy is indicated for: • Mild constipation • Emptying of the bowel before bowel surgery or GI tests, eg abdominal radiography • Ensuring an empty rectum before childbirth. Colonic peristalsis can be stimulated by laxatives or purgatives. Laxatives can be used as follows: • Synthetic laxatives such as bisacodyl (eg Dulcolax®) can be administered orally (acts within 6 to 12 hours) or rectally (acts within 30 minutes to an hour) as it has a stimulant effect on the rectal mucosa. • Dihydroxyanthraquinone is another synthetic laxative resembling the natural anthraquinone laxatives. • Phenolphthalein is a non-toxic laxative even in large doses. It acts within 5 hours and its action lasts a few days – therefore valuable in chronic constipation. It is an ingredient of many purgative mixtures, eg Agarol. –– The anthraquinone group of laxatives includes rhubarb, aloes, cascara and senna. These substances stimulate the neuromuscular apparatus of the colon – their action closely imitates normal peristalsis

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and defecation and is therefore not harmful. The action of these agents is delayed for approximately 9 hours after ingestion. –– Senna causes no mucosal irritation or systemic toxicity. It is of special value in the treatment of chronic constipation in the aged. It can be used in the re-education of the bowel in chronic constipation. Senna may cause hypomotility of the bowel if used regularly over a number of years where the neurones in the submucosal ganglia cannot function without the stimulation of senna. –– Cascara has a nauseous, bitter and persistent taste. It is usually administered as an elixir and is also suitable for the treatment of chronic constipation. Both senna and cascara will cause abdominal cramps if too large a dose is taken. The optimal dose should be determined for each person by consulting dosage instructions on the leaflet. When the constipation has been corrected, the dose must be gradually diminished until it is finally discontinued. • Lactulose is a synthetic disaccharide that is split by bacterial action in the bowel and then acts as a laxative (eg Duphalac®). It is used to control the symptoms of hepatic encephalopathy. Purgatives can be used in the following way: • Purgatives that cause loose, watery stools and abdominal cramps should be avoided, eg saline purgatives (such as fruit salts, Epsom salts, milk of magnesia). These purgatives increase faecal bulk by retaining sufficient water in the intestine to hold them in osmotic equilibrium. The contents of the small intestine then become abnormally liquid which stimulates strong peristalsis and evacuation of liquid stools. These agents usually act an hour after ingestion. Excessive use will cause hypokalaemia. • Castor oil is a drastic purgative that is first digested in the small intestine before it can stimulate the intestinal wall to work out a strong peristaltic movement that empties the intestine completely, thereby causing constipation. Its main use is in food poisoning to rid the bowel of organisms and toxins, and just before labour. • Vegetable laxatives, eg aloe, consist of jalap and colocynth that are drastic purgatives which may cause enteritis and dehydration if given in overdose. • Many traditional medicines, such as Isihlambiso (a herbal decoction used by many Zulu women in South Africa as a preventative health tonic during pregnancy), contain drastic herbal purgatives. If these traditional medicines are taken in excess, they can be

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dangerous, causing severe dehydration, renal failure, systemic toxicity and even death. Glycerine suppositories are other forms of stimulants that will increase peristalsis. Enema. An enema is an introduction of fluid into the rectum and colon by means of a tube. It is usually given to stimulate peristalsis and the urge to defecate if immediate evacuation of the colon is required. A conventional enema makes use of a fairly large quantity of fluid. Microenemata or disposable enemata of small size are currently available. There are two types of enemas: 1. Evacuant enemas. These are small enemas supplied in single doses to evacuate the rectum and sigmoid colon of faeces and flatus. The enema is retained for a short time only. 2. Retention enemas. These are usually oil enemas that are retained to soften impacted faeces. Bowel washout. Bowel washout is done to cleanse the colon and rectum. This can be done to remove any blood from the large bowel in cases of liver failure and bleeding oesophageal varices. It prevents the absorption of ammonia (formed by the breakdown of protein in the blood) that causes encephalopathy. Bowel washout is also done before diagnostic procedures or surgery of the bowel. Faecal impaction. Faecal impaction is a mass or collection of hardened, putty-like faeces in the folds of the rectum. It results from unrelieved constipation. In severe cases, it may extend well up into the sigmoid colon and beyond. Faecal impaction is recognised by the passage of liquid faecal seepage (diarrhoea) and no normal stool. The liquid faeces seep out around the impacted mass. Impaction can also be assessed by digital examination of the rectum. This should be done gently because stimulation of the vagus nerve in the rectal wall can slow a patient’s heartbeat. Other symptoms that may be experienced are: • rectal pain • frequent non-productive desire to defecate • anorexia • distended abdomen and cramping • nausea and vomiting. Nursing management of faecal impaction depends on the degree of impaction. Manual removal of faecal impaction entails breaking up of the faecal mass and then manually removing the pieces through the process of rectal examination. This is a distressing and uncomfortable procedure. Care must be taken to avoid injury of the

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Clinical alert! Patients with a history of cardiac disease and/or dysrhythmias may be at risk with digital stimulation to remove an impaction. If in doubt, you should check with the primary care provider before performing the procedure.

bowel, mucosa and sphincter. Laxatives and a balanced diet must always follow this procedure. An oil retention enema may also be given to soften the stool.

Essential health information for the patient and family It is important to prevent constipation because it is uncomfortable and inconvenient. Simple measures include the following: • Drink at least 2–3 ℓ of water per day. • Avoid caffeinated drinks as these stimulate fluid loss through urination. • Institute regular times to go to the toilet, eg after breakfast when the gastrocolic reflex is strongest and the urge to defecate must not be ignored. • Pay attention to the urge to defecate, frequent postponing can lead to constipation. • Allow for sufficient time and privacy for defecation. • Provide a hot drink or lemon juice early in the morning which may initiate strong peristaltic movements that lead to bowel evacuation. • Undertake regular exercise to stimulate normal motility of the intestines and strengthen abdominal muscles. Walking is very good for bowel function. • Take in a diet that contains high fibre (20–35 g/day) such as unprocessed cereals, raw and stewed fruit,

Clinical alert! The dangers of laxative abuse should also be brought to the attention of the community: the use of safe laxatives, such as fibre or bulk-forming laxatives should be promoted. Many traditional African treatments involve purging, as this is believed to purify the body by cleansing the bowel. However, traditional herbal remedies vary enormously in strength, and many such remedies are toxic even when taken in small doses, eg Isihlambiso, which is made up of purified compounds like sitosterol and combretastatin. Community members should be made aware of the possible dangers of the over-enthusiastic use of traditional purgatives.

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brown bread, breakfast cereals and increased fluid intake to increase bulk. • Avoid the use of laxatives, purgatives and enemas as these disturb the normal motility of the bowel – the rational use of laxatives and purgatives is an important topic for health education in the community. • Generally, a balanced diet with adequate amounts of fibre will ensure regular bowel actions. The frequency of bowel action is usually related to the amount and type of food eaten, and it is not necessary to have a bowel action once a day in order to be in good health.

Diarrhoea Diarrhoea is the frequent passage of loose faeces and can be acute or chronic. It results from rapid movement of faecal contents through the large intestine with the result that the time available for reabsorption of water and electrolytes from the chyme is reduced. The individual with diarrhoea finds it difficult to control the urge to defecate for very long. The threat of incontinence is very real and often a source of embarrassment. Spasmodic and piercing abdominal cramps often accompany diarrhoea. Diarrhoea can be described as: • Secretory diarrhoea. This occurs in instances where the small and large intestine secrete salts, particularly sodium chloride and water into the stool due to intestinal infections or as an action of laxatives. Some tumours can also cause secretory diarrhoea. • Osmotic diarrhoea. This is due to substances that remain in the intestine because of non-absorption into the bloodstream. These substances draw excessive amounts of water into the intestinal lumen. • Exudative diarrhoea. This is seen in diseases like ulcerative colitis, Crohn’s disease and other diseases where there is inflammation and ulceration of the lining of the large intestine. The inflamed lining releases mucus, fluids and proteins which increase the bulk and fluid content of the stool.

Causes of diarrhoea • Intestinal infections, eg Vibrio cholerae, staphylococcal toxins, Clostridium, E. coli, Shigella, Salmonella, Staphylococcus, viral agents, and parasites, eg Giardia lamblia, Entamoeba hystolytica • Psychological stress and anxiety • Medication, eg antibiotics, iron (also causes consti­ pation), purgatives, digitalis • Food allergies or intolerance to food including milk, spicy and greasy foods • Chemical substances, eg arsenic and organo-phos­ phates • Diseases of the GIT, eg malabsorption syndrome,

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Crohn’s disease, chronic pancreatitis and colitis • Surgical alterations, eg gastrectomy • Radiation therapy • Diseases outside the GIT, eg pellagra, endocrine and metabolic disturbances such as uraemia and thyrotoxicosis.

Pathophysiology of diarrhoea The intestinal mucosa secretes large amounts of water and electrolytes into the intestinal lumen as a response to the irritation by infective organisms or the osmotic pressure exerted by the particles that are not absorbed in the chyme. Peristalsis is increased leading to the frequency in bowel emptying. Depending on the severity of the diarrhoea, electrolyte imbalance occurs. Metabolic alkalosis occurs with the loss of sodium and potassium. Severe diarrhoea causes dehydration, hyponatraemia and hypokalaemia.

Assessment and common findings Subjective data. The patient will report the following: • Explosive and frequent passing of watery, large amounts of faecal fluid which may contain blood or mucus (more than 300 g in 24 hours) • Nausea and vomiting • Fever • Abdominal pain or cramps • Abdominal distension and tenesmus • Irritation of the anal region with persistent diarrhoea • Weakness • Fatigue • Malaise • Blood, mucus and/or undigested food in the stool • Emaciation or weight loss following prolonged diarrhoea. Objective data • Abdominal tenderness on palpation • Mucous membrane and skin may be dry and inelastic denoting dehydration. • The immediate causes of dehydration include not enough water, too much water loss, or some combination of the two. Table 7.9 indicates the types of dehydration in relation to the indicators. Diagnostic studies include: • Stools that are collected for culture to identify causal organisms and to detect the presence of blood, pus, mucus, cells and parasites. • Measurement of stool electrolytes, pH, and osmolality which is done to determine whether the diarrhoea is related to decreased absorption or increased fluid

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128  Juta’s Complete Textbook of Medical Surgical Nursing Table 7.9 Signs of dehydration

Indicators

Mild dehydration

Moderate dehydration

Severe dehydration

Thirst

Increased thirst

Very thirsty

Extreme thirst

Skin

Dry skin

Dry with loss of skin turgor

Dry and no elasticity

Urinary output

Decreased urinary output

Mild oliguria

Anuria

Alertness

Tired

Exhausted

Moribund

secretion. Measurement of stool fat and undigested fibre may indicate protein and/or fat malabsorption. • Endoscopy which is done to obtain specimens from the mucosal lining. • Upper and lower gastrointestinal radiological studies can be done, using a barium contrast to detect structural abnormalities as well as mucosal lining diseases.

Care of a patient with diarrhoea Diarrhoea is a sign and, as such, it is necessary to find the cause and treatment. Intake of fluids and food should be encouraged to prevent dehydration and malnutrition. Ingestion of food and fluids stimulates the gastrocolic and duodeno-colic reflexes, thus inducing more stools, and the individual may be reluctant to eat and drink. Intake of fluids and electrolytes through the oral or parenteral route is extremely important, especially if the patient is dehydrated. Avoid very hot or cold fluids, as these will stimulate peristalsis. Treatment of symptoms consists of inhibition of peristalsis by oral administration of drugs such as codeine or Lomotil/Kaopectin for absorption of toxic substances that are formed in the bowel as a result of the putrefaction of proteins. Ensure that the patient’s basic hygienic needs are met. Specific antimicrobial and/or anti-diarrhoeal treatment is sometimes administered on the physician’s prescription.

Clinical alert! • Only in severe cases of diarrhoea should food be withheld. In cases of diarrhoea, strictly monitor intake and output. • In patients with lactose intolerance, the ingestion of milk and milk products should be discouraged.

Essential health information Nurses have a responsibility to educate patients on the facts of elimination. The significance of diarrhoea and vomiting cannot be overemphasised in South Africa. Each year thousands of infants and young children die as a result of neglected or inappropriately treated diarrhoea and vomiting. The

Rectal catheter A rectal catheter (faecal incontinence device) is an external drainage pouch that fits over the anus to collect stool. It consists of an indwelling rectal catheter through which liquid or semi-liquid stool passes and is drained into an external drainage pouch. Patients’ fluid and electrolyte status should be monitored to guard against possible electrolyte imbalance. The advantage for use of rectal catheters is that they prevent acquired pressure ulcers, which are a serious adverse event. Furthermore, the device minimises odour and enhances accurate output monitoring and patients’ comfort.

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Figure 7.8 Rectal catheter

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7.6  Oral rehydration therapy

7.7  Benefits of ORT

Oral rehydration therapy (ORT) using homemade or prepacked electrolyte solution is very effective in the prevention of dehydration. Homemade ORT solution is prepared as follows: • 1 ℓ of preboiled and cooled water in which 8 teaspoons of sugar and ½ a teaspoon of salt have been dissolved. • Orange juice to improve the flavour (optional).

It is important to note that this solution is absorbed readily in the intestines and will prevent dehydration which is the killer in these instances. Treatment with ORT is not confined to infants and young children only – adult sufferers can also benefit from ORT.

Clinical alert! • A cup of ORT should be taken after every loose stool. • Maintain normal nutritional intake. Eating small amounts of bland foods or a clear fluid diet can be of value as these are more easily absorbed. Easily digestible carbohydrates (eg well-cooked refined cereals prepared with water, honey, sugar and glucose sweets) can be given. When the diarrhoea has stopped, soups and milk dishes can be gradually introduced. Convalescence will proceed through a low residue, a light, and then a full diet. Encourage the intake of foods high in potassium. conditions, diarrhoea and vomiting, whether occurring individually or both, are lethal and must be given priority. ORT is a worldwide effective management of diarrhoea or vomiting or both recommended by the WHO. Communities should be taught on how to make a simple oral rehydration treatment solution (see Box 7.6). For children: A cupful of the solution should be given after each loose stool.

Faecal incontinence Faecal incontinence is the inability to control the passage of faeces and gas from the anus. Incontinence may occur irregularly or at specific times, such as after meals. It is usually associated with impaired functioning of the anal sphincter or its nerve supply in cases of spinal cord injury. Faecal incontinence is an emotionally distressing problem that may lead to social isolation, changes in body image and feelings of inadequacy.

Causes of faecal incontinence • Constipation with impaction and diarrhoea with overflow • Severe diarrhoea due to drugs • Sphincter incompetence due to illness • Neurogenic conditions, following spinal injuries

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7.8  About diarrhoea and vomiting Diarrhoea and vomiting in infants and young children is often as a result of inadequate hygiene of feeding bottles. Ideally, infants should be breastfed, and then the question of hygiene of feeding bottles does not arise. The promotion of breastfeeding is an important priority for health workers, especially in poor communities who may not have access to a clean water supply, and who can barely afford the cost of infant formula. If breastfeeding is not possible, mothers should be encouraged to use a cup and spoon to feed their babies and infants. Water-borne diseases such as typhoid and cholera are important epidemic diseases in South Africa, especially in rural communities and in informal settlements where there is inadequate water supply, or the available water supply is suspect. Both of these serious illnesses present with diarrhoea and vomiting. It is therefore essential that health workers do not ignore cases of diarrhoea and vomiting, especially in the summer months. It is important for the community to be made aware of the need for a clean water supply. If the local water supply is not clean, the people need to be shown how to boil their drinking water, or alternatively how to sterilise their drinking water using a small amount of bleach. • Psychological and behavioural disorders, especially in children • Encopresis, which is a form of faecal soiling that is found in children between 4 and 8 years of age, mainly boys, and may be a symptom of an underlying psychological problem.

Care of a patient with faecal incontinence Faeces are acidic and contain digestive enzymes that are highly irritating to the skin.

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The skin area around the anus should therefore be cleansed and dried regularly and protected with zinc oxide or a similar ointment. If the problem is chronic, and not an isolated occurrence due to illness, the patient can be advised about various incontinence aids that are available, and carrying a deodorant spray may increase social confidence. Individuals who suffer from faecal incontinence may be able to have some form of surgical correction to restore the tone of the anal sphincter. The patient should be encouraged to have the problem investigated, as chronic faecal incontinence is extremely distressing to both patient and family.

Essential health information for the patient and family Caring for an incontinent person at home can be very difficult and distressing for both the patients and carers. Such families need practical advice on how to cope with the situation, as well as support from health workers. Education could include advice regarding the use of

various incontinence aids, as well as how to make simple incontinence aids at home, if the family cannot afford to buy commercial incontinence pads and condom drainage systems. Advice about giving the patient a receptacle for defecation at regular intervals can be useful, as this serves as a type of bowel training and may reduce episodes of incontinence considerably.

Flatulence Flatulence refers to a sensation of bloating and abdominal distension accompanied by excess gas in the lumen of the intestines.

Causes of flatulence • The action of bacteria on the chyme in the large intestine • Swallowed air • Gas generated by some foodstuffs, eg onions, beans, cabbage

Table 7.10 Nursing care plan for a patient with altered bowel elimination

Diarrhoea Nursing diagnosis

• Alteration in bowel elimination related to intestinal disorders evidenced by frequent passage of loose stools or straining at a stool

Expected outcome

• Patient to have normal bowel action per day without risk for dehydration.

Nursing interventions and rationale

• Encourage fluid intake and bland food for easy absorption. • Observe and record the frequency, volume and characteristics of defecation. • Teach the patient about foods and drinks that may precipitate diarrhoea, as knowledge of causative factors can clarify an appropriate treatment approach.

Evaluation

• Patient reports no passage of watery stools.

Constipation Nursing diagnosis

• Alteration in bowel elimination related to intestinal disorders • evidenced by passage of hard painful stools.

Expected outcome

• Patient to have a bowel movement within 2 days of intervention.

Nursing interventions and rationale

• Identify factors that contribute to constipation to assist in determining whether enough fluids and fibre are consumed. • Encourage intake of fluids to promote proper stool consistency. • Provide a high-fibre diet to soften stool elimination. • Encourage walking and abdominal muscle-setting exercises to assist with evacuation efforts.

Evaluation

• Patient reports passage of normal soft stools.

Source: adapted from Gulanick & Myers, 2011; DeWit & O’Neill, 2014

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• Constipation • Medication such as codeine, barbiturates, narcotics and other drugs that decrease intestinal motility • Anxiety states • Anaesthesia • Dietary changes • Reduced physical activity as may be the case in a patient recovering from surgery.

Pathophysiology of flatulence An adult normally forms 7–10 ℓ of flatus in the intestine every 24 hours. The gases include carbon dioxide, methane, hydrogen, oxygen and nitrogen. Most of the gas swallowed is expelled through the mouth by eructation or belching. Normally all but 0.6 ℓ of the gases produced are absorbed into the intestinal capillaries. Excessive flatus in the intestines and stomach leads to stretching and inflation (distension).

Care of a patient with flatulence • The patient who cannot expel gas through the anus may need to have a rectal tube inserted or an enema to remove it. • Dietary measures may play an important role in the prevention of flatulence, for example exclusion of

gas-forming foods, such as cabbage, onion and beans from the diet. • Exercise is also important as this encourages peristalsis.

Essential health information about managing flatulence • It is imperative for people to know the importance of exercise – daily non-strenuous walks should be encouraged. • Encourage fluid intake of 1–3 ℓ a day. • Eat a well-balanced diet with adequate fibre. • Always respond to the urge to eliminate. • Do not abuse laxatives and purgatives. • Maintain personal hygiene.

Conclusion Elimination of both urine and faeces is an important regulatory mechanism. Inability to eliminate is always cause for concern, as it may signal a major medical or surgical condition that will require extensive management that is costly for the health of the individual. Nurses, as part of their clinical practice, should assess all patients for elimination patterns, and plan for management of the identified problems.

Suggested activities for learners Activity 7.1 Scenario: A 40-year-old rural female patient admitted in hospital for the first time is much more likely to experience discomfort in using a commode. The operation she is about to undergo is likely to keep her in bed for 5 days. In welcoming the patient to hospital and preparing her for the operation and thereafter, describe how you will facilitate faecal elimination. Activity 7.2 Describe the health education you would give to a patient prior discharge regarding promotion of good bowel elimination. Activity 7.3 Visit the medical outpatients’ department in your hospital or clinic and collect urine specimens from five patients. In the classroom, test these specimens, record results and discuss these against the knowledge of normal urine and urination in terms of physical properties, chemical constituents, reaction, specific gravity volume, and manner of micturition. In a tabular format, indicate common problems that are associated with micturition, indicate possible causes and nursing interventions thereof.

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8

Comfort, rest and sleep needs

learning objectives

On completion of this Chapter, the learner should be able to: • describe comfort, rest and sleep and how these concepts relate in healthcare provision • explain the physiology, requirements, stages, types, pattern and importance of sleep • outline the factors that influence comfort, rest and sleep in an individual • describe the significant subjective and objective data related to comfort, rest and sleep that should be obtained from patients consulting in the health facilities • explain the factors which impact negatively on comfort, rest and sleep • describe information sourced to elicit discomfort and pain in patients and how this affects comfort, rest and sleep • describe nursing interventions designed to promote comfort, rest and sleep in a patient. key concepts and terminology

bruxism

Grinding of teeth.

cataplexy

Sudden loss of muscle tone triggered by an emotional change, such as laughing or anger.

comfort

A state in which a person is relieved of distress.

hypersomnia

Feeling sleepy during the day despite getting adequate sleep during the night.

hypersomnolescence

Excessive sleeping for long periods.

hypnologic hallucination

Dreamlike auditory or visual experience while dozing or falling asleep.

insomnia

Inability to sleep or difficulty falling asleep, waking up frequently during the night, or awakening early resulting in an inadequate amount and quality of sleep.

jet lag

Emotional or physical changes experienced when arriving in a different time zone. This usually affects the sleep pattern.

massage

Rubbing the muscles to promote relaxation and improve circulation.

narcolepsy

Also known as ‘sleep attack’ – a sudden wave of overwhelming sleepiness that occurs during the day accompanied by sleep paralysis, cataplexy, hypnologic hallucinations and automated behaviour.

nocturnal

Any activity happening at night.

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non-rapid eye movement (NREM)

Light sleep, easily aroused, gradual reduction of vital signs.

parasomnia

This is a term associated with activities that cause arousal or partial arousal usually during transitions in NREM periods of sleep. These include somnambulism (sleepwalking), sleep talking, nocturnal enuresis, nocturnal erection and bruxism.

REM sleep

Active sleep where most dreams occur.

rest

Waking state characterised by reduced activity and reduced mental stimulation.

sedatives

Drugs that produce a relaxing and calming effect.

sleep

State of arousable unconsciousness.

sleep apnea

This is a situation where the sleeper stops breathing or breathing slows for 10 seconds or more, five or more times per hour at night.

snoring

Noisy breathing during sleep.

somnambulism

Sleepwalking.

prerequisite knowledge

• Human anatomy and physiology • Basic hygienic needs such as bed bath, bed-making • Temperature needs • Elimination needs • Nutrition needs • Nursing positions assumed in bed. medico-legal considerations

It is imperative to: • provide an environment that is physically conducive and safe for the patient. There must be a comfortable bed with raised side rails if necessary; secure doors and windows, especially in cases of sleep-walking; preferred temperature; ventilation; lighting; quietness • use prescribed medication that promotes comfort, rest and sleep in correct doses, route and frequency to avoid overdose • ensure that the patient assumes an appropriate position to enhance comfort, rest and sleep and prevent contractures and bedsores. ethical considerations

Nurses are ethically obliged to provide an environment which is safe, pleasant, therapeutic and conducive to rest and sleep. essential health literacy

Rest in the form of inactivity and sleep is important for tissue repair in cases of ill health and tissue injury regardless of cause. As a preventative measure, the community needs to know that it is important to rest physically, psychologically and emotionally. It is therefore legislated that working people must work stipulated hours per day and per week, and that they must rest in terms of breaks taken during work periods, as well as leave from work. A working person also needs to rest and sleep for productivity, better output and refreshed thinking. A comfortable

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environment (ie a well-ventilated, quiet space with tolerable temperature and lighting levels that is safe and clean, as well as a comfortable bed or chair or position), as well as freedom from pain, enough food and a bladder and bowel that are not full, will enhance comfort, rest and sleep.

Introduction Comfort, rest and sleep are aspects that are necessary to facilitate patient recovery. The purpose of this Chapter is to make nurses aware of the importance of these aspects and to assist them in developing an understanding of sleep and its functions, as well as measures to promote sleep and rest in the patients they care for. The understanding of pain, its importance and functions, and measures to relieve pain and promote comfort will be discussed in line with the content as contained in Chapter 14.

Sleep: its functions and importance Sleep is a basic physiological need and can be described as a state of inhibited/suppressed consciousness from which a person can be aroused with appropriate sensory and other stimuli. Sleep is essential for normal body function and takes up approximately 30% of our lives. Comfort and rest are integral to sleep.

Sleep requirements The amount of sleep that individuals need differs according to age and state of health. Babies sleep more than 12 hours per day, the elderly seldom sleep more than 6 hours per day, and the average adult sleeps between 7 and 8 hours per day (see Table 8.1). Epidemiological studies have indicated that adults who usually sleep more than 9 hours or less than 4 hours per night have a higher mortality than those sleeping between 7 and 8 hours per night. Females on average sleep more than males, and both sexes sleep more during autumn than during spring. Whether adults really need 8 hours of sleep is debatable. Griffiths (2013) found that people who sleep an average of less than 6 hours per day are probably better able to handle their daily activities than people sleeping for long periods. ‘Short sleepers’ are usually energetic people who work hard, feel good in the morning and are happy with their lives and jobs. ‘Long sleepers’ (more than 9 hours) tend to always be worried, and they have aches and pains and are unsure of themselves, their job and lifestyle.

Circadian rhythm The bodily functions of a human being follow a pattern over a 24-hour period known as the circadian rhythm. It

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Table 8.1  Sleep requirements according to age

Age

Sleep requirements

Newborn

16–20 hours per day (50% in REM)

3 months–1 year

14–15 hours per day (35% in REM)

Toddler (3–5 years)

12 hours in the night and 1 or 2 naps in the day

Preschool (3–5 years)

9–12 hours per night

5–6 years

9 –11 hours per night (20% in REM)

11 years

9 hours per night

Adolescent

7–9 hours per night (25% in REM)

Adult

7–-9 hours per night (20–25% in REM)

Elderly

7–9 hours per night (13–15% in REM)

is almost as if the body has a biological stopwatch that controls its activities. Body temperature, pulse rate and blood pressure fluctuate through the day and are usually lowest in the early morning hours (04:00 to 07:00), but circadian rhythms differ between individuals. This phenomenon is attributed to a point in the 24-hour cycle where an individual’s temperature falls to the lowest point. Should the person’s temperature fall to the lowest point late during the person’s sleep cycle, they will find it difficult to get up and to get going. Most people find that their reaction time is slower early in the morning than later in the day. With some individuals, peak efficiency is reached between 07:00 and 11:00 when the body temperature approaches its highest level. At this stage, the person’s metabolism is at its highest and they are at their most energetic. The pattern is found in all people, even among those working on night duty. Air travel may prolong or shorten one’s day while the body still functions according to its own biological clock,

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REM sleep is not a passive state, but is relatively active and is therefore referred to as paradoxical sleep. The sympathetic nervous system dominates during REM sleep. REM sleep restores a person’s ability to learn. It facilitates psychological adaptation and memory. Daily events are revised, processed and stored during REM sleep. This provides a perspective on events and may even solve a few problems – hence the sensible advice ‘to sleep on a problem or difficult decision’. In an adult, REM sleep constitutes 25% of total sleep. NREM sleep includes four phases of deep, peaceful sleep during which tissue repair, rest and resistance against infections are promoted. The respiratory rate, the minute volume and the response of the respiratory centre in the brain to a decrease in carbon dioxide levels are diminished, with a resultant increase in arterial carbon dioxide levels. In an adult NREM sleep makes up 75% of total sleep.

activity of glands and involuntary smooth muscle in the walls of tubes, hollow organs and the heart. Basal metabolic rate decreases by 10–30% during NREM sleep. Even during REM sleep, it is lower than during the wakeful state. Sleep therefore is an energysaving state. Muscle tone decreases, especially during NREM sleep. The relaxing of skeletal muscle enables the body to channel energy to essential cellular activity, eg tissue repair. Sleep facilitates restoration, and decreases stress and anxiety, which enables the person to regain stamina for concentration, interest in daily activities and the ability to handle these circumstances: • Growth hormone is increased during sleep. Depriva­ tion of NREM stage 4 sleep decreases the release of growth hormone, making one feel tired, depressed and miserable. This hormone promotes tissue repair, and lack of sleep may be particularly detrimental to sick or injured patients. • Breastfeeding mothers should ensure that they get enough sleep, as the secretion of prolactin increases during sleep. • Secretion of adreno-corticotropic hormone (ACTH) decreases during NREM sleep. This hormone influen­ ces the adrenal cortex to secrete hormones such as cortisol aldosterone and cortico-steroid during REM sleep. These hormones influence a person’s vitality, tiredness, metabolism, transmission of nerve impulses and resistance against infection. Deprivation of REM sleep may lead to adrenal hormones being released into the bloodstream at the wrong time, which will make a person feel depressed and tired with poor concentration.

Physiological changes during sleep

Stages of sleep

Sleep does not recharge the energy consumed the previous day, because the duration of waking and sleep periods would then be the same. People who have not slept for a number of days usually sleep for less than a day before resuming normal activities. In contrast to this, sick people sleep much more than healthy people do.

Individuals falling asleep go into a pre-sleep period. • They feel relaxed and drowsy. • Vital signs such as pulse rate and temperature start to drop. • They may experience jerking movements.

hence the phenomenon of ‘jet lag’. These people will need a few hours or days to return to their normal sleep, eat and work pattern. At birth, the sleep-wake cycle has not been developed yet – this only happens during the first 3 months. Hospitalisation has a great impact on this cycle because it disturbs a patient’s normal life pattern and routine.

Types of sleep There are two types of sleep: 1. Slow-wave synchronised sleep or non-rapid eye movement (NREM) sleep 2. Desynchronised, dream, paradoxical or rapid eye movement (REM) sleep.

Physiology of sleep

Practical implications of physiological activities during sleep Sleep deprivation results in the progressive dysfunction of the central nervous system with dysfunctional behaviour, irritation, anxiety, apathy, decreased concentration, and decreased ability to think and/or remember. The primary function of sleep is therefore to restore the natural balance between centres in the brain. This activity is the function of the autonomic nervous system, which regulates the

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A sleeping person moves back and forth through the stages of REM and NREM throughout the sleep cycle.

The sleep cycle Sleep involves a cycle of five different stages with a duration of approximately 90 minutes each in an adult. This cycle is organised in a typical manner (see Table 8.2). Sleep in the early evening may have proportionally more NREM sleep than REM sleep. During the early morning the period of REM sleep becomes longer and

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136  Juta’s Complete Textbook of Medical Surgical Nursing Table 8.2  REM and NREM stages of sleep

REM

NREM

• Definition: this is light sleep, during which hypnogogic hallucination may occur because dreams are experienced • The dreams promote the psychological integration of activities during the day • Vital signs fluctuate • Heart and respiratory rates are irregular • Cough reflex decreases • There is darting eye movement, increased relaxation of muscles, especially those of the neck and face • Very difficult to awaken • Brain metabolism increase by 10–20% • Adrenal hormones are secreted • Duration is 5–30 minutes

• NREM Stage 1: This is the transition between being awake and asleep. This stage follows on to the presleep period. It is very light sleep. It overlaps with REM. Vital signs drop further and muscles feel more relaxed. Perception of visual and auditory stimuli decrease. Slow rolling movement of the eyes may occur. Individual can easily be woken up. • NREM Stage 2: Commencement of sleep. 10–20 minutes after starting to fall asleep. If not disturbed, body functions diminish further, no eye movement is present, but the person can still be easily awakened. The stage lasts for 10–15 minutes. • NREM Stage 3: This stage follows 15–30 minutes after falling asleep. There is no movement and it is difficult to wake the person up. • NREM Stage 4: The heart and respiratory rates diminish by 20–30%, the person is very relaxed, seldom moves, difficult to arouse. This is the period during which there is sleep-walking, sleep-talking, bedwetting, and snoring. Dreams and nightmares may be experienced but are not fixed in the memory and therefore not remembered. Tissue repair takes place during this phase as a result of increased secretion of growth hormone. Duration of this phase is ± 30 minutes.

NREM sleep shorter. Severe sleep deprivation may cause a patient to skip all the phases and fall into NREM stage 4 sleep almost immediately. NREM 1 and 2 make up 50% to 60% of total sleeping time; and NREM 3 and 4, 15% to 25% of total sleeping time in young adults. This progressively decreases from the age of 30 and can even be absent in the elderly. Sleep deprivation accelerates the start of NREM sleep and increases the fraction of NREM sleep in the total sleeping time. REM sleep makes up 20% to 25% of sleeping time and this percentage stays relatively constant, even in old age. In babies, REM sleep appears at least 80 to 100 minutes after the commencement of sleep. Commencement of REM sleep sooner than 30 minutes after falling asleep is associated with sleep disturbances, such as narcolepsy or depression. It is extremely important that nurses take note that it takes time for a patient to move into NREM sleep. Once there, a sufficient amount of NREM sleep is necessary to ensure enough rest and repair of the body. Waking a patient up frequently will

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make them tired and negatively influence their ability to adjust to changes. Once awake, the patient will have to start the whole cycle from the beginning, and the chance that they will have sufficient sleep will become smaller.

Nursing assessment of sleep Sleep history

Sleep history includes: • Sleep pattern, which includes the sleeping and waking times, hours of undisturbed sleep, what facilitates sleep and what interferes with it, and any changes in the sleep pattern • Bedtime rituals such as reading, watching television • Use of medication • A description of the sleep environment, including whether the person requires dead silence to fall asleep, background music, dark or light, and what temperature is conducive to promote sleep • Identifying any aspects that worry the patient such that they impact on the patient’s sleep • A record of the pattern of sleep as in a sleep diary.

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Objective data This includes what will be found on physical examination and observation, such as: • Patient’s facial appearance, eg darkened areas around the eyes, puffy eyelids, reddened conjunctiva, glazed or dull eyes • Patient’s behaviour, eg irritability, yawning, slumped posture, rubbing of eyes, tremors, confusion, lethargy.

Factors that influence sleep and rest The factors discussed below influence both the quantity and the quality of sleep. Illness. Disease increases the need to sleep and disturbs the normal sleep-wakefulness pattern. In illness there may be: • Pain, which will render sleep impossible or will wake the patient up. Patients with stomach ulcers often wake up at night as a result of secretion of gastric juices during REM sleep. • Shortness of breath, which will make sleeping difficult. Patients must usually be propped up in bed with a number of pillows to lift the head and chest and to ease breathing. • A blocked nose and draining sinuses will hamper breathing and therefore also prevent a patient from sleeping. Some diseases, such as liver failure and encephalitis, may cause reversal of day and night patterns. Hyperthyroidism may increase the pre-sleep period causing patients to find it difficult to fall asleep, and depression may increase or decrease sleep. There is a strong relationship between the respiratory changes during REM sleep and the pathogenesis of obstructive sleep apnoea and cot death. Micturition. A full bladder and the need to urinate will interrupt sleep, irrespective of whether it occurs as a result of disease or not. Once the patient has got up, they may find it difficult to fall asleep again. Environment. The environment can improve or inhibit sleep. Any deviation from the normal sleep environment at home may play a role. People used to the dark and the sound of traffic at night may not be able to sleep if it is too light or too quiet. New or unfamiliar sounds and environment may also disturb sleep. Lifestyle. A change in routine or lifestyle may impact negatively on sleep, such as shift work that requires an individual to sleep during the day or in the middle of the night.

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Fatigue. A more tired person tends to have short naps instead of a deep sleep. Temperature. The ability of the body to regulate temperature decreases during sleep and is totally absent during REM sleep. To prevent sleep disturbance, one must therefore be appropriately covered to prevent being either too hot or too cold. Exercise. The influence of exercise differs among individuals. Exercise during the day up to 2 hours before bedtime can improve sleep. Exercise nearer to bedtime may hamper sleep. A lack of sufficient exercise may make it difficult for some people to sleep. Emotional problems. Emotional problems and anxiety disturb sleep, because the person cannot relax enough to fall asleep. Excessive stimulation – that is, more excitement than one is accustomed to – will make it more difficult to fall asleep for most people, unless they are exhausted by the stimulation. Medication. Sedatives and hypnotics – for example non-barbiturates such as sodium triclofos (Tricloryl® syrup), benzodiazepines (Midazolam®, Dormicum®), nitrazepam (Mogadon®), temazepam (Normison®), and barbiturates such as phenobarbitone (Lethyl®) – decrease REM sleep even though total sleep is increased. Amphetamines (central nervous system stimulants) and antidepressants (prescribed for the treatment of depression) cause an abnormal decrease in REM and NREM 3 and 4 stages of sleep. Long-term use of amphetamines can cause abnormal behaviour as a result of REM sleep deprivation. People being withdrawn from these drugs get much more REM sleep than normal, wake up frequently through the night, and may suffer from bad dreams. These patients will therefore require a lot of support and reassurance from the nursing staff. Diuretics also tend to disturb sleep in relation to frequency in micturition. Caffeine. Caffeine is a product found in coffee, tea, certain cold drinks and ‘stay awake’ tablets. This product stimulates the nervous system and causes diuresis, which can negatively influence sleep. Alcohol. Alcohol abuse disturbs REM sleep, although it may hasten the start of sleep. As the effect of alcohol decreases, REM sleep periods increase and bad dreams may be experienced. Alcohol tolerance may be the cause of a lack of sleep, which leads to irritability.

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Nutritional status. Loss of weight is associated with a decreased amount of total sleep, broken sleep periods and waking up early in the morning. In contrast, weight gain is associated with an increase of total sleep, decrease of broken periods of sleep and waking up later in the morning. L-tryptophan is an amino acid (building block of protein which is found in milk, cottage cheese, beef and canned tuna) that probably promotes sleep. This could explain why hot milk helps some people to fall asleep. A protein snack before bedtime can help to induce and maintain sleep. Snoring. Snoring may cause extreme embarrassment, because other patients may be disturbed, resulting in nurses waking the patient up. In this way, the patient’s sleep is disturbed. Management of snoring may include assisting the patient to change the position of the neck by adjusting the head on a firm pillow.

Facilitating rest and sleep The following are some of the nursing interventions found to be helpful in making a patient comfortable and promoting rest and sleep. These are largely nonpharmacologic and include: • A warm bath before bedtime. • A comfortable position in bed, especially for a person who cannot move. • Duplication of a person’s usual night-time rituals as much as possible, eg children sleeping with a teddy bear. • Sufficient diversional activities throughout the day if the person’s condition permits, to prevent too much sleep during the day. Morning naps are considered more beneficial than afternoon naps, as they are a continuation of the light REM sleep, whereas if a person sleeps in the afternoon, it is often a heavy deep sleep from which they awaken feeling groggy. • If hypnotic drugs have been ordered, they should be given a few minutes before the lights are turned off. Analgesics to relieve pain should be administered sufficiently early for them to take effect before the hypnotic is given. This enhances the effect of the hypnotic. • Avoid tea and coffee before bedtime – both are stimulants. Warm milk or a glass of wine have been found to act as a mild sedative in inducing sleep. Snacks, especially if a patient is used to them, may be helpful. • Provide for quiet and darkness. Close window curtains, or curtains between patients in non-private rooms, reduce or eliminate overhead lighting, but

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provide lighting in the toilets and bathrooms. Close the door of the patient’s room if the patient so wishes. • Limit noise and other external stimuli. Wear rubbersoled shoes, keep required staff conversation at low levels, and nursing reports or discussions are to be conducted in a separate area away from the patient’s room. For patients with a tendency of sleep-walking: • Make the patient aware of the problem, because in many instances the patient may not be aware of sleepwalking. • Provide a safe and secure environment. • Reassure the patient before they sleep. • Provide massages to get the patient into a deep uninterrupted sleep again. • Ensure that all exits from the ward are securely closed. • Should the patient wake up to walk in their sleep, assist and kindly guide them back into bed. For patients who talk in their sleep or with bruxism: • Make the patient aware of the fact that they talk or grind their teeth in their sleep. • When they talk, gently wake them up to change position and assist them to fall asleep again. • If the patient talks about things that are worrying them in their sleep, refer them to a psychologist for counselling. • For patients who grind teeth, gum shields may be necessary to protect the teeth.

Essential health information regarding comfort, rest and sleep Feeling comfortable and being able to sleep is indicative of well-being. Patients must know that their prognosis is measured by the degree of how comfortable they feel. It is important for patients to explain discomfort so that measures to counter this can be instituted and rest and sleep promoted. Being uncomfortable can be due to pain, position, full bladder, hunger, and thirst. These factors, together with environmental factors such as temperature, light, and noise, can impact negatively on sleep and rest.

Pain: its functions and importance Pain is usually an important symptom to indicate that something is physiologically wrong. Pain receptors differ from the other sense organs in that they do not adapt to continuous stimulation. The non-adaptability of the pain receptors provides a very important aspect of the body’s protective mechanism in that the pain fibres are indefatigable in transmitting stimuli warnings that tissue damage, or potential damage, is in progress. The principal

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pain receptors, called nociceptors, are the several million bare sensory nerve endings found chiefly in the skin, muscles, joints, tendons, dura mater, periosteum and arterial walls, and to a lesser extent in the viscera, and which respond to a variety of noxious stimuli. The nociceptor is either stimulated directly by damage to the receptor cell or secondarily by the release of chemicals such as bradykinin, histamine, prostaglandins, acids and potassium ions from the damaged tissues. Pain is one of the factors that cause discomfort and disturb sleep. For further discussion on the physiology of pain, see Chapter 14.

Nursing assessment of comfort Causes of discomfort

A person’s comfort can be adversely affected by sensations of physical distress or pain and also by dissatisfaction related to the individual’s psychological or physiological comfort. Discomfort and pain may be associated with the existent pathology and the bodily reactions to it, and the psychological stresses associated with hospital admission. Physical conditions causing discomfort that may be encountered by a sick person include nausea and vomiting, distended bladder or bowel, hunger, thirst, coughing, vertigo, headache, muscle tension or pain. Discomfort may result from the tension of continued unsatisfied needs. External sources of discomfort can include many factors, for example: • Personal hygiene needs. A dry, coated oral mucous membrane causes a lot of discomfort and presents a source of possible infection. A weary, restless perspiring patient with crumpled, soiled bed linen will experience improved comfort levels from a bed bath and a change of bed linen. • Uncomfortable position. Improper positioning of the body and/or limbs may cause muscle and joint discomfort. • Pressure. Pressure from casts, bandages, bed blankets and other appliances may cause considerable pain to a patient and may even be dangerous, as such pressure can lead to pressure sores, or even loss of blood supply and gangrene. • Environmental factors. A great many environmental factors may be experienced as disturbing by a patient, such as noise, lights, ventilation, disturbing sights, or the behaviour of other patients. These factors contribute to irritability, restlessness and emotional tension.

Assessment of discomfort An individual may be aware of the source of discomfort and may be able to communicate with the nurse about it

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if encouraged to report and discuss physical needs with the nurse. If hospitalised and unable to report needs, the patient is totally dependent on the nurse for assessment and intervention. To assess a person’s status with regard to comfort, rest and sleep, the nurse needs information about the person’s usual sleep and rest patterns, any sleep problems they may have (eg insomnia, hypersomnia, hypersomnolence), as well as the nature of their current health problem that may be causing discomfort. In addition to this, the nurse needs to know whether any restrictions were placed on the patient’s mobility and what treatment their doctor prescribed. Most of this information should be obtainable from the nursing history and the initial assessment of the patient. This information is supplemented by the nurse’s objective observations. Complete information about the patient’s discomfort should be gathered as accurately as possible and evaluated in relation to significant factors such as the patient’s age, general physical condition, diag­ nosis, and the commonly associated problems, emotional status, and attitude towards illness. Any new, severe or sudden pain and discomfort not quickly relieved by nursing measures should be recorded as such and reported promptly. Sensory deprivation such as room isolation, one or more eye patches, lack of room light, social isolation, restriction of movement and inactivity – frequently increases awareness of what might otherwise be considered to be minor discomforts such as mild headache or thirst. The following findings may indicate discomfort: • Restlessness, tossing and turning in bed, sighing, tenseness, or muscular rigidity, which can be related to many factors, such as pain or a full bladder • Space and place disturbance, which is recognisable by overzealous protection of ‘established territory’ (bed, bedside table, belongings) • The patient may be irritable or difficult. Disturbed sleep patterns as evidenced by easy arousal and awakening may also be indicative of discomfort.

Assessment of pain A full history and assessment of a patient is necessary for successful pain management because: • Body weight and other physical factors may influence the treatment of pain. • The presence of other diseases such as kidney or liver disease will influence the type and dosage of any drugs to be administered. Patients with debilitating diseases, whether old or young, have a heightened sensitivity to the effects of narcotics.

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Defining the cause of the pain will be valuable in that it enables the health professional to choose the treatment according to the different responses to pain. For example, chronic bone pain may respond dramatically to radiation treatment and, if drug therapy is necessary, the addition of a non-steroidal anti-inflammatory drug is usually indicated. In contrast, a patient with chronic pain due to nerve injury with the development of a traumatic neuroma will probably require some form of interventional treatment such as surgery.

Clinical manifestations of pain Subjective data is obtained by taking a pain history. Objective data can be obtained by observing the beha­ vioural responses of a patient, such as: • Facial expression (eg clenched teeth, biting the lower lip, tightly shut eyes) • Purposeful body movements (eg immobilising the painful body part, flexing the knees and hips when experiencing abdominal pain and ensuring limited mobility) • Purposeless body movements (eg flinging arms about, tossing and turning) • Rhythmic body movements (eg rubbing, tapping, massaging) • Changes in speech (eg rapid speech and elevated pitch may indicate anxiety; slow speech and monotonous tone may signal intense pain) • Associated symptoms (eg vomiting, dizziness, consti­ pation). For further management of pain, see Chapter 14.

Patients who cannot communicate A patient’s self-report is always the best indicator of the existence of pain. A patient who can’t tell you about the nature and severity of their pain presents a challenge. For a patient who can’t speak or point to a scale, you need to look for other indicators of pain, such as behavioural and physiological responses. When assessing patients who can’t communicate the presence of pain, first consider all of the factors that can result in discomfort. Check the patient’s diagnosis. For example, if you’re aware that a patient’s condition usually results in pain, anticipate the need to intervene appropriately. Conditions such as tumour/growth, pneumonia, arthritis and pressure ulcers can be very painful. Surgical procedures such as chest, abdominal or major orthopaedic procedures certainly result in pain and need intervention. The best way to manage these patients is to request that a physician select an around-the-clock schedule for pain medication. But also remember to check your patient’s position in the bed,

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any devices or intravenous lines, and whether they are possibly lying on something that could cause discomfort.

Management of specific problems Common sleep disorders Sleep disorders can be presented as: • Primary sleep disorders. These are disorders in which the person’s sleep problem is the main disorder, such as insomnia, parasomnia, sleep apnoea, sleep deprivation and narcolepsy. These conditions disturb sleep to the extent that rest is not realised. • Secondary sleep disorders. These are sleep disorders that are as a result of other clinical disorders that cause sleep disturbances and they actually form part of the presenting signs and symptoms, for example conditions of the thyroid, depression and alcoholism. Other sleep disorders include bruxism and snoring.

Facilitating comfort Facilitating comfort is generic for the management of sleep disorders. When the nature of a patient’s discomfort has been identified and evaluated, the nurse may intervene appropriately to relieve or minimise the discomfort and try to prevent complications. Whatever is done for the patient should be planned with the patient whenever possible. Knowledge of what is to be done and why it is to be done provides a feeling of some control over the situation and helps to restore a feeling of ease and comfort that may have been disrupted by the illness. A feeling of psychological comfort and safety will enhance other measures to promote comfort. A feeling of safety and security can be achieved in an individual by: • increasing knowledge about a situation before it occurs • physical care ministrations that can be used to develop a trusting relationship • supportive relationships with others to whom the patient may verbalise about the situation • the experience of approval and acceptance by significant others • the ability to communicate needs to a trusted person. Specific interventions to promote comfort could include the following: • Promote relaxation. Learning the skill of progressive relaxation can assist a person to reduce tension in their breathing, neck, shoulders, abdomen, leg, and other muscles. • Minimise or avoid factors that increase tension. This will also promote relaxation.

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• Identify and fulfil all unmet basic needs. This includes hunger, thirst, excretion, emotional and hygiene needs. A bed bath and mouth care for a bedridden person will contribute immensely to their comfort. • Comfort. Always ensure that the person who is in your care is comfortable, whether they are lying in bed or sitting in a chair. Ensure correct body alignment, regular massage of pressure parts and a clean, neat and wrinkle-free bed. • Rest. Promote sufficient rest and sleep.

Relief of pain

(Please note that pain management is dealt with in Chapter 14.) Specific therapy should, whenever possible, be directed at the cause of pain. Ancillary problems that aggravate pain (eg coughing, anorexia, diarrhoea, and constipation) need to be treated as well. Palliation, or pure symptom-control measures may be used: • if the primary cause of pain cannot be treated or removed • temporarily, until the primary cause can be found • to supplement other therapeutic measures. The usual clinical practice for controlling pain is to give analgesic medication along with other supplementary medication or therapeutic measures, eg rest and a proper position. As emotion and social situations affect the experience of pain, the concept of total pain management has become an important factor. This means that physical, emotional and psychological aspects of pain must be addressed simultaneously and should therefore ideally involve a multidisciplinary team. Postoperative pain is the most common form of acute pain and is often not adequately treated. Adequate postoperative analgesia produces a more mentally alert patient who can effectively cough, breathe and move around, and therefore lower the incidence of respiratory complications and deepvein thrombosis as well as pulmonary embolism. Severe chronic pain is a problem in its own right and can be more debilitating and intolerable than the disease process or injury that initiated it. Such pain imposes severe emotional, physical, economic and social stress on the patient and their family, and is one of the most costly health problems for society. People suffering from chronic pain should be assessed and a treatment programme planned by a multidisciplinary team.

General measures to relieve pain and promote comfort and sleep Care must be taken to prevent fatigue. Overtiredness decreases pain tolerance. Plan general nursing care measures to relieve pain in conjunction with a careful assessment to determine if analgesics are needed. Measures that must be kept in mind are the following: • Correct alignment and positioning in bed – for example, by correctly positioning the patient’s leg in a cast, pain may be relieved to such an extent that no analgesic is required. The muscles surrounding painful inflamed or injured tissues should be supported in a way that ensures the complete relaxation of these muscles. • Massage is most useful in the early stage of inflam­ matory swellings and in treating the pain of various forms of myalgia, fibrositis or child birth. Effective massage, however, can be a useful adjunct to other pain relief measures, and may lessen the need for drugs. The nurse must protect the patient from painproducing stimuli such as distension of hollow visceral organs (full bowel/bladder), or further damage to traumatised tissue. • Injured tissue should be handled carefully. • Painful procedures should be done at a time when pain-relieving medication is having its maximum effect. In fact, analgesic doses should be planned so that the dose can be given prior to a painful procedure or dressing. • Drainage tubes should be checked frequently to ensure that they are not caught, stretched, pulled, kinked or looped, and that they are positioned correctly to enhance drainage and reduce distension and pressure. • Immobilisation may reduce pain caused by inflammation or the interruption of blood supply. • Elevation may relieve pain in swollen body parts. • A position of semi-flexion may reduce the pain of joint disorders. • The pain of muscle spasm may be relieved by a change in position. • Frequent position changes along with a good body alignment may prevent painful muscle contractures. Any unmet needs that may be contributing to a patient’s pain should be identified. If a patient’s basic needs are met, pain or discomfort may be reduced or even eliminated.

Behavioural techniques The intensity of pain can be reduced by various behavioural techniques, as described below.

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Distraction techniques Distraction draws the person’s attention away from the pain, lessens perception of pain and makes a person less aware or even unaware of pain. Similarly, a patient recovering from surgery may feel no pain while watching rugby on television, and feel the pain again when the game is over. The effectiveness of distraction is based on the ‘gate control’ theory. The receptor cells in the spinal cord receiving the peripheral pain stimuli are inhibited by stimuli from other peripheral nerve fibres carrying different stimuli. Because pain messages travel more slowly than other stimuli, the other stimuli enjoy priority and arrive at the brain first. This phenomenon is described in terms of a pain gate, which can be opened or closed, depending on the number and type of stimuli arriving at the spinal cord. When numerous other stimuli are arriving, the ‘pain gate’ is said to close, fewer pain stimuli are transmitted to the brain, and the patient feels less pain. Unpleasant distractions (loud noises or odours, bright light, unwelcome visitors) may, however, increase pain perception because of the unpleasant feelings associated with them. The nurse needs to reduce such stimuli. Distraction techniques are discussed in the sections below. Slow, rhythmic breathing. Instruct the person to stare at an object and inhale slowly through the nose while counting from 1 to 4 and then exhale slowly through the mouth while counting from 1 to 4 again. Encourage the person to concentrate on the sensation of breathing and to picture a restful scene. Continue until a rhythmic pattern is established. Massage with slow, rhythmic breathing. Instruct the person to breathe rhythmically and at the same time massage the painful body part with stroking or circular movements. Rhythmic singing and tapping. Ask the person to select a well-liked song and concentrate attention on its words and rhythm. Encourage the person to mimic the words and tap a finger or foot. Loud, fast songs are best for intense pain. Active listening. Have the patient listen to music and concentrate on the rhythm by tapping a finger or foot. Guided imagery. Ask the patient to close their eyes and then imagine and describe something pleasurable. As they describe the image, ask about the sights, sounds and smells imagined, encouraging the patient to provide details.

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Cutaneous stimulation. This is a refinement of distraction in which tactile stimulation is used to distract the patient from their pain: • Heat (hot water bottle, hot pads and ultra-sound) and cold (ice packs) applications can be used for pain relief. Heat stimulates serotonin production; cold stimulates norepinephrine production. • Cold packs slow the conduction of pain impulses to the brain and motor impulses to muscles in the painful area and provide quicker and longer-lasting pain relief than hot packs. Cold packs help to relieve headaches, muscle strains, joint pain, and muscle spasm and back pain during childbirth. • Analgesic ointments containing menthol relieve pain, but the analgesic mechanism is unknown. These ointments produce immediate sensations of warmth that last for several hours, and even longer if the body part is wrapped in plastic. They can be used to relieve joint or muscle pain. Menthol ointment rubbed into the neck, scalp or forehead sometimes relieves tension headaches. • Counter-irritants, such as mustard plasters and liniments may be used to relieve the aching joint pain of rheumatoid arthritis and osteoarthritis. Counterirritants are thought to relieve pain by increasing circulation to the painful area. • Contralateral stimulation involves stimulating the same part in the opposite side of the body, eg stimulating the left knee if the pain is in the right knee. The contralateral area may be scratched for itching, massaged for cramps or treated with cold packs or analgesic ointments. This method is particularly useful when the painful area cannot be touched because it is hypersensitive, or inaccessible because of a cast or bandages. Relaxation. This is a specific form of distraction that is very effective for chronic pain and for people subjected to other forms of stress. Relaxation techniques reduce anxiety or stress, ease the pain of muscle tension, dissociate a person from pain, help the person to obtain maximum benefits from sleep and rest periods, enhance the effect of other pain therapies, and relieve hopelessness and depression associated with pain. Women in labour are an excellent example of a situation where relaxation and breathing have been used for many years to lessen pain. The person should be positioned comfortably with all body parts supported and joints slightly flexed with no strain or pull on muscles such as crossed arms or legs. Several relaxation methods have been described. An easy one is to first tense separate muscle groups (eg neck, shoulder, back, arms and legs) and then relax them.

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After all muscle groups have been done, the whole body is tensed and then relaxed. This can be repeated a few times, after which the person should be relaxed and can then concentrate on slow rhythmic breathing.

Drug therapy Analgesics alter the perception and interpretation of pain by depressing the central nervous system at the level of the thalamus and the cerebral cortex. Analgesics are more effective when given before the patient feels severe pain than given after the pain has become severe. For this reason, analgesics are given at regular intervals (see Chapter 14).

Opioids Opioids relieve pain by binding to opiate receptors and thereby activating endogenous pain suppression in the central nervous system. Changes in mood and attitude and feelings of well-being make the person feel more comfortable even though the pain may persist. Pure agonists, such as morphine, pethidine, papaveretum (Omnopon) and codeine; and agonist–antagonists, such as pentasocine (Sosegon), buprenorphine (Temgesic) and nulbuphine (Neubain), are examples of drugs used for pain management. In order to achieve an acceptable level of analgesia, relatively constant plasma opioid concentrations must be rapidly achieved and then maintained. The route of administration plays an important role.

Non-steroidal anti-inflammatory drugs and simple analgesics Non-narcotic analgesics include non-steroidal antiinflammatory drugs (NSAIDs) such as aspirin and acetaminophen. Non-narcotic analgesics relieve pain by acting on peripheral nerve endings at the injury site and interfering with the prostaglandin system. In many types of pain, particularly the pain of inflammation, it is the production of prostaglandins that causes pain by irritation of the nerve endings. In addition, several combinations of narcotic and non-narcotic analgesic drugs are available, such as Tylenol. NSAIDs are often combined with simple analgesics such as paracetamol after minor peripheral surgery and are very valuable in combination with opioids after major surgical procedures, as they can be used to enhance and prolong the analgesic effect of narcotics. NSAIDs are very effective for incisional pain and bone and post-thoracotomy pain, but should be used for as short a time as possible because of the risk of side effects.

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Local anaesthetics These can be administered topically, by infiltration, via nerve blocks, plexus blocks or spinal/epidural routes. Currently, postoperative opioids are combined with local anaesthetics in the form of regional or epidural block.

Radiation therapy Palliative radiation therapy (and/or chemotherapy) will usually be considered in cancer patients with bone metastases, spinal cord compression, bleeding or painful skin and mucosal lesions, masses that cause pressure or obstruction, cerebral metastases and pain in organs, eg pancreas, liver or stomach, which does not respond to the traditional treatment modalities. Radiation therapy can also be utilised for benign conditions, eg peptic ulcer, or arthritis in selected cases. Radiation therapy must, however, provide increased physical well-being and not increase the patient’s discomfort.

Other supportive therapies Supportive therapy, particularly in cases of chronic pain, may consist of one or more of the following therapies: • Counselling in groups or as an individual • Stress management courses • Assertiveness training • Hypnosis, which has been used to treat psychogenic pain, to achieve anaesthesia and to enhance effectiveness of medication given for pain aggravated by tension. The susceptible person accepts positive suggestions, which tend to alter perceptions. The success of hypnosis depends to a large degree on the person’s openness to suggestion, emotional readiness and faith in the effectiveness of the hypnosis • Physiotherapy, which prevents postoperative complications as well as muscle contrac­tions, and can be used to teach a patient to use an artificial limb • Occupational therapy, which can, for example, provide a patient with distraction activities • Dietary management, which helps patients adapt to their conditions and helps prevent complications such as constipation.

Conclusion Comfort, rest and sleep are very important for recovery after illness. Nursing activities should be directed at promoting a patient’s comfort in terms of always ensuring that the patient’s hygiene needs are attended to; a restful and conducive environment is created; pre-sleeping rituals/routines are taken care of; relaxing activities are enhanced; and, where necessary, prescribed sleep-

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enhancing medication is given in the correct doses at an appropriate time through the correct route. Being able to

make a patient comfortable is basic nursing care, outcomes of which should be routinely achieved by nurses.

Suggested activities for learners Activity 8.1 Sleep promotes rest, which is important for the body to recuperate. Analyse the possible sleep pattern and possible disturbances that could be experienced by a patient admitted into hospital. Activity 8.2 Pain, although distressing, is necessary. Discuss how pain impacts on comfort and sleep, and outline the nursing interventions to promote comfort in a patient who experiences pain.

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9

Homeostasis

learning objectives

On completion of this Chapter, the learner should be able to: • explain the importance of fluids, electrolytes and acid–base balance in maintaining body function • describe the physiologic mechanisms that regulate body fluids, electrolytes and acid–base balance • explain the classification of body fluids, electrolytes and acid–base imbalances according to the causative factors • list the risk factors for the imbalances of body fluids, electrolytes and acid–base • describe the significant subjective and objective data related to the imbalances of fluid, electrolytes and acid– base that should be obtained during assessment • explain the significance of various diagnostic tests and procedures used to assess fluid, electrolytes and acid– base imbalances • describe the patient preparation for common tests and procedures used for assessing fluid, electrolytes and acid–base imbalances • plan effective care of patients with imbalances of fluid, electrolytes and acid–base • describe the causes, pathophysiology, signs and symptoms and treatment of fluid volume deficit and fluid volume excess • describe the causes, signs and symptoms and treatment of imbalances of sodium, potassium, calcium and magnesium • describe the causes, pathophysiology, signs and symptoms, diagnosis and treatment of acidosis and alkalosis • describe the essential health education to be given to patients with imbalances of fluid, electrolytes and acid– base • classify shock according to the causative factors • explain the signs and symptoms of shock according to its pathophysiology • describe the management of shock. key concepts and terminology

acid

A chemical compound that can react with a base to form a salt.

acidosis

A condition where the blood and body tissue fluid are less alkaline (or more acidic) than normal. Blood pH is decreased to less than 7.35.

active transport

The process by which dissolved molecules move across a cell membrane from a lower to a higher concentration. In active transport, particles move against the concentration gradient and, therefore, require an input of energy from the cell.

alkalaemia

Abnormally high blood alkalinity.

alkalosis

Excessive alkalinity of the blood and body tissue fluid. Blood pH is increased to more than 7.35.

anasarca

Generalised body oedema (swelling of the body).

base

A chemical compound that can react with an acid to form a salt.

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body fluid

Water in the body and all substances dissolved in it.

colloids

Substances such as large protein molecules that do not readily dissolve into true solutions.

colloid osmotic pressure

Plasma proteins exert an osmotic draw called colloid osmotic pressure to pull water from the interstitial space into the vascular compartment.

crystalloids

Solutes such as salts that dissolve readily into true solutions.

dehydration

Water loss from the body.

diffusion

The movement of particles of water from an area of high concentration to an area of low concentration. This is described as moving down a concentration gradient.

diuretic

An agent or drug that eliminates excessive water in the body by increasing the flow of urine.

electrolyte

An electrolyte is a chemical compound that forms ions when dissolved in water. An electrolyte’s water solution will conduct an electric current and ionise. Acids, bases, and salts are electrolytes.

filtration

A process whereby fluid and solutes move together across a membrane from one compartment to another. The movement is from an area of higher pressure to one of lower pressure.

fluid deficit or hypovolaemia

Fluid imbalance caused by the active loss of excessive amounts of body fluid.

fluid excess or hypervolaemia

Fluid imbalance as a result of excessive fluid intake or because of fluid retention. The circulation is overloaded with fluid, leading to excess fluid in the tissues.

homeostasis

Stability, balance or equilibrium.

hyperkalaemia

Plasma potassium levels in excess of 5.5 mmol/ℓ.

hypokalaemia

A serum potassium level of less than 3.3 mmol/ℓ constitutes hypokalaemia.

hypertonic

A solution with a higher osmolality than body fluids. Eg a solution of 3% sodium chloride or a solution of 5% dextrose.

hypotonic

A solution that has a lower osmolality than body fluids. Eg one-half normal saline (0.45% sodium chloride).

isotonic

An isotonic solution has the same osmolality as body fluids. Eg normal saline, 0.9% sodium chloride.

osmolality

The concentration of solutes in body fluids, determined by the total solute concentration within a fluid compartment and measured as parts of solute per kilogram of water.

osmolarity

The number of solute particles per litre of solution.

osmosis

Movement of water from a dilute solution to a more concentrated solution through a partially permeable membrane.

osmotic pressure

The power of a solution to draw water across a semipermeable membrane.

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pH

A measure of the acidity or alkalinity of a solution (the concentration of hydrogen ions (H+) in a solution).

solutes

Substances dissolved in a liquid.

solvent

Component of a solution that can dissolve a solute.

shock

A state of circulatory dysfunction leading to inadequate oxygen delivery or utilisation to meet the metabolic demands of cells.

tonicity of a solution

Effect of the concentration of the solution on the volume of a cell (eg erythrocytes).

prerequisite knowledge

• Anatomy and physiology of the vascular system, body fluid compartments and movement of fluids and electrolytes between compartments • Biochemistry and biophysics • Specific nursing skills such as monitoring of intake and output, preparation for the insertion of intravenous infusion, care of patients on intravenous infusion, blood pressure monitoring, taking of pulse and basic life support. medico-legal considerations

Fluids, electrolytes and acid–base balance is a life-sustaining activity. Imbalances in fluids and electrolytes can impact negatively on the cellular functioning in the body. When replacing these it is imperative that they are in the correct concentrations and ratios. Intravenous fluid replacement therapy that infiltrates the tissues can result in tissue necrosis and amputation of the affected limb. In such instances, affected patients can suffer much pain and emotional upheaval, in some instances leading to litigation. Patients with fluid volume imbalances are vulnerable to infection and poor skin perfusion. Care must be taken to prevent infection and cross-infection. Nurses must also take the necessary measures to prevent the development of pressure sores in patients with poor skin perfusion. Tissue necrosis and ulceration are possible complications that may arise when the rate of a drip is allowed to run into tissues causing intense local irritation, especially if the intravenous solution contains potassium. Nurses should at all times monitor the rate of flow and observe the limb that is cannulated for signs of infection and swelling, which may indicate that the drip is running into the surrounding tissue. ethical considerations

Nurses are obliged to ensure that patients have given informed consent for tests and procedures done for assessment of fluid, electrolytes and acid–base imbalances. Legally, patients have a right to accurate information about their care, tests and treatment. The information must be given in the patient’s preferred language and at the level of understanding of the patient. The patient must be given an opportunity to ask questions, and the questions must be answered to the patient’s satisfaction. essential health literacy

During the hot months, dehydration resulting from exercise or any physical exertion is common. It is essential for the community to realise the importance of drinking enough water to replace fluid lost as a result of the weather. Both electrolyte solutions and adequate amounts of plain water should be drunk to replace the water lost through sweating. • The patient should be taught about body fluids and electrolytes as well as the problems resulting from fluid and electrolytes imbalances. • Information on the management of common problems such as diarrhoea, vomiting, fever should be given to patients and the community. The patients should also be taught the importance of oral rehydration and how

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to make oral rehydration solution at home in order to maintain hydration or rehydrate. This is best used as preventive measure rather than therapy. Fluids such as water used for cooking rice, potatoes and barley are recommended. • Wherever possible, the patient should be educated about the recording of their intake and output. The patient should be encouraged to remember what they have eaten or drunk. The patient should also be aware that all output is measured, which means that they need to request a bedpan/urinal from the staff. If the recording of intake and output is being done at home, the patient will need to be educated about the use of charts, the volumes of common household utensils and methods of measuring urine output. The family or carer should also be included in this education. • Dehydration due to gastric ailments/disorders is a common cause for the admission of infants to hospital, and can lead to the death of the infant. A very important aspect of patient education in terms of care of infants and small children is the use of oral rehydration therapy (ORT). • A glass of ORT or a feeding bottle to suck, depending on the age of the patient, is given after every loose stool. If the diarrhoea does not settle in 24 hours, the patient should be seen at the nearest casualty, clinic or doctor’s office, as they may require IV fluids. • Proper mixing of infant formula is also important. Infant formula is designed to give balanced proportions of nutrients, vitamins and minerals when the formula is mixed correctly. If too much formula is used, on the theory of ‘more is better’, too much salt will be ingested. If too little formula is used (if the family intends to save money, for example), too much plain water is ingested and the infant may become undernourished. The importance and benefits of breastfeeding cannot be over-emphasised in relation to infant feeding. Breast milk is always sterile, it contains the right amounts of nutrients, it costs the mother nothing apart from the cost to feed herself, and it is the best possible option for infants. • Water-borne disease such as Salmonella and cholera are endemic in South Africa and every year many avoidable deaths occur due to gastrointestinal disease. The importance of a clean water supply cannot be over-emphasised. Ensuring a clean water supply to every community is a government priority even though this is likely to take many years before every community is reached. Communities need to know how to make water safe for human consumption. Education should concentrate on prevention of water pollution and also on how to economically sterilise water used for drinking. Water can be sterilised by boiling or by the use of sodium hypochlorite (a chlorine compound often used as a disinfectant or bleaching agent), where 5 ml of hypochlorite is added to 20–25 ℓ of water and allowed to stand for 30 minutes. • Patients should be encouraged to read the labels of foods to detect and avoid food high in sodium content. • The importance of elevation of swollen limbs should be emphasised because oedema is an indication of fluid volume excess, especially in dependent parts of the body, ie around the ankles and sacrum region.

Introduction The word homeostasis means balance, stability or to remain the same. In a healthy body, a balance of fluids, electrolytes, and acid–base is necessary for the survival and optimum functioning of body cells. This balance depends on a variety of multiple physiologic processes that regulate fluid intake and output and the movement of water and the substances dissolved in it between the body fluids compartments. Homeostasis in the body or maintenance of a stable internal environment is controlled mainly by the nervous and endocrine systems through feedback mechanisms involving various organs and body systems. These mechanisms are designed to re-establish homeostasis by constant monitoring and adjusting physiological processes as conditions in the external environment change. In addition to the internal

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control mechanisms, there are external influences based primarily on lifestyle choices and environmental exposures that influence our body’s ability to maintain cellular health. The process of adjusting changes in the internal body environment is called homeostatic regulation. Examples of homeostatic processes in the body include the regulation of water and electrolytes, temperature, blood pressure and respiration, blood glucose and blood pH. Almost every disease has the potential to threaten homeostasis, and an inability to maintain it may result in disease and potentially death. The focus of this Chapter is on fluid, electrolytes and acid–base imbalances, including the management of patients with imbalances of fluid, electrolytes and acid–base.

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Overview of the body fluids, electrolytes and acid–base balance Water makes up to approximately 70% of the total body mass. The total water content of the body is determined by age, gender and the amount of body fat. The body of an infant contains about 75% water, while in a person older than 60 years water represents about 45% of the body weight. Women have a lower percentage of body water than men. Women and the elderly have reduced body water content because of decreased muscle mass and a greater percentage of fat tissue. Water is vital to health and normal cellular function, because it serves as the medium for various enzymatic and chemical reactions in the body; a lubricant; shock absorber; an insulator; and it plays an important role in the regulation and maintenance of body temperature. Body water is contained within various tissues and organs of the body and these are organised into larger collections of water called compartments. The major body fluid compartments are based on which side of the cellular membrane the fluid lies, namely the extracellular and the intracellular compartments as shown in Figure 9.1. Two thirds of the total body fluid is located within the cellular membrane (intracellular fluid, ICF) and the

remaining third outside the cells (extracellular fluid, ECF). The ECF is divided into the intravascular (within the vascular system) and extravascular fluid compartments. These two compartments are separated by the blood vessel walls. The fluid in the intravascular compartment is plasma; it is the fluid present in all blood vessels, and it makes up 20% of the ECF. The extravascular compartment is made up of the interstitial and transcellular compartments. The interstitial fluid is found between the cells and tissues and it is about 75% of the volume of the ECF. Transcellular fluid is found in small but significant amounts in different body regions, and in total it makes up to 1 ℓ. Examples of transcellular fluid include cerebrospinal, pericardial, pancreatic, pleural, intraocular, biliary, peritoneal, and synovial fluids. A selectively permeable cell membrane separates body fluids into compartments. Body fluids are in constant flow between the compartments, but the volume of each fluid compartment at any given time remains relatively constant.

Fluid balance The body is in fluid balance when the required amount of water is present in the correct proportions among the body fluid compartments. Fluid balance can only be maintained if fluid intake equals fluid output. During

Total body water (TBW) 60% of body weight 42 ∙ in a 70 kg man

Intracellular fluid (ICF) 2 /3 of TBW 28 ∙ in a 70 kg man

Extracellular fluid (ECF) 1 /3 of TBW 14 ∙ in a 70 kg man

Intravascular fluid (IVF) 20% of ECF 3 ∙ of plasma

Extravascular fluid 80% of ECF 11 ∙

Interstitial fluid 80% of ECF 10,5 ∙

Lymph and transcellular fluids 0.5–1 ∙

Figure 9.1  Distribution of body fluids in compartments (70 kg man)

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150  Juta’s Complete Textbook of Medical Surgical Nursing Table 9.1  Fluid gain and fluid loss for the average adult in 24 hours

Fluid in = 2 500–2 800 ml

Fluid out = 1 900–2 200 ml

Oral intake: 1 200–1 500 ml Water in food: approx. 1 000 ml Metabolism water: approx. 300 ml

Urine: approx. 1 400–1 500 ml Faeces: approx. 100–200 ml Perspiration: approx. 100 ml, depending on the weather Exhaled air: approx. 300 ml–400 ml

Insensible loss Fluid lost via the skin and lungs is known as insensible loss. It is called insensible because it is usually noticeable but not measurable. The amount of insensible fluid loss through the skin (perspiration) depends on the temperature in the environment and the metabolic activity. In the case of a patient who is at rest and whose physical activity is minimal, the insensible loss can be assumed to be between 400 and 600 ml. Obligatory loss Obligatory losses are required to maintain normal body function. For example, the minimum amount of urine which must be passed in order to excrete metabolic wastes is approximately 500 ml per day. Water losses through respirations, through the skin, and in faeces are obligatory losses necessary for temperature regulation and elimination of waste products. The total of all obligatory losses is approximately 1 300 ml per day. a 24-hour period, an individual needs approximately 2 500 ml of water through eating and drinking, as well as the water produced as a by-product of metabolic processes in the body. Fluid is lost via urine, faeces, perspiration and exhaled air as shown in Table 9.1. Perspiration varies depending on environmental temperature and metabolic activity. For example, fever and exercise increase metabolic activity and heat production, thereby increasing fluid losses through the skin.

Regulation of fluid intake and output Fluid intake is regulated by thirst. When fluid losses exceed fluid intake, the resulting dehydration stimulates thirst. Dehydration causes a decrease in the ECF, resulting in: • A decrease in saliva production and the normally moist mucous membrane of the mouth becomes dry, resulting in the stimulation of the thirst centre in the hypothalamus • An increase in the ECF osmotic pressure, which leads to the stimulation of osmoreceptors in the hypothalamic thirst centre to send a signal for the release of antidiuretic hormone (ADH) from the posterior pituitary gland. ADH is the principal compound that controls water balance by decreasing water output by the kidneys – the result is decreased or concentrated urine • A decrease in blood volume and blood pressure, which activates the renin–angiotensin–aldosterone mechanism to restore volume by retaining sodium.

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Fluid output is regulated primarily by the kidneys. The kidneys will adjust the volume of fluid lost through various means in response to the amount of fluid present in the body. As a general rule, if the TBW output exceeds intake, the kidneys retain fluid and the urine output decreases to compensate. If intake exceeds bodily requirements, the kidneys retain less fluid and urine output increases.

Electrolyte balance Electrolytes are chemical compounds that form electrically charged ions when dissolved in water. Electrolytes that carry a positive charge are known as cations, while negatively charged electrolytes are known as anions. Examples of cations are sodium (Na+), potassium (K+), calcium (Ca++) and magnesium (Mg2+), and examples of anions are chloride (Cl–), bicarbonate (HCO3–) and phosphate (PO42–). Electrolytes are minerals and salts that are found in all body fluids. They play an important role in maintaining the constancy of the internal environment of the body. Electrolyte concentrations in the body are expressed in millimoles per litre (mmol/ℓ), which indicates the concentration of particles present. However, nurses have to be aware that different systems of measurement may be found when interpreting laboratory results. Laboratory tests for electrolytes are usually performed using blood plasma, an extracellular fluid. The results reflect what is happening in the ECF. It is generally not possible to directly measure electrolyte concentrations within the cell.

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The composition of fluids varies from one body compartment to another. In the ECF, the principal electrolytes are sodium, chloride, and bicarbonate. Other electrolytes such as potassium, calcium and magnesium are also present but in much smaller quantities. Plasma and interstitial fluid contain essentially the same electrolytes and solutes, with the exception of proteins. Plasma is a protein-rich fluid, containing large amounts of albumin, but the interstitial fluid contains little or no protein. Potassium and magnesium are the primary cations present in the ICF, with phosphate and sulphate as the major anions. Like with the ECF, there are other electrolytes which are present within the cell, but in smaller concentrations. Electrolyte concentrations in body fluids are shown in Table 9.2. Please note that figures given represent an average figure, and not the normal range.

Regulation of electrolyte balance The regulation of electrolyte balance is mainly carried out by the kidneys, which excrete excess electrolytes and conserve those needed by the body. The ability of the kidneys to perform this function depends on the volume of body fluid. Too little body fluid means that insufficient urine is formed by the kidneys to excrete waste products and excess electrolytes. A body fluid overload will result in increased urine formation, and needed electrolytes may be lost through being ‘washed out’ with the large volume of urine. Every electrolyte has a specific function, but generally electrolytes serve to maintain body fluid volume and they regulate acid–base balance. Electrolytes create electrical impulses across cell membranes, making it possible for

muscles to contract, for excretion of hormones and the transmission of nerve impulses. Table 9.3 presents major electrolytes and their functions.

Sodium Sodium is the most predominant electrolyte in ECF. The level of serum sodium is regulated by the kidneys in response to the levels of ADH and aldosterone, which will signal to the renal tubules to reabsorb water and sodium respectively. The normal concentration of sodium in blood is 135–145 mmol/ℓ. Serum sodium of less than 135 mmol/ℓ is called hyponatraemia and sodium level of above 145 mmol/ℓ is referred to as hypernatremia. The functions of sodium are presented in Table 9.3. The average dietary intake is 6–12 g per day. Foods high in sodium include canned meat, fish, soups, olives, preserved meats, salted peanuts, popcorn and gravy mixes. Sodium is lost through the kidneys, sweat and faeces.

Potassium Potassium is predominantly an intracellular ion and most of the total body potassium is inside the cells; the next-largest proportion is in the bones. The normal concentration of potassium in blood is 3.5–5.1  mmol/ℓ. Serum potassium of less than 3.5  mmol/ℓ is called hypokalaemia, and a potassium level of above 5.1  mmol/ℓ is referred to as hyperkalaemia. The functions of potassium are presented in Table 9.3. For the sources of dietary intake of potassium, refer to Table 6.2. The body can excrete a large K+ load but it is unable to conserve K+. Even when oral K+ intake is inadequate, or in a person with K+ depletion, there will still be a loss of K+ in the urine and faeces.

Table 9.2  Electrolyte concentrations in body fluids

Electrolyte

Interstitial

Intracellular

145 mmol/ℓ

142 mmol/ℓ

14 mmol/ℓ

Potassium

4.5 mmol/ℓ

4.0 mmol/ℓ

140 mmol/ℓ

Calcium

2.5 mmol/ℓ

2.4 mmol/ℓ

0 mmol/ℓ

Magnesium

1.5 mmol/ℓ

1.4 mmol/ℓ

31 mmol/ℓ

105 mmol/ℓ

108 mmol/ℓ

5 mmol/ℓ

25 mmol/ℓ

28 mmol/ℓ

11 mmol/ℓ

2 mmol/ℓ

2 mmol/ℓ

70 mmol/ℓ

Sodium

Chloride Bicarbonate Phosphate Proteins Organic acids

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Plasma

4.0 mmol/ℓ 16 mmol/ℓ

(proteins + organic acids = 10 mmol/ℓ)

99 mmol/ℓ

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Electrolyte

Functions

Sodium (Na+)

• Regulates the movement of water within the body • Important for the maintenance of acid–base balance • Required for many of the chemical reactions that take place within the cell • Essential for nerve activity and conduction of electrical impulses within the body

Potassium (K+)

• Essential for chemical activity within the cell • Essential for normal excitability and stimulation of nerve and muscle tissue, particularly in the myocardium • Maintains acid–base balance

Chloride (Cl–)

• Essential for the maintenance of acid–base balance • Essential for the formation of hydrochloric acid

Calcium (Ca++)

• Essential for building bones and teeth • Regulates the excitability of nerve and muscle tissue • The presence of calcium is required for the normal coagulation of blood

Magnesium (Mg++)

• Essential catalyst for many chemical reactions involving enzymes • Essential for the normal functioning of the heart, nerves and muscle tissue • Dilates peripheral blood vessels

Phosphate (PO4–)

• Forms part of the substance of bone • Required for the transfer of energy within the cell • Required for the transfer of energy during cell division and the replication of DNA • Required for normal nerve and muscle function • Essential for the maintenance of acid–base balance

Bicarbonate (HCO3–)

• Essential for the maintenance of acid–base balance • Forms part of the bicarbonate buffer system

Chloride

Magnesium

The normal values of this extracellular anion are 96–106 mmol/ℓ and its loss is through vomiting or gastric suction. Chloride imbalances are not common, since most diets contain adequate amounts of chloride to meet the body’s requirements. The functions are presented in Table 9.3.

Magnesium is an extracellular electrolyte. The normal concentration of magnesium in blood is 1.5– 2.5 mmol/ℓ. Serum magnesium of less than 1.5 mmol/ℓ is called hypomagnesaemia and magnesium level above 2.5 mmol/ℓ is called hypermagnesaemia. The functions of magnesium are presented in Table 9.3. Good food sources are listed in Table 6.2.

Calcium This is a very important electrolyte, 99% or more of which is deposited in the bones. Absorption of calcium is controlled by vitamin D and parathyroid hormones. There is a constant loss of calcium by the kidneys even if there was none in the diet. The normal concentration of calcium in blood is 2.1–2.8 mmol/ℓ. Serum calcium of less than 2.1 mmol/ℓ is called hypocalcaemia, and a calcium level of above 2.8 mmol/ℓ is called hypercalcaemia. The functions of calcium are presented in Table 9.3. Sources of dietary intake are presented in Table 6.2.

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Phosphate The usual amount of phosphate in the diet is about 1 g per day, but not all is absorbed. Any excess is excreted by the kidneys and this excretion is increased by parathyroid hormone. Parathyroid hormone also causes phosphate to be released from bone. Plasma phosphate has no direct effect on parathyroid hormone secretion.

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9.1  Intake of electrolytes The intake of electrolytes in the form of the various minerals contained in food is mandatory. A balanced diet, which contains adequate amounts of all essential nutrients, will provide all of the body’s electrolyte requirements, as well as the vitamins needed to absorb the minerals. Electrolytes are lost from the body with fluid loss as it happens in severe vomiting or diarrhoea.

Acid–base balance The quality of the internal environment of the body depends not only on fluid and electrolyte concentrations, but also on the acidity or alkalinity of the body fluids. The body’s regulatory mechanisms must maintain a delicate balance between the concentrations of acids and those of alkalis or bases. The correct ratio of 1:20 between acids and bases is essential for the normal chemical and physiological processes of the body. Acids are substances that contain hydrogen which dissociates when in solution to liberate free hydrogen ions. Strong acids dissociate more than weak acids. Hydrochloric acid is an example of a strong acid which dissociates into free hydrogen ions (H+) and chloride (Cl–) when dissolved in water. Carbonic acid (H2CO3) is a weak acid because only a portion of it dissociates into hydrogen ions and bicarbonate ions (H+) and (HCO3–). Large amounts of acids are produced in the body from normal metabolism. Other sources are acids ingested in food, such as citric acid in citrus fruits and acetic acids in vinegar. Despite the constant manufacturing of acids in the body, the hydrogen ion concentration remains low and constant because of the body’s homeostatic processes. Bases are chemical compounds that react with acids to form salts. A strong base is able to bind with hydrogen ions more readily than a weak one. The ratio of acids to bases in the body is reflected by the pH, which is an indication of hydrogen ion concentration in the body fluids. A decreased pH indicates that this ratio has increased, ie there are more acids present in the body fluid. The increasing number of acids relative to the number of bases means that the body fluid has become acidic. An increased pH means that the ratio of acids to bases has decreased, ie there are fewer acids present relative to the number of bases, and the body fluids thus become more alkaline. The pH of the body fluids is slightly above neutral at 7.40, and ranges between 7.35 and 7.45, depending on conditions in the body. The 7.35–7.45 range is the norm for plasma, as well as for ECF and ICF. Other body fluids, however, have specific pH ranges depending on

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Table 9.4  pH of body fluids

Fluid

pH range

Saliva

5.5–7.5

Gastric juice

1.5–1.8

Duodenal juice

5.5–7.5

Bile

5.5–7.7

Pancreatic juice

7.5–8.2

Urine

4.5–8.0

Blood

7.35–7.45

the chemical functions which take place in that fluid, as shown in Table 9.4.

The regulation of acid–base balance Acid–base balance is the regulation of free hydrogen ions in body fluids to maintain homeostasis. The concentration of hydrogen ions (pH) is maintained within the normal limits by the relationship between carbonic acid to bicarbonate at a ratio of 1:20. The regulation of acid– base balance occurs through the lungs and kidneys, which excrete excess acids to maintain the pH within normal limits. The homeostatic processes involved in the regulation of acid–base balance are discussed below.

Chemical buffer systems The chemical buffers are the first line of defence against changes in pH. Buffers serve to resist changes in pH when a strong acid or a base is added to or removed from a solution. They do this by either binding to hydrogen whenever pH drops or releasing hydrogen whenever pH rises. The main buffer systems are carbonic acid and bicarbonate, proteins, haemoglobin, and phosphate. Carbonic acid and bicarbonate buffer. Chemical reactions in the body result in the production of carbon dioxide. When in solution, the carbon dioxide (CO2) reacts with water (H2O) to form carbonic acid: CO2 + H2O = H2CO3. Carbonic acid is a weak acid and it dissociates to form hydrogen ions and bicarbonate as follows: H2CO3 = H+ + (HCO3–) This indicates that when an acid is added to a solution that contains carbonic acid, the bicarbonate (HCO3–) immediately binds with the free hydrogen ions to form carbonic acid. This happens so that some of the added

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hydrogen ion is removed from the solution without affecting the pH. This is a very effective buffer in the ECF, because carbonic acid and bicarbonate are present in large amounts in the ECF. Further carbonic acid is regulated by the lungs and bicarbonate is regulated by the kidneys. Protein buffers. This system consists of plasma proteins and intracellular proteins. The proteins have groups that are acids and bases capable of giving up or taking up hydrogen ions. They are effective buffers in the ICF. Haemoglobin buffer system. This system buffers the hydrogen ions generated from carbonic acid. Most of the hydrogen ions become bound to haemoglobin (Hb) as Hb + H = HHb. This means the hydrogen ion can no longer contribute to the acidity of the body fluids. Phosphate buffers. The phosphate acid salt is capable of donating free hydrogen ions when the hydrogen

concentration falls, and a base phosphate salt which can pick up free hydrogen ions when the hydrogen concentration rises.

The respiratory system The respiratory system responds quickly to changes in pH. When the pH level decreases, the rate and depth of respiration increase, so that carbon dioxide is excreted from the lungs. In this way, there will be less carbon dioxide to produce carbonic acid and the pH will increase. When the pH level increases, respiration rate and depth will decrease, so that more carbonic acid is formed, because carbon dioxide will be retained and the pH will decrease.

The renal system The kidneys control the pH by controlling the excretion or retention of excess bicarbonate anions and hydrogen ions. They excrete acidic urine, because of the excess acid metabolic products.

Table 9.5  Classification of disorders related to imbalances of fluid, electrolytes and acid–base

Causative factors

Disorders

Fluid loss without adequate replacement could be loss due to: • Bleeding • Gastric suctioning • Vomiting • Diarrhoea • Diuresis

Fluid volume deficit Hypovolaemia Dehydration Shock

Inadequate intake of fluids in patients who are unable to ingest fluids independently or do not respond appropriately to thirst Disoriented or unconscious patients

Dehydration

Fluid shifts from intravascular compartment to the interstitial spaces causing a drop in the circulating fluid volume as it happens in burns

Hypervolaemia Oedema

Abnormal fluid retention as in cardiac failure, renal failure and liver cirrhosis Overloading of circulation with sodium containing fluids in someone with impaired regulation or excessive intake of salt

Fluid volume excess Hypervolaemia Oedema

Electrolytes loss without replacement Inadequate intake of electrolytes

Hyponatraemia Hypokalaemia Hypocalcaemia

Excessive intake of electrolytes Impaired excretion of electrolytes

Hypernatraemia Hyperkalaemia Hypercalcaemia

Loss of bicarbonate Excessive accumulation of acids

Acidosis (respiratory and metabolic)

Loss of acid–base balance

Alkalosis Acidosis (respiratory and metabolic)

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Classification of disorders caused by the imbalances of fluid, electrolytes and acid–base The classification of imbalances of fluid, electrolytes and acid–base is done according to the causative factors as shown in Table 9.5.

Risk factors that lead to fluid imbalances • Age: Very old and very young people are likely to experience major consequences with minor changes in fluid balance • Obesity • Kidney diseases: These interfere with the maintenance of fluid, electrolyte and acid–base balances • Health status: Very ill or critical patients and those with chronic diseases such as diabetes mellitus may lose fluid through sweating or inadequate intake, resulting in dehydration • Low fluid volumes: –– Loss of whole blood from trauma or surgery –– Loss of other body fluids –– Fluid shift: ascites, bowel obstruction, peritonitis • Congestive cardiac failure • Septicaemia • Anaphylaxis • Diet high in salt intake • Endocrine conditions such as adrenal insufficiency, diabetes insipidus • Trauma to the skin (burns), head injury and crush injuries.

It is also important to obtain the following information: • General biographical information such as age, which will assist in anticipating the effects of fluid loss or gain • Lifestyle habits such as excessive intake of salt in the diet, intake of water and elimination patterns • Occupation, whether indoors or outdoors • Past and present health history to detect the presence of kidney, respiratory and cardiovascular disease, and information about medication that the patient has used or may still be using such as diuretics.

Objective data Physical examination Physical examination comprises a head-to-toe examina­ tion, focusing particularly on the skin turgor for signs of dryness, inelasticity or oedema. On observation, the lips and mucous membranes of the mouth are dry and cracked, the skin is dry and inelastic. In children, eyes may appear sunken in the face and, in babies, the fontanel may be sunken. Changes in the tone and elasticity of the skin are particularly significant in the assessment of fluid balance. Skin turgor is a reliable indicator of the fluid status. Determine the extent of dehydration in children. Severe dehydration is characterised by lethargy, drowsiness, sunken eyes, inability to drink or not drinking well and a skin pinch that returns to normal slowly as in Figure 9.2.

Nursing assessment and common findings It is important to obtain focused subjective and objective data in order to identify problems. Always start the assessment with establishing the presenting complaint and its duration. The final diagnosis is usually the summary of the objective and subjective data.

Subjective data Patients with fluid and electrolyte deficiencies are likely to complain of excessive thirst and of feeling faint and weak. A patient with excess fluid may present with oedema at various parts of the body, depending on the cause and severity of fluid retention. The oedema may be localised or generalised. The common sites for oedema are the lower limbs, sacral region, around the eyes (periorbital) and abdominal cavity (ascites). Anasarca is the term used to describe generalised body oedema. Complaints of restlessness, sleepiness, dyspnoea, irrita­ bility and arrhythmias should be noted, because they are common manifestations of electrolytes and acid–base imbalances.

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Figure 9.2  Pinch test

9.2  The pinch test When a small fold of skin is pinched, the skin should rapidly resume its normal position when released. If the fold of the skin does not return to its normal position, but remains pinched, fluid volume deficit is present.

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Oedema is a state in which excess fluid is present in the tissues. The nurse should observe oedema for pitting and areas affected by it. •

Figure 9.3  Pitting oedema

•

9.3  Pitting oedema Normally the skin will resume its position after pressure has been applied with the fingertips. If the skin retains the imprint of the nurse’s fingertips for longer than 30 seconds, oedema is present and it is referred to as ‘pitting oedema’. Observations made to confirm fluid imbalances The following observations should be made: • Weight. The patient’s baseline weight should be measured in order to observe an increase or decrease in the fluid status of the patient. One litre of fluid weighs about 1 kg, therefore any fluid loss will result in weight loss. • Urine. Urine should be observed for quantity, colour, odour and concentration to detect dehydration. Diluted urine may indicate fluid overload, while concentrated urine with a high specific gravity (SG) may indicate dehydration. A high SG (1 010 or more) is found on urine dipstick in fluid volume deficit. A high SG also occurs in glycosuria, where sugar is being passed in the urine, increasing the particle load of the urine. Decreased urine output may indicate fluid volume deficit. An increased urine output is seen in fluid overload, provided that kidney function is adequate. Oedema is usually present where kidney function is deficient and fluid is retained in the tissues. • Temperature. An elevated temperature may occur in dehydration or in infection, leading to excess loss of

Clinical alert! Infants are another vulnerable group for fluid and electrolyte imbalances. A lethargic, ‘floppy’ baby who does not respond to stimuli may be suffering from fluid volume deficit (dehydration).

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•

•

fluids in sweating. A subnormal temperature, as well as cold extremities, may also indicate fluid depletion, particularly if the fluid loss is severe. Pulse. The pulse is an indirect indicator of cardiac function. Cardiac function may be affected by fluid, electrolyte and acid–base disturbances or imbalances. An increased pulse rate occurs in fluid volume deficit, as a compensatory mechanism due to the drop in cardiac output. A rapid, weak and thready pulse indicates impending circulatory collapse due to fluid volume deficit. A full bounding pulse with extra systoles is frequently found in potassium imbalance. Respiration. Deep sighing respiration, known as Kussmaul’s breathing, is characteristic of acidosis. Dyspnoea is seen in fluid volume excess, due to the fact that excess fluid from the circulation has entered the alveoli, causing respiratory distress. Blood pressure. This is an indicator of circulating blood volume. Changes in blood pressure are frequently seen in fluid imbalances. Hypotension is seen in fluid volume deficit, while hypertension may indicate fluid volume excess. Mental state. The nurse should observe changes in the mental state that frequently accompany imbalances of fluid, electrolyte and acid–base balance. Restlessness and confusion are very common early signs in many of the clinical problems related to fluid, electrolyte and acid–base balance.

Diagnostic studies The diagnostic studies performed to assess fluid, electro­ lyte and acid–base imbalances include: • Blood urea nitrogen (BUN), which is a measure of nitrogenous urea in the blood. The normal BUN is 2.1–7.1 mmol/ℓ. It increases when there is fluid volume deficit. • Haematocrit (Hct), which is the volume percentage of red blood cells in the blood. The normal range is 40–50% in males and 37–47% in females. When the patient is dehydrated, Hct increases and in overhydrated states and anaemia Hct decreases. • Osmolarity studies on urine to measure the concentration of solutes. Urea, creatinine and uric acid concentrations are measured as indicators of urine concentration. • The SG of urine indicates the amount of dissolved substances that are present in the urine. It is a measure of the concentration or dilution of urine. Normally the SG of urine varies between 1 008 and 1 030, depending on the individual’s fluid intake. • Electrocardiogram (ECG) will confirm certain electro­ lyte imbalances. For example, hyperkalaemia is

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marked by the presence of a peaked T-wave, wide QRS complexes and a prolonged P–R interval. In hypokalaemia the T-waves are flat and inverted.

Common nursing diagnoses for fluid, electrolytes and acid–base imbalances Nursing diagnoses include: • Fluid volume deficit/hypovolaemia related to fluid loss; inadequate intake of fluids; fluid shift between body fluid compartments and failure of regulatory mechanisms. This regulatory failure is evidenced by a drop in blood pressure, tachycardia, dry mucous membranes, inelastic skin, thirst, cold and clammy extremities or fever, oliguria and weight loss • Fluid volume excess/hypervolaemia related to overloading of the circulation due to liver, cardiac and/ or renal diseases; low protein intake or low serum protein evidenced by oedema; distended neck veins; dyspnoea; weight gain; hypertension and increased central venous pressure.

Specific disorders related to fluid, electrolytes and acid–base imbalances Serious illness and major injuries cause fluid, electrolytes and acid–base imbalances because illness and trauma disrupt the homeostatic processes of the body. The imbalances can either be a deficit or excess of body fluid, electrolytes and acid–base. Even though the imbalances are interrelated, they will be discussed separately.

Fluid imbalances Fluid imbalance occurs when the fluid intake is not equal to the fluid output. There are two types of fluid imbalances, namely, fluid volume deficit and fluid volume excess. The manifestations of fluid volume deficit are dehydration and hypovolaemia or volume depletion, and those of fluid volume excess are oedema and hypervolaemia. The causes of fluid imbalances are presented in Table 9.5.

Dehydration and fluid volume depletion Illness/disease causes fluid imbalances by creating an inability to ingest fluids, impairing absorption from the gastrointestinal tract and secretion by the kidneys. Fluid volume deficit, or hypovolaemia, is due to the active loss of excessive amounts of body fluid. Significant loss of body fluid leads to circulatory impairment, shock and ultimately death if it is not treated. It may be present in hospitalised patients who are: • confused and therefore unable to respond to thirst • unconscious, on tube-feeding and are not receiving enough fluids • unable to or have difficulty in swallowing (dysphagia)

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• having impaired thirst mechanism secondary to head injury. Common causes of fluid volume deficit include severe diarrhoea, vomiting and use of diuretics without proper monitoring. Dehydration from diarrhoea and/or vomiting as a result of gastroenteritis is a common cause of fluid volume deficit in infants. Infant gastroenteritis is a serious problem in South Africa, which results in many infant deaths. Excessive loss of body fluid through sweating may occur in sports, particularly if the participants do not replace lost fluids adequately. Long-distance running, popular in South Africa, yields an annual tally of individuals who collapse as a result of dehydration. Individuals carrying out manual labour in hot weather conditions (farm workers) are also at risk of dehydration. Fluid losses can be secondary to excessive sweating, fever, burns, blood loss following trauma or surgery, gastrointestinal suction and medical conditions such as diabetes insipidus, acute renal failure and Addison’s disease. Refer to Table 9.5 for the causes of dehydration and fluid volume depletion.

Pathophysiology of dehydration and volume depletion Fluid loss from the body is through urine, faeces, breathing and sweating. More fluid is lost when the metabolic rate is increased in conditions such as burns, massive trauma, stress and fever. A reduction in ECF volume causes a drop in arterial blood pressure, and an increase in ECF volume causes a rise in arterial blood pressure. Fluid shifts between the intravascular and interstitial spaces temporarily and automatically serves as a compensatory measure to maintain arterial blood pressure. A shift of fluid from the interstitial spaces to the intravascular compartment serves to expand the circulating volume if there is a reduction in plasma volume. In dehydration, water is lost from the body, resulting in a rise in osmolality. The high osmolality activates ADH secretion, which causes water retention. Water, electrolytes and blood are lost in volume depletion, resulting in a drop in blood pressure. A drop in blood pressure causes fluid to diffuse from the interstitial spaces into the vascular compartment, and albumin and haematocrit both decrease as a result. Volume depletion activates the renin–angiotensin–aldosterone system to retain sodium and water in the body, resulting in a rise in sodium concentration. Sodium-retaining hormones are predominantly regulated by the volume of fluid and blood pressure. Failure of the homeostatic processes of the body to re-establish fluid balance may lead to significant loss of

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body fluid, leading to circulatory impairment, shock and death if not treated.

9.4  Water loss from the body About 2 ℓ per hour can be lost through perspiration/ diaphoresis associated with fever. Ten per cent water loss can occur with every 1 degree increase on the Celsius scale.

Signs and symptoms of dehydration and volume depletion Typical signs and symptoms of dehydration and volume depletion include: • Complaint about thirst • Dry mucous membranes of the eyes and mouth • Decreased urinary output • Decrease in systolic pressure • Weak, rapid pulse • Poor skin turgor and a positive pinch test • Loss of body weight • Weakness. Children under the age of 18 months will have a sunken fontanel. Reduction in circulation to the brain may give rise to restlessness and confusion or convulsions. In the case of severe fluid volume deficit, the following clinical signs and symptoms of shock may be present: • Pronounced hypotension • Rapid, weak and thready pulse • Oliguria • Cold and clammy skin • Altered level of consciousness.

Nursing management The principles in the management of fluid volume deficit are: • Fluid replacement • Prevention of further fluid loss • Treatment of the underlying cause. Ideally the lost fluids should be replaced with the same type of fluid. Blood loss should be replaced with whole blood or plasma, gastrointestinal losses should be replaced with fluids containing electrolytes. Dextrose is usually given as well to maintain nutritional and energy requirements. Fluid losses may be replaced orally or intravenously. The only contraindication for oral replacement is inability to ingest or absorb fluid/electrolytes from the gastrointestinal tract. In severe gastroenteritis, replacement of fluids

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and electrolytes is essential. Intravenous replacement is the ideal if circumstances permit, but oral replacement therapy may be just as effective and can be used as an emergency measure in situations where intravenous replacement is not feasible. Oral rehydration solutions contain a combination of sugar and salt. Sugar and salt facilitate the absorption of fluid in the gastrointestinal tract: as the sugar and salts are absorbed, water follows by osmotic attraction. Oral rehydration therapy (ORT) should be given freely, or as often as needed, depending on the amount of fluid that has been lost. In gastroenteritis, 1 cup (250 ml) should be given after each loose stool. Several good oral rehydration solutions are available commercially, but a simple and effective solution can be made at home, as follows: • One litre of water: tap water may be used if the water supply is safe, otherwise the water should be boiled • Add 8 teaspoons of sugar and ½ teaspoon of salt. Orange juice may be added as desired to improve the taste. Orange juice also acts as a source of potassium and vitamins. Fluid replacement in burns consists of a combination of electrolytes, fluid, plasma (human albumin) and oc­casionally whole blood. Fluid lost through excessive sweating can be replaced in the same way as gastro­ intestinal losses. Intravenous replacement with electrolyte solutions is considered the ideal, but oral rehydration therapy can be just as effective, particularly if the dehydration is mild. There should be strict and careful monitoring of intake and output. All fluids taken in or lost must be recorded. The nurse must ensure that prescribed intravenous replacement fluids are given at the correct rate. Patients who are suffering from fluid volume deficit are more vulnerable to infection, and care must be taken to avoid cross-infection. Poor skin perfusion constitutes an increased risk for the development of pressure sores, and measures must be taken to prevent this. Careful monitoring is necessary for all patients who are suffering from fluid volume deficit. Monitoring must include: • Vital signs: temperature, pulse, respiration and blood pressure • Level of consciousness • Skin turgor • Urinalysis • Daily weighing.

Fluid volume excess The causes of fluid volume excess are two-fold. The first cause is the administration of too much fluid and/

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or rapid administration of intravenous infusion where kidney functioning is not adequate. The second cause is related to the inability or failure of the body to excrete fluids adequately. It occurs in conditions such as heart failure, liver cirrhosis, renal failure, burns and ingestion of or administration of high sodium content substances. Some drugs, such as cortisone, may cause fluid retention. Patients whose cardiac and/or renal function is impaired are particularly at risk. Elderly patients may easily become overloaded, because cardiac and renal functions are diminished due to the ageing process. An infant’s cardiac and renal function is still immature, and an infant may easily become overloaded with fluid if the infusion is given rapidly or if too much fluid is given.

Signs and symptoms of fluid volume overload/fluid volume excess The patient with fluid volume overload presents with the following: hypertension and a full, bounding pulse, dyspnoea and respiratory distress, accompanied by an irritating cough. Rales and crepitations may be heard on auscultation due to the presence of excess fluid in the lung tissue. Oedema is frequently noted and the ankles, feet and sacrum are common sites. In ambulatory patients the feet swell, while for bedridden patients oedema is observed on the sacral area. If the fluid overload has built up over a longer period of time, ascites and pleural effusion may be noted. Other signs include an increased urinary output with decreased SG. As fluid continues to accumulate, the patient develops confusion, headache, seizures and coma.

Nursing management Fluid volume excess is managed by facilitating the excretion of the excess fluid and restricting fluid intake. Fluids may be restricted so that intake is less than output. Fluid should be restricted to prescribed amount and the fluid allocation should be spread over the entire 24-hour period. Make allowances for fluid used to take medication and for the fact that some fluid may be taken during the night. Remember, also, that ice chips are a popular remedy for a dry mouth and are formed from water. This should be taken into account when planning the patient’s fluid intake. Frequent sucking of ice chips, if not regulated, may cause the patient to exceed their fluid restriction by a considerable margin. Fluid intake and output should be monitored strictly. Make sure that intravenous infusions are run at the correct rate and check the rate frequently. Do not increase the rate if the infusion is behind schedule, as this can lead to further fluid overload in vulnerable patients. It is

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preferable to reschedule the infusions, taking the deficit into account. Careful control of infusion rates is crucial in infants and small children, since a relatively small increase in rate can lead to fluid overload. Dietary sodium is restricted to 2 g (less than a teaspoon) per day. Sodium promotes fluid retention. Reducing the sodium intake will reduce water retention. Discontinue the administration of sodium containing solutions. Diuretics may be administered if prescribed to actively promote the excretion of excess fluid. Plan the nursing regimen of patients on diuretics in such a way that the diuretic is given during the early part of the day. This will ensure that fluid is excreted during the day when renal function is most efficient. It will also spare the patient the trouble of getting up several times during the night to pass urine. The oedematous areas, where possible, should be elevated to improve venous return. Frequent position changes will relieve pressure on the oedematous areas. The nurse should carry out meticulous care to the skin in order to prevent injury to the swollen areas. An increase or decrease in the degree of fluid overload can be detected by: • Checking for pitting, particularly over the sacrum, shins and ankles. Follow the procedure outlined in Figure 9.3. • Daily weighing is also useful, since gains or losses in fluid can be detected as variations in weight – weighing should be done at the same time each day and with the same scale, and preferably with the patient wearing the same type of clothes. • Measurements of abdominal girth can also be done, especially if the abdomen is distended and the patient has ascites. However, it is important to note that measurements of abdominal girth should always be made at the same place on the abdomen, with the same tape and with the patient in the same position (Figure 9.4). If the patient is dyspnoeic, oxygen should be administered and the patient placed in High Fowler’s position (sitting up) if permitted, to ease breathing. Careful observation of respiration, colour of sputum and cough should be carried out. Electrolytes imbalances should be corrected. Excess fluid may be removed during dialysis in patients whose renal function is compromised.

Electrolyte imbalances Electrolyte imbalances are found in many disease states and the nurse must always be aware of the possibility

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of electrolyte imbalance. Circumstances that commonly cause electrolyte imbalance include: • Inadequate/reduced intake of electrolytes or excessive intake of electrolytes • Electrolytes loss without replacement • Impaired excretion of electrolytes • Diuretic therapy • Severe illness and/or trauma • Impaired renal function • Immobility • Drugs, eg over-the-counter antacids. The significant electrolyte imbalances tabulated in this Chapter are those of sodium, potassium and calcium. For functions of each major electrolyte in the body, refer to Table 9.3.

Figure 9.4  Taking the abdominal girth of a patient Table 9.6  Causes, signs and symptoms and management of major electrolyte imbalances

Hypernatraemia or sodium excess is a serum sodium concentration of more than 140 mmol/ℓ Causes

• Ingestion of excessive amounts of sodium; commercially prepared ‘sports’ drinks often contain high quantities of sodium, and these drinks should be used with great caution • Excessive loss of water from the body due to fever, diarrhoea and infection • Decreased excretion of sodium; renal failure, diabetes insipidus • Parenteral administration of hypertonic saline • Acute sodium excess may be the direct cause of death in seawater drowning as hypertonic seawater is swallowed and absorbed

Signs and symptoms

• A dry mouth and mucous membranes, loss of skin turgor • Intense thirst • Pyrexia, tachycardia • Oliguria with increased SG • Restlessness, confusion, convulsions • Coma may follow • Laboratory findings show: –– increased serum sodium –– increased serum osmolarity

Nursing management

• Aim: Serum sodium levels must be reduced • Increase intake of water to dilute the sodium • Restrict sodium intake • Diuretics may be prescribed to facilitate the excretion of sodium and water, taking care to replace the lost water with plain water or 5% dextrose water • Nurses must ensure that patients have an adequate intake of plain water, especially those who are being tube fed • Treat the underlying cause

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❱❱

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Hyponatraemia or sodium deficit is a serum sodium concentration of less than 135 mmol/ℓ Causes

• An excess intake of water or a loss of sodium from the body due to: –– a diet deficient in sodium –– diuretic therapy –– gastrointestinal tract suction –– burns –– fluid retention • Fresh water drowning causes acute water excess as large amounts of plain water are swallowed and absorbed from the stomach

Signs and symptoms

• Polyuria • Headache • Irritability, cramps • Postural hypotension • Confusion, convulsions and coma • Shock • Laboratory findings show: –– decreased serum sodium –– decreased serum osmolarity

Nursing management

• Aim: Serum sodium levels must be brought up to normal level of 140 mmol/ℓ, slowly • Restrict fluid intake • Cautious use of small infusions of hypertonic saline may be appropriate, as prescribed by the medical physician • Sodium levels must be checked regularly • Homemade oral rehydration solutions can be very effective in replacing fluids lost from diarrhoea, vomiting or sweating • Treat the underlying cause

Hyperkalaemia or potassium excess is potentially life-threatening and may be considered to be present if plasma potassium levels are in excess of 5.5 mmol/ℓ Causes

• Excessive intake of potassium-rich foods • Impaired renal function where potassium is retained, due to the fact that the diseased kidneys do not excrete potassium • Massive tissue damage may cause the release of large amounts of potassium from the cells This occurs following: –– severe burn injuries –– massive crush injuries, eg polytrauma –– severe infections involving significant tissue destruction • Less commonly, hyperkalaemia is caused by the administration of large amounts of potassium salts orally or intravenously

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Signs and symptoms

• Laboratory findings show increased serum potassium • Other signs and symptoms include: –– nausea, vomiting –– diarrhoea –– abdominal cramps and muscle twitching. The muscular symptoms may progress to weakness and paralysis –– oliguria or anuria –– arrhythmias –– abnormal ECG pattern; distinctive peaked, tent-shaped T-waves, widened QRS complexes and S–T segment depression • Eventually the heart will arrest in a systole

Nursing management

• Aim: Serum potassium levels must be reduced • Decrease the dietary intake of potassium-rich foods • Increase fluid intake • Administer potassium excreting diuretics as prescribed • Administer the following medication as per doctor’s prescription: –– Glucose and insulin intravenously as prescribed to promote the uptake of potassium. Redistribution of potassium involves shifting potassium from the ECF to the ICF. Insulin produces this effect, but must be given with 50% dextrose water in order to prevent profound hypoglycaemia –– Calcium gluconate intravenously to counteract the effects of potassium on the heart –– Ion exchange, cation exchange resins such as Kayexalate orally or an enema to remove potassium from the body • As a last resort, in the case of uncontrollable hyperkalaemia associated with compromised renal function, dialysis can be used to remove excess potassium • Assess and maintain fluid, electrolyte and acid–base balance • The nurse must be aware of the causes of hyperkalaemia, and those patients at risk must be monitored • As the clinical signs and symptoms of hyperkalaemia are somewhat non-specific, the best way of monitoring at-risk individuals is by regular estimation of serum potassium levels through blood tests • Place the patient on a cardiac monitor to identify the distinctive ECG changes • Daily electrocardiograms will also allow the ECG changes of hyperkalaemia to be identified NB: The nurse must also note the precautions to be taken when administering intravenous potassium

Hypokalaemia is a serious and potentially life-threatening clinical problem, and one that nurses must be able to detect: it is when serum potassium levels are of less than 3.3 mmol/ℓ Causes

• An inadequate dietary intake of food rich in potassium. This may be due to conditions such as chronic alcoholism and excessive dieting • Excessive losses of potassium from the body through: –– gastrointestinal fluid losses through the use of strong purgatives and laxatives, nasogastric drainage –– fluid losses from intestinal fistulae or stomas –– the use of diuretics –– the use of steroids and some antibiotics • Renal and metabolic diseases such as Cushing’s disease and acute renal failure also lead to potassium loss • Profound hypokalaemia is a common and dangerous feature of the diuretic phase of acute renal failure

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Signs and symptoms

• Fatigue • Muscle weakness and decreased reflexes • Abdominal distension, decreased gastrointestinal motility, paralytic ileus and anorexia • Shallow respiration • Weak and irregular pulse with extra systoles • Postural hypotension • Laboratory findings show decreased potassium levels in blood • The ECG findings are quite characteristic: multifocal ventricular extra systoles are present, as well as low, flat T-waves, with a U-wave following the T-wave • If hypokalaemia is left untreated, the extra systoles increase in number and an R-on-T phenomenon may occur, in which an ectopic beat falls on the T-wave of the preceding normal beat and may trigger ventricular tachycardia or ventricular fibrillation • Eventually the heart will arrest in fibrillation

Nursing management

• Aim: replace potassium and eliminate the underlying cause • Potassium replacement aims to restore serum potassium levels to normal • Potassium may be replaced orally or intravenously • For mild hypokalaemia oral replacement may be suitable • Severe hypokalaemia requires intravenous replacement • When replacing potassium orally, the nurse should bear in mind that potassium salts cause gastrointestinal irritation, nausea, vomiting, as well as gastric ulceration • Oral potassium preparations are often unpleasant to the taste, and should not be given immediately prior to a meal • It is a good idea to try and find ways to make the potassium preparation more palatable, for example by giving it with apple juice • At-risk patients (those with poor renal function) should be monitored for the development of hypokalaemia • The best way to do this is by regularly estimating serum potassium levels • A cardiac monitor or daily ECG recording will allow the nurse to detect extra systoles that may be due to hypokalaemia • Assess and maintain fluid, electrolyte and acid–base balance

Hypercalcaemia: Calcium excess Causes

• Excess intake of calcium-rich foods and medication; this is a potential problem associated with the injudicious use of over-the-counter preparations of calcium salts • Overactivity of the parathyroid gland • Also found in renal failure for two reasons: the diseased kidneys do not excrete calcium salts; or the kidneys are not manufacturing the active vitamin D, which is needed for the absorption of calcium • In the absence of active vitamin D, the parathyroid glands secrete parathormone, which releases calcium from the bones and raises the level of calcium in the plasma • Vitamin A or D intoxication • Malignancies of bone tissue, such as multiple myeloma or bony metastases cause mobilisation of calcium from the bones, leading to hypercalcaemia • Thiazide diuretics may also cause calcium excess • Osteoporosis and bone fractures

Signs and symptoms

• Generalised muscle weakness • Depressed or absent tendon reflexes • Tachycardia • Hypertension • Cardiac arrhythmias • Gastrointestinal tract upset; anorexia, vomiting • Lethargy and exhaustion • Confusion

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Nursing management

• Goal: to eliminate the cause and to restore serum calcium levels to normal • Ensure that the patient is adequately hydrated • Phosphorus supplements will promote the re-uptake of calcium by bone • Steroids and calcitonin will also promote the re-uptake of calcium by the bones • Calcitonin may, however, cause an allergic reaction and steroids need several days to take effect • Early ambulation of patients is important in order to minimise demineralisation of bone; in the case of patients who are unable to ambulate, range-of-motion exercises should be done on a regular basis • The indiscriminate use of vitamin D or calcium supplements is potentially harmful and should be discouraged

Hypocalcaemia: Calcium deficit Causes

• Inadequate dietary intake • Vitamin D deficiency • During pregnancy the body’s demand for calcium is increased and a deficit may occur if calcium intake is not increased to meet the demand • Calcium may be lost from the body in diarrhoea; diarrhoea impairs absorption of calcium • End-stage renal disease • Acid–base imbalance

Signs and Symptoms

• Tetany, which is characterised by: spontaneous carpo-pedal spasm, tonic muscle spasms, and rigidity of the limbs and of the abdominal wall (see Figure 9.5) • The pulse may be irregular with extra systoles • Trousseau’s and Chvostek’s signs are both positive • Serum calcium levels are below 2.10 mmol/ℓ • Chronic calcium deficit may lead to rickets, osteomalacia and osteoporosis

Nursing management

• Goal: to eliminate the cause and to restore serum calcium levels to normal limits • Increase dietary intake of calcium, vitamins A and D • Chronic calcium deficit can be managed by using oral calcium supplements • Acute hypocalcaemia causing tetany is corrected by the intravenous administration of calcium salts, calcium gluconate or calcium chloride may be used • Continuous cardiac monitoring

9.5  Trousseau’s sign and Chvostek’s sign Trousseau’s sign is positive if the characteristic carpopedal spasm in the hand occurs when the circulation to the hand is constricted by the use of a tourniquet or sphygmomanometer cuff. Chvostek’s sign: A tap below the temple, where the facial nerve crosses the mandible, produces a spasm of the facial muscles.

Acid–base imbalances

Figure 9.5  Carpo-pedal spasm

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The regulation of acid–base balance occurs through the lungs and kidneys, which excrete excess acids and maintain the pH within normal limits. The concept pH is used to express the concentration of hydrogen ions (H+) in a solution. A high pH indicates an alkaline solution, and a low pH indicates an acidic solution. For pH values see Table 9.7. Acid–base disturbances occur in many disease

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Pathophysiology of acid–base imbalances

Clinical alert! Intravenous administration of potassium A potassium level greater than 6 mmol/ℓ is a medical emergency and requires immediate attention: • Potassium should never be administered directly into the vein as a bolus or a ‘push’. The administration of a concentrated amount of potassium may cause acute hyperkalaemia, which is invariably fatal. Potassium should always be diluted. • As a guide, each 20 mmol of potassium should be diluted in 50–100 ml of saline or dextrose water. • The rate of the infusion should be monitored: usually no more than 20 mmol per hour infused, unless prescribed otherwise. • All patients on intravenous potassium should be placed on continuous cardiac monitoring. • Central lines are often preferable for the administration of intravenous potassium, because it is easier to control the infusion rate and there is far less likelihood that the infusion will extravasate causing intense local irritation, which may lead to necrosis and ulceration. If a potassium infusion does extravasate, the line should be discontinued. • Observe the intravenous infusion site for pain, irritation and swelling. Pain can be reduced by slowing the infusion rate and by using more fluid to dilute the potassium. states such as fluid and electrolytes imbalances, lung and kidney diseases. It is therefore important to recognise them, because normal cellular and organ functions are adversely affected by alteration in the pH of body fluids. A disturbance of acid–base balance may cause acidosis (excess acid), characterised by a pH that falls below 7.35, or alkalosis (excess base), characterised by a pH of above 7.45.

In the presence of any imbalance of acid–base, the normal bicarbonate/carbonic acid ratio of 1:20 is altered. The kidneys and lungs perform the compensatory functions to restore the ratio to normal. The kidneys compensate for changes in blood carbon dioxide by making a corresponding adjustment in serum levels of bicarbonate. The lungs correct the abnormal changes in serum bicarbonate by making corresponding changes to the partial pressure of carbon dioxide.

Diagnosis: Arterial blood gases analysis An arterial blood gases (ABG) analysis provides useful indicators of the acid–base status or recovery from/ deterioration in acid–base status. ABG presents the concentrations of hydrogen ions and percentages of oxygen and carbon dioxide in blood. It is also a test done to assess the ability of the lungs and kidneys to compensate for alterations in acid–base status to re-establish homeostasis. Base excess and base deficit refer to the amount of base present in the blood. At a normal ratio of 20 bases to 1 acid, the base excess is 0 and the pH is 7.40. A typical/ normal range for base excess is −2 to +2 mmol/ℓ. Positive numbers indicate an excess of base, and negative numbers indicate a base deficit. A base excess higher than +2 mmol/ℓ indicates metabolic alkalosis, and one lower than −2 mmol/ℓ) indicates metabolic acidosis.

Units of measurement The unit of measurement for blood gas estimations is the kilopascal (kPa) or mmHg. Differences between sea level and the Witwatersrand are due to differences in atmospheric pressure, which affects the amount of gas that is able to dissolve in the plasma. The higher the atmospheric pressure, the greater the amount of gas that dissolves in the plasma and vice

Table 9.7  Important values in a blood gas result

Value

Significance

Normal value

pH

Shows acidity/alkalinity of body fluids

7.35–7.45

PCO2

Shows the partial pressure of carbon dioxide in the blood

35–45 mmHg

PO2

Shows the partial pressure of oxygen in the blood

95–100 mmHg

HCO3–

Shows the level of bicarbonate in the blood

22–27 mmol/ℓ at sea level

Base excess/ base deficit

Shows the ratio of base to acids in the blood At a ratio of 20 bases to 1 acid, the base excess is 0 and the pH is 7.40

Base excess –2 to +2 mmol/ℓ

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versa. Because levels of carbon dioxide are higher at sea level, levels of bicarbonate are increased.

• Base excess below –3, due to renal compensatory mechanisms.

Types of acid–base imbalances

Renal retention of bicarbonate and excretion of hydrogen ions helps to maintain the ratio of base to acid close to the normal range.

Acidosis is an acid–base imbalance where too much acid is present. Alkalosis is the other type of acid–base imbalance, where too much base is present. Each can be either respiratory or metabolic. A discussion of each of these four types of acid–base imbalance follows. Acid–base imbalances

Acidosis Respiratory

Metabolic

Alkalosis Respiratory

Metabolic

Figure 9.6  Types of acid–base imbalances

Respiratory acidosis Respiratory acidosis is defined as an accumulation of carbonic acid as a result of failure of the lungs to excrete carbon dioxide. Carbon dioxide thus builds up in the bloodstream, forming carbonic acid, which causes the pH to drop. The problem is primarily a respiratory one, and may be due to a variety of pulmonary problems. This could be any condition that reduces gas exchange in the lungs that results in respiratory acidosis, eg pneumonia, atelectasis, pneumothorax or depression of the respiratory centre. The onset of acute respiratory acidosis is sudden and it is caused by accumulation of secretions, oedema, bronchospasm and the presence of a foreign body in the airways. Chronic respiratory acidosis is a slow process characterised by a gradual loss of pulmonary function caused by obstructive pulmonary disease, weakness of the respiratory muscles and atelectasis. Signs and symptoms The patient presents clinically with the signs and symp­ toms of respiratory insufficiency: dyspnoea, cyanosis, productive cough, tachypnoea and the use of accessory muscles of respiration. Definitive evidence of respiratory acidosis is obtained from blood gas estimation which shows: • A low pH of below 7.35 • Increased pCO2 • Decreased pO2 • Slightly decreased or normal HCO3–

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Nursing management • Treatment of respiratory acidosis is directed at identifying the underlying cause and improving the patient’s gas exchange • Excess secretions should be cleared and mechanical ventilation commenced if indicated • Maintain adequate hydration • Administer antibiotics as prescribed • Administer supplemental oxygen as indicated • Monitor ABG.

Metabolic acidosis In metabolic acidosis, there is excess production of acids in the body, or the body is unable to excrete acids via the kidneys. Excess acid production occurs in diabetic keto-acidosis, starvation and high-fat diets where the breakdown of fats produces large amounts of acid metabolites. In the case of tissue anoxia, lactic acid is produced. Other causes of excess acid production include pyrexia, hepatitis and general anaesthesia. Metabolic acidosis occurs in renal failure because acids are not excreted by the damaged kidneys. Loss of bicarbonate will also lead to metabolic acidosis. Loss of bicarbonate may occur in diarrhoea, pancreatic as well as duodenal fistulae. Metabolic acidosis may also be due to the administration of large amounts of acid substances, such as ammonium chloride or aspirin. The body compensates for metabolic acidosis by stimulating respiration, thereby enabling some of the acids to be excreted. Signs and symptoms In addition to the signs and symptoms of the causative problem, the patient presents with deep sighing respirations, vomiting and diarrhoea, weakness, malaise, headache, stupor, and dyspnoea on exertion. The urine is markedly acidic if renal function is normal. Mental confusion and alteration in the level of consciousness occur. Disturbances of cardiac rhythm may occur. Definitive evidence of metabolic acidosis is obtained from blood gas estimation which shows: • A low pH of below 7.35 • Decreased pCO2 due to deep rapid breathing that causes carbon dioxide to be blown off • Normal or increased pO2 due to respiratory stimulation

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• Markedly decreased HCO3– • Base excess markedly below –3. Nursing management Treatment is aimed at alleviating the underlying causes of the acidosis: • Restore blood sugar and fluid balance to normal in the case of diabetic keto-acidosis. • Maintain adequate hydration. • Give oxygen therapy and intravenous dextrose to correct lactic acidosis. • The metabolic acidosis of renal failure is usually managed by dialysis. • General measures include the correction of fluid and electrolyte imbalances. In particular, imbalances of sodium, potassium and chloride should be corrected. It is usually preferable to allow metabolic acidosis to correct itself once therapy for the primary cause has been instituted. • In severe cases, however, where the pH is less than 7.10, the cautious use of sodium bicarbonate may be justified. • Nurses must be aware of conditions that lead to metabolic acidosis, and monitor at-risk patients accor­ dingly. Regular blood gas estimations, as determined by unit protocol or as requested by the doctor will provide precise information. • Nurses should ensure that patients are adequately nourished and hydrated, as this will facilitate the maintenance of acid–base balance, as well as promoting the maintenance of fluid and electrolyte balance. • Cardiac rhythm should be monitored in the acidotic patient, because arrhythmias are common in acidosis. A cardiac monitor is useful. Alternatively, a daily ECG and regular monitoring of the pulse can be carried out.

Respiratory alkalosis Respiratory alkalosis occurs when excessive amounts of carbon dioxide have been blown off during hyper­ ventilation. This loss of carbon dioxide and water effectively means loss of acid, because carbon dioxide and water are formed from carbonic acid. Hyperventilation may be due to anxiety, hysteria, intentional over breathing, raised intracranial pressure or mechanical ventilation. The body compensates for the problem by excreting bicarbonate ions via the kidneys, making the urine more alkaline. Hyperventilation due to anxiety or hysteria is often selflimiting: the drop in CO2 causes the individual to faint, and normal breathing re-establishes itself during the brief period of unconsciousness.

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Signs and symptoms The patient presents with deep rapid respiration, dizziness due to cerebral hypoxia, pallor and muscle irritability and spasm. Tetany and carpo-pedal spasm may occur. An alkaline pH causes calcium to bind with plasma albumin, effectively reducing serum calcium and causing tetany. Definitive evidence of respiratory alkalosis is obtained from blood gas estimation which shows: • pH above 7.45 • pCO2 markedly decreased • pO2 normal, or may be increased due to over-breathing • HCO3– decreased due to renal excretion of bicarbonate • Base excess above +1, but not markedly so due to renal compensatory mechanisms. Excretion of bicar­ bonate helps to maintain the normal ratio of base to acid. Nursing management The goal of management is directed at eliminating the cause of the hyperventilation. Where hyperventilation is due to anxiety or hysteria, the individual can be asked to breathe into a paper bag. Breathing into a paper bag forces the individual to re-breathe their own carbon dioxide, which restores carbon dioxide levels. If the individual is too anxious to tolerate a paper bag, the nurse should try and get the patient to relax and breathe more slowly. Correction of fluid and electrolyte balance is necessary in longstanding hyperventilation, as a great deal of water vapour is lost during deep heavy breathing. Nurses must be aware of the possibility of hyperventilation in anxious patients, or in the relatives of very sick patients, and be ready to apply a paper bag. This type of reaction may also occur when patients or their relatives have been given bad news. Over-ventilation in patients who are being mechani­ cally ventilated can be detected by means of regular blood gas estimations. If attempts to calm the individual down are unsuccess­ ful, the nurse may administer prescribed sedatives to calm the patient.

Metabolic alkalosis In metabolic alkalosis, the problem is that of an excess of base. This may be due to loss of acid, or to the ingestion of large amounts of base. Loss of acid may occur when large amounts of gastric acid have been lost. Potassium depletion may also be associated with metabolic alkalosis. Excess ingestion of bicarbonate is often an iatrogenic problem (a problem caused as a result of a medical treatment) following the administration of large amounts of sodium bicarbonate. An overdose of bicarbonate may also follow

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indiscriminate self-medication with alkalising agents such as antacids. In metabolic alkalosis, the body compensates by retaining acids and excreting bicarbonate, making the urine more alkaline. Carbon dioxide is retained in the lungs and breathing becomes slow and shallow, with periods of apnoea. Signs and symptoms The patient presents with lethargy, irritability and sometimes convulsions. The breathing is slow and shallow with decreased chest movements and cyanosis. Definitive evidence of metabolic alkalosis is obtained from blood gas estimation which shows: • pH above 7.45 • pCO2 increased due to slow, shallow breathing that promotes the retention of carbon dioxide • pO2 decreased due to hypoventilation • HCO3– markedly increased • Base excess markedly above +1, as the ratio of base to acid has increased considerably. Nursing management This includes the following: • Correcting the underlying cause. • The administration of solutions containing chloride ions such as NaCl. Increasing the levels of chloride promotes the excretion of bicarbonate by the kidney. Fluids containing chloride should be used to replace fluid lost during gastric suction. • Administration of diuretic therapy to aid in excretion of HCO3– through the kidneys. • Potassium replacement may also be necessary as potassium becomes depleted in alkalosis. Any other fluid and/or electrolyte imbalance must be corrected. • Monitor ABG. • It is worth noting that metabolic alkalosis is difficult to treat and several days are needed to correct the problem. For this reason, the condition should be prevented if at all possible.

Shock Shock is a state of circulatory dysfunction leading to inadequate oxygen delivery or utilisation to meet the metabolic demands of cells. The major causes of shock are insufficient intravascular/circulating volume, changes in the tone of blood vessels and ineffective pumping action of the heart as illustrated in Figure 9.7. Shock is a disruption of homeostasis. Its onset may be insidious but its progression is very rapid.

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Causes of shock Hypovolaemia

Hypovolaemia refers to low circulating blood volume as a result of a large loss of body fluids or a displacement of a significant amount of vascular volume into body compartments that do not usually contain large amounts of fluid as in oedema, ascites and pneumothorax. Dehydration and excessive loss of blood or plasma reduce the circulating volume.

Pump failure This occurs when the ability of the heart is impaired, resulting in marked reduction in cardiac output and tissue perfusion.

Massive vasodilatation This results in disproportion between the size of the vascular space and circulating volume. Blood pools in dilated blood vessels causing a decrease in venous return and a drop in cardiac output. Pump failure Hypovolaemia

Massive vasodilation Shock

Figure 9.7  Causes of shock

Classification of shock Shock is classified according to causative factors also indicated in Table 9.8.

Hypovolaemic shock This results from the loss of blood volume or plasma caused by conditions such as: • massive haemorrhage as it occurs in trauma, and gastrointestinal tract (GIT) bleeding • loss of plasma, eg burns • severe dehydration, eg vomiting, diarrhoea, diuresis, diabetes insipidus, ascites, peritonitis, haemothorax and wound drains.

Cardiogenic shock This is characterised by primary myocardial dysfunction, resulting in the inability of the heart to maintain adequate cardiac output, caused by conditions such as: • trauma to the heart, including cardiac surgery

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• myocardial infarction • heart failure • structural problems such as ventricular aneurysm, cardiomyopathy, cardiac tamponade and tension pneumothorax.

Clinical alert! It is very important to note that shock results when 25% of body fluids is lost in adults and 10% in children.

Distributive shock In this type of shock, blood vessels become so dilated that slow-moving blood pools in capillary beds. The types of shock that result are neurogenic shock, anaphylactic shock and septic shock. Neurogenic shock. This is as a result of loss of tone of blood vessels as happens in spinal cord injury and head injury. Anaphylactic shock. This is as a result of massive release of histamine in response to allergic hypersensitivity leading to increased capillary permeability and vasodilatation. This is commonly seen in allergic reaction to contrast media, antimicrobial agents such as penicillin, vaccines, certain foods and food additives and incompatible blood transfusion. Septic shock. This is as a result of systemic infections, bacterial toxins, wound infections, invasive procedures, respiratory tract infections and urinary tract infections. Immune-compromised patients are particularly at risk for septic shock.

Overview of physiology of blood pressure Blood pressure is the force that is exerted by blood against the walls of the blood vessels in which it is contained. It is influenced by the intravascular volume, vasculature tone and the pumping action of the heart. Blood pressure (BP) = cardiac output (CO) × systemic vascular resistance (SVR) BP = CO x SVR

(Stroke volume)

SV HR (heart rate)

Table 9.8  Classification of shock

Cause of shock

Associated type(s) of shock

Hypovolaemia (circulating Hypovolaemic shock volume loss) Pump failure

Cardiogenic shock

Massive vasodilatation

Distributive shock: • Neurogenic shock • Anaphylactic shock • Septic shock

This balance has to be maintained for effective tissue perfusion. If one side changes, the other side needs to change in the opposite direction to balance out; for example, if BP is increased, CO or SVR or both must increase in order to maintain homeostasis. Cardiac output is the amount of blood pumped out of the left ventricle to the body tissues each minute, and it is approximately 5 ℓ per minute. Changes in the blood flow and volume are sensed by the arterial baroreceptors, chemoreceptors and the osmoreceptors, which will automatically make the necessary adjustments according to the needs of the body. The nervous and the endocrine systems are responsible for the tone of blood vessels.

Pathophysiology of shock according to stages Compensated stage (early stage)

Decreased cardiac output is considered the stimulus to initiate the body’s response to compensate for hypovolaemia to maintain blood pressure regardless of the cause. During this stage, the body’s compensatory mechanism can maintain blood pressure within relatively normal limits to maintain tissue perfusion to vital organs (see Figure 9.9). Signs and symptoms These are indicative of cerebral hypoxia, and they include increased respiration, restlessness, anxiety, tachycardia and a complaint of thirst.

Decompensated stage If the compensatory vasoconstriction persists, or shock was not detected, or the precipitating cause of shock was not corrected, a massive sympathetic nervous system response takes place. Extensive vasoconstriction of most vascular beds occurs with some peripheral blood vessels becoming totally occluded, resulting in reduced blood supply to body tissues. This results in anaerobic metabolism, lactic acidosis and metabolic acidosis.

Figure 9.8  Blood pressure

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Cardiac output Mean arterial pressure

Vasomotor centre in the medulla and the sympathic nervous system to release adrenalin and noradrenalin Selective vasoconstriction

Dilatation of coronary arteries

Increased venous return Increased myocardial contractility

Normal blood pressure Adequate tissue perfusion Figure 9.9  Compensated stage of shock

Renal ischaemia leads to further activation of the renin– angiotensin–aldosterone mechanism, causing even more pronounced vasoconstriction. Metabolic acidosis leads to extensive tissue hypoxia. Signs and symptoms These include decreasing level of consciousness, hypotension. Respiration rate increases, urinary output is greatly reduced, indicating inadequate renal perfusion. The patient has tachycardia, cool clammy extremities, but dry skin and mucous membranes, and poor skin turgor.

Irreversible stage/progressive stage The irreversible stage of shock is reached when the compensatory mechanisms are totally ineffective, and the cycle of inadequate tissue perfusion has not been interrupted. Cellular ischaemia and necrosis lead to organ failure and/or death. Signs and symptoms These are unconsciousness, and blood pressure continues to fall. The heart rate becomes progressively slower, cardiac arrhythmias may develop as a result of ischaemic myocardium. Urinary output continues to decrease. The skin becomes cold and cyanosed.

Nursing management of shock A quick evaluation of the airway, breathing and circulation should be done and any life-threatening situation managed before history is taken.

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The history of the causes of shock may be obtained from the patient or escort. This information may include questions regarding: • past and present health history with specific reference to conditions such as myocardial infarction, heart failure and septicaemia • injury that could have caused excessive blood loss or plasma loss as in burns, spinal cord injury or head injury • any recent episodes of severe diarrhoea and vomiting • allergic reaction to toxins, medication or blood transfusions. A comprehensive physical examination from head to toe should be done to identify typical findings suggestive of any type of shock and/or its complications. The nurse should: • assess the patency of the airway • auscultate the chest to determine adequacy of air movement • monitor respiratory rate and effort • evaluate all chest expansions to detect wall defects • monitor vital signs as baseline, then frequently as required to check for adequate perfusion • observe the skin condition • assess the level of consciousness. Nursing management is as follows: • Position the patient in such a way so as to promote cerebral blood flow and ensure patency of the airway. If there is no evidence of raised intracranial pressure, the patient is put in a supine position, legs elevated to improve venous return to the heart. Turn the patient to the side to allow the drainage of secretions. The secretions should be suctioned. • Oxygen should be administered through a mask, nasal prongs or endotracheal intubation. • Intravenous fluids should be administered to support circulation, to replace losses and also as a vehicle for administration of drugs. Colloids and crystalloids are given to expand the plasma volume and to replace fluid and electrolytes respectively. Examples of crystalloids are Ringers’ lactate and normal saline. Plasmante, albumin, haemacell, and mannitol are examples of colloids. The rate of infusion must be carefully monitored. Strict monitoring of intake and output is mandatory. Medication should be administered as prescribed. The types of medication used for the treatment of shock are: • Sympathomimetics, given in low doses to decrease the vasoconstriction and to increase renal perfusion. They also increase the strength of cardiac contractility. Dopamine is the commonly used drug in shock and

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• •

• •

it is administered via a continuous infusion. Blood pressure should be monitored strictly. Vasopressors such as adrenalin and noradrenalin are used to stimulate vasoconstriction. Vasodilators to increase peripheral perfusion and decrease constriction caused by vasopressors. Example of commonly used drugs are nitroprusside and nitroglycerine. Osmotic diuretics to increase renal blood flow. Bronchodilators and steroids for use in anaphylactic shock to relieve bronchospasms and to stabilise the cell membranes respectively.

Other treatment modalities include: • A MAST suit (military anti-shock trousers), which may be used to redirect blood flow to the heart and control bleeding • An intra-aortic balloon counter pulsation to augment perfusion pressures.

9.6 U  se of vaso-active drugs in the treatment of shock The commonly used drugs are alpha- and betaadrenergic drugs and vasodilators, namely dopamine, adrenalin, noradrenalin, nitroprusside and nitroglycerine. The following guidelines must be followed when administering vaso-active drugs: • They must be diluted in a compatible solution. • They must be administered slowly and the use of an infusion pump is mandatory. • BP and urinary output should be monitored 1- to 2- hourly. • The intravenous insertion set and the vein used for infusion must be observed for signs of infiltration, necrosis and ulceration respectively. • To discontinue its administration, the medication must be tapered slowly and blood pressure monitored.

Complications of shock Multiple organ dysfunction syndrome is a complication of all types of shock. Organs suffer damage as a result of inadequate perfusion, leading to organ failure.

Recording of intake and output An accurate record of the patient’s intake and output is essential in order to monitor fluid status, which will also give an indirect indication of electrolyte and acid–base balance. The amount and type of all fluids taken in or lost should be recorded. The intake/output record should be accurate enough to enable it to be used as an aid in the diagnosis and treatment of fluid, electrolyte and

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acid–base disturbances. All patients who are potentially at risk for any imbalances should have their intake and output recorded. The following categories of patients are particularly vulnerable and should automatically have their intake and output recorded – they are patients: • who have had major surgery • with burn injuries • with other serious or extensive injuries • with acute renal failure with oliguria • with congestive cardiac failure • with abnormal or excessive loss of body fluid • on diuretic therapy • with inadequate intake of food or fluid • who are unconscious • with confusion and mental disorientation • who must have artificial feeding. The specific objectives of intake/output monitoring are as follows: • To assess the patient’s fluid status • To monitor urine output and renal function • To supervise the patient’s fluid intake – this is parti­ cularly important if the patient’s intake is restricted or if an increased fluid intake has been prescribed • To monitor the type of fluid that the patient is taking, particularly if nourishing fluids have been prescribed. Ensure that all members of the multidisciplinary team are aware that intake and output is being recorded. Make sure that this is recorded in the patient’s care plan. It may be useful to place a sign by the bedside. The nurse should check the recording of intake and output at regular intervals, particularly after each meal and after refreshments. Intake and output records should be updated at the end of each shift. Most institutions require the totalling of intake and output after each 12-hour period (eg 07:00 and 19:00). Often the balance between intake and output must be worked out. This daily balance indicates whether the patient is retaining fluid or is losing fluid overall. All output must be recorded. Output, such as vomitus, liquid faeces, wet beds, and wound drainage, must be estimated if measurement is not possible. Unsatisfactory intake or output should be reported. The recording of intake and output is not the only parameter that requires monitoring. It is important for the nurse to note all clinical manifestations that could relate to fluid, electrolyte and acid–base balance, such as: • blood pressure, pulse, temperature and respiration • level of consciousness and mental state • skin turgor and perfusion

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• note the presence of oedema • short-term fluctuations in body weight.

9.7 Volume of common utensils for eating and drinking The nurse should be familiar with the volume of common eating and drinking utensils, as this will make accurate recording easier: • Teacup: 120–150 ml • Coffee mug: 150–180 ml • Porridge bowl: 200–250 ml • Water glass: 150–180 ml Most cold drink bottles and cartons show the volume.

Intravenous therapy Intravenous therapy is the administration of fluids, electrolytes or nutrients directly into the circulation via a vein. The indications for intravenous therapy are as follows: • The replacement of lost body fluids • The replacement of electrolytes in order to correct electrolyte imbalances • The provision of essential nutrients such as glucose, amino acids, lipids and vitamins • Where oral and/or enteral nutrition is inadequate or contraindicated • As a vehicle for the administration of medication directly into the circulation • To provide access to the circulation in case of emergency.

Nursing management of a patient on intravenous therapy Intravenous therapy is invasive and as such is a risk for infection. The nurse must ensure that the procedure is explained to the patient and those who will be caring for the patient at home. Consent to do the procedure must be obtained from the patient. The procedure for putting up a drip is sterile, with the skin being thoroughly cleansed before the drip can be put up. The doctor must prescribe intravenous therapy and the following must be clearly stated: • The type of fluid to be administered. This will also assist in the choice of the administration set to use. • The amount to be infused. • The time over which it is to be infused – this is stated in terms of rate, ie the number of drops per minute. This ensures that fluid is not rushed into the system to cause fluid overload.

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Aspects to keep in mind when preparing for intravenous therapy: • The giving set/drip set must be sterile and appropriate for the fluid to be given. • The fluid to be infused must be clean, clear, with no floating particles. The container must be sealed and patent. • The fluid to be infused must always be checked for correctness against the prescription. • Always check the expiry date on the vacolitre. • Check the identity of the patient to ensure that the correct patient is infused. • Blood must be correctly labelled with patient details and kept in the refrigerator until the time of administration. • Avoid introducing air into the intravenous lines. Replace each vacolitre on time before it is completely empty. • Intravenous therapy is uncomfortable and in some instances painful, therefore it is important to explain the procedure to the patient to elicit cooperation. • Where possible, the patient should stay in bed to minimise the chances of displacing the needle and the drip infiltrating the tissue. A vein is used and even though this can be any vein in the body, the usual part of the body used is the forearm or the back of the hand. The point of insertion is secured with a plaster or a bandage. Depending on location, a splint may be used to further minimise movement in the area, especially where the insertion is near a joint. In children, the doctor may even prescribe restraints to be applied, to ensure stability of the limb.

Care of a patient on intravenous therapy • The limb or body part used must be supported to ensure stability. • Monitor the flow of the infusion. In some instances an Ivac Pump may be used to regulate the flow. • Vital signs, including weight, must also be monitored to identify circulatory overload and possible infection for early intervention. • Observe the area of needle insertion and the surrounding area. Oedema, inflammation and pain may be indicative of infiltration. • Record intake and output and report on the progress of the therapy. • In cases where intravenous therapy is used for administration of medication, this must be prescribed and if added in the vacolitre, the vacolitre must be labelled accordingly.

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Conclusion Fluid, electrolytes and acid–base balance play an important part in normal body function. Nurses play a key role in identifying and preventing the causes of

homeostatic imbalances related to fluid, electrolytes, acid–base balance and the management of the disorders of fluid, electrolytes and acid–base balance.

Suggested activities for learners Activity 9.1 For each of the following items choose the most appropriate answer. 1. The fluid link between the external and internal environment is: a) plasma b) intracellular fluid c) interstitial fluid d) cerebrospinal fluid. 2. A solution that is similar to the osmolality of plasma that will cause no cell damage is called: a) hypotonic b) normal saline c) isotonic d) hypertonic. 3. Electrolytes are chemical compounds that dissociate in water to form charged particles called: a) sodium b) electrons c) potassium d) ions. 4. Which of the following patients is at risk for developing hypernatremia? a) 50-year-old with pneumonia, diaphoresis, and high fever b) 62-year-old with congestive heart failure taking loop diuretics c) 39-year-old with diarrhoea and vomiting d) 60-year-old with lung cancer and syndrome of inappropriate antidiuretic hormone. 5. When a patient with hypoparathyroidism complains of numbness and tingling in their fingers and around the mouth, the nurse should assess for what electrolyte imbalance? a) Hypernatremia b) Hypocalcaemia c) Hyperkalaemia d) Hypomagnesemia. 6. Which of the following should the nurse include when preparing to teach a class on the regulation and functions of electrolytes? a) Sodium is essential to maintain ICF water balance b) Magnesium is essential to the function of muscle, red blood cells, and nervous system c) Less calcium is excreted with aging d) Chloride is lost in hydrochloridic acid 7. The principal treatment for hypernatremia is fluid restriction. • True • False. 8. Vomiting, diarrhoea, excessive sweating, exercise and gastrointestinal aspirations are common causes of __________________ through the gastrointestinal tract. a) excess sodium loss b) excess potassium loss c) excess sodium production d) excess potassium loss. ❱❱

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9. A base is defined as a chemical compound that a) removes hydrogen ions from a solution b) adds sodium chloride to a solution c) adds hydrogen ions to a solution d) eliminates sodium ions from a solution. 10. Respiratory acidosis can occur when: a) a person consumes excessive amounts of antacids b) a person’s breathing is shallow due to obstruction c) a runner has completed a very long marathon d) the kidneys secrete hydrogen ions. Activity 9.2 Read the case study below and answer the questions that follow. Scenario: A 25-year-old female was transported from her rural village to the emergency room at City Hospital after she developed severe diarrhoea and vomiting for 2 days. On examination, she was afebrile with a pulse of 120 bpm and a blood pressure of 85/45 mmHg. Tissue turgor was markedly reduced, and she had dry mucous membranes. Blood chemistry showed: Hematocrit of 45% Na+ of 140 mmol/ℓ (135–145) K+ of 2.5 mmol/ℓ (3.5–5.0) Cl– of 100 mmol/ℓ (98–107) Creatinine of 320 µmmol/ℓ (0.04–0.12) Bicarbonate of 10 mmol/ℓ (22–26). Answer the following questions: 1. Which of the physical examination findings and laboratory values indicate dehydration? 2. Is the patient in shock? If yes, what is the stage of the shock? If no, what are the findings that exclude shock as a diagnosis? 3. What is the significance of the elevated creatinine? 4. Describe the acid–base status of the patient. 5. Formulate at least three nursing diagnoses for the patient.

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10

Mobility and exercise needs

learning objectives

On completion of this Chapter, the learner should be able to: • accurately assess movement, muscle tone and coordination • identify and assess patients who are at risk of developing the complications of immobility like pressure sores, deep-vein thrombosis and hypostatic pneumonia • effectively prevent and manage the complications of immobility • implement nursing interventions designed to maintain mobility and to prevent the related complications • list the complications of immobility. key concepts and terminology

active exercise

The patient independently moves all joints through a complete range of movement.

atrophy

A decrease in muscle size and bulk due to disuse.

basal metabolic rate

Minimal energy required to maintain physical and chemical processes within the body.

body alignment

The position of body parts in relation to each other.

contracture

Permanent shortening of the muscle leading to limited joint mobility.

embolus

A clot that has moved from its point of origin, causing an obstruction elsewhere in the circulatory system.

exercise

Any physical activity that raises the heart rate above resting levels.

mobility

The ability to engage in activity and free movement, which includes walking, running, sitting, standing, pushing, pulling, etc.

passive exercise

Another person moves the patient’s joints through the full range of movement.

proprioception

The awareness of posture, movement, and changes in equilibrium and the knowledge of position, weight and resistance of objects in relation to the body.

range of movement

Maximum movement possible for a specific joint.

thrombophlebitis

Inflammation of a blood vessel in the area of a clot.

thrombus

Blood clot found in a vessel.

prerequisite knowledge

• Anatomy and physiology of the musculoskeletal system.

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medico-legal considerations

Immobility, if not well managed, can result into a variety of complications which may end up claiming the life of the patient. Some of these include pneumonia, thrombosis and bedsores. Development of bedsores is an indication of poor nursing care. If these occur within a healthcare facility, the facility and the caring staff may be sued by the patient for neglect. As a matter of policy, if a patient develops an acquired pressure sore, this adverse event must be reported to the authorities within 24 hours and possible disciplinary measures may be brought for negligence. ethical considerations

Mobility needs are part of the basic nursing care to prevent respiratory and cardiovascular systems complications. The duty of the nurse to take due care is very clear and mobility needs are part of the basic nursing care that does not require to be prescribed. Bedsores are an indication of neglect and poor nursing care. essential health literacy

Bed rest, although therapeutic, can also be detrimental to all the systems of the body and as a result, patients should be encouraged to do mild exercise even if they are on bed rest. This could include sitting up in bed, moving the arms through the full range of movement, breathing and leg exercises. Patients should be encouraged to execute some of their tasks of daily living themselves, for example: bathing, eliminating and eating and drinking. Where this is not possible, patients must submit to passive exercises.

Introduction Movement is an important aspect of human function and health as it influences optimal functioning of many systems of the body. For example, when people stand up and move about, the lungs expand more easily, the kidneys function better and the digestion of food is enhanced. On the other hand, when people are ill, immobility often ensues, and it has a number of deleterious effects on the body. Physical movement has two main functions in the body. Firstly, it allows the human being to carry out the normal activities of daily living, which, besides mobility, include feeding, grooming, dressing, bathing, personal hygiene, toileting, skin management, shopping, cooking, cleaning etc. Secondly, mobility provides pleasure for individuals. Many people undertake physical activities such as exercise in order to experience a sense of wellbeing. Exercise is any physical activity involving muscles that elevate the heart rate above resting levels. It has a positive effect on all the systems of the body, especially the cardiovascular and respiratory systems, as well as the metabolism generally. Generally people automatically exercise their joints and muscles when they engage in activities of daily living. However, ill health curtails or restricts this exercise and hence movement as well.

Types of exercise Several types of exercise promote physical psychological well-being (see Table 10.1).

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and

10.1  The benefits of exercise • Muscle tone is improved • Cardiovascular efficiency and cardiac reserve are increased • Oxygenation and pulmonary efficiency are improved • Digestion is enhanced • The utilisation and metabolism of foodstuffs are improved • Mental alertness is increased • Work and stress tolerances are increased • Sleep is improved • Cholesterol levels are decreased • Haemoglobin levels are increased • The amount of fatty tissue in the body is decreased, which results in weight loss • A good feeling is experienced as a result of the secretion of endorphins during exercise • Provides a healthy way to relax and relieve stress • Promotes bone density • Reduces blood pressure

Clinical alert! Individuals with cardiovascular problems should be reminded to exhale when performing isometric exercises, to prevent their blood pressure from increasing.

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Chapter 10 – Mobility and exercise needs  177 Table 10.1  Types of exercise

Type of exercise

Purpose

Examples

Aerobic

• Improves cardiovascular fitness • Assists with weight control • Improves general functional ability

• Rowing a boat • Jumping a rope • Brisk walking • Jogging • Swimming

Strengthening

• Maintains or increases muscle strength

• Weight training • Manual labour • Tai chi • Yoga

Isometric

• Maintains muscle tone and strength

• Quadriceps setting • Gluteal setting • Triceps setting

Isotonic

• Increases and maintains muscle tone and strength • Shapes muscles • Maintains joint mobility • Improves cardiovascular fitness

• Weight lifting • Working with pulleys • Range-of-movement exercises • Performing activities of daily living

Isokinetic

• Conditions muscle groups

• Exercise equipment • Resistive water exercises

Range of movement

• Maintains joint mobility • Maintains and increases flexibility

• Adduction and abduction • Flexion and contraction

Weight-bearing exercises

• To increase bone density and mass

• Walking • Hiking • Jogging • Climbing stairs • Playing tennis • Dancing

Non-weight-bearing exercises

Activities of daily living

• Swimming • Cycling phase. It is a professional expectation of the nurse to facilitate mobility in a patient according to the Scope of Practice (SANC, 1985). As previously stated, when a pressure sore develops in a hospitalised patient it is often regarded as an indicator of poor nursing care. Other complications of immobility like urinary stasis and hypostatic pneumonia also prolong the stay of a patient in hospital unnecessarily.

Movements and activities, makes one able to undertake the activities of daily living (ADL). Most of these activities have been highlighted in the introduction. For an individual to be able to carry out these activities, the following varieties of motor skills are required: • Lifting the head • Grasping objects and lifting them • Lifting the arms and above the head • Rolling over and turning • Sitting, lying, standing and walking.

Factors affecting mobility Health status

The motor skills required to perform the activities of daily living are important in nursing, as these are the movements that must be encouraged when promoting independence, particularly during the rehabilitative

The general health status of a person will influence the desire to exercise or tolerance for activity. Physical conditioning will also influence mobility or stamina. Other physical factors such as fatigue, muscle cramps, dyspnoea, chest pain etc will also impact on mobility and exercise.

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Growth and development

Prescribed limitations

• Newborn babies have movements which are generally in flexion; however, all joints can be moved through all ranges of motion. Gross motor development occurs first, followed by fine motor skills. • School-going children develop further motor skills including balancing, eg on a bicycle. Physical education and sports at school assist in development of mobility and promote a healthy lifestyle. • Teenagers need to be encouraged to exercise, espe­ cially if they are involved in sedentary activities such as computer games. Schools should discourage the use of shoulder bags for heavy books as these can adversely affect the posture by placing increased strain on one side of the body. • Advancing age affects bones, joints and muscles. Bones lose mass and density and thus become fragile, placing the patient at risk for easy fractures. Compression fractures of the vertebrae cause alteration in posture (posture becomes forward-leaning and stooped) and therefore alteration in gait and balance. Muscle tone also decreases, resulting in decreased ability to perform strenuous activities. Joints lose flexibility and may develop arthritic changes, causing pain and decreased movement.

• Health status may determine the amount and type of exercise a person may do, such as people with cardiac or respiratory conditions. • Patients in plaster of Paris or traction will be temporarily less mobile and may require rehabilitation to regain full mobility. • Neuromuscular disorders such as muscular dystrophies, or disorders following a head injury, stroke or spinal injury, will also decrease the person’s mobility. • Sensory conditions such as decreased vision will affect the person’s ability to mobilize freely and without assistance.

Nutrition • Good nutrition is essential for optimal musculoskeletal functioning and mobility. • Under-nutrition results in muscle weakness and fatigue. • Lack of minerals such as calcium can result in osteoporosis and subsequent fractures. • Obesity places joints under excess stress, resulting in decreased ability to move. Obesity also puts strain on the cardiovascular and respiratory systems, causing decreased activity tolerance and thereby affecting the person’s ability to move and exercise.

External factors • Environmental temperature and level of humidity affect the desire to exercise and move around generally. Most people avoid as much activity as possible in hot, humid weather. Fluid intake needs to increase in these circumstances, and replacement of fluid and electrolytes needs to be adequate while exercising. Very cold weather may also decrease motivation to be active as one tends to want to stay warm indoors. • The safety of the neighborhood is also a factor as people need a safe place to exercise. Walking is an excellent form of exercise, but will be less utilized if the area is not safe. • The availability and access to gyms also plays a role.

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Nursing assessment of mobility A general assessment of the patient’s mobility is essential in order for the nurse to identify any limitations to movement and to fully ascertain the extent to which the patient will require assistance in carrying out the activities of daily living. The nurse can make use of some of the widely used assessment tools to evaluate the balance and gait in determining the mobility of older adults or to evaluate changes over time, for example the Performance Oriented Mobility Assessment (POMA) (Tinetti in Faber, Bosscher and Van Wieringen, 2006). The nurse can also determine the mobility of a patient during physical examination on admission. The following are suggested.

Physical assessment • Ask the patient to rise from a lying position to a sitting position on the edge of the bed or examination table. Normally the patient should be able to do this unaided. If the patient is suffering from muscle weakness, they may push on the bed, or pull themselves up by means of the cot sides or other handy items of furniture. • Observe the appearance of the joints. • Observe for swelling, redness, deformity or increased temperature over the joint. • Palpate for signs of tenderness. • Observe the range of movement the patient can achieve with each joint. • Ask the patient to stand up out of a chair. Normally the patient should be able to do this unaided. If muscles are weak, the patient may push themselves up with the hands, or may lean forward before rising. • Observe the amount of assistance needed by the patient to move in bed. The nurse should note whether the patient can turn in bed unaided or not, as well as sit up in bed.

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• Assess the patient’s gait by asking the patient to walk a short distance and note the following: – the steadiness of the gait – balance and coordination while walking – whether the trunk is upright (posture) – any curvature of the spine – whether the feet and legs are lifted normally or the patient just shuffles along – whether the steps are appropriate or are too small – activity tolerance – whether the patient easily tires or becomes breathless.

Nursing history The following questions will elicit both the subjective and objective data in patient assessment: • Ask the patient about the ability to perform normal activities of daily living. • If the patient is unable to perform these activities, find out what the restrictions are and to what extent they are restricted. • Ask the patient if they experience any form of activity intolerance. • If yes, find out to what extent they experience activity intolerance. • Ask if the patient follows any exercise programme. • Ask what activities the patient normally does (eg walking up stairs). • Ask about the medical history of any conditions that may affect the patient’s ability to move and mobilise. (The summary of the assessment is given in Box 10.2).

10.2 Aspects to be considered for musculoskeletal assessment These include the following: • Body alignment • Body mechanics • Posture (sitting and sitting) • Range of motion of joints • Endurance • Muscle tone • Size and contour of joints • Inspection of the skin • Palpation of the skin, muscles and joints.

Meeting the mobility needs of the patient If the patient is unable to meet their own activity needs, the nurse must do so for the patient. This is not merely a comfort measure, as there is some evidence to suggest that exercise helps to promote recovery by stimulating the

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10.3  Specific joint movements Flexion. Decreases the angle of the joint; brings two bones together, such as bending the elbow. Extension. Increases the angle of the joint; increases the distance between the two bones, such as straightening. Rotation. Movement of a bone around its longitudinal axis, such as shaking the head. Abduction. Moving a limb away from the midline of the body such as crossing one’s legs. Circumduction. Combination of flexion, extension, adduction and abduction seen in ball-and-socket joints, such as bowling a ball in a game of cricket. Pronation. Moving the bones of the forearm to turn the palm of the hand to face down. Supination. Turning the bones of the forearm so that the palm of the hand faces upwards.

immune system and increasing the secretion of growth hormone, which is required for healing and rebuilding of tissues.

Active exercise This is exercise that is actively carried out by the patient. In the case of a patient who is not fully mobile, or who is only able to carry out a limited number of activities, the nurse should encourage them to do as much for themselves as possible. It may be helpful to refer the patient to the physiotherapist who can work out a specific programme of active exercise for the patient. Once an exercise programme has been worked out, the nurse should acquaint themselves with it and should actively help and encourage the patient to carry out the programme.

Passive exercise Passive exercise is done by the nurse or physiotherapist where the patient is unable to carry out the movements, or is paralysed or unconscious. When carrying out passive exercise, the following principles should be kept in mind: • Unused muscles degenerate and atrophy. • Bone and skin also degenerate and atrophy with disuse. • All joints have a specific range of motion. • Brute force should never be used in moving a limb, and the natural limitation of movement at the joints should never be exceeded. • Regular passive exercise prevents stiffness and con­ tractures, but only active exercise can preserve muscle tone and strength.

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Toes: Flexion and extension

A. Flexion of the toes

Fingers: Flexion and extension

B. Extension of the toes

A. Flexion at the fingers

B. Extension at the fingers

Ankle: Flexion and extension

Wrist: Flexion, extension, supination and pronation

A. Flexion at the ankle

A. Flexion at the wrist

B. Extension at the wrist

C. Supination at the wrist

B. Pronation at the wrist

B. Extension at the ankle

Knee: Flexion and extension

A. Flexion at the knee

B. Extension at the knee

Hip: Flexion, extension, abduction, adduction and circumduction

A. Flexion at the hip

B. Extension at the hip

C. Abduction at the hip

D. Adduction at the hip

E. Abduction at the hip

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Shoulder: Flexion and extension; abduction, adduction and circumduction

A. Flexion at the shoulder

B. Abduction at the shoulder

C. Adduction at the shoulder

D. Circumduction a the shoulder

Figure 10.1  Movement of the joints

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Relaxation Relaxation is as important as exercise because it gives the mind and body a break and can be both mental and physical: • Anxiety, overwork, noise and other disturbances will interfere with mental relaxation. • Pain, discomfort, tension, hunger will interfere with physical relaxation.

10.4  Relaxation response During relaxation: • The activity of the sympathetic nervous system is decreased • Blood pressure and pulse rate are decreased • Muscular activity is decreased.

Bed rest Confinement to bed is often prescribed as part of therapy. This allows the patient to recover where activity and strain will hinder recovery. The patient is kept at rest in order to facilitate healing or to prevent further damage. Conditions in which bed rest is prescribed include the following: • Myocardial infarction • Severe respiratory distress • Disease with marked dyspnoea • Cerebral aneurysm • Some cases of hypertension. The patient may also be confined to bed because of an inability to move such as in paralysis, or unconsciousness. Patients may be placed on strict bed rest – ie not allowed up at all – or may be allowed up to use the bathroom and toilet only. It is the nurse’s duty to ascertain the degree of bed rest that is required. Most doctors, however, will allow even the patient on strict bed rest to stand out of bed or sit

on a bedside commode to urinate. This is because trying to get the patient to pass urine in the recumbent position involves more strain than assisting the patient to stand by the bed or sit on a commode at the bedside.

Positions that can be assumed in bed The position of the patient in bed depends on several considerations: • Maintenance of comfort and good body alignment. • The presence or absence of factors such as hyper/hypo­ tension, cardiac problems, respiratory distress and dyspnoea, head injuries, or raised intracranial pressure. • The presence of injuries or surgical incisions that may affect the position of the patient in bed. • The presence of IV lines, arterial lines, ventilator tubing and surgical drainage tubes/bottles. Table 10.2 indicates positions that patients can assume in bed.

Table 10.2  Positions which patients can assume in bed

Position Fowlers Dorsal recumbent or supine Prone

Lateral

Semi-prone or Sims’ position

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Description Semi-sitting position. Head of bed is elevated 45–60 degrees; knees slightly elevated.

Indications • Promotes comfort • Improves respiratory problems eg dyspnoea • Encourages postoperative drainage Back-lying position. Head and shoulders may be • Promotes comfort slightly raised. • NB: Head and shoulders are kept flat after procedures involving the spinal cord Facedown position. Head is turned to one side. • Comfort/preference Pillows are placed under the abdomen and • To facilitate the drainage and removal of the lower legs to provide support. The head secretions from the bases of the lungs • To facilitate ventilation and expansion of the is supported with a pillow to maintain good alignment. bases of the lungs Side-lying position. A pillow is placed to support • Comfort/preference the head, and at the back to support the patient. • Used as an alternative to the dorsal position Another pillow can be placed between the • Relieves pressure on the sacrum and heels knees to relieve pressure. The position between the lateral and prone • Promotes comfort, especially in pregnant position. The patient lies on their side with legs patients flexed, the upper leg being flexed more acutely • For unconscious patients to promote at both hips and knee so that it lies in front of drainage from the mouth and maintain clear the lower leg. The lower arm is placed behind airway the patient and the upper arm is placed in front • Used for patients recovering from of the head. A pillow is placed to support the anaesthesia head. Pillows are placed under the knee of the • For administration of enemata upper leg and under the upper arm.

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10.5 Guidelines for positioning of a patient

A. Semi-Fowler’s position

B. Fowler’s position

• The position must be suitable for the patient’s general physical condition; for example, it is appropriate to place a shocked patient in the High Fowler’s position • The position must be appropriate for the patient’s medical or surgical condition • The position should be comfortable • The limbs should be placed in a natural and functional position • Circulation should not be impeded in any way • The body and limbs should be in the proper alignment and be supported where appropriate • The patient should not have to exert any effort in order to maintain the position

Clinical alert! Positioning of a patient To prevent the development of contractures and pressure sores, change the patient’s position every 2 hours and record on a chart.

C. Dorsal position (recumbent or supine position)

D. Prone position.

E. Lateral position

F. Semi-prone position (Sims’ position) Figure 10.2  Positions in bed

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Common clinical problems related to maintenance of mobility Effects of bed rest Activity, in one form or another, is essential to health. Bed rest has a number of effects on the body, which, if not taken into account and counteracted, may lead to serious complications, and even to the death of the patient. • Oxygen requirements are reduced and breathing is shallower. As a result, only certain areas of the lungs are expanded, usually the apices. The bases of the lungs and areas that are dependent due to the recumbent position are not adequately expanded. This allows secretions to accumulate and some of the alveoli in the unexpanded areas may collapse. Painful wounds or operation sites may further restrict respiratory movements. • The pumping action of the leg muscles, which helps to return blood to the heart from the lower extremities, is decreased, leading to circulatory stasis. Circulatory stasis also occurs in the lower abdomen because the movements of the hip and back that normally assist venous return from these areas are decreased. • The skin overlying bony prominences in dependent areas of the body is subjected to pressure that cannot be relieved by activity and walking about. • Joints become stiff and sore due to inactivity.

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• Disused muscles become weak and wasted. • Lack of activity may cause loss of minerals from bone. • The bladder may not be properly emptied due to the awkwardness of voiding in the recumbent position. • Lack of activity may result in sluggishness of bowel activity. • Under-stimulation may predispose to boredom and depression. • Inactivity results in a lack of appetite.

Complications of bed rest Pulmonary

Areas of the lung that are not properly expanded due to the recumbent position may eventually collapse, a condition known as atelectasis. Secretions pool in the collapsed area such that the patient may be unable to remove by coughing. The stagnant mucus forms an excellent culture and growth medium for bacteria, resulting in hypostatic pneumonia. In elderly, immuno-suppressed or debilitated patients, pneumonia is a serious complication that frequently leads to the death of the patient. Other complications of pneumonia such as pleurisy, lung abscesses and pleural abscesses may occur and further retard the patient’s recovery.

Circulatory Stasis of the circulation due to immobility, particularly in the legs and pelvic area, increases the coagulability of the blood, leading to the development of a deep-vein thrombosis in the leg veins or in the pelvic veins. The formation of a blood clot further impairs the venous return from these areas and, especially in the legs, the parts distal to the clot become oedematous and painful. The vessel wall surrounding the clot may become inflamed, a condition known as thrombo-phlebitis. Patients most at risk are: • Immobile patients, for example those who are too weak to move by themselves, unconscious or comatose. • Those who have recently undergone surgery, especially orthopaedic, abdominal or cardiac surgery. • Those who are pregnant or who have recently been delivered and are post-partum. • Obese patients. • Patients who have suffered trauma, especially major trauma or multiple trauma. • Those with a history of a previous deep-vein thrombosis. • Patients over 50 years of age. • Patients who are on oestrogen therapy, and some forms of oral contraceptives.

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Integumentary Pressure on the skin over bony prominences in certain areas of the body occurs during bed rest. The most common areas for such pressure to occur are parts where bones lie close to the surface of the skin. Prolonged pressure on the soft tissues due to immobility, and especially the skin, causes capillary compression and subsequent occlusion of blood flow to the area. Microthrombi develop within the capillaries, which totally occlude blood flow. This leads to tissue necrosis, skin breakdown and ulceration of the underlying soft tissue. Once the underlying tissue has started to break down, the sore may become deeper until even bone and cartilage may be exposed, which may also become infected and eroded. Chronic bedsores that fail to heal may ultimately become cancerous. Other factors contributing to the development of pressure sores include: • Immobility. This may be due to bed rest or confinement to a chair or wheelchair. • Moist skin. Moisture softens the skin and encourages skin breakdown. This is a factor in patients who are incontinent of urine or faeces, or who sweat profusely. • Poor nutrition. Poor nutrition results in poor healing and increased friability of the skin. The fragile, friable skin is more liable to break down. • Sensory loss. Loss of sensation as in paralysis means that the patient is unable to perceive the discomfort caused by the pressure on the skin and will not feel the urge to change position or ask for their position to be changed. • Friction and shearing forces. These occur in patients who are on bed or chair rest. A force is exerted on the skin from the underlying tissues with pressure and movement. This shearing force may cause small breaks in the skin, which then develop into bedsores with continued pressure. • Old age. The skin loses its ability to maintain normal integrity with advancing age. In the elderly, the skin becomes thinner and more fragile and thus more prone to breakdown. • Other conditions, such as poor circulation, diabetes mellitus, impaired mental functioning, anaemia, or pyrexia may also make the skin more prone to break­ down. • The very obese and/or the very thin are more at risk than normal-weight individuals.

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Musculoskeletal • Deformities and contractures may occur. Joint stiffness due to bed rest reduces mobility of the joints. Tendons, around the immobile joints or joints, may become permanently lengthened or shortened over time. Once this has happened, the resulting deformity can usually only be corrected by surgery. These deformities, which are usually in a position of flexion, may occur in any joint that is immobile for a prolonged period. However, in the hand and foot deformities occur in a dependent position ie a position of extension. Joint deformities interfere with movement and with the normal function of the joint. An untreated joint contracture may be crippling, which makes it very important for the nurse to prevent these deformities from developing. • Demineralisation of bone during bed rest leads to loss of bone mass; a condition called osteoporosis. • Severe loss of muscle strength and bulk is also a result of bed rest. The unused muscle loses mass and becomes wasted.

Renal and urinary • Demineralisation of bone during bed rest releases calcium salts into the circulation, which are then excreted by the kidneys. Large quantities of calcium salts passing through the kidneys may result in the formation of kidney stones, or renal calculi. • Inactivity also leads to urinary stasis, with the awkwardness of using a bedpan or urinary bottle as a contributing factor. This stagnant urine is a good culture medium and easily becomes infected. The development of urinary tract infection may lead to death due to renal sepsis and septic shock or renal failure, or to permanent renal impair­ment. • If the bedridden patient is catheterised, the likelihood of urinary tract infection is even higher. After pneumonia, renal failure from repeated urinary tract infections is the leading cause of death in patients who are immobile or bedridden for long periods of time.

Gastrointestinal • Inactivity reduces the activity of the gastrointestinal tract (GIT), causing constipation. The decrease in bowel motility results in more water re-absorption from the bowel thus decreasing the amount of water in the faeces, making them hard and small. • A poor or lack of appetite due to decreased basal metabolic rate (energy requirements are diminished). This may result in the patient taking in insufficient nutrients and fluids for recovery. An inadequate food intake may exacerbate muscle wasting and may

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predispose the patient to an infection that they can ill afford.

Psychological • The monotony of bed rest can result in boredom and depression. The patient may become anxious about family well-being if they are the breadwinner and the period of bed rest is long. This anxiety may occur even if the patient is not the breadwinner, due to the isolation from the family experienced while the patient is in hospital. • The patient may also be worried about job security and the financial implications of the hospitalisation. The resulting stress and anxiety may lead to a feeling of decreased self-esteem. • Hospital also engenders a feeling of being isolated and cut off from one’s family and from the rest of the community. The bored patient thus has very little to do except watch the activities of the nursing staff and the other patients, which could lead to feelings of depression. • A further problem, particularly if the period of bed rest is prolonged, is overdependence on the staff. The patient may seem to be very demanding and unable to do anything for themselves. The patient may also feel apprehensive and anxious about resuming independent activities after a long period in bed.

Prevention and management of the complications of bed rest Pulmonary

Identify those patients who are most likely to develop pulmonary complications. These patients may fall into the following groups: • Elderly or debilitated patients • Patients with infections of the upper respiratory tract • Patients who may have inhaled vomitus • Patients with chronic lung conditions • Obese patients. In order to promote full expansion of the lungs: • the patient’s position should be changed regularly in order to expand the lungs during respiration • encourage deep breathing at regular intervals • encourage and assist the patient to cough up secretions • the patient can be referred for preventative physio­ therapy. The nurse should be alert for any signs of pulmonary complications, such as: • a rise in temperature • an increase in pulse and respiration

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• restlessness, anxiety and confusion, particularly in the elderly • dyspnoea, cough and/or chest pain. Management of pulmonary complications involves the following: • Treatment of infection with an appropriate antibiotic, as prescribed by the doctor • Intensive chest physiotherapy to promote lung expansion and the removal of secretions • Oxygen therapy as prescribed to ensure adequate oxygenation • Progress is monitored by means of vital signs taken every 4 hours and regular chest X-rays, taken as prescribed by the physician.

Circulatory Prevention of clot formation: • The nurse should carry out passive leg exercises at regular intervals; where possible, the patient should be encouraged to do this for themselves. • Elastic anti-embolism stockings may be applied; pressure thus applied at the surface helps to move the blood back to the heart. • Low doses of an anticoagulant such as Clexane may be prescribed; this reduces the coagulability of the blood and reduces the chances of clot formation. • Prevent dehydration by encouraging fluid intake. • Take care not to place pillows or support devices under the popliteal fossa as these can occlude venous return and predispose the patient to venous stasis and subsequent clot formation. • Early ambulation and mobilisation are highly desirable. Early detection and reporting of any sign of circulatory complications: • A deep-vein thrombosis should be suspected if the patient presents with a painful, oedematous ankle and calf, which may be accompanied by a slight rise in temperature. • A positive Homen’s sign, in which flexion of the ankle causes a sharp pain in the calf, is also suggestive of a deep-vein thrombosis. • The sudden onset of dyspnoea, together with a sharp, knife-like chest pain should make the nurse to suspect a pulmonary embolism. This constitutes a medical emergency. The diagnosis thereof may be confirmed by an electrocardiogram and a chest X-ray.

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Figure 10.3  Homen’s sign

Circulatory complications of bed rest are managed as follows: • Anticoagulant therapy is commenced as prescribed by the doctor. First heparin is given intravenously. After a few days the patient may be changed to Clexane or to oral Warfarin. • The patient is kept in bed until the clot has resolved. • Do not massage the painful area as this may dislodge the clot and cause an embolus. • Anti-embolism stockings or elastic bandages are applied. • If thrombophlebitis is present, anti-inflammatory and anti-phlebitic ointments such as Reparil gel can be applied as prescribed. Old-fashioned hot poultices are very good at reducing the pain of thrombophlebitis but these have fallen into disuse and are seldom used nowadays. • The weight of the bedclothes should be kept off the affected limb by means of a bed cradle. This reduces pain in the limb and promotes comfort. • Elevation of the foot end of the bed assists with venous return and prevents venous stasis. • For patients who repeatedly develop deep-vein thrombosis, surgical procedures such as the insertion of an umbrella filter in the inferior vena cava may be carried out, to prevent the migration of clots to the heart and the lungs.

Integumentary Identify the patients most at risk. These patients fall into the following groups: • The obese and the emaciated • Patients with poor circulation • Patients with fragile, dry skin • Restless, unconscious or paralysed patients • Patients with lowered resistance, namely very ill patients, malnourished patients, oedematous patients, anaemic patients, patients with malignant disease, patients with diabetes mellitus and patients taking systemic cortico-steroids.

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186  Juta’s Complete Textbook of Medical Surgical Nursing Table 10.3  The Norton Scale

General condition

Mental state

Activity

Mobility

Incontinence

Good

4

Alert

4

Ambulant

4

Full

4

Not

4

Fair

3

Apathetic

3

Walks with help

3

Slightly limited

3

Occasional

3

Poor

2

Confused

2

Confined to chair

2

Very limited

2

Usually of urine

2

Bad

1

Stuporous or unconscious

1

Confined to bed

1

Immobile

1

Urine and faeces

1

NB: The lower the score, the higher the risk Source: Norton, McLaren & Exton-Smith, 1962

Patients need to be assessed in relation to their risk for development of pressure ulcers. This assessment should be carried out on all patients on admission, and at least every third day on long-term patients. High-risk patients should be assessed on a daily basis. Risk assessment tools are often used to determine the risk and to prevent the onset of pressure sores; they include the Norton Scale and the Waterlow Scale. The Waterlow Scale is a scoring system to stratify the risk of decubitus ulcer development. The higher the score, the more at risk the patient is. The Norton Scale is indicated in Table 10.3. Measures to relieve pressure over pressure points are: • Regular turning and position changes – frequency depends on the risk as assessed above; usually done every 2–4 hours • Use of appliances and/or bed accessories, eg monkey chain and bed cradle and/or special beds and mattresses to relieve pressure (a monkey chain is particularly useful in aiding patients who are able to hoist themselves to relieve pressure on the back without nursing intervention; other modern patient lift devices which are hydraulic or battery operated can also be used to lift or hoist patients to increase the mobility of patients in order to effect nursing interventions) • Maintaining the condition and integrity of the skin by: – massaging the pressure points to promote adequate circulation in the area – protecting the skin from injury, especially from long nails and jewellery of staff – applying lubricants and barrier creams to protect dry skin – preventing friction and shearing, especially when moving a patient in bed: taking care not to drag the patient up the bed but lifting them every time you are to change position; ensuring that there is sufficient staff to assist to prevent shearing force and injury to the nurse and patient

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– preventing friction from foreign objects in the bed such as crumbs and creased linen – keeping the patient clean and dry if incontinent • Maintaining and improving resistance by ensuring adequate diet and fluids.

Musculoskeletal • Place limbs in a natural, functional position. – A position of slight flexion is recommended. – The hand should always be positioned in the grip position. – The ankle should be flexed in the ‘standing’ position. – The hands and the feet may require splinting to keep them in the functional position. – The limbs should be adequately supported using pillows. • Range-of-motion exercises should be carried out on all joints at regular intervals, unless contraindicated by injury. Any stiffness or tendency of a joint to remain in one position should be reported. • Once contractures have occurred, long-term physio­ therapy will be required to restore some degree of function at the affected joint. If this is unsuccessful, surgery is required to lengthen the tendons and adjacent soft tissue and restore a degree of function. Neither of these options has a particularly high success rate, and the patient is often left with a residual permanent deformity. • Dropfoot is a type of joint contracture in which the patient is unable to dorsiflexion the foot. That is, the foot is contracted in the position of plantar flexion. It is caused by the shortening of the Achilles tendon due to poor positioning of the foot or possibly due to the weight of the bedclothes continually pressing the foot into a position of plantar flexion. – As with the other types of contracture, exercise of the ankle joint is vital.

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– The nurse should also check the position of the foot and use a bolster or some other device to keep the foot in a neutral position. – The bedclothes should not be tightly tucked in over the foot and a bed cradle may be useful in relieving pressure on the foot. – A special orthosis or splint may be made to maintain the correct position of the foot. • Dropped hand is a type of contracture in which the hand is contracted in a position of flexion. The primary cause seems to be poor positioning of the hand in bed, particularly in the case of unconscious patients and those with decorticate or decerebrate positioning of the hand. Although the patient can still grip, the hand cannot be extended and this limits its function. – Exercise of the wrist joint is essential – exercises should include not only range-of-motion exercises but also exercises that strengthen grip and flexibility at the wrist. – A splint is usually needed to keep the hand in the functional position. It is not possible to prevent osteoporosis in a patient who is on bed rest for a prolonged period of time. Early ambulation is essential to prevent severe osteoporosis, and most patients will regain normal bone mass within a few weeks of commencing active mobilisation. On discharge, the patient must be educated to exercise actively and to take care not to fall, as such patients are more prone to fractures until normal bone mass has been regained. Research studies have shown that with prolonged bed rest, patients lose bone mass, and a calcium-rich diet is advised to counteract the onset of osteoporosis. While this viewpoint is corroborated by Parry and Puthucheary (2015), the latter add that the culture of physical activity in the critical care setting should be reviewed, and they call for a paradigm shift from bed rest and inactivity to physical activity and mobility. Moreover, increased calcium intake could increase the risk of renal calculi. Muscle weakness and muscle wasting can be alle­viated by active/passive exercises to a limited extent. The nurse should take care when the patient first starts to ambulate, as the muscle weakness makes the patient much more liable to falls until normal muscle strength is regained.

Renal and urinary The management of renal and urinary needs of patients on bed rest is as follows: • An adequate fluid intake of about 2 000 to 2 500 ml in 24 hours for an adult should be promoted in order to prevent urinary stasis. Adequate fluids will also help to prevent renal calculi by flushing the kidneys.

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• Intake and output should be monitored. • Regular urination should be encouraged on a 3- to 4-hourly basis. The nurse should provide privacy for the patient. As far as possible, the patient should be assisted to assume the normal position for passing urine. • The treatment of urinary tract infection consists of a suitable antibiotic as prescribed by the doctor. Adequate fluids will help to flush the bladder and remove infected urine.

Gastrointestinal The management of gastrointestinal needs of patients on bed rest is as follows: • The nurse must ensure that the patient has an adequate fluid intake. • The amount of fibre in the patient’s diet should be increased. Fibre provides bulk and helps to retain water in the large bowel, thereby maintaining the normal consistency of the faeces. • Regular bowel movements should be encouraged as this prevents stasis of faecal matter. This is not always easy, as many patients are embarrassed to use a bedpan or commode in the ward. The nurse should provide as much privacy as possible. • The above measure can also be used to manage constipation. The doctor may prescribe a mild laxative while the patient is immobile, but this should be discontinued as soon as possible. • If constipation is allowed to become prolonged, faecal impaction results, necessitating manual removal. This can be a painful and unpleasant procedure for both patient and nurse. • Adequate nutrition should be actively promoted. A diet that is high in proteins and vitamins should be encouraged. Attention to the patient’s likes and dislikes may stimulate appetite.

Psychological Try to interest the patient in their surroundings by doing the following: • Providing books, magazines and newspapers • Placing the patient in a bed with a view, or with patients who will provide pleasant and congenial company • Providing a radio or television for patients who do not feel like reading, or who cannot read • If the patient is interested, the occupational therapist will organise handwork for the patient.

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A referral to the social worker may be necessary to solve family or finance-related problems that are causing anxiety.

Moving patients Patients who have decreased mobility may need assistance in moving in bed. The nurse must take care to move the patient correctly to minimise injury to the patient or themselves. Moving a patient up in bed involves the following actions: • Place the bed in as suitable a position as possible for the condition of the patient. • Remove as many pillows as possible. • Ask the patient to flex both knees and place feet fat on the bed to assist in pushing up in the bed. • If a monkey chain is available, ask the patient to hold with both hands and assist in lifting with the chain. • Otherwise, ask the patient to fold the arms over the chest, flex the neck and keep head off the surface of the bed. • Place one arm under the patient’s thighs, the other under the shoulders and assist the patient to lift the buttocks off the bed and push up towards the head of the bed using the feet. Ensure that the buttocks are lifted off the bed to prevent a shearing force on the skin. • If the patient is unable to assist in moving, two nurses are required to move the patient.

Turning a patient in bed Where possible, two nurses may be engaged to perform the following actions: • Move the patient closer to the side opposite to the one which they will be facing when turned. • Put up the side rail to prevent the patient from falling. • Go to the opposite side of the bed, place one hand on the patient’s shoulder, the other on the patient’s hip and pull the patient towards you. • Position the patient in a lateral position, supporting the back and arms with pillows where necessary. Place a pillow between the patient’s legs to prevent pressure on the knees and ankles. • A pull sheet may be used to assist if the patient is immobile.

Logrolling a patient This technique is used to move a patient whose body needs to be kept in a straight alignment. The patient is turned as if rolling a log. It is used particularly on patients with spinal injuries or following spinal surgery. At least two nurses are required for this procedure; three if the cervical spine is the affected area.

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Do the following: • All nurses stand on the same side of the bed. • One nurse places one hand on the shoulder of the patient and the other on the buttocks. • The second nurse places one hand in the waist area and the other behind the knee. • The first nurse coordinates the roll, counting to three and the patient is rolled towards the nurses on the count of three.

Clinical alert! Application of body mechanics involves the following actions: • When lifting objects from the floor, bend at the hips and knees keeping the back straight and maintaining a wide base of support • Avoid bending from the waist as this will strain the muscles of the lower back • Adjust the height of the patient’s bed to avoid back strain • Carry objects close to the midline of the body • Avoid stretching to reach objects • Never lift alone, especially when lifting a patient who fell; use team lift or a mechanical assistance • Do not lift a patient who cannot support their own weight • Limit the number of manual ‘lifts’ during a shift • Avoid lifting with spine rotated

10.6  Guidelines for moving patients • Assess the patient’s level of mobility, size and weight • Assess the amount of strength required to move the patient to decide if you need assistance • Plan and utilise assistive devices that may be required • Assess the need for any analgesia before moving the patient • Explain the procedure to the patient as well as the ways in which the patient can assist if appropriate • Raise the height of the bed for your comfort and safety, this makes it easier to move the patient correctly • Ensure that the wheels on the bed are locked for the safety of the patient • If moving the patient on your own, consider putting up the side rail (cot side) on the side opposite to you to ensure safety

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• The side rail is put up, and the nurses move to the other side of the bed to pull the patient to the centre of the bed. • A pillow is placed behind the patient’s back and one under the head to maintain alignment of the neck and one between the legs. • If the patient has a cervical spine injury, the third nurse stands at the head of the bed (behind the bed) and maintains alignment of the head and neck by supporting the head on either side. This nurse must coordinate the roll.

Applying the principles of body mechanics As indicated above, the nurse needs physical strength in order to assist patients with mobility. Nursing care may require nurses to carry, pull and lift patients and objects. Nurses are among the groups at risk for back injuries when performing routine tasks of patient care, especially when lifting, position and transfer of patients. Implementation of the correct body mechanics helps the nurse to minimise the following: • Injury to the patient • Nurse work-related musculoskeletal injury • Nurse fatigue.

The collaborative role of the physiotherapist and the nurse The physiotherapist plays a vital role in the mobility and rehabilitation of the patient. The physiotherapist will assess the patient’s mobility and prescribe an exercise regimen for the patient. The patient on bed rest will receive chest physiotherapy to prevent hypostatic pneumonia and atelectasis. The nurse may continue to assist the patient with chest and breathing exercises in the absence of the physiotherapist. Passive or active exercise regimes will be commenced by the physiotherapist and continued by the nurse. On mobilising a patient, especially where assistive devices such as crutches or walking frames are used, the physiotherapist will initially educate the patient on the use of these. Thereafter the nurse can assist the patient until full mobility is gained. This role forms part of the interdependent function of a nurse (working in collaboration with other members of the health team).

Suggested activities for learners Activity 10.1 Describe the negative outcomes of immobility according to the systems of the body. Activity 10.2 Identify the various types of exercise and explain the benefits of each. Activity 10.3 Design a discharge plan for an elderly patient who requires a walker to take home for mobility.

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11

Temperature regulation needs

learning objectives

On completion of this Chapter, the learner should be able to: • identify the physiologic mechanisms that regulate temperature, including the factors that may influence the body temperature • explain how temperature is measured and monitored in patients • discuss ways in which heat is lost via the skin • distinguish between heat stroke and hypothermia • implement nursing interventions designed to manage temperature deviations. key concepts and terminology

heat stroke

A condition characterised by collapse following exposure to a very high temperature of 40 °C or higher.

hyperpyrexia

A very high body temperature of more than 40 °C.

hypothermia

An abnormally low body temperature of less than 35.5 °C.

normothermia

Normal temperature (between 36.1 °C and 37.2 °C).

pyrexia

Pyrexia, or fever, is an increase in body temperature; it is part of the body’s defence mechanisms against infection.

rigors

A severe febrile reaction, characterised by an alternating rapid rise and sudden drop in body temperature, accompanied by profuse shivering and sweating.

prerequisite knowledge

• Anatomy and physiology of the integumentary, nervous, cardiovascular and respiratory systems. medico-legal considerations

Failure to assess and monitor the body temperature of the patient may lead to misdiagnosis. Use of the breakable oral glass thermometer with unconscious patients and/or patients who are mentally unstable and children may lead to litigation following patients biting the thermometer and swallowing the mercury and glass. It is the nurse’s responsibility to ensure the safety of the patients under their care in line with their health status. ethical considerations

Failure to accurately assess vital signs, including body temperature, may lead to incorrect treatment as well as failure to identify problems timeously and/or changes in a patient’s condition, such as the onset of infection. essential health literacy

Maintenance of body temperature is one of the basic needs to enable the body to function normally. The thermoregulatory centre of the brain triggers changes in effectors, such as sweat glands and muscles, to constantly balance our temperature gains and losses. To survive in acute heat or cold, you’ll need to help your body out with a few preparations and some temperature-sustaining hacks.

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191

Communities need to know the importance of maintaining body temperature. When it is hot people may be dehydrated and/or suffer heat stroke. The ultraviolet rays of the sun may burn the skin and with constant and prolonged exposure cause cancer of the skin. People therefore need to adequately protect themselves against strong heat or sun exposure by using appropriate clothing such as long-sleeved shirts, wide brimmed hats and application of sunscreen. Where possible activity in the heat and exposure to the sun must be limited. Those exposed to the sun also need to drink plenty of water. Similarly in cold weather, people may suffer hypothermia and frostbite. If one is to be exposed to cold one must wear warm clothes, eat energy-generating food and drink hot liquids. Parents of children under 5 must try and not let the children develop a high temperature, ie > 38 °C, as this may lead to febrile convulsions.

Introduction The physiological function of temperature regulation, or thermoregulation, is the process whereby the temperature is kept within the normal range. The internal body temperature is regulated to provide the optimum conditions for enzyme reactions to be carried out. The normal internal body temperature for people ranges between 36.0 °C and 37 °C (degrees Celsius), and is the optimum temperature range for normal body processes. The development, implementation and evaluation of effective care plans for patients with altered body temperature are thus important aspects of basic nursing care.

Overview of regulation of body temperature Body temperature is the difference between the amount of heat produced by body processes and the amount of heat lost to the external environment. Temperature is measured with a thermometer or temperature probe. The normal basal body temperature is termed normothermia. The temperature of the body is regulated by neural and vascular feedback mechanisms which operate primarily through the hypothalamus. The hypothalamus contains not only the control mechanisms, but also the key temperature receptors, namely peripheral receptors found in the skin and central receptors found in the internal organs. Under the control of these mechanisms, sweating begins almost precisely at a skin temperature of 37 °C and increases rapidly as the skin temperature rises above this value. Temperatures above 37 °C start to denature enzymes and block metabolic pathways. The heat production of the body under these conditions remains almost constant as the skin temperature rises. Temperatures below 37 °C slow down metabolism and affect the brain. If the skin temperature drops below 37 °C, a variety of responses are initiated to conserve the heat to maintain the body temperature. These responses include: • Vasoconstriction to decrease the flow of heat to the skin

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• Cessation of sweating • Shivering to increase heat production in the muscles • Secretion of norepinephrine, epinephrine, and thyro­x­ ine to increase heat production • An action to cover up in warm clothes.

The mechanisms of heat production and heat loss The hypothalamus acts as a thermostat by attempting to maintain a comfortable temperature at a ‘set point’. The hypothalamus receives nerve impulses from heat and cold thermoreceptors in the skin. The preoptic area of the hypothalamus contains large numbers of neurons that are sensitive to temperature changes. Some of these neurons are sensitive to heat, while others are sensitive to cold. These heat-sensitive neurons are stimulated by an increase or decrease in body temperature. The skin, abdominal viscera and the spinal cord also contain heat and cold receptors, which are stimulated by an increase or decrease in body temperature. Stimulation of these receptors triggers reflex actions designed to increase or decrease body temperature in order to maintain body temperature within the normal range. When the body temperature rises above normal, the hypothalamus sends out a signal through the nervous system that causes vasodilation, sweating and inhibition of heat production. Conversely, if the hypothalamus senses the body’s temperature lower than the set point, it sends a signal out to increase heat production by vasoconstriction and muscle shivering. When the body is too hot, the following temperaturereducing mechanisms come into play: • Vasodilation takes place throughout the skin and sweating increases, which enhances the amount of heat lost by radiation, conduction, convection and evaporation. • Heat-generating activities, such as shivering, are strongly inhibited. Indeed, the individual is inclined

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•

•

•

•

to feel lethargic in hot conditions to minimise bodily activity and heat production. When the body is too cold, temperature-increasing mechanisms are induced. Blood vessels supplying the skin become constricted. This reduces the amount of heat brought to the surface, and reduces heat loss through radiation, conduction, convection and evaporation. Shivering triggered by the hypothalamus increases heat production. Impulses arise in the primary motor centre for shivering, which is situated in the posterior part of the hypothalamus. The muscular activity that occurs during shivering produces heat and increases body temperature. Sympathetic stimulation of heat production occurs through an increase in the rate of cellular metabolism. Chemical thermogenesis results from the action of adrenaline and noradrenaline. This chemical thermogenesis involves the uncoupling of oxidative phosphorylation, which means that all of the energy released from food is released in the form of heat instead of being stored as ATP. Thyrotropin-releasing hormone is secreted by the hypothalamus. This in turn causes the release of thyroid-stimulating hormone from the pituitary gland, causing the production of thyroxin by the thyroid gland to be increased. This increased production of thyroxin causes a long-term increase in cellular metabolism, which is one of the ways in which the body adapts to a colder climate.

In addition to these subconscious reflex mechanisms, conscious behavioural control of body temperature also takes place. When the environmental temperature falls, a person adds clothing, moves to a warmer place, raises the thermostat setting on a furnace, increases muscular activity by moving around, or sits with arms and legs tightly wrapped together. In contrast, when the temperature becomes hot, a person removes clothing, stops activity, lowers the thermostat setting on an air conditioner, seeks a cooler place or takes a cool shower.

Heat production Thermoregulation requires normal heat production processes. Heat is produced in the body through the following six mechanisms: 1. Metabolism of foodstuff. Most of our energy for growth and repair of tissues, for work and for body warmth comes from the food we eat. Different foods provide different amounts of energy. As metabolism increases,

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2.

3.

4.

5. 6.

the body produces additional heat. Conversely, when metabolism decreases, the body produces less heat. Most of this energy is transferred to adenosine triphosphate (ATP), which is a chemical that is used for the storage of energy within the cells. However, not all of this energy contained in foodstuffs is transferred to ATP. Some (35%) of this energy is released as heat. More heat is released when energy is transferred from ATP to the functional systems of the cell. Muscular activity and movement. Metabolic rate increases during activity, sometimes causing heat production to increase up to 50 times; and subsequently increasing the demand for energy. During muscular contraction, energy is used, and some of this energy is released as body heat. Muscular movement also causes friction within the tissues, and this generates additional heat. Thyroxine output. An increased thyroxine output increases the rate of cellular metabolism throughout the body. Epinephrine, norepinephrine and sympathetic stimu­ lation/stress response. These hormones immediately increase the rate of cellular metabolism in many body tissues. Fever. Fever increases cellular metabolic rate and thus increases the body’s temperature further. Blood flow. As it flows, blood causes friction against the walls of especially the arteries, but also the peripheral blood vessels. Friction also occurs as the different layers of blood move over each other.

Heat loss Heat loss and production occur simultaneously. The skin’s structure and exposure to the environment result in constant, normal heat loss through radiation, conduction, convection and evaporation. Blood flow from the internal organs carries heat to the skin, which is dissipated and lost to the atmosphere in order to avoid a dangerous build-up of heat in the body.

Heat loss via the skin Heat is brought to the skin from the inner organs via the circulation. The skin contains a vast network of blood vessels, many of which are interconnected to form an effective ‘radiator’ mechanism for the dissipation of body heat to the environment. The amount of blood, and therefore body heat, which enters this radiator mechanism, is regulated by the sympathetic nervous system, which controls the degree of vasoconstriction in the arterioles feeding the subcutaneous capillary network. Heat is transferred from the skin to the environment in several ways. The external heat transfer mechanisms

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are through radiation, conduction, convection and evaporation. Radiation. Radiation is the transfer of heat between two objects without physical contact. Heat radiates from the skin to any surrounding cooler object. If the heat of the body is greater than that of the environment, heat is lost from the body to the environment. Conduction. Conduction is the transfer of heat from one object to another with direct contact. Heat may be lost when warm skin touches a cooler object until the temperatures are similar. Heat may also be lost by conduction from the skin to the layer of air immediately in contact with the skin or clothes. Conduction will also occur if the body is immersed in cool water, eg when applying an ice pack or bathing a patient. In fact, water attracts far greater amounts of heat than air. Convection. Convection is the dissipation of heat away from the body by air movement. Heat is lost to the layer of air immediately adjacent to the skin by convectional currents, where warmed air from the skin rises and is replaced by cooler air that is in turn warmed by conduction. This effect is enhanced if the body is exposed to wind, because the warmed air next to the skin is replaced much faster. For example, an electric fan promotes heat loss through convection. Evaporation. Evaporation is the transfer of heat energy when a liquid is changed to a gas. When water in the form of sweat dries and evaporates from the skin, surface heat is lost. Insensible loss of + 600 ml of water per day takes place even when the individual is not actively sweating. About 12 to 16 calories per hour are lost due to this insensible loss. Regulating the rate of sweating can control the rate of heat loss by evaporation. Evaporation is an essential heat loss mechanism when the temperature of the ambient air is very high. For as long as the temperature of the surrounding air is cooler than that of the skin, heat can be lost by radiation, conduction and convection. But if the surrounding temperature is greater than that of the body, the body will gain heat by the above-mentioned mechanisms, unless sweating occurs, which allows heat to be lost by evaporation. Clothing affects heat loss by conduction and convection. In this case air is trapped next to the body by the fabric of the clothing, reducing conduction. Obviously this varies according to the weight, amount and thickness of the clothes.

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Heat loss from other sources Body heat is also lost via exhaled air, as well as via urine and faeces. Exhaled air, urine and faeces are all at body temperature when eliminated, which removes heat from the body. Excessive diarrhoea will reduce body heat, hence hypothermia is a dangerous sign in diarrhoeal cases.

Normal variations in body temperature Body temperature is lowest in the early morning when metabolic rate and heat production are at their lowest. The temperature is highest in the afternoon and early evening when one is active.

Factors which affect a person’s temperature Age. Temperature regulation varies with age. Infants have an immature thermoregulatory mechanism and their temperature is greatly influenced by the environment, which is why infants need protection from extreme alterations in environmental temperature. Children’s temperature tends to be more imbalanced than that of adults. Elderly people have decreased thermoregulatory controls and are also more sensitive to extremes of environmental temperature changes. Elderly individuals are particularly at risk for hypothermia due to poor activity and poor diet, as well as poor temperature-regulating mechanisms. Exercise. Strenuous exercise or physical labour can raise body temperature due to the increase in muscular activity. The menstrual cycle. The action of hormones may have an effect on body temperature. At ovulation, a woman’s body temperature may increase by ±1°C, due to the influence of progesterone. Just prior to ovulation, the oestrogen peak may cause a slight decrease in body temperature. Eating a meal. The process of breaking down and metabolising food produces body heat. A high-fat and -carbohydrate diet will yield more heat than that of a lowfat and -carbohydrate diet. Other hormones. Thyroxin, adrenaline and noradrenaline all increase body temperature. Heat production is increased by stress, due to the action of adrenaline and nor-adrenaline. The body is not at a uniform temperature at all sites or in all tissues. Skin temperature varies in accordance with air temperature and will be considerably lower than oral, axilla or rectal temperature, we refer to core temperature and peripheral temperature.

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Measuring the body temperature Clinical thermometers A thermometer is a device that measures temperature or temperature gradient using a variety of different principles. Different types of clinical thermometers are available depending on the body part used to measure the temperature, namely, mercury thermometers, electronic thermometers, and rectal and surface/skin thermometers.

The mercury thermometer The mercury thermometer is the most commonly used, but with recent developments and efforts to reduce cross-infection, other types of thermometers that are less invasive have come to the fore. The mercury thermometer is often made from a sealed glass tube with a small column of mercury metal at the tip of the glass tube, as seen in Figure 11.1. The mercury changes volume by expanding when hot, and will rise into the shaft of the thermometer which is graded. The hotter the temperature, the higher the mercury rises. The temperature is simply read off markings on the tube at each height. Thermometers are calibrated in either degrees Fahrenheit (°F) or degrees Celsius (°C), depending on the custom of the region. The standard in most countries is degrees Celsius.

Practice alert! In the wake of adverse encounters in healthcare, the nurse should recommend the replacement and safe disposal of mercury thermometers with less hazardous thermometers.

Electronic thermometers Electronic thermometers are very accurate and often more suitable for measuring a patient’s temperature than mercury thermometers. Ear (tympanic) thermometers are examples of electronic thermometers as seen in Figure 11.2. These thermometers determine temperature by detecting infrared radiation emitted from the tympanic membrane. A thermopile, an infrared sensor, is commonly used in ear thermometers.

Other electronic thermometers Electronic clinical thermometers include under-arm and oral thermometers as seen in Figure 11.3. The underarm thermometers are kept in the armpit to measure the body temperature of the patient. Likewise, the oral thermometers are held in the mouth (posterior sublingual pocket) for temperature measurement.

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Rectal and surface/skin thermometers A plastic thermometer strip placed on the forehead gives an approximate local reading, which depends to a great extent on ambient air temperature and local circulation effects. The tip of the thermometer is placed in contact with the skin, which may be the armpit, groin or at the back to provide a reading of the skin temperature. A rectal thermometer, as seen in Figure 11.6, is placed in the rectum to provide a reading of the core temperature in the rectum.

Sites for taking temperature Taking a patient’s temperature is an initial and routine part of a full clinical examination. Normal human body temperature varies slightly from person to person and by the time of day. The temperature reading depends on which part of the body is being measured. Consequently, each type of measurement has a range of normal readings. The sites that are used for measuring temperature are as follows: the mouth (oral temperature), the armpit (axillary temperature), the anus (rectal temperature), the ear (tympanic temperature), the skin of the forehead and over the temporal artery. The common sites for measuring temperature are discussed in Table 11.1.

11.1 Nursing considerations for measuring body temperature • Patient safety should be considered when selecting a method for measuring a patient’s temperature • The appropriated route, device and site based on the patient’s condition and age should be considered • Avoid rushing the procedure for temperature measurement; always measure the temperature for long enough (correct stipulated time) to allow time for the thermometer to indicate the reading correctly • Determine previous activity that will interfere with accuracy of temperature measurement; for example, always check if the patient has smoked or ingested anything hot or cold just prior to having the temperature measured (if that is the case, the nurse should wait for 20–30 minutes before measuring the temperature) • Antipyretic drugs should be used with caution: the anti-inflammatory effect of these drugs could inhibit the normal defence mechanisms of the body

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Figure 11.1  Mercury thermometer

Figure 11.2  Tympanic thermometer

Figure 11.3  Electronic clinical thermometer

Figure 11.4  NexTemp thermometer

Figure 11.5  Tactile/surface thermometer

Figure 11.6  Rectal thermometer

Clinical alert!

Clinical alert!

Please note that each patient must have their own thermometer.

NB: Do not use the axilla if the patient has skin lesions, as this alters local temperature and the area is painful to touch.

See Table 11.2 for the measurement of oral tempe­rature. See Table 11.3 for the measurement of rectal tempe­ rature. See Table 11.4 for measurement of axillary/skin tem­ perature.

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Management of common clinical problems related to temperature regulation Pyrexia Pyrexia, or fever, occurs when the body’s core temperature rises above the normal limit for that individual at rest,

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196  Juta’s Complete Textbook of Medical Surgical Nursing Table 11.1  Sites for body temperature measurement: advantages and disadvantages

Site

Nursing practice

Advantages

Disadvantages

Mouth

Oral thermometer is placed • Safe and accessible for under the tongue in the mouth. older children and adults For the mercury in the glass • Reliable indication of thermometer to expand and give body temperature a correct reading, it is left in situ for 1 minute. The normal range is between 36.5 °C and 37.5 °C.

• Inaccurate results after ingestion of hot or cold drinks, food or smoking • Wait for 20–30 minutes before taking measurements under these circumstances

Axilla

The thermometer is placed in the centre of arm pit the arm is held against the chest. The thermometer is left in position for 3 minutes.

• Ideal for babies and toddlers

• Less accurate than oral and rectal measurements • Measurement can be affected by external influences

Rectum

The rectal thermometer is inserted 4 cm into the anus (adults) and 2–3 cm in infants. It is left in situ for 4 minutes.

• Suitable for babies and unconscious patients

• Rectal temperature may be higher than at other sites • Not suitable for conscious patients

Ear/tympanic membrane

Gently pull the pinna of the ear backwards. Insert the ear piece into the auditory canal. The thermometer emits a ‘buzz’ when the measurement is complete.

• Simple and quick • Measurement takes 1-–2 seconds • Plastic disposable probes reduces risk of infection to the patient as well as cross-contamination

• The ear piece can be difficult to place in babies • May result in inaccurate measurements if the thermometer is not placed correctly • False low readings occur when ears are cold

Source: adapted from Stellenberg & Bruce, 2007

11.2  Resources for monitoring vital signs Measuring temperature is part of the routine in monitoring cardinal vital signs which also includes respiration, pulse, blood pressure and, in some instances, oxygen saturation. Resources required to monitor vital signs (temperature, pulse and respiration) are: • An appropriate thermometer for the chosen site (oral, axilla and rectal) • Swabs or tissues to wipe the thermometer after use • Two receptacles for used thermometers and used swabs • A watch with a second hand • Lubricant (for rectal measurements only) • Disposable gloves when needed • A stethoscope if blood pressure will be monitored as well • Appropriate forms or flow sheet for recording. It is important to make sure that the vital signs are recorded on one form for meaningful interpretation.

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eg up to 38.2 °C. Pyrexia is part of the body’s defence mechanisms against infection. The pathophysiology of pyrexia includes: • The presence of viruses, bacteria, fungi or bacterial endotoxins in the circulation stimulates the immune system. • Stimulation of the immune mechanism triggers the production of antibodies and the activation of the inflammatory response. • As a result of these processes, substances such as complement prostaglandins, interleukins and inter­ feron are formed, which act as internal pyrogens and which stimulate the temperature-regulating centres and increase body temperature. • This increase in body temperature causes an increased pulse rate, and increased respiratory rate. The increased body temperature that occurs in pyrexia also enhances the host defence mechanisms. • The individual who is pyrexial feels hot, is flushed and sweating and may experience general malaise accompanied by aches and pains as well as weakness. The individual has a tachycardia and a reduced urine output. If the temperature is very high, a trace

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Table 11.2  Measuring oral temperature with a mercury thermometer

Action

Rationale

1. Assemble the equipment

To ensure a smooth flow of the procedure

2. Ensure that the patient has not recently had a smoke, a hot or cold drink, a hot bath or been engaged in exercise

To ensure correct body temperature readings

3. Explain the activity as well as what is expected from the patient, ie keeping the thermometer in the mouth under the tongue without biting it

To gain cooperation To obtain correct readings

4. Assist the patient to assume the most comfortable position that will provide easy access to route through which you will measure temperature

To ensure comfort and accuracy of temperature reading

5. Wash hands and wear gloves

To reduce the risk of infection

6. Remove the thermometer from the container and shake it with a whipping movement

To get the mercury down to the tip of the thermometer to get the correct reading

7. Request the patient to open their mouth, and place the thermometer probe in the mouth under the tongue, reinforcing the instruction to the patient to hold the thermometer under the tongue – ask the patient to hold the thermometer with the lips closed and not to bite the thermometer

To maintain proper position of the thermometer and obtain an accurate reading from the thermometer

8. Leave the thermometer in their mouth for at least 1 minute (most thermometers have instructions on how long they should be left in the mouth)

To ensure accurate reading

9. Remove the thermometer when the optimum time (according to the manufacturer) has elapsed

For accurate reading

10. Read the temperature measured by the thermometer immediately by holding the thermometer parallel at the level of the eyes

The reading has to be taken before the mercury contracts

11. Record the reading of the temperature accurately in the temperature chart and in the patient’s record; compare the reading with previous recordings and report on abnormal findings

For reference and meaningful care of the patient

12. While the thermometer is in the mouth, measure the pulse by locating the radial artery. Place the second, third and fourth fingers of the right hand along the artery at the wrist and press lightly against the underlying bone; measure pulse in terms of rate, rhythm and quality. You may also be able to detect abnormalities in terms of the stated variables.

To enable you to count the pulsation of the artery as the blood passes through the lumen, denoting heartbeat

13. Pulse is counted for 1 minute

Sufficient time enables you to detect any abnormality as indicated in Chapter 32

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Action

Rationale

14. Record the measurement immediately and appropriately and also compare with previous readings

To ensure accuracy and detect abnormalities early for timely intervention

15. Respiration is also measured while the thermometer is in the mouth. For best results, the patient should be positioned comfortably and should not be aware that their breathing is being measured. For this reason respiration is measured simultaneously with temperature and pulse.

Knowing that their respiration is being measured may cause undue anxiety and subconsciously affect the respiratory rate

16. With the thermometer in the mouth and three of your fingers on the pulse point, breathing is discreetly counted

This helps to reduce the risk of the patient becoming aware that the respiratory rate is being assessed

17. Count the respiratory rate for 1 minute by observing the rise and fall of the patient’s chest: one count constitutes a cycle of inspiration and expiration

The 1-minute observation provides a long enough time to observe any abnormalities in rate rhythm and quality

18. Record the counted frequency and any abnormalities

For analysis and reference

19. Leave the patient comfortable

To complete the activity

20. Discard used supplies; remove the gloves; wash the used thermometers in soapy water

To reduce the risk of cross-infection

of albumin may be found in the urine on testing. Temperatures of up to 39.5 °C can be considered to be a normal response to infection. • Because pyrexia enhances the host’s defence mechanisms, low-grade and moderate pyrexia should not be actively reduced with antipyretics. If, however, the temperature rises above 40 °C, active reduction may be necessary. At temperatures of above 40.5 °C, body proteins start to become denatured, or altered. Denatured body proteins are unable to perform their normal functions.

Management of pyrexia For moderate pyrexia, management is directed at maintaining the patient’s comfort, as follows: • Remove excess clothes and bedclothes, but do not allow the patient to become chilled. • Fanning may be used, as well as tepid sponging to remove excess sweat and increase comfort. Unless contraindicated, plenty of water and other fluids should be given to replace fluid lost in sweating. • Nutritional requirements are increased during pyrexia, and adequate nutrition should be given. A diet that is high in protein and calories, and that contains adequate amounts of vitamins, should be provided. • Antipyretics drugs, such as aspirin, paracetamol and indomethacin should only be given if the temperature is very high and approaching danger level.

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• Antibiotics may be given as prescribed to combat infection.

Rigors A rigor is a severe febrile reaction, characterised by a rapid rise in body temperature, followed by a sudden drop in body temperature back to normal or even subnormal levels. A sudden onset of ‘rigor’ or ‘chill’ is characteristic of some disease such as severe infection and malaria. Rigors may be caused by a variety of factors, including the following: • The onset of a febrile illness, such as flu (influenza) • Incompatible blood transfusion • Contaminated intravenous fluids • Septicaemia • Malaria. A typical rigor has the following distinct stages: • Cold stage. The patient feels cold and shivers uncontrollably, which increases the temperature. The nurse should cover the patient with blankets and ensure comfort. The temperature should be recorded at regular intervals. • Hot stage. The patient feels hot and has a headache. The skin is hot and dry and the temperature reaches its peak. The nurse should continue to record the temperature at regular intervals and the peak

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Table 11.3  Measuring rectal temperature

Action

Rationale

1. Draw the curtain around the bed and/or close the door

To provide privacy, promote comfort and minimise embarrassment

2. Explain the activity, as well as what is expected from the patient, ie keeping the thermometer in the rectum and not to strain

To gain cooperation Not to expel the thermometer from the rectum

3. Assist the patient to assume the most comfortable position, eg Sims’ position (see Chapter 10)

To facilitate easy accessibility

4. Perform hand hygiene

To reduce the risk of cross-infection

5. Wear gloves

To minimise cross-infection from the nurse

6 Take the thermometer from the container and shake it with a whipping movement

To get the mercury down to the tip of the thermometer to obtain the correct reading

7. Lubricate the thermometer with a water-based lubricant

To make insertion easy and prevent any damage to the mucous membrane

8. Separate the buttocks with the non-dominant hand and gently insert the thermometer into the anus for 2–4 cm and hold in position for the required recommended time according to the manufacturer’s instruction (this is usually 3 minutes)

To obtain an accurate reading from the thermometer

9. Remove the thermometer when the optimum time (according to the manufacturer) has elapsed

For accurate reading

10. Read the temperature measured by the thermometer immediately by holding the thermometer parallel at the level of the eyes before wiping the thermometer with a swab/tissue paper

The reading has to be taken before the mercury contracts

11. Accurately record the temperature in the temperature chart and in the record of the patient; in reading the temperature, compare the reading with previous recordings and report on abnormal findings

For reference and meaningful care of the patient

12. Leave the patient comfortable

To complete the activity

13. Discard used supplies; take off the gloves and wash the used thermometers in soapy water

To reduce the risk of cross-infection

NB: If you cannot insert the thermometer into the rectum, remove the thermometer and consider an alternative route. temperature should be recorded. To maintain comfort, excess bedclothes should now be removed. Tepid sponging or fanning may also enhance comfort. Cool drinks may be given. If indicated and/or prescribed by the doctor, an appropriate antipyretic may be given if the peak temperature is in excess of 39.5 °C. • Sweating stage. The temperature drops rapidly, accompanied by profuse sweating. Keep the patient dry and comfortable and prevent chilling. Continue to

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record the temperature regularly. Warm or cold drinks can be given, if permissible. Ways in which the temperature may drop are as follows: • Crisis. This is an abrupt decline in fever and may occur when the body controls the infection. The temperature falls to normal over a period of a few hours, accompanied by profuse sweating and an improvement in the patient’s condition.

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200  Juta’s Complete Textbook of Medical Surgical Nursing Table 11.4  Measuring axillary temperature

Action

Rationale

1. Draw a curtain around the bed and/or close the door

To maintain privacy, promote comfort and minimise embarrassment

2. Explain the activity as well as what is expected from the patient, ie the importance of maintaining proper position until reading is complete

To gain cooperation and get the correct reading

3. Assist the patient to remove clothing to expose the axilla

For easy accessibility

4. Perform hand hygiene

To reduce the risk of cross-infection

5 Ask the patient to lift the upper arm if possible

To expose the axilla

6. Wipe the axilla dry with a tissue paper/cotton wool swab

Because a film of moisture in the armpit can cause inaccurate temperature readings

7. Take the thermometer from the container and shake it with a whipping movement

To get the mercury down to the tip of the thermometer to get the correct reading

8. Place the thermometer bulb in the axilla; instruct the patient to close the axilla, such that the skin surfaces surround the bulb of the thermometer. Make sure that the bulb of the thermometer is in contact with the skin; if not, it may be necessary to remain with the patient and hold the arm firmly down over the thermometer.

To obtain accurate temperature reading from the thermometer

9. Leave the thermometer in position for the optimum time that is recommended by the manufacturer

For accurate reading

10. Remove the thermometer when the optimum time (according to the manufacturer) has elapsed

For accurate reading

11. Read the temperature measured by the thermometer immediately by holding the thermometer parallel at the level of the eyes

The reading has to be taken before the mercury contracts

12. Accurately record the reading in the temperature chart and in the record of the patient; in reading the temperature, compare the reading with previous recordings and report on abnormal findings

For reference and meaningful care of the patient

13. Leave the patient comfortable

To complete the activity

14. Discard used supplies; take off the gloves and wash the used thermometers in soapy water

To reduce the risk of cross-infection

• Lysis. The temperature falls gradually over a period of a few days, accompanied by a gradual improvement in the patient’s condition.

catabolic syndrome, associated with the administration of general anaesthesia, and in particular with the use of muscle relaxants such as Suxamethonium.

Malignant hyperpyrexia/hyperthermia

Causative factors

Hyperthermia occurs less frequently than hypothermia in a surgical patient. Malignant hyperthermia (MH) is a hyper-

The condition is due to an inherited defect in the control of calcium concentrations within the muscle cell.

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201

Anaesthetic agents and depolarising muscle relaxants such as Suxamethonium cause muscle fasciculation or twitching before producing neuromuscular blockade. In individuals with malignant hyperpyrexia, this low-grade activity of skeletal muscle continues, causing the body temperature to soar to dangerous levels. Although general anaesthesia is the most-commonly documented cause of this condition, it is thought that malignant hyperpyrexia may also be triggered by excessive exercise, stress or fever, dehydration and endocrine disorders such as thyroid disease and intracranial infection. The clinical manifestations of malignant hyperpyrexia include: • An elevated body temperature, which continues to rise • Muscular rigidity • Tachycardia • Hyperkalaemia • Hypotension • Headache • Nausea and vomiting.

Blood tests The patient will present with acidosis, due to excessive lactic acid production in the skeletal muscles. Levels of creatinine phosphokinase will be elevated, indicating cellular and muscular damage.

Management of hyperthermia Treatment of a patient with hyperthermia should be conducted as follows and as demonstrated in Figure 11.7. • Eliminate underlying cause if identifiable and possible; for example, if hyperthermia is caused by extensive sun exposure, move the patient to a cool, shaded area and provide lots of fluid to alleviate symptoms. • Remove excess blankets and administer iced saline irrigations via rectal and/or nasogastric tubes. • Apply cool water to the patient’s skin with a tepid sponge. • Use an automatic cooling blanket. • Tissue damage is monitored by regular estimations of haemoglobin, myoglobin and urinary myoglobin through blood tests. • Fluid balance is extremely important, therefore adequate fluids are given both orally and intravenously to maintain hydration and to prevent kidney damage. • Antipyretic agents like Paracetamol, Ibuprofen and Aspirin may be given to diminish hyperthermia.

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Figure 11.7  Immediate management of a hyperthermic patient should include sponging/cold compresses, airconditioning and fluid intake

• The condition is treated with a skeletal muscle relaxant. This stops the excessive contractile action that pushes the temperature up to dangerous levels. • Following an episode of malignant hyperpyrexia, the patient must be educated about the condition, and it should be explained to them that the wearing of a MedicAlert® bracelet is mandatory.

11.3  Febrile convulsions in children Febrile convulsions in children are as a result of hyperthermia/hyperpyrexia (see Chapters 14 and 45).

Heat stroke This condition is due to an imbalance between heat gain and heat loss. The normal heat-dissipating mechanisms, such as sweating, are unable to keep up with heat gained from the environment, or from bodily activity, or both. Classic heat stroke commonly occurs in the elderly or the very young during exposure to high temperatures. Because autonomic function is often impaired in the elderly and in immature infants, making heat loss difficult, elderly people and infants are at risk of getting heat stroke during periods of very hot weather. Heat loss mechanisms are also impaired in the chronically ill due to debility, and this group of people is also at risk of getting heat stroke during very hot weather. But heat stroke may occur in healthy adults as well, in cases where heat gain exceeds heat loss.

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Physical exertion carried out in hot or humid conditions, especially if the individual is not adequately hydrated, may lead to heat stroke. The clinical manifestations of heat stroke include: • A body temperature that is 40 °C or higher • Metabolic acidosis, which may occur due to increased lactate levels in exertional heat stroke • Respiratory alkalosis, wich is common in classical heat stroke due to hyperventilation that occurs as an attempt to lose body heat by panting • Neurological changes, including confusion and impaired consciousness • Rhabdomyolysis, due to breakdown of muscle tissue (may lead to acute renal failure) • High levels of creatinine phosphokinase, which also indicates cellular damage • Elevated levels of serum amylase and aspartate, which is another indication of cellular damage • Cardiovascular manifestations include tachycardia and hypotension: on an ECG, some victims may present with a prolonged Q–T interval, which predisposes to dysrhythmias. The Q–T interval returns to normal once the heat stroke is reversed.

Nursing management of heat stroke The patient must be cooled gradually. Rapid cooling is not advisable as convulsions may occur. Effective methods of bringing about a steady decline in temperature include: • Fanning • Tepid sponging/spraying • Rehydration if necessary • Acid–base abnormalities should correct themselves once the primary problem of hyperthermia has been rectified, but cautious correction may be needed in cases of severe metabolic acidosis • Urine output must be carefully monitored in order to detect incipient renal failure.

Hypothermia Hypothermia is defined as an abnormally low body temperature. For example, 35 °C to 36 °C constitutes mild hypothermia, while a temperature of less than 35  °C is termed severe hypothermia. Factors that predispose patients to hypothermia are as follows: • Age. The very young and the very old have an increased risk for accidental hypothermia because of their impaired ability to adapt to a colder environment. The elderly, in particular, have both a decreased

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•

•

•

•

•

•

•

metabolic rate as well as a diminished sympathetic vasoconstrictor response to colder conditions. Malnutrition. Malnourished and starving people have decreased heat production, which places them at risk for hypothermia. Trauma. Burns victims may lose a considerable amount of body heat via the wound, placing them at risk for hypothermia. Other trauma victims are also at risk through loss of blood and exposure of injured tissues to cool air. Medical conditions. Diabetics have autonomic neuropathy, which decreases their ability to vaso­ constrict in cold conditions. Patients with a decreased metabolic rate, as in hypothyroidism, produce less body heat and are therefore vulnerable to hypothermia. Medication. Certain medication may also impair the body’s heat-generating mechanisms, for example, muscle relaxants and phenothiazines. Sedations. Certain medication impairs the ability to vasoconstrict, such as beta-blockers and vasodilators, and may also put the patient at risk for hypothermia. Surgery. The greatest heat loss occurs in the first hour of surgery. The patient should be covered as much as possible before surgery begins. Other causes. Alcohol, coupled with exposure to cold, is often a cause of hypothermia. Alcohol depresses the central nervous system, causes peripheral vasodilatation, and gives the individual a feeling of being warm. A drunken person who is exposed to cold is less likely to protect the body and is thus more likely to develop hypothermia.

Clinical manifestations of hypothermia include: • A very low body temperature, less than 35 °C. Recording the temperature in hypothermia can be problematic, and the temperature should be taken with a special low-reading rectal thermometer. • Initially, exposure to cold causes vasoconstriction with increased blood pressure, heart rate and cardiac output. However, as the body temperature continues to fall, the blood pressure and heart rate also drop. • At a body temperature of 32 °C or less, the victim is hypotensive and atrial and ventricular dysrhythmias may also occur. • At a temperature of around 27 °C, cardiac arrest from ventricular fibrillation occurs. • Metabolic acidosis may occur due to a build-up of lactic acid in tissues that are poorly perfused due to vasoconstriction.

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• Shivering may also contribute to the build-up of lactic acid. • Hypothermia also affects coagulation, so intra-tissue bleeding may occur. • Alterations in CNS function in hypothermia begin with fatigue and apathy, progressing to impaired judgement, hallucinations and bizarre behaviour culminating in a coma. • Urine output increases in hypothermia due to a phenomenon known as ‘cold diuresis’. It is thought that this is due to a combination of factors such as: –– An interstitial space-to-intravascular compartment fluid shift –– Increased excretion of sodium by the kidney that pulls water with it –– Decreased sensitivity to an antidiuretic hormone (ADH), which increases urinary output. • The loss of fluid via an increased urine output will increase the viscosity of the blood and may lead to thrombosis.

Management of hypothermia NB: Prevention is the best treatment of hypothermia. • Remove the patient/victim from the cold environment. • Remove any wet clothes, which will exacerbate the heat loss and skin irritation. • Cover the patient with warm blankets. • Provide warm fluids if the victim is conscious and able to swallow. • Radiant heat lamps can also be used to provide warmth. • Intraoperatively, the nurse should ensure that the patient’s skin is exposed as little as possible during positioning, preparation and draping. • A forced-air warming device is commonly used during surgery to conserve body temperature. • Use a warming blanket, although this is controversial as it can cause heat loss due to vasodilatation. Vasodilatation will increase blood flow through peripheral tissues that are cool due to the hypothermia, and may drop the victim’s temperature yet further – a phenomenon known as ‘after drop’. • More aggressive forms of treatment include: –– Giving warmed intravenous fluids –– Irrigating body cavities, such as the peritoneum and/or mediastinum, with warmed saline –– Continuous arterio-venous re-warming may be instituted. • As a rule, passive therapies are appropriate for patients with mild to moderate hypothermia, while aggressive

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re-warming is reserved for patients with severe hypothermia. During treatment blood pressure, heart rate and heart rhythm must be constantly monitored. The rectal temperature is continuously monitored using an electronic probe. The management and nursing care plan of patients with altered body temperatures is summarised in Table 11.5.

Essential health information South Africa has a hot climate in summer, any person exercising in the heat should be made aware of the potential danger of heat stroke. • Joggers and cyclists must be encouraged to drink adequate fluids while exercising. • Infants and toddlers have an immature temperatureregulating mechanism, and are sometimes inclined to develop inappropriately high temperatures for what is normally a mild illness such as flu. If a child develops a hyperpyrexia, remove excess clothing or bedclothes, increase fluid intake and tepid sponge. If the pyrexia does not settle, the child should be taken for medical consultation. • People at risk for hyper- or hypothermia include those living and working in very hot or very cold environments, as well as the very young and the very old. These should be educated on measures to prevent these problems from occurring. • Clinical thermometers are relatively inexpensive and are useful items to have in the home in the first-aid box or medicine cupboard. Community members should be taught the correct use and handling of home clinical thermometers. Clinical thermometers can be a danger in the home, especially if small children are present, as thermometers break easily and the mercury and glass may be swallowed and glass may cut the skin. Thermometers should be kept in a safe place out of the reach of children. The nervous system of a very small child is also much more sensitive to a high temperature than that of an adult’s. Many toddlers and infants may have febrile convulsions when their temperature is very high, causing great alarm in the household. If a child does have a febrile convulsion, the first thing to do is to reduce the temperature. This can be done by removing clothes, giving a tepid sponge or by giving a paediatric dose of a simple antipyretic such as paracetamol when the child is conscious. Bringing the temperature down relieves the convulsions, which are due to irritation of the neurons by the high temperature.

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204  Juta’s Complete Textbook of Medical Surgical Nursing Table 11.5  General nursing care plan of a patient with altered body temperature

Problem/ Need

Nursing diagnoses

Expected outcomes

Nursing interventions and rationale

Evaluation

• Pyrexia • Rigors • Hyperthermia • Hypothermia

Altered thermoregulation related to the disease/condition as evidenced by elevated temperature, convulsions or low temperature, sweating, shivering and patient verbalising that they are feeling hot or cold

Body temperature maintained at 36–37.5 ºC

Pyrexia: nurse in a cool room, remove extra blankets and clothing, tepid sponge the patient, provide a fan, open windows, encourage intake of cold oral fluids, monitor temperature hourly, administer antipyretics and antibiotics as prescribed. Rigors, sweating: reassure the patient and explain the cause of rigors, cover patient adequately, change clothing when required, ensure safety during the rigors, record patient’s condition accordingly. Hypothermia: nurse in a warm room, provide a heater, put on extra blankets as required, provide a forced-air warming device while taking care not to overheat the patient, monitor temperature hourly, provide warm drinks orally if permitted.

• Temperature 36–37.5 ºC • Patient not sweating, nor shivering • Patient not feeling cold

11.4  Arterio-venous re-warming The femoral artery is cannulated and blood is led through a heat exchanger. The blood flows in one direction over the membrane in the heat exchanger, while warm saline flows in the opposite direction on the other side of the membrane. The warmed blood is then led back to the circulation via the femoral vein.

Once the temperature and the convulsions have been brought under control, the child should be seen at a clinic, casualty or doctor’s office.

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Conclusion A human being’s body temperature is maintained within a narrow range irrespective of the temperature of the environment. The physiological functions of the body take place within the narrow temperature range of 36–37 ºC. When the body temperature leaves this normal range, altered metabolic processes, injury to cells and tissues, and ultimately death may result. Exposure to heat and cold, as well as pyrexial conditions, all affect the body’s ability to keep the temperature within the normal range. Implementation of nursing interventions, designed to maintain the body temperature within normal range, include methods of reducing the temperature as discussed in the text, management of rigors, management of hypo­ thermia, and management of malignant hyperthermia.

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Chapter 11 – Temperature regulation needs 

205

Suggested activities for learners Activity 11.1 Baby Simelane, aged 3 years, had what were thought to be febrile convulsions. Why was such a diagnosis made? And how will you manage the febrile convulsions? Activity 11.2 In groups of not more than five per group, visit a medical ward in the institution to which you are attached. Measure a patient’s temperature and record this under the supervision of your lecturer. Prepare a teaching guide that you would use to advise the patient and/or the patient’s relatives about the maintenance of normal body temperature. Activity 11.3 A patient admitted to hospital with abdominal pain has had a fluctuating oral temperature (36.5–37.5 °C) for 2 days. Now the patient’s temperature is 39 °C and she is complaining of feeling cold. Her hands and feet are cold and she looks ‘mottled’. She is shivering. Describe nursing interventions to be undertaken in the management of this patient.

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12

Competencies of the professional nurse

learning objectives

On completion of this Chapter, the learner should be able to: • describe the core competencies of the professional nurse • identify the supporting competencies of the professional nurse • demonstrate comprehension of the scope of practice of the professional nurse • explain the various roles of the nurse • practice nursing in a variety of settings • relate the competencies of the professional nurse to the scope of practice. key concepts and terminology

clinical decisionmaking

A problem-solving activity, which uses critical thinking to solve clinical problems. It is a dynamic process which involves adequate knowledge of clinical problems, patient information and available treatment options.

competence

The level of performance demonstrating the effective application of knowledge, skill and judgement (ICN, 2002). It includes the ability to effectively and efficiently deliver a specified professional service.

core competencies

Competencies which are required of a professional nurse, which learners must demonstrate on completion of basic nursing education. These competencies, which must be demonstrable early in the learners’ development career, must closely match the professional competencies.

critical thinking

A learned skill where one uses scientific knowledge, facts, principles and laws to determine, influence, relate, understand and control actual and potential concepts and propositions.

evidence-based practice (EBP)

The use of the best evidence from research findings, in combination with expert input from the clinical area, preferences of the patient, and values to support clinical decisionmaking.

protocol-based practice (PBP)

Step-by-step best practice guidelines compiled in protocols to guide practitioners in practice.

scope of practice

The legal boundaries within which a nurse can practise.

standards of care

Yardsticks or the measures of quality regarding nursing care.

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Introduction Nursing has an obligation to keep pace and remain relevant with the changing healthcare delivery system and to satisfactorily respond to healthcare policy. In 1994, with the beginning of democracy in South Africa, the national health policy was changed from a comprehensive healthcare system which focused primarily on curative care, to primary healthcare (PHC). The legislative framework was also adapted to suit the new healthcare delivery system. These changes subsequently impacted on the nursing education system, and the South African Nursing Council (SANC) responded to these changes by starting with the process of reviewing the scope of practice that would allow nurses to function in the health delivery system. The Regulation on the scope of practice of professional nurses and midwives (R786, SANC, 2013) provides for the competencies of professional nurses and also indicates the limitations of a professional nurse. The regulation clearly states that it is within the competency of the professional nurse to assume full responsibility and accountability for all the listed activities. The competencies of the professional nurse need to be reviewed regularly by the regulatory body, the SANC, to accommodate new challenges and demands for care within a dynamic healthcare environment, especially with new health threats. New disease conditions like the HIV/Aids pandemic also call for contemporary and timeous competencies to mitigate the new challenges brought about by this disease. Competencies for HIV/Aids are included in this Chapter because of the topical nature of the disease, and also because South Africa has one of the highest rates of HIV infections in the world. (Refer to Chapter 19 on HIV/ Aids for a more comprehensive discussion.) This Chapter will provide a description and discussion of the core competencies of the professional nurse.

Defining nursing practice In order to determine the competencies of the nurse, it is helpful to review the meaning of nursing and nursing practice. A comprehensive discussion of nursing practice is provided in Chapter 1. For the common understanding of nursing worldwide, the International Council of Nurses (ICN) has defined nursing as follows: Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well, and in all settings. Nursing includes the promotion of health, prevention of illness, and care of ill, disabled and dying people. Advocacy,

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promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles. (ICN, 2002)

In the South African context, nursing includes both midwifery and nursing practice, with community health nursing forming the basis. General nursing education lays the foundation for midwifery training and education, and as such the two are inextricably linked. A primary healthcare oriented healthcare delivery system requires nurses who can provide quality care in all the settings, rural and urban, where health services are needed. Education of such nurses is informed by the scope of practice which is based on a competency framework facilitated by an outcomes-based nursing education system.

Roles of the nurse The definitions of nursing allow for the determination of the various roles of the nurse. Nurse theorists like Callista Roy and Dorothea Orem have determined that nursing fulfils certain roles in healthcare. These include: practitioner or caregiver, educator or teacher, advocate, leader, manager, expert, case manager, and team member. The nurse practitioner uses effective communication and interpersonal skills to move between the various roles and to influence others. The fundamental roles of the generic professional nurse practitioner are identified, but are also applicable to other levels of the nurse, like the advanced nurse or the advanced clinical specialist, albeit that the depth and expertise may differ. In the latter two, the roles are more specialised and circumscribed in the area of speciality. Table 12.1 outlines and describes the roles of the nurse.

Scope of practice The scope of practice delineates all the activities, duties and functions which the nurse practitioner can do within the parameters of the law and also in terms of their professional licence. The presumption is that nurses are educated and skilled in those activities, and are competent, safe and empowered by law to practise them. This is usually determined by a regulatory body which has legal powers to do so. In South Africa, the scope of practice of the registered nurse and midwife is prescribed by the SANC under Regulation 786 in terms of the Nursing Act 33 of 2005. In its position statement, the International Council of Nurses (ICN) states that the scope of practice communi­cates to others the competencies and professional accountability

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208  Juta’s Complete Textbook of Medical Surgical Nursing Table 12.1  Roles of the nurse

Role

Description

Practitioner/ caregiver

This is the primary and most important role of the nurse. The nurse provides direct care to, is supportive of, and ensures comfort for the patient. The nurse demonstrates clinical proficiency in the provision of care.

Educator/teacher

Provides information to patients, in order to empower them. In this instance the nurse is a counsellor and a health promoter.

Advocate

Supports the patient in the articulation of their healthcare rights. Gives relevant information to the patient to facilitate decision-making. Supports the decisions of the patient. In this instance, the nurse is a change agent, and is assertive.

Leader

The nurse initiates change and maintains group goals and focus through effective interaction. Influences and empowers others.

Manager

Here, the nurse coordinates activities of others and makes decisions. Allocates resources and appraises care and personnel. Prioritises activities in the delivery of care, and manages time appropriately.

Expert

The nurse is an advanced practice clinician. Conducts research, develops theory, and contributes to the scientific base of nursing. Uses evidence-based practice to improve the quality of care. Adds to professional literature. Teaches nurses in the clinical area and at the school of nursing.

Case manager

Keeps accurate records and coordinates care to ensure continuity.

Team member

Practises good collegiality, and possesses good communication skills. Facilitates interprofessional and interdisciplinary collaboration to improve patient outcomes.

of the nurse. Furthermore, the scope of practice is not limited to specific tasks, functions or responsibilities, but includes the direct caregiving and evaluation of its impact, advocating for patients and for health. It also adds that nurses should define their scope themselves, but should take into account the views of others in society. The scope of practice is not static, it can be expanded when the need arises, and continuing education is undertaken to upgrade the skills and competencies. In line with other related health professions, it is also expected of the professional nurse to remain a lifelong learner.

Clinical alert! Continuing Professional Development (CPD) is provided for in the Nursing Act 33 of 2005 to ensure that nurses are kept abreast of developments, especially developments in clinical practice.

Standards of care in nursing The scope of practice allows nursing professionals to determine activities which nurses are responsible for. These activities entail what is taught to learners in nursing in terms of what they ought to do for patients in order to provide holistic, quality and effective care. The standards

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of care as provided for in the regulations providing for the professional conduct of nurses (SANC 767) elaborate on the key competencies in nursing. The standards are the yardsticks or the measures of quality regarding nursing care. Standards in nursing care focus on patient care and professional performance, and relate to responsibilities in which a nurse should be competent. These responsibilities include the following aspects: • Safe and competent nursing care • Effective and efficient resource utilisation • Patient education/health education • Ethical–legal practice • Record-keeping • Research and evidence-based practice • Personal and professional development • Communication • Collegiality, teamwork and interprofessional collaboration • Quality improvement • Therapeutic environment • Critical thinking • Ethical decision-making • Reflective practice • Cultural competence • HIV- and Aids-related delivery of care.

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The basic competencies of the professional nurse The competencies of the nurse practitioner are indicated individually or in groups, or in association with each other. These competencies often overlap because nursing care is holistic and intertwined in nature, and as such, the competencies are integral to one another. These competencies comply with the current scope of practice as indicated by the SANC Regulation 786. The competencies are based on the knowledge, attitudes and skills (KAS) relevant to nursing. Knowledge. This includes the mental abilities and cognitive learning that results from teaching and didactics in nursing education, continuing education and/or in-service education. Nursing knowledge includes the science and practice of nursing. The science entails a body of knowledge incorporating the meta-paradigm of nursing, which includes the relationships among nurses and nursing, and patients and their environment within the context of health. There are specific concepts and theories particular to nursing, and those that are derived from other natural and behavioural sciences, as well as other disciplines. Attitudes. Attitudes consist of the ability to translate knowledge in order to critically think in real life situations and to make independent and correct decisions on the spot. The competencies are meant to enable a nurse practitioner whose orientation is primarily to function effectively and efficiently in a healthcare system. Skills. These include the abilities to provide care to, communicate with, and interact in collaboration with others as a member of the multidisciplinary team.

The core competencies in nursing practice and the related competency standards Core competence: Safe and competent nursing care Related competency standards. The nurse will display the following competencies: • Demonstrates comprehensive knowledge and understanding of health–illness continuum of an individual or groups • Carries out a comprehensive and accurate nursing assessment of individuals and groups in a variety of settings to determine health needs • Provides sound decision-making in the care of individual patients, groups and communities • Prioritises and selects appropriate actions to provide adequate and effective nursing care based on identified and verified needs

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• Administers medication and other health therapeutics based on the five Rs (right patient, right medication, right dosage, right route and right time) in the administration of medication • Keeps accurate records taking into account the legal principles of record-keeping • Maintains confidentiality and privacy in utilising the patient’s record, especially their electronic health record, as these are more vulnerable to breaches • Ensures continuity of care by timeous referrals and consultations • Promotes the safety of the patient in terms of their person, name or reputation and their property while under their care • Functions in various roles as the need arises, ie as a health provider, coordinator, consultant, educa­tor, coun­ sellor, leader, advocate, manager and admini­strator.

Core competence: Effective and efficient resource utilisation Related competency standards. The nurse will display the following competencies: • Ensures the availability of adequate resources to facilitate patient care, as well as the optimum utilisation thereof • Plans duties, tasks and responsibilities (DTRs) based on needs and priorities regarding patient care • Ascertains the competency of staff in the use of equipment when delegating duties, and provides the required guidance where possible • Develops the budget to ensure adequate resources for nursing care • Develops an effective maintenance plan for all equipment to ensure optimum functioning.

Core competence: Patient education/health education Related competency standards. The nurse will display the following competencies: • Assesses the knowledge deficit or learning needs of patients, family and community • Develops a patient, family and/or community educa­ tion plan based on the identified and anticipated learning needs of the patient • Includes the patient, family, significant other and community in the education plan and subsequent lifestyle modifications • Implements and evaluates the patient and/or commu­ nity education plan, and reviews the plan whenever necessary based on the outcome of the educational intervention.

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Core competence: Ethical-legal practice Related competency standards. The nurse will display the following competencies: • Functions within the ethical and legal framework of nursing and other applicable laws of the country • Registration with the professional regulatory statutory body, eg the South African Nursing Council (SANC), and has indemnity insurance cover from a reputable provider, eg the Democratic Nursing Organisation of South Africa (DENOSA) • Practises in accordance with the institutional and national public health policies • Applies the Batho Pele Principles in the provision of health services • Adheres to the Patients’ Rights Charter and assists the patient to undertake their responsibilities • Provides ethically based care based on the Nurse’s Pledge of Service and the Code of Ethics for Nursing Practitioners in South Africa (SANC, 2013) • Promotes and projects a positive image of the nursing profession • Does not participate in unethical or immoral conduct and reports such to the proper authorities.

Core competence: Record-keeping Related competency standards. The nurse will display the following competencies: • Maintains accurate and complete records regarding patient care • Observes the legal prescripts of sound record-keeping • Demonstrates knowledge and understanding of professional accountability • Adheres to the legal provisions regarding the maintenance and release of public records • Maintains an effective and safe document management system.

Core competence: Personal and professional development Related competency standards. The nurse will display the following competencies: • Develops self-awareness regarding strengths, weaknesses and limitations • Determines own personal and professional aspirations in order to shape own career path • Identifies own learning needs and pursues continuing education • Applies acquired knowledge to improve the quality of care • Practises nursing according to professional standards

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• Projects a positive attitude towards change and criticism • Maintains membership of a professional organisation and participates in professional matters • Acts to promote and enhance the development of self and others.

Core competence: Communication Related competency standards. The nurse will display the following competencies: • Interacts effectively with patients, families, groups, communities and colleagues, fostering mutual respect and shared decision-making for the benefit of the patient • Uses appropriate information technology to facilitate communication • Documents interventions and nursing outcomes accurately and completely (if there is no record of a intervention, one cannot claim that it has been done or measure its success) • Identifies verbal and non-verbal cues, and uses therapeutic touch, empathy, warmth and comforting words to reassure patients and families • Assesses and overcomes barriers to effective communi­ cation, eg language, disabilities, developmental challen­­ ges, anxiety levels, etc, and adapts accordingly • Uses clear, concise and effective verbal, written and electronic communication.

Core competence: Research and evidencebased practice Related competency standards. The nurse will display the following competencies: • Values research in contributing to the scientific basis of nursing, developments and improved standards of care • Identifies and specifies researchable problems regarding patient care and community health • Applies appropriate research designs and methods to systematically investigate a problem in the care of patients and communities • Implements the research findings in the provision of care to patients and communities • Shares/presents research findings with or to colleagues and adds to the body of knowledge and literature in nursing • Uses evidence-based nursing to enhance quality patient care • Uses current evidence and clinical experience to formulate protocols of care

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• Identifies, evaluates and uses the best current evidence coupled with clinical expertise according to the patient’s preferences and values in order to make practice decisions • Advocates for patients and groups who participate in research studies.

Core competence: Collegiality, teamwork and interprofessional collaboration Related competency standards. The nurse will display the following competencies: • Functions effectively with colleagues in nursing and with interdisciplinary and interprofessional team members • Develops and plans care in collaboration with others, including the patient and family • Comprehends and respects the roles of other members of the interprofessional and multidisciplinary teams • Demonstrates self-awareness of strengths, weaknesses and limitations as a team member • Improves self to become and remain a loyal and respectful team player • Maintains own scope of practice within team dynamics and is assertive and accountable to team functioning for better patient outcomes • Advocates for the patient and manages the collaboration and teamwork effectively • Fosters and maintains good interpersonal relationship with patients, family colleagues and other team members • Keeps accurate records and clear communication to minimise risks in the delivery of care within the team.

Core competence: Quality improvement Related competency standards. The nurse will display the following competencies: • Uses data to monitor outcomes and care processes and uses quality improvement methodologies for clinical problems • Participates in medical rounds and nursing audits • Participates in the use of quality improvement tools, eg flow charts, to make the processes of care explicit • Participates in the use of quality measures to assess performance and to identify gaps between institutional practices and best practice • Values the use of standardised procedures to improve the quality of care • Uses quality indicators and core measures to evaluate the effect of the implemented changes in the delivery of care • Recommends solutions to the relevant groups in order to improve care.

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Core competence: Therapeutic environment Related competency standards. The nurse will display the following competencies: • Creates and maintains a safe therapeutic environment conducive to a speedy recovery • Establishes a psychosocial environment which exhibits unconditional acceptance of the patient, respect of their human worth and health rights • Adheres to the norms and standards of safety in a public area • Controls all kinds of pollution in the environment where care is given • Adheres to the procedures, protocols and the standard precautions of infection control • Observes proper disposal of wastes, hazardous materials, sharps and needles • Provides clear steps to follow in case of emergency or disaster situations • Assesses and controls all types of medico-legal risks in the practice environment.

Core competence: Critical thinking Related competency standards. The nurse will display the following competencies: • Makes independent judgements based on a solid knowledge base and the proven ability to synthesise information within the context in which it is presented • Asks questions to understand why the events occur­ red, gathers enough information, and validates the evidence, analyses and draws on past clinical expe­ rience to explain events • Maintains a flexible attitude to allow for the facts to guide the thinking and takes into account all the possibilities • Makes decisions that reflect creative, rational, considered and independent decision-making.

Core competence: Ethical decision-making Related competency standards. The nurse will display the following competencies: • Uses the ethical principles and duties like those of autonomy, beneficence, confidentiality, fidelity, justice, non-maleficence, paternalism and veracity to validate moral claims and to provide ethically based nursing care • Uses steps similar to the nursing process and other models to analyse an ethical problem in order to facilitate ethical decision-making • Appeals to the current ethical–legal framework in ethical decision-making • Uses the shared ethical decision-making modality by appealing to the ethical committee for inclusivity.

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Core competence: Reflective practice Related competency standards. The nurse will display the following competencies: • Applies proven theoretical knowledge and skills in nursing practice • Demonstrates critical thinking, critical analysis, synthesis and evaluation of clinical situations in nursing practice • Reflects on all actions and activities undertaken regarding patient care • Shows flexibility, autonomy, open-mindedness and eagerness to learn from others as well.

Core competence: Cultural competence Related competency standards. The nurse will display the following competencies: • Shows respect for the inherent human dignity of every human being, whatever the age, gender, religion, race or country of origin, ethnicity, socioeconomic status or sexual orientation • Recognises and respects cultural issues and interacts with patients from other cultures in culturally sensitive ways • Recognises culture as a fundamental human right • Is self-aware regarding personal biases and ensures that these do not interfere with the delivery of quality care • Incorporates cultural preferences, health beliefs and safe or harmless traditional practices into the management plan in accordance with the wishes of the patient • Develops culture-congruent resources to deliver care, including the language of the patient • Avoids ethnocentrism, takes diversity into account when planning and providing care.

Other competencies Core competence: Essential competencies related to HIV/Aids According to Relf (2011), these competencies include the following: • Care for patients with HIV and Aids • Treatment of patients with HIV and Aids • Preventing the transmission of and infection by HIV and Aids • Psychosocial, spiritual and ethical issues related to HIV and Aids • Psychomotor skills necessary to provide effective and appropriate nursing care to patients with HIV and Aids

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• Professional conduct regarding the delivery of nursing care to patients with HIV and Aids • Recognising the human right violation of stigma against people living with HIV/Aids. Related competency standards. The nurse will display the following competencies: • Ability to distinguish between the normal functioning immune system and an HIV-compromised immune system • Applies World Health Organization (WHO) guidelines in staging the HIV patient based on the assessment findings • Plans and implements evidence-based nursing interventions in the clinical management of people living with HIV and Aids and related conditions across the lifespan • Makes appropriate decisions regarding the assessment, initiation and follow-up of patients on anti-retroviral therapy (ART) • Supports the patient psychologically and emotionally to accept and positively cope with an HIV diagnosis • Performs all the necessary skills related to the delivery of care to the patient with HIV/Aids • Adheres to the principles of infection control in protecting others and self from HIV infection.

Conclusion The identification and description of the competencies for nursing practice are essential in informing patients of what they can expect from nurse practitioners. This is standard practice for the nursing profession internationally. Each country has specific expectations in terms of the healthcare delivery system. However, the International Council of Nurses (ICN) sets the tone for nursing to find commonalities in nursing practice despite the diversity of cultures, resources, etc. The competencies of general nurses across the globe are all focused on the provision of quality care in the prevention, management and rehabilitation of ill health and diseases across the lifespan. The competencies are evident with a therapeutic, safe and conducive environment where nursing care takes place. These competencies are necessary to define the scope of practice, which is legally sanctioned and ensures professional accountability. There should be coherence between the national legislative framework and what nursing is capable of providing, so as to avoid malpractice lawsuits. Measurement of the quality of care is by means of standards derived from the scope of practice.

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Suggested activities for learners Activity 12.1 Distinguish between: • Evidence-based practice (EBP) and protocol-based practice (PBP) • Scope of practice and standards of care. Activity 12.2 You have admitted a patient who is a refugee who fell ill while in the process of applying for political asylum in South Africa. He is a 40-year-old man from a strife-torn country in central Africa. The medical diagnosis of this patient is diabetes mellitus. The patient does not speak any South African languages. Describe your plan of action for meeting the health needs of this patient from a diverse cultural background. Activity 12.3 List five competency standards regarding the competence of record-keeping by the professional nurse.

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13

The nursing process

learning objectives

On completion of this Chapter, the learner should be able to: • explain the nursing process, its phases and how these apply in nursing care • conduct a detailed and accurate assessment of each patient in order to draw a specific nursing care plan • correctly formulate nursing diagnoses by identifying patients’ needs that need to be addressed through nursing actions • differentiate between medical and nursing diagnoses • prioritise patients’ needs in order to give attention to those deemed important first • prioritise nursing actions so that key interventions can be implemented first • specify realistic and achievable outcomes within specified time frames • select interventions that are scientifically correct, but that also take the realities and constraints of the patientcare environment into account • apply a systematic and scientific approach to the planning and implementation of nursing care • draw nursing care plans that are based on patients’ needs and are flexible and can be used with ease by everyone who is involved with the care of the patient • validate and check the nursing care plans and the use of specific criteria to do this • develop effective and realistic criteria for the evaluation of expected outcomes in nursing care • develop assessment and record-keeping systems that encourage the effective and appropriate use of the nursing process, and can be adapted to the needs of different clinical practice areas while retaining the essential features of the nursing process • use nursing care plans as a teaching tool in clinical practice • use the nursing process and nursing care plans to facilitate ongoing discussion and evaluation of nursing care within the multidisciplinary team. key concepts and terminology

assessment

Gathering of information about a patient in order to facilitate effective nursing care and medical management.

nursing process

A systematic, problem-solving approach to nursing care that involves interaction with each patient to assess needs and problems, make decisions regarding the patient’s needs and problems, and implement the planned nursing actions based on the assessed needs and problems.

objective data

Information that the nurse finds based on examination, observation and laboratory findings.

outcomes

Expected results following an intervention.

subjective data

Information that is given by the patient verbally about their illness.

prerequisite knowledge

• Natural sciences: Human anatomy, physiology, biochemistry and biophysics • Social sciences • Professional practice • Basic nursing care.

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medico-legal considerations

Nurses are duty-bound to make correct nursing diagnoses through thorough assessment so that patients’ needs can be individually met. Failure to do so may constitute an omission that could result in inadequate care, thus making the nurse liable. ethical considerations

Patients’ subjective and objective assessment data are key to nursing diagnoses and focused nursing care. The nurse should: • obtain informed consent to do any form of assessment or intervention • respect the patient’s rights to information: every activity should be explained to the patient to obtain consent • respect the patient’s rights to: dignity; participation in their own care and decision-making; privacy; confidentiality; refusal of treatment without penalty. The nurse is morally and legally obliged to provide nursing care that is safe, ethical and holistic; there should be: • transparency and integrity with regard to nursing regimen • accountability and responsibility in the care given based on identified needs and nursing diagnoses • appropriate and accurate record-keeping • peer review and interprofessional validation of nursing actions and care plans. essential health literacy

Communication is an important skill in healthcare. Every encounter with patients presents a teaching and learning opportunity for both the nurse and the patient. During patients’ assessments, cultural aspects and beliefs are learnt, and attitudes which impact on service delivery and compliance with care are brought to the fore. It is during this first encounter with the patient that the nurse will get to know the patient’s profile; how much the patient knows about their illness or ill health and what measures they have taken to rid themselves of the signs and symptoms. It is at this stage that education about the disease, its pathology, presentation, management and control, as well as preventative measures are discussed. Thus empowering patients with knowledge so that they can take informed decisions and participate in their care.

Introduction

The nursing process

The use of the nursing process subjects nursing actions to critical and scientific reasoning. The nursing process facilitates the development of holistic and individualised nursing care plans. The structure of the nursing care plans requires nurses to substantiate and provide a rationale for all nursing actions, thus effectively providing an analysis of nursing care and placing nursing on a scientific basis. In this Chapter nurses will be introduced to the nursing process and written care plans that translate the nursing process into action, referred to as nursing care. Further applications of the nursing process, in administration and teaching, will be introduced in order to provide additional insight into the many advantages of the nursing process.

The nursing process is a deliberate, systematic, problemsolving approach to nursing that involves interaction with each patient to assess their needs and/or problems; making nursing diagnoses and decisions regarding the patient’s needs and problems; and implementing the planned nursing actions based on the assessed needs and problems. The nursing process is a scientific, step-by-step method of creating holistic, individualised evidence-based care for each patient. Fundamental to the nursing process are the principles of assessing and identifying unmet patient needs, and of specifying nursing interventions to meet each need. Through the nursing process nurses are able to determine their scope of practice, and consult or make referrals to other health professionals on those needs that they cannot meet themselves.

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The five generic phases or steps of the nursing process are as follows: 1. Assessment 2. Planning 3. Implementation 4. Evaluation 5. Record-keeping. Discussions around these steps or phases have led to them being modified. Now, recording is no longer a stand-alone step separate from all the others, as it has been found to be applicable to all steps. To this effect, the five steps are now: 1. Assessment 2. Nursing diagnosis 3. Planning 4. Implementation 5. Evaluation.

Practice alert! Recording is an integral part of the nursing process and is done with every phase of the nursing process. In the South African law, nurses are responsible and accountable for all their nursing actions. This implies that nurses must be able to provide proof that care has been given. They must also be able to provide proof of the type, quality and effectiveness of nursing actions. Record-keeping is therefore an essential part of the duties and responsibilities of professional nurses, and reflects their accountability.

Application of the nursing process phases/ steps The nursing process is a way of thinking and an approach to nursing care. At its simplest, the nursing process involves finding answers to four simple questions: 1. What is wrong with this patient? What are this patient’s needs and problems? This is addressed by the assessment phase where the patient’s problems are identified and categorised, and nursing diagnoses are made to guide interventions and indicate problems needing immediate attention and those that can wait or be referred to other health professionals. To achieve this, the nurse must do the following: • Interview the patient for their health history • Interview the patient’s family and/or significant other

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13.1 Types of problems used to generate an individual nursing care plan Actual problems are those problems that are related to disease, eg in patients with pancreatitis, vomiting and intense pain are actual problems. Potential problems are complications that may arise if the actual problems are not attended to. For example, in the above scenario, the patient may collapse from the pain. Potential problems are complications of the main disease. Pancreatitis is often sudden in onset and the patient may have to be hospitalised unexpectedly. This may socially and emotionally impact on the patient’s well-being. For example, class attendance, child care, employment and hospitalisation costs. These translate into possible problems.

• Do a physical examination • Review test reports such as laboratory results and X-rays. When making a nursing diagnoses, the nurse must do the following: • Identify the patient’s needs • Identify actual, potential and possible problems • State the nursing diagnoses in writing. 2. What can be done about the situation? What nursing care and nursing actions will help this patient? In response to these questions, a plan has to be devised. This requires an aggregation of resources. In devising this plan, the nurse must do the following: • Assign priority to the nursing diagnoses • Outline immediate, intermediate and long-term goals that are realistic, measurable and culturally acceptable to the patient • Identify nursing interventions appropriate to achieve the goals • Identify nursing teams needed to achieve the goals • Identify other health teams to work with the nursing teams to achieve the stated goals • Identify the equipment and supplies required to achieve the goals • Develop a written plan of the nursing care to be provided • Enlist patient involvement (only the patient can decide if it is achievable).

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3. How will the planned nursing actions be implemented and why? This relates to the implementation of the plan in line with available resources to meet the patient’s identified needs. The nurse must do the following to determine how the planned nursing actions will be implemented: • Put the nursing care plan into operation • Coordinate all activities • Keep a record. 4. What were the results of the nursing care? It is important to determine whether the solutions were effective in order to evaluate the nursing actions taken. To make this evaluation, the nurse must do the following: • Assess the prognosis of the patient • Communicate with the patient, family and/or significant other about the effectiveness of the care given • Record observations and compare with the physical state of the patient • Identify improvements, changes and reinforce­ ments that need to be made in the plan and its implementation.

Steps in the nursing process Step 1: Assessment Nursing assessment comprises the gathering of all the information relevant to a patient. During nursing assessment, a nurse uses a variety of sources to obtain information that will enable them to build a database for each patient. This step also includes the identification of needs and problems, as well as the formulation of a nursing diagnosis.

Subjective data Subjective data is information given to a nurse by a patient or significant other. This type of information is obtained by taking a detailed history from the patient or the significant other during a nurse-patient interview. The purpose of history taking is to establish a health history as well as a psychosocial profile of the patient. The interview also assists to establish/initiate the therapeutic relationship. Often a standardised questionnaire, which may or may not be part of the patient’s admission documentation, is used. The interview enables the nurse to establish rapport with the patient and the patient’s family, and to begin to plan the care with the patient. The health history should include the following aspects: • Demographic information about the patient, which tells the nurse something about the patient and the type of person that the patient is.

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13.2 Some facts about the nursing process In order to understand how the nursing process works to ensure patient wellness, the following information is important: • The nursing process is a precise instrument that has advantages for both the nurse and patient • The nursing process facilitates individualised patient care, tailored to meet the patient’s needs • Problems and goals are clearly stated, and are used as the basis for decision-making about nursing care • Continuity and coordination of care are ensured, as the care plan is written down and made available to all health workers who come into contact with the patient • The nursing process makes it possible to evaluate nursing techniques and standards of care as indicated in the prognosis of the patient; a written care plan ensures that the patient receives consistent care • Being a logical process, the nursing process is used to clarify and focus the nurse’s thinking and nursing activities, and it requires the nurse to identify patient needs and problems and to plan specific nursing actions that will meet the patient’s needs and address the patient’s problems • The systematic approach enables even the most inexperienced nurse to meet the patient’s needs, within the limits of their capabilities, by referring to a written care plan • The built-in evaluation step gives flexibility, which means each step or phase can be revisited depending on need • The patient is an active participant in every phase of their care, instead of being a passive recipient of care – this is consistent with modern philosophies of nursing that stress a holistic approach and patient involvement • The nursing process facilitates quality assurance in patient care • Nursing care plans are an excellent teaching tool in the ward situation

• The history of the present problem, including the specific reason for the patient to seek healthcare. • Past medical and surgical history relevant to the present problem.

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• Family history relevant to the present problem. The family medical history will enable the nurse to determine whether the patient is at risk for conditions with a genetic or familial aetiology. Information relating to family dynamics and interaction should also be obtained, because nursing care will need to take the patient’s family, and the way in which the patient interacts with their family, into account. • The patient’s background should be explored, as this information will provide clues to environmental and sociocultural factors that may impact on the patient’s health, eg residence, occupation, cultural practices and habits. Lifestyle and habits have a considerable influence on health, and the nurse should obtain as much information about these aspects as is possible. • The nurse should find out about medication taken by the patient, as drugs may affect the patient’s prognosis. • The nurse should also assess the patient for disabilities and underlying chronic medical problems. These underlying conditions may not necessarily be related to the presenting problem, but may impact on the medical management as well as nursing care. Other sources of information about the patient’s health history could be obtained from their family, other members of the multidisciplinary team, as well as their medical and other records. Although information obtained from these sources is not subjective information in the true sense of the word, this type of information serves to substantiate, validate and amplify information obtained during the interview between the nurse and the patient.

Objective data Objective data is obtained independently by a nurse through observation, physical examination and diagnostic tests. Objective information is self-evident and can be obtained by any member of the health team who examines the patient. Observation. The nurse’s observation of the patient begins at their first encounter and continues throughout the duration of the therapeutic relationship between the nurse and the patient. Observation of the patient is carried out in order to assess their progress and response to healthcare received. It includes assessment of the physical condition of the patient, as well as the mental state, communication ability, adaptation to healthcare, and cooperation with the health team. Physical examination and diagnostic tests. Examination of the patient includes specific tests that are carried out in order to obtain or clarify physiological data that cannot be

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obtained by simple observation. The nurse’s examination of the patient would include routine nursing observations such as vital signs, level of consciousness, weight, height measurement and urinalysis, as well as a comprehensive assessment of all body systems. A head-to-toe approach or a body-systems approach may be used. The initial examination must be thorough and systematic, and it is well worth a nurse’s while to develop a sound method and use it consistently. Information obtained from diagnostic tests, such as laboratory tests and X-rays, should also be included in the objective information, as these results all help to build a comprehensive picture of the patient and their needs and problems. Once all the relevant data has been obtained and checked for accuracy, the information must be organised in a meaningful way, analysed and interpreted. Nursing theory holds that nursing is a human activity that is focused on meeting the individual’s needs. It follows, then, that the analysis of data involves the identification of unmet patient needs and the diagnosis of the problems that are the reason for needs not being met. To do this, the nurse interprets the information obtained during assessment to determine the needs of the patient. All observation and examinations done are written down at each stage. The interpretation of data means that all data collected during assessment is compared with documented norms. For example, if the patient’s temperature is found to be 39 °C, the nurse compares that reading with what is known to be a normal temperature reading, which is 37–37.5 °C. The interpretation is therefore a temperature reading above the normal values, which is called pyrexia. The need that arises from an elevated temperature is a body fluid deficit as a result of a loss of body fluid associated with pyrexia and resultant sweating. Pyrexia also causes a lot of discomfort and the resultant sweating may compromise the hygiene of the patient, as well as their comfort, rest, and sleep.

Identification of needs With the relevant information at hand, the nurse must determine which of the patient’s basic bio-psychosocial needs (such as respiration, nutrition, relaxation, recognition, respect) are not being met because of the patient’s illness. This can be accomplished by using a standard list of bio-psychosocial needs and determining whether the patient can meet each respective need unaided. Unmet needs would indicate areas where nursing intervention is required. For example, if the answer to oxygen need in the first row of Table 13.1 is ‘no’, the reason for the need not being met must be found. This could be related to the difficulty in breathing as expressed

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Chapter 13 – The nursing process  219 Table 13.1  Identification of patient’s needs

Patient’s need/s

Can the patient meet this need unaided? Yes or No

Oxygen

No

Respiratory obstruction

Circulation

No

Excessive haemorrhage

Fluid and electrolytes balance

No

Unconsciousness, dehydration

Nutrition

No

Dysphagia

Elimination

No

Dehydration or constipation

Temperature regulation

No

Head injury

Skin integrity

No

Unconsciousness/ wounds

Mobility and exercise

No

Paralysis

Hygiene

No

General debility

Comfort and rest

No

Pain

Safety

No

Unconsciousness

Sensation/perception

No

Unconsciousness

Sexuality

No

Genital injuries

Cognition

Yes

Adaptation

Yes

Self-esteem

No

Safety and security

Yes

Autonomy

Yes

Relatedness

Yes

Stimulation

Yes

Communication

No

Religious expression

Yes

by the patient, observed by the nurse during physical examination, and confirmed by laboratory tests such as arterial blood gases. It is important to use appropriate techniques and tools or instruments during data collection. As indicated above, record-keeping is integral to all steps of the nursing process, therefore all assessment findings should be documented in accordance with principles of recordkeeping.

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If ‘No’ in column 2, specify reasons for the need/s not being met

Change in body image

Confusion

Step 2: Making a nursing diagnosis A nursing diagnosis is a statement of a patient’s problem that requires nursing intervention in order to ensure that the patient’s needs are met, whereas a medical diagnosis is a statement identifying a disease condition in the patient. A nursing diagnosis identifies functional aspects that impact on the patient’s health and their ability to perform activities of daily living and response to healthcare. Determining the reasons for a patient’s needs not being met provides nursing diagnoses.

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A nursing diagnosis has two components: 1. The statement of the problem. This is a statement describing an alteration in a need, or a specific nursing problem relating to an unmet need. Any patient factor that can be identified during a nursing assessment may be used as a nursing diagnosis. The North American Nursing Diagnosis Association (NANDA) has provided a useful list of standard nursing diagnoses (see Table 13.2). The existence of such a list, however, should not prevent the nurse from expressing the patient’s problems in a manner more appropriate to both the patient and the nurse who will be caring for the patient. 2. A description of related or supporting factors. This supporting information should provide a description of causative factors, as well as the information and observations that support or prove the nursing diagnosis. Supporting statements should include all information, both subjective and objective. Nursing diagnoses provide guidance to the nurse on nursing interventions to be undertaken. For example, where a medical diagnosis indicates ‘constipation’, nursing diagnoses will describe how that particular patient presents. The patient may present with a variation

in passing a stool and the nursing diagnosis will state ‘altered elimination’ and continue to qualify it further so that it is easy to apply relief measures to facilitate normal defeacation. From the assessment it may also turn out that the patient’s food intake is inadequate. The nursing diagnosis will refer to this as ‘inadequate nutrition: less than body requirements’ or ‘knowledge deficit related to nutrition’. Nursing diagnoses should always exhibit the following characteristics: • They should be brief and specific. • It should be possible to relate each nursing diagnosis to an identified patient need. Obviously more than one nursing diagnosis may be made for each identified need of the patient; for example, for comfort and rest, identified nursing diagnoses could be related to: –– pain –– distended bladder –– temperature in the environment or fever –– anxiety. Each nursing diagnosis should be based on actual patient information obtained during the nursing assessment of the patient.

Table 13.2  Patients’ needs and related nursing diagnoses

Need

NANDA-approved nursing diagnosis

Evidence from assessment that supports the diagnosis

Oxygen need

• Activity intolerance • Altered pattern of breathing • Ineffective breathing pattern • Ineffective airway clearance • Potential for aspiration • Inadequate pulmonary ventilation • Inability to sustain spontaneous respiration

• Fatigue • Dyspnoea (difficulty in breathing) • Dyspnoea • Dyspnoea on exertion • Dyspnoea • Weak cough • Productive cough • Cyanosis • Weakness of respiratory muscles

Circulation need

• Activity intolerance • Decreased cardiac output • Fatigue • Decreased tissue perfusion

• Dyspnoea on exertion • Hypotension, tachycardia • Hypertension, • Ischaemia, cyanosis

Fluid and electrolyte need

• Fluid volume deficit

• Dehydration • Decreased urinary output • Complaints of thirst • Inelastic skin • Cold, clammy skin • Inadequate fluid intake • Electrolyte imbalance (specify) • Oedema • Large volumes of dilute urine passed • Wet cough

• Fluid volume excess

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Need

NANDA-approved nursing diagnosis

Evidence from assessment that supports the diagnosis

Nutrition need

• Ineffective breastfeeding • Ineffective infant feeding • Altered nutrition: more/less than body requirements • Altered oral mucosa membrane • Inadequate nutrition: less than body requirements • Inappropriate dietary pattern • Inadequate food intake • Knowledge deficit related to nutrition

• Inadequate breast milk production • Difficulty in swallowing • Loss of appetite

• Altered elimination

• Constipation • Diarrhoea • Incontinence • Urinary retention • Decreased urinary output • Dysuria, burning on micturition

Elimination need

• Impaired renal function • Difficulty in micturition

• Sores in the mouth • Loss of appetite • Eats once a day • Nausea, vomiting • Taking large amounts of energy foods for muscle strength

Temperature regulation need

• Altered vital signs

• High temperature above 38.2 °C • Restless • Temperature lower than 35 °C • Cold or warm extremities

Skin integrity need

• Impaired skin integrity • Impaired tissue integrity

• Poor wound healing • Abnormal healing of wounds • Potential skin breakdown • Pressure sores

Mobility and exercise need

• Activity intolerance • Impaired physical mobility • Potential disuse syndrome

• Immobility, weakness • Abnormal body movements, dysreflexia, • Potential contracture/s or deformity

Hygiene need

• Altered oral mucous membrane • Self-care deficit

• Poor oral/dental hygiene • Poor personal hygiene • Inability to clean and groom the body unaided

Comfort and rest need

• Altered sleep pattern • Inability to sleep, rest and relax • Altered body temperature

• Insomnia, pain, restlessness • Restlessness, pain, wakefulness, noise • Hot or cold environment

Safety need

• Impaired protective mechanisms (unable to cough or stay away from injury, infection) • Potential or high risk for eg aspiration, suffocation, trauma

• Unconsciousness

Safety and security need

• Post-traumatic stress • Powerlessness

• Anxiety, fear, apprehensiveness, dependency • Helplessness

Sensation and perception need

• Altered sensation/perception

• Anosmia, impaired vision, hearing, taste, balance, touch • Confusion, disorientation • Confusion, disorientation

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• Altered thought process • Altered mental state

• Unconsciousness

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Need

NANDA-approved nursing diagnosis

Evidence from assessment that supports the diagnosis

Sexuality need

• Rape trauma syndrome • Sexual dysfunction/impaired reproductive capacity • Altered sexuality

• Presence of vulval injuries • Impotence/loss of libido • Altered gender concept/image • Impaired gender role concept

Cognitive need

• Altered thought process/altered mental state • Altered mood

• Confusion, disorientation • Display of improper mood, eg laughing when there is great sorrow

Adaptation need

• Ineffective coping • Ineffective denial, non-compliance • Dysfunctional grieving • Anticipatory grieving • Impaired adjustment, poor healthseeking behaviour, altered health maintenance

• Maladaptive behaviour • Denial of reality, unrealistic expectations • Inappropriate defence mechanisms • Lack of insight

Need for autonomy

• Altered role performance • Altered thought process • Impaired communication • Knowledge deficit

• Indecisiveness, inability to assert own wishes • Poor problem-solving skills, lack of insight • Indecisiveness, poor problem-solving skills, lack of reports, no meetings called • Poor communication • Poor interpersonal skills • Anxiety, fear, dependency

Need for relatedness

• Impaired communication • Impaired social interactions • Social isolation • Impaired self-esteem • Altered family processes

• Poor interpersonal skills • Poor social skills/inability to establish and maintain relationships • Poor social support systems • Dysfunctional social/family dynamics

Stimulation need

• Altered sensation/perception • Altered thought process • Impaired communication • Diversional activity deficit

• Boredom • Sensory deprivation/overload

Need for communication

• Impaired communication • Impaired social interaction • Social isolation

• Aphasia • Language deficit • Deafness/hearing deficit • Blindness/visual deficit • Illiteracy/semi-literacy

Need for meaningfulness

• Spiritual distress • Hopelessness

• Dysfunctional grieving, despair, • Depressed mood, lack of purpose • Agitation and distress

Need for religious expression

• Spiritual distress • Hopelessness

• Disruption of pattern of worship • Disruption/contamination of religious rituals

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13.3 Medical and nursing diagnoses as solutions Although nursing diagnoses are distinct from medical diagnoses, it is very likely that the solution to a patient’s problem could involve both medical and nursing interventions. For example: Mr Jones is suffering from bronchial pneumonia, as a result of which he is cyanosed and breathless. • Medical diagnosis: Bronchial pneumonia • Nursing diagnosis: Impaired gaseous exchange or abnormal breathing pattern due to respiratory infection, evidenced by cyanosis and breathlessness

13.4 The nursing diagnosis expressed in a full sentence Many authorities express the nursing diagnosis as a sentence, which reads as follows: (Problem), due to (causative factors), evidenced by (information derived from assessment that supports the diagnosis), for example: • Altered nutrition, due to anorexia (inadequate intake), evidenced by weight loss • Fluid volume deficit, due to diarrhoea, evidenced by complaints of thirst, inelastic skin and decreased urinary output

Step 3: Planning During the planning stage the nurse determines what can be done to help the patient meet their needs. This will include determining nursing interventions and outcomes, decisions on equipment, and methods to use in order to meet the identified needs. The planning stage involves drawing up a care plan according to which the patient will be nursed.

Priority setting Setting priorities is about choices and alternatives. It involves making decisions about the sequence in which the patient’s problems will be addressed. The principles used in determining nursing care priorities will depend on the patient-care setting. Some of the principles are: • Nurses can use Maslow’s Hierarchy of Needs model. If this system of prioritising is used, lower order basic

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needs are met first followed by higher order needs. This method of prioritising is useful if the patient is physically ill and not in a state to make decisions about their care. In these circumstances, the use of Maslow’s Hierarchy of Needs model is appropriate and the nurse applies their professional expertise to ensure that the most vital of the patient’s physiological needs (life-threatening needs) are met first, eg the need for respiration, nutrition, water, sleep and excretion. • Nurses can first meet those needs that the patient feels are most important. This method of prioritising is suited to the primary healthcare situation in which individuals and communities are encouraged to identify their own needs and problems and work with healthcare professionals to meet their healthcare needs. • Nurses can consider potential future problems and deal with those problems that are most likely to develop. This method of prioritising is useful in situations in which active measures are required to prevent a problem from developing. Example: a patient with a fragile skin and who is relatively immobile is at risk of developing pressure sores, and specific nursing actions must be implemented in order to prevent skin breakdown. This method of prioritising is also useful for mentally ill patients. While these patients may be physically well, they may be at risk of self-destructive or aggressive behaviour, and nursing actions are necessary in order to prevent injuries in these patients and those around them.

Specifying the outcomes, goals and objectives of nursing care The objectives of nursing care identify the results that the nurse expects to achieve by the nursing care rendered to the patient. A nursing goal describes the changes that will be brought about by nursing care. Objectives, or expected outcomes, should be patient oriented in that they should describe what will be seen in the patient, and not what the nurse proposes to see or do with the patient. Expected outcomes should alleviate problems specified in the nursing diagnosis, and an expected outcome should be specified for each nursing diagnosis. Expected outcomes should take other forms of treatment into account, and the patient, as well as the doctor and other members of the healthcare team, should feel that the outcome is valid and worth attaining. Expected outcomes may be in the short or long term, depending on the time required for the achievement of the outcome. The nurse should begin with short-term outcomes before proceeding to long-term outcomes.

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Outcomes should meet the following assessment criteria: • They should be derived from actual or potential diagnoses to ensure that planned interventions based on the outcomes are appropriate and relevant. • Where possible, outcomes should be mutually formulated with the patient, family and other healthcare providers. These should be appropriate for the patient. They should be achievable and allow for ongoing assessment of the patient’s progress and response to treatment. • Outcomes should be individualised and realistic. They should be culturally appropriate, and must take into account the age of the patient, present and potential capabilities, as well as the patient’s beliefs. • Outcomes should be attainable in relation to available resources. An unattainable outcome is impractical and does not allow for a realistic evaluation of nursing care. It is frustrating and demoralising for both the nurse and the patient. • Outcomes should be measurable. They should provide a time estimate within which the expected outcome should be achieved. Determining timeframes involves deciding how much time should elapse before the patient shows a response to treatment. Timeframes vary according to the nature of the patient’s needs and problems, and may not be necessary for chronic and ongoing problems. They should be stated in acute situations. For example, if the patient does not respond within the specified time period, medical assistance may have to be summoned, the patient’s treatment may need to be changed, or current nursing interventions will need to be evaluated and, where necessary, changed. • Outcomes provide direction for continuity of patient care in order to match the nurses’ competencies with the needs of the patients. • Outcomes provide a basis for evaluating patient care. • As in all the steps of the nursing process, outcomes should be documented. • An outcomes statement should include the desired patient’s behaviour, the timeframe set to achieve the outcome, as well as conditions/special circumstances regarding the achievement of the outcome. An example of an outcome in an adult patient with ‘altered breathing evidenced by dyspnoea’ should be: ‘restored to normal breathing of 10–20 breaths per minute within 10–15 minutes with the accompanying calmness of the patient’.

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Practice alert! The nurse must always bear in mind that ‘altered breathing’ is an immediate need and should be resolved within the shortest possible span of time, eg 15 minutes, because it poses a threat to life.

Selecting nursing actions Nursing actions or interventions describe nursing activities which are directed at enabling the patient to meet their needs and achieve the expected outcomes of care. When specifying nursing actions, the following aspects must be considered: • Nursing activities must be safe and must not jeopardise the patient’s safety in any way. • Standard protocols and standing orders relevant to the patient should be specified. • Nursing actions must be compatible with other forms of treatment prescribed for the patient, and the nursing regimen must be able to accommodate the activities of the other members of the multidisciplinary healthcare team who are involved with the patient. • Nursing actions must be scientific, and nurses must use the correct procedures and techniques for their patients’ problems. • Nursing actions should relate to the expected outcomes of care. • Nursing actions should be effective; in other words, the planned nursing actions must be selected and applied in order to achieve the expected outcomes. • Nursing actions should be practical in terms of the patient, the available equipment and the staff and their experience. • Nursing actions should be discussed with the patient and family wherever possible, and both patient and family should feel that the envisaged plan is worthwhile and valid. • Nursing actions should take suggestions from the patient into account and, wherever possible, the nurse should individualise the plan and take individual patient likes and dislikes into consideration. • The sequence in which nursing actions will be carried out, should be according to the identified priorities of care. • Nursing actions should be ethical. • Nursing actions should entail preventive treatment and promotion of health.

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Drawing up a care plan

Step 4: Implementation

A care plan should be drawn up for each patient based on identified needs and the care plan should contain the following: • The nursing diagnoses • The expected outcomes for each nursing diagnosis • The planned nursing actions.

This step involves the implementation of the care plan in the clinical situation. Care plans should be written down, checked and validated before they are implemented. A patient’s care plan should also be used as the framework for recording nursing care and patient progress. The elements of a patient’s care plan should form the basis of daily reports, and cardex or routine nursing records relating to patients.

Nursing interventions should be scientifically correct and relevant to both the nursing diagnosis and the expected outcome, as indicated in Table 13.3. Nursing interventions should give a rationale, and also provide details of technique and frequency.

13.5  Integrated care pathways As an alternative to nursing care plans, integrated care pathways (ICPs) may be used at some institutions providing nursing care. This is a single document in which all the members of the multidisciplinary team record their care. The ICP describes all the expected problems, interventions and outcomes for a specific condition. These ICPs are designed by a specific group of multidisciplinary team members and the aim is to give a comprehensive (plan) or pathway for a specific condition so that all the members would interact with one document and that everyone involved would have access to all the information, ensuring comprehensive care to the patient.

Standard care plans. Standard care plans are useful as teaching tools. They also help to provide consistency of care, and can be used as a reference by staff members who are unfamiliar with the clinical area. Standard care plans are also useful in very busy clinical areas where such plans may be used to streamline administration and record-keeping. Standard care plans should not, however, be applied without individual assessment of patients, and without adapting and tailoring the standard care plan in the light of such assessment ie they must be individualised when implemented.

Validating the care plan All nursing care plans should be checked with a colleague or a superior. The purpose of this is to eliminate errors and to ensure that the care plan is as comprehensive as possible. When validating a care plan, the following aspects should be taken into account and checked: • Patients’ safety should receive priority. • The plan should be based on scientific principles. • The plan should be developed in collaboration with other healthcare team members, the patient and the family, and in a manner that encourages each member’s contribution towards attaining the outcomes. • The nursing diagnoses should be supported by the assessment information, and not based on assumptions. • The expected outcomes should be designed to alleviate identified needs and problems. • The expected outcomes should be measurable and it should be possible to use them to evaluate a patient’s progress. • It should be possible to achieve the expected outcomes by means of the planned nursing actions. • The nursing actions should be arranged in a logical se­ quence and should reflect identified priorities of care. • The plan should be individualised for each patient, and it should take the patient’s likes and dislikes into account as far as possible, meaning that the care plan should reflect the patient’s characteristics and needs. • The nursing care plan should provide for continuity of patient care. • Relevant records should be kept in line with the hospital protocols.

Table 13.3  Suggested format for nursing care plan

Nursing diagnosis

Expected outcome

Nursing intervention

1. Patient’s problem 2. Requiring intervention 3. Supporting information/ database

1. Objective 2. Evaluation criteria/parameters 3. Time factor (if appropriate)

1. Nursing actions 2. Rationale and techniques 3. Protocols and standing orders 4. Frequency

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Once validated, the care plan is put into operation. The nurse continues to observe, assess and collect information during the implementation of the care plan.

Step 5: Evaluation Evaluation involves assessing a patient’s response to nursing care. To evaluate the care plan, the achievement of the expected outcomes is assessed using the specified evaluation criteria. Evaluation of the care plan is a systematic, criterion-based and ongoing process, and not something that occurs just prior to the discharge of a patient. The care plan may have to be revised according to the results of the evaluation. The evaluation takes into account: • The resolution of the patient’s needs • The set timeframes for achievement of results after interventions are started • The effectiveness of the interventions based on the achievement of the set outcomes • The ongoing evaluation results in line with the revisions of nursing diagnoses and plan of care. The evaluation date is documented in accordance with the principles of record-keeping.

Revision of the care plan The care plan should be revised if the expected outcomes are not achieved or are only partially achieved as a result of the following circumstances: • The priorities of care may have changed, requiring an alteration in the plan or in the sequence of the activities. • Priorities may have changed as a result of a reaction to treatment or as a result of complications that could be due to treatment or to an exacerbation of a patient’s medical condition. • It sometimes happens that a new problem, which is unrelated to the needs and problems identified at the time of the initial assessment of a patient, arises. For example, a patient may present with a myocardial infarction while undergoing routine surgery for a minor problem. The unexpected can never be disregarded in patient care, and nurses should be on the alert for it. Careful assessment and identification of underlying chronic problems may reveal potential problems. • While revising the care plan, nurses should examine the planned nursing care very closely. In particular, nurses should assess the care plan for unrealistic outcomes, inaccurate nursing diagnoses and ineffec­ tive nursing actions.

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13.6  The importance of record-keeping Record-keeping is an essential requirement for the effective use of the nursing process. Recording is carried out in all the steps in the nursing process. Nurses should take note that in the South African Nursing Council disciplinary hearings, the majority of those accused of misconduct have also not kept accurate records to support their defence. The following factors are important to note in recordkeeping: • Recording must take place at every stage of the nursing process • Nursing records are legal documents and must reflect the nursing actions carried out for a particular patient accurately and honestly • An indelible pen must be used, the colour of which will be dictated by the circumstances (a black or blue pen is normally used; a red pen is only used in those cases where the attention of the care team is urgently required, eg allergy to medication, blood group) • Records are an important way in which the accountability of nurses is reflected – records provide proof that nursing care was carried out • Nursing records must be clear, concise and correct, and must reflect the true facts regarding the patient • All statements made on a patient’s nursing record must show the time that the statement was made, the date and must be signed by the person making the statement

All nursing and medical activities, treatments, investi­ gations, and the patient’s response to treatment and nursing care must be recorded. An example of the recording of a patient’s care plan is given in Table 13.4. The nurse should record everything that happens regarding the patient. Patient records must be complete, and it should be possible to gain an accurate history of the patient’s progress from the records long after the patient has been discharged.

Conclusion The nursing process is a methodical, step-by-step approach to patient care which is flexible and can be adapted and used in every clinical situation. The use of the guiding principles of assessment, planning, implementation and

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Chapter 13 – The nursing process  227 Table 13.4  Example of a care plans to address various needs and documentation thereof

Comfort and rest need Nursing diagnosis

• Altered sleep due to pain postoperatively, evidenced by restlessness and inability to fall asleep

Expected outcome

• Restful undisturbed sleep for 4 hours.

Nursing interventions and rationale

• Assist the patient to assume a comfortable position • Ensure that dressings are comfortable, ie not tight, but supportive • Ensure that there is no haemorrhage and the bladder is empty • Make sure that the room is quiet, well ventilated and a comfortable temperature • Plan nursing activities to provide undisturbed periods of rest and sleep • Give prescribed analgesics to relieve pain

Evaluation

• Patient restful • Patient lying/sleeping quietly, breathing normally for at least 4 hours

Oxygen need Nursing diagnosis

• Altered breathing due to disease process evidenced by dyspnoea and cyanosis

Expected outcome

• Normal breathing immediately

Nursing interventions and rationale

• Put patient in Fowler’s position if permitted • Ensure adequate ventilation without draught • Give oxygen by mask or catheter whichever is comfortable for the patient • Monitor and record vital signs every hour during the acute period and 4-hourly when the patient is settled • Report any untoward signs • Administer medication as prescribed

Evaluation

• Normal rate of breathing • Normal skin colour/no cyanosis

Skin integrity need Nursing diagnosis

• Potential for impaired skin integrity due to bed rest

Expected outcome

• Normal skin

Nursing interventions and rationale

• Encourage patients who can move about to do so • Change position of bedridden patients every 2 hours • Bed linen to be dry, without creases or food crumbs

Evaluation

• Check skin every time the position is changed, and keep a record of the condition of the skin

evaluation ensure that nursing care is holistic, systematic and individualised for each patient. The use of logical methods in nursing enhances professionalism and quality of care by making patient care and the recording of patient care more precise and accurate. The use of the process also encourages creative and independent thinking in nursing. Nursing care becomes a specific process, which

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is unique to nursing. The nursing process encourages the nurse to think about the application of care to each patient individually and eliminates the use of routine patterns of nursing care that have been learnt by rote. Nursing care becomes a dynamic and interpersonal interaction between the nurse, patient, family and community with many positive results.

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Suggested activities for learners Activity 13.1 Mr Peters is admitted into a medical ward. On arrival he was accompanied by his wife and brother. The porter in the outpatients’ department put him on a trolley and tied him down so that he wouldn’t fall. In the ward the wife and the brother told the nurse that he collapsed in the sitting room that morning. They continued to state that he had not been well in the past 2 months. He had complained of tiredness and had been to see the general practitioner twice. Recently he had complained about practically everything, ie frontal headache, dizziness, sore feet, sore eyes with poor vision and backache, and he has not been eating well. Because he was conscious, the wife suggested that he give the rest of the history. He told the nurse that he is feeling weak and has palpitations. These signs and symptoms (including those cited by the wife and brother) only intensified in the last 2 weeks. Working in groups and using the needs list in Table 13.1, perform the following tasks: 1. Identify the patient’s needs. 2. Categorise these into actual, potential and possible needs. 3. Make nursing diagnoses. 4. Draw a nursing care plan to address Mr Peters’ needs. 5. Submit a record of all that you have done to the class teacher for evaluation.

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14

Symptoms management

learning objectives

On completion of this Chapter, the learner should be able to: • define each of the common symptoms associated with disease • state the aetiology of cough, cyanosis, dyspnoea, fatigue, nausea and vomiting, and convulsions • describe the pathophysiology of cough, cyanosis, dyspnoea, fatigue, nausea and vomiting, and convulsions • provide the significant subjective assessment data that should be obtained from a patient presenting with cough, cyanosis, dyspnoea, fatigue, nausea and vomiting, and convulsions • explain the significant objective data that nurses should look for during the physical examination of a patient presenting with cough, cyanosis, dyspnoea, fatigue, nausea and vomiting and convulsions • explain the significance of various diagnostic tests and procedures used to assess patients presenting with cough, cyanosis, dyspnoea, fatigue, nausea and vomiting, and convulsions • design a care plan based on assessment findings of patients presenting with cough, cyanosis, dyspnoea, fatigue, nausea and vomiting, and convulsions • describe the physiology of pain • describe the different types of pain • provide the significant data to be collected during the assessment of pain in adults and in children • describe the principles of pain management • explain the use of analgesic medication, including opioids • explain the rationale for the use of adjuvant analgesics • apply non-pharmacological methods in the management of chronic pain • provide effective management of pain in general and under emergency situations. key concepts and terminology

acute pain

Incident-related pain that is sharp, intense, localised and does not last long. Acute pain has a protective function and is associated with anxiety. It is usually manageable with a single dose of analgesic.

antiemetic drugs

Drugs that prevent vomiting.

antitussives

Drugs that suppress cough.

cachexia

Extreme emaciation as a result of rapid weight loss.

cardinal symptom

A symptom that ultimately leads to a diagnosis.

chronic pain

Pain that can last for a longer period of time and has no clear cause. It can be either localised or diffuse, dull ache or intense. Chronic pain impairs function, has a psychological impact, serves no useful purpose, and requires ongoing analgesia to control.

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chronic symptoms

Long-lasting and recurrent symptoms as may be the case with diseases such as diabetes, asthma or cancer.

emetics

Drugs that provoke vomiting.

expectorants

Drugs that loosen the sputum resulting in its release from the bronchi.

general symptom

A symptom which is common in all diseases, eg malaise.

haematemesis

Vomiting of blood.

haemoptysis

Expectoration/coughing of blood.

hypoxia

Low oxygen levels in the tissues.

malaise

A feeling of being unwell.

neuropathic pain

Pain as a result of damage to or dysfunction of the nervous system.

nociception

Perception of pain produced by stimulation of peripheral pain receptors (nociceptors).

pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

pain threshold

The lowest intensity of stimulation at which pain is experienced.

pain tolerance

The upper limit at which a patient is prepared to put up with pain. Usually when a patient experiences pain beyond this level they seek help.

phlegm

A mucoid secretion in the respiratory tract.

presenting symptom

Also referred to as a chief complaint. It is the initial symptom that brought the patient to hospital/doctor.

psychogenic pain

This type of pain has no physical basis, so it is important for medical practitioners to look for emotional, psychological and spiritual distress.

psychosomatic pain

Nociceptive pain with an underlying psychological cause.

relapsing symptoms

Symptoms that had occurred in the past, disappeared and then came back, as it may be with depression and cancer.

remitting symptoms

Symptoms that improve and sometimes disappear without the disease being cured, eg cancer symptoms.

sympathetic dependent pain

Neuropathic pain associated with dysfunction of sympathetic nervous system (SNS).

prerequisite knowledge

• Anatomy and physiology of the respiratory, gastro-intestinal and nervous system • Biophysics • Specific nursing skills such as blood pressure monitoring, taking of pulse, collection of specimen and basic life support.

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medico-legal considerations

Nurses are obliged to ensure that the patients have given informed and written consent for symptoms management. Legally, the patients have a right to accurate information about their illness, care, tests and treatment. The information must be given in the language and level of understanding the patient is comfortable with. The patient must be given an opportunity to ask questions, and the questions must be answered to the patient’s satisfaction. essential health literacy

Patients should be advised never to use medicines bought over the counter for the treatment of symptoms for longer than 2 weeks. If any of the symptoms persist, the patients must consult the doctor for detection and management of the underlying cause. Patients need to stop smoking, avoid food and respiratory allergens when coughing persistently. First aid and home management of symptoms such as convulsions, dyspnoea and vomiting should be taught by health professionals, including nurses. A healthy diet, regular exercises and compliance to prescribed medicines should be encouraged.

Introduction In this Chapter, a variety of symptoms associated with diseases in all body systems are discussed. The purpose is to provide the learner with information that will enable them to effectively manage common symptoms of diseases. This Chapter deals with the management of a variety of common symptoms such as cough, cyanosis, dyspnoea, fatigue, nausea and vomiting and convulsions. The management of pain is also included in this chapter because pain is an important symptom experienced in almost all diseases and illnesses, and it is the main reason people seek medical aid.

Symptoms management A symptom is a feeling or something that a person experiences in their body that is different from normal. It is an abnormality of function, sensation or appearance experienced by a person that indicates the presence of disease. A symptom is a subjective report of what the patient experiences and family members, nurses and doctors only come to know about it if the patient tells them. Examples of symptoms are fatigue, headache, nausea and pain. The objective evidence of disease that is detected by nurses, doctors or laboratory evidence during a physical examination of a patient are referred to as ‘signs’: an elevated blood glucose reading is an example of a sign. A patient may experience an abnormality or abnormal feeling that the nurses, doctors and family members also notice. Such an abnormality is referred to as a ‘sign and symptom’. There are many of these signs and symptoms, and the scope of this book allows for a discussion of abnormalities such as cough, diarrhoea, vomiting, mouth sores, a rash or swelling on the body.

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General symptoms management Cough Cough is a protective reflex action that clears the airways of mucus and irritants such as dust and smoke. It is an important part of the body’s defence mechanisms.

Pathophysiology Normally, the lungs and the respiratory passages are sterile. Regular deep breathing and ciliary action remove foreign particles that have been inhaled. Cough becomes necessary when the stated mechanisms become ineffective and the secretions and foreign particles accumulate in the respiratory tract. It is started by the stimulation of the sensory nerves found in the lining of the respiratory tract. When coughing takes place, there is a short intake of breath and the larynx closes momentarily. The chest and abdominal muscles contract resulting in increased pressure needed to drive the air out of the lungs when the larynx re-opens. The resulting blast of air comes out at high speed, clearing the airway of excessive secretions, dust particles and any foreign material present in the airways. Persistent and prolonged cough may cause exhaustion and muscle pain.

Causes of cough Cough may be provoked by the following causes: • Respiratory irritants • Choking • Cigarette smoking. This can cause chronic cough usually referred to as the ‘smoker’s cough’ • Infections: upper and lower respiratory tract infections that produce a lot of phlegm • Air pollutants, eg smoke, fumes or cold air • Allergy as in allergic rhinitis or hay fever

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• Medication used in heart disease called angiotensinconverting enzyme (ACE) inhibitors causes dry cough in some patients (as do other expectorants). Cough is a common symptom in the following medical conditions: • Respiratory conditions such as asthma, acute bron­chitis, colds and flu, pneumonia, pulmonary tuber­ cu­ losis, pulmonary embolism and lung cancer. In children, the cough is a common symptom for conditions such as bronchiolitis, croup, whooping cough or cystic fibrosis • Acute heart failure • Gastroesophageal reflux.

Types of cough Cough can be described as: • Acute or chronic. An acute cough has a sudden onset and short duration, while a chronic cough has an insidious onset and is long lasting. • Productive or unproductive. A productive cough results in phlegm or sputum being coughed up. It is also referred to as a wet or chesty cough. A dry cough is characterised by the absence of phlegm, and it is usually very irritating and sometimes tickly and barky or brassy.

• The nature of the secretions. If the cough is productive, then the nature of secretions produced should be assessed, eg frothy, blood-stained or purulent sputum. • The fequency of the cough. How often and times during the day when the cough gets better or worse is important to note. A cough on waking up in the morning may be suggestive of chronic bronchitis or bronchiectasis. A cough later in the day may be related to exposure to respiratory irritants, and a cough at night may be related to asthma and left-sided heart failure. • The sound of the cough. A barking cough is common in influenza or laryngotracheobronchitis (croup), and a hacking cough in viral infection; and it may be associated with bronchogenic cancer. In asthma, laryngeal oedema or epiglottitis, the cough may be associated with wheezing. • Factors that affect the cough (make it better or worse). A cough that occurs when lying down may be related to pulmonary oedema, chronic post-nasal drip, or gastroesophageal reflux and aspiration. • The presence of pain. If patients experience pain when coughing, it may be associated with respiratory infection.

Coughing is not a disease, but a symptom of a variety of diseases. The underlying cause of coughing needs to be identified and treated. Identification of the cause of cough depends on the correct assessment of the cough by the nurses and the doctors.

The nurse should also obtain medical history from the patient regarding asthma, allergies and current respiratory infections. It is important to enquire if the patient is a cigarette smoker or has been exposed to environmental irritants such as fumes. The appropriate nursing interventions for cough are described in the care plan in Table 14.4.

Subjective data

Essential patient teaching

When cough is reported as the presenting symptom by the patient, the nurse is required to obtain more information about it. The important history to obtain about the cough relates to: • The onset of the cough. The patient is asked to describe the onset of cough and the nurse should ascertain whether the onset is acute (started suddenly over hour or days) or chronic (started insidiously over weeks or months). • The type of cough. The nurse should determine if the cough is dry or productive and whether it is forceful enough to clear the airway of excessive secretions and foreign particles inhaled. A weak and ineffective cough is present in patients with weak muscles, in post abdominal surgery when the patient experiences pain, and in chronic obstructive airway disease (COPD). The patient with a poor cough reflex is susceptible to infection of the lower respiratory tract and pneumonia.

Patients must be advised to cover their mouth and nose during coughing, as coughing and sneezing are mechanisms for droplet infection. The correct way of covering the mouth when coughing is shown in Figure 14.1. Patients should be advised never to use cough mixtures bought over the counter for longer than 2 weeks. In order to relieve dry cough, warm water with lemon or herbal tea with honey can be taken. If the cough persists, patients must consult the doctor for detection and management of the underlying cause. Medical aid should be sought if cough is accompanied by: • Green, rusty brown, yellow or blood-stained foul smelling sputum • Chest pain • Shortness of breath or wheezing • Pain and swelling in the neck • Recurrent night-time cough

Assessment and common findings

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assess the sputum for colour, odour, consistency or the presence of foreign material, such as blood, pus, and mucus plugs in the sputum. The following factors should be noted: • Increased production of sputum on waking up in the morning indicates that the secretions accumulated overnight as it happens in bronchitis; decreased amount of sputum is found in dry cough. The amount may be described as being ‘scanty’, ‘moderate’ or ‘copious’ (large amounts) • The colour of the sputum is normally clear • The odour of the sputum may vary from odourless to foul smelling • The consistency may be frothy, thin, thick, viscous or tenacious (sticky). During assessment of the sputum, the abnormal features presented in Table 14.1 should be documented and reported. Figure 14.1  Covering of the mouth when coughing

• Sudden weight loss • Fever and sweating • Hoarseness of voice and chronic cough that does not clear up with medication and physiotherapy. The patient must be taught cough exercises in order to achieve effective, deep coughing that reaches into the lungs and not merely the throat. The patient must be instructed to: • Assume a sitting position • Hold their breath for about 3 seconds • After deep inhalation, to cough forcefully using the abdominal and other accessory respiratory muscles • Support an incision by placing your palms on either side of the incision during coughing • For patients with abdominal incision, splint the abdomen with a rolled pillow held against it.

Sputum Normally, about 100 ml of clear sputum is produced in the respiratory tract in a day. The sputum is brought up by the upward movement of the cilia and it is usually swallowed. The production of sputum is the reaction of the lungs to persistent irritation of the respiratory tract. Any change in the colour, consistency and amount is abnormal.

Assessment and common findings Normal sputum is clear and odourless and we are usually unaware of it because it is swallowed. The nurse must

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Essential patient teaching Encourage the patient to cough into a tissue and place the tissues in a separate waste paper bin or plastic bag. Although handkerchief may be used, tissues are more hygienic. Used tissues may be flushed down the toilet.

Cyanosis Cyanosis is a blue discoloration of the skin resulting from an inadequate amount of oxygen in the blood. It occurs when deoxygenated blood, which is bluish rather than red in colour, circulates through the skin. Cyanosis cannot be seen until at least 5 g of haemoglobin per 100 ml of blood is deoxygenated. Cyanosis can be classified as central where the blue discoloration affects lips and mouth, tongue and conjunctiva, or peripheral where ear lobes, finger tips and toes are affected.

Causes of cyanosis Cyanosis may be caused by a variety of lung or heart diseases that decrease the uptake of oxygen in the blood. Certain blood vessel and heart malformations allow venous blood to mix with arterial blood in the heart as may be the case in ventricular or atrial septal defects and tetralogy of Fallot. This abnormal blood flow is called a shunt. In a shunt, blood from veins in the body may flow directly into blood vessels returning blood from the lungs to the left side of the heart or directly into the left side of the heart itself. The deoxygenated blood is then pumped out to the body, to circulate through the skin and other tissues.

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234  Juta’s Complete Textbook of Medical Surgical Nursing Table 14.1  Abnormal characteristics of sputum

Characteristic

Description

Associated conditions

Abnormal colour and consistency

Black thick sputum

Associated with inhalation of smoke or coal dust

Greenish grey sputum

Advanced tuberculosis

Rusty coloured sputum

Pneumococcal pneumonia

Yellow or green purulent sputum

Bacterial infection or bronchiectasis, lung abscess

Copious watery frothy pink sputum

Pulmonary oedema

Sputum with streaks of blood or frank blood

Pulmonary infarction or embolism, lung cancer, pulmonary tuberculosis, haemophilia and patients on anticoagulation therapy; coughing up of blood is called haemoptysis

Mucoid, thin, clear and viscid

Over secretion of bronchial mucus as seen in asthma

Mucopurulent sputum, thick, viscid; may or may not be offensive smelling

Cystic fibrosis

White thin mucoid sputum

Common colds

Foul smelling sputum

Bronchiectasis Lung abscess

Abnormal odour

Assessment and common findings A change in the colour of the skin is observed as it becomes bluish. Measurements of the amount of oxygen in the blood are estimated by the use of pulse oximetry, in which a sensor is attached to a finger or an earlobe. It can also be measured directly by arterial blood gas analysis. In order to determine the cause of low oxygen in the blood, tests such as chest X-rays, echocardiography, cardiac catheterisation, and pulmonary function tests may be ordered.

Management of cyanosis • Treat the underlying cause • Give oxygen therapy • Malformations that cause shunts may need surgery to be corrected.

Dyspnoea Dyspnoea is a subjective sensation or feeling of difficult and/or laboured breathing or shortness of breath. It is a sign of many serious diseases of the airway, lungs, heart or general circulation. Dyspnoea is a scary and distressing

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symptom for patients and healthcare workers alike. It may occur with other symptoms such as cough, chest pain and fever.

Pathophysiology of dyspnoea Dyspnoea occurs when the: • levels of oxygen in the blood decrease and those of carbon dioxide increase • ability of the lung to expand is reduced, resulting in impaired gaseous exchange • work of breathing is increased. People with lung disorders often experience dyspnoea during physical exertion. For example, when they exercise, the body makes more carbon dioxide and uses more oxygen. The respiratory centre in the brain accelerates breathing when blood levels of oxygen are low or blood levels of carbon dioxide are high. If the heart or lungs do not function properly, even minor exertion can lead to tachypnoea and dyspnoea. As the lung disorder becomes more severe, dyspnoea may even occur at rest.

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Causes of dyspnoea The causes of dyspnoea are presented in Table 14.2.

to diagnose and further evaluate anaemia, heart problems, certain specific lung problems, and kidney failure.

Assessment and common findings

Management of dyspnoea

The patient may use terms such as tightness of chest, breathlessness and suffocation to describe dyspnoea as the chief complaint during history-taking. Because of the subjective nature of dyspnoea, the nurse might find it difficult to quantify and rate its intensity. The visual analogue scale (VAS) of dyspnoea has been found helpful in assessing the intensity of dyspnoea. The patient is requested to indicate on the scale the extent of their breathlessness. The nurse is also expected to take history regarding the characteristics of dyspnoea such as dyspnoea occurring when the patient lies down, on exertion or during sleep. Diagnostic studies are used in addition to the subjective data from the patient to assess dyspnoea. These include a chest X-ray and arterial blood gases testing or pulse oximetry. The chest X-ray may show evidence of pneumonia and many other lung abnormalities, and can often show evidence of heart failure. A low blood oxygen level usually indicates a heart or lung problem. Pulmonary function testing can measure the degree of restriction or obstruction and the ability of the lungs to transport oxygen from the air to the blood. A lung problem may include both restrictive and obstructive defects, as well as abnormal oxygen transport. Other tests may be necessary

The treatment of dyspnoea is directed at its cause. Supplemental oxygen using nasal prongs or a mask worn over the face is given to patients with low oxygen in the blood. In severe cases, the patient may be assisted by mechanical ventilation administered through a breathing tube inserted into the trachea, or through a tight-fitting face mask.

Fatigue Fatigue is one of the symptoms that patients mention when they visit healthcare facilities. It is a state in which one feels tired or exhausted. Fatigue is a feeling that is experienced occasionally by everyone, and it is an indication of the body’s need for rest and sometimes sleep. Ordinary fatigue is a normal response to exertion and it is relieved by rest. Persistent fatigue, which develops insidiously over time, is abnormal. It is distressing to the person experiencing it, because it is usually not relieved by rest and sleep. This type of fatigue is characterised by profound lack of energy, feelings of weakness, lack of mental clarity, and loss of concentration, and in extreme cases, loss of memory. The patient may report fatigue as feeling tired, weak, weary, worn out, worn down or drained.

Table 14.2  Causes of dyspnoea

Respiratory causes

• Obstruction of the airway as seen in obstructive lung diseases such as asthma, emphysema, bronchiectasis and lung infections • Damaged lung tissue by tumours, infections and fluid accumulated in the lungs • Impaired movement of air in and out of the lungs due to pain in the chest and weak chest wall movement • Severe curvature of the spine (scoliosis) also restricts breathing by reducing the movement of the rib cage

Cardiac causes

• Inability of the heart to pump adequate blood to supply oxygen to the tissues of the body occurs in heart failure, pericarditis and cardiomyopathy • Dyspnoea of cardiac origin occurs first during exertion, but later it occurs even at rest • The other severe types of dyspnoea are: –– Orthopnoea: Breathlessness when a person lies down. It is relieved by an upright position. The patient breathes comfortably only when they assume a sitting or standing position. –– Paroxysmal nocturnal dyspnoea: A sudden, often terrifying, attack of shortness of breath during sleep. The person awakens gasping and must sit or stand to take a breath.

Other causes

• Anaemia, because of the decreased number of red blood cells which carry oxygen to the tissues • The person breathes rapidly and deeply in an effort to try to increase the amount of oxygen in the blood • Cancer of the lung, severe kidney failure, anxiety and metabolic acidosis

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Causes of fatigue Some causes of fatigue include: • Anaemia • Cardiac failure, due to increased energy expended for breathing and impaired oxygenation of tissues as a result of low cardiac output • Cancer treatment, chemotherapy and radiation • Coughing • Cachexia, often seen in gastrointestinal diseases, lung cancers and Aids patients • Insomnia • Depression • Pain • Anxiety • High stress levels. The goal of management of fatigue is the identification and management of the underlying cause. See the nursing care plan (in Table 14.4) for the symptomatic management of fatigue.

Nausea and vomiting The body’s vomiting centre is situated in the medulla in the brain. In response to stimulation, this centre sends messages to the diaphragm, abdominal muscles, stomach and oesophagus. The result is the relaxation of the muscles of the stomach and oesophagus when the pyloric sphincter contracts. At the same time the diaphragm and abdominal muscles contract against a closed glottis to exert pressure on the stomach from above and below, ejecting the stomach contents, known as vomitus, upward through the relaxed oesophagus and pharynx and through the mouth. The stimulation of the vomiting centre may produce a sensation known as nausea, which is often associated with increased secretion by the salivary and bronchial glands. Nausea may occur before vomiting, or the patient may not vomit, but continue to experience nausea.

Causes of vomiting The following causes can stimulate the vomiting centre: • Local factors in the gastrointestinal tract (GIT) and abdomen may cause reflex vomiting, eg an obstruction anywhere along the length of the upper GIT • Stretching of a hollow organ, eg renal colic, gastric distension • Inflammation of the GIT, eg gastritis, hepatitis, appen­ dicitis • Irritation of the gastric mucosa by emetics (salt solutions) and poisons (including food poisoning) • Lesions of the stomach, eg ulcers • Radiation and chemotherapy

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• The vomiting centre may be stimulated directly from the labyrinth of the ear in conditions such as car, sea, or air sickness, and Ménière’s syndrome or vertigo. The centre can also be stimulated as follows: • Via the chemoreceptor trigger zone which is situated close to the vomiting centre by a number of circulating toxins (alcohol), drugs such as narcotics (morphine) and hormones (oestrogen in pregnancy) • By mental activity such as being sick with fright, a sight or odour which may be so repulsive as to cause vomiting • By emetics (eg Ipecacuanha, Antabuse, if taken concomitantly with alcohol) • By metabolic disorders (eg hypoglycaemia) • Uraemia, ketosis, Addison’s disease • Pressure on the vomiting centre due to raised intracranial pressure (headaches) • Psychological factors, which include hysterical vomiting, bulimia, and irritable bowel syndrome • Vomiting may occur with diarrhoea.

Assessment and common findings Most individuals vomit occasionally due to overeating, indigestion or taking too much alcohol. However, if the patient is vomiting frequently or regularly, the situation should be investigated. Nurses should note the following: • The quality, colour, reaction and consistency of the vomitus • The presence of mucus, blood, bile (green and greenish-yellow liquid), worms, or undigested food in the vomitus • Whether the vomitus is of a specific type, eg greenish colour, or undigested or digested food • The time of vomiting in relation to food and medicine (see Table 14.3 for the causes of vomiting at different times of the day) • Whether vomiting is accompanied by pain or relieves pain: if vomiting relieves pain, it may indicate the presence of gastric ulcers, cancer or dyspepsia; cramp-like abdominal pain accompanied by vomiting is a sign of colic • The frequency and duration of vomiting • Also evaluate the patient for the presence of the consequences of vomiting, such as: –– Dehydration –– Sodium and potassium depletion –– Metabolic alkalosis

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–– Aspiration pneumonia in unconscious patients, where the valve action of the glottis is not func­ tioning –– Chronic vomiting (eg in bulimia) will cause erosion of the teeth as a result of the acid stomach contents –– Persistent vomiting may cause tears in the oesophageal and gastric mucosa. Table 14.3 Identifying potential causes of vomiting based on the time of vomiting

Time

Cause

Early morning before eating

Pregnancy; alcoholic gastritis

After eating

Gastric ulcers, gastritis, dyspepsia, nervousness

After taking medicine

Irritation of gastric mucosa by the drug; sensitivity or toxic reaction to drug

During or after a meal

Psychogenic; pyloric ulcer; toxin-producing organisms, eg staphylococcus aureus

4–6 hours after ingestion of food/poisonous substance

Salmonella and shigella

Management of vomiting • • • •

Remove dentures if present Assist the patient by supporting their head Support any abdominal or chest wounds if present For nursing management see Table 14.4.

Treatment of vomiting • First remove the cause • Decompression (suction) of the GIT in cases of persistent postoperative vomiting • Discontinuation of medicines causing vomiting • Administration of antispasmodic analgesics for colic as prescribed • Anti-emetics are administered for nausea, motion sick­ness, radiation sickness, chemotherapy and preg­ nancy – these may be administered orally or intramuscularly and some even rectally, as prescribed • Drugs that may be prescribed are: –– antihistamines with powerful anti-emetic action (cyclizine, promethazine, cinnarizine) –– dopamine antagonists, which block the effects of dopamine on the chemoreceptor trigger zone (metoclopramide, haloperidol and prochlor­ perazine, stemetil).

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The nursing care plan of a patient who is vomiting is presented in Table 14.4.

Convulsions Convulsions are sudden bursts of uncontrolled muscle contractions that are almost always accompanied by a loss of consciousness. During convulsions, the person’s muscles contract and relax repeatedly, resulting in jerking or twitching movements. The abnormal movements are caused by a generalised contraction or a series of contractions of skeletal muscles. There are various types of convulsions. Those that are experienced by patients with epilepsy are usually accompanied by a loss of consciousness. In others, the twitching may occur while the person is fully conscious. In such cases, the convulsions are likely to be a symptom of an underlying disease or a reaction to a drug or some other toxic substance. Febrile convulsions occur in young children as a result of a rapid increase in body temperature. Convulsions of all types are caused by disorganised and sudden electrical activity in the brain.

Causes of convulsions • • • • • • • • • •

Brain tumours Epilepsy Head injury Fever Uraemia related to kidney failure Hypoglycaemia Infections, eg meningitis Toxaemia of pregnancy Cerebral palsy Abuse of alcohol or illegal drugs.

Assessment and common findings There are a wide variety of possible symptoms of seizures, depending on what parts of the brain are involved. Most types of convulsions cause loss of consciousness and twitching or uncontrollable shaking of the body. In epilepsy, the attacks usually begin with a loss of consciousness and motor control, and jerking of all extremities. The hands are clenched, arms and legs jerk, muscles twitch, the face darkens, and the person falls into unconsciousness. The duration is short, and when the person wakes, they do not remember what happened shortly before, during and after the seizures. Convulsions can be unsettling to watch.

Management of convulsions Convulsions are relatively easy to manage. The nursing interventions for convulsions are outlined in the care plan (see Table 14.4) meant for all symptoms discussed in this Chapter.

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Introduction to pain management

Nursing alert! Any high temperature (over 38.5 °C) in a child under 3 years of age is an indication to act and summon medical aid as febrile convulsions may set in. The convulsions occur once in a single illness and comply with all the phases of a grand mal seizure. Febrile convulsions usually last from 30 seconds to 2 minutes. Febrile convulsions begin at the height of the fever. At the end of the clonic stage of the grand mal the temperature usually decreases to normal. Seizures become a medical emergency if: • prolonged; more than 5 minutes • multiple convulsions happen • the person doesn’t awaken in between.

The International Association for the Study of Pain (IASP, 2011) defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage and described in terms of such damage. Pain is a subjective experience unique to each individual, it is a protective mechanism and it is modified by developmental, behavioural, personality and cultural factors. It is a common presenting symptom of illness with many different causes and people often present to the healthcare facility because pain is a symptom that needs attention. The description of pain is also varied depending on age, cause, individual perception and culture. The words that people commonly use to describe the pain include ‘aching’, ‘pricking’, ‘pins and needles’, ‘burning’, ‘nagging’, ‘throbbing’, ‘dull’, ‘excruciating’, ‘unbearable discomfort’, etc.

Table 14.4  General nursing care plan for the symptoms outlined

Cough Nursing diagnosis

• Ineffective airway clearance related to infection evidenced by coughing • Ineffective cough secondary to pain evidenced by excessive secretions

Expected outcome

• Adequate airway clearance • Effective coughing techniques

Nursing interventions and rationale

• Increase fluid intake to decrease the viscosity of a thick sputum through adequate hydration • Give inhalation therapy/nebuliser to increase the water content of thick sputum • Encourage the patient to cough and provide a sputum mug, and replace with a clean one before it is full • Chest physiotherapy • Teach coughing techniques and supervise coughing • Relieve pain by: –– supporting the chest during coughing –– administering the prescribed analgesics • Administer cough medication as prescribed: Expectorant/antitussives • Observe sputum

Evaluation

• Airway clearance • Effective cough secretions expectorated

Cyanosis Nursing diagnosis

• Impaired tissue oxygenation related to disease evidenced by cyanosis

Expected outcome

• Adequate oxygenation of tissues

Nursing interventions and rationale

• Administer oxygen therapy by nasal prongs or mask

Evaluation

• Normal colour of the mucous membranes and skin

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Diarrhoea Nursing diagnosis

• Fluid volume deficit evidenced by dry mucous membrane of the mouth and poor skin turgor • Altered comfort, anal soreness, abdominal pains and cramps evidenced by diarrhoea • Altered nutrition/loss of nutrients in watery stools • Anxiety/ embarrassment related to foul-smelling stools

Expected outcome

• Restore fluid balance • Pain relief and promotion of comfort • Restore normal nutrition • Allay anxiety, and embarrassment

Nursing interventions and rationale

• Oral rehydration or IVI fluids as prescribed to replace lost fluids and electrolytes • Continue with baby feeds (breastfeeding or milk formula) • Take food with high calories • Administer antidiarrhoeal drugs as prescribed • Place patient close to the toilet • Supply soft tissues or wet wipes • Encourage perianal hygiene • Apply barrier cream to prevent excoriation around the anus • Observe the skin/nappy rash in children and change nappies promptly

Evaluation

• Normal stool passed • Adequate intake of food and fluid

Dyspnoea Nursing diagnosis

• Impaired gaseous exchange • Impaired oxygenation of tissues due to disease process evidenced by difficulty in breathing and cyanosis

Expected outcome

• Optimal oxygenation of tissues

Nursing interventions and rationale

• Supplemental oxygen using nasal prongs or • A mask worn over the face is given to patients with difficulty in breathing and cyanosis 

Evaluation

• Patient breathing normally

Fatigue Nursing diagnosis

• Activity intolerance evidenced by the patient’s report of being tired

Expected outcome

• Tolerance of daily normal activities

Nursing interventions and rationale

• Provide adequate nutrition with high calories to increase energy and essential nutrients • Avoid high-fat foods as they increase the level of fatty acids in the blood • Gentle exercises • Balance rest and activity periods

Evaluation

• Increased energy levels • Patient participates in activities of normal living without assistance

Nausea and vomiting Nursing diagnosis

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• Fluid volume deficit evidenced by dry mucous membrane of the mouth, poor skin turgor; in children, the fontanelle may be sunken • Altered nutrition due to nausea evidenced by vomiting and loss of appetite

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Expected outcome

• Electrolyte and fluid balance maintained • Absence of nausea and normal intake of food

Nursing interventions and rationale

• Assist the patient by supporting their head in keeping it upright to make vomiting easy • If any abdominal or chest wounds are present, the nurse should support the chest and abdomen during vomiting so that pain is minimised during vomiting • Remove offensive items such as bedpans with or without contents so that smells and sights of these items are absent next to the patient • Hold the emesis bowl for the patient and remove used ones; a clean bowl should be available before the soiled one is removed • Rinse or clean the patient’s mouth after vomiting • Wipe hands and face, replace dentures, change soiled linen and clothes and provide ice tubes to suck or something to drink where allowed • Do the necessary observations and save the vomitus for inspection if indicated • Notify the person in charge about the observations • Administer prescribed antiemetic drugs • Decompression (suction) of the GIT in cases of persistent vomiting

Evaluation

• Normal intake of fluids and nutrients • No vomiting

Pain Nursing diagnosis

• Altered comfort related to pain due to disease process • Altered sleep pattern related to pain • Risk of anxiety and depression due to pain • Inability to function

Expected outcome

• Pain relief • Promotion of comfort

Nursing interventions and rationale

• Conduct a comprehensive pain assessment • Administer analgesics as prescribed and as required • Bed rest • Apply cold or heat massage

Evaluation

• No report or expression of pain

Convulsions Nursing diagnosis

• Impaired cerebral perfusion evidenced by cyanosis during convulsions

Expected outcome

• No convulsions

Nursing interventions and rationale

• Clear hard or sharp objects away from the vicinity of the patient to prevent injury • Remember that convulsions can be violent enough to injure a patient • Remain calm • Loosen tight clothing around the neck which may restrict breathing or block the airway • Note the time and nature of convulsions – it is important to time the seizure from the beginning of convulsions to the end of convulsions • Pad under the head with a pillow or rolled-up jacket • If possible, roll the patient onto their side so that sputum or vomitus will drain out of the mouth away from the airway

Evaluation

• Normal skin colour • Patient restful, no convulsions

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Pain can be described as a discomfort, but in basic biological terms, pain is useful and necessary for the following reasons. • It is nature’s protective mechanism. Acute pain has meaning and draws attention to the cause. For example, if you place your hand on something that is very hot, the normal reaction is to immediately and instinctively withdraw the hand even before there is a conscious perception of the pain. In inflammatory conditions, one of the cardinal symptoms is pain. The affected area is usually ‘guarded’ so that the inflammation is localised. This phenomenon will contain an abscess and allow the inflammatory response to take effect. • In healthcare, pain will give an indication of the severity of the disease, as well as the impact and effect of treatment instituted. It will also determine the urgency with which the treatment should be instituted. • Pain is also intimately related to the process of life, such as giving birth, working, learning, growing and dying. Pain must be understood in all aspects in order to manage it effectively. It is frequently inadequately treated resulting in unnecessary suffering. It is essential that nurses and other healthcare workers are skilled in the assessment and management of pain to ensure that patients are free of pain, or that pain is sufficiently controlled so that is does not unduly interfere with activities of daily living or quality of life. The purpose of this section is to provide information about pain as a symptom in illness in order to assist the nurse to gain an understanding and master the knowledge and the competencies necessary to effectively manage a patient experiencing pain in a variety of health conditions and settings.

Overview of pain physiology A basic understanding of the physiology of pain is necessary to understand the consequences of assessment and intervention. The peripheral nervous system contains a multitude of nerve endings, known as receptors. Receptors are specialised parts of the cell, usually on the cell surface, which recognise specialised substances that deliver messages from other cells. The messengers may be hormones, inflammatory mediators, or neurotransmitters. Nociceptors , also known as pain receptors, are free nerve endings in the skin that respond to intense and potentially damaging stimuli such as thermal, chemical or mechanical damage. The cornea, joints and tendons have nociceptors too. Large internal organs do not have nerve endings. Non-nociceptive pain is nerve pain from within the nervous system.

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Peripheral nociceptive fibres respond to tissue damage and the release of chemicals (bradykinins, prostaglandins) from damaged cells, and transmit the pain signal from the periphery across the synapse in the dorsal horn of the spinal cord to ascending pain fibres within the spinal cord. There are two main types of peripheral pain fibres involved in the transmission of nociception: • Aδ (delta) fibres – small myelinated fibres which respond to pin-prick. They are activated by thermal and mechanical stimuli. • C fibres – small non-myelinated fibres from nociceptors in the skin and viscera, transmit pain due to thermal, mechanical, chemical damage. They are implicated in the transmission of pain described as dull, throbbing, diffuse and burning sensations. Within the spinal cord there are interneurons that connect the sensory pain fibres with other neurones such as: • Motor neurones that will effect reflex withdrawal from noxious stimulus • Neurones of the sympathetic nervous system that cause a sympathetic response to pain-sweating, tachycardia, hypotension, nausea • Inhibitory interneurones that reduce the amount of neurotransmitters released and can block the transmission of the pain signal.

Modulation of pain – changing the perception of the pain experience Perception is when a person becomes aware or conscious of the pain because the somatosensory cortex identifies the location and intensity of pain. Pain threshold is the least amount of stimuli required for a person to label sensation as pain. It is modulated by the patient’s mood, morale and meaning of the pain for the patient. Modulation refers to inhibition of the transmission of pain impulse. A number of factors impact on the pain threshold of an individual patient as indicated in Table 14.5. If the pain threshold is raised, the patient’s perception of pain is less. There are a number of non-pharmacological interventions that will reduce the pain experience for a patient. Lowering the pain threshold increases the pain perception for an individual. Pain perception is also increased by the following physiological phenomena: • Peripheral sensitisation. Nociceptors that are repeatedly stimulated become responsive to weaker stimuli that under normal circumstances would not result in pain. This can be caused by tissue damage and is mediated by inflammatory chemicals released by damaged cells.

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Pain threshold raised

Pain threshold lowered

• Relief of symptoms • Sleep/rest & relaxation therapy • Understanding/ sympathy • Companionship/listening • Elevation of mood • Understanding of the meaning and significance • Social inclusion • Diversional activity • Encouragement to express emotions

• Discomfort • Insomnia/fatigue • Sadness • Isolation • Depression • Anxiety • Anger • Boredom • Fear • Introversion • Social abandonment • Mental isolation

Source: Twycross & Lack,1996, cited in SIGN Guideline 106: 2008

• Wind-up. repeated stimulation of C fibres results in an increased response by neurones in the dorsal horn so that the pain signal is amplified. This occurs through activation of N-Methyl-D-aspartate (NMDA) receptors in post-synapatic neurons, resulting in an increased transmission of pain signal to the thalamus. • Central sensitisation. this is when prolonged stimu­ lation that occurs through peripheral sensitisation or ‘wind-up’ results in the development of more excitatory neurones. There appears to be death of inhibitory neurones and development of ‘neuronal memory’, that means that there is a stronger awareness of pain. In these instances pain becomes chronic, and chronic pain has been described as a disease entity and not just a symptom. Pain perception is decreased by the following physiological mechanisms: • ‘Gate control’ of transmission of pain signal mediated through Aβ pain fibres. These stimulate the inhibitory interneurones which release encephalins and inhibit transmission of C fibre impulse, closing the gate on transmitting the pain signal. • There are descending inhibitory pathways from the peri-aqueductal grey area of the brain which is rich in opioid receptors. Endogenous opioids and opioid medication stimulate descending pathway and inhibitory neurones to reduce or block the transmission of the pain signal. • Neurohumoral substances which are naturallyoccurring endorphins stimulate opioid receptors. Opioid receptors. Opioids (endogenous and exogenous) exert their effect through stimulation of opioid receptors (Back, 1998). There are three types of opioid receptors:

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1. μ – (Mu) the Greek letter M (morphine). There are at least nine identified subtypes of μ receptors that are responsible for the analgesic effect in spinal cord, peripheral nerves, and peri-aqueductal grey matter. 2. δ – (delta) post synaptic receptor between inhibitory neurone and pain fibre in the spinal cord. 3. κ – (kappa) responsible for euphoric effects of opioids. It is postulated that κ receptors are blocked by inflammatory chemicals. Peripheral opioid receptors are present in the afferent ends of C-fibres and are activated in inflammation, ischaemia and following nerve injury. There are central opioid receptors in the spinal cord and in the periadequeductal grey matter of the brain. Pain may be the result of an acute condition and responds once that condition is treated. It is also commonly associated with chronic conditions, such as arthritis, cancer and HIV/Aids. Treating the condition often does not of itself relieve pain.

Types of pain Pain is classified according to its duration (acute or chronic), aetiology (cause), origin (somatic or visceral) and intensity. Acute pain has a sudden onset and is commonly associated with specific injury, with the duration of 6 seconds to 6 months. Acute pain is often related to the severity of injury. It is usually described as sharp, intense, throbbing, or burning. The level of pain decreases as healing of the injury begins. Causes of acute pain may include surgery.

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Chronic pain has an insidious onset, with constant or intermittent pain that continues beyond the expected healing time. It can last for 6 months or longer. It is caused by diseases and medical conditions such as cancer and diabetic neuropathy. The pain is usually described as achy, sore and uncomfortable.

Pain assessment Pain is an internal, subjective experience that cannot be directly observed by others or by the use of physiological markers or bioassays. Pain assessment therefore relies largely on the use of self-report. A comprehensive clinical assessment is fundamental to successful pain management. Nurses are often the first healthcare providers to encounter the person in pain, and as such are the ones to communicate the necessary information about the pain to others. Collecting adequate information about the patient’s pain is essential.

14.1  Guidelines for taking pain history Here are some guidelines and questions that can be asked for taking pain history: • Severity/intensity – how much does it hurt? • Location – where is the pain? • Quality – is it a burning, stinging, colicky, throbbing, sharp or dull type of pain? • Onset – when and how did it start? • Duration – how long has the pain been present? • Frequency – is the pain constant or intermittent? • Aggravating or relieving factors – what makes the pain better or worse? • Disability – how does the pain affect the patient’s function? • Responses to current or previous treatments – what previous or current treatment has the patient received?

History taking When a patient is in severe, acute pain and is also anxious, it is important to alleviate the pain and anxiety as much as possible. The patient may be unable or unwilling to spend a long time providing history on the pain – at least until some measure of pain relief has been obtained. Any information given at this time must be clear and concise and directed towards meeting the patient’s needs. If a measurement tool is used, it must be simple and easy to implement. Taking and recording the pain history is crucial, and should include possible causes and a plan for appropriate treatment. Ask the patient to describe the pain in their own words. Prof Robert Twycross, previous professor of Palliative Medicine at Oxford University, suggests using the PQRST method of assessing pain (Twycross, 2002). P Precipitating and palliating (relieving) factors – what causes the pain, what makes the pain better, what makes it worse? Q Quality of pain – description of how the pain feels (eg burning, stabbing, throbbing) R Radiation of pain – does the pain move anywhere? S Severity of pain – how much does it hurt? T Timing of pain – the onset and duration of pain. Patients, especially those with chronic pain, may have previously received medication or treatment for their pain. It is important to get information about: • The prescriptions and over-the-counter analgesics used to relieve the pain, and whether there have been any side effects • Any consultation with traditional healers and/or whether the patient has used any complementary

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therapies such as herbs, aromatherapy or massage • Coping strategies used to alleviate the pain, such as distraction therapy (for example listening to music), cognitive reinterpretation, assumption of a certain position, rest and movement – coping strategies vary widely between patients and it is good to find out what has been found to work • How the pain impacts on activities for daily living, including sleep patterns, nutrition, concentration, and relationships at home, at work, and in the community • What support the patient is receiving from family and friends.

Observations The nurse should observe non-verbal signs such as: • Psychological factors (patient’s mood, morale, meaning of pain) • Communication through body language, such as posture, facial expression, and hand movements. Non-verbal communication also includes what one hears, smells, touches and sees, and is particularly important when assessing pain in children, the elderly, unconscious patients and the mentally challenged, or those with psychological disturbances.

14.2 Project empathy in all communication The nurse must remember that both their verbal and non-verbal communication must project empathy.

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Pain assessment in children

Questioning the parents about the child’s pain

At 26 week’s gestation the foetus or premature baby has the required anatomical and neurochemical function/ ability to experience nociception. Pain in children is expressed by crying, restlessness, body twisting and facial expressions, poor feeding, lack of sleep. With chronic pain the child may even fail to thrive. The parent is the best instrument to provide information about pain in the child.

Parents (or primary caregivers) know the child best and are sensitive to changes in the child’s behaviour. Parents’ ability to recognise pain in their child varies. Some parents may never have seen their child in severe pain. However, others are aware that certain behaviours signal pain. In addition, parents usually know what comforts the child, such as rocking, stroking, talking or feeding. To better assess the child’s pain, the nurse can interview the parents about their child’s previous pain experiences. Parents need to realise that their knowledge of their child is important in providing quality care. Questions to ask the parents include: • Describe any pain your child has had before. • How does your child usually react to pain? • Does your child tell you or others when they are hurting? • How do you know when your child is in pain? • What do you do to ease discomfort for your child when your child is hurting? • What does your child do to get relief when hurting? • Which actions work best to decrease or take away your child’s pain? • Is there anything special that you would like me to know about your child and pain?

14.3 Everybody experiences pain in the same way It should be remembered that mentally challenged patients and children experience pain in the same way as everybody else.

Since pain is both a sensory and an emotional experience, several assessment strategies should be used to gather information about pain, including the following: • If possible, ask the child about the pain • Ask the parents about the pain • Use pain rating scales • Evaluate behavioural changes • Evaluate physiological changes.

Questioning the child about pain Children’s verbal statements and descriptions of pain are the most important aspects in assessing pain. However, young children may not know what the word ‘pain’ means and may need help in describing it, using familiar language. Asking children to locate the pain is also helpful, and play can provide other means for helping children to reveal discomfort. When asking children about pain, the nurse must remember that children might deny pain, because they fear receiving an injectable analgesic or because they believe they deserve to suffer as punishment for being naughty. Suggested questions for obtaining information about pain from the child, if possible, include the following: • Tell me what pain is? • Tell me about the hurt you have had before? • What do you do when you hurt? • Do you tell others when you hurt? • What do you want others to do for you when you hurt? • What don’t you want others to do for you when you hurt? • What helps the most to take away your hurt? • Is there anything special that you want me to know about you when you hurt?

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Pain measurement Palliative care clinicians maintain that pain is the fifth vital sign and should be measured alongside blood pressure, temperature, pulse rate and respiratory rate. Because pain is subjective, an objective measurement of pain is not possible. However, pain rating scales are simple techniques designed to follow the course of a patient’s pain and the effect of treatment. Pain rating scales are also an effective and practical way for a nurse or doctor to demonstrate concern about their patient’s pain.

Pain rating scales Pain rating scales provide a subjective, quantitative measure of pain. There are several types of rating scales to determine the intensity of the pain. These include: • Visual analogue scale (VAS) • Numeric pain intensity scale • Verbal rating scales. The visual analogue scale (VAS) is a simple line on which the patient marks with an ‘X’ how strong their pain is, and the nurse or the doctor measure 0–10 on the line. With the numerical rating scale, the patient rates their pain on a scale of 0 to 10. Again the patient is asked to put a mark on a figure that explains the intensity of pain experienced. The two scales are easy to use and can give direction in the management of pain.

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No pain

Worst possible pain

0 1 2 3 4 5 6 7 8 9 10 Figure 14.2  Visual analogue scale No pain

Worst possible pain

0 1 2 3 4 5 6 7 8 9 10 Figure 14.3  Numerical pain rating scale

A verbal rating scale consists of various words, such as ‘no pain’, ‘mild pain’, ‘moderate pain’, ‘severe pain’ and ‘unbearable pain’. The words are placed along a 10 cm line, with equal intervals. Some patients may prefer to use the words to describe the experience, while others may have problems with the words chosen to describe the intensity of the pain. This scale is sensitive in measuring small changes in pain intensity over time and the effectiveness of interventions, both pharmacological and non-pharmacological. The advantages of using the three scales above include: • Simplicity. The patient or caregiver, professional or not, can use the scales effectively. • Clarity. The data collected provides clear evidence of pain intensity. The disadvantages are that: • The scales should not be used in isolation • The person in pain must understand and agree to use the scale • The scales are more suitable for patients with a single site of pain rather than for patients with multiple sites of pain • The question asked must relate to pain intensity, for example, ‘How is your pain now?’

the scale, it will make it easier for them to use the scale in actual pain (Srouji et al, 2010).

Examples of useful pain rating scales for children Faces scale. The scale consists of six cartoon faces, ranging from a smiling face for no pain, to a tearful face for worst pain. Several variations of face scales exist. Oucher. This consists of six photographs of a child’s face representing ‘no hurt’ to ‘the biggest hurt you could ever have’. This also includes a vertical scale with numbers from 0 to 10. Colour tool. Using a body-figure and crayons, the child can show the location and intensity of the pain. Different intensities of pain are marked with different colours. Most children tend to choose red or black for the worst pain. FLACC. This method is used for pre-verbal children and assesses how they respond to pain with their face; legs; activity; whether or not they are crying; and how easily they can be consoled. The scale for the FLACC method is described in Table 14.6.

Body outline To communicate the sites of pain from the posterior of the body, an outline can be helpful (see Figure 14.4). This is particularly important when a patient may be experiencing pain at a number of different sites. A body diagram can be filled in by the patient or with the help

Pain rating scales for children Children may display behaviours that indicate local body pain, for instance pulling the ears for ear pain. Although various pain scales exist, not all of them are appropriate for children in all age groups. For the most valid and reliable pain intensity rating, a scale that is suitable for the child’s age, ability, and performance is selected. The same scale is used for subsequent assessments to avoid confusing the child with different instructions. Ideally, children are taught to use the scale before pain is experienced, such as preoperatively. If the nurse familiarises the child with

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Figure 14.4  Body chart to document site of pain

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246  Juta’s Complete Textbook of Medical Surgical Nursing Table 14.6  FLACC scale for assessment of pain in the pre-verbal child

Face

0 No particular expression or smile

1 Occasional grimace, frown; withdrawn; disinterested

2 Frequent/constant frown; clenched jaw; quivering chin

Legs

0 Normal position; relaxed

1 Uneasy, restless, tense

2 Kicking or legs drawn up

Activity

0 Lying quietly, moves easily

1 Squirming, shifting back and forth

2 Arched, rigid or jerking

0 Not crying

1 Moans or whimpers, occasional complaint

2 Crying steadily, screams or sobs

0 Content, relaxed

1 Reassured by touching, hugging, voice; distractable

2 Difficult to console

Cry

Consolability

Source: Merckel et al, 2002

of the nurse. The advantage of the body outline is that it gives clear evidence of location and distribution of a patient’s pain, as well as the characteristics of the pain. The disadvantage lies in the fact that the diagram cannot indicate whether the pain is superficial or deep, and it also gives limited information about the complex pain experience. This tool would be useful to incorporate with other more multidimensional pain assessment tools or observational charts available in many hospitals.

Pain questionnaires Pain questionnaires are invaluable for healthcare providers when trying to assess the pain experience of patients. These questionnaires employ a combination of different approaches, such as rating scales and body outlines. They also include the Initial Pain Assessment tool, as well as the Edmonton Symptom Assessment System. The McGill Pain Questionnaire (MPQ) has been used extensively in clinical research because it has proved to be valid and reliable. A short version (form) of this (SF-MPQ) has been developed for use in more clinical situations when time to collect information is limited. The questionnaire consists of a rating scale to assess pain intensity and the pattern of the pain. It also contains a body outline to show the sites of the pain. MPQ can also discriminate between different types of pain and can be used as an evaluation on pain treatment given. Both forms of MPQ incorporate an extensive list of words from which the patient can choose words to describe different aspects of the pain experience. This can be useful in situations where it is difficult for the patient to find the appropriate words to express feelings and emotions, as words are already

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provided. In comparison with the simpler rating scales, the disadvantages of using MPQ are as follows: • It is time-consuming to complete. • It requires concentration from the patient, which may prove challenging for one who is in pain, and it is there­ fore inappropriate when the patient is in acute pain. • Some of the words may not be well understood by all patients. The Initial Pain Assessment tool includes a diagram with the body outline, questions about quality of the pain, onset, duration, variation, factors which increase/ relieve pain, and effects of pain – such as accompanying symptoms, appetite, sleep and concentration.

Observation charts Observation charts are tools that provide an objective measurement of pain for children, patients with a poor command of language, and confused and unconscious patients. The charts report on a number of behaviours such as breathing, facial expression, body language and the amount of fidgeting or restlessness. The observation charts provide an accurate measure of discomfort, more than the intensity of pain. The nurse must remember that much of the behaviour may be attributed to other factors in addition to pain, such as internal haemorrhage, temperature, or a full bladder.

Pain diaries Another way of getting information about the pain experience, mood and consequences of the pain is to ask the patient to keep a pain diary. By writing about their

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pain, the patient will become more involved and active in their own care. Secondly, the information will be useful in estimating the impact of pain on the person’s life. One significant disadvantage, however, is that the diary, and therefore the pain, could become the main focus of attention. The diary method is also limited to those who can read and write.

Choosing a pain assessment tool There is a lot to gain by using tools in pain assessment. The decision about which instrument to use should be based on a number of considerations, such as: • The instrument must be valid and reliable, sensitive and easy to use. • The nurse must ensure that those who are to use the tool are competent in using it. • The nurse has to take into account the patient’s general condition, level of cognitive ability, level of concentration and most importantly, the level of pain during the assessment. • A more formal tool is required for effective assessment, and it is in the patient’s best interest if this is done in the form of a written document. The data collected will be incorporated into the patient’s individual care plan. • Pain assessment should be approached with a positive attitude and not be seen as yet another form to complete.

Nursing interventions for patients in pain Principles of pain management A comprehensive clinical assessment is fundamental to successful pain management. • Believe the patient. • Ask the patient to describe the pain in their own words. Supplement this information by specific questions to define the exact nature of the pain, such as the onset of the pain, its duration, location and quality, aggravating or relieving factors, whether it radiates to other sites, as well as the impact of the pain on sleep, mobility and function. Also ask about the effect of previous and current medication and what the pain means to the patient. It is important to assess and measure each pain separately on a suitable pain scale, as many patients tend to have two to three different kinds of pain simultaneously. The nursing care for people in pain involves both technical and management skills in the use of pharma­ cological and non-pharmacological therapies. Once the cause has been determined and the symptom defined,

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decisions need to be made about effective interventions. Decisions about acute pain are less complicated than those required for chronic pain. Acute pain is transient and the patient also knows that the pain will subside once the cause has been treated. Chronic pain is more persistent and serves no useful purpose. Psychological, social and spiritual factors are much more likely to contribute to or result from the chronic pain. The goal of pain management in chronic pain is more often to minimise rather than to eliminate entirely. The goal may also be to rehabilitate the patient in order to achieve optimal functioning in activities of daily living.

Treatment of pain It is important for nurses to stay informed about the patient’s pain. Patient care should be focused on preventing pain before it returns and to individualise the analgesic dosage. This approach applies to both acute and chronic pain.

Use of preventive approach This means that the analgesic must be given before the pain occurs or before it worsens – this is referred to as pro re nata (PRN) administration of medication. PRN is not advised for chronic pain control, as patients then experience regular episodes of pain which can be avoided through regular administration of appropriate analgesics. The analgesic can also be administered on a regular basis, but if the pain occurs consistently, then use analgesia as required. Patients are usually not aware that they can ask for pain medication. It is important to inform them of this possibility so that they can participate in the management of pain. Individualised analgesic dose. The correct amounts of analgesic must be given so that it is effective and adjusted to the individual patient. The goal is to get pain relief with the fewest side effects by giving the most effective analgesic through the most convenient and effective route. It is important to watch the individual’s response to the drug. Use a pain management tool or a pain medication assessment sheet to monitor responses. It should be remembered that pain can only be felt by the person who is experiencing it and the key concept of patient-controlled analgesia (PCA) may be defined as the patient’s self-administration of all forms of pain control, not only analgesia therapy. With guidance and adequate safety precautions, the patient can determine what is necessary to relieve or control pain. These actions require patient teaching.

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Pharmacological interventions Pharmacological interventions have always had a valued place in pain management, but as the causes of pain are multifactorial, the approach to treatment may vary. There are different types of pharmacological agents available and they act by different mechanisms. The analgesic agents are divided into three groups: 1. Non-narcotic analgesics or non-steroidal antiinflammatory drugs (NSAIDs) 2. Narcotic analgesic or opioids 3. Adjuvant analgesics or co-analgesics. They may not have pain as their primary indication. Adjuvant drugs enhance the effect of other analgesic drugs.

Weak opioids ± non-opioid ±adjuvants Non-opioid ±adjuvants

Step 3

Step 2

Step 1 Figure 14.5  WHO 3-step analgesic ladder Source: World Health Organization

Choice of drugs The World Health Organization (WHO) introduced the analgesic ladder which is an intensity-controlled ladder for treating nociceptive cancer pain. Individual treatment can be devised by starting at the bottom of the ladder and progressing upwards until the pain is controlled (see Figure 14.5). The model has been used in patients with nociceptive pain, as well as for patients with neuropathic pain. Using a combination of analgesics and adjuvants enhances the effects, and the dosage of a single agent can be minimised, thus also limiting side effects. Figure 14.5 can be explained as follows: • Step 1: Non-opioids. Examples include paracetamol and NSAIDS. Start with a non-opioid analgesic such as paracetamol and/or a non-steroidal anti-inflammatory agent. • Step 2: Mild opioids. Examples include codeine, dihydrocodeine, and tramadol. If pain is not controlled by Step 1 analgesics, a weak opioid can be added. If a weak opioid has been used in the maximum dose and the patient still has pain, then move to Step 3. If a mild opioid ceases to be effective, it is important not to switch to another mild opioid on the same step of the ladder. Many preparations in South Africa are made up of combinations of Step 1 and Step 2 drugs. A combination of a non-opioid and an opioid drug is effective in that the different drugs have different mechanisms of action and they potentiate each other’s actions. Codeine is not recommended as 30% of people do not have the enzyme that converts codeine into morphine in the body. It is also a more constipating drug than morphine.

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• Step 3: Strong opioids. Examples include morphine, fentanyl, buprenorphine, tilidin. If Step 2 drugs are not effective, a strong opioid can be prescribed. Morphine oral solution is usually prescribed as the strong opioid of choice when commencing Step 3, as it is a quick but short-acting drug, hence rapidly effective yet safe. –– Morphine is given orally in the form of a titration until pain settles. –– Only once pain is under control should a change to other more convenient strong opioid be considered, such as the slow-release morphine preparation or the fentanyl patch. –– It is often necessary and beneficial to continue with Step 1 analgesics even when a patient is on Step 3.

Non-steroidal anti-inflammatory drugs (NSAIDs) NSAIDs are beneficial in pain associated with inflamma­ tion. They exert their action through inhibition of cyclooxygenase, an enzyme involved in the production of prostaglandins. NSAIDs should be used with caution, preferably for a short duration until inflammation is controlled (3–5 days). Side effects include an effect on the GIT with risk of gastrointestinal bleeding and reduced platelet stickiness. Other side effects are: • Aspirin may cause tinnitus and deafness, especially in patients with low plasma albumin. • Salicylates have a hypoglycaemic effect. • All NSAIDs cause salt and water retention and antagonise diuretics. • NSAIDs may cause renal failure, especially in patients with low plasma volume. • Some patients may experience a hypersensitivity reaction manifest as bronchospasm.

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Broad-spectrum analgesia In palliative care, patients often need a combination of a non-opioid, with an opioid (weak or strong) and an adjuvant analgesic to adequately control pain in advanced illness. Please note that: • Weak opioids should not be combined with strong opioids. • Non-opioids may be combined with weak or strong opioids. • Adjuvant analgesics can be added to any step of the WHO ladder at any stage. If patients have pain that is difficult to control using the guidelines of WHO and opioid or non-opioid analgesics, it may be necessary to use a combination of medicines in a broad spectrum approach. The adjuvant analgesics may contribute significantly to pain relief, whether used alone or in combination with the analgesics on the WHO three-step ladder. Adjuvants that are useful for pain that is less sensitive to opioids include neuropathic pain, bone pain, pain associated with inflammation and sepsis. Pain associated with smooth or skeletal muscle spasm will not respond to an opioid and will need an adjuvant analgesic.

Pain related to anxiety will also benefit from adjuvant analgesics. Commonly used adjuvants for pain relief and their uses are indicated in Table 14.7. Analgesics to manage children’s pain are mentioned in Table 14.8.

General principles of treatment for chronic pain The general principles of pain management are to prevent recurrence and discourage the acceptance of pain. The nurse should remember the five Rs: 1. The right dose. Give medication in the dose that is required for the individual patient. The correct dose is the dose that gives relief. There is a maximum dose for most commonly used analgesics. However, morphine has no maximum dose, provided it is prescribed incrementally, until pain relief is obtained. Please note that the correct dose of morphine, therefore, is the dose that gives relief. 2. The right time. Analgesics should be given at regular intervals. Analgesics are given according to a strict schedule determined by the duration of action, in order to prevent recurrence of pain. Analgesics for chronic pain should never be given PRN (as required). It is important to give the next dose before recurrence of pain. If pain is allowed to resurface, higher doses

Table 14.7  Examples of adjuvant analgesics

Adjuvant analgesics

Example

Use

Corticosterioids

Dexamethasone Prednisolone

• Bone pain • Inflammation • Neuropathic pain • Headache due to raised intracranial pressure, pain associated with oedema and inflammation.

Antidepressants

Amitriptyline

• Neuropathic pain

Anticonvulsants

Carbamazepine Gabapentin

• Neuropathic pain

Antispasmodics

Hyoscine butylbromide

• Smooth muscle spasm, eg colicky abdominal pain, renal colic

Muscle relaxants

Benzodiazepine, eg Diazepam

• Skeletal muscle spasm • Tension headache

Anxiolytics

Benzodiazepine, eg Diazepam Alprazolam

• Anxiety-related pain

Bisphosphonates

Pamidronate

• Bone pain

Source: Hospice Palliative Care Association of South Africa

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Type

Medication

Dose

Step 1: non-opioid

Paracetamol Ibuprofen

10–15 mg/kg 4- to 6-hourly 10mg/kg 8- to12-hourly

Step 2: weak opioid

Codeine Tilidine

0.5–1mg/kg 4-hourly 1 mg/kg/dose 6-hourly (Each drop = 2.5 mg)

Step 3: strong opioid

Morphine

Start 0.3 mg/kg 4-hourly

of analgesics will be required to suppress the pain and it will subsequently be more difficult to control. A patient on a strict, regular schedule of analgesia will also need to have available a ‘breakthrough’ dose for any episodes of breakthrough pain. 3. The right route. The oral route is best for management of chronic pain. Oral medication should only be abandoned if the patient is unable to take or retain them. The intramuscular and intravenous routes are seldom used for long-term pain control. There are many other less invasive alternatives when a patient is no longer able to take oral medication, such as the subcutaneous, buccal, sublingual, transdermal and rectal routes. 4. The right drug. (According to the WHO analgesic ladder.) The choice of analgesic is determined by the severity, site and type of pain. The choice of analgesic should be guided by the WHO three-step analgesic ladder. 5. The right patient. Ensure that the medication is administered to the right patient. Ask the patient for their name, do not tell them. If further clarification is needed to confirm the patient’s identity, ask them for their address.

Morphine Guidelines to starting morphine • Start morphine treatment as quick-acting oral medi­ cation (ie oral morphine solution). The starting dose depends on the patient’s age and general condition and whether the patient has been using a regular dose of a weak opioid. • HIV-positive patients respond well to low-dose morphine. The usual adult starting dose is 10–20 mg of morphine solution every 4 hours. Patients who are frail and HIV-positive start on 5–10  mg of morphine solution every 4 hours. Regular 4-hourly administrations are required to ensure that pain remains controlled, eg 06:00, 10:00, 14:00, 18:00, 22:00, 02:00 (if patient is awake).

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• The dose of morphine is then titrated against the patient’s requirements for pain relief and response to analgesia. The dose is increased by 30–50%. For example, if the patient starts on 10 mg of morphine and pain is not controlled at this dose, the dose is increased to 15 mg 4-hourly, then to 20 mg 4-hourly, then to 30 mg 4-hourly, then to 45 mg 4-hourly, then to 60 mg 4-hourly, then to 90 mg 4-hourly, then to 120 mg 4-hourly. • When pain control is achieved, this dosage of morphine is used to maintain pain control. • If the patient is being managed as an outpatient, the increments may be every 24 hours and may be decided by the number of additional doses of morphine required to manage breakthrough pain. • When starting a patient on morphine, always give instructions for dealing with breakthrough pain, and ensure that a qualified person can be contacted to give ongoing support. • If pain resurfaces before the next 4-hourly dose of morphine is due, an additional dose of morphine equivalent to the regular dose should be taken as well as the prescribed dose of morphine at the time due for the next regular dose of morphine. Morphine dosage can be adjusted by adding the total amount of morphine required in the past 24 hours for pain relief – regular doses and breakthrough doses – and dividing the amount by 6 to recalculate the dose of morphine required for pain control in a 24-hour period. It is reassuring for a patient and their family to know that a breakthrough dose can be used to ensure that pain is controlled, and it helps the patient to feel in control and avoid the despair of living with uncontrolled pain. There is much ignorance surrounding the use of morphine and as a result, patients often suffer unnecessarily. There are many myths about morphine, including fear of addiction, respiratory depression, hastening of death, tolerance and drowsiness.

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14.4  Four myths about morphine • Myth 1 – Tolerance. People should not take morphine before their pain is severe, lest it lose its effect. Fact. There is no upper dose limit to the use of morphine or other strong opioids. If pain increases, the dose can be increased. Using opioids early in the course of a terminal illness does not mean that they will not continue to work later in the disease. Tolerance of the analgesic effect of morphine is unusual. • Myth 2 – Addiction. Using opioid medication will lead to addiction. Fact. There is often confusion between physical dependence and psychological dependence (addiction). Physical dependence is a normal physiological response to chronic opioid therapy that causes withdrawal symptoms if the drug is abruptly stopped or an antagonist administered. Physical dependence is not unique to the opioid drugs and occurs with many other medication such as corticosterioids, antidepressants and certain benzodiazepines. Patients whose pain has been relieved by surgical or other means should have their opioid reduced by about 25% per day. Patients should be reassured that physical dependence does not prevent withdrawal of the medication if their pain has been relieved by other means, provided the drug is weaned slowly. Psychological dependence and addiction is a pre-existing condition characterised by abnormal behavioural and other responses, which always include a compulsion to take the drug to experience its psychic effects. When prescribed appropriately in a dose sufficient to relieve pain, there is no evidence that opioids lead to addiction. • Myth 3 – Respiratory depression. People on morphine die sooner because of respiratory depression. Fact. Respiratory depression is very uncommon except in opioid naïve patients commenced on parenteral therapy. Respiratory depression will not occur if morphine is given orally at a low starting dose and titrated carefully against a patient’s response, ie increased until pain is relieved. In palliative care, low doses of morphine are also safely used in patients with end stage chronic obstructive airway disease (COPD), lung cancer and to relieve the symptom of dyspnoea. • Myth 4 – Fear of hastening of death. Using morphine means that the end of life is near and morphine can hasten death. Fact. Morphine can be used for many months or years, and if correctly used is compatible with a normal lifestyle.

Side effects of morphine It is essential for the patient and family to understand that morphine will have side effects that can be managed. The doctor or nurse recognises that the common side effects of morphine need to be anticipated and prevented include: • Drowsiness and possible confusion. This is a temporary effect and will wear off in 3–4 days, provided morphine is taken regularly. Intermittent morphine administration interferes with developing tolerance to this side effect. The patient has usually had a long period of lack of sleep because of pain and in starting morphine the drowsiness and past insomnia will result in significant sleepiness. Explain that there will be a period of catching up on lost sleep, that the drowsiness and mental clouding will wear off, and that within a week the person using morphine will be more alert and able to function normally and experience better quality of life as their functioning is no longer limited by pain. Patients on a stable dose of morphine should have normal cognitive function.

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Clinical alert! There is no ceiling dose to morphine. Morphine dosage is determined by the patient’s analgesic requirements.

• Nausea and vomiting. Approximately 30–40% of people will experience nausea when starting morphine, and some patients will also experience vomiting. These are distressing symptoms and it is important to control pain without adding unpleasant symptoms. It is important to co-prescribe a medication that will control the side effect of nausea due to morphine. The two medications that are effective in preventing nausea are metoclopramide, 10 mg three times a day, and a low dose haloperidol, which counteracts the toxic effect of morphine mediated through the chemoemetic trigger zone in the brain (0.5 mg three times a day). Tolerance to this side effect also develops within

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3–4 days, so the prescription of these medications should be for 5–7 days. • Constipation. Tolerance to the constipating effect of codeine and morphine does not develop unless morphine is improving diarrhoea. For example, in a patient who is HIV-positive, laxatives should be co-prescribed on an ongoing basis for patients taking morphine. There are often additional factors causing constipation such as frailty, inactivity, and reduced intake of dietary fibre in patients with chronic pain. A stool softener such as lactulose should be prescribed together with bowel stimulation such as senna.

Slow-release opioids Once pain is controlled on morphine solution, a patient can change to using a slow-release medication if this is available, affordable and more convenient for the patient.

Changing to slow-release morphine Add the total dose of morphine required for pain control and divide this amount by two to calculate the dose of slow release morphine required as a twice-daily dose of morphine. If, for example, a patient is on a dose of morphine syrup 20 mg 4-hourly, this is a total daily dose of 120 mg of morphine. If this is to be administered twice a day in a slow-release form of morphine, the patient will require 60 mg morphine twice a day. They will still need quick-acting morphine solution for breakthrough pain. Fentanyl is available in South Africa as a slow-release transdermal patch. It should only be used once a patient’s pain is controlled on morphine. Conversion to fentanyl is guided by the manufacturer’s tables. The patient will still need a quick-acting morphine solution for breakthrough pain.

• • • • • • • • • •

Psychosocial support and counselling Providing adequate information Support groups Relaxation therapy Meditation Coping skills training Cognitive therapy Hypnosis Psychotherapy or cognitive behavioural therapy Anxiolytics and antidepressants.

Social factors Unresolved social problems can aggravate pain, whereas recognition and management of social issues can greatly facilitate pain control. This includes supportive counselling, practical assistance such as the provision of aids for daily living, accessing community resources and services. Financial and legal problems should be sensitively managed. Sensitivity to the different cultural and ethnic backgrounds will help facilitate pain control. Patients of differing cultural backgrounds vary greatly in their response to pain and the palliative care professional should be non-judgemental in their assessment of pain.

Spiritual and religious concerns Spiritual and existential problems are an important source of clinical suffering and can aggravate pain and even cause pain. Recognition and successful management of spiritual problems is an important part of pain control. Spiritual and existential distress may manifest in physical problems. Pain that is unresponsive to the appropriate therapy should alert the healthcare professional to the possibility of unrecognised spiritual or existential problems.

Non-pharmacological therapy for pain

Common nursing diagnoses related to pain

Psychological, social and spiritual factors can play an important role in the aggravation or relief of pain. Assessing psychosocial and spiritual issues in a patient with chronic pain requires the approach of an interdisciplinary team.

Nursing diagnoses regarding pain are formulated in relation to the cause and are expressed as: • Altered comfort related to pain due to disease process • Altered sleep pattern related to pain or discomfort • Risk of anxiety and depression due to pain • Inability to function evidenced by expression of pain (see Table 14.4).

Psychological distress Psychological distress related to chronic pain often manifests in depression or anxiety. However, distress associated with chronic pain may present as anger, frustration, hopelessness, helplessness, denial, grief, sadness or withdrawal. Management should be directed at facilitating the patient’s adaptive and coping mechanisms. Psychosocial support of a patient with chronic pain could have a profound effect on pain control and on the patient’s quality of life. Psychological therapy for pain includes:

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Community care There are facilities in the community that cater for patients with chronic pain. Both pharmacological and complementary interventions can be utilised by nurses, including those in non-governmental organisations, such as hospices and community care facilities. Complementary interventions include physical techniques, such as

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massages, application of cold and heat, transcutaneous electric stimulation (TENS), acupuncture and acupressure. The cognitive-behavioural strategies include a range of different interventions, from simple distraction to more complicated procedures, such as cognitive-behavioural pain management programmes. The latter include both physical and cognitive-behavioural strategies and are often multidisciplinary. Cutaneous stimulation is thought to close the ‘gate’ in the spinal cord by either increasing transmission of non-noxious inputs into the spinal cord or modulating the transmission of noxious inputs via afferent peripheral and/ or descending central effects. Massage is the manipulation of soft body tissue with the use of hands and has been used as a therapeutic intervention for many years. There

14.5  Other pain remedies • Psychosocial support and counselling • Manipulation (physiotherapy: massage, immobilisation, active and passive exercises) • Application of heat and cold • Acupuncture • TENS (transcutaneous electrical nerve stimulation) • Trigger point injections • Reflexology • Aromatherapy • Radiotherapy (important for bone lesions, spinal cord compression, and fungating malignant lesions) • Nerve blocks • Neurosurgical approaches (rarely needed) • Relaxation therapy • Heat therapy, including ultrasound • Distraction therapy • Surgery (eg for orthopaedic complications and visceral obstruction) • Palliative radiotherapy should employ the minimum dose of radiotherapy required to achieve the desired result given in the minimum number of treatment fractions – the doses used for the palliation of pain in patients with advanced disease are usually much less than the doses used to treat the cancer, and small but effective doses can often be delivered, even in previously treated areas • Mobility aids (crutches, walking frames) • Immobilisation • Local anaesthetics and nerve blocks for painful bone metastases and neuromas. Peripheral and spinal nerve blocks (eg epidural anaesthetic block) are performed for specific pain syndromes

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are a number of different techniques in massaging, but the best known are the touch and stroking techniques. The patient’s involvement in this is minimal, which can be an advantage when the patient lacks energy or is functionally limited. Massage also encourages the patient to relax, and by so doing, spasms may be relaxed and thus reduce pain.

Essential patient and family teaching Asking a patient about their pain can sometimes increase the pain and anxiety. It is therefore important for the patient to have sufficient knowledge about their disease/condition and the likely process. The nurse must remain sensitive and empathetic towards the patient, but the information must be realistic. The nurse should also try to dispel any myths and misconceptions a patient might hold. The first step in patient education is to establish what the patient knows about pain and what they would like to know. Some patients will require extensive information, while for others it may be a matter of filling in gaps to clarify aspects previously misunderstood. Oral information should be supplemented with written material if the patient can read. Family members should also receive this information, because they often have to provide physical, social and psychological support to the patient. This education process should be updated as the disease/condition progresses. When starting a patient on morphine, always give in­struc­tions for dealing with breakthrough pain and en­sure that a qualified person can be contacted to give ongoing support.

Conclusion Assessment and management of distressing symptoms is an essential approach to patient-centred care. The approach enhances quality of life for the patient and encourages better adherence to medication that will control the disease process. With good attention to detail in assessment and treatment of pain, complete pain control can be achieved allowing patients a more active life. Adequate pain relief must ensure a good night’s sleep, free of pain, comfort at rest during the day and comfort when active. For patients with persisting movement related to pain it may be necessary to modify lifestyle activities which cause pain.

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Suggested activities for learners Activity 14.1 For each of the following items choose the most appropriate answer. 1. There are various types of pain: acute and chronic. How long does pain have to remain for it to be considered chronic? a) More than 2–4 months b) More than 3–6 months c) More than 1–3 months d) More than 6–12 months. 2. A 45-year-old patient reports pain in the foot that moves up along the calf, saying: ‘My right foot feels like it is on fire.’ The patient reports that the pain started yesterday and that they have no previous history of injuries or falls. Which components of pain assessment has the patient reported? a) Aggravating and alleviating factors b) Exacerbation, and associated signs and symptoms c) Intensity, temporal characteristics, and functional impact d) Location, quality, and onset. 3. Which of the following statements is correct for exertional dyspnoea? a) Breathlessness in the recumbent position, relieved by sitting or standing b) Shortness of breath that awakens the patient, often after 1 or 2 hours of sleep, and is usually relieved in the upright position c) It occurs at a level of activity that is usually well tolerated d) Breathlessness that occurs in the upright position and is relieved with recumbency. 4. Neuropathic pain is due to injury of the nerves, the spinal cord pathways. • True • False. 5. Orthopnea occurs in both cardiac and pulmonary disease, but paroxysmal noctural dyspnoea is characteristic of heart disease only. • True • False. 6. Cyanosis occurs when circulating quantity of reduced haemoglobin is more than 5 mg/dl. • True • False. Activity 14.2 Write at least three nursing interventions for each of the following symptoms of disease: • Nausea and vomiting • Cough • Fatigue.

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15

Multiple trauma and emergency care

learning objectives

On completion of this Chapter, the learner should be able to: • describe the aetiology, pathophysiology, clinical manifestations, and therapeutic and pharmacological management of life-threatening conditions including multiple trauma • perform accurate assessment on patients with life-threatening conditions • explain the assessment findings, including the results of diagnostic studies in patients with life-threatening conditions • outline the plan for prioritisation and provision of safe patient care • discuss the management of emergencies and/or complications of multiple trauma • describe the care for sexually assaulted patients. key concepts and terminology

anoxia

Absence of oxygen supply to the tissues of the body.

atelectasis

Collapse of the alveoli of the lung due to injury or underlying diseases.

cardiopulmonary resuscitation (CPR)

The measures undertaken to maintain life by means of mechanical, physiological and pharmacological methods in the event of respiratory and/or cardiac arrest.

definitive care

Care following emergency care when the patient has been given a definitive diagnosis and is transferred to a relevant unit for management.

Glasgow Coma Scale

An international scale for assessing the level of consciousness.

haematoma

A collection of extravasated blood trapped in the tissues of the skin or in an organ, resulting from trauma or blood stasis after injury.

haemothorax

Accumulation of blood in the pleural space.

Heimlich manoeuvre

The manual abdominal thrusts performed to create pressure to expel an object that is causing airway obstruction.

melaena

The production of dark sticky faeces containing partly digested blood, as a result of internal bleeding or the swallowing of blood.

multiple trauma

Injury to two or more body systems.

pericardiocentesis

Drainage or removal of fluid or blood from the pericardial space.

rape

Sexual assault without consent of the victim. The act impacts negatively on the physical, emotional and psychological state of the person affected.

resuscitation

The measures undertaken by skilled health professionals to revive an individual from a life-threatening state or apparent death.

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thoracocentesis

Procedure done for the release of air or fluid from the pleural space.

thoracostomy

Decompression of the chest with a needle following a tension pneumothorax.

trauma

A state of emotional or physical shock or injury caused by violent or disruptive action or illness which may or may not need emergency care.

trauma/emergency unit

A unit providing emergency and specialised care to the injured and/or critically ill.

triage

The process of sorting patients in a disaster situation according to severity of injury and making decisions about management of patients with multiple trauma in an emergency.

prerequisite knowledge

• Anatomy and physiology of the human body (all systems) • First aid • Microbiology, parasitology and pharmacology. medico-legal considerations

It is important to know and to maintain medical and legal standards of care during emergency management. Therefore the nurse has an obligation and responsibility to: • maintain control during an emergency and ensure the safety of everyone, including all team members, the patients, and their relatives • ensure that the structure and layout of the emergency unit and resuscitation areas are well organised • familiarise themselves with the common emergency procedures and preparation for such procedures • check equipment regularly for correct functioning, and drug supplies for potency • sort and prioritise patients according to the severity of their injuries, and give prompt and efficient emergency care safely • monitor the patient’s response to treatment by frequently assessing the vital signs and mental status and keep an accurate record thereof (as this may be called for during litigation) • follow institutional policies regarding the safekeeping of the patient’s property and keeping accurate records of same. essential health literacy

It is important to ensure efficient and effective communication with the patient or family during an emergency situation. The nurse should explain to the patients, witnesses or family all the procedures that will be done in order to give prompt and efficient emergency care safely. To ensure effective communication, the nurse should monitor the patient’s response to treatment by frequently assessing the vital signs and mental status. The nurse should explain to the patient the expectations regarding care in order to gain cooperation during emergency treatment and care. The patient should be advised to remain still and avoid excessive movement where necessary as injury to one system in the body may affect others.

Introduction An emergency is any sudden unexpected event, illness, or injury that requires immediate intervention. Trauma usually presents as an emergency and requires prompt attention in terms of rapid assessment, intervention and management. During emergencies, nurses and healthcare providers are expected to provide emergency care to save lives. The role of the nurse thus includes reception of the

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patients, assessment and categorisation of the conditions, and provision of basic life support care. The aim of this Chapter is to provide you with adequate knowledge and skills to efficiently manage the care of patients presenting with a variety of life-threatening conditions, including patients with multiple trauma, in a variety of clinical settings.

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An overview of multiple trauma and emergency care Trauma and emergency nursing care is a speciality designed to care for the suddenly ill or injured. It begins with resuscitation and ends when the patient has been transferred for definitive care. The unique environment of an emergency unit, triage practices and assessment of trauma and emergency patients are essential in multiple trauma and emergency care. Nursing in emergency situations includes addressing problems that may be actual or potential, sudden or urgent, physical or psychological, and acute or episodic. Attention to these problems may require lifesaving measures, patient and family education, appropriate referral and a discharge plan. Emergency care may be delivered in a variety of care settings, including acute care settings, casualty departments, prehospital and military settings, clinics, and business, educational, industrial and correctional institutions. The roles of the emergency nurse are as follows: Provision of safe care. The emergency nurse must be able to perform a scene assessment and ensure safety in the area. This may include removing potential hazards, examining, and prioritising patient care according to the principles of triage. They must be able to conduct a primary and secondary assessment and implement nursing interventions to prevent complications. Management of the emergency/trauma unit. The nurse in the trauma/emergency unit must be familiar with the layout of the unit to facilitate prompt treatment during an emergency. Equipment for resuscitation should be readily available, including drugs for resuscitation. The nurse should be familiar with the type and operation of the equipment, such as the defibrillator, cardiac monitor, ventilator and blood gas machine. The nurse must be able to prepare and assemble emergency equipment, and initiate resuscitation protocols in order to give prompt and efficient emergency care safely. Activities must be well coordinated to ensure safe and effective emergency management. Essentially, staff members working in this environment need to be trained and accredited in Basic and Advanced Life Support which is renewable after every second year. Triage. The emergency nurse is responsible for triage in the emergency unit, through prioritisation of injuries and conditions from high priority to low priority. A standardised four-colour-coded triage system or a Revised Trauma Score (RTS) may also be used. RTS is one of the common physiologic scores in use. For field triage, the score adds the values of three specific parameters, namely

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the Glasgow Coma Scale (GCS), systolic blood pressure (SBP) and respiratory rate (RR) (see Table 15.1). The RTS ranges from 0-12; where an RTS of 11 indicates patients who need admission in a trauma unit. Table 15.1  Revised Trauma Score

Coded value

GCS

SBP (mmHG)

RR (breaths /min)

0

3

0

0

1

4–5

 90

10–30

15.1  Triage priorities Prioritisation of conditions during triage is communicated by priority or colour coding as follows: High priority: Code Red. This is the group of patients who need immediate emergency care. It includes patients with the following critical or life-threatening conditions: • Airway obstruction leading to breathing problems • Circulatory problems in patients presenting with severe bleeding or loss of fluids as in severe burns • Unconsciousness • Shock and severe head, chest and abdominal injuries. Medium priority: Code Yellow. These are patients who can wait for medical help, as there is no immediate threat to their lives. Their conditions are serious and include: • Fractures • Head and spinal injuries • Burns of less than 40%, and that do not involve the face and chest. Low priority: Code Green. This category relates to patients who are out of danger and can be given care later. The conditions include: • Minor wounds and light bleeding • Behavioural problems. Least priority: Code Black. This category refers to patients who are dead.

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Continuous assessment. This must continue until the patient is transferred to the relevant unit for definitive care. Ongoing care must be done to assess the patient’s response to emergency treatment and to identify further problems. The level of consciousness, skin condition, pulse and breathing should be continuously assessed and a record kept of all activities. Record-keeping. Accurate records must be kept of care given and the condition of the patients. Communication. The emergency nurse needs good com­ mu­nication skills to be able to communicate effectively with other members of the team, the patient‘s family and outside agencies including the media.

Classification of emergency conditions The conditions are classified according to the involvement of the different systems in the body as indicated in Table 15.2. Table 15.2 Classification of conditions according to the body part affected

Body system involved

Condition

Respiratory emergencies

• Choking • Near drowning

Head trauma

• Scalp injury • Skull injury • Brain injury

Chest trauma

• Fractured ribs • Flail chest • Pulmonary contusion • Pneumothorax (tension and open) • Haemothorax • Cardiac tamponade

Abdominal trauma

• Blunt abdominal trauma • Penetrating abdominal trauma

Musculoskeletal trauma

• Avulsion • Fractures • Compartment syndrome

Special senses

• Eye injuries • Ear injuries • Nose injuries

Emotional trauma

• Violence (physical, psychological, sexual) • Rape

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Risk factors for emergency conditions Accidents. Accidents in the home such as falls, fires that cause burns, medication over dosages (intentional or accidental), near drowning, and food poisoning contribute to some of the injuries brought to the healthcare institution as emergencies. Road traffic accidents. Motor vehicle and bike accidents are caused by high speed and negligent driving, not wearing seat belts or helmets, driving under the influence of alcohol or drugs, failure to obey the rules of the road, and violence from road rage. Roads without signs, markings, or with inadequate lighting also increase the risk of accidents. Industrial accidents. These include accidents such as falls from scaffolding during construction work, burns from explosives, and agricultural injuries as a result of limbs being caught in machinery resulting in lacerations and amputations, or crush injuries from other industrial machinery. Sports injuries. The healthcare institution’s emergency unit sees injuries caused during sporting activities, such as soccer, rugby, diving, swimming and motor racing. These injuries are often caused by ineffective use of head, face and mouth, and eye protection and may result in drowning, head injuries, fractures and even death. Violence. The emergency units attend to many injuries resulting from criminal activities and fighting. These include gunshot and knife wounds, injuries resulting from rape, abuse, domestic violence and attempted suicide. Alcohol or drug abuse. Overindulgence in alcohol and/ or drugs may lead to irrational and/or violent behaviour or physiological trauma that may require emergency attention. Medication. An unintentional or intentional overdose (attempted suicide) would require emergency medical attention.

Nursing assessment and common findings Assessment of the patient must be done to identify and determine the life-threatening conditions or injuries needing emergency action. This includes collecting the subjective and objective data discussed in the sections that follow. Subjective data. The history of the mechanism of injury should be obtained to gain insight into the cause, pattern

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of injury, and to estimate the amount of force applied when the trauma was sustained. The history can be obtained from the patient, the relative, the paramedics or anyone who witnessed the injury and includes: • How the injury occurred • Where the injury occurred in terms of the location, such as at home, on the road or at work • To whom it occurred, that is, the patient’s personal information including name and age, if known • When it occurred, so that the healthcare provider can estimate the duration of injury and exposure • Occupation or activity during the trauma/emergency in terms of what the person was doing at the time of injury • Time of last meal in case there is a need for surgery • Details of allergies and other known illnesses or diseases, such as diabetes mellitus or hypertension • Any medication taken presently • Habits and lifestyle such as smoking, alcohol consumption, diet and exercise. Objective data. A thorough head-to-toe examination without repositioning the patient should be conducted. This should be done through two phases – primary and secondary assessment – during which objective data is obtained. Primary assessment. The aim of this phase is to identify life-threatening conditions and treat them immediately. Although each patient is treated as an individual, the primary assessment is done on all the patients arriving in the emergency unit. The emergency nurse should position the patient in such a way that it does not exacerbate the injuries, but enables the nurse to assess especially the airway, breathing, circulation and status of the neurological system. The outcomes of primary assessment should be a clear airway, effective breathing and a good heartbeat; which denotes patient stability. Airway. Assess the mouth for secretions, vomitus, blood or other debris likely to block the airway. If present, remove this with a finger sweep or the use of suction where necessary. Place an oral airway in situ, tilt the head and lift the chin or use the jaw thrust method in cases where a cervical spine injury is suspected, to keep the airway patent. Maintain an open airway by placing a hard neck collar on the patient’s neck to stabilise the spine. Breathing. Observe for signs of respiratory distress such as rapid and shallow respirations and apnoea. The nurse should assess breathing by looking, listening and feeling for breathing; and take action as follows:

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• Look for breathing. Look for chest expansion and symmetry or asymmetry of the chest wall during expansion. • Listen for breathing. Auscultate with a stethoscope or listen for air sounds such as wheezes and stridor. • Feel for breathing. Place a hand in front of the patient’s nose and mouth and feel for the air. • If there is no breathing, start artificial ventilation by providing oxygen to the patient through a tight-fitting silicone face mask and bag. If breathing is severely compromised, endotracheal intubation may be necessary. In the meantime, assess the patient’s airway for obstruction, tension pneumothorax, open chest wound, haemothorax and flail chest. (These conditions will be explained in detail later in this Chapter.) Circulation. Assess the skin temperature (warmth or coldness), texture (dryness or clamminess) and colour (pallor, redness and cyanosis). Check the capillary filling time to assess whether it is brisk, delayed for more than 3 seconds, or absent. Assess the pulse by palpating the carotid artery for 60 seconds. If there is no pulse, start cardiopulmonary resuscitation (CPR) immediately. When the pulse has been restored, monitor blood pressure, pulse rate, volume, and rhythm. Connect the patient to a cardioscope to monitor abnormalities of the heartbeat; also use a pulse oximeter to monitor peripheral saturation. Neurological system. The patient’s level of consciousness should be assessed. This can be done by assessing the patient for alertness, response to verbal commands and painful stimuli, and unconsciousness (the AVPU method). The patient may be requested to lift their hand, open their mouth or close their eyes to assess for alertness. Verbal commands and pain can be assessed by giving verbal commands or inflicting pain as a stimulus. Pupil size and reaction to light and movement of the limbs should also be assessed to exclude unconsciousness. Secondary assessment. Secondary assessment should be done when the patient is stable; that is, if the patient is breathing effectively and has a good heartbeat. This phase is done to identify other injuries that were not immediately obvious. It can also be done if the patient has more than one injury, so that a management plan can be formulated before commencing definitive care. A quick and thorough physical examination should be performed. The assessment should be conducted systematically from head-to-toe, comparing the findings with the history of the illness or injury and the observations made during the primary assessment.

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Head and neck • Using the GCS, assess the patient’s level of consciousness (refer to Box 15.2 for the GCS). A very low score is 8/15 and less. Also assess motor and sensory function. Abnormalities may denote head injury. • Assess the head and scalp for swelling, lacerations, depressions, contusions and concussions. The occipital area can be inspected when the patient is log-rolled onto a spine board or during assessment of the spine. • Examine the eyes, ears, nose and mouth for bleeding, the presence of foreign bodies, drainage of cerebro­ spinal fluid, or mucus. The mucous membrane must also be assessed for cyanosis and pallor. For penetrating injuries in any of the sensory organs, refer to the specialist concerned immediately. • Examine the mouth and gums for soft tissue injuries and loose or lost teeth. • Palpate the face for deformities and tenderness, and examine the maxilla and mandible for stability and fractures. • Assess for the nature, location, intensity and radiation of pain, if any, and determine activities that relieve or worsen the pain. • Assess the neck for stiffness and pain. Tracheal deviation may denote a tension pneumothorax. Distended neck veins may denote a rise in central venous pressure from cardiac tamponade or internal bleeding.

Chest and spine • Inspect the chest for bruising, wounds, any signs of airway obstruction and symmetry of the chest wall. • Observe for signs of respiratory distress, the motion of the chest with respiration, and note paradoxical breathing. • Assess and obtain history about haemoptysis. • Palpate the clavicle, sternum and the ribs for tenderness, surgical emphysema and fractures. • Auscultate for the presence of abnormal breath and heart sounds. • Assess sensory and motor functioning to exclude spine injuries.

Abdomen and pelvis Most abdominal and pelvic injuries are not immediately identifiable. The abdomen should be examined to determine if the patient requires immediate surgery. • Inspect the abdomen for distension, lacerations, penetrating or puncture wounds with bowel exposure.

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15.2  Glasgow Coma Scale ratings Eye opening • Opens eyes spontaneously • Opens eyes to speech • Opens eyes to pain • No response

4 3 2 1

Verbal response • Orientated 5 • Confused 4 • Uses inappropriate words 3 • Makes incomprehensible sounds 2 • No response 1 Motor response • Obeys commands • Localises pain • Withdraws from pain • Abnormal flexion to pain • Extension to pain • No response Total score

6 5 4 3 2 1 15/15

Source: Teasdale & Jennett, 1974

• Auscultate for bowel sounds and determine if they are present or absent. • Palpate the abdomen for tenderness and assess pain if present. • Observe for the signs of internal bleeding: a cold and clammy skin, weak pulse, pallor, low blood pressure and/or abdominal distension, sometimes with guarding. • Obtain history about haematemesis and blood in stools. • If a rectal examination has to be carried out, the nurse should prepare the patient for the procedure and position them correctly, provide privacy and comfort, and assemble any necessary equipment before the procedure.

Extremities • Palpate the skin for warmth, inspect the colour and palpate the pulses. • Assess pain for type, location and radiation. • Inspect the limbs for bleeding, bruises, lacerations and deformities. • Palpate for fractures which are not immediately obvious on inspection. • If the patient is conscious, all the joints should be rotated to assess movement and strength of the limbs.

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Back and perineum • Carefully and gently log-roll the patient and palpate the spine for tenderness and gaps in its continuity, which may denote spine injury. • Inspect the back for contusions, lacerations and penetrating wounds and/or impaled objects. • Examine the rectum for bleeding to exclude bowel injury.

Diagnostic studies The diagnostic studies will provide objective data to support the history taken and the physical examination done. It is important to note that not all the diagnostic studies will be applicable, but they will vary according to the patient’s condition. The studies include vital signs, blood tests and radiological examinations. Vital signs. Monitor temperature, pulse, respiration, blood pressure, weight and urinalysis. A low temperature ( 1 month • Unexplained persistent fever for > 1 month ( > 37.6°C, intermittent or constant) • Persistent oral candidiasis (thrush) • Oral hairy leukoplakia • Pulmonary tuberculosis (current) • Severe presumed bacterial infections (eg pneumonia, empyema, pyomyositis, bone or joint infection, meningitis, bacteraemia) • Acute necrotizing ulcerative stomatitis, gingivitis, or periodontitis • Unexplained anaemia (haemoglobin 10kg

OR child > 3 years exposed to NVP > 6 weeks

If child is positive: do CD4 and follow algorithm

1st Line: ABC + 3TC + EFV

Switch d4T to ABC if VL is undetectable If VL > 1 000 copies/ml – manage as treatment failure If VL is 50–1 000 copies/ml – consult with expert for advice

Follow-up tests

Routine

Test CD4 at 12 months on ART and then every 12 months. Test VL at 6 months and 12 months into ART, THEN 6-monthly in children < 5 years and 12-monthly in children 5–15 years.

Repeat HIV test 6 weeks after breastfeeding ends Do 18-month ELISA on all HIV exposed infants

Child on d4T regimen

1st Line: ABC + 3TC + LPV/r

Breastfeeding or ever breastfed

NonRoutine

Hb or FBC at month 1, 2, 3 into ART and then annually if on AZT. If child on a PI regimen test for Cholesterol + Triglyceride, if child on TDF regimen test for Creatinine + Urine dipstix, if child is jaundiced or has TB test for ALT. At every routine check-up screen for: TB, weight, height, head circumference ( 1 000 copies/ml: –– Include intensified adherence for a month –– Then repeat VL after 3 months of elevated VL –– If VL remains > 1 000 copies/ml on NNRTI regimen or 10 000 copies/ml on PI regimen, then treat as virological failure • Never switch only one drug in a failing regimen and do not continue therapy with a failing NNRTI regimen for prolonged periods as there is an increased risk of accumulating NRTI resistance mutations

Table 19.11  Second-line treatment failure and third-line regimen in adolescents 10–15 years

Third-line regimen Failing any second-line regimen

Refer for specialist opinion – Regimen based on genotype resistance testing, expert opinion and supervised care Access to third-line ART will be managed centrally by the National Department of Health

Table 19.12  ART first-line regimen for adolescents ≥15 years and adults

Population

Drug

Comments

Adolescents > 15 years and weighing > 40 kg Adults
 All TB co-infection All HBV co-infection

TDF + 3TC (or FTC) + EFV provide as fixeddose combination (FDC)

Replace EFV with NVP in patients: • with significant psychiatric co-morbidity or intolerance to EFV • where the neuropsychiatric toxicity of EFV may impair daily functioning, eg night shift workers

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❱❱

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Population

Drug

Comments

Adults and adolescents on d4T

Change d4T to TDF (No patient must be on d4T)

Switch to TDF if virally suppressed and the patient has normal creatinine clearance, even if d4T is well tolerated If VL > 1 000 copies/ml, manage as treatment failure and consider switching to second-line regimen

Adolescents 180 mmHg; diastolic > 110 mmHg), papilloedema and encephalopathy. Encephalopathy is due to cerebral oedema and is manifested by visual

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•

•

disturbances, confusion, severe headache, vomiting, coma and paralysis. Other clinical manifestations include left ventricular hypertrophy, left ventricular failure, as well as renal impairment. The prognosis is poor unless the condition can be adequately treated. Treatment consists of reducing the blood pressure using IV antihypertensives, vasodilators, afterload reducing agents, ACE inhibitors and diuretics. Care should be taken not to reduce the blood pressure too rapidly otherwise cerebral perfusion as well as myocardial perfusion will be reduced, causing further problems and complications. The nurse must monitor the blood pressure closely and adjust the dosage of IV drugs according to protocol or prescription. Admission to the intensive care unit for invasive haemodynamic monitoring may be required. The patient should be kept on bed rest with the head of the bed elevated. Central nervous system damage. This complication occurs as a result of reduced cerebral blood flow coupled with cerebral oedema. This condition is also referred to as hypertensive encephalopathy and it is characterised by altered mental status, headache and transient neurological deficits. Other manifestations of central nervous system damage include cerebrovascular accident and cerebral infarction due to the reduction in cerebral blood flow. Encephalopathy may progress to coma and death if it is not treated adequately. Treatment consists of reducing the blood pressure with IV drugs over a period of days, to avoid a sudden drop in blood pressure and cerebral perfusion. The nurse must monitor blood pressure and neurological status very closely. Drugs must be given accurately and strictly according to protocol or prescription. Once the blood pressure has been reduced and the patient is stable, they can be re-established on conventional antihypertensive therapy. Renal insufficiency. Hypertension causes damage to the renal blood vessels and renal function may deteriorate rapidly in severe or malignant hypertension. Renal function may recover, however, if the blood pressure can be controlled – reducing the BP allows renal lesions to heal. Myocardial ischaemia. With hypertension, the left ventricle becomes enlarged and the coronary blood supply becomes inadequate, leading to ischaemia, episodes of angina and myocardial infarction. Acute left ventricular failure. With severe hypertension, there is severe stress on the left ventricle with increased cardiac work, leading to left ventricular failure.

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Essential health information Helpful information includes: • Lifestyle management. Effective lifestyle management, especially in at-risk individuals, may be instrumental in slowing down both the onset and the severity of hypertension. The nurse must ensure that the patient is appropriately advised regarding lifestyle modifications such as diet, weight control, stress management and exercise. It is important to take the patient’s individual circumstances into account in order to tailor an individualised programme for each patient. Properly planned lifestyle modification will enhance the effectiveness of drug therapy. • Drug therapy. It is also important to stress the need for compliance to long-term and follow-up treatment since hypertension cannot be cured but controlled. The patient should know the names, dosages and specific side effects of prescribed medication. The times for taking medication should be planned and should be convenient for the patient. Should side effects develop, the patient should not stop treatment abruptly but should return to the clinic. The patient should not double up on the dose if a dose is missed, nor should the patient omit a dose because they are feeling better. Discourage medication swapping in the

strongest possible terms, and advise the patient to seek medical advice before taking over-the-counter drugs, as many of these contain sympathicomimetics, which raise the blood pressure. • Early detection. Reaching a diagnosis of hypertension is possible through screening in the community, therefore people should be encouraged to have their blood pressure checked at regular intervals, or whenever they visit their doctor or health clinic. In fact, a strong argument can be made for actively educating all healthcare providers to routinely check blood pressure every time a patient visits a clinic or doctor’s surgery. In the case of at-risk individuals, such as those with a strong family history, those who are over 40 years of age, and those who are overweight, blood pressure should be checked at least once a year. Community awareness programmes should emphasise screening and early detection, as well as the benefits of early treatment.

Conclusion In this Chapter, the conditions that affect the blood vessels were discussed, with specific reference to the risk factors, aetiology, pathophysiology, nursing management and essential health information.

Suggested activities for learners Activity 35.1 For each of the following items choose the most appropriate answer. 1. All of the following statements are true about arteries except … a) arteries carry blood away from the heart b) arterial walls have a thicker layer of smooth muscle than found in venous walls c) arteries are under higher pressure than veins d) arteries have one-way valves. 2. In which blood vessels does most of the exchange of nutrients and wastes between the blood and body tissues occur? a) arteries b) veins c) capillaries d) venules 3. Which technique is considered standard for diagnosing deep-venous thrombosis? a) MRI b) Doppler flow study c) ultrasound imaging d) venography 4. Which of the following characteristics is typical of the pain associated with deep-venous thrombosis? a) tingling b) sudden onset c) no pain d) dull ache ❱❱

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5. With peripheral arterial insufficiency, leg pain during rest can be reduced by … a) placing the limb in a plane horizontal to the body b) lowering the limb so it is dependent c) elevating the limb above heart level d) massaging the limb after application of cold compresses. 6. Buerger’s disease is characterised by all of the following except … a) venous inflammation and occlusion b) redness or cyanosis in the limb when it is dependent c) lipid deposits in the arteries d) arterial thrombosis formation and occlusion. 7. Mike, a 43-year old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is the calf pain during minimal exercise that decreases with rest. The nurse assesses Mike’s symptoms as being associated with peripheral arterial occlusive disease. The nursing diagnosis is probably: a) impaired mobility related to stress associated with pain b) impairment in muscle use associated with pain on exertion c) dysfunctional use of extremities related to muscle spasms d) alteration in tissue perfusion related to compromised circulation 8. Hypertension is caused by all of the following except … a) periodic elevated blood pressure levels b) hardened arteries c) high salt intake in the diet d) narrowed blood vessels 9. Which of the following statements describing hypertension is false? a) Hypertension is a significant risk factor for cardiovascular disease. b) Hypertension is easily diagnosed because of its many observable symptoms. c) In hypertensive people, blood vessels become less able to stretch during cardiac systole. d) The heart experiences greater strain in hypertensive individuals. 10. State the differences between: a) Arteriosclerosis and atherosclerosis b) Primary and secondary hypertension. 11. Design an information leaflet on the risk factors of cigarette smoking.

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36

Management of the disorders of the haematological system

learning objectives

On completion of this Chapter, the learner should be able to: • describe the structure and function of blood • classify the disorders of the haematological system according to the causative factors • describe the risk factors associated with the disorders of the haematological system • describe the significant subjective assessment data related to the haematological system that should be obtained from a patient presenting with the disorders of the haematological system • explain the significance of various diagnostic tests and procedures used to assess the haematological system function • describe the preparation for, and the nursing care of, patients following diagnostic studies done for assessment of haematological system • describe the nursing care of a patient on blood transfusion • describe the causes, classification, pathophysiology, signs and symptoms, diagnosis and treatment of all diseases affecting the red blood cells • describe the causes, classification, signs and symptoms, diagnosis and treatment of all diseases affecting the white blood cells • describe the causes, classification, pathophysiology, signs and symptoms, diagnosis and treatment of diseases affecting the platelets. key concepts and terminology

anaemia

A reduction to below normal of the oxygen-carrying capacity of blood.

arthralgia

Joint pain.

culling

The natural destruction of red blood cells after 120 days.

ecchymosis

Spontaneous bruising as a result of bleeding into the tissues.

erythropoeisis

The process by which new red cells are generated by the bone marrow.

fatigue

A feeling of extreme tiredness.

glossitis

Inflammation of the tongue.

haemathrosis

Bleeding into a joint.

haematocrit

Percentage of total blood occupied by erythrocytes. Also known as packed cell volume.

haematopoiesis

The process of formation and development of blood cells.

haematuria

Passage of blood in urine.

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haemoglobin (Hb)

An important feature of erythrocytes made up of globin protein and ironcontaining haeme group. Hb enables the red blood cells to transport oxygen.

haemolysis

Rupture of red blood cells.

haemophilia

A disease resulting from a deficiency of clotting factors, characterised by bleeding tendencies.

haemostasis

The ability to stop bleeding.

jaundice

Yellow discolouration of the mucous membranes and the skin.

leukaemia

A malignant condition characterised by abnormal and unregulated proliferation of white blood cells.

leukocytosis

Increased number of leukocytes.

leukopenia

Decreased number of leukocytes.

meleana

Blood in the stool.

neutropenia

Decreased number of neutrophils.

petechiae

Pin-pointed red lesions that occur as a result of bleeding arterioles, capillaries and/or venules.

phagocytosis

The process, during which microbes and any unwanted substances are engulfed, ingested and killed by the white blood cells.

plethora

Ruddy reddish-purple, dusky complexion due to capillary congestion with blood.

polythaemia

Excess circulating erythrocytes.

pruritus

Itching of the skin.

serum

Plasma without fibrinogen.

thrombocytopenia

Deficiency of platelets.

venipuncture

Puncturing a vein to collect blood or for initiating intravenous infusion.

prerequisite knowledge

• Structure and function of blood • Biochemistry and biophysics • Specific nursing skills such as monitoring of vital signs, intake and output, preparation for the insertion of intravenous infusion, care of patients on blood transfusion and basic life support. medico-legal considerations

The universal or standard precautions should always be observed when administering blood and blood products. Nurses must practise hand hygiene and put on gloves to protect themselves and the patient from infection transmission. Nurses should at all times observe the patients on blood transfusion so that associated complications such as infection and anaphylaxis are detected early. Patients with disorders such as anaemia are prone to infection and fatigue. The importance of rest and adherence to a well-balanced diet and medication cannot be overemphasised.

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ethical considerations

Nurses are obliged to ensure that the patients have given informed and written consent for tests and procedures done for assessing fluid, electrolytes and acid–base imbalances. Legally, the patients have a right to accurate information about their care, tests and treatment. The information must be given in the patient’s preferred language and at the level of understanding of the patient. The patient must be given an opportunity to ask questions, and the questions must be answered to the patient’s satisfaction. With regard to blood transfusion, the patients’ religious beliefs should be respected. essential health literacy

Nutrition plays an important part in the normal functioning of the blood. An adequate intake of essential nutrients such as iron, folic acid and vitamin B12 must be emphasised when health education is given. In pregnancy there is an increased demand on the iron reserves of the mother and, as such, inadequate intake of iron can result in iron deficiency anaemia of pregnancy. When iron supplements have been prescribed, the patients must be encouraged to take them 1 hour before meals because these are best absorbed in an acid environment. They should also be encouraged to take iron supplements with orange juice because vitamin C improves the absorption of iron. The risk factors such as alcohol intake, cigarettes smoking and use of unprescribed medication should be avoided. It is important that patients are taught to recognise signs of bleeding and how to stop bleeding such as gentle application of pressure on bleeding sites, as well as the use of cold compresses. Blood must be treated with high suspicion of HIV and gloves must be worn when handling blood. Nurses need to do all in their power to protect patients from the risk of anaphylaxis.

Introduction Blood is a specialised connective tissue that exists in a fluid state circulating in the blood vessels. It constitutes 8% of the total body fluid. There are approximately 4–5 ℓ of blood in women and 5–6  ℓ in men. Blood volume varies according to body composition and age; the less body fat, the more blood there is per kilogram of body weight. The colour of blood depends on the amount of oxygen it is carrying. Arterial blood is bright red because of the high amount of oxygen bound to the haemoglobin (Hb) in the red blood cells (RBCs), whereas the blood in the veins is dark red as a result of low oxygen in the Hb. Blood is about four times thicker than water, with a specific gravity of 1.048–1.066 and a pH of between 7.35 and 7.45 (slightly alkaline). Blood sustains life for every cell: it transports oxygen, water, nutrients, hormones, enzymes, and sometimes medication to cells. Blood also carries waste products produced by cellular metabolism to the lungs, skin, liver, and kidneys, where they are eliminated from the body. This Chapter presents a discussion of disorders that affect blood and its formed elements as well as the organs that produce various blood cells.

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Overview of the structure and functions of blood Composition of blood Blood consists of 55% plasma and 45% cellular components suspended in plasma. The detailed presentation and structure of blood constituents is outlined in Table 36.1.

Functions of blood • Blood serves as the medium in which blood cells and other substances are transported. It transports: –– Dissolved gases, for example oxygen and carbon dioxide, to and from the tissues respectively –– Waste products of metabolism, urea, water –– Hormones –– Enzymes –– Nutrients (amino acids, glucose, vitamins and minerals) –– Plasma proteins associated with clotting of blood and antibodies as well as blood cells. • Blood maintains optimum body temperature throughout the body. • It controls the pH in the blood and body tissues, maintaining this within an optimum range at which the cells can thrive. • Blood also maintains an ideal balance of electrolytes in the blood and tissues of the body, and in that way regulates fluid balance.

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Blood constituents

Description/Structure

Plasma

• Plasma is the liquid part of blood, composed of 90–92% water in which the blood cells are suspended, and consists of: –– dissolved substances, including electrolytes, sodium, potassium, calcium, and chloride –– plasma proteins: albumin, fibrinogen, and globulin –– hormones

Erythrocytes

• There are approximately 4.5–5.8 million erythrocytes per micro-litre of healthy blood (though there are variations between racial groups and men/women) • Erythrocytes have a lifespan of approximately 120 days • The active part of erythrocytes is haemoglobin, which relies on the presence of iron • Haemoglobin combines with oxygen to form oxyhaemoglobin • Erythrocytes are broken down in the spleen into blood pigments, bilirubin, and iron, which are transported by the blood to the liver, where the iron is reused by new erythrocytes and the blood pigments (bilirubin) to form bile salts • The function of the erythrocytes is to carry oxygen to the blood

Leukocytes

• There are approximately 5 000–10 000 leukocytes per micro-litre of blood • Leukocytes have a lifespan of a few hours to a few days • Classification of leukocytes: –– Granular; neutrophils, eusinophils, basophils –– Agranular; monocytes, lymphocytes • The function of the leukocytes is mainly defending the body against invasion by microbes; leukocytes therefore form part of the immune system

Thrombocytes/ platelets

• There are approximately150 000–400 000 thrombocytes per micro-litre of blood • They have granules but no nucleus • They are mainly involved in blood clotting

• Blood removes toxins from the body. The kidneys remove the toxins from the blood and toxins leave the body in the urine.

Blood groups An ABO system is used to classify human blood into one of four basic blood groups: A, B, AB or O, defined by the presence of antigens on the surface of erythrocytes. The erythrocytes of individuals with blood group A contain A antigens; those with blood group B contain B antigens; blood group AB contains both A and B antigens; and blood group O does not contain any antigens. Human plasma does not contain antibodies against antigens present in its own red blood cells, but it does contain antibodies against antigens of other blood groups. The plasma of type A blood group contains anti-B antibodies; type B blood group contains anti-A antibodies; and type AB does not contain antibodies for any group type. Blood group O can be transfused into people of any blood group type, because the erythrocytes in type O do not have A or B antigens and cannot therefore be attacked

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by anti-A or anti-B antibodies. Blood type O individuals can only receive blood from blood type O individuals. Blood group AB contains no antibodies and can therefore receive blood from any type, but can only donate to individuals with blood group AB.

Clinical alert! Blood group A: Donates to A and AB and can receive blood from blood groups A and O. Blood group B: Donates blood to B and AB and can receive blood from blood group B and O. Blood group O: This is a universal blood donor. It can donate blood to Groups A, B, AB but can only receive blood from blood group O. Blood group AB: This is a universal recipient. It can receive blood from Groups A, B and O.

Another important classification is that of the rhesus (Rh) factor. People are said to be Rh-positive when the Rh antigen is present in their blood, and they are Rh-negative

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when it is not present in their blood. Rh antibodies are produced by Rh-negative individuals during their first exposure to Rh-positive blood. Subsequent exposure will cause antigen–antibody reaction. Rh-positive blood should only be given to Rh-positive recipients, and Rh-negative only to Rh-negative people.

Table 36.2 Classification of disorders of the haematological system according to the causative factors

Causative factors

Condition

Nutritional deficiencies

Anaemia: • Iron and folic acid deficiency (Microcytic anaemia) • Pernicious anaemia (vitamin B12 deficiency)

Trauma with massive loss of blood

Haemorrhagic anaemia

Genetics

Haemophilia Sickle cell disorders Agranulocytosis

Destruction of red blood cells

Haemolytic anaemia Malaria

Drugs, radiation, toxic chemicals Bone marrow suppression and haemolysis

Aplastic anaemia Haemolytic anaemia

Coagulation defects

Thrombocytopenia Disseminated intravascular coagulopathy

Idiopathic

Polycythaemia

Malignancy

Hodgkin’s disease Leukaemia Multiple myeloma

Classification of the disorders of the haematological system Classification of the disorders of the haematological system is done according to the causative factors. The causative factors of the different disorders of the haematological system are given in Table 36.2. Nutrition. Nutrition plays an important part in the normal functioning of the haematological system and an inadequate intake of essential nutrients such as iron, folic acid and vitamin B12 interferes with erythropoeisis. Nutritional deficiencies cause pernicious, megaloblastic (folic acid deficiency) and iron deficiency anaemia. Trauma. Injury to the system results in blood loss with resultant anaemia. The injury can be in the form of accidental tearing or cutting of blood vessels or surgery. Blunt trauma to the spleen, such as might be caused by motor vehicle accidents, may lead to massive internal bleeding. Genetics. Some disorders, such as haemophilia and sickle cell disorders, are inherited. Destruction of blood cells. Certain chemicals cause excessive destruction of blood cells (haemolysis) resulting in haemolytic anaemia. Transfusion of incompatible blood also causes haemolysis. Drugs. Certain medication, chemotherapy and radiation depress the activity of bone marrow, resulting in decreased production and supply of blood cells. These factors can also interfere with the normal cell growth and function. Malignancy causes the growth of abnormal blood cells and interferes with the production of normal cells. Occupational exposure. Exposure to toxic chemicals and ionising radiation can cause suppression of the bone marrow resulting in aplastic anaemia.

Risk factors Alcohol. Excessive alcohol intake results in poor nutrition, causing iron and folic acid deficiency anaemia. Alcohol also predisposes a person to gastrointestinal bleeding due

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to gastritis and oesophageal varices. It also destroys the structure and function of the liver, resulting in failure to produce clotting factors. Medication. Some medication, when used for longterm treatment can cause red cell haemolysis and/or suppression of bone marrow functioning, while others interfere with platelets aggregation. Gender. Some disorders are age specific, while others are gender specific. Haemophilia is an example of a genderspecific disorder. Heredity. Conditions that impact on blood and bloodforming mechanisms are usually genetic in nature, for example haemophilia.

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Pregnancy. In pregnancy there is an increased demand on the iron reserves of the mother and as such, inadequate intake of iron can result in iron deficiency anaemia of pregnancy.

Nursing assessment and common findings It is important to obtain focused subjective and objective data in order to identify the specific problems. Always commence the assessment by establishing the presenting complaint and its duration. The final diagnosis is usually the summary of the subjective and objective data based on the chief complaint.

Subjective data Chief complaint/presenting symptoms. The presenting symptoms determine the focus of the history to be taken. Some of the symptoms may suggest haematological or immunological problems. As the immunological problems are discussed in Chapter 18, only haematological problems will be presented in this Chapter. The patient may think that symptoms such as fatigue, headache, faintness are minor and may not find it necessary to report them. The nurse must therefore probe by asking specific questions to elicit relevant information such as breathlessness, chest pain, intermittent claudication, palpitations. It is important to assess the onset, duration, quality, severity and location of each of the reported symptoms, how they have affected the patient and how they have managed them. Any factors that precipitate, aggravate or relieve the symptoms must be noted and recorded. Family history. Any family history of genetic blood disorders such as haemophilia, sickle cell disease or trait or aplastic anaemia must be obtained. Travel history. In instances where anaemia is related to malaria, it may be necessary to establish recent travel and locations as this might exclude malaria as a potential cause of haemolytic anaemia. Past health history. A history of anaemia, frequent throat infections and any chemotherapy treatment for cancer must be obtained. It is also important to obtain history regarding bleeding disorders, such as nosebleeds and excessive, uncontrollable bleeding following minor surgical procedures (such as tooth extractions). Again any history of liver diseases, such as liver cirrhosis and hepatitis, with immune deficiency should be obtained. It is important to obtain history about allergies to past blood transfusion and drugs.

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A history of past surgery must also be obtained because this could have a bearing on the presenting symptoms: operations such as mitral valve replacement cause red cell destruction, gastrectomy reduces the intrinsic factor and the absorption of vitamin B12 and surgical removal of the duodenum reduces the absorption of iron. Medication. The nurse must obtain a history of any medication being taken, with a specific focus on the drugs that suppress the bone marrow activity, destroy red blood cells, and interfere with platelets aggregation. Examples of such drugs include chloromycetin, furosemide, antihypoglycaemic, antihypertensive drugs and antineoplastic drugs. Oral contraceptives interfere with folic acid absorption. Use of any herbal medication should also be noted. Lifestyle. Any exposure to radiation and toxic chemicals must be recorded, as should excessive intake of alcohol, as this causes nutritional deficiencies and gastrointestinal irritation leading to diarrhoea, poor absorption of nutrients and bleeding.

Physical examination Head and neck. Check for: • Pallor and jaundice of the mucous membranes of the eyes, mouth and the gums • Condition of the mucous membranes of the mouth including the gums and the tongue • Presence of enlarged cervical lymph nodes. Skin. Check the skin for the presence of: • Brittle and, in some instances, spoon-shaped fingernails that indicate iron deficiency anaemia • Ecchymosis and petechiae • Scratch marks as a result of scratching itchy skin. Chest and abdomen. Check for the presence of: • Chest pain • Tachycardia • Tachypnoea, dyspnoea or orthopnoea • Epigastric tenderness • Abdominal pain • Hepatomegaly • Splenomegaly. Extremities. These must be observed for painful and oedematous joints. Elimination (urine and stools). Urinalysis: check for colour. A brown, smoky and hazy colour may indicate internal bleeding that is linked to the urogenital system.

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Observe colour and consistency of stools. Black tarry coffee ground stools indicate digested blood from the gut. Vital signs. Information relating to fever, tachycardia, tachypnoea/dyspnoea and weight loss is crucial. It is also important to note and record the presence of orthostatic hypotension.

Diagnostic studies The most reliable way to diagnose haematological disorders is the examination of the patient’s blood through various blood tests. Venous blood is used mostly in the blood tests and it is obtained by withdrawing blood directly from the veins (venipuncture). The venous blood specimen can also be obtained from finger, heel or ear-lobe pricks. Arterial blood can be obtained from an arterial line or directly from radial, brachial and femoral arteries for diagnostic purposes. The responsibilities of nurses regarding the collection of blood specimen are presented below. Blood tests are done for diagnostic purposes and for the evaluation of improvement or deterioration in the patient’s condition. The tests that are performed are discussed below. Complete/full blood count (FBC). FBC is done to determine the number of erythrocytes, leukocytes and platelets in circulation (normal FBC values are shown in Table 36.3). The following information is obtained from FBC: • Haemoglobin (Hb) determination is used to assess the oxygen carrying capacity of red blood cells. It measures the number of grams of Hb in a decilitre of blood. Hb measurement is used to indicate anaemia or polycythaemia. Levels vary with circumstances, age and gender. There is an increase (haemoconcentration) in dehydration and a decrease (haemodilution) during fluid infusion in blood loss. • Haematocrit (Hct) levels are measures of the volume of red blood cells (RBC) in whole blood expressed as a percentage. This is helpful in the diagnosis of anaemia, fluid volume deficit, and polycythaemia. Levels are high in haemoconcentration, dehydration and polycythaemia and are low in fluid and blood loss. • Red blood cells are a measure of the number of red blood cells per cubic metre of blood. This test is used to diagnose disorders of red blood cells. The normal values vary with gender and age, and increase in polycythaemia, dehydration and acute poisoning and decrease with bleeding, fluid overload and in leukaemia.

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36.1 Collection of blood specimens Precautions and nursing responsibilities regarding collection of blood specimens are as follows: • Only nurses competent in venipuncture procedures may obtain the blood specimen, otherwise nurses should prepare the patient and the necessary equipment for the collection of blood specimen by the doctor • Aseptic technique principles should be upheld at all times to prevent infection • Give adequate information regarding the procedure and the importance thereof • Ensure that an informed consent has been obtained • Ensure privacy, safety and comfort of the patient throughout the procedure • Consider the patient’s religion • Do not take more blood than is necessary for the test • After the blood specimen has been taken, apply sufficient pressure on the punctured site to prevent bleeding and apply continuous pressure for 3–5 minutes following collection of blood from an artery • Ensure correct labelling of specimen bottle/s and completion of laboratory form/s • Ensure safe and speedy dispatch of the blood specimen.

• Red blood cell indices are measurements of erythrocytes size and haemoglobin content and are used to assess anaemia. • Reticulocyte count is an indication of red blood cells produced by the bone marrow and released into circulation. • White blood cell count (WBC) measures the number of white blood cells per mm3 of blood and is useful for the detection of infection and to monitor the patient’s response to radiation and chemotherapy. Levels are increased by infection, inflammation, leukaemia and tissue necrosis, and decreased in bone marrow suppression. • White cell differentials are helpful in identifying the different white blood cells available to overcome infections, such as granulocytes and agranulocytes, so that infections, anaemia and allergies can be classified. • Platelet count is a measure of platelets per cubic metre of blood and it is to assess thrombocytopenia and coagulation defects. The count is usually increased in

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polycythaemia and malignancy and is low in aplastic anaemia, haemolysis and bone marrow suppression. Table 36.3  Normal FBC values

Measure

Value

Erythrocytes Hb Hct RBC count

Men

Women

13–18 g/dl

12–16 g/dl

42–45%

37–47%; can be less than 33% in pregnancy

4.7–6.1 million/mm3 Reticulocytes Red cell indices

Leukocytes WBC Granulocytes Neotrophils Eusinophils Basophils Agranulocytes Lymphocytes Monocytes Platelets

4.2–5.4 million/mm3

0.5–2% of total erythrocytes MCV; 80–95/micrometre MCH; 21–31 pg (pictogram) MCVH; 32–36 g/dl 4 000–9 000/mm3 55–70% 1–4% 0.5–1% 20–40% 2–8%

150 000–450 000/mm3

Coagulation studies. These studies are used to detect the types and causes of bleeding disorders and they include: • Bleeding time, which measures the ability of the body to stop bleeding following injury; a normal time in adults is 3–8 minutes • Platelet count • Prothrombin time (PT), which determines the activity of clotting factor, factor V, VII and X. The normal PT is 11–15 seconds • Partial thromboplastin time (PTT) tests the intrinsic pathway of blood coagulation; normal between 25–28 seconds; if PTT is prolonged, the clotting factors are deficient • Other coagulation studies are fibrinogen levels, fibrinogen degradation products (FDPs), D-dimer, capillary fragility test, clot retraction and INR (International Normalised Ratio).

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Blood grouping. Patients who have lost a lot of blood may need a blood transfusion: they would therefore need to have their blood typed and matched. The purpose of cross-matching is to match as near as possible the red cells and serum of donors and recipients in order to administer compatible blood. The blood is checked for antigens and antibodies on the red cells – this is done routinely on donated blood or blood components. Coombs test. This test can show whether the body is making antibodies (proteins) to destroy red blood cells. It is used for the diagnosis of haemolytic anaemia. Sickling test. A blood specimen is collected by means of a finger prick, which is then mixed with an oxygenconsuming substance such as sodium metabisulfite. Once the oxygen has been removed, the cells are examined under a microscope to identify sickle cells. This test is used to diagnose sickle cell anaemia and disease. However, it is not able to indicate whether the person has the disease or is just a carrier of the trait. Haemoglobin electrophoresis. Sickle cells have a characteristic pattern of movement in an electrical field. The pattern and rate of Hb movement can be studied using the electrical field employed for this test. Schilling test. This is done to detect the ability to absorb vitamin B12. The patient is given radioactive vitamin B12, and the amount excreted in urine is measured. In individuals who cannot absorb vitamin B12, the radioactive vitamin B12 will be excreted. Bone marrow aspiration and biopsy. Bone marrow aspiration is the withdrawal of bone marrow fluid from the posterior iliac crests or sternum. The aspirated bone marrow is used to diagnose anaemias, leukaemias and thrombocytopenia, and for the assessment of treatment during the course of a disease. The test provides information about the number, size and shape of erythrocytes, white blood cells and the platelets precursors. Nursing care before the procedure includes: • giving information about the procedure • obtaining informed consent • starving the patient for 6–8 hours and administering premedication. After the procedure: • Vital signs must be monitored • Sterile dressings must be applied • The procedure site must be observed for bleeding.

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Common assessment findings Typical assessment findings vary according to the disorder and the type of blood cells affected. Findings in diseases that affect the red blood cells are associated with tissue hypoxia, while those that affect the white blood cells are associated with infection. Bleeding is associated with disorders that affect the platelets and clotting factors. Assessment findings that are indicative of abnormalities of the blood are indicated in Box 36.2.

Blood transfusion Blood transfusion is the administration of blood and specific blood components such as fresh frozen or dried plasma, packed cells, albumin, coagulation factors and platelets. A blood transfusion is indicated in the

management of the disorders of the haemotological system for the following purposes, as: • Support for some surgical procedures • Treatment of anaemia • Replacement of blood lost as a result of injuries and surgery • Replacement of clotting factors in patients with bleeding disorders. The blood for transfusion can be obtained from a donor. This type of transfusion is known as homologous blood transfusion. Alternatively, the patient’s own blood can be used for reinfusion in what is known as autologous blood transfusion.

36.2 Symptoms of decreased oxygen supply The symptoms caused by insufficient oxygen reaching the brain and other tissues as a result of reduced red blood cells are: • Headache, dizziness, fainting spells • Pallor of the mucous membranes of the conjunctiva, gums, oral cavity and nail beds • Fatigue associated with malaise and weakness • Chest pain, when the myocardial oxygen supply is lower than the demand • Behavioural changes: Poor memory and concentration, irritability and slower verbal response. Symptoms related to bleeding with resultant decrease in oxygen supply to the tissues are: • Ulcerative sores, inflammation and bleeding in the mouth • Smooth, beefy red tongue • Spontaneous nosebleeds • Tachycardia • Blood in the stools and urine characterised by black, tarry stools and brown hazy urine respectively • Joint pains, brittle nails, ecchymosis (large bruises) • Fatigue. Symptoms associated with infection are: • Fever. Common nursing diagnoses The following are the common nursing diagnoses based on the subjective and objective assessment findings. • Altered tissue perfusion related to hypovolaemia, secondary to blood loss, hyperviscosity of blood manifested by a low Hb content in the blood, pallor, dyspnoea, weakness, tachycardia and fatigue • Activity intolerance related to tissue hypoxia, secondary to decreased blood supply or low Hb manifested by fatigue, weakness and dizziness • Altered comfort related to joint swelling and pain or breakdown of oral mucosa, secondary to tissue hypoxia and hyperviscosity of blood manifested by reports of bone and joint pain, swelling of the joints and ulcerative lesions of the tongue, gums and oral mucous membranes • Altered nutrition (less than body requirements) caused by inadequate intake of essential nutrients, resulting in oral cavity ulcers, weakness, fatigue and weight loss • Increased risk of infection caused by lowered body resistance secondary to reduced or non-functioning WBC • Risk of fluid volume deficit related to blood loss secondary to injury, decreased platelets and deficient clotting factors • Lack of knowledge (knowledge deficit) of the disease, its treatment and prevention.

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688  Juta’s Complete Textbook of Medical Surgical Nursing Table 36.4  General nursing care plan for patients with disorders of the haematological system

Pallor, weakness, tiredness Nursing diagnosis

• Altered tissue perfusion related to hypovolaemia and hyperviscosity of blood, secondary to anaemia manifested by low Hb, pallor, dyspnoea, weakness, tachycardia and fatigue; • Activity Intolerance related to tissue hypoxia, secondary to decreased blood supply manifested by fatigue and weakness

Expected outcome

• Adequate tissue perfusion • Increased activity tolerance

Nursing interventions and rationale

• Bed rest to reduce oxygen demand • Increase activity as patient’s tolerance increases • Administer oxygen as prescribed • Administer blood transfusion as prescribed • Monitor pulse, BP and respirations • Assist with full range of movement exercises

Evaluation

• Hb within normal ranges • Skin colour pink • Normal pulse and respiration • Patient is able to participate in activities of daily living without assistance • Increased level of energy

Headache, fainting spells Nursing diagnosis

• Altered comfort related to the disease process manifested by reports of a headache and fainting spells

Expected outcome

• No headaches or fainting spells

Nursing interventions and rationale

• Encourage rest • Administer medication and oxygen as prescribed • Monitor and record vital signs 4-hourly

Evaluation

• Patient report improving or absence of pain and fainting

Painful and swollen joints; sores in the mouth Nursing diagnosis

• Altered comfort related to joint swelling and pain or breakdown of oral mucosa, secondary to tissue hypoxia and hyperviscosity of blood manifested by reports of bone and joint pain, swelling of the joints and ulcerative lesions of the tongue, gums and oral mucous membranes

Expected outcome

• Optimised comfort • No joint pain • No sores in the mouth

Nursing interventions and rationale

• Assess pain to obtain baseline data • Administer analgesics as prescribed • Apply moist heat to joints • Elevate the extremities • Provide oral hygiene • Do not give hot and/or spicy food as these irritate the oral mucosa

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❱❱

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Evaluation

• Swelling of joints subsided • No joint pain or pain improving • Sores in the mouth clearing

Weakness Nursing diagnosis

• Altered nutrition (less than body requirements) related to inadequate intake of essential nutrients due to oral cavity ulcers, manifested by weakness, fatigue and weight loss

Expected outcome

• Adequate nutrition

Nursing interventions and rationale

• Give a balanced diet; include vitamin B12, iron and folic acid • Give small meals at frequent intervals and allow time to eat; do not rush the patient • Weigh the patient daily • Encourage oral hygiene to stimulate appetite • Administer supplements as prescribed; iron and folic acid

Evaluation

• Increased levels of energy • Progressive weight gain • Optimal nutrition

Weight loss Nursing diagnosis

• Increased risk of infection caused by lowered body resistance, secondary to reduced or non-functioning WBC

Expected outcome

• Prevention of infection

Nursing interventions and rationale

• Minimise the risk of infection by nursing the patient away from other patients with infection, enhancing environmental and personal hygiene and Adhering to aseptic techniques in all procedures undertaken on the patient • Give a nutritious diet high in blood-forming substances • Give medication as prescribed • Monitor and record vital signs 4-hourly to detect infection early

Fatigue Nursing diagnosis

• Risk of fluid volume deficit related to blood loss, secondary to injury, decreased platelets and deficient clotting factors

Expected outcome

• Prevention of blood loss

Nursing interventions and rationale

• Minimise the risk of fluid volume deficit by administering fluid replacement and deficient clotting factors as prescribed in cases where there is a need

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With homologous transfusions, there are risks involved. The associated risks include: • Transfusion reactions resulting in haemolysis of RBCs • Risk of contracting infectious infections such as hepatitis B or C, or HIV/Aids. Blood transfusion reactions can be classified according to onset of the reaction into acute, immediate or delayed reaction. Table 36.5 gives an outline of acute transfusion reactions, aetiology and assessment findings of each transfusion reaction. Delayed blood transfusion reactions include delayed haemolytic anaemia, HIV/Aids, iron overload and, rarely, Hepatitis B and C. Nursing responsibilities regarding blood transfusion are to: • Explain the procedure to the patient and establish if the patient accepts the transfusion, as there are instances, for example religious beliefs, where patients may not receive blood transfusion. • Check the doctor’s prescription regarding blood or blood component in respect of specific blood component, volume to be given (number of units). • Assist the doctor with equipment to establish venous access. The central venous catheter is ideal. The catheter should be appropriate for transfusion of blood and blood components, specially designed for the purpose.

• Follow unit protocols regarding collection of blood from the blood bank, identification of the patient and putting up of the first unit of blood. Ideally, the blood should be removed from the blood bank fridge not more than 15–30 minutes before the transfusion, and the blood must be administered at room temperature. • Obtain and record the history of allergies. • Baseline vital signs are taken and recorded followed by 2- to 4-hourly observations during transfusion. • In the presence of a witness, check at the bedside the name and number on the identification band, and compare with those on the blood bag. If possible the information must be verified with the patient. Follow the policies of the institution regarding the identification procedures before the commencement of the transfusion. The law in South Africa states that the unit of blood is put up by a registered professional nurse or doctor (National Health Act 61 of 2003). Also, check the file of the patient to ensure that the patient is receiving the correct blood group as stated in the cross-match results. • Ensure that the blood is administered at room temperature and that it is warmed accordingly using facilities such as warmers or in line with hospital or unit protocol. • Before administration, observe the blood for abnormal colour, leaks, presence of clots and excessive bubbling.

Table 36.5  Acute transfusion reactions, aetiolgy and assessment findings of each transfusion reaction

Reaction type

Aetiology

Assessment findings

Transfusion of incompatible blood

Fever and chills Flushing Lower back pain Hypotension Tachypnoea Haemoglobinuria Haemoglobinaemia Vascular collapse Shock, renal failure and cardiac arrest

Allergic

Reaction to certain proteins in the blood

Flushing, urticaria, pruritus

Anaphylaxis

Giving IgA proteins to people who have developed IgA antibodies

Urticaria, wheezing, cyanosis, shock and cardiac arrest

Reaction due to circulatory overload

Rapid transfusion of blood

Pulmonary congestion signs; hypertension, tachycardia, distended neck veins, dyspnoea

Infection/septicaemia

Transfusion of contaminated blood

Fever, chills, hypotension, shock

Haemolytic

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Once the blood is on, calculate the rate of flow and observe the patient for signs of reaction. • Ensure that the equipment used is disposed of safely in accordance with the universal precautions. Gloves should be worn at all times when handling blood and administration sets that were used for the transfusion.

36.3 Management of blood transfusion reactions During management of transfusion reactions, consult the policies of the institution and: • Stop the transfusion • Keep the intravenous line open with normal saline • Notify the doctor and the blood bank • Check again the information on the identification band, the patient’s records and blood bags • Monitor the vital signs • Monitor urinary output • Follow the doctor’s prescription in managing the symptoms • Save the blood bag and the intravenous tubing and send to the blood bank • Complete the transfusion reaction report as per institutional protocol • Collect urine and blood samples in line with the institutional policy • Keep a record of the patient’s condition and all interventions, and the transfusion reaction forms in accordance with the policy of the institution.

Specific disorders of the haematological system Disorders affecting the red blood cells Red blood cells (RBCs) or erythrocytes are flat, disc-shaped cells that are produced in the red bone marrow. The red blood cells are indented in the middle and on both sides, giving them a biconcave shape. The importance of this unique shape of the RBC is that it: • provides a larger surface area for diffusion of oxygen across the membrane than a spherical cell of the same volume • facilitates rapid oxygen diffusion between the exterior and inner parts of the cells • is capable of manoeuvering through the small capillaries during circulation without damaging itself. During childhood, almost all bones produce erythrocytes, but as a person grows and matures, this function is aggregated at certain parts of the skeletal system, for

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instance, the red bone marrow of the ribs, vertebrae, base of the skull and proximal ends of long bones. Erythropoeisis is the process by which erythrocytes are formed and mature and this process is influenced by the hormone erythropoietin, which is secreted by the kidneys. Other essential substances for normal development of RBC include vitamin B12 and the intrinsic factor, folic acid, copper, iron, pyridoxine and protein. Vitamin B12 is stored in the liver and released to the bone marrow to complete the development of red blood cells. Intrinsic factor is produced by the stomach mucosa and is needed for absorption of vitamin B12. There are about 4.5–5 million erythrocytes in every cubic millilitre of blood, which is equivalent to a drop of blood the size of a small pinhead. Erythrocytes have a life span of 120 days, after which they become fragile and susceptible to rupture. New red cells are produced at the rate of 2–3 million per second in order to keep pace with the destruction of old cells. At the end of the 120 days of existence, the haemoglobin of the RBC disintegrates into the protein, the globin, and the iron-containing haeme group. The iron-containing haeme group is further metabolised to form the yellow colouring in bile. This activity takes place in the spleen, liver and lymph nodes. Erythrocytes contain haemoglobin (Hb), which carries oxygen to the tissues and carbon dioxide from the tissues. As blood circulates through the lungs, haemoglobin in each red cell gains oxygen and gives up carbon dioxide. Haemoglobin is pigmented and appears red when combined with oxygen, and bluish when deoxygenated. Haemoglobin is also a buffer and helps to maintain normal acid–base balance. Disorders of the red blood cells are due to: • Decreased production of RBC • Blood loss • Excessive destruction of RBC impacting on the oxygen carrying capacity in the haemoglobin.

Anaemia Anaemia is a state that occurs as a result of a reduced number of functioning RBCs. It can be brought about by decreased production of erythrocytes, a release of immature RBCs (reticulocytes) into the circulation, deficiency in the Hb content of erythrocytes and excessive loss of erythrocytes due to excessive destruction and blood loss. Anaemia is not a disease, but an indication of an underlying disorder that results in a decreased amount of oxygen delivery to body tissues. Once anaemia is identified, the underlying cause must be investigated and treated.

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Classification Anaemia is classified according to the disease process as indicated in Table 36.6. Table 36.6  Classification of anaemia

Disease process involved

Type of anaemia

Decreased production of erythrocytes

Aplastic anaemia Pernicious anaemia Iron-deficiency anaemia Folic acid deficiency anaemia

Increased erythrocyte destruction

Haemolytic anaemia Sickle cell anaemia

Blood loss

Haemorrhagic anaemia

Pathophysiology The main characteristic of anaemia, regardless of type, is poor perfusion of body tissues resulting in hypoxia. When hypoxia is sensed, the compensatory mechanisms are activated to restore adequate supply of oxygen to the tissues. These compensatory mechanisms include: • Increasing the rate at which the red cells are produced • Increasing the heart rate to increase cardiac output • Redirecting blood from tissues of low oxygen needs (skin, GIT) to vital organs (brain, heart) • Shifting the oxyhaemoglobin dissociation curve to the right to increase the removal of more oxygen by the tissues at the same partial pressure of oxygen.

Medical management The aims of management and care of patients with anaemia are: • Identification and management of the underlying causes of anaemia –– Improve dietary intake of iron and folic acid. –– Prevent haemmorhage and the bleeding from all sites should be arrested or repaired by surgery. –– Minimise/prevent exposure to toxic agents that cause aplastic anaemia. –– Stem cell or bone marrow transplant. –– Blood component therapy; plasma, platelets or plasma proteins such as albumin. • Symptom management –– Administration of oxygen to prevent hypoxia and help reduce the workload of the heart.

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–– Administration of prescribed erythropoietin to help increase the production of RBCs. The usual route of administration of erythropoeitin is subcutaneous. However, the patient has to have an adequate nutritional status and a well-functioning bone marrow that is able to produce RBCs for this treatment to be effective. –– Iron supplements: Oral administration for mild anaemia for replacement and to replenish iron stores. Administration of intramuscular iron supplements is indicated for patients with malabsorption of oral iron, poor tolerance of oral medication and a specific need for large amounts of iron. The specific health information for patients taking iron supplements is described under ‘Essential health information’ below.

Aplastic anaemia Aplastic or hypoplastic anaemia results from failure of the erythrocyte-producing organs, in particular bone marrow, to produce adequate numbers of erythrocytes. It can be congenital or acquired. The causes of aplastic anaemia include destruction of the bone marrow by toxic chemicals (benzene and its derivates, pesticides, inorganic arsenic), toxic drugs (chloramphenicol, phenylbutazone, sulphonamides and some anticonvulsants), and radiation. Other causes of aplastic anaemia are invasion of the bone marrow by cancer cells, viral infections, pregnancy, and autoimmune factors. The onset of aplastic anaemia is insidious, but in some cases it may evolve rapidly. If the cause is not corrected, the condition may be fatal. Death would be caused by infection, weakness or bleeding tendencies.

Assessment and common findings • A history of exposure to the causative factors. • Complaints of progressive weakness, fatigue, numbness and a tingling sensation in the extremities, dyspnoea on exertion, and pallor. The patient may complain of headaches, anorexia, and an increased tendency to bleeding, for example nosebleeds, bleeding gum, and ecchymosis. Because the patient is prone to infection, fever may be detected, as well as ulcers in the mouth. • A diagnosis can be made on the findings of low Hb, low RBCs, platelets and prolonged bleeding time. Bone marrow aspiration will show bone marrow replacement by fat. Reticulocytes and immature granulocytes may be detected by a peripheral blood smear. If there is an infection, blood cultures will detect the offending micro-organisms.

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Management

Management

• Identify and treat the underlying cause. • Toxic medication may only be prescribed if there are no alternative therapies, and monitor blood cell counts of patients on these medication closely. • Administer red blood cells and platelets if necessary. • Bone marrow transplantation – this procedure would be carried out by the doctor. • Administer drugs as prescribed, including antibiotics to treat infection if present, immunosuppressive drugs before bone marrow transplantation, and steroids to stimulate the production of granulocytes. • Administer oxygen in cases of severe anaemia as prescribed.

Oral supplements of vitamin B12, iron, folic acid or intramuscular injection for defective absorption, increase dietary intake of vitamin B12 and encourage bed rest during the acute phase.

Iron deficiency anaemia Iron deficiency anaemia occurs when there is insufficient iron for Hb synthesis. This may be caused by insufficient dietary intake of iron, inadequate absorption of iron, blood loss, and increased iron demands as in pregnancy, childhood and adolescence.

Risk factors

Nursing management is symptomatic, and is detailed in the nursing care plan in Table 36.4.

Risk factors include a history of peptic ulcers and/or gastritis, chronic alcoholism, a high-fibre diet and/or menorrhagia.

Pernicious anaemia

Common assessment findings

Pernicious anaemia is sometimes known as megaloblastic anaemia. It is caused by a failure to absorb adequate amounts of vitamin B12 from the gastrointestinal tract. Vitamin B12 is essential for the proliferation and maturation of erythrocytes and is found in animal proteins such as eggs, milk, cheese, fish, meat, and liver. The intrinsic factor is deficient in pernicious anaemia, hence the inability to absorb vitamin B12, causing the impairment of red blood cell production and maturation, leading to anaemia. The factors that interfere with the secretion of the intrinsic factor are atrophy of the mucous membrane of the stomach, resulting in reduced amounts of hydrochloric acid, gastric surgery (partial or total gastrectomy, gastrojejunostomy) and autoimmune factors.

• A history of malnutrition, peptic ulcers, alcoholism, high-fibre diet and menorrhagia • Complaints of weakness, fatigue, irritability, dyspnoea on exertion • Pregnancy • The skin may be dry and pale, and nails spoon-shaped and brittle • Stomatitis and cheilosis are common. The patient may report pica, headache and difficulty in concentrating.

Common assessment findings • A history of gastric surgery or a vegetarian diet with an inadequate intake of vitamin B12 • Fatigue, weakness, dyspnoea, palpitations and pallor of the skin may be evident • Numbness and tingling of the extremities, irritability, depression and decreased ability to concentrate • Skin and sclera of the eyes may be jaundiced • On inspection, there may be sores in the mouth and the tongue may appear beefy red. Other gastrointestinal symptoms include weight loss, indigestion, bloating, diarrhoea or constipation.

Diagnostic studies

Diagnostic studies A diagnosis can be made on the following findings: • FBC: low Hb, Hct and red blood cell count • Low serum iron and ferritin in the blood • Endoscopic studies, bone marrow and radiographic tests of the GIT may be done to detect the underlying causes of bleeding and iron deficiency anaemia • Stools may be tested for occult blood.

Management This involves early detection and treatment of the cause of anaemia. Iron replacement in the form of an iron preparation, orally or intramuscularly. Examples of iron supplements include ferrous sulphate, ferrous gluconate and iron dextran. A blood transfusion may be given for very sick individuals.

Nursing management This is symptomatic; refer to Table 36.4.

A diagnosis can be made on the findings of low Hb of 4–5g/dl, low RBC, WBC and platelets, low serum levels of vitamin B12 and folate, and/or a positive Schilling test.

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Essential health information

Haemolytic anaemia

Useful information includes the following: • Teach the patient to take iron supplements 1 hour before meals because these are best absorbed in an acid environment. Also encourage them to take iron supplements with orange juice because vitamin C improves the absorption of iron. • Advise patients that iron salts change the colour of stools to black or dark green. • Inform the patient that iron salts irritate the GIT when taken on an empty stomach. • Encourage patients on iron supplement therapy to brush and floss their teeth frequently because ferrous sulphate may be deposited on the teeth and gums and will stain these dark brown. • Advise patients to use a straw for taking liquid iron and to rinse the mouth with water after taking it as it will stain their teeth. • Instruct patients not to crush enteric-coated or sustained release tablets or capsules. • Test patients with a small dose of the intramuscular iron supplement prior to commencing therapy, to avoid the risk of anaphylaxis. • Inform patients about the indications for administration of intramuscular iron supplements, should this type of supplement be indicated for them, which includes: –– Malabsorption of oral iron –– Poor tolerance of oral medication –– A specific need for large amounts of iron.

Haemolytic anaemia results from premature or abnormal destruction of RBCs by the macrophages or a hyperactive spleen. It may occur because the bone marrow fails to replace destroyed RBCs.

Folic acid deficiency anaemia Folic acid deficiency anaemia occurs as a result of inadequate intake of folate.

Risk factors

Risk factors • • • •

Infection Radiation Transfusion of incompatible blood Abnormal immune response and ingestion of drugs, such as methyldopa, and phenacetin • It may also be secondary to malaria.

Clinical manifestations Clinical manifestation includes fatigue, lassitude, pallor and intermittent dizziness.

Diagnostic studies Diagnosis can be made on the following findings: • Decreased Hb and Hct • Increased serum bilirubin because the liver cannot process the excess destruction of RBC and increased release of LDH (lactate dehydrogenase). LDH is an enzyme that is released when red blood cells are destroyed • Increased urinary and faecal urobilinogen • Bone marrow aspiration which reveals erythroid hyperplasia to compensate for excessive erythrocytes destruction • Positive Coombs test • Positive Schilling test.

Management of haemolytic anaemia

Clinical manifestations

• Treat the underlying cause. • Increase fluid intake to flush the kidneys. • Give sodium bicarbonate or sodium lactate in order to make the urine alkaline thereby decreasing the risk of precipitation in the renal tubules. • Splenectomy may be performed.

Clinical manifestation includes weakness, listlessness, pallor, a sore red tongue, and diarrhoea.

Sickle cell anaemia

These include pregnancy (increased demand), patients with malabsorptive bowel syndrome, alcohol abuse, haemolytic anaemia and old age.

Diagnostic studies A diagnosis can be made on the following findings: • Low Hb of 4–5 mg dl, low WBC and low platelets. The levels of folate and vitamin B12 are decreased. • Positive Schilling test.

Management This is by treating the underlying cause, and administration of folic acid supplements as prescribed.

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This is an inherited homozygous recessive genetic disorder of haemoglobin synthesis characterised by abnormal crescent-shaped, rigid and elongated erythrocytes that resemble a sickle. The abnormal shape and rigidity of the red blood cells interfere with circulation and make it impossible for these cells to get through the microcirculation. They are therefore destroyed in the process, resulting in obstruction of blood vessels and tissue hypoxia.

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Risk factors When one parent has a sickle cell trait, there is a 50% probability that the child will be a carrier of the sickle cell trait. When both parents have the sickle trait, there is a 25% probability that the child will suffer from sickle cell disease, and 50% probability of being a carrier of the sickle cell trait. This trait is common among the black population of central Africa and among black descendents of these populations.

Pathophysiology Normal Hb consists of globin, a protein made up of four polypeptide chains arranged in pairs and four ironcontaining haeme groups. Each chain of polypeptides has a specific amino acid sequence and number. Deviation from the normal number or sequence of these amino acids results in abnormal Hb synthesis. The genetic defect results in the substitution of the amino acid valine for glutamine on one chain of the globin portion of Hb. This results in abnormally shaped red blood cells caused by intermolecular rearrangement. Erythrocytes appear sickle shaped and are rigid. The blood becomes increasingly viscous with the red blood cell not being able to carry oxygen. The high viscosity of blood reduces the speed of blood flow, which then forms clots that may, if big enough, occlude blood vessels resulting in emboli and/or hypoxia, infarction and necrosis of cells. The most vulnerable organs are the brain and kidneys.

The clinical manifestations • Weakness and fatigue • Failure to thrive and growth retardation in children • Oedema of hands and feet caused by sluggish circulation • Jaundice or pallor • Leg ulcers in about 70% of patients (children and adults), due to hypoxia • Osteomyelitis and necrotic bone marrow caused by necrosis of the head of the femur • Ischaemia of the kidneys resulting in diminished capacity to concentrate urine • Other ischaemic effects are pulmonary, cardiac and brain infarctions.

Sickle cell crisis Sickle cell crisis is the sudden exarcerbation of sickling due to stressors such as infection, dehydration, hypoxia, nutritional deficiencies (folic acid) and anaesthesia.

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The types of sickle cell crisis are: • Thrombotic/vaso-occlusive crisis, caused by occlusion of blood vessels by sickle cells; the patient will have pain originating from the site of occlusion • Aplastic crisis secondary to infection, which is characterised by a decrease in erythropoiesis – Hb and RBC counts will be low • Megaloblastic crisis, which occurs as a result of depletion of folic acid • Sequestration crisis, resulting from sudden and massive trapping of RBC by the spleen • Haemolytic crisis, caused by excessive destruction of RBC and fever.

Clinical alert! Very cold and iced liquids precipitate a crisis, and should therefore be avoided.

Essential health information • The nature of the disease must be explained to the patient, including the complications and crisis • Explain to young adults the importance of undergoing genetic counselling before having children • Recommend non-stressful exercises to stimulate circulation and to increase muscle tone • Encourage a range-of-motion exercises to maintain muscle tone and joint mobility during the acute phase • Refer to an orthopaedic surgeon in the event that the patient develops an orthopaedic problem such as haemarthrosis or avascular necrosis • Stress the importance of good nutrition – a diet rich in vitamins, calcium and proteins is recommended, and should include adequate fluid intake.

Manifestations of sickle cell crisis • Cardiac enlargement, dysrythmia and systolic murmurs • Respiratory signs including dyspnoea, cyanosis and chest pain • Renal manifestations of uraemia, oliguria and oedema • Cerebral bleeding, resulting in increased intracranial pressure.

Diagnostic studies findings Any black person with haemolytic anaemia should be tested for sickle cell anaemia. The disease can be confirmed by a positive sickle cell solubility test for anaemia. Another test is a blood smear for detection of the presence of sickle cells. Hb electrophoresis will help to differentiate sickle cell anaemia from sickle cell trait.

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Management

Diagnostic studies

• • • • •

Diagnosis can be made on the following findings: • Elevated Hb of 18–25 g/dl, Hct of 60% and elevated RBC and platelets count • Bone marrow aspiration reveals the cause of overproduction of cells.

Recommend rest as the patient will be weak. Give oxygen therapy during the acute phase. Administer IV fluids and electrolytes as prescribed. Administer packed cells as prescribed. Exchange transfusions or hypertransfusion: this involves transfusions until more than 50% of circulating RBCs are of donor origin.

Medication • Daily supplements of iron, folic acid and vitamin B12 to promote RBC production • Antibiotic therapy for infection • Analgesics for pain management during a crisis and for chronic pain relief • Sedatives • Hydroxyurea and erythropoietin, which are being used in clinical trials and have shown an ability to decrease haemolysis and to increase foetal Hb • Give advice on how to prevent a crisis: –– Avoid becoming dehydrated, but if this does occur, then it must be managed promptly –– Avoid high altitudes, infection, emotional stress, trauma, alcohol and cigarette smoking –– Emphasise the importance of follow-up care.

Management The goals of management are to reduce the volume and thickness of the blood and to prevent complications. These goals are achieved by the performance of emergency or intermittent phlebotomy: 2 000 ml and 330– 500 ml of blood can be removed from the patient during emergency and intermittent phlebotomy respectively. The aim is to reduce the volume until the Hct reaches 45%. • Vital signs should be monitored during phlebotomy. • Intravenous fluids should be administered. • An accurate record of intake and output must be maintained. The activity of the bone marrow may be suppressed with myelosuppressive agents such as chlorambucil, bisulphan and hydroxyurea. Radiation therapy may be done using radioactive phosphorus.

Polycythaemia vera

Disorders affecting the white blood cells

Polycythaemia vera is a disorder characterised by an overproduction of erythrocytes, leukocytes, and platelets resulting in increased blood viscosity, increased blood volume, and blood congestion in all body tissues and organs. This disorder is caused by bone marrow diseases, neoplasms, and drugs. It is also common in chronic lung diseases.

White blood cells (WBCs) or leukocytes develop from a stem cell. They are classified according to the presence or absence of granules in their cytoplasm as well as their staining characteristics. Granulocytes are WBCs that have large granules on their cytoplasm and make up about 65% of the total number of leukocytes. These mature in the bone marrow over a 2-week period into neutrophils, eusinophils and basophils. The main function of granulocytes is to protect the body against parasitic infections and to Immunoglobulin E allergic response. Agranulocytes are divided into monocytes and lymphocytes. The monocytes are released from the bone marrow and attach to the endothelium of the spleen, liver, connective lymphoid tissue and lungs. They are then transformed into macrophages capable of ingesting large quantities of foreign material from sites of inflammation. Lymphocytes are produced in the lymphoid tissue. The types of lymphocytes are T-cells, B-cells and null cells (natural killer cells). The T-cells mature in the thymus gland, B-cells in the bone marrow, and the null cells are not identifiable as T-cells. Lymphocytes serve the functions of antibody-mediated and cell-mediated immune response. Plasmacytes are derived from the B-cells and are formed in the bone marrow and lymph nodes. They produce immunoglobulin or antibodies.

Clinical manifestations • The patient presents with a typically dusky complexion (plethora) on the face, hands, feet and mucous membranes, which is due to capillary congestion. • There may be complaints of headache, dizziness, tinnitus and increased blood pressure as a result of increased blood volume and viscosity. • There may be bone pains, tenderness of the ribs and sternum due to increased bone marrow activity. • Possible additional manifestations include pruritus, diaphoresis, bleeding tendencies, oedema of the lower extremities and distended neck veins. • Splenomegaly and hepatomegaly will be present.

Complications These include deep-vein thrombosis, myocardial infarction and cerebrovascular accident (stroke).

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The disorders of white blood cells discussed in this Chapter are agranulocytosis, leukaemia and multiple myeloma.

Agranulocytosis Agranulocytosis is an acute, potentially fatal condition characterised by a reduced number of circulating neutrophils (neutropenia). It is more common in women than in men. The patient may die within weeks if the condition is not detected and treated early.

Malignancies of this system are classified according to the affected cells and they include the following: • Leukaemia, which is an abnormal proliferation and accumulation of white blood cells (WBC) • Multiple myeloma, which is a malignant disease that affects plasma cells.

Leukaemia

The aetiological factor of this condition is inadequate production of neutrophils with excessive destruction. The risk factors include exposure to ionising radiation, chemicals, drugs, infections, chemotherapy and autoimmune diseases.

Leukaemia is defined as abnormal and unregulated proliferation of white blood cells. It is classified according to the type of cells involved, for example lymphocytic and myelocytic leukaemia. Leukaemia can be acute or chronic depending on the characteristics of the cells involved. Acute leukaemia occurs as a result of the proliferation of immature cells, whereas chronic leukaemia is as a result of proliferation of mature differentiated cells. Acute leukaemia has rapid onset and progression.

Clinical manifestations

Pathophysiology

A decrease in the number of neutrophils deprives the patient of protection against micro-organisms, thereby predisposing the patient to infections. The onset is acute and has a rapid progression. The patient presents with: • Lethargy, fatigue, weakness • Throat infections, ulceration of the mouth • Dysphagia • Severe fever and chills • Weak, rapid pulse.

There is efficient regulation of cell proliferation and maturation in the normal bone marrow. These regulatory mechanisms ensure that there is normal production of cells to meet the body’s needs. In leukaemia, the regulatory mechanisms are disrupted leading to uncontrolled proliferation of leukocytes. The normal bone marrow is replaced by blast cells (immature and undifferentiated leukocytes) which are released into the circulation and are not able to perform the phagocytic function of mature cells. The circulating abnormal and immature leukocytes also infiltrate blood-forming organs and other sites in the body.

Aetiology and risk factors

Diagnostic studies Agranulocytosis is diagnosed on the history of exposure to the risk factors, findings of decreased WBCs on FBC, absence of granulocytes on bone aspiration and biopsy. The cultures of blood, lesions on the mouth and urine reveal the presence of Gram-positive bacteria.

Management • Identify and treat the underlying causes. • Provide nursing care that focuses on prevention of infection, oral hygiene and provision of rest. It will be necessary to support and reassure the patient. • Give broad-spectrum antibiotics for infection, as prescribed. • Administer erythropoietin and colony stimulating factors to stimulate the production of WBC if recommended.

Malignant conditions In the bone marrow, the normal production of specialised cells is regulated carefully to meet the body’s needs. When the regulatory mechanisms are disturbed, abnormal proliferation and maturation of cells occur.

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Classification • Acute leukaemia; acute lymphocytic leukaemia (ALL), and acute myelocytic leukaemia (AML) • Chronic leukaemia: chronic lymphocytic leukaemia (CLL), and chronic myelocytic leukaemia (CML).

Incidence Leukaemia is the most common cancer in children. It accounts for 8% of all human cancers.

Risk factors • Exposure to radiation, chemicals or alkylating agents • Viral infections • Genetic disposition and congenital defects such as Down’s syndrome and Fanconi’s aplastic anaemia • Unknown causes.

Clinical manifestations • Bleeding tendencies, including bleeding into tissues (ecchymosis), gums, joints, petechiae

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• • • •

Haemolytic anaemia caused by bleeding Fever due to recurrent infection Pain and headache Vomiting, papilloedema, facial palsy, blurred vision, meningial irritation and intracranial haemorrhage indicate the involvement of the central nervous system.

Diagnostic studies The diagnosis can be confirmed by an X-ray of the bones, which will reveal diffuse bone lesions, due to bone marrow infiltration. Urine tests will show the presence of a typical Bence-Jones protein in urine (consisting of immunoglobulin light chain).

Diagnostic studies

Management

FBC will reveal an abnormal white blood cell count, and peripheral blood smears will reveals immature blasts. Bone marrow aspiration and biopsy may be done to confirm the condition by showing the proliferation of WBC. Other tests may be done to locate the lesions in other parts of the body. These include lumbar puncture, X-ray of the bones, CT scan of the brain and MRI.

The goals of management are early detection and prevention of complications. This includes reducing calcium levels to normal rates, palliative radiation for patients with disabling pain, and chemotherapy. For management of patients on chemotherapy and radiation, see Chapter 17.

Management

Haemorrhagic and coagulation disorders Thrombocytopenia

The goals of management are: • Prevention and management of bleeding • Destruction of neoplastic cells • Maintenance of a sustained remission.

Thrombocytopenia is a disorder that occurs when there is a reduction of platelets, resulting in bleeding disorders. It may be congenital or acquired.

Radiation therapy and chemotherapy may be used as treatment (see Chapter 17). A bone marrow transplant may also be recommended.

The causes of thrombocytopenia include the following: • Inadequate production of platelets by the bone marrow. Bone marrow activity may be depressed by disease such as cancer, or drugs such as chloromycetin or cytotoxic drugs, or chemicals in industry at work, alcohol, genetic factors or exposure to radiation • Increased and premature destruction of circulating platelets by antibodies, malignancy, immune disorders, bacterial and viral infections and drugs such as sulphonamides and quinine • Loss or increased utilisation of platelets in patients with mechanical prosthetic heart valves (mechanical prosthetic heart valves damage platelets) • Secondary to haemolytic anaemia and disseminated intravascular coagulopathy • Abnormal distribution of platelets as a result of hypersplenism and hypothermia.

Multiple myeloma Multiple myeloma is a neoplastic condition characterised by abnormal proliferation of plasma cells.

Risk factors These include a genetic predisposition, exposure to ionising radiation, and/or occupational exposure to industrial chemicals.

Pathophysiology With this condition, there is over-production of plasma cells and bone destruction due to abnormal proliferation of plasma cells. Red and white blood cells and platelet production is disrupted making the patient susceptible to anaemia, infection and bleeding.

Clinical manifestations • • • • • •

Backache and bone pain High incidence of pathological fractures Deformities of the rib cage and sternum Osteoporosis Renal stones Nausea, vomiting, anorexia and drowsiness as a result of hypercalcaemia.

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Aetiology

Pathophysiology Regardless of the cause, thrombocytopenia affects coagulation and haemostasis, resulting in bleeding tendencies.

Assessment and common findings There may be a history of recent infections, a positive family history of thrombocytopenia, or intake of alcohol and medication that is implicated in the destruction of the bone marrow and platelets.

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Diagnostic studies • FBC results may reveal low Hb and Hct as a result of blood loss. • Platelets count below 100 000/m3. Severe bleeding occurs when platelets are decreased to less than 20 000/mm3. • Blood smears may reveal the presence of large immature platelets (megathrombocytes) that are prone to premature destruction. • Platelets antibody screening may be positive for IgG antibodies. • Coagulation studies may show increased bleeding time, PTT, PT and INR. • Bone marrow aspiration may reveal the presence of immature red blood cells.

Clinical manifestations • A history of prolonged and sometimes uncontrollable bleeding following minor trauma • Spontaneous bleeding from the nose, gums, urinary system, gastrointestinal tract and excessive menstruation in women • Petechia in the skin as well as ecchymosis • Signs of anaemia as a result of bleeding • Joint pains due to extravasations into tissues • Fever, lethargy and weakness.

Nursing management The goal of management is to prevent bleeding, therefore the patient should be put on bed rest with the head elevated to prevent intracranial bleeding. Advise patients to use a soft-bristled toothbrush for cleaning their teeth, and to use an electric razor for shaving to prevent bleeding. Instruct patients in measures to avoid constipation, as straining could cause bleeding. The choice of drugs will depend on the underlying causes of thrombocytopenia, but choices include corticosteroids to increase the production of platelets, intra­ venous immunoglobulin in cases where corticosteroids have not been effective, or immunosuppressive agents. Medication that interferes with platelets must be avoided. A splenectomy may also be performed and where this has been successful, it has produced a lasting remission in the majority of patients with thrombocytopenia. Replacement therapy with blood or blood components is also an option.

Essential health information

include gentle application of pressure on bleeding sites, as well as the use of cold compresses. Patients must be encouraged to take medication as prescribed.

Haemophilia Haemophilia is an inherited sex-linked chromosomal defect where there is a deficiency of one or more of the clotting factors carried on the X chromosome, hence females are carriers and males are sufferers. The recognised types of haemophilia are: • Haemophilia A, also known as classic haemophilia – caused by a deficiency of clotting Factor VIII. This can be mild, moderate or severe. • Haemophilia B/Christmas disease – due to a deficiency of clotting Factor IX. This can be mild, moderate or severe. • Haemophilia C – due to a deficiency of Factor XI. The incidence of haemophilia A is about 3 times more common than haemophilia B. Types A and B are both sexlinked inherited disorders of recessive pattern. Males are almost exclusively affected by this disorder, and females transmit the defective gene. Haemophilia is usually recognised in early childhood.

Pathophysiology Normally, haemostasis is a regulated process that depends on the interaction between the blood vessels, blood platelets and coagulation factors. Clotting factors are multiple plasma proteins (numbered I to XIII) that cause cascades of enzymatic reactions in blood plasma. These cascades of reactions are often divided into an intrinsic, extrinsic and a common clotting pathway. Patients with haemophilia A have an abnormality of the gene coding for coagulation Factor VIII, leading to abnormally low plasma levels of Factor VIII. This factor is involved in the intrinsic pathway of coagulation. Haemophilia B is the result of an abnormality of the gene coding for clotting Factor IX. Because Factor IX is also involved in the intrinsic clotting pathway, the low levels of Factor IX give rise to a disease with clinical manifestations identical to those of haemophilia A. The coagulating factor deficiency in haemophilia results in failure of blood to clot and therefore a tendency to bleed spontaneously, after minor trauma and after major trauma and surgery. There are, however considerable variations in the degree of this bleeding tendency among patients.

Patients must be taught to recognise signs of bleeding and how to prevent episodes: methods of arresting bleeding

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Clinical manifestations The clinical manifestations of haemophilia A depend on the levels of Factor VIII. These patients present with forms of bleeding listed below: • Haemarthroses causes pain, redness and swelling of the larger joints, commonly the knees, elbows and hips. Repeated episodes can result in limitation of movement and ankylosis, which can be crippling without adequate treatment. • Bleeding into muscle is common after relatively minor trauma or intramuscular injections. Deep visceral; bleeding in the internal organs occurs occasionally. Bleeding from the GIT, urinary tract and skin occurs manifested by blood in the stools and haematuria. The condition can lead to hypovolaemic shock due to massive bleeding. Bleeding into the brain substance has proved fatal. The manifestations of haemophilia B are very similar to those of haemophilia A listed above. Other manifestations include decreased sensation and weakness due to peripheral nerve compression by haematomas.

Common assessment findings The presenting symptoms, in particular, the pattern of bleeding are helpful in the diagnosis of haemophilia. The exact diagnosis is made if patients who present with a positive family history are found to have abnormally low levels of coagulation factors VIII or IX in blood assays. Further diagnostic studies needed are: • FBC will reveal a low Hb and Hct due to bleeding. • The bleeding time: An abnormal bleeding time points to the possible platelet or blood vessel defects. Bleeding time will be prolonged to more than 8 minutes. • The clotting profile shows some suggestive but not specific abnormalities. The PTT is prolonged and INR (international normalised ratio) normal. These two tests give an indication of the time it will take the blood to clot. • Assays of Factors VIII and X will be low.

Management Haemophilia is not curable, but bleeding episodes can be adequately controlled. This requires understanding of the disease process and high levels of motivation from the patient and those living with and around the patient. In order to manage haemophilia effectively, it is important to note that the symptoms often precede objective evidence of bleeding and bleeding may not appear until several days after well-documented trauma.

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Give a transfusion of blood and fresh frozen plasma as prescribed to replace blood loss. Replacement of deficient clotting factors is achieved by the administration of: • Factor IX concentrates during bleeding • Plasma-derived concentrate • Cryoprecipitate infusion to replace deficient Factor VIII, Factor XIII and fibrinogen. Administer prescribed medication as follows: • Analgesics as prescribed for pain, but aspirin and NSAIDS must be avoided because these increase the incidence of bleeding • Aminocaproic acid in cases of clot formation to slow down the dissolution of clots • Synthetic vasopressin (DDAVP®) can be administered intravenously, subcutaneously or intranasally to produce a transient rise in Factor VIII concentration in patients with mild haemophilia. Care of the joints should be done in the following way: • Apply splints and other supportive devices to immobilise painful and swollen joints. • Elevate the affected joint to improve venous return. • Apply cold compresses to joints. • Handle the swollen joints gently. • Joint mobilisation and physical therapy. • Joint replacements are sometimes required. • Assist with passive or active range of motion exercises daily. Prevent bleeding as follows: • Avoid, whenever possible, intramuscular injections. • Avoid injury. • Observe the patient for signs of bleeding.

Essential patient teaching • Teach the patient and their family about the nature of the condition in order to promote understanding and cooperation. • Stress the importance of preventing injury. • Encourage the patient to seek medical help for any suspected or obvious bleeding. • Instruct the patient on procedures to stop bleeding, such as application of cold compresses, gentle direct pressure and elevation of the affected area. • Inform the patient about the importance of notifying dentists and other doctors about the condition for when dental care is required or illness occurs.

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• It is of paramount importance to avoid aspirin or other drugs that may impair blood platelet function and cause severe bleeding. • Follow-up care and blood transfusion may be required regularly. • Stress the importance of a MedicAlert® bracelet and identification card. • Recommend that children wear a helmet during play to protect the head against bumping. • Refer for genetic counselling.

Disseminated intravascular coagulopathy Disseminated intravascular coagulopathy (DIC) is an acute disorder characterised by widespread blood clotting and haemorrhage.

Risk factors These include: sepsis, extensive surgery, burns, shock, malignancy, haemolysis, trauma, obstetric conditions, transplant rejections, fat emboli.

Pathophysiology In DIC, the flow of blood is disrupted by the precipitating factors, resulting in the formation of tiny clots within the micro-circulation. These clots consume platelets and clotting factors and the blood loses its ability to clot, which causes bleeding.

Clinical manifestations • Acute onset with rapid development of the signs and symptoms • Bleeding from the body, which may be mild or severe (signs of bleeding that may be observed include petechiae, ecchymosis, purpura, bleeding from

mucous membranes, lungs and from venipuncture sites) • Signs of hypolaemic shock will be evident.

Diagnostic studies Coagulation studies show decreased PT, PTT, platelets count factor assays II, V and VIII and prolonged bleeding time.

Nursing management • Treat the underlying cause. • Improve oxygenation and tissue hypoxia. • Give fluid replacement therapy: transfusion of blood, RBCs and cryoprecipitate as prescribed. • Low doses of heparin may be prescribed, although this is controversial. • Monitor vital signs carefully. • Keep intake and output records.

Conclusion Disorders of blood and blood constituents are some of the most difficult and serious conditions to manage because blood is the life line for the whole body. Most of the conditions are chronic in nature and usually occur as a complication to another condition or exist with other diseases. For example, anaemia may be a complication of poor nutrition or infection. Some of the risk factors for these disorders, such as the genetic make-up and drugs, cannot be avoided. The medication that we use to contain some infections is hepatotoxic and suppresses the functioning of the bone marrow, resulting in one or the other blood dyscrasia. Prevention of these conditions requires individuals to lead a healthy lifestyle that does not predispose one to ill health.

Suggested activities for learners Activity 36.1 Match to each of the descriptions in the first column the most appropriate concept in the second column below: Description

Concept

1. A bleeding disorder that occurs when there is a reduction of platelets

a) Leukopenia

2. The disorder characterised by an overproduction of erythrocytes, leucocytes and platelets

b) Thrombocytopenia

3. The decrease in the total number of white blood cells circulating in the blood

c) Agranulocytosis

4. An increase in the number of white blood cells circulating in the blood

d) Polycythaemia vera ❱❱

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Activity 36.2 1. The deficiency of clotting Factor … causes haemophilia A. a) VII b) VIII c) IX d) III 2. Which of the following clotting factors causes haemophilia C? a) Factor VII b) Factor VIII c) Factor IX d) Factor III 3. What’s the most common major complication of severe haemophilia? a) intracranial bleeds b) joint damage c) anaemia d) excessive bleeding 4. Which of the following diagnostic test is done to diagnose Haemolytic anaemia? a) genetic testing b) Schilling test c) Coombs test d) peripheral blood smears 5. Which of the following is the function of white blood cells? a) Transport oxygen b) Maintain homeostasis c) Defend against infection d) Produce haemoglobin 6. Multiple myeloma is form of blood cancer that develops in the bone marrow. • True • False

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37

Management of the disorders of the lymphatic system

learning objectives

On completion of this Chapter, the learner should be able to: • describe the structure and function of the lymphatic system • classify the disorders of the lymphatic system according to the causative factors • describe all the risk factors associated with disorders of the lymphatic system • describe the significant subjective assessment data related to the lymphatic system that should be obtained from a patient presenting with the disorders of the lymphatic system • explain the significance of various diagnostic tests and procedures used to assess the lymphatic system function • describe the preparation for, and the nursing care of patients following diagnostic studies done for assessment of the lymphatic system • describe the causes, pathophysiology, signs and symptoms, diagnosis and treatment of all inflammatory disorders of lymphatic system • describe the causes, classification, signs and symptoms, diagnosis and treatment of all disorders associated with impaired flow of the lymphatic system • describe the causes, classification, pathophysiology, signs and symptoms, diagnosis and treatment of malignant disorders of the lymphatic system. key concepts and terminology

interstitial space

The narrow spaces found between tissues or parts of an organ.

lymph

The slightly opalescent fluid found within the lymphatic system.

lymphadenitis

Inflammation of the lymph nodes.

lymphadenopathy

Swelling or enlargement of the lymph nodes.

lymphangitis

Inflammation of the lymph vessels, characterised by typical streaks that follow the course of the infected and inflamed blood vessel and extend to the lymph nodes.

lymphangiectasia/ lymphangioma

Dilatation of the lymphatic vessels.

lymphangiosarcoma

A cancerous condition that begins in the lymphatic vessels, rather than the lymph nodes.

lymphatics

The system of lymphatic vessels.

lymphoedema

Swelling in one or more extremities that results from impaired flow in the lymphatic system.

lymph nodes

Bean-shaped swellings along the lymphatic vessels that contain macrophages and lymphocytes.

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lymphoma

Neoplasm of the lymphoid tissue such as the thymus glands, lymph nodes, spleen, liver and bone marrow.

T-lymphocytes (T-cells)

A type of white blood cell that originates in the thymus and attaches to foreign organisms, secreting lymphokines that kill the foreign organisms.

tonsil

A collection of lymphocytes that form a mass in the back of the pharynx.

prerequisite knowledge

• Structure and function of the lymphatic system • Biochemistry and biophysics • Specific nursing skills such as monitoring of vital signs, intake and output, preparation for the insertion of intravenous infusion and administration of medicines. medico-legal considerations

Nurses are obliged to ensure that the patients have given informed and written consent for tests and procedures done for assessing cardiac function. Legally, the patients have a right to accurate information about their care, tests and treatment. The information must be given in the patient’s preferred language and at the level of understanding by the patient. The patient must be given an opportunity to ask questions, and the questions must be answered to the patient’s satisfaction. essential health literacy

The challenge for patients with disorders of the lymphatic system is care of the swollen body part. The patient must be given information on the course of the disease process and prevention of complications such as infection. The patient must be encouraged to do the prescribed exercises and to maintain the compression bandages on the swollen parts.

Introduction The lymphatic system consists of organs, ducts and nodes. The organs related to this system are the spleen, thymus gland, adenoids and tonsils. This system assists with the distribution of immune cells throughout the body, drains the fluid from the spaces around each cell and channels it to the circulatory system. The purpose of this Chapter is to present a discussion of disorders of the lymphatic system.

Right lymphatic duct Thoracic duct Lymphatic vessels

Overview of the structure and functions of the lymphatic system The lymphatic system contains immune cells called lymphocytes, which protect the body against antigens such as viruses and bacteria that invade the body. These cells are organised into specific structures. The major structures of the lymphatic system include the bone marrow, the thymus, the spleen, tonsils as well as the lymph and vessels that transport the lymph. The main functions of the lymphatic system are to: • Collect and return the excess interstitial fluid and plasma protein to the blood, thus maintaining fluid balance

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Lymph nodes

Figure 37.1  Structures of the lymphatic system

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Soft palate

• Produce the lymphocytes to defend the body against micro-organisms and disease • Absorb fats and fat-soluble vitamins from the gastrointestinal tract and transport them to the circulation. The mucosa of the small intestines is covered by the villi. At the centre of each villus, there are blood capillaries and special lymph capillaries known as lacteals. The fats and fat-soluble vitamins are absorbed by the lacteals while the blood capillaries absorb most of the nutrients. The lymph in the lacteals is called chyle.

Tonsils Uvula Tongue

Bone marrow Red blood cells, white blood cells (including lymphocytes and macrophages) and platelets are produced from the stem cells in the bone marrow.

Thymus The thymus gland is found in the thoracic cavity, anterior to the ascending aorta and posterior to the sternum. It has two lobes. It is large during childhood, but after puberty it begins to decrease in size, and in adults it is small. The primary function of the thymus is the processing and maturation of special lymphocytes called T-lymphocytes or T-cells. In the thymus gland, the lymphocytes do not respond to pathogens and foreign agents. After the lymphocytes have matured, they enter the blood and go to other lymphatic organs where they help provide defence against disease. The thymus also produces a hormone, thymosin, which stimulates the maturation of lymphocytes in other lymphatic organs.

Tonsils The tonsils are clusters of lymphatic tissue just under the mucous membranes that line the nose, mouth, and pharynx. The three groups of tonsils are: 1. The pharyngeal tonsils, located near the opening of the nasal cavity in the pharynx. When these tonsils become enlarged they may interfere with breathing and are called adenoids. 2. The palatine tonsils are located near the opening of the oral cavity in the pharynx. 3. Lingual tonsils are located on the posterior surface of the tongue, which also places them near the opening of the oral cavity into the pharynx. Lymphocytes and macrophages in the tonsils provide protection against harmful substances and pathogens that may enter the body through the nose or mouth.

Spleen The spleen is the largest lymphatic organ in the body. It is located in the upper left quadrant of the abdomen just

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Figure 37.2 Tonsils

beneath the diaphragm and posterior to the stomach. It is similar to a lymph node in shape and structure, but much larger. It is surrounded by a connective tissue capsule, which extends inward to divide the organ into lobules. The spleen consists of two types of tissue called white pulp and red pulp. The white pulp is lymphatic tissue consisting mainly of lymphocytes around arteries. The red pulp consists of venous sinuses filled with blood and lymphatic cells, such as lymphocytes and macrophages. Blood enters the spleen through the splenic artery, moves through the sinuses where it is filtered, then leaves through the splenic vein. The spleen filters blood in the same way that the lymph nodes filter lymph. Lymphocytes in the spleen react to pathogens in the blood and attempt to destroy them. Macrophages then engulf the resulting debris, the damaged cells, and the other large particles. The spleen, along with the liver, removes old and damaged erythrocytes from the circulating blood. The spleen, like other lymphatic tissue, produces lymphocytes, particularly in response to the invasion of the body by pathogens. The spleen has two main functions: that of acting as part of the immune system, and as a filter.

Lymph Lymph is a clear fluid derived from blood plasma as fluids pass through capillary walls at the arterial end. As the interstitial fluid begins to accumulate, it is picked up and removed by tiny lymphatic vessels and returned to the blood. As soon as the interstitial fluid enters the lymph capillaries, it is called lymph. Lymph is similar in composition to blood plasma. Lymph distributes immune cells and other factors throughout the body. It also

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interacts with the blood circulatory system to drain fluid from cells and tissues.

Classification of the disorders of the lymphatic system

Lymphatic vessels

The classification of the disorders of the lymphatic system is done according to causative factors as indicated in Table 37.1.

Lymphatic vessels carry fluid away from the tissues. The smallest lymphatic vessels are called lymph capillaries, which begin in the tissue spaces as blind-ended sacs. The lymph capillaries are very permeable. The lymph can drain easily from the tissue into the lymph capillaries because they are not pressurised. Lymph capillaries are found in all regions of the body except the bone marrow, central nervous system, and tissues that lack blood vessels, for example the epidermis. The lymph capillaries join to form lymphatic vessels. Small lymphatic vessels join to form larger tributaries, called lymphatic trunks, which drain large regions. Lymphatic trunks merge until the lymph enters the two lymphatic ducts. The right lymphatic duct drains lymph from the upper right quadrant of the body. The thoracic duct drains all the rest. The lymphatic tributaries have thin walls and have valves to prevent backflow of lymph. Like the blood vessels, the lymph vessels form a network throughout the body but the lymph system drains lymph from the tissue in a one-way direction and returns it to the blood. There is no pump in the lymphatic system, like the heart in the cardiovascular system. The pressure gradients to move lymph through the vessels come from the skeletal muscle action, respiratory movement, and contraction of smooth muscle in vessel walls.

Lymph nodes The lymph nodes are lumpy masses of cells found at the points where the smaller lymph vessels unite to form larger ones. Lymph nodes are small, oval or beanshaped swellings found at intervals along the length of the larger lymphatic vessels. They range in size from a few millimetres to about 1–2 cm in their normal state. They are aggregated in particular sites in the human body, such as the neck, axillae, groins and para-aortic region. The lymph nodes perform the function of acting as filters for particulate matter and micro-organisms (phagocytic cells).

Nursing alert! The knowledge of the sites of lymph nodes is important in physical examination of patients. Lymph nodes become enlarged when the body is infected because of increased production of some cells, and division of activated T- and B-cells.

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Table 37.1 Classification of the disorders of the lymphatic system

Causative factors

Conditions

Lymphatic blockage as a result of tumours, infection, inflammation or anatomical abnormalities of the lymphatic system

Lymphadenitis Lymphangitis Lymphoedema Lymphangiectasia

Cancer

Lymphoma

37.1 Comparison between lymph vessels and veins A comparison between lymph vessels and veins shows the following: • Both have an interconnecting network of progressively larger vessels. • Both transport fluids to the heart. • The larger lymph vessels have the same structure as veins, ie their walls have the same three layers and they have semi-lunar valves that prevent back­flow. The lymph capillaries consist of a single layer of squamous endothelium just like blood capillaries. • The flow of fluid is slow but steady and at low pressure, and the fluid is deoxygenated. The differences between the lymph vessels and veins are as follows: • The walls of lymph vessels are thinner and more transparent. • The muscle layer in lymph vessel is much less developed, but there is more connective tissue. • Blood capillaries form a continuous, open circuit, whereas lymph capillaries end blindly in the tissues. • Lymph capillaries have a larger diameter than blood capillaries. • Lymph capillaries have walls which are more permeable than the walls of blood capillaries. Consequently, larger molecules (such as proteins) are able to diffuse through them.

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Subjective data Subjective data collection should include general biographical information, and should focus on the specific risk factors mentioned earlier, for example the health history, family history, medication used by the patient, and history of exposure to hazardous substances.

Figure 37.3  Lymph nodes

Risk factors and aetiology The causes of most of the diseases of the lymphatic system are not known, but the following factors have been found to be involved: • Viral infections. A number of viruses are believed to be involved in cancers of the lymphatic system. • Immunodeficiency. About one in three people with Aids develop lymphoma, because of immunodeficiency rather than any direct effect of the HI virus. • Immunosuppressive medication after organ transplants increases the risk for lymphoma. • Regular exposure to hazardous substances such as pesticides and weed killers appears to increase the risk of contracting lymphoma. • Exposure to high doses of radioactive irradiation and the use of certain chemotherapeutic drugs. • Gender. Lymphoma is more common among males than females. • Previous history of treatment for lymphoma runs an above-average risk of contracting a different form of the disease. • Heredity. Those with a family history are at increased risk. No connection has been found between lifestyle, diet and the occurrence of lymphatic cancers.

Pathophysiology The blockage of the lymphatic system, tumours, autoimmune diseases and immunodeficiency cause disorders of the lymphatic system and associated organs resulting in swelling that can be acute or chronic.

Nursing assessment and common findings Obtain focused subjective and objective data in order to identify the problem. Always commence the assessment by establishing the presenting complaint and its duration. The final diagnosis is usually the summary of the subjective and objective data based on the chief complaint.

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The presenting complaint. The presenting complaint, such as swelling, should be accompanied by enquiry into its duration and location. Swelling of the limbs related to a dependent position which is relieved by elevation, may confirm interruption of lymph drainage. However, always exclude other causes of swelling, such as heart failure, renal disease and peripheral vascular problems. The patient may also present with the general malaise, fatigue, fever and jaundice. Previous illnesses and treatment of lymphatic cancer and viral infections. A history of serious or acute infection and trauma must be considered, because these may alter the properties of some cells. Trauma, surgery, radiotherapy or malignancy to the limbs can result in the interruption of the lymphatic flow and drainage. Family history of lymphoma and other diseases of the lymphatic system should also be established.

Objective data A review of all the systems should be done through inspection, palpation, percussion and auscultation. Examine the patient as follows: • The skin and mucous membranes should be inspected for colour and swelling. • The lymph nodes should be inspected and palpated for any enlargement. If palpable, the location, symmetry and distribution of enlargement, size, consistency, mobility and tenderness should be established. • The liver and spleen should be palpated to check for enlargement. • The respiratory system should be assessed for dyspnoea due to airway obstruction by enlarged lymph nodes.

Diagnostic studies Lymph nodes biopsy. For this procedure, a piece of tissue from the lymph nodes or a whole lymph node is surgically removed and examined for the presence of abnormal cells. The specimen can be collected by means of needle aspiration, incisional or excisional biopsy and may be collected from the cervical, supraclavicular or axillary lymph nodes.

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Radiological studies Through lymphangiography the lymphatic system can be visualised to assess obstructions and malignancy. Lymphoscintigraphy. This is a test that involves injecting a tracer dye into lymph vessels and then observing the flow of fluid using imaging technologies. It can illustrate blockages in lymph flow. CT or MRI scans. These may be useful to help define lymph node architecture or to identify tumours or other abnormalities.

Specific conditions Lymphadenitis and lymphangitis These are inflammatory conditions, usually caused by infections. Lymphadenitis is characterised by one or more swollen lymph glands, sometimes far from the source of infection. For example, an injury to the leg may cause swelling of the lymph glands in the groin. The main feature is swelling of the affected body part if the lymph is unable to pass through the swollen glands. Although it is painful, it helps to prevent the spread of the infection. Inflammation of the tonsils or adenoids is a form of lymphadenitis. Lymphadenitis is usually treated with antibiotics. Once an abscess has formed, it has to be drained by a doctor.

Nursing alert! Lymphadenitis in more than one part of the body, for example in both armpits and the groin, is usually a symptom of an infectious disease such as tuberculosis, mononucleosis and syphilis. One or more chronically swollen lymph nodes could indicate cancer, and should be examined by a doctor. Lymphangitis is defined as inflammation of the lymph vessels caused by bacterial infections. It is characterised by typical red streaks that follow the course of the infected and inflamed blood vessel and extend to the lymph nodes. The signs and symptoms of lymphangitis include: • Red streaks from the source of infection to the lymph nodes • Swollen, enlarged lymph nodes • Pain and swelling of the affected area • Elephantiasis.

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It is treated by antibiotics such as dicloxallin, ampicillin, vancomycin and erythromycin. To reduce oedema, the affected limb should be elevated and compression bandages applied.

Lymphoedema Lymphoedema is a condition characterised by swelling in one or more extremities that result from impaired flow of the lymphatic system. The two types of lymphoedema are primary lymphoedema (congenital) and secondary lymphoedema. The causes of secondary lymphoedema include: • Excision of blocks of tissue rich in lymph nodes during an operation on an armpit or groin. For example, following a total mastectomy when not only the breast, but also the adjacent lymph nodes are removed, women often experience swelling of the arm on the affected side. • Trauma, burns, radiation or compression of lymph nodes by tumours. • Elephantiasis, which is a tropical disease, also endemic in warmer parts of South Africa. It is caused by the parasite Wuchereria bancrofti. The disease is spread among people by mosquitoes. The infestation by the parasite damages the lymph system, leading to swelling in the arms, breasts, legs, and, for men, the genital area. The entire leg, arm, or genital area may swell to several times its normal size. Also, the swelling and the decreased function of the lymph system make it difficult for the body to fight infections. • Genetic disorders. Meige disease is a congenital lymphoedema. Symptoms usually appear during or after puberty and affect both the upper and lower body. Some forms of hereditary lymphoedema may occur along with other symptoms.

Diagnosis History is obtained and physical examination performed to rule out other causes of limb swelling, such as oedema due to congestive heart failure, kidney failure, blood clots, or other conditions. Often, the medical history of surgery or other conditions involving the lymph nodes will point to the cause and establish the diagnosis of lymphoedema. If the cause of swelling is not clear, other diagnostic tests can be done to determine the cause of limb swelling. They include CT or MRI scans, lymphoscintigraphy and Doppler ultrasound scans, whereby sound wave tests are used to evaluate blood flow, and can help identify blood clot in the veins that may be a cause of limb swelling.

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Skin care and prevention of infection Taking good care of the skin is important, because it will reduce the risk of developing an infection, such as cellulitis. Use of moisturising creams may be helpful in preventing drying out of the skin. Remedial exercises are designed to strengthen the muscles that are involved in lymph drainage. A personalised exercise plan to the patient’s requirements and ability is recommended.

Lymphangiectasia Lymphangiectasia or lymphangioma is dilatation of the lymphatic vessels caused by lymphatic damage and scarring, resulting in obstruction of local lymph drainage.

Oedema

Pathophysiology

Oedema

Figure 37.4 Lymphoedema

Treatment Lymphoedema cannot be cured, but it can be controlled with: • Diuretic therapy • Wrapping the affected part in an elastic bandage to prevent further swelling • In the case of elephantiasis, deworming with diethylcarbamazine should prevent further complications if the condition is diagnosed and treated early • Surgery plays a limited role in the management of lymphoedema. In some cases, a surgical procedure using liposuction (where a tube is used to suck fat out of tissue) can be used to treat lymphoedema. Liposuction is used to remove excess fat from the affected limb to help reduce the swelling. Once the surgery is complete, the patient will have to wear a compression garment on the affected limb for at least a year.

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The pathophysiology of lymphangiectasia is not known, but the vesicles associated with lymphangiectasia are thought to represent saccular dilations of local superficial lymphatics. These vesicles develop secondary to increased intralymphatic pressure as a result of a build-up of lymph in the superficial vessels caused by damage to previously normal deep lymphatics. This mechanism explains the accompanying lymphoedema seen in most patients with lymphangiectasia. The lymphoedema usually arises as a result of obstructed lymphatic drainage after mastectomy, radiation therapy, or tumour mass compression. Lymphangiectasia may also result from abnormal dermal structure and function.

Clinical manifestations There are fluid-filled vesicles in a chronic lymphoedematous area several years after surgery, more commonly due to a malignancy. The lesions of lymphangiectasia can range from clear, fluid-filled blisters to smooth, flesh-coloured nodules, often appearing along an incision. Lymphangiectasia consists of clusters of translucent, thick-walled, fluidfilled vesicles. Conjunctival lymphangiectasis may be evident as intermittent conjunctival swelling and dilated conjunctival vessels. Lymphoedema is a common physical finding in patients with acquired lymphangioma. Pain and recurrent cellulitis are complications associated with lymphangiectasia.

Treatment It is important to minimise the risk of ruptured vesicles because they may provide a portal of entry for infection and subsequent cellulitis. To prevent infection, the affected area should be cleaned daily with topical antibacterial agents, and applying mupirocin ointment or silver sulfadiazine cream as per doctor’s prescription.

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Surgical treatment modalities advocated in the care of lymphangiectases include laser therapy, sclerotherapy, cryotherapy, and surgical excision. Daily compression through bandaging or hosiery in accessible areas provides relief.

Lymphoma Lymphoma is cancer of the lymphoid tissue, such as the thymus glands, lymph nodes, spleen, liver and bone marrow. Original cell divides uncontrollably, and the cancer usually spreads to other lymph nodes first before radiating to organs outside the lymphatic system. The rate at which it spreads depends on the type of lymphoma, the sufferer’s response to the disease, and the duration of the illness.

Symptoms of lymphoma • • • • • •

Painless swelling of one or more lymph glands Fever Night sweats Weight loss Loss of appetite Fatigue and chronic itching of the skin.

Later tumours may spread to organ systems outside the lymphatic system. Lymphomas range from slow-growing neoplasm to aggressive cancers that rapidly spread through the body. The involvement of the lymph glands and lymphocytes is an important feature of many types of leukaemia. Lymphomas are classified as Hodgkin’s and nonHodgkin’s depending on the type of the cell involved.

Hodgkin’s disease Hodgkin’s disease is a malignant disorder that affects the lymph nodes of the lymphatic system. It is characterised by an abnormal proliferation of lymphocytes. Men are more affected than women and the peak incidence is in the early 20s and 50s.

Causes The cause of the Hodgkin’s disease is not known, but Epstein-Barr virus has been implicated. Genetic predisposition has also been implicated.

Clinical manifestations Hodgkin’s disease starts as a painless enlargement of the lymph nodes observed on one side of the neck. Later the lymph nodes in other regions enlarge, such as the other side of the neck, mediastinal and retroperitoneal.

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The manifestations of Hodgkin’s disease are related to the pressure the enlarged nodes exert on various parts of the body, and include: • Breathing and swallowing problems due to pressure on the trachea and oesophagus, respectively • Oedema of the extremities, pleural and peritoneal effusion resulting from pressure on the veins • Laryngeal paralysis due to pressure on nerves • Jaundice related to bile duct obstruction caused by enlarged nodes • Paralysis due to spinal cord compression • Urinary retention as a result of obstruction of the ureters by enlarged nodes. Other manifestations include hepatomegaly, splenomegaly, fever, weight loss, pruritus, anaemia and cachexia.

Diagnostic studies • Biopsy: the presence of a gigantic atypical cell tumour (Reed-Sternberg cell) confirms Hodgkin’s disease • FBC and ESR to determine the involvement of the cardiovascular system • Bone marrow biopsy, scans of the liver and spleen, and X-rays of the bones to determine the extent to which these organs are involved.

Management The treatment depends on the extent of the disease, which is determined by staging. The treatment includes radiation therapy and chemotherapy. For nursing care of patients on radiation and chemotherapy, refer to Chapter 17.

Non-Hodgkin’s disease Non-Hodgkin’s disease refers to malignancies affecting the lymphoid tissue, other than those affected in Hodgkin’s disease. The cause is unknown, but the contributory factors include viral infections and immune deficiency related to treatment for organ transplant and Aids. The manifestations are the same as for Hodgkin’s disease, except that when it is diagnosed, it is more likely to have already spread. Chemotherapy is the management of choice.

Conclusion Most conditions of the lymphatic system affect the appearance of the patient, which inevitably will have a negative effect on the self-image and dignity of the patient. The nurse has a duty to educate the patient about the condition, about care of the oedematous areas and the use of compression bandages where applicable.

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Suggested activities for learners Activity 37.1 1. The lymphatic system consists of: a) lymphatic vessels and lymphoid organs b) all of the plasma component of the bloodstream c) all fluids inside the body’s cells d) all liquids in the body whether inside cells or in spaces between tissues 2. Which of the following is not a lymphoid organ? a) adenoids b) spleen c) tonsils d) kidney 3. Lymphoedema typically involves the foot. • True • False 4. Erythematous streak is a typical early sign of lymphangitis. • True • False 5. Tissue fluid in the lymphatic system is called plasma. • True • False Activity 37.2 Draw up a nursing care plan for a patient with lymphoedema, with specific focus on swelling and risk for altered self-image.

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38

Introduction to the disorders of the gastrointestinal system

learning objectives

On completion of this Chapter, the learner should be able to: • describe the aetiology, pathophysiology, clinical manifestation, therapeutic and pharmacological interventions in patients presenting with the disorders of the gastrointestinal system • perform accurate assessment of patients suffering from the disorders of the gastrointestinal system • interpret the assessment data including the results of diagnostic tests in patients suffering from conditions of the gastrointestinal system • design a care plan for patients presenting with the disorders of the gastrointestinal system. key concepts and terminology

absorption

A process whereby digested nutrients from the stomach and intestines is taken into the body via the bloodstream in readiness for further uptake into the tissues.

amylase

Carbohydrate-splitting enzyme found in the mouth (salivary amylase) and in the pancreas (pancreatic amylase).

anus

The outlet at the end of the rectum and also at the end of the digestive tract.

caecostomy

A surgical opening through the abdominal wall into the caecum to allow for passage of bowel contents in cases where this cannot be affected through the large intestine due to trauma.

choledochojejunostomy

Opening between common bile duct and jejunum.

chyle

Emulsified fats in the lymph vessels after a fatty meal.

chyme

A semi-liquid mass of food mixed with saliva, mucus, salivary and gastric enzymes and gastric juices which passes from the stomach to the intestines.

colostomy

Opening into the colon to allow temporary or permanent drainage of bowel contents.

digestion

The process by which food mixes with saliva, mucus, digestive enzymes and gastric secretions, and is broken down into small components/molecules which can be absorbed into the body.

diverticulitis

Inflammation of a diverticulum resulting in abscess formation.

diverticulum

A scale-like outpouching of the lining of the bowel or oesophagus.

dysphagia

Difficulty in swallowing.

elimination

The process that occurs after digestion and absorption when waste products are removed from the body.

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endoscopy

An examination of the inside of a body cavity using an illuminating flexible tube.

enzyme

A chemical catalyst that facilitates chemical reactions and changes, without itself undergoing any change.

fibroscopy

Intubation of a part of the gastrointestinal tract with a flexible illuminating tube to assist in the visualisation, diagnosis and treatment of diseases of that area.

glossectomy

Removal of the tongue.

hemiglossectomy

Partial removal of the tongue.

hydrochloric acid

An acid found in the gastric juices, secreted by the glands in the stomach. The acid mixes with chyme to render it acidic while in the stomach for optimum functioning of gastric juices and digestive enzymes.

ingestion

The act of taking food into the gastrointestinal tract via the mouth or oesophagus.

intrinsic factor

A protein that is produced in the gastric glands and combines with vitamin B12 to aid in the absorption of the vitamin, and which, if lacking, causes pernicious anaemia.

lipase

An enzyme also called lipolytic enzyme, which breaks down fats in the intestine.

odynophagia

Acute pain on swallowing.

pepsin

An enzyme in the stomach which breaks down the proteins in food to peptones.

pepsinogen

A secretion from the gastric glands, which is the inactive form of pepsin.

peptidase

An enzyme which breaks down proteins in the intestine into amino acids.

peptide

A compound formed of two or more amino acids.

peptone

A substance produced by the action of pepsin on proteins in the food.

pyloroplasty

Repair of the pyloric sphincter area.

pyrosis

Chest pain and heartburn.

vagotomy

Resection of a portion of the vagus nerve.

prerequisite knowledge

• The scientific approach to nursing • Anatomy and physiology of the gastrointestinal system and that of the accessories organs to the system • Biochemistry and biophysics applied to nursing. medico-legal considerations

The gastrointestinal system is the channel through which nutrients are received, digested and absorbed to sustain the body activities. The nurse, in the case of patients who are not able to do this themselves, has to assist the patient in a way that food is delivered to the system safely. A nasogastric tube is usually inserted to feed patients who are unable to feed themselves. The insertion has to be safe and follow the correct route. The risk of it going into the trachea is high, especially in those patients whose coughing reflex is suppressed. The danger is the flooding of the lungs if the tube is in the respiratory tract and not in the stomach resulting in drowning. The insertion has to be done correctly and before any fluid or feed can be introduced through the tube, the nurse has

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to test the position of the tube by aspirating the contents which, if in the stomach should turn the blue litmus paper red. Failure to test the position of the tube and aspiration thereafter constitutes a medico-legal hazard. Another medico-legal hazard is failure to provide nutrition to patients who cannot meet the nutrition need such as the unconscious patients, small babies and children. ethical considerations

Providing nutrition is a basic need and nutrients are also therapeutic. In providing nursing care nutrition becomes the essence of care. Those patients who are not able to meet this need must be assisted by manually feeding them or providing enteral or parenteral feeding. essential health literacy

Food and food intake is a basic need for survival. It is imperative that people know about the importance of food and how the food becomes accessible to their bodies. They must know about the gastrointestinal system and factors that enhance or inhibit its function. They must know about the gastric juices that enhance digestion such as hydrochloric acid so that they do not induce early morning vomiting or take purgatives or give an enema to induce diarrhoea to clean the gut. Gastrointestinal irritants are likely to cause diarrhoea and vomiting. These conditions will interfere with the digestion and absorption of adequate nutrients including medication. Food that is contaminated or too high in roughage is likely to cause gastric irritation. To keep the gastric mucosa healthy and highly absorbent, people must eat fresh and clean (hygienic) food, take in enough fibre from fruits and vegetables, and drink enough water if allowed. People also need to know that diarrhoea, nausea, anorexia and vomiting are the signs which denote that there is something wrong with the gastrointestinal system and can also be indicative of some diseases in the body, such as raised intracranial pressure (vomiting). Of importance is that diarrhoea and vomiting are the major causes of dehydration, especially in children and in the aged. The management involves resting the gut but not in relation to fluids which must be taken in line with the diarrhoea and/or vomiting experienced. Every person must know how to prepare rehydration solution to give to someone with diarrhoea and/or vomiting. The rehydration solution is prepared as follows: 1 ℓ of boiled (and cooled) water, ½ teaspoon of salt and 8 teaspoons of sugar; and, where available, orange juice to improve the flavour.

Introduction The gastrointestinal system is composed of two parts, that is, the gastrointestinal tract which is also known as the digestive tract or the alimentary tract; and the associated accessory organs of digestion, composed of the liver, biliary tract and the pancreas. The purpose of this Chapter is to introduce you to the gastrointestinal system. The conditions related to the gastrointestinal tract and the accessory organs of digestion will be discussed in Chapters 39–41.

Overview of the anatomy and physiology of the gastrointestinal system The gastrointestinal tract (GIT) is a hollow muscular tube that extends from the mouth to the anus. The structures involved are the mouth and teeth, oropharynx, oesophagus, the stomach, small intestines (duodenum, jejunum and ileum), large intestines (colon), rectum and anus. The mouth is a cavity that extends from the lips in the front, and to the oropharynx in the back. The roof of the mouth is made up of the hard and soft palates and the arch

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of the upper teeth; and its floor is made up of the tongue and the arch of the lower teeth. The sides of the mouth are closed by the cheeks and the rami branches of the left and right mandibles. The space between the lips and the teeth is the vestibule of the mouth and the rest is referred to as the buccal cavity. The submandibular salivary gland is found along the lower border of the mandible, while the sublingual salivary gland lies under the front part of the tongue along the floor of the mouth. The parotid gland is situated at the back of the tongue. The oropharynx is the opening to the pharynx, and provides a passage to both food and air for respiration, as it posteriorly opens into the back of the nose as nasopharynx. The pharynx continues from below as the oesophagus behind the laryngopharynx. The laryngopharynx has an epiglottis and forms the topmost part of the larynx. The larynx, in turn, continues as the trachea. The oesophagus is a collapsible 25–30 cm long tube which lies behind the trachea, in front of the vertebral column, and extends from the pharynx to the stomach. It traverses the thoracic cavity and pierces the diaphragm to enter the abdominal cavity. The inlet of the oesophagus into the stomach

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has a sphincter, namely, the cardiac sphincter which prevents the reflux of food from the stomach back into the oesophagus. The stomach is the j-shaped dilated portion of the GIT between the oesophagus and the small intestines. It has a lesser and greater curvatures and has three parts which are from the oesophogeal junction, the fundus, the body and the pyloric portion with the pyloric antrum. Circular smooth muscles in the wall of the pyloric antrum form the pyloric sphincter which prevents chyme from the small intestines flowing back into the stomach once this has left the stomach. The stomach has specially arranged muscular layers to ensure strong contractions, that is, the outer longitudinal muscular layer, intermediate circular layer and an inner oblique muscle layer. These muscular layers are covered on the outside by a serous layer; while on the inside are the submucous layer and a rugous mucous layer. Its musculature ensures specific peristalsis that churns and pushes its contents forwards to the intestines. The intestines, also called the bowels consist of the small and large intestines. The small intestine extends from the pyloric antrum to the caecum and is divided into the duodenum, jejunum and ileum. The duodenum forms the first part of the small intestine and bears the common opening from the pancreas and the biliary tree for the passage of bile and pancreatic juices, including enzymes into the GIT to assist with digestion. The mucous membrane of the small intestine is marked by rugae which serve to increase the absorptive surface area. The large intestine, commonly known as the colon, extends from the caecum through to the rectum and anus. The caecum has a worm-like extension called the appendix. The appendix rests in the iliac fossa, while the body continues as the large colon. From the caecum, the large intestine forms the ascending colon that proceeds upwards to the inferior surface of the liver where it makes a bend called the right hepatic flexure, to form the transverse colon. The transverse colon makes another bend below the spleen, called the left splenic flexure, to form the descending colon and the sigmoid, rectum and anus. Whereas the other parts are in the abdomen, the sigmoid, rectum and anus are in the pelvic cavity. The pancreas is situated behind and under the stomach, and attached to the duodenum by a common duct with the biliary tree. It is an essential organ responsible for the major activities of digestion, and together with the liver, the biliary system and the gastrointestinal tract are responsible for chemical digestion of food and absorption of nutrients.

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The gastrointestinal tract is composed of four layers, namely, the innermost layer called the mucosa, the submucosa that is beneath the mucosa, the muscular layer and the connective tissue serosa layer. The muscular layer is varied and modified according to function as is the case with the stomach.

Tongue

Mouth Pharynx Oesophagus

Liver Gallbladder Large intestine Rectum

Stomach Pancreas Small intestine Anus

Figure 38.1  Organs of the gastrointestinal system

The functions of the gastrointestinal system The function of the gastrointestinal system is to provide nutrients to the body cells so that the organism can grow and develop. Through the gastrointestinal system the nutrients are broken down by mechanical and chemical digestion. The nutrients are then made accessible to the body through absorption into the bloodstream in order to build and repair cells and tissues, and provide energy for cellular activities. Undigested food particles are eliminated as faeces. The substances secreted to effect digestion, absorption, metabolism and elimination are the saliva, mucus, enzymes, hormones, gastric juices and bile. Enzymes are protein catalysts that accelerate chemical reactions without themselves undergoing any change. Enzymes are reaction-specific and function best within optimum pH and temperature. In digestion, specific enzymes break down specific food components, which mean that there are specific enzymes to break down proteins, carbohydrates

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or fats at particular levels in the digestive tract (see Table 38.1). The mouth secretes saliva which is composed of water, mucus and a carbohydrate splitting enzyme called salivary amylase/ptyalin. In the mouth, food is chewed and mixed with saliva and mucus rendering the mixture alkaline to enable the enzyme ptyalin to start breaking down carbohydrates. The semifluid bolus of food is swallowed through the oropharynx, down the oesophagus into the stomach past the cardiac sphincter. The action of ptyalin is stopped in the stomach where the gastric juices containing acid and other enzymes, pepsin and rennin, are activated to start on the digestion of proteins. Pepsin is a derivative of pepsinogen, while rennin is specifically for children to coagulate milk protein in the stomach and prevent rapid passage thereof (see Table 38.1). The digestion of carbohydrates, proteins and fats is continued in the small intestine (see Table 38.1).

Regulation of chemical digestion The secretion of the digestive chemicals and the functioning of the gastrointestinal system are intricate. These are regulated by the central nervous system which controls gastric secretions; and the endocrine system

which controls hormones involved in digestion. Gastric secretions occur in three phases, namely, cephalic, gastric and intestinal phases. The cephalic phase is the response of the nervous system in the hypothalamus to hunger which stimulates the appetite at the thought, sight, smell and taste of food. The hypothalamus via the vagus nerve sends impulses, whereby the person will salivate and stimulate the secretion of gastrin, which in turn stimulates the secretion of gastric juices (hydrochloric acid) and digestive enzymes (pepsin, rennin and lipase) and stimulate peristaltic movement in the gut. The gastric phase is characterised by the secretion of gastric juices; and is further increased by the distension of the abdominal wall as the bulk of food enters the stomach. It happens in the local mesenteric where secretory stimuli, vagal reflexes and gastrin stimulation occur. The intestinal phase involves the nervous and hormonal mechanisms and is marked by the continued secretion of the gastric juices long after the chyme has left the stomach. The acidic chyme is neutralised and made alkaline by bile and pancreatic juices in the first part of the duodenum.

Table 38.1  Digestion in the gastrointestinal tract

Level in the GIT

Food characteristic

Enzyme description and function

Mouth

• Chewed food mixed with saliva • Alkali in reaction

• Ptyalin (salivary amylase) breaks down starch into maltose and carbohydrates but in a small scale

Stomach

• Chewed food continues to mix with gastric juices, eg hydrochloric acid, water, mucus, and it is further churned to a paste referred to as chyme • The mixture is acidic in reaction

• The activity of the salivary amylase is inhibited by the acidic medium; pepsinogen is activated to pepsin in the presence of the hydrochloric acid; pepsin breaks proteins into polypeptides • Rennin is an enzyme in children to coagulate milk to form curds to delay the passage through the stomach and allow pepsin to partially break down milk protein • Gastric lipase to a limited extent also breaks down fats

Small intestines

• Bile and pancreatic juices mix with the acidic chyme to render it alkaline again

• The action of the enzymes in the stomach is inhibited by the alkaline environment in the intestines as a result of among others, bile, salts and pancreatic juices • Trypsin and chymotrypsin break down proteins, pancreatic lipase breaks down fats and pancreatic amylase breaks down carbohydrates

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Vagul centre of medulla Food

Afferent fibres Vagus trunk Small bowel

Cephalic phase via vagus Gastric phase Circulatory system Intestinal phase

Figure 38.2 The phases of gastric secretion and their regulation

Classification of disorders of the gastrointestinal system The disorders of the gastrointestinal system are classified according to the regions of the alimentary tract as indicated in Table 38.2.

Risk factors related to the disorders of the gastrointestinal system Mechanical and chemical irritation to the mucosal lining. Chemical irritants include alcohol, tobacco, betel nut, spicy food and mouth infections from poor oral hygiene. People using these are at a great risk of developing oral cancer. Mechanical irritants are sharp edges of broken teeth, dental occlusions or other prosthesis. Diet. Food can be a form of an irritant. Apart from spicy food, people can be allergic to certain foods such as fish or nuts. Individuals can also have intolerance as is the case with lactose in milk, or may develop disorders such as diarrhoea due to changes in eating patterns, or irregular food intake in terms of time and amount. Food low in fibre can predispose an individual to constipation. Fatigue and emotional stress. Fatigue and emotional stress may result in the malfunctioning of the gastrointestinal tract. During periods of anxiety or grief the gastrointestinal tract has been shown to: • produce strong non-propulsive contractions of the colon resulting in constipation • decrease secretion of saliva resulting in dryness in the mouth and offensive breath • decrease mucus secretion, thus exposing the gastric mucosa to irritation and erosion • increase the acid secretion in the stomach resulting in ulceration of the mucosa.

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Table 38.2 Classification of disorders of the gastrointestinal system

Gastrointestinal tract

Accessory organs of digestion

Upper GIT • Mouth/Oral • Oesophagus • Stomach and duodenum

• Liver • Pancreas • Biliary tract

Lower GIT • Intestines (small and large) • Rectum • Peritoneum • Anus Drugs. Certain drugs, particularly non-steroidal antiinflammatory drugs such as aspirin and ibuprofen may cause erosion and ulcers in the stomach, especially in the elderly, or when taken on an empty stomach. Some antibiotics may destroy the normal flora of the gut resulting in diarrhoea. Critical illness. Critical illnesses such as burns or trauma may cause stress ulcers. Anxiety. Anxiety may result from lack of knowledge about the disease process. Patients may present with psychological problems such as depression and withdrawal.

Nursing assessment and common findings Subjective data

In the disorders of the gastrointestinal system the history is related to food intake and elimination. The history includes issues of: Eating pattern/appetite. Questions that should be asked include the eating pattern, if the patient is eating well and regularly; food preference; allergies or intolerances such as lactose intolerance; presence of nausea and when is this most noticed, incidents that can be linked to this, such as sight of food, smell or after food intake, type of food, any pain experienced, eg colic, and what makes the pain better or worse; vomiting, and if so, when does vomiting occur, whether vomiting is related to food, whether vomiting is related to colic, what triggers vomiting, the type of vomiting, if it is projectile, and the composition of the vomitus.

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Elimination patterns. Information about bowel habits should be obtained. This includes regularity of bowel action, diarrhoea or constipation, relationship of defecation to food or pain experienced. Stool. Characteristics of stool in relation to colour, shape, composition and nature (see Chapter 7). Nutrition. Nutritional status in relation to food intake, elimination, nausea and vomiting. The nurse must find out whether there has been weight gain, weight loss or a stable weight. Health history. An assessment of the patient’s past health history that includes past and current use of medication, surgery or other treatments as well as functional health patterns related to the gastrointestinal system, such as, elimination patterns, indigestion, flatulence, nausea, vomiting, change in bowel habits and stool characteristics, any unexplained weight loss or weight gain, intolerance or allergies to food. General information. Other information would relate to activity, sleep, rest and stressors. Medication. The patient should also reveal information on the use of non-steroidal anti-inflammatory drugs or antacids including the frequency and duration of usage. Use of over-the-counter and appetite suppressant medication should also be noted. Medical history. Data related to any hospitalisation and gastrointestinal surgery should be obtained, including any blood transfusions.

Objective data Physical appearance. The patient should be inspected for height, weight, gait and general appearance. The mouth and oropharynx. The various structures forming the mouth, which are the lips, tongue, teeth, gums, and mucous membrane should be inspected and examined individually for symmetry, colour and size. For example, the lips should be inspected and palpated for swelling, nodules, cracks, ulcers or fissures, pallor or cyanosis. The tongue should be inspected for colour, fissures, shape, texture and growths. The buccal mucosa should be inspected for areas of pigmentation or any lesions. The teeth should be observed for caries, fit (whether loose or not), abnormal shape and position. The gums should be inspected for swelling, bleeding, discolouration and inflammation. Note also the breath odour.

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To inspect the pharynx, the patient’s head should be tilted back, the tongue depressed with a tongue depressor, and a light shone to the back of the throat. To facilitate further inspection of the pharynx, the patient should be asked to say ‘ah’ for clear visualisation of the uvula, soft palate, tonsils and the anterior and posterior pillars. Ulcers, nodules, indurations and areas of tenderness should be observed and palpated if necessary. The ability to swallow should also be established by stimulating the soft palate with a tongue depressor, and the patient instructed to initiate swallowing movements to test for a gag reflex.

Practice alert! Dentures must be removed during oral examination.

Abdomen. The abdomen is divided into four abdominal quadrants or nine regions for the purpose of identifying positions of abdominal organs. The patient should be placed in a supine position with both knees slightly flexed and the head slightly raised on a pillow. The patient must be relaxed, and should breathe slowly through the mouth. All four examination techniques should be used on the abdomen, namely, inspection, palpation, auscultation and percussion. Inspection and auscultation must preferably be done before palpation and percussion because the latter two techniques may alter the character of the bowel sounds.

Practice alert! The bladder must be emptied before abdominal examination; and the examiner must warm their hands before touching the abdomen to promote relaxation of abdominal muscles.

Inspection. The abdomen should be inspected for symmetry and contours. Assess whether it is flat, rounded, convex, concave, has protuberances, or is distended. Look for signs of obvious masses such as hernias, skin changes such as colour, texture, scars, striae, dilated veins, rashes and lesions. Assess the umbilicus for position and condition, and intestines for movement such as peristalsis and pulsations. For example, the abdomen may be distended, while the abdominal aortic aneurysm may pulsate in the epigastric region. Peristalsis may be visible in emaciation, dehydration or extreme obstruction, for example in pyloric stenosis in children.

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Auscultation. Use the diaphragm of the stethoscope to listen to bowel sounds. Warm the stethoscope to promote relaxation of the abdominal muscles. Auscultation should be done on the four quadrants to listen to bowel and vascular sounds. The intensity and frequency of bowel sounds varies with the phase of digestion and tension of the intestines. Bowel sounds may be described as present, absent, diminished or increased. Loud gurgles of bowel sounds indicate exaggerated peristalsis called borborygmi and may be caused by intestinal obstruction. High pitched, tinkling, gurgling and rushing sounds are usually associated with hyperperistalsis. Vascular sounds would be heard with aortic aneurysms and are best heard with the bell of the stethoscope. These can be described as bruit, which is a swishing sound indicating turbulent blood flow in a blood vessel with altered contours such as dilation or narrowing. Percussion. Percussion of the abdomen establishes the presence of fluid, air and masses. Sounds produced on percussion depend on the density of the underlying tissue, for example because air is less dense, it produces a highpitched hollow sound called tympany, while dense fluid or masses produce a dull sound, which can be described as a short high-pitched sound with little resonance. All four quadrants must be percussed to elicit the distribution of the dullness or tympany. A dense liver will always give a dull sound on percussion in the right upper quadrant. Palpation. Palpation may be light, moderate or deep. It is necessary to start with light palpation to promote relaxation for deeper palpation. Light palpation is used to detect tenderness, hypersensitivity of the skin, muscular resistance, masses and swelling. The abdominal wall should be compressed lightly to a depth of about 1 cm with fingers kept together. All quadrants should be palpated. With moderate palpation, the fingers exert firmer pressure to detect tenderness that may have been missed from lighter palpation. Deep palpation is performed to isolate or locate abdominal organs and deeper masses. During palpation the examiner must note the location, size, shape, mobility and texture of organs and the presence of tenderness. Deep palpation for the presence of tenderness can be performed with one or both hands placed one above the other. Rebound tenderness may also be palpated by applying firm pressure over the painful site and quickly withdrawing fingers.

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38.1 Organs within abdominal quadrants Anatomical location of organs within each abdominal quadrant are as follows: Right Upper Quadrant (RUQ): Liver, gall bladder, duodenum, right kidney and hepatic flexure of the colon Right Lower Quadrant (RLQ): Caecum, appendix, left ovary and fallopian tube Left Upper Quadrant (LUQ): Stomach, spleen, left kidney, pancreas and splenic flexure of the colon Left Lower Quadrant (LLQ): Sigmoid colon, right ovary and fallopian tube.

The rectum, anus and perianal area. The rectum, anus and perianal area should be inspected for colour, texture, lumps, rashes, excoriations, fissures and external haemorrhoids. To do a rectal examination, the nurse must wear gloves and the patient must be relaxed. The examination can reveal nodules, tenderness and any other irregularities. Pain. The presence of pain must be explored. The location and type of pain can be identified by palpation, while the intensity can be observed from position, facial expression, gait and verbal expression by the patient.

Diagnostic procedures • Laboratory tests such as routine blood tests, abdominal aspirates and stools. • Radiological studies such as X-rays with or without contrast media, eg ultrasound, CT scans, and barium swallow and enema. A barium swallow can be tracked down the length of the gastrointestinal tract. • Endoscopic studies. The gastrointestinal tract can be visualised through the fibreoptic scope. The visualisation includes laryngoscopy, oesophagoscopy, oesophagogastro-duodenoscopy, fibreoptic colonoscopy, anoscopy, protoscopy and sigmoidoscopy. The nurse has a major responsibility in the preparation of the patient for the different procedures, and also nursing care after the procedures. See Table 38.3 for the role of the nurse in preparing for the different diagnostic procedures.

Clinical alert! Information relating to allergies must be obtained from the patient as some individuals may react to the contrast medium. Strict post-test observations must be done as recommended.

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Common signs and symptoms in the disorders of the gastrointestinal system (Some of these are discussed in Chapter 14) Clinical presentations of the gastrointestinal tract dysfunction are related to an increase in gastric secretions which erode the gastric mucosa and motility as evidenced by increased or decreased peristalsis resulting in either diarrhoea or constipation. The most common symptoms are the following: Anorexia. This is a loss of appetite and is a general sign that accompanies many other systemic disorders. It may

be caused by medication or it may be functional in origin resulting from emotional disturbances. Anorexia may be accompanied by revulsion to certain food smells. In cases where the stomach empties slowly or where there is gastric stasis because of a gastric disorder, anorexia may be due to a feeling of fullness. Intestinal gas or flatulence. This is accumulation of intestinal gas due to swallowed air, ingestion of gasforming foods such as cabbage and onions, abnormal fermentation of food in the stomach caused by bacteria, indigestion or obstruction where the intestinal contents

Table 38.3  The responsibilities of the nurse in diagnostic procedures

Radiological studies • X-ray • Barium swallow • Barium enema Description

• Provides an outline of the inside of the gastrointestinal tract as evidenced by the contrast media used in the barium swallow or enema • X-rays show the general shadows, fluid levels and gas. X-rays are taken in different positions and allow for identification of abnormalities in the anatomy and physiology of the upper GIT • The contrast medium in the barium swallow or enema enables the visualisation of the inside of the gastrointestinal tract; the contrast medium is a radiopaque, tasteless, odourless smooth and a completely insoluble substance which is swallowed by the patient for a series of fluoroscopic X-rays to be taken. With a barium enema, X-rays are taken to detect the rate of elimination of the barium and that enables the determination of the efficiency of emptying at different levels of the alimentary tract

Indication/s

• Allow for identification of abnormalities in the anatomy and physiology of the upper GIT such as oesophageal strictures, varices, polyps, tumours, hiatal hernias, lesions, inflammatory bowel diseases and malabsorption syndromes including ulcers of the stomach

Responsibilities of the nurse

• Advise the patient to have low-residue diet several days before the procedure • Withhold meals after midnight on the day before the test • Withhold cigarettes and drugs • Give the barium meal in an empty stomach • An enema need not be on an empty bowel • There may be a need to administer a laxative or cleansing enemas as prescribed to facilitate elimination of the contrast medium • Increase fluid intake

Analysis of gastrointestinal tract secretions Description

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• Analysis of small bowel secretions where secretions are collected either during biopsy, scope or through aspiration with calibrated tube to mark certain points in the gastrointestinal tract

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Indication/s

• To diagnose gastric ulcers and pernicious anaemia • Ascertain the presence and amount of digestive enzymes and bile • To diagnose conditions such as colitis, parasitic infestations, infections and rectal bleeding • Mark certain points in the gastrointestinal tract that could be associated with the disease process

Responsibilities of the nurse

• Starve the patient 8–12 hours or after midnight before the procedure • Withhold factors that affect gastric activity such as cigarettes, vitamins B and C and antacids the morning of the procedure • Administer prescribed pre-procedure medication • During the procedure: keep the patient in semi-Fowler’s position • Monitor blood pressure and pulse every 15 minutes because histamine causes vasodilatation and a drop in blood pressure

Faecal analysis Description

• Stools are examined for chemical constituents such as electrolytes (calcium and phosphates), food constituents (carbohydrates, fats, nitrogen and protein), enzymes (such as amylase, lipase and trypsin), bacteria, parasites and overt or occult blood

Indication/s

• To exclude bowel diseases and identify site of bleeding

Responsibilities of the nurse

• Observe the stool for colour, odour, consistency and frequency of defecation • Provide a high-fibre diet 48–72 hours prior stool collection • Administer an enema as prescribed • Avoid red meat, turnips and horseradish, and medicines such as iron preparations, bromides, iodides and Rauwolfia derivatives, for 48–72 hours before test if stool is to determine occult blood

Endoscopies Description

• Direct visualisation of the gastrointestinal tract using an illuminated flexible tube • Upper GIT endoscopy: a tube is inserted through the mouth to visualise the oesophagus, stomach, and duodenum • Lower GIT endoscopy (anoscopy, protoscopy, sigmoidoscopy): a tube is inserted through the anus to visualise the rectum, sigmoid, descending, transverse and ascending colons • Laparascopy: allows for visualisation of the abdominal organs and structures to determine peritoneal disease, abdominal masses, gallbladder and liver disease • Enteroscopy: to control bleeding following a diagnostic test such as a biopsy • Scopes regardless of level of the gastrointestinal tract can be used to obtain tissue specimen (biopsy)

Indication/s

• Identify the source of bleeding • Indicate surface lesions such as inflammatory, neoplastic or infectious processes and healing status of tissues • Remove gallstones from the biliary tract • Dilate strictures • Control GIT bleeding as in oesophageal varices • Treat gastrointestinal neoplasms through laser therapy

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Responsibilities of the nurse

• Starve the patient 6–12 hours before the procedure, especially where general anaesthesia is to be used • Obtain an informed consent from the patient • Administer premedication as prescribed, such as sedation (midazolam) to reduce anxiety and atropine to reduce gastric secretions, glucagon to facilitate smooth muscle relaxation • Position the patient on the side to facilitate drainage of secretions and provide easy access for the endoscope • Maintain a patent airway during the procedure, monitor breathing, breath sounds, oxygen saturation and skin colour • Insert a bite block in the patient’s mouth to prevent biting of the scope • Ensure that the emergency equipment is readily available during the procedure; position the patient in the correct position during and after the procedure • Upper GIT endoscopy: give nothing by mouth 1–2 hours after the procedure and until the gag reflex returns to prevent aspiration • Monitor signs of possible perforation such as abdominal pain, bleeding, abdominal distension, difficulty in swallowing, restlessness, abdominal distension and fever • Provide mouth gargles, lozenges and oral analgesics for throat discomfort if the gag reflex is present • Keep the patient on bed rest if still sedated • Lower GIT endoscopy: give tap water or fleet enema until the return is clear • Place in exaggerated Sims’ position with right leg bent and placed interiorly • Explain to the patient that the pressure of the scope may stimulate an urge for defecation • Collect the specimen or tissue in an appropriate receptacle, label and send to laboratory for analysis immediately • Observe the patient for signs of intestinal perforation such as fever, rectal bleeding, abdominal distension and pain following the procedure

Fibreoptic colonoscopy Description

• To provide direct visualisation of the whole colon up to the caecum using a flexible tube • Video or still recordings can be taken during the procedure

Indication/s

• Diagnostic or therapeutic to evaluate diarrhoea of unknown cause, occult bleeding, anaemia, cancer, polyps, inflammation bowel disease, to remove polyps, control bleeding, dilate strictures and to decompress the bowel • To take a biopsy and cytology brush for the study of tissues and cells respectively

Responsibilities of the nurse

• Restrict oral fluid intake 24–72 hours before examination • Cleanse the bowel using fleet enema, laxatives or lavages with electrolyte solutions for 2 consecutive evenings • Provide liquid diet 1 day before the procedure • Obtain an informed consent before the procedure • Administer a sedative as prescribed (eg midazolam) to allay anxiety • Administer premedication (eg glucagon) to relax the colon muscle and reduce spasms during the procedure • After the procedure, keep the patient on bed rest until the sedation wears off, monitor for complications such as abdominal cramps, bleeding and pain

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Abdominal ultrasonography Description

• Non-invasive procedure that provides information on the size and configuration of the abdominal organs

Indication/s

• To diagnose cholelithiasis (gallstone disease), cholecystitis (inflammation of the gallbladder) and appendicitis

Responsibilities of the nurse

• Starve the patient 8–12 hours before the procedure • Advise the patient to take a fat-free meal the evening before the procedure

Computed tomography (CT) Description

• Non-invasive three-dimensional images

Indication/s

• To identify diseases of the liver, spleen, kidney, pancreas and pelvic organs

Responsibilities of the nurse

• Starve the patient 6–8 hours before the procedure

Magnetic resonance imaging (MRI) Description

• Non-invasive imaging procedure used to supplement ultrasonography and computed tomography

Indication/s

• To detect soft tissues abnormalities such as sources of bleeding, cancers and fistuale

Responsibilities of the nurse

• Exclude permanent implants such as pacemakers, metal valves, defibrillators, implanted insulin pumps and metal clips implanted for aneurysms. • Notify the doctor if such devices exist • Obtain an informed consent from the patient • Starve the patient 6–8 hours before the procedure

Gastrointestinal motility study Description

• Liquid and solid components of a meal are attached to radionucleid markers and X-rays are taken every 24 hours until all markers have been emptied

Indication/s

• To diagnose the problems of gastric emptying and chronic constipation

Responsibilities of the nurse

• As it is done in the outpatients department over 4–5 days, clear instruction should be given to the patient regarding daily preparations

Defecography Description

• Barium paste used directly into the rectum followed by fluoroscopic X-ray

Indication/s

• Measures the anorectal function

Responsibilities of the nurse

• No procedure specific preparation is required for this test

Manometry and electrophysiologic studies Description

• Electrophysiologic studies that are useful in problems with chronic constipation, diarrhoea or incontinence

Indication/s

• Measure problems of the oesophageal, gastroduodenal, small intestines and colonic motility • Measures the intraluminal pressures which are recorded manually or electronically • Measures gastric emptying • Measures pressure and tone of the rectum and sphincter

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Responsibilities of the nurse

• Administer an enema as prescribed, that is, phosphosoda or saline cleansing enema an hour before the test • Position patient in lateral or prone position

Stool tests Description

• Examination of the stools for consistency, colour, parasites and occult blood

Indication/s

• Early diagnosis of cancer and parasites

Responsibilities of the nurse

• Advise the patient to avoid red meat, turnips or horseradish 24 hours before the procedures to avoid false positive results • Avoid medication such as iron, iodides, indomethacins, colchicines, salicylates, corticosteroids and vitamin C

Urea breath test Indication/s

• To detect the presence of Helicobacter pylori, a bacteria that can cause peptic ulcers

Responsibilities of the nurse

• Stop antibiotics 24 hours before the procedure • Stop antacids such as cimetidine 1 week before the procedure

are not moving. Excessive flatulence may also denote the presence of gallbladder disease. The patient may complain of a full, bloated feeling (abdominal distension), difficulty in breathing, pressure or discomfort and anorexia. Excessive air in the gut may be released by belching or as flatus. This is the main cause of colic in children. Nausea and vomiting. Nausea is commonly a result of conditions which increase tension in the lower end of the oesophagus, wall of the stomach or duodenum. Nausea usually precedes vomiting, but vomiting may occur without nausea. Vomiting is ejecting the contents known as ‘vomitus’ upward through the relaxed oesophagus and pharynx and through the mouth. It occurs when the vomiting centre is stimulated by several different factors in the gastrointestinal tract, in the circulation, or by reflex activity in the brainstem. The vomitus may vary in colour and composition, depending on the underlying cause. Abdominal pain. This is indicative of the irritation of nerve endings due to excess acid that may erode the stomach mucosa, infection (gastritis) where the rate of peristalsis may be increased, or abdominal distension as a result of indigestion, accumulation of flatus or other gastric contents. Pain can also be due to strong contractions of muscle tissue, as is found in obstruction. The pain may be intense, leaving the patient writhing or immobile depending on the cause of pain. Heartburn is a form of pain that occurs as a burning sensation felt behind

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38.2 Preparation for diagnostic procedures Preparation for diagnostic procedures includes the following aspects: • Endoscopies, barium swallows and enemas can be very uncomfortable and unpleasant • The patient needs to be well prepared psychologically and physically, not only to gain cooperation but also so that the procedure is successful and does not have to be repeated • Patients must be given adequate information about the procedures and their implications, including possible complications • The nurse must give strict instructions about physical preparation, for example about cleansing the bowel or fasting • The nurse must find out about allergies if contrast medium is to be used. the sternum, usually due to irritation of the oesophageal mucosa caused by regurgitation of gastric acid fluid into the oesophagus. Abdominal rigidity. This is an indication of pain which is noted on palpation of the abdomen and may be evident in patients with peritonitis where it is referred to as ‘guarding’.

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Changes in bowel habits. Stool character may signal the presence of colon disturbances. Diarrhoea, which is an abnormal increase in the frequency and liquidity of the stool, occurs when there is an increase in peristalsis which results from an increase in the gastric colic reflex or from the effort of the stomach and intestines to eliminate a localised irritant. Diarrhoea may be associated with abdominal pain and cramps, nausea and vomiting. Constipation occurs as a result of delayed movement of contents through the intestines and it is evidenced by a decrease in the frequency of stool. Stools which are hard dry and of smaller volume than normal may result in anal discomfort or rectal bleeding (read Chapter 7). Stool characteristics. A normal stool is light to dark brown in colour. The colour is usually influenced by food and/ or medication ingested, as well as the presence of blood in the intestines. Melaena is the presence of digested blood in the stools, giving it a tarry colour. Frank blood in the stools denotes bleeding in the colon, rectum or anal cavity (for other normal characteristics and abnormalities, read Chapter 7). Haemorrhage/bleeding. This may result from trauma or irritations that cause erosion or ulceration of the gastrointestinal mucosa, stomach neoplasms, gastritis, and gastric and duodenal ulcers. Oesophageal varices may cause bleeding in the upper gastrointestinal tract, while bleeding from the lower part of the tract may be due to new growths, ulcerative colitis, haemorrhoids or anorectal fissures. Bleeding in the gastrointestinal tract is evidenced by haematemesis, melaena or frank blood in the stools. Hiccups. This results from intermittent spasms of the diaphragm due to gastric distension, irritation of the phrenic nerve or metabolic disorders such as anaemia. Hiccups may be persistent or frequent in organic disorders of the intestinal tract. Loss of weight and strength. This can be related to poor dietary intake caused by an inability to eat, swallow, digest or absorb food. Dysphagia. This may be due to mechanical obstruction, dysfunction in the neuromuscular structures involved in swallowing or inflammatory disease of the pharynx.

Nutritional disorders and feeding modalities Adequate nutrition is essential for tissue regeneration and building resistance to infection. Malabsorption and protein calorie malnutrition are the most common nutritional disorders.

Malabsorption Malabsorption refers to disorders that share the common feature of failure to assimilate one or more ingested nutrients.

Risks It may result from impaired function of any of the primary or accessory organs of digestion, or impairment of nutrient transport across the mucosa.

Pathophysiology Malabsorption can occur with any nutrient. However, malabsorption syndrome is a group of symptoms produced by inadequate absorption of fat, protein or carbohydrates.

Causes of malabsorption • • • • • •

Diseases such as coeliac diseases or lactase deficiency Inflammatory bowel disease Gastrectomy or gastric bypass Pancreatic diseases Liver or biliary diseases or obstruction Infection of the bowel that can be bacterial, viral or parasitic • Drug side effects such as antibiotics.

Assessment findings • Steatorrhoea (greasy, bulky and foul smelling stool due to excess fat in the stool). The stools usually float because of the low SG. Steatorrhoea is accompanied by loud bowel sounds, flatulence and abdominal distention. • The patient has weight loss, weakness, fatigue and anorexia due to decreased fat absorption. • Abdominal cramps and bloating related to malabsorption of carbohydrates. • Anaemia and bone loss. • Bleeding such as ecchymosis and haematuria, pathologic fractures, bone pain, hypocalcaemia and muscle tenderness due to deficiencies of fat soluble vitamins. • Hypoalbuminaemia, oedema and loss of muscle mass due to protein deficiency.

Changes in the mouth. It may take a form of coated or furred tongue, dryness, soreness, small ulcers and halitosis, mainly presenting with anorexia.

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726  Juta’s Complete Textbook of Medical Surgical Nursing Table 38.4  General nursing care plan for patients with disorders of the gastrointestinal system

Anorexia, nausea and vomiting, diarrhoea and dysphagia Nursing diagnosis

• Risk for altered nutrition, less than body requirements, due to malabsorption, poor intake of food manifested by poor appetite, nausea and vomiting and diarrhoea, weakness and loss of weight

Expected outcome

• Stop nausea and vomiting • Improve appetite • Maintain normal bowel habit • Maintain normal weight

Nursing interventions and rationale

• Give nothing orally until nausea is controlled and vomiting has stopped • Maintain hydration with intravenous infusion • Record and keep strict intake and output • Ensure a pleasant and relaxed environment before food is served by removing unpleasant odours and sights • Measure, record and report vomiting and vomitus in terms of when it occurred especially in relation to food, the manner in which it occurred the consistency and composition of the vomitus • Provide mouth care by rinsing the mouth after vomiting • Administer antiemetic as prescribed • Serve food attractively and in smaller amounts • Weigh the patient regularly to monitor weight

Evaluation

• The patient is eating well, and not vomiting or complaining of nausea • Normal weight according to height achieved • Passing normal formed stools, no diarrhoea

Fever, anorexia, vomiting, diarrhoea, dysphagia and/or gastric bleeding Nursing diagnosis

• Risk for fluid volume deficit secondary to anorexia, vomiting, diarrhoea, dysphagia, diaphoresis and gastric bleeding due to disease process

Expected outcome

• Maintain fluid volume status (hydration) and normal urine output maintained • Reduce fever • Control bleeding

Nursing interventions and rationale

• Continuously monitor intake and output to determine the fluid volume status • Put up an intraveneous infusion where vomiting is present • In cases of diarrhoea, collect stools for culture and sensitivity to identify the causal organism and medication to be used • Administer antidiarrhoeal medication as prescribed • In the absence of dysphagia, anorexia and nausea and vomiting, give electrolyte fluid orally (this may be prepared at home as 1 ℓ of boiled cooled water in which 8 teaspoons of sugar and ½ teaspoon of salt have been dissolved) • Monitor fluid and electrolyte balance regularly • Monitor temperature, pulse and blood pressure hourly • Collect blood for culture and sensitivity to detect the systemic organisms and medication the organisms are sensitive to • Administer antibiotics as prescribed • Do a full blood count and haematocrit investigation to determine the impact of bleeding • Monitor transfusions as prescribed

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Evaluation

• Patient takes in and retains adequate amounts of fluid as required by the body • The patient reports no diarrhoea and no vomiting • Passing adequate amounts of urine of 1ml/1hr/1kg body weight • No fever • No bleeding or bleeding stopped

Abdominal pain and tenderness Nursing diagnosis

• Altered comfort and disturbed sleep related to reported pain due to the disease process, eg eroded gastric mucosa in gastritis, ulcers, flatulence, distended abdomen and/or abdominal surgery

Expected outcome

• Relieve pain

Nursing interventions and rationale

• Identify the cause of pain and treat • Administer medication as prescribed, eg antacids for gastric irritation and narcotics for surgical pain • For a distended abdomen, withhold all oral forms of intake, insert a nasogastric tube and connect to a continuous suction/free-flowing bag to decompress the distension, monitor bowel sounds to exclude obstruction, insert a flatus tube to relieve flatulence and monitor stools for presence, colour and consistency • Put up an intraveneous infusion to maintain hydration • Advise the patient to avoid gas-forming foods and irritants such as cabbage and alcohol and nicotine • Nurse in semi-Fowler’s position or assist the patient to assume a comfortable position, avoid pressure on the abdomen and operation site such as tight clothes and dressings, administer analgesics as prescribed

Evaluation

• Pain is controlled • Patient reports no pain and sleeps well

Swelling of the tongue in oral cancer; dysphagia; vomiting; abdominal distension Nursing diagnosis

• Risk for altered breathing and altered airway clearance due to aspiration as a result of oesophageal overflow in dysphagia, obstruction in the swelling of the tongue and/or oesophagus, pressure on the trachea as a result of oesophageal swelling and abdominal distension

Expected outcome

• Maintain normal breathing and a clear airway

Nursing interventions and rationale

• Monitor and record breathing hourly • Suction to clear the airway • Administer oxygen as prescribed to support breathing • Nurse in Fowler’s position and provide tissues/receiver to spit into to prevent aspiration of saliva that cannot be swallowed • Dispose of tissues and saliva or vomitus safely and hygienically • Give nothing by mouth and maintain hydration through an intravenous infusion • For abdominal distension insert a nasogastric tube and allow it to drain in a drainage bag continuously to decompress the abdomen and relieve the pressure on the diaphragm

Evaluation

• The patient breathes normally and swallows fluids and solids with no difficulty

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Restlessness Nursing diagnosis

• Risk for anxiety related to knowledge deficit about the disease process and care

Expected outcome

• Relieve anxiety and provide information regarding the disease and management processes • Involve patient in own care

Nursing interventions and rationale

• Assess the level of anxiety to determine the approach in the care • Assess the patient’s normal coping. mechanisms and support base to cope with stress of the diagnosis • Provide information at the patient’s level of understanding, explain all the tests and procedures to increase knowledge about the disease and reduce anxiety • Answer questions truthfully to reduce anxiety and encourage the patient to express fears openly, and provide emotional support • Encourage sleep and rest to promote recovery

Evaluation

• Anxiety is relieved and patient is restful • The patient understands the disease process and adheres to the treatment regimen

38.3 Malabsorption disorders in adults

38.4 Types of enteral tubes

• Coeliac disease: Permanent intolerance to gluten • Dissacharide malabsorption: Congenital lactase deficiency • Short bowel syndrome: Loss of half of the length of the small bowel

Enteral tubes are classified according to their composition, external diameter, length and presence or absence of weighted tip. The types of tubes are: • Polyurethane or silicone tubes. These tubes have larger internal diameter which facilitates fluid flow. • Nasogastric tubes. They are used in patients with intact gag and swallow reflexes, and a competent lower oesophageal sphincter to prevent reflux. • Nasointestinal tubes. These tubes are used in patients who are at risk of aspiration. • Gastrostomy tubes. The tubes are inserted endoscopically or surgically through an incision in the abdominal wall.

Management of malabsorption • • • •

Treat the underlying cause Modify diet and supplements Provide parenteral feeding Teach the patient: –– To maintain adequate nutrition –– About the warning signs and complications related to vitamin deficiency –– About the gentle care to promote comfort and safe administration of total parenteral nutrition (TPN).

For protein–calorie malnutrition, see Chapter 6.

Feeding modalities See Chapter 6 for further information.

Enteral nutrition Enteral nutrition is the delivery of nutrients directly into the gastrointestinal tract via a feeding tube. It is used to supplement or replace oral nutrition.

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It may be administered to the stomach by nasogastric tube or to the distal duodenum or proximal jejunum by nasointestinal tube.

Advantages of enteral feeding • It is cost-effective. • Less likely to cause sepsis. • Preserves the normal sequence of intestinal and hepatic metabolism. • Maintains insulin/glucagon ratios. • Maintains lipoprotein synthesis. • Stimulates gall bladder motility. • Prevents biliary sludge and cholelithiasis.

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38.5 Enteral feeding formulas

38.6 Intermittent (bolus) feeding

Enteral feeding solutions have the following types of formulas: • High-density formulas. They are more hypertonic solutions which may lead to diarrhoea. • Lower-density formulas. These formulas need a lot of fluid supplement and may be contraindicated in patients with restricted fluid intake. • Polymeric formulas. They contain proteins. • Oligometric formulas. They contain predigested proteins. • Monometric formulas. They contain nitrogen in the form of free fatty acids.

• Ensure that the tube is patent • Attach the syringe on the tube • Elevate the syringe above the patient’s head • Fill the syringe with the feed • Allow the feed to empty by gravity, careful not to introduce air • Close the system quickly when feeding is completed to prevent air entry

Care of the patient receiving enteral feeding: • Nurse with the head end of the bed elevated during feeding. • Put the patient in High Fowler’s position for intermittent feeding. • Check and confirm the length of the tube by injecting 10–30 ml of air into the tube while auscultating over the left upper quadrant of the abdomen or aspirate secretion if possible, and check the pH of the aspirate on a litmus paper. Note that a pH of 1–5 indicates gastric contents. • Flush the tube with 30 to 50 ml of clear water before initiating the feed every 4–6 hours for continuous feeding and at the end of the feed. • Flush the tube before and after medication administration. • Infuse the feed through a pump and monitor the amount to be given. • Secure the tube properly, and prevent nasal or oral irritation. • Record administered fluid including the flush solution. • Monitor blood glucose regularly depending on the levels. • Wean from the feed gradually. • Monitior stool for frequency and consistency.

• Regurgitation or aspiration due to improper positioning of the patient’s head or infusion of large amounts of feed fast.

Parenteral nutrition Parenteral nutrition is indicated in patients whose gastrointestinal tract is not functioning well. It delivers concentrated solutions intraveneously to supplement or maintain a patient’s nutritional balance. It is administered via a central venous catheter. For more information, read Chapter 6.

Indications for parental nutrition • Acute inflammation or malabsorption • Extreme hypermetabolism from trauma or sepsis • Patients on nil per os for more than 5 days.

Care of the patient receiving parenteral nutrition The objectives of care are to: Promote comfort • Provide good oral hygiene • Encourage ambulation if possible.

Complications of enteral feeding

Maintain fluid and electrolyte balance • Infuse at a preset rate through an ivac/infusion pump • Wean the patient off the feed gradually • Monitor signs of over- or underhydration • Weigh the patient daily • Keep accurate intake and output record • Monitor electrolytes and replace.

• Tube obstruction due to pill fragments, formula residue adhering to the tube and lack of thorough flushing of the tube • Diarrhoea due to feed containing lactose, prescribed medication, or bacterial contamination • Constipation due to fluid volume restriction and immobility

Prevent infection • Maintain a closed system and strict aseptic technique. • Refrigerate the feed and keep cool. • Change dressing on the CVP catheter regularly • Change sets with every new feed • Use appropriate filters on the lines

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• Administer antibiotics as prescribed • Prevent feed–medication interactions. Prevent air embolism • Always clamp the catheter before opening the system or while changing the lines • Tape all connections securely • Ensure that the feed does not run dry. Prevent metabolic imbalance • Monitor blood glucose as prescribed • Administer insulin according to prescribed sliding scale.

Complications of parenteral feeding • • • • •

Problems with the catheter such as wrong insertion Catheter-related sepsis Metabolic imbalances such as glucose intolerance Dehydration related to hypoglycaemia Fluid, electrolyte and acid imbalances.

Conclusion Proper function of the gastrointestinal system is essential to maintain nutrition and health. The nurse’s role in the care of the patient includes provision of essential health education relating to the normal functioning of the gastrointestinal system and its contribution to proper nutrition.

Suggested activities for learners Activity 38.1 Mr Sibiya, who is a smoker, has had part of his stomach removed (partial gastrectomy) because he had a lesion that involved the length of the oesophagus and the fundus of his stomach. Post-surgery he is on parenteral nutrition and has bouts of diarrhoea. He has also been very quiet; his mouth does not look good and his teeth are not that healthy looking either. Formulate nursing diagnoses and design a nursing care plan for this patient (Mr Sibiya) based on the scenario.

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39

Management of disorders of the upper gastrointestinal tract

learning objectives

On completion of this Chapter, the learner should be able to: • outline the classification of the disorders of the upper gastrointestinal tract • describe the aetiology, pathophysiology, clinical manifestation therapeutic and pharmacological interventions in patients presenting with disorders of the upper gastrointestinal tract • perform accurate assessment of patients suffering from disorders of the upper gastrointestinal tract • interpret the assessment data including the result of the diagnostic tests in patients suffering from conditions of the upper gastrointestinal tract • apply the nursing care plan framework designed for patients presenting with disorders of the upper gastrointestinal tract in all instances • describe the management of emergencies and complications related to the disorders of the upper gastrointestinal tract. key concepts and terminology

achalasia

Absence or ineffective peristalsis in the distal part of the oesophagus accompanied by the oesophageal sphincter failing to relax during swallowing.

antrectomy

Removal of the antrum portion of the stomach.

heartburn

A burning feeling in the chest due to acidic stomach contents being regurgitated into the oesophagus

gastrectomy

Partial or total removal of the stomach.

gastrostomy

Opening into the stomach.

odynophagia

Severe pain on swallowing.

oesophagoenterostomy

Removal of a portion of the oesophagus with a segment of colon attached to the remaining portion to effect a required length.

oesophagogastrostomy

Removal of a portion of the oesophagus and anastomosis of the remaining portion to the stomach.

peptic ulcer

A benign ulcer in the duodenum or stomach.

pyloroplasty

Repair of the pyloric sphincter area.

pyrosis reflux

Chest pain and heartburn. The term for when stomach contents are pushed back through the oesophageal sphincter into the oesophagus. The stomach contents are acidic in nature and would therefore cause burning in the oesophagus.

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stomach

A distendable j-shaped pouch, into which food passes after being swallowed and where the process of digestion continues.

prerequisite knowledge

• Anatomy and physiology of the gastrointestinal system and that of the accessory digestive organs • Disorders of the gastrointestinal system (read Chapter 38) • Principles of scientific record-keeping • A basic understanding of the professional, ethical and legal practice framework of nursing in South Africa. medico-legal considerations

Nurses may be guilty of malpractice as a result of failure to assess patients thoroughly; resulting in inadequate care, or the development of complications. The nurse has the obligation to participate in the preparation for diagnostic and operative procedures undertaken. essential health literacy

Conditions such as halitosis, dental caries, and heartburn are some of the common upper gastrointestinal tract disorders that we tend to sometimes overlook. Patients need to be informed that halitosis can be prevented by simple actions such as oral hygiene (brushing and flossing teeth twice a day – in the morning and in the evening before retiring to bed). Sometimes it is an indication of dental caries where a dentist may need to be engaged to treat the caried teeth. Dental cleaning and treatment is provided in public health facilities and people must be informed about these services and encouraged to use them. In some instances halitosis can be a symptom of liver diseases in which case the patient must be referred accordingly. People with heartburn must be advised not to drink too much water or any fluid with their food and to sit up after meals to prevent reflux. Other common complaints relate to abdominal pain where people become anxious about ulcers. People need to be educated about the risks for gastric ulcers and how to prevent these from occurring. They also need to know the different types of pain for the various abdominal conditions.

Introduction The upper gastrointestinal system consists of the mouth, oesophagus and stomach. These organs assist in the ingestion and digestion of food. The purpose of this Chapter is to introduce you to the specific disorders of the upper gastrointestinal tract.

Classification of upper gastrointestinal tract disorders The upper gastrointestinal tract disorders are discussed according to the regions of the alimentary tract as follows: • Disorders of the mouth • Oesophageal disorders • Disorders of the stomach • Upper gastrointestinal tract emergencies.

Overview of the mouth The mouth is the beginning of the gastrointestinal tract, and it is subjected to micro-organisms especially from dental caries, irritation from coarse, hot or spicy foods and

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chemicals which are responsible for inflammation and infection. The mouth has an arched roof that is formed by the palate and a floor to which the tongue is attached. The tongue is surrounded by three salivary glands, namely, the sublingual, the submandibular and the parotid glands. The other contents of the mouth are the teeth and gums (see Figure 39.1). The digestive process begins in the mouth with mechanical and chemical breakdown of food (read Chapter 38). Table 39.1 presents the conditions of the lips, mouth, teeth, gums and salivary glands.

Cancer of the mouth Definition

Carcinomas are cancers that originate in the lining of the mouth or surface tissues, while sarcomas are cancers that originate in the deeper tissues. The two types of oral carcinomas based on the cells involved are: • Basal cell carcinoma. This appears as a scab that develops into an ulcer.

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Gingivae (gums) Palatine raphe

Superior lip Superior labial frenulum

Hard palate

Soft palate Palatoglossal arch Uvula Palatine tonsil

Palatopharyngeal arch Posterior wall of oropharynix Tongue Lingual frenulum

Duct of submandibular gland Inferior lip

Gingivae (gums) Inferior labial frenulum

Figure 39.1  The structure of the mouth

• Squamous cell carcinoma. This is the leading type of cancer that arises from the flat squamous cells that line the mucous membrane. The squamous cell cancer is the leading type of oral cancer.

Incidence and causes Cancer of the mouth accounts for less than 5% of all body cancers. Oral cancer occurs mostly in individuals between the ages of 50 and 60 years. Cancer of the tongue has the poorest prognosis because of its extensive blood and lymph supply and also because of its position which subjects it to constant irritation or trauma. Cancer of the lips on the other hand has an 80–90% cure rate because it is usually diagnosed early. Oral cancer is often associated with: • Poor oral hygiene in the presence of irritating infection • Mechanical trauma from jagged teeth or improperly fitted dentures • Chemical and thermal trauma from tobacco, alcohol and hot or spicy foods • Malnutrition, syphilis and cirrhosis • Constant exposure to ultraviolet rays • Family history of oral cancer.

Pathophysiology The lesion often appears on the lips or mucosa, first as a small, firm, painless lump which persists and later breaks down (ulcerates) into a painful ulcer. The ulcer appears

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indurated with raised edges. Other sites for oral cancer are the floor of the mouth, sides, and under the surface of the tongue and soft palate. Mouth cancers have the potential to spread to the lymph nodes of the neck or even to other parts of the body such as the lungs as distant metastasis.

Assessment and common findings Subjective data. On subjective data collection there may be a history of the use of alcohol, smoking and exposure to sunlight, or tumours or lesions that have been removed previously. As the lesion develops the patient may complain of some or all of the following: • Difficulty with chewing, swallowing and speech including neck stiffness • Intolerance to certain foods or temperature of food • Reduction in oral intake with weight loss • Hypersalivation. Objective data. On physical examination there will be: • Alteration in the symmetry, colour and size of the lips • Cracked lips with ulcers and fissures • Lesions such as leukoplakia and krythoplakia with limitation of the movement of the tongue • Pigmentation and tenderness of oral mucosa • Increased salivation, possible halitosis, slurred speech and neck masses • Blood-stained sputum and enlarged cervical lymph nodes may be found later.

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734  Juta’s Complete Textbook of Medical Surgical Nursing Table 39.1  Conditions of the lips, mouth, teeth, gums and salivary glands

Conditions of the lips Herpes simplex Description

• Sometimes called herpes labialis, fever blister or cold sore • Type I or II • Clear vesicles located at the mucocutaneous junction of lips and face

Causes

• Herpes simplex virus (primary or secondary infection) • Exposure to sunlight especially after a short period of fever • Upper respiratory infections, eg bacterial, fungal or viral • Food allergies • Emotional tension • Opportunistic infections such as in immuno-compromised patients

Clinical manifestations

• May occur as vesicles singly or clustered • Extreme pain

Management

• Apply prescribed ointments and give anaesthetics to soothe the lips as prescribed • Advise the patient: –– not to break the vesicles –– avoid irritating foods –– use protective ointments with sunblock

Chancre Description

• A highly contagious primary lesion of syphilis

Causes

• Treponema pallidum

Clinical manifestations

• The lesion is red and circumscribed • Lesions ulcerate and form a crust

Management

• Use comfort measures, eg cold soaks to the lips, mouth care and prescribed antibiotics • Educate the patient on the contagious nature of the condition

Actinic cheilitis Description

• Premalignant squamous cell skin cancer • Indurated painless ulcer

Causes

• Exposure to the sun leading to squamous cell skin cancer

Clinical manifestations

• Common in light or fair skinned people • Appears as lip irritation with accompanying scaling and crusting • Fissures occur with hyperkeratosis

Management

• Radiation after surgical excision may be necessary. • The patient should be advised to use sunscreen and lotions for protection from the sun

Contact dermatitis Description

• Allergic reaction on the lips

Causes

• Allergic reaction to cosmetics and/or toothpaste

Clinical manifestations

• Occurs as a red area on the mouth or may appear as an itchy rash

Management

• Identify the cause and avoid its use • Administer corticosteroids as prescribed by the doctor

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Conditions of the lips Lip cancer Description

• A lip lesion that is painless and indurated

Causes

• Overexposure to the sun • Constant irritation such as smoking a pipe • Immunosuppression • Syphilis

Clinical manifestations

• A painless indurated ulcer

Management

• Surgical removal of the ulcer followed by radiation may be necessary. • Cancer of the lips has the highest cure rate, but the patient’s • choice of treatment may have a bearing on their appearance, so cosmetic surgery have to be considered in the management thereof.

Conditions of the gums Gingivitis Description

• Inflammation of the gums

Causes

• Plague at the neck of the teeth due to neglected oral hygiene • Eating of soft rather than fibrous food • Missing or irregular teeth

Clinical manifestations

• Swollen, inflamed painful gums • Alteration in the colour of the gingival trough • Bleeding during tooth brushing • Pus develops and teeth become loose (periodontitis)

Management

• Remove devitalised tissues • Administer analgesics to relieve pain • Do peroxide mouthwash to promote comfort • Advise the patient to: –– Follow good oral hygiene –– Avoid smoking and alcoholic drinks –– Eat foods with plenty of vitamins B and C –– Avoid spicy foods

Trench mouth Description

• Grey-white pseudomembranous ulcerations found at the gum edges and mucosa, tonsils and pharynx • May be acute, sub-acute or chronic

Causes

• Fusiform bacteria • Vincent’s spirochete • Poor oral hygiene • Vitamin B and C deficiencies • Stress as a predisposing factor

Clinical manifestations

• Swollen and bleeding gums • Eroding and necrotic lesions of interdental papillae • Metallic taste of saliva • Foetid mouth odour accompanied by anorexia and fever

Management

• Same as for Gingivitis

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Conditions of the gums Periodontitis Description

• Diseases of the tissues that attach and support the teeth, gums, periodontal membrane and alveolar bone

Causes

• Untreated gingivitis • Poor dental hygiene • Vitamins B and C deficiencies

Clinical manifestations

• Infection of the gums with bleeding • Gum recession occurs • The teeth become loose • Tooth loss occurs as the disease progresses

Management

• Advise the patient on: –– Proper oral hygiene –– Visiting the dentist regularly

Conditions of the teeth Dental plaque Description

• A transparent colourless mass that adheres to the teeth; it consists of proliferating bacteria with leukocytes, macrophages and epithelial cells in a sticky polysaccharide protein matrix

Causes

• Poor dental hygiene

Clinical manifestations

• Teeth covered by plaque • Halitosis

Management

• Advise the patient on good oral hygiene through brushing, flossing and rinsing after meals to remove plaque • Refer to a dentist to reduce sticky adherent mass between teeth

Dental caries or tooth decay Description

• Decalcification of the mineral components and dissolution of the organic matrix of the teeth

Causes

• Lactobacilli and Streptococcus mutans which produce acid from sugars deposited on teeth; the acid produced destroys the outer enamel as well as the dentine of the teeth • Infection of the pulp occurs if decay progresses

Clinical manifestations

• Formation of cavities • Plaque builds up over the teeth and adheres to teeth • Outer enamel of teeth and dentine is destroyed by acid • Pulpitis occurs with abscess formation • Pain, facial oedema, tiredness and pyrexia • Irreversible damage to the pulp may occur

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Conditions of the teeth Management

Advise the patient on: • Prevention of decay through good oral care, tooth brushing and flossing to remove plaque • Use of fluoride to prevent dental caries • Taking a diet low in carbohydrates • Referral to a dentist for further management; the dentist may: –– Remove the affected teeth if necessary –– Do a root canal therapy which involves removal of the pulp –– Fill the pulp cavity with inert material –– Advise on regular dental check-ups

Conditions of the mouth Stomatitis Description

• Inflammation of the oral cavity involving the gums, angles of the mouth and lips

Causes

• Mechanical trauma such as jagged teeth, cheek biting and mouth breathing, and tobaccoa smoking • Vitamin deficiencies

Clinical manifestations

• Pain and discomfort • There may be loose teeth • Halitosis • Cracking at the mouth corners

Management

• Avoid aetiological factors such as tobacco use • Ensure an intake of vitamins • Good oral hygiene • Referral to the dentist for further care of the teeth

Primary aphthous stomatitis Description

• Shallow ulcer with a white or yellow centre and a red border on the inner aspect (mucous membrane) of the lip or cheek • The lesion appears singly or in crops on mucosa of the mouth and tongue • A small painful inflamed area is seen initially, then vesicle formation occurs • Vesicle ruptures leaving an ulcer that heals in a few days • There may be frequent attacks of such lesions

Causes

• Emotional or mental stress • Hormonal factors • Minor trauma, eg biting • Vitamin deficiency • Associated with HIV infections, cancer chemotherapy and radiotherapy

Clinical manifestations

• Starts with a burning or tingling sensation and slight swelling • Continues to become painful • Heals after 7–10 days without a scar

Management

• Saline mouth wash • Soft, bland diet • Local or systemic antibiotics may be prescribed • If lesion persists longer than 2 weeks, a physician must be consulted and a biopsy should be performed

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Conditions of the mouth Nicotine stomatitis Description

• Begins as red stomatitis over the tongue • Later it is covered with thick creamy white mucous membrane • Membrane may slough leaving lesion with beefy red base • Halitosis

Causes

• Initially it is caused by chronic irritation by the use of tobacco during smoking • Indiscriminate use of antibiotics which destroy the normal flora of the mouth

Clinical manifestations

• Sore mouth • Mucous membrane red and tender • Excessive salivation • Herpes simplex may also be present

Management

• If lesion persists longer than 2 weeks, a physician must be consulted and a biopsy should be done • Advise the patient to stop the use of tobacco • Good oral hygiene • Proper use of prescribed antibiotics

Conditions of the tongue Oral candidiasis (moniliasis or thrush) Description

• Cheesy white patches/plaque on the tongue, palate and buccal mucosa

Causes

• Candida albicans • Decrease in normal oral flora • Immunocompromised state, eg patients: –– on high doses of antibiotics or steroid therapy –– with HIV/Aids or who have diabetes mellitus –– who are pregnant or suffering from stress or undergoing prolonged tube feeds

Clinical manifestations

• Lesions adhere firmly to tissues and are difficult to remove • Lesions resemble milk curds • Described as dry and hot, and when rubbed off leaves an erythematous and often bleeding base • The lesion is painful and tender

Management

• Assess for the presence of pain, tenderness and bleeding in the oral cavity • History of systemic infection, use of antibiotics, treatment with chemotherapy and radiotherapy • Administer analgesics and antifungal medication as prescribed • Apply topical agents that relieve pain • Offer fluid or pureed diet • Avoid spicy hot foods including citrus juices and fruits • Promote good oral hygiene

Oral tumours Leukoplakia Description

• Yellowish or greyish-white lesion with hyperkeratisation

Causes

• Chronic irritation with physical, thermal and chemical factors such as the use of tobacco

Clinical manifestations

• Painless lesion found in varying sizes and shapes

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Oral tumours Management

• Eliminate risk factors such as tobacco and hot beverages • Check teeth and correct defects that may cause irritation • Give a high-vitamin diet • If lesion persists for 2 weeks, advise patient to see a doctor • A biopsy may have to be done to determine if it is malignant; and if malignant, surgical intervention may be necessary • Radiotherapy may be prescribed

Hairy leukoplakia Description

• White patches with rough hairlike projections on lateral border of the tongue

Causes

• Systemic factors such as poor nutrition • Syphilis, viral infection and opportunistic infection in HIV and Aids

Clinical manifestations

• An elevated lesion with roughened or leathery surface • Lesion may disappear with elimination of the irritation

Management

• Same as for leukoplakia

Krythoplakia Description

• Red velvety-appearing patch on the oral mucous membrane

Causes

• As for hairy leukoplakia

Clinical manifestations

• A precancerous lesion • Non-specific inflammation

Management

• Same as for leukoplakia

Cancer of the tongue Description

• An ulcer or area of thickening on the tongue

Causes

• Tobacco and alcohol use • Chronic irritation and syphilis

Clinical manifestations

• Soreness may occur especially on eating spicy foods • Increased salivation (late sign) • Slurred speech due to limitation of movement of the tongue • Dysphagia • Toothache and earache (late symptoms)

Management

• Surgery for resection of the tumour from the tongue • Internal and external radiation therapy • Chemotherapy

Kaposi’s sarcoma Description

• Initially appears as a red, purple or blue lesion (hyperpigmentation) • Single or multiple lesions which may be flat or raised

Causes

• HIV infection

Clinical manifestations

• Painless single or multiple lesions, flat or raised • Accompanies systemic manifestations such as diarrhoea

Management

• Chemotherapy (alpha interferons) • Radiotherapy

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Conditions of the salivary glands Parotitis Description

• Inflammation of one or both parotid glands; can be acute or chronic • It is common in dehydrated and debilitated patients often in postoperative period • Seen more commonly during and/or after radiotherapy or in patients with compromised immunity • Viral parotitis (mumps) is common in children 4–10 years of age

Causes

• Decreased flow of saliva, often secondary to either blockage of salivary duct by a stone or the formation of a stricture or micro-organisms in bacterial infections such as Staphylococcus aureas and Streptococci • Viral infection such as mumps

Clinical manifestations

• Redness, swelling and tenderness over the gland • Overlying skin swells and becomes red and shiny • Initially there may be increased salivation, but as the inflammation progresses, the saliva diminishes • Pus may even be present in bacterial infection

Management

• Massage the gland to stimulate the flow of saliva • Administer analgesics to control pain • Administer antibiotics for bacterial infection • Surgical drainage for chronic parotitis or surgical removal of damaged infected gland • Maintain oral hygiene • Maintain adequate nutrition

Calculi or sialolithiasis Description

• Formation of stones in the salivary glands due to inactivity of the gland or in a case where the patient has a condition that favours precipitation of sodium • The calculi may be diagnosed by performing an ultrasonography (sialography) or a radiopaque substance is injected and demonstrates obstruction of the duct by a calculi

Causes

• Calculi are formed from calcium phosphates

Clinical manifestations

• Localised colicky pain • Swollen gland which is tender and painful • Stone may be palpable

Management

• Surgical removal of the stone

Neoplasms of the salivary glands Description

• These occur in the parotid gland and are benign • Tumours occurring in the submaxillary are prone to malignancy

Causes

• Prior exposure to radiation

Clinical manifestations

• Pain due to expansion of the gland thus causing pressure on the sensory nerves

Management

• Surgical excision of both benign and malignant tumours • Note: the facial nerve must be preserved • Radiotherapy may be necessary if the tumour is malignant or recur • Chemotherapy is palliative

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Diagnostic studies. A biopsy of suspicious lesions may be done and oral mucosa scraped for cytology.

Management Available medical and surgical options for the treatment of oral cancer are surgical resection, radiation therapy and chemotherapy or a combination of these therapeutic modalities. Radioactive implants may also be used. If the cancer has spread to cervical lymph nodes and neck region, then reconstructive neck surgery may be done. Possible surgical procedures are glossectomy, mandibulectomy and radical neck dissection. Survival in oral cancer depends on the site involved and the stage of the tumour when diagnosis is made.

Nursing management Provision of nutrition. A patient with oral cancer has difficulty eating as a result of pain and/or possible surgical resection or swelling resulting from radiation therapy. These factors impact on nutrition and may result in an intake less than body requirements. Alcohol, depression, or presurgical radiation therapy may aggravate the nutritional status of the patient, therefore the nutritional status should be monitored, especially when being prepared for surgery. A dietician may have to be consulted as the patient may need enteral or parenteral feeds. Gastrostomy may be indicated if the patient is unable to swallow. Oral hygiene. Good oral hygiene may promote appetite and comfort, and the nurse can assist with doing gentle mouth washes with a mild anaesthetic antiseptic spray and/or irrigation. Cotton-wool applicators may be used to remove debris. Solutions such as normal saline, sodium bicarbonate, diluted mouthwashes and antibiotics may be used. Be careful to avoid trauma when performing oral procedures such as irrigation. Pain management. Adequate pain management should be given, based on severity. Mild to moderate systemic analgesics can be given over and above the use of local anaesthetic antiseptics. Airway clearance. If the patient has undergone reconstructive surgery, they may experience problems with airway clearance related to swelling and aspiration of secretions. Swabs must be provided for hypersalivation and an emesis basin provided and emptied frequently. The patient should be assessed for adequacy of breathing or ventilation by checking the respiratory rate, rhythm and

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depth, oxygen saturation and colour of extremities. To establish and maintain a patent airway, the patient should be assisted to a sitting position and the airway cleared by suctioning. The colour of the face and oral mucosa must be checked for indications of circulatory failure. A tracheostomy may need to be done if the swelling obstructs the airway. Hydration. The patient’s hydration should be assessed because there is a potential for haemorrhage, hypersalivation and altered nutrition. Assess the patient for bleeding and apply pressure dressings if this is possible. Risk of infection. Oral infection may result from surgical incisions in the oral cavity as food passes through. It is therefore necessary to maintain frequent oral hygiene and apply prescribed local medication. Systemic medication (prescription drugs that work throughout the body) may also be ordered to prevent infection. Anxiety. The patient may be suffering anxiety and selfconcept disturbance related to altered body image after radical surgery. The nurse should be aware of this, and should provide emotional support to the patient and family.

Disorders of the oesophagus The oesophagus is the muscular tube that links the stomach to the oropharynx (see Figure 39.2). Its main function is to pass food and fluid from the mouth to the stomach by the process of swallowing (as is indicated in Figure 39.3), hence the main symptom of all oesophageal disorders is dysphagia of varying degrees.

The three phases of swallowing 1. The voluntary phase: the tongue forces a bolus of food into the pharynx 2. The involuntary pharyngeal phase: food moves into the upper oesophagus 3. The oesophageal phase: food moves down into the stomach. Swallowing may be impaired by the following factors: • A disturbance in the neuromuscular functioning • A decrease or obstruction in the lumen of the oesophagus due to swelling, foreign body or inflammation • Degenerative changes occurring in the muscular wall of the oesophageal tube.

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Throat (Pharynx)

Oesophagus Trachea Upper oesophageal sphincter (UES) Diaphragm Lower oesophageal sphincter (LES) Stomach Figure 39.2  The structure of the oesophagus Peristaltic wave

Causes of oesophageal disorders The causes of oesophageal disorders may be intrinsic or extrinsic. The extrinsic causes affect the mouth, tongue and the pharynx. Any disease or tumour affecting these structures may cause an interference with swallowing and passage of food from the mouth to the stomach. The presence of conditions such as goitre, aortic aneurysm and enlargement of lymph nodes in the mediastinum which compress the oesophagus may also interfere with swallowing. Difficulty in swallowing may result from a neuromotor malfunction. It may also be caused by neurological diseases such as cerebrovascular accidents, multiple sclerosis, poliomyelitis, myasthenia gravis and damage to the swallowing centre in the medulla oblongata, or in the area of the fifth, seventh, ninth, tenth and twelfth cranial nerves, which are responsible for coordinating the act of swallowing. Intrinsic causes of oesophageal disorders can be classified as congenital abnormalities, inflammatory diseases, achalasia, diverticulitis and neoplasms.

Congenital abnormalities The most common oesophageal congenital abnormalities occur during the embryonic stage of the development of the oesophagus as it separates from the trachea. These abnormalities in turn impair the swallowing function in the newborn. These include stenosis, atresia and tracheooesophageal fistulae, which require immediate surgical repair for the survival of the newborn. Atresia and fistulae

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Oesophagus

Bolus Stomach Figure 39.3  Movement of food through the oesophagus

are the most common and can occur in different forms (see Figure 39.4). In stenosis there is a constriction of the oesophagus which then prevents the passage of food to the stomach. The implication of these abnormalities is that the neonate will not be able to feed as the feed will be diverted to the trachea resulting in asphyxiation. In the case of Figure 39.4(b), not only will the food be aspirated, but gastric contents will also be regurgitated into the trachea, resulting in fatal acid aspiration pneumonia. The diagnosis of oesophageal anomalies in neonates is usually made soon after birth: the neonate has a low Apgar score, suffers from cyanotic attacks, is bubbly and chokes on its saliva.

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Inflammatory conditions of the oesophagus Oesophagitis Definition

An acute or chronic inflammation and sometimes ulceration of the mucosa and submucosal lining of the oesophagus. The two principal types of oesophagitis are: • Corrosive oesophagitis: This is caused by ingestion of caustic chemicals, for example acid. The severity of the inflammation depends on the type, amount and concentration of the caustic chemical swallowed. • Reflux oesophagitis or gastroesophageal reflux disorder (GERD): This is a common condition which is caused by poor functioning of the musculature of the lower oesophageal segment including the cardiac sphincter which permits a reflux of stomach contents. a)

b)

c)

a) The trachea presents oesophagus atresia without tracheal involvement in two pieces with blind ends b) Oesophagus with a fistula connecting it to the trachea c) The lower part of the oesophagus terminates with a blind end, while the top part is connected to the trachea Figure 39.4  Disorders of the oesophagus

Management Management includes emergency surgery. Specific preoperative care of the neonate aims at preventing inhalation or aspiration into the lungs and is as follows: • Prop the baby up • Do not feed • Insert a nasogastric tube to continuously aspirate gastric contents or saliva from the oesophageal stump • Administer a 5% dextrose intravenous infusion to prevent hypoglycaemia • Keep neonate warm to prevent hypothermia.

Clinical alert! It is important not to insert the nasogastric tube into the trachea in all the abnormalities indicated above. In Figure 39.4, deformities (a) and (c) ensure that the tube is not inserted too deep and the aspirate must be alkaline in reaction. For deformity (b), the nasogastric tube can get to the stomach and the aspirate should test acidic.

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Risk factors These include haitus hernia and consumption of caffeinated drinks.

Causes • Infections, for example candida, herpes, HIV and cytomegalovirus • Medicines such as doxycycline, ascorbic acid, potassium chloride and biophosphates • Motility disorders such as achalasia, scleroderma and oesophageal spasm • Mechanical injury or trauma to the oesophageal mucosa caused by rough or sharp instruments, eg trauma during a scope with scarring on healing.

Pathophysiology In gastroesophageal reflux associated with an incompetent lower oesophageal sphincter, the acidic gastric contents flow backwards through the weak cardiac sphincter into the oesophagus. Contributory factors include impaired gastric emptying from gastroparesis or partial gastric outlet obstruction, inflammation, ulceration and mucosal damage of the oesophagus.

Assessment and common findings Subjective data • Heartburn (main symptom), with or without regurgitation of gastric contents into the mouth, which worsens on bending over. The heartburn occurs 30 to 60 minutes after meals when in a reclining position • Spontaneous regurgitation of sour and bitter gastric contents into the mouth with a burning pain in the chest, sometimes accompanied by vomiting • Regurgitation of food, especially when lying down or in bed at night. If severe, the patient will wake up coughing and have a choking sensation

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• A burning sensation in the lower chest immediately after swallowing hot fluids, hot fatty foods and/or concentrated fruit juices • Intolerance of spices, alcohol and caffeine • Dysphagia (less common symptom) • Atypical chest pain, odynophagia, hoarseness, chronic cough and bronchospasm • Pain due to ulceration of the lining of the oesophagus. This may lead to possible narrowing due to scarring, resulting in difficulty in swallowing: first solid food and later also liquids. Diagnostic tests • Endoscopy to visualise the inflammation, lesions or erosions • Biopsy to confirm diagnosis and rule out malignancy • Oesophageal manometry to measure the pressure of the lower segment sphincter and determine the adequacy of the oesophageal peristalsis; this is done before surgery is undertaken to treat reflux • Ambulatory 24-hour pH monitoring to determine the amount of gastroesophageal reflux • Barium oesophagography (barium swallow) to diagnose mechanical and motility disorders

Management of oesophagitis/gastroesophageal reflux disorder Lifestyle changes. It is important for the patient to stick to a bland diet. The patient should be advised to avoid spicy foods, garlic, fatty foods, onion, peppermint, coffee, citrus juices and tomato products as these foods lower the oesophageal sphincter competence. Over-eating should be avoided because it causes lower oesophageal sphincter relaxation. If necessary, a weight reduction programme should be encouraged to decrease intraabdominal pressure. Alcohol and smoking should also be avoided. Drug therapy. This is divided into first- and second-line drug therapy. • First-line drug therapy. Antacids can be given to neutralise gastric acidity and possibly increase the lower oesophageal sphincter competence. Histamine receptor blockers (H2 blockers) such as lansoprazole (Prevacid®) and rantidine (Zantac®) can be given to reduce stomach acidity and provide symptomatic relief. • Second-line drug therapy. High dose of H2 blockers and prokinetic agents such as metoclopramide to promote gastric emptying and prevent reflux are added. Also protons pump inhibitors to block gastric acid secretion.

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Drug maintenance therapy may be needed depending on the severity of the oesophagitis and the recurrence of symptoms after the initial drug has been stopped. The lowest effective drug dose of H2 receptor blockers or proton pump inhibitors can be used. Treatment of corrosive oesophagitis involves reducing pain and making the patient comfortable. Analgesics are thus given for pain. Gastric lavage should be avoided as it may worsen the condition. Surgical treatment. Surgery is indicated for patients who do not respond to drug therapy or who fail to adhere to lifestyle changes and pharmacological treatment. If a severe oesophageal stricture develops, surgery to dilate the oesophagus may be necessary. A vagotomy (see Chapter 38) may be performed to reduce the acidity of the stomach contents and tighten the sphincter muscles to reduce reflux. Gastrostomy may be performed to assist with nutrition where swallowing is not possible.

Essential health information • Teach the patient to avoid any situation that decreases pressure at the lower oesophageal sphincter or causes irritation of the oesophageal mucosa (eg smoking and alcohol). Smoking causes increased stomach acid and reflux. • Stress increases the amount of stomach acid reflux and therefore stress management should be discussed, as well as some coping mechanisms. • Instruct the patient to eat a high-protein, low-fat diet and avoid spicy foods, chocolate, carbonated drinks, and beverages containing caffeine. Milk products should be avoided as this increases the production of gastric acid. Small, frequent meals should be taken to avoid over-distending the stomach. The last meal and drink should be taken 3 hours before bedtime. The patient should not lie down during the first 2–3 hours after eating to allow the stomach to empty its contents into the intestine. • Advise the patient not to drink any fluids during their meals. • Elevate the head side of the bed at night on 15–20 cm blocks to enhance oesophageal emptying. Advise the patient not to prop the head with more than one pillow as the abdomen folds increase the reflux. • Refer the patient to a dietician for a weight reduction programme if obese. • Discuss necessary lifestyle changes and concerns about the chronicity of the condition with the patient and family.

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Achalasia Definition

Achalasia is a chronic progressive condition in which the tone in the lower two thirds of the oesophageal musculature is increased, resulting in the sphincter failing to relax, thus delaying the passage of swallowed food into the stomach, while the peristalsis in the oesophagus is ineffective, weak or absent. This results in the accumulation and stagnation of food and fluids in the oesophagus, causing inflammation and mucosal irritation.

Causes Achalasia may be caused by degenerative changes in the ganglion cells or impairment of impulses from the Auerbach’s plexus that innervates the muscle tissue of the oesophagus. It may occur at any age but usually begins almost unnoticed between the ages of 20 and 40 years, and progresses over months and years.

Pathophysiology In achalasia, there is increased tone of the lower oesophageal sphincter, due to the defective innervation by the Auerbach’s plexus with the resultant failure of normal peristalsis in the lower two thirds of the oesophagus. The result is poor tone and peristalsis, distention of the lower part of the oesophagus and delayed emptying of the oesophagus into the stomach.

Assessment and common findings Objective data. Achalasia is characterised by progressively increasing difficulty in swallowing both solids and liquids and a feeling of something stuck in the throat. In the early stages the patient may complain of heartburn in the substernal region which results from spasms of the oesophagus. Other complaints may include inability to belch, regurgitation of undigested food and persistent cough especially at night, recurrent upper respiratory tract infections, overeating and emotional disturbances. Weight loss may be present. Diagnostic tests and findings • Chest X-rays may show an enlarged, fluid-filled oesophagus. • Barium swallow with X-rays of the oesophagus will be taken during swallowing. These may show an absence of peristalsis and decreased emptying. The oesophagus may also be widened but narrows at the lower oesophageal sphincter. • Manometry, which is the measurement of pressure inside the oesophagus, may indicate lack of contractions, incompetent opening of the sphincter on swallowing and an increased closing pressure of the lower oesophageal sphincter.

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• Oesophagoscopy will show widening of the oesophagus with no obstruction. • A biopsy will be taken to exclude oesophageal cancer. • An examination will be done to rule out scleroderma, which is the disorder that impairs swallowing.

Management The management of achalasia is aimed at relieving the symptoms. The patient should be given frequent doses of prescribed antacids to neutralise the gastric contents, small, frequent, semi-soft and warm meals, fluids with meals to facilitate passage of food, but no spicy foods. The patient should be encouraged to chew food properly and adopt an upright position at night to prevent the reflux of food.

Surgical management This will include dilatation of the oesophageal sphincter or enlargement of the sphincter which is called oesophagomyotomy. The sphincter may be opened mechanically by inflating a balloon inside it. Drugs such as nitrates (eg nitroglycerin) and calcium-channel blockers (eg nifedipine) may be administered sublingually before meals to help relieve the sphincter.

Oesophageal diverticulum Definition

Diverticula are sacs or pouches formed at weak points in the walls of the gastrointestinal tract. In the oesophagus these sac-like outpouchings occur in three main areas: • The upper part of the oesophagus, which is the most common location and is called Zenker’s diverticulum or pharyngo-oesophageal diverticulum • The middle part of the oesophagus at the level of the bifurcation of the bronchus, midoesophageal diverticulum; also known as traction diverticulum • The lower end of the oesophagus known as epiphrenic diverticulum.

Causes Oesophageal diverticula are associated with improper functioning of the lower oesophageal sphincter, motor disorders of the oesophagus and strictures of the oesophagus. They are usually common in people of the age 60 years or older.

Pathophysiology A large pouch may fill with food that is regurgitated when the person bends over or lies down. This causes food to be inhaled into the lungs during sleep resulting in aspiration pneumonia. Rarely, the pouch enlarges and causes dysphagia.

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Assessment findings

Pathophysiology

Objective data. The clinical manifestations of diverticula are dependent on the size and the amount of food accumulated. The patient may complain of an odour caused by the stagnant food, a sour taste in the mouth, regurgitation of stagnant food, dysphagia and halitosis, pain in the chest and weight loss. Coughing may be evident and will be due to tracheal irritation from the regurgitated food, or from distension of the diverticula with pressure on the trachea. Weight loss may occur due to nutritional depletion.

The oesophagus has no serosal layer to limit its extension, which allows the tumour to spread rapidly. The oesophageal mucosa has a rich lymphatic supply which provides an excellent means for the tumour to spread widely. As the disease progresses, most patients experience pulmonary complications and aspiration occurs due to the formation of tracheo-oesophageal fistulae. The liver and lung are the most common metastatic sites. It may also spread to the trachea, bronchi and diaphragm depending on its location.

Diagnostic studies. A video X-ray that produces a moving image may be done during barium swallow to diagnose a pouch.

Assessment findings

Management A surgical excision of the diverticulum may be necessary if symptoms become severe. Small frequent meals should be encouraged. The patient should maintain an upright position to prevent nocturnal reflux of food.

Oesophageal neoplasms/cancer Definition

Neoplasms of the oesophagus may be benign or malignant. Benign tumours of the oesophagus are rare and mostly asymptomatic. Leiomyomas are the most common benign tumours encountered. Less frequently encountered are polyps, cysts, fibromas, adenomas and fibrolipomas. Malignant neoplasms of the oesophagus are usually the squamous cell epidermoid type. Adenocarcinoma of the oesophagus occurs less often than squamous cell cancer and develops primarily in the distal oesophagus.

Risk factors and incidence • Cancer of the oesophagus is related to a combination of alcohol and tobacco consumption. • Other important risk factors are chronic irritation, exposure to asbestos and metal. • Poor socioeconomic conditions. • A diet lacking fresh fruit and vegetables. • The presence of achalasia, hiatus hernia, strictures, reflux or poor oral hygiene increases the risk for oesophageal cancer. The incidence of oesophageal cancer increases with age. The prognosis is poor because the onset of symptoms is usually late in relation to the extent of the tumour, and early spread to the surrounding lymph nodes is common.

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Objective data • The most common symptom is dysphagia with solid foods which progresses to difficulty in swallowing liquids. • Substernal discomfort and pain occur as the tumour invades the deeper layers of the oesophagus and nearby structures such as the bronchus. Pain is, however, a late occurrence and may be felt over the neck, ears, shoulders and the jaw. • A sore throat and hoarseness of voice may occur if the tumour is in the upper third of the oesophagus. • Regurgitation and increasing dysphagia occur with oesophageal obstruction. • Loss of weight. • Bleeding occurs with the advancement of the disease and with the severity of the stenosis of the oesophagus. Diagnostic studies. Diagnosis of the cancer may be confirmed through X-ray examination and endoscopy. A biopsy and a smear may be taken from the lesion for cytology. Tumour invasion into the muscle layer may be confirmed by an endoscopic ultrasonography. To assess the extent of the disease computerised axial tomography (CT) scanning is done as well as magnetic resonance imaging (MRI).

Management The treatment of cancer of the oesophagus is mainly surgical or palliative, depending on the extent of the disease. Treatment may therefore be a combination of surgery, radiation and chemotherapy. The types of surgical procedures for treatment of oesophageal cancer are as follows: • Oesophagectomy, which is the removal of part of or the entire oesophagus, which is then replaced by a Dacron graft. It can be subtotal or total oesophagectomy. • Oesophagogastrostomy, which is the removal of a portion of the oesophagus. The remaining portion is then anastomosed to the stomach.

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• Oesophagoenterostomy, which is the resection of a portion of the oesophagus, stomach and part of the intestine. An anastomosis is performed between the remaining oesophagus and the intestine. • The surgical incisions used can be thoracic, abdominal or thoraco-abdominal. • Oesophageal dilatation can be done as part of palliative management to keep the oesophagus open and to assist with nutrition. A celestine tube may also be inserted through the constricted area of the oesophagus and is left in place to relieve dysphagia and improve nutrition. Long-term use of the tube may cause ulceration and bleeding. • A gastrostomy may be performed to maintain nutrition for the remainder of the patient’s life.

Principles of care for a patient undergoing oesophagectomy Preoperative care • Provide nutritional support via tube feeding or parenteral nutrition. • Monitor strict intake and output and weigh the patient daily. • Encourage and provide frequent mouth care to reduce discomfort and the risk of postoperative oral infection from retained or regurgitated food particles, blood or pus from the tumour. • Provide sufficient information to the patient and family about the planned surgery and expected outcomes. • Teach the patient about the wound drains and tubes, location and purposes to gain cooperation. • Instruct the patient about the importance of chest physiotherapy and deep-breathing exercises postoperatively. • Explain to the patient about the possible intubation and mechanical ventilation postoperatively. • Encourage the patient to verbalise feelings and ask questions. • For general preoperative preparation, read Chapter 20.

Postoperative care Maintain a patent airway and prevent aspiration. Nurse in semi-Fowler’s position, elevate the head end of the bed to 30 degrees, monitor respiratory rate and depth hourly, suction to remove excess secretions while careful not to disturb the anastomosis, restrict movement of the neck to prevent disturbing the anastomosis and initiate coughing and chest physiotherapy.

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Relieve pain. Administer adequate analgesia as prescribed, monitor neurological status and respiratory response, encourage sleep and rest, and avoid unnecessary movements and turnings. Maintain drainage systems as instructed. Ensure patency of the drainage systems, monitor colour and amount of drainage and report abnormalities. Maintain adequate nutrition. Keep the patient on nil per mouth for 5–7 days or as prescribed to promote healing, provide frequent oral hygiene to promote comfort, provide parenteral nutrition as prescribed, administer intravenous fluids as prescribed, monitor albumin levels and maintain to normal levels, and start with clear fluids when oral intake is permitted, then introduce small amounts of small, soft and bland diet at frequent intervals. Promote coping. Provide psychological support and refer for counselling when necessary. Nursing management. This is usually aimed at improving the patient’s nutritional status in preparation for surgery, radiotherapy and/or chemotherapy. A dietician should be consulted and where necessary, parenteral or enteral nutrition is initiated. This feeding programme should be continued postoperatively. For general postoperative care, read Chapter 22.

Alternative feeding modalities Alternative feeding modalities are indicated where: • the patient will not be able to swallow for prolonged periods following surgery of the mouth, larynx, oesophagus or stomach to allow affected structures to heal • the patient is not taking adequate amounts of food and fluids due to gastrointestinal disease processes • the patient is undergoing radiation therapy in the mouth or in the oesophagus • there is an increased risk of aspiration due to oesophageal obstruction. Alternative feeding modalities include: • Nasogastric tube feeding • Gastrostomy or jejunostomy tube feeding • Parenteral feeding. For alternative feeding modalities, read Chapter 6.

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Hiatus hernia Definition

A hiatus hernia, also known as a diaphragmatic hernia is a condition in which a portion of the stomach herniates through the oesophageal opening of the diaphragm that has become weak and/or enlarged, into the lower end of the thoracic cavity.

Incidence and causes Hiatus hernia occurs more often in men than in women. The causes of hiatus hernia are unknown but the contributing factors are: • Congenital muscle weakness • Structural changes such as weakening of the muscles of the diaphragm around the oesophagogastric opening • Factors which increase intra-abdominal pressure, eg pregnancy, abdominal tumours, obesity, tight underwear such as corsets, increased physical exertion as well as continual heavy lifting • An increase in age • Trauma • Poor nutrition • Prolonged weakness in which a recumbent position is assumed for long periods.

Pathophysiology Normally, the muscles in the diaphragm encircle the oesophageal junction and thus the stomach is prevented from ascending into the thoracic cavity. In a hiatus hernia, part of the stomach herniates upward into the mediastinal cavity through a weakness in the diaphragm, caused by

trauma or loss of muscle tone. The major clinical feature of hiatus hernia is the regurgitation of gastric contents. The reflux that is experienced by the patient may cause oesophagitis, or ulcerations with resultant bleeding.

Types of hiatus hernias Type I. Sliding or oesophagogastric hernias. This is one in which the oesophagogastric junction and a portion of the fundus of the stomach are displaced upwards into the thoracic cavity, but which can slide back into the abdominal cavity when an upright position is assumed. Type II. Rolling or paraoesophageal hernias. This is one in which the oesophago-gastric junction remains below the diaphragm but a sac-like portion of the peritoneum and all or part of the stomach herniates through the oesophageal opening into the thorax alongside the oesophagus. The complication of a rolling hernia may be obstruction from strangulation and the development of a volvulus (see Chapter 40 for definition).

Assessment and common findings Subjective data. The clinical features of hiatus hernia normally depend on the size of the hernia and the amount of displaced abdominal viscera, and include: • Heartburn due to regurgitation of acid fluid • Flatulence and belching • A feeling of fullness and dyspnoea • Dysphagia if the hernia is accompanied by oesophagitis or ulceration

a)

Oesophagus Diaphragm Stomach

Gastroesophageal junction Herniated portion of the stomach

b)

c)

Oesophagus Herniated portion of the stomach Diaphragm Gastroesophageal junction

Diaphragm

a) Normal oesophagus b) Sliding hiatal hernia c) Rolling or paraoesophageal hernia Figure 39.5  Types of hiatus hernia

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• Severe burning pain caused by bending over, large meals, alcohol and smoking and increased intraabdominal pressure. The pain is normally relieved by sitting or standing up. Diagnostic studies. Accurate diagnosis is dependent on diagnostic studies such as oesophagoscopy and a barium swallow which will show the position of the stomach in relation to the diaphragm. An oesophagoscopy may also be done to obtain a biopsy specimen for cytological studies. An electrocardiogram (ECG) may be done to differentiate the pain the patient presents with from that of angina pectoris. A detailed description of the pain and discomfort caused by hiatus hernia must be taken to differentiate it from the pain caused by gastric and duodenal ulcers.

Management Medical management. Antacids can be taken after meals and at bedtime. Surgical intervention. The goal of surgical intervention is to reduce reflux by enhancing the integrity of the lower oesophageal sphincter, repair the hernia below the diaphragm and narrow the oesophageal opening. Possible surgical procedures used are valvuloplasty or antireflux procedures. The surgical approach used may be thoracic or abdominal surgery. For general perioperative management, read Chapters 20, 21 and 22.

Nursing management The main goals of management are to protect the oesophagus from ulceration caused by acid reflux, and to prevent and manage complications.

Oesophageal vascular disorders The major oesophageal disorder which is of vascular origin is oesophageal varices which result from portal hypertension. This condition is discussed under disorders of the liver in Chapter 41.

Disorders of the stomach The stomach is a J-shaped organ that lies in the upper abdomen. It is composed of the fundus, body and antrum. The shape of the stomach changes with its contents. It has sphincters, namely, the cardiac sphincter which prevents the reflux from the stomach to the oesphagus, and the pyloric sphincter which prevents the reflux from the duodenum into the stomach. The function of the stomach is to digest food, secrete enzymes and serve as a reservoir to store food until digested. The rugae or folds on the stomach mucosa allow it to increase in size from a resting volume of 50 ml to about 1 500 ml for food digestion without major changes in pressure. Hydrochloric acid is secreted by the fundus and contributes to the acid medium inside the stomach. Bicarbonate which acts as a buffer to neutralise the acid secretions is secreted by the mucosal cells. Emptying of the stomach contents is controlled by hormonal and autonomic nervous system activity. The parasympathetic nervous system increases peristalsis and secretion, and the sympathetic nervous system inhibits them. Stomach contents are emptied into the duodenum through peristaltic contractions and the opening of the pyloric sphincter. The duodenum is the first part of the small intestine. Oesophageal sphincter Oesophagus

Essential health information • Advise the patent to wear loose underwear which does not constrict the body. • Eat small, frequent, bland meals which are high in fibre. • Drink lots of water, as this will help to wash the food down in the oesophagus after eating. • Eat the evening meal 3 hours before going to bed. • Avoid smoking and drinking alcohol and citrus juices. • Assume an upright or Fowler’s position, especially after eating and at night, to keep the stomach in the abdominal cavity. • Avoid bending, heavy lifting, coughing, vomiting or straining while passing stools. • Reduce weight if overweight, and join a weightloss support group.

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Pyforic sphincter

Rugae Stomach Figure 39.6  Structure of the stomach

The main function of the stomach is to deliver nutrients into the duodenum at a size and rate optimal for chemical digestion and absorption. In order to accomplish this role,

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the stomach displays a complex motor activity during and after the ingestion of food. The upper part of the stomach acts as a reservoir for large volumes of food without a substantial increase in intragastric pressure. The presence of food in the stomach stimulates peristaltic contractions that promote movement of the contents. Mechanical digestion occurs due to the continuous movement of food particles within the gastric antrum. In addition, the gastric mucosa releases gastric secretions such as hydrochloric acid and enzymes, which then result in the chemical digestion of nutrients. Absorption of food nutrients in the stomach is very limited. The two most important chemicals absorbed in the stomach are alcohol and acetylsalicylic acid. Fat and other foods that have not been chewed properly remain in the stomach for a long time.

Causes of disorders in the stomach • Excessive gastric secretions which erode the gastric mucosa causing ulceration. This may result in bleeding and pain. • Excessive motility, stretching and sudden contractions of the stomach which may also cause pain. An increase in peristaltic movements may result from an increased gastrocolic reflex or from the effort of the stomach to eliminate a local irritant, which may result in diarrhoea. • Retention of gastric contents which may result in nausea, anorexia, acid eructations and belching. When the stomach empties slowly, anorexia may result. Retention of gastric contents may also produce unpleasant stimuli or distention which then increases tension on the distal end of the oesophagus, the walls of the stomach and duodenum. This results in nausea and vomiting.

Inflammatory conditions of the stomach Acute gastritis Definition

Gastritis is the inflammation of the lining (mucosa) of the stomach. Gastritis may either be acute or chronic, as well as diffuse or localised.

Causes • Infection. Infections may be bacterial, viral or fungal, eg Staphylococci, Salmonella, rotavirus or Candida. Helicobacter pylori may be found living in the thick mucosal lining of the stomach and may result in acute or chronic inflammation. The infection can lead to ulcers and possibly even to cancer of the stomach in later life.

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• Autoimmune causes. The mucosal lining of the stomach may be attacked by the immune system leading to loss of stomach cells. This results in acute or chronic inflammation which can result in pernicious anaemia due to the inability of the body to absorb vitamin B12. Stomach cancer can occur later in life when the lining of the stomach becomes very thin and atrophies or is attacked by antibodies, thus losing many or all cells that produce acid and enzymes. This is common in people who have had a partial gastrectomy. • Medication. This could include aspirin, caffeine, alcohol-containing drugs and anti-inflammatory drugs which inhibit the synthesis of prostaglandins, resulting in an increase in the secretion of hydrochloric acid. • Diet. Especially with ingestion of spicy foods. • Reflux. Of bile salts from the duodenum into the stomach where the pyloric sphincter is lax. • Vomiting. Continuous vomiting may also cause a reflux of bile salts which act as an irritant to the stomach mucosa. • Stress. Physical, emotional and physiological stress may result in hypersecretion of hydrochloric acid (HCl), resulting in the inflammation of the gastric mucosa. • Inflammation. Hypertrophic gastritis occurs when the folds of the stomach become enlarged, swollen and inflamed. Very little is known about why this occurs. In Ménière’s disease, the gastric folds become enlarged. This condition is followed by protein loss into the stomach from the weeping folds. • Radiation. Radiation therapy causing inflammation of the stomach lining sometimes leads to the development of stomach ulcers. • Injury. Sudden severe illnesses or injury may cause acute stress gastritis. The injury does not have to be to the stomach; severe burns and injuries involving major bleeding are typical causes. • Parasites. Roundworm infestation may cause eosinophilic gastritis which results from a reaction to the worm infestation.

Pathophysiology The stomach tissue is protected from autodigestion by gastric acid secretions, pepsin and mucus. The mucosal lining barrier is composed of prostaglandins. When this barrier is broken or penetrated, the acid is able to diffuse back into the mucosa. On entering the stomach the hydrochloric acid (HCl) stimulates the conversion of pep­ sinogen into pepsin. Pepsin stimulates the mast cells to produce histamine. All these occurrences cause oedema and hyperaemia of the gastric mucosa with superficial erosion which can lead to bleeding due to injury of small vessels.

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Chapter 39 – Management of disorders of the upper gastrointestinal tract  751 Table 39.2  Causes of altered gastric motility and secretion

Altered function

Causes

Increased secretions

• Presence of food in the stomach • Sight, smell and taste of food • Prolonged anxiety • Conflict situations • Hostility, guilt or resentment

Decreased secretions

• Fear and depression • Presence of fats, carbohydrates and acids in the duodenum • Enterogastrone release

Increased motility

• Presence of appetising food • Hunger • Pleasant sensory stimuli • Stimulants such as alcohol and coffee • Emotions such as anxiety, hostility and resentment

Decreased motility

• Overeating which leads to gastric distension • Fat ingestion • Emotions such as pain, fear, shock and depression

Assessment and common findings Objective data. Some of the common symptoms are epigastric discomfort and abdominal tenderness, indigestion, feelings of fullness, cramps and belching, hiccups, anorexia, nausea and vomiting. Gastric haemorrhage and diarrhoea will be present if gastritis is caused by ingestion of contaminated food. Diagnostic tests. Diagnosis is based on a detailed medical history of food intake and medication. An endoscopy and biopsy of the stomach lining is done to confirm diagnosis and exclude cancer. A blood analysis is done to determine the presence of anaemia or infecting organisms. Stools are tested for occult blood and parasites.

Chronic gastritis Chronic gastritis is more common in older people. It also occurs in different forms, which are: • Superficial gastritis, which is evidenced by oedema and redness of the stomach mucosa. Small erosions with haemorrhages may also occur. • Atrophic gastritis, which affects all layers of the stomach and is associated with pernicious anaemia, gastric ulceration and gastric cancer. Autoimmune atrophic gastritis affects the fundus and body of the stomach.

Pathophysiology Chronic alteration of the protective mucosal barriers may cause progressive gastric atrophy which is accompanied

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by death of the chief and parietal cells. Parietal cells are acid secreting, and as these decrease because of atrophy of the gastric mucosa, hypochlorhydria progresses on to become achlorhydria. The loss of the acid-secreting cells results in the loss of the intrinsic factor, which normally facilitates the absorption of vitamin B12 in the ileum. Vitamin B12 is essential for the growth and maturation of red blood cells and because of the lack of this vitamin, pernicious anaemia may result. Hypertrophic gastritis This is evidenced by a nodular, irregular, thick and dull mucosa and frequent haemorrhages.

Assessment and common findings Same as for acute gastritis.

Nursing assessment A thorough nursing assessment must be done before a specific plan of care can be developed and this must be discussed with the patient and family. The focus should be on the risk factors, such as: • The patient’s diet, whether bland or spicy, eating patterns and a 72-hour dietary recall • Lifestyle in relation to alcohol consumption and tobacco use • Occupation • Possible stressors • Presence of pain • Presence of diarrhoea and composition of stool.

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For management, read Table 38.4, the general nursing care plan for disorders of the gastrointestinal system in Chapter 38.

Ulceration Definition

An ulcer is a break in the continuity of the skin or mucous membrane lining the alimentary canal that fails to heal. Ulceration is a sharply circumscribed area in which there is loss of tissue. Gastric secretions are capable of breaking down any living tissue but in the stomach these secretions occur in a diluted, neutralised and buffered form and therefore are incapable of digesting the stomach mucosa. Furthermore, the stomach mucosa has a thick layer of mucus which is highly protective. The gastric mucosa heals very quickly, which is also a protective measure. Autodigestion will occur if there is an alteration in either of these defence mechanisms.

39.1 Names of ulcers • Duodenal ulcers are the most common type of peptic ulcers and occur in the duodenum; these are associated with a high acid content • Gastric ulcers occur along the upper curve of the stomach and are considered to be less common • Oesophageal ulcers occur in the lower oesophagus due to repeated regurgitation of stomach acid into the lower part of oesophagus, resulting in oesophagitis and ulceration • Marginal ulcers may develop after surgical procedures, for example after gastrojejunal anastomosis, where part of the stomach is removed surgically and the remaining part is anastomosed or reconnected to the intestine or jejunum • Stress ulcers occur as a result of stressful environments, for example a severe illness, trauma or major surgery

Peptic ulcers Definition

identified and removed. It is usually a superficial erosion accompanied by very little inflammation. A chronic ulcer is of long duration, occurring intermittently throughout a person’s life and is accompanied by the erosion of the muscular wall, in addition to which there is formation of fibrous tissue.

A peptic ulcer is a well-defined round or oval excavation where the lining of the stomach or duodenum has been destroyed by stomach acid and digestive juices. It occurs as a hollowed-out area in the mucosal wall of the stomach. If the ulcer is shallow it is called erosion. The name of the ulcer identifies the anatomic location or the circumstances under which the ulcer developed.

Causes

Peptic ulcers can be acute or chronic, depending on the degree of mucosal involvement. An acute ulcer is of short duration and will quickly resolve when the cause is

An ulcer develops when the defence mechanisms protecting the gastric mucosa from stomach acid break down, for example when the amount of mucus production changes. The causes of such breakdowns are not known.

Oesophagus

Ulcer Mucosa

Duodenum Submucosa

Ulcer

Muscle

Figure 39.7  Peptic ulcer

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Chapter 39 – Management of disorders of the upper gastrointestinal tract  753

The increase in gastric juice secretion may be the result of: • Decreased inhibition of gastric secretions • Increased capacity or number of parietal cells to secrete acid, or increased response of the parietal cells to stimulation • Increased stimulation of the vagus nerve.

Risk factors • Smoking is associated with peptic ulcer disease. Smoking causes a reduction of pancreatic bicarbonate secretion thus creating a decreased pH in the duodenum. Nicotine is thought to enhance a reflux of duodenal contents into the antrum of the stomach. • The presence of biliary and liver disease increases the risk of ulcer formation. • Coffee, tea, fizzy drinks and foods that contain caffeine are thought to stimulate acid secretion in the stomach. • Certain medication, such as corticosteroids, aspirin and non-steroidal anti-inflammatory drugs like ibuprofen and reserpine, are associated with acute gastric ulcers which can become chronic. • Stress is thought to be accompanied by an increase in the secretion of stomach acid. This is due to increased vagal stimulation causing hypersecretion of hydrochloric acid. Increased concentrations of hydrochloric acid cause an alteration of the mucosal barrier. Duodenal ulcers are associated with a high acid content.

Pathophysiology Peptic ulcers develop in the presence of an acid environment and to this effect it has been established that individuals with pernicious anaemia and achlorhydria rarely develop peptic ulcers. Stomach acid is produced in different amounts and in different production patterns throughout life. People who tend to secrete high amounts of acid are at a greater risk of developing peptic ulcers than people who secrete low amounts. The stomach is also protected by the thick mucosal barrier from autodigestion. The gastrointestinal tract has a high cell turnover rate and the surface mucosa of the stomach is renewed about every 4–5 days. The mucosa is able to repair itself except in extreme instances when the rate of cell breakdown exceeds the rate of cell renewal. The mucosal barrier also prevents the back diffusion of acid from the gastric lumen through the mucosal layers to the underlying tissue. When this barrier is broken, the acid can diffuse back, enter the mucosa and cause injury to the tissues. This also results in the release of histamine from the damaged mucosa. The histamine released is

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capable of stimulating a further secretion of acid and pepsin. Adrenocorticosteroids may also increase the suscep­ tibility of the mucosa. They also reduce the rate of mucosal cell renewal and the formation of granulation tissue. Stressful events have been shown to affect the development of peptic ulcers. This is more common for the duodenal than the gastric ulcer. When individuals are faced with stressful situations, the sympathetic nervous system is activated, causing the blood vessels in the duodenum to constrict, thus making the mucosa more vulnerable to injury from the secretion of gastric acid and pepsin. The adrenal cortex is also activated, decreasing the production of mucus. Stress ulcers may occur as a result of prolonged stress from severe trauma such as burns, severe sepsis, shock and multiple organ traumas. Other factors that are known to destroy the mucosal barrier are the presence of Helicobacter pylori bacteria in the stomach. It is not known how the bacteria contribute to ulcer formation. The bacteria are thought to interfere with the normal defences against stomach acid, or they may produce toxins that contribute to ulcer formation. Certain medication contribute to gastroduodenal ulceration by altering gastric secretion, producing localised damage to the mucosa and interfering with the repair or healing process. Ulcers are rarely caused by excessive amounts of the hormone gastrin, which is produced by certain tumours. In Zollinger-Ellison syndrome there is a nonislet cell tumour of the pancreas called a gastrinoma. This tumour secretes high levels of gastrin without relation to the normal factors that cause the antral cells to secrete gastrin. The abnormal blood level of gastrin increases the volume of gastric secretions and results in multiple ulcers of the duodenum. The tumour is very difficult to locate and results in multiple locations through metastasis. In such cases, total gastrectomy must be done to stop the acid secreting ability of the stomach. Although gastric and duodenal ulcers are defined as peptic ulcers, they are distinctly different in their causation and incidence as indicated in Table 39.3.

Assessment and common findings Subjective data Pain. Chronic and periodic pain is the most common and typical symptom in ulcer disease. The mucosal lining of the stomach and the duodenum are not very rich in sensory pain fibres and it is common for pain to be absent for an individual with gastric or duodenal ulcers. If pain is present, it is described as gnawing, aching, burning and cramp-like and it is related to food intake.

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754  Juta’s Complete Textbook of Medical Surgical Nursing Table 39.3  Comparison of duodenal and gastric ulcers

Assessment data

Duodenal ulcers

Gastric ulcers

Lesion

Penetrating

Superficial with smooth margins which can be round, oval or cone shaped

Location of ulcer

First 1–2 cm of the duodenum

Junction of fundus and pylorus; can also be found in the body of stomach, or in the antrum

Incidence

• 80% of peptic ulcers are duodenal • Greater in men but also in postmenopausal women • Between the ages of 25 and 50 years • Associated with psychological stress • Increases with smoking, drugs and alcohol use • Associated with other diseases, eg chronic obstructive pulmonary disease, pancreatic diseases, chronic renal failure, Zollinger-Ellison syndrome, hyperparathyroidism

• 15% of peptic ulcers are gastric ulcers • Greater in women • Peaks between the ages of 45 and 54 years • More common in people of lower socioeconomic status and unskilled labourers • Increases with smoking, drug and alcohol use • Increases with incompetent pyloric sphincter • Increases with stress after severe trauma, burns and major surgery

Acid secretion

Increased

Normal to decreased

Serum pepsinogen I

Increased

Normal

Associated gastritis

None

Common and increased

Bleeding pattern

Melaena more common than haematemesis

Haematemesis more common than melaena

Pain

• Burning, cramping, pressure-like pain across midepigastrium and upper abdomen, back pain with posterior ulcers • Pain occurs on an empty stomach • Episodic pain 2–4 hours after meals • The pain is usually relieved by antacids and food • Occasional nausea, vomiting and weight loss

• Burning or gaseous pressure in upper left epigastrium • Pain 1–2 hours after meals • Pain may be worsened by food. • Antacids are ineffective • Occasional nausea and vomiting

Nutritional status

Usually well nourished

Probably malnourished

Potential for malignancy

Rare

Occurs in 10% of individuals

Recurrence rate

High – may occur as marginal ulcers after surgery

Recurrence unlikely with surgery

Serum gastrin: Fasting

Normal

Elevated

Risk factor

Alcohol, smoking, cirrhosis of the liver and stress

H. pylori, gastritis, alcohol, smoking, use of non-steroidal anti-inflammatory drugs (NSAIDs) and stress

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The pain in duodenal ulcers is often located in the right mid-epigastrium below the xiphoid process. Ulcers located on the posterior aspect of the duodenum are manifested by back pain. Individuals with duodenal ulcers have typical symptoms of gnawing and burning pain. The pain tends to occur when the stomach is empty and usually occurs in the early hours of the morning as well as mid-morning between breakfast and lunch. The pain is relieved by drinking milk, eating or administration of antacids; but it usually returns 2–3 hours later. In gastric ulcers the pain is mainly felt high up in the epigastrium. The pain is localised to the left of the midline and is not relieved by eating. Gastric ulcers extend to the small intestine. This results in slow passage of food out of the stomach causing bloating, nausea or vomiting after eating. With oesophageal ulcers, the pain is felt while swallowing or lying down. Nausea and vomiting. Vomiting occurs often with gastric ulcers and occurs frequently if the ulcer is located in the upper pylorus or antrum. Vomiting may or may not be preceded by nausea and it usually follows bloating and a severe bout of pain which is relieved by the ejection of stomach contents. Vomiting undigested food which was eaten many hours earlier is suggestive of a gastric ulcer or pyloric obstruction. The presence of an oesophageal tear should be suspected if vomiting is accompanied by severe retching. Heartburn or pyrosis. Heartburn may be present and it is accompanied by a sudden accumulation of gas in the stomach. Constipation or diarrhoea. This may result from the diet or medication. Bleeding. This occurs in 25% of cases of gastric ulcers as a result of an erosion of a blood vessel. It may occur as a massive observable haemorrhage or as progressive occult bleeding. Diagnostic tests Diagnostic tests are needed to confirm the presence of ulceration because gastric cancer can present with similar clinical features. The following diagnostic procedures may be done: • Endoscopy to detect lesions that are not evident on X-ray studies due to their size or location. An

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endoscopy can also be performed to stop bleeding from an ulcer. During an endoscopy, a biopsy may be done to exclude the presence of gastric cancer or to identify the presence of Helicobacter pylori. • Barium contrast X-rays of the stomach and duodenum when an endoscopy fails to reveal the presence of an ulcer. • Gastric analysis to evaluate the amount of gastric acid secreted in the stomach. • Blood tests to detect anaemia resulting from a bleeding ulcer. Other blood tests may include the urea breath test to detect the presence of Helicobacter pylori.

Complications of peptic ulcers Peptic ulcers can develop potentially life-threatening complications, such as the following: Haemorrhage. Haemorrhage is the most common complication of peptic ulcers and it can vary from minimal, evidenced by occult blood in the stool (melaena), to massive in which the patient vomits bright red blood (haematemesis). Duodenal ulcers account for a greater percentage of upper gastrointestinal bleeding episodes than gastric ulcers. If the bleeding is severe, the patient may show signs of shock such as hypotension, palpitations, weak and thready pulse, chills and perspiration. A slight weakness and diaphoresis may occur when the bleeding is mild. In severe bleeding, blood volume should be replaced to prevent dehydration, shock and electrolyte imbalance. An endoscopy may be performed to locate the bleeding ulcer and cauterise it. Surgical intervention may be necessary if the bleeding is massive or persistent. Obstruction. A patient with an obstruction will have a long history of ulcer pain. The long-standing ulcer disease causes scarring from the repeated ulcerations and healing. Swelling of inflamed tissues around an ulcer and scarring can narrow the outlet from the stomach, or narrow the duodenum. Obstruction is evidenced by a generalised pain over the upper abdomen which worsens as the stomach fills and dilates. The pain will be relieved by belching or vomiting. Vomiting is projectile and of an offensive odour if the contents have been in the stomach for some time. Vomiting can cause weight loss, dehydration and an imbalance in body minerals. Other clinical manifestations are swelling in the upper abdomen and loud and visible peristaltic waves over the abdomen. Severe obstruction may require surgical intervention.

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Perforation. Perforation occurs when ulcers on the duodenum (or less commonly in the stomach) go through the wall and create an opening into the free space in the abdomen. Perforation is a surgical emergency and it is also considered to be the most lethal complication of peptic ulcers. Perforated duodenal ulcers are normally found on the posterior mucosal wall and perforated gastric ulcers are found on the lesser curvature of the stomach. Duodenal ulcers are said to perforate more frequently, but high mortality rates are associated more with gastric ulcers. When a perforation occurs there is a spillage of the gastric or duodenal contents into the peritoneal cavity. The spillage is made up of swallowed saliva, air, food particles, hydrochloric acid, bile, bacteria, pancreatic fluid and enzymes. Within 6–12 hours of the spillage peritonitis occurs, followed by paralytic ileus. The clinical manifestations of perforation are characterised by: • A sudden onset with an intense and steady pain that spreads throughout the abdomen • The spillage also causes irritation to the phrenic nerve, resulting in a radiation of the pain to one or both shoulders • The pain intensifies with deep breathing and changes in position and the patient may lie very still • In order to protect the abdomen from further injury, the abdominal muscles contract, become rigid and board-like and bowel sounds are absent denoting functional obstruction – this is called ‘guarding’ • The patient’s respirations become shallow and rapid • Nausea and vomiting may occur. Penetration. Penetration occurs when an ulcer goes through the muscular wall of the stomach or duodenum and continues into adjacent structures such as the pancreas, the biliary tract or the gastrohepatic omentum. The clinical manisfestations of penetration are an intense, piercing and persistent pain which is felt outside the area involved, for example back pain when a duodenal ulcer penetrates the pancreas. The pain is not relieved by medication that was effective in the past.

Management of perforation and penetration • Immediate replacement of fluid, blood and electrolytes; and administration of antibiotics is necessary to combat peritonitis. • Nasogastric suction should be started immediately to drain gastric secretions and prevent further spillage. The nasogastric tube should remain in the stomach until peristaltic movements return.

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• Penetration requires surgical intervention which is also necessary to close a large perforation. Smaller perforations normally seal by themselves through the production of large amounts of fibrin produced in response to the perforation. The symptoms cease as soon as sealing occurs. • Complications such as subphrenic abscess, duodenal and gastric fistulae, pneumonia, atelectasis and haemorrhage may occur postoperatively. Medical management of peptic ulcers. The goals of treatment of a patient with peptic ulceration are to: • Prevent complications to the ulcerative process • Reduce discomfort related to peptic ulcer disease • Allow the ulcer to heal completely • Make appropriate lifestyle changes to prevent recurrence • Encourage compliance with the prescribed therapeutic regimen. The gastric mucosa is able to regenerate and once the causal agent has been removed the ulcer will heal. In order to achieve results, it is important to promote mental, physical and gastric rest. The patient and family will need emotional support and education as they learn to identify the stressful factors in their lives and learn to either eliminate or cope with them. Pharmacological management. Pharmaceutical preparations include antacids, hyposecretory drugs, anticholinergics, histamine (H2) antagonists, prostaglandin analogues, mucosal barrier fortifiers or cytoprotective agents and proton pump inhibitors (see Table 39.4).

Helicobacter pylori treatment. Helicobacter pylori is a bacterium responsible for more than 90% of ulcers. Multidrug regimens are needed to heal ulcers caused by this organism. These regimens consist of antibiotics, proton pump inhibitors, H2 blockers and cytoprotective agents. Also available in combination products are helidac and prevac which contain a combination of the above drug classes, for example bismuth subsalicylate, metronidazole and tetracycline combination (helidac) and lansoprazole, clarithromycin (prevac) and amoxicillin. Surgical management. Surgical management of ulcers is seldom needed because of the effectiveness of drug therapy. Surgery is used primarily for recurring ulcers and to deal with complications of peptic ulcers such as perforation, acute obstruction, acute intractable haemorrhage, or a gastric ulcer that is suspected of being cancerous.

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Chapter 39 – Management of disorders of the upper gastrointestinal tract  757 Table 39.4  Examples of medication commonly used to treat peptic ulcer disease

Pharmacological

Action

Side effect

Implications for nursing

Amphogel

Neutralises and buffers acid in the gastrointestinal tract

Anorexia, constipation

• Give 1–2 hours after meals and at night before bed • Monitor and treat constipation

Aluminium–magnesium combination, eg Maxolon, Gelucil

Reduces pepsin activity by increasing gastric pH and strengthens the gastric mucosal barrier

Mild constipation and diarrhoea

• Prohibited in patients with renal disease • Monitor and treat constipation • Do not give within 1 hour of H2-receptor antagonists

Magnesium oxide

Increases gastric pH to reduce pepsin activity and strengthen the gastric mucosal barrier

Diarrhoea, nausea and hypermagnesaemia

• Do not use in patients with renal disease • Do not give within 1–2 hours of H2-receptor antagonists

Histamine 2-antagonists ranitidine (Zantac®)

Blocks H2 receptors or parietal cells thus inhibiting gastric acid secretion

Side effects are rare but nausea, constipation, bradycardia and headache may occur

• Antacids given 1–2 hours after Zantac®

Cimetidine (Tagament®)

Same as ranitidine, inhibits acid secretion

Headache, dizziness, fever, and rash can cause confusion in the elderly or those with renal or hepatic insufficiency

• Monitor mental status in the elderly • Do not administer antacids within 1 hour of cimetidine • Long-term use may cause diarrhoea and impotence

Famotidine (Pepcid®)

Same as ranitidine, inhibits acid secretions

Headache, nausea, diarrhoea, constipation, increased blood urea, nitrogen and creatinine

• Do not administer for more than 8 weeks • May be combined with antacids

Protects the gastric mucosa from ulcerogenic agents and increases mucus production

Diarrhoea and abdominal cramping including uterine cramping

• Not to be used in pregnancy because it can cause abortion, premature birth or birth defects if given in the first trimester • Administer with food • Use with caution in patients with renal impairment

Antacids

Hyposecretory agents

Prostaglandin analogues Misoprostol (Cytotec®)

❱❱

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Pharmacological

Action

Side effect

Implications for nursing

Inhibits secretion of gastric acid when given in large doses

Large doses will cause dryness of the mouth, blurred vision, constipation, urinary retention, paralytic ileus and tachycardia

• Very rarely used because of their tendency to decrease gastric motility. This causes stasis of secretions thus increasing the pain and discomfort • Monitor vital signs, urinary output and bowel action • Ensure adequate fluid intake and mouth care • Ensure safety of the patient

Sucralfate (Carafate®)

Forms a viscid and sticky gel that adheres to ulcer surface, forming a protective barrier

Constipation, indigestion, flatulence, dizziness, sleepiness, nausea, dry mouth and gastric discomfort

• Administer on empty stomach • Monitor constipation: sucralfate is • absorbed minimally to lessen adverse reactions

Bismuth subsalicylate (Pepto-bismol®)

Forms a protective barrier Inhibits H. pylori activity

Neurotoxidty, patient could have an allergic reaction to bismuth and salicylates

• Bismuth and salicylates may cause the tongue and stools to darken – do not confuse with melaena • Administer 30 minutes before or after antacids • The tablets should be chewed and swallowed • Take adequate fluids especially with bedtime dose to decrease the risk of oesophageal irritation and ulceration • Double doses are not to be taken if a dosage is missed

Decreases gastric acid secretions by slowing the ATPase pump on the surface of parietal cells; promotes healing in a shorter period than H2 inhibitors; it also has antimicrobial activity against H. pylori

Abdominal pain, anorexia, nausea, constipation or diarrhoea, dry mouth, dyspepsia, faecal discolouration, cardiospams and headache

• Swallow the whole capsule, do not chew to delay release • Take before meals • Useful in treating people with oesophagitis with or without oesophageal ulcers

Anticholinergics Dicyclomine hydrochloride (Bentyl®)

Mucosal barrier fortifier

Proton pump inhibitors Lansoprazole (Prevacid®)

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Chapter 39 – Management of disorders of the upper gastrointestinal tract  759

Pharmacological

Action

Side effect

Implications for nursing

Omeprazole (Prilosec®)

Same as for lansoprazole

Abdominal pain, diarrhoea, nausea and headache

• Long-term use may cause stomach tumours and bacterial invasion • Also used to treat conditions that affect gastric acid secretion, eg Zollinger-Ellison syndrome

Pantoprazole sodium (Protonix®)

Same as for lansoprazole

Same as lansoprazole

• Can be taken orally or administered intra­ venously in hospital

The goals of surgical management are to: • Reduce acidity and allow the ulcer to heal • Re-establish the patency of the lumen of the bowel by removing or relaxing the pyloric scar or by creating a new exit for the stomach contents if there is an obstruction. Types of surgery. Two surgical approaches are commonly used to reduce acidity, namely vagotomy, which involves severence of the vagus nerve to eliminate stimulation of the acid-secreting gastric cells, and antrectomy, which is removal of the acid-secreting portions of the stomach. There are three ways of doing vagotomy: 1. Truncal vagotomy, which interrupts the parasympathetic innervation to the stomach, bile ducts, liver, pancreas and small intestine. 2. Selective vagotomy which eliminates vagal stimulation to the entire stomach. Since the vagus nerve stimulates gastric motility, the stomach empties slowly causing a feeling of fullness, belching and weight loss. 3. Proximal vagotomy, also called parietal cell vagotomy is a procedure in which the branches of the vagus nerves which supply the acid-secreting portions of the stomach are cut. Motility is increased and the need for a gastroenterostomy is eliminated. An antrectomy or subtotal gastrectomy refers to surgery that involves partial removal of the stomach, thus eliminating the acid-secreting cells. The extent of the reduction of acid is determined by the amount of stomach removed. A vagotomy may accompany a partial gastrectomy. Pancreatic secretions and bile continue to be secreted into the duodenum after gastrectomy to continue the digestive process and therefore a route is preserved for them to reach the chyme.

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A Billroth I gastrectomy is surgery for the removal of a part of the distal portion of the stomach, which contains the cells that secrete gastrin; and an anastomosis is established between the stomach and duodenum (gastroduodenostomy). This operation decreases the incidence of dumping syndrome which often occurs with a Billroth II gastrectomy. A Billroth II gastrectomy involves resection of the distal portion of the stomach and the establishment of an anastomosis between the stomach and jejunum (gastrojejunostomy). Recurrent ulceration develops less frequently with Billroth II gastrectomy (see Figure 39.8). Nursing management of the patient with ulcer disease. The goal of nursing management is to promote recovery by: • Helping the patient achieve total physical and mental rest by relieving pain • Maintaining nutrition • Reducing anxiety • Encouraging compliance with prescribed therapeutic regimens to manage and prevent recurrence of ulcers, including complications

a) a)

a) Billroth I: Gastroduodenostomy b) Billroth II: Gastrojejunostomy Figure 39.8  Billroth gastrectomies

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• Providing emotional support to the patient and family and assisting them to identify stressful factors in their lives and learn to eliminate or cope with these. The patient usually presents with pain, anorexia, nausea and vomiting, and haemorrhage in complicated ulcers. Consult the general nursing care plan for more information (Table 38.4 in Chapter 38).

Cancer of the stomach Cancer of the stomach can affect any part of the stomach.

Causes The exact cause of stomach cancer is not known.

Risk factors • Diet appears to be a significant factor in the causation of gastric cancer, specifically items such as large amounts of nitrates and nitrites, large amounts of smoked foods and spices, salted fish and meat, foods high in starch and low in fibre. • Excessive smoking and alcohol abuse. • Family history of non-polyposis colon cancer, familial adenomatous polyposis, stomach cancer, blood type A and exposure to environment factors such as dust. • Infections such as chronic inflammation of the stomach, especially chronic atrophic gastritis with intestinal metaplasia and Helicobacter pylori infection. • Some diseases, for example megaloblastic (pernicious) anaemia, collagen disorders, dermatomyositis and gastric ulcers. • The incidence of gastric cancer increases with age and is more common in men than it is in women.

Pathophysiology The most common cancers of the stomach are adenocarcinomas, melanomas, lymphomas and leiomyosarcomas. Squamous metaplasia is rare. The spread of cancer is directly through the mucosal lining. Contiguous spread is through the wall of the stomach, which then involves the adjacent extension to the pancreas. The lymphatic spread occurs early and involves the local, regional and distal lymph nodes. Haematogenous spread to the liver, lung and bones occurs at varying times. Intraperitoneal spread through lymph occurs later in the disease and may in females extend to the ovaries (Krukenberg’s tumour). The spread of cancer by the mentioned routes is dependent mainly on the location of the tumour and the type of growth it undergoes, since some ulcerate while others penetrate or spread along the tissue planes. The prognosis is poor if metastasis is present.

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Assessment findings Symptoms may be absent in the early stages of gastric cancer. The symptoms occur late and are vague and indefinite unless haemorrhage or perforation occurs. Symptoms also depend on where in the stomach the tumour occurs. If the tumour begins on the lesser curvature, symptoms are absent because there is little disturbance of gastric function. If the tumour is near the cardia, the patient may experience difficulty in swallowing (dysphagia) from the early involvement of the oesophagus; and if it is near the pylorus symptoms may occur because of obstruction. In most cases patients will present with the same symptoms as gastric ulcer. In addition there may be: • A progressive loss of appetite • Indigestion, which may be vague and often accounts for the delay in diagnosis, because it is insidious and the symptoms are not recognised as abnormal • Occult blood in stools • Anaemia from blood loss • Nausea and vomiting which may indicate an obstruction at the pylorus or the cardiac orifice – the vomitus is usually of a coffee-ground colour due to slow leaks of blood from the ulceration of the cancer • Bone pain which may be indicative of metastasis • Pain in the epigastrium which is a later assessment finding and is induced by eating and relieved by vomiting. Objective data. Physical examination will reveal the following: • Weight loss that is accompanied by weakness, haemorrhage, anaemia, obstruction and metastases especially to the liver • The presence of a palpable abdominal or epigastric mass and ascites. Diagnostic studies • Full blood count and blood chemistry • Upper gastrointestinal tract radiography and endoscopy which will afford visualisation and provide a means for obtaining tissue samples for histological or cytological review • Chest X-rays for metastasis in the lungs • Bone or liver scan to determine extent of the disease.

Management Nursing management is based on the following nursing diagnoses: • Risk of anxiety related to the prognosis of the disease and knowledge deficit about treatment and care

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• Altered nutrition, less than body requirements related to the disease process and anorexia • Altered comfort due to reported pain related to metastasis. Refer to the general nursing care plan for disorders of the gastrointestinal tract in Chapter 38 (Table 38.4).

Surgical management Surgical intervention is the treatment of choice for gastric carcinomas. The usual procedure is a partial or total gastrectomy depending on the size and the extent of the tumour. Lymph nodes may be removed. If there are metastases to other vital organs such as the liver, the tumour is left in situ and palliative bypass surgery is performed, for example gastroenterostomy or gastrojejunostomy. In total gastrectomy, the oesophagus is anastomosed to the jejunum (see Figure 39.9). Oesophagus Duodenum

Diaphragm Stomach Oesophagus Diaphragm

Duodenum

Jejunum

Figure 39.9 Total gastrectomy with anastomosis of the oesophagus to the jejunum

Radiation therapy is not always effective because gastric tumours do not respond to radiation; and high doses of radiotherapy are contraindicated because of the effect on organs such as the pancreas, kidneys, liver and the spinal cord. Chemotherapy may be used to control rather than cure the disease. Combined chemotherapy agents have been found to be more beneficial than single treatment. Chemotherapy has also been used to provide palliation in the management of metastatic disease. Pre- and postoperative care for gastric surgery. The goals are to: • Reduce fear and anxiety • Relieve pain • Maintain nutrition • Educate the patient and family about the specific surgical procedures and postoperative care • Manage and avoid complications

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• Continue with care and follow-up management • Enhance self-care skills at home. For general pre-, intra- and postoperative care, refer to Chapters 20, 21 and 22.

Complications after gastric resection A marginal ulcer develops when gastric acids come into contact with the operated site, which may cause haemorrhage, perforation, scarring, or obstruction. Alkaline reflux gastritis occurs after pyloroplasty or gastrojejunostomy from the reflux of duodenal contents after gastric surgery in which the pylorus has been bypassed or removed. Haemorrhage is usually caused by injury to the splenic artery or slippage of a ligature. Nutritional problems may develop as a result of the gastrectomy performed, where there is a shortage of the intrinsic factor which results in inadequate absorption of iron and indigestion from the rapid entry of food into the bowel. Nutritional problems include vitamin B12 and folic acid deficiency, megaloblastic anaemia, pernicious anaemia, calcium and vitamin D metabolism disorders. Dumping syndrome is a complication that occurs soon after gastric resection and subsides in 6–12 months. The gastric contents are normally delivered into the intestine via the pylorus in very small amounts. After gastrojejunostomy, the chyme, especially that which is rich in carbohydrate, passes rapidly into the jejunum before it has undergone the necessary dilution and digestive changes. This leads to a rapid distension of the jejunum and the drawing of extracellular fluid into the lumen to dilute the concentrated carbohydrate-rich chyme. The release of insulin leads to hypoglycaemia-like symptoms. Early manifestations of dumping syndrome include a feeling of fullness, sweating, pallor, vertigo, palpitations, diarrhoea, nausea and the desire to lie down. Steatorrhoea may also be a result of rapid gastric emptying. Dumping syndrome is managed by: • Decreasing the amount of food taken at any one time. Gastric emptying is delayed by not taking fluids with meals. Gastric emptying can also be delayed by the use of antimotility medication. • Encouraging the patient to assume a recumbent or semi-recumbent position during meals. Surgical management includes reducing the size of the gastroenterostomy or converting a Billroth II resection into a Billroth I by inserting a short segment of jejunum between the duodenal stump and the remaining stomach.

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Peritonitis Definition

The peritoneum is the membrane that lines the wall of the abdomen and covers the abdominal organs. Peritonitis is the inflammation and infection of the peritoneum, often caused by introduction of infective material into the otherwise sterile peritoneal environment through: • Perforation of the bowel such as a ruptured appendix, colonic diverticulum, a perforated ulcer, perforated gall bladder or a lacerated liver thereby introducing chemically irritating material such as gastric acid, bile or blood. In female patients, localised peritonitis most often occurs in the pelvis secondary to pelvic inflammatory diseases, eg infected fallopian tube or a ruptured ovarian cyst. Other causes include penetrating injuries from stab wounds or blunt trauma from blows, abdominal surgery or peritoneal dialysis. • Common causative organisms are E. coli, Streptococci, Staphylococci, Pneumococci, Klebsiella and Pseudomonas. • Tuberculous peritonitis is a significant problem among patients with HIV diseases and the presenting symptoms are often non-specific and insidious in onset with low-grade fever, anorexia and weight loss.

Pathophysiology In peritonitis, the flow of blood to the inflamed area is increased resulting in congestion and increased permeability of the membrane. This facilitates the production of large amounts of fluid containing protein and electrolytes that flow into the potential space leading to electrolyte imbalance, dehydration, hypovolaemia and in severe cases, shock. In cases of perforation the fluid mixes with gastric or intestinal contents and becomes infected. Similarly, with trauma or surgery, organisms may be introduced into the peritoneal cavity. Initially the bowel becomes irritated and there is hypermotility, soon to be followed by paralysis, whereupon the bowel is distended with no bowel sounds. At this point the body may create a natural barrier to try and localise and control the inflammation manifested by muscular rigidity described as ‘guarding’. An abscess may develop from the localised infection. When healing occurs, the infected peritoneum may cling to intestines, forming adhesions. As healing progresses the adhesions may shrink and disappear, or may form constrictions that press on the involved structures causing intestinal obstruction.

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Assessment and common findings Objective data • Abdominal pain and rebound tenderness over the involved area are the most common symptom of peritonitis. • There is guarding and abdominal distension or ascites, and paralytic ileus develop as inflammation progresses. • Systemic manifestations include fever, nausea and vomiting, and symptoms of early shock such as tachycardia, tachypnoea, oliguria, restlessness, weakness and pallor. Diagnostic tests • Abdominal X-rays can be taken with the patient lying down or standing. In cases of perforation, free gas can be seen in the abdomen. • Fluid can also be aspirated from the abdominal cavity for culture and sensitivity to identify the causal organism and also to relieve distension (abdominal paracentesis). • Blood tests for serum electrolytes can also be done. • Peritoneoscopy can be done in patients without ascites.

Management The goals of management are to: • Identify and eliminate the cause • Relieve abdominal pain • Combat infection • Maintain normal nutritional status • Prevent complications. The first measure is emergency exploratory surgery, especially when appendicitis, perforated peptic ulcer or diverticulitis seems likely. For acute pancreatitis or pelvic inflammatory disease in female patients, antibiotic treatment is the preferred line of action. Fluids and electrolytes may be given intravenously to replace lost fluids. Analgesics may be administered for pain and a nasogastric tube inserted to relieve distension. Nursing management. The patient with peritonitis is extremely ill and therefore needs supportive and skilled care, careful monitoring of vital signs, gastrointestinal function and ongoing assessment of pain, fluid and electrolyte balance. • Bed rest is important. The patient should be nursed in a semi-Fowler’s position to support ventilation and increase comfort. Alternatively the patient should be placed on the side with knees flexed to decrease tension on the abdominal organs.

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• The patient should be monitored for pain and response to analgesic therapy. Report the nature of pain and its location in the abdomen. • Strict monitoring and recording of intake and output, and adjustment of IV lines are important. The fluid shifts that cause hypovolaemia and shock need aggressive management. • Drains will be inserted postoperatively. The character of the drainage, amount and odour must be observed and recorded. Care must be taken when turning the patient that the drains are not dislodged. • A nasogastric tube will be inserted and connected to a drainage bag to relieve distension from gastrointestinal contents including gas in intestinal obstruction. • Antiemetics should be administered as ordered to decrease nausea and vomiting and further fluid losses. Fluid and food intake will be determined by the patient’s response to treatment. Signs that indicate that peritonitis is subsiding will include a decrease in temperature and pulse rate, softening of the abdomen, return of peristaltic sounds, passing of flatus and bowel movements. Fluids and food intake should be increased gradually as ordered. Nutritional management with parenteral feeding may be necessary when sepsis is severe. • Comfort measures should be carried out, namely frequent mouth and basic hygiene. Measures to

decrease anxiety should be instituted, for example provide the patient and family with information about the condition and ongoing care, and listen attentively to their concerns.

Essential health information Education is important because peritonitis develops rapidly and creates a serious and frightening situation for the family and the patient. The nurse should: • Reinforce teaching about the nature of the problem and its management • Provide ongoing support and encouragement • Encourage free verbalisation of concerns and anxiety • Encourage early ambulation to minimise complications • Teach normal coping mechanisms • Teach wound management to the patient and family • Introduce home-care health services • Prepare for discharge, and include referrals and advice regarding follow-up appointments.

Conclusion It is essential to promote health related to conditions of the mouth as the disorders of the mouth may affect the oesophagus and stomach. The role of the nurse is to provide health education regarding oral care and lifestyle modification to prevent disorders of the stomach and oesophagus.

Suggested activities for learners Activity 39.1 Design an information leaflet highlighting the effectiveness of lifestyle modifications recommended for patients with gastroesophageal reflux disorder (GERD).

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40

Management of disorders of the lower gastrointestinal tract

learning objectives

On completion of this Chapter, the learner should be able to: • outline the classification of lower gastrointestinal tract disorders • describe the aetiology, pathophysiology, clinical manifestation, therapeutic and pharmacological interventions in patients presenting with disorders of the lower gastrointestinal tract • describe the assessment of patients suffering from disorders of the lower gastrointestinal tract • interpret the assessment data including the result of the diagnostic tests in patients suffering from conditions of the lower gastrointestinal tract • plan, implement and evaluate scientifically correct nursing care, based on assessment findings in patients presenting with disorders of the lower gastrointestinal tract • describe the management of emergencies and complications related to the disorders of the lower gastrointestinal tract. key concepts and terminology

caecostomy

A surgical opening through the abdominal wall into the caecum to allow for passage of bowel contents in cases where this cannot be affected through the large intestine due to trauma.

choledochojejunostomy

Opening between common bile duct and jejunum.

colostomy

Opening into the colon to allow temporary or permanent drainage of bowel contents.

diverticulitis

Inflammation of a diverticulum resulting in abscess formation.

diverticulum

A scale-like outpouching of the lining of the bowel.

fistulectomy

Surgical removal of a fistula or excision of a fistula.

fistulotomy

Incision of a fistula.

ileostomy

Opening into the ileum.

small intestine

The longest portion of the gastrointestinal tract extending from the stomach to the caecum consisting of the duodenum, jejunum and ileum.

volvulus

A loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction.

prerequisite knowledge

• Anatomy and physiology of the gastrointestinal system including that of the accessory organs of digestion • The principles of scientific record-keeping • A basic understanding of the professional, ethical and legal practice framework of nursing in South Africa • Also read Chapter 38.

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medico-legal considerations

Nurses may be guilty of malpractice as a result of failure to assess patients thoroughly; resulting in inadequate care, or the development of complications. The nurse has the obligation to participate in the preparation for diagnostic and operative procedures undertaken. essential health literacy

Many complaints relating to the lower GIT are related to diarrhoea or constipation and both of these can present with or without abdominal pain. Because of diarrhoea and constipation and abdominal pain or discomfort, patients tend to self-medicate to stop the diarrhoea and/or pain, or relieve the constipation. Most would take constipating substances for diarrhoea and laxatives, purgatives and sometimes herbal enemas for constipation. In some instances this self-medication, especially for constipation, ends up causing terrible diarrhoea with dehydration, especially in children and the elderly. Patients should be advised not to self-medicate in cases of abdominal pain, diarrhoea or constipation. For diarrhoea and constipation the best cure is water and other fluids, while abdominal pain could be indicative of disorders of the GIT, genito urinary system and/or gynaecological problems and analgesics might mask the progression of disease. It is for this reason that the patients are advised to visit the doctor as soon as they experience abdominal pain. It is also important for the patient to communicate the history of pain accurately in terms of nature, location and frequency as this information is useful for diagnoses and management. To keep the bowel regular, it is required of individuals to eat a balanced diet, rich in vitamins and minerals and high in fibre. In general individuals are advised to exercise and drink plenty of water to keep the bowels regular.

Introduction The lower gastrointestinal tract (GIT) consists of the small and large intestines, the rectum and the anus. The purpose of this Chapter is to introduce you to the specific disorders of the lower gastrointestinal tract. The disorders in this part of the GIT are mainly related to elimination.

Overview of the anatomy and physiology of intestines, rectum and anus The small intestines consist of three parts, namely the duodenum which is connected to the stomach, the jejenum in the middle, and the ileum which connects to the large intestines. The small intestine is 6 m long and fills most of the abdomen. The function of the small intestine is digestion of food and absorption of the nutrients which occur in the jejenum and ileum. The contents of the small intestine are called chyme. The large intestine is 1.5 m long and consists of the caecum which connects to the small intestines, the colon and rectum. The colon is further divided into four sections: the transverse, ascending, descending, and sigmoid colons. The ileocaecal valve is found between the small and large intestines and prevents backward flow of faecal contents to the small intestines. An appendix is located next to the ileocaecal valve. Its function is not known. The function of the large intestine is to absorb

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water and electrolytes from chyme and store food waste until defecation. The rectum is the last part of the large intestines. It is 20 cm long and connects to the opening of the anus which is controlled by the internal and external muscle sphincters. Faeces collects here until pressure on the rectal walls cause nerve impulses to pass to the brain, which then sends messages to the voluntary muscles in the anus to relax, permitting expulsion. The defecation reflex occurs when the faeces enters the rectum. The rectum is innervated with sensory fibres.

Classification of lower gastrointestinal tract disorders • Bowel movement disorders elimination) • Bowel obstruction • Inflammatory bowel disorders • Anorectal disorders.

(problems

with

Specific disorders of the lower gastrointestinal tract Bowel movement disorders Bowel movements refer to the frequency of passage of stool as determined by consistency. Bowel movements are influenced by stress, diet, drugs, disease, habit and

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Stomach Duodenum

Ascending colon Caecum Rectum

Transverse colon Descending colon Small intestine Sigmoid colon

Figure 40.1  Structure of the intestines

social and cultural patterns. Changes in bowel movements include frequency of the passage of stools, consistency, volume and composition of stool, for example the presence of excess water, blood, mucus, pus or excess fatty material. Please note: Conditions such as diarrhoea, constipation and faecal incontinence have been discussed under elimination in Chapter 7.

Irritable bowel syndrome Definition

resulting rapid transit of food and faeces through the small intestine often leads to diarrhoea.

Assessment and common findings Subjective data • A bloated feeling with the accumulation of gas • An alteration in bowel patterns such as increased mucus in the stool or constipation, diarrhoea or a combination of both – diarrhoea usually occurs after eating or first thing in the morning • Abdominal pain and cramps that may disappear after a bowel movement – pain comes in bouts of continuous dull aching or cramps, usually in the lower abdomen • Nausea, headaches, fatigue, depression, anxiety and difficulty in concentration usually accompany the other signs Diagnostic studies • Blood tests, stool examination and a sigmoidoscopy to differentiate IBS from inflammatory bowel disease (IBD) and other conditions are done. • Barium enema and colonoscopy may reveal a spasm or mucus accumulation in the intestine. • Manometry and electromyography to study intralumi­ nal pressure changes generated by spasticity are done.

Irritable bowel syndrome (IBS), also called irritable colon, spastic colon, or spastic bowel is a disorder of motility of the entire intestinal tract that produces abdominal pain, constipation and/or diarrhoea. It occurs more commonly in women than in men.

Management

Causes

Essential health information

The cause of IBS is unknown, but the following are thought to contribute to its occurrence: • Heredity • Stress • Psychological factors • Emotional distress accompanied by anxiety and depression • Specific food intolerances • A diet high in fat, alcohol consumption and smoking.

Diet. The patient will have abdominal distension and increased flatulence, therefore gas-forming foods such as beans and cabbage should be eliminated from the diet, and yogurt should substitute milk if there is lactose intolerance. The patient should be encouraged to include at least 20 g of dietary fibre per day in their diet to control diarrhoea and constipation. They should also be encouraged to eliminate any irritating substances such as spicy foods, alcohol or fried foods.

Pathophysiology

Stress reduction. Encourage stress reduction exercises to reduce anxiety. Establish a trusting relationship with patient and family so that the patient will feel comfortable verbalising anxiety and concerns.

IBS is thought to result from disturbances in the nervous system’s control of the intestine, causing visceral hypersensitivity and abnormal bowel motility. The change in bowel motility may also be due to infection or irritation, or a vascular or metabolic disturbance. The disturbance of the peristaltic movement occurs at certain segments of the intestine and varies in the intensity with which it propels the faecal matter forward. During an episode, the

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The goals of treatment are to: • Relieve abdominal pain • Control diarrhoea or constipation • Relieve stress.

Pharmacological management • Anticholinergic agents such as dicyclomine (Bentyl) can be given before meals to alleviate the pain associated with ingestion of food.

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• Hydrophilic colloids which form bulk and antidiarrhoeal agents, for example loperamide, can be given to control diarrhoea and faecal urgency. • Loperamide can be used to treat patients with IBS whose primary bowel symptom is constipation. • Antidepressants can be given to treat underlying anxiety and depression.

Intestinal (Bowel) obstruction Definition

Normal bowel

Intussuception

Intestinal obstruction is a blockage of the intestines evidenced by partial or complete impairment to the forward flow of intestinal contents. Intestinal obstruction commonly occurs in the small intestine and most often in the ileum.

Causes Mechanical causes of intestinal obstruction. Mechanical obstruction can be intraluminal, mural or extraluminal. • Intraluminal obstruction is due to the presence of blocking objects in the lumen, such as worms, undigested food, impacted faecal matter or tumours. Tumours are the chief causes of obstruction in the large bowel, mainly in the sigmoid colon, for instance bowel cancer. • Mural causes are those that impact on the intestinal wall and interfere with the passage of intestinal contents, such as: –– Intussusception. This occurs when a leading segment of bowel invaginates into an adjacent segment. The common cause is increased peristalsis. Intussusception is most common in infants at the time solids are introduced in the infant’s diet, usually 9 months. The common site of occurrence is the ileocaecal junction. In adults it is usually associated with a tumour of the large bowel. The bowel segment containing the mass is propelled by peristalsis into the adjacent bowel segment. The inner walls of the trapped segment become oedematous and venous obstruction, infarction and necrosis can occur rapidly. –– Hernia. A hernia may be incarcerated or strangulated, depending on the size of the hernia ring. A strangulated hernia always causes obstruction because the bowel is not functional when its blood supply is cut off. –– Volvulus. This is a twisting of the bowel on itself and occurs in either the large or small bowel. –– Stenosis or strictures. This is the narrowing down or closure of the lumen from smooth muscle spasm. Please note that stenosis may also be due

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Figure 40.2 Intussusception

to hypertrophy of the smooth muscles applying pressure to the intestinal lumen from outside, for instance, pyloric stenosis. • Extraluminal causes usually apply pressure on the lumen, eg adhesions and tumours. Adhesions are bands of fibrous/scar tissue that form commonly following surgery, ulceration or inflammatory processes, such as peritonitis. Adhesions are one of the most common causes of intestinal obstruction. Adhesions may be massive in some individuals. These fibrous bands of scar tissue can become looped over bowel segments, contract with time, and mechanically obstruct the bowel by external pressure or strangulation. Non-mechanical causes of intestinal obstruction. A non-mechanical obstruction can be caused by vascular or neuromuscular disorder. Vascular factors that cause obstruction are due to interruption of blood supply to the bowel. Any partial or complete occlusion of arterial blood supply to the bowel will effectively stop bowel function. Most common causes are emboli and atherosclerosis of the mesenteric arteries. Neurogenic causes of intestinal obstruction. These are commonly due to the manipulation of the bowel during surgery. Examples are paralytic ileus, which is caused by the absence of peristaltic activity. The diagnosis is made when the absence of peristalsis persists for longer than 72 hours. Other causes of paralytic ileus include inflammatory responses, such as pancreatitis or acute appendicitis.

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Other neurogenic disorders that cause obstruction are multiple sclerosis, Parkinson’s disease or Hirschsprung disease. Other causes of intestinal obstruction. In addition, primary collagen or muscle disorders can affect bowel propulsion and cause obstruction. Endocrine disorders such as diabetes mellitus can also cause intestinal obstruction.

•

Pathophysiology Each day the small intestine secretes 6–8  ℓ of fluid rich in electrolytes. Most of this fluid is reabsorbed before the chyme reaches the caecum. Some of the fluid is lost in the stool. When an obstruction occurs, an imbalance between secretion and absorption develops. Intestinal fluid contents and gas accumulate above the obstruction. This causes abdominal distension which results in the reduction in fluids absorbed and increase in intestinal secretions. The distension is made worse by an accumulation of gas in the bowel from swallowing air; and the action of intestinal bacteria on stagnant bowel contents. As production of intestinal secretions increases, the pressure in the lumen of the bowel also increases. The bowel wall becomes oedematous and venous drainage is impeded. The increase in pressure results in an increase in capillary permeability that allows extravasation of fluids and electrolytes into the peritoneal cavity. The bowel wall also becomes permeable to bacteria, and bowel organisms enter the peritoneal cavity. Increasing pressure in the bowel wall soon slows the arterial blood flow, causing necrosis and eventual rupture or perforation of the intestinal wall, with the resultant peritonitis. The retention of fluid in the intestine and peritoneal cavity may lead to hypotension and hypovolaemic shock. If severe, hypovolaemia can compromise renal perfusion resulting in dehydration and electrolyte imbalance.

Assessment and common findings Subjective data. Bowel obstruction is usually sudden where the patient complains of abdominal pain. The pain is characteristic, depending on its cause. The initial diagnosis is usually made based on the description of the pain and its accompanying signs, such as nausea and vomiting and faecal elimination pattern. Objective data. Onset is rapid in small intestinal obstruction and gradual in large intestinal obstruction. • Pain due to the stretched intestinal muscles, increased peristalsis, or pressure to the nerve endings as would be the case in volvulus or strangulation. The pain

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•

•

•

•

•

may be colicky, wavelike and poorly localised if the obstruction is in the small intestine; or it may be severe and continuous with strangulation of the bowel. A paralytic ileus produces a generalised discomfort. Nausea and vomiting that may be projectile and contain bile if the obstruction is located high in the small intestine. Vomiting from distal obstructions of the small intestine or large intestine is not forceful but can be frequent, faecal and copious. Vomiting is rare in large intestinal obstructions. Vomiting temporarily relieves the pain in proximal but not distal obstructions. Abdominal distension is a common manifestation in intestinal obstruction and it is due to accumulation of intestinal contents including gas. It is gradual, but greatly increased in large bowel obstruction. Severe constipation is also common as no stool is passed; or in cases of intussusception, a small bloody, mucoid stool is passed. Dehydration evidenced by intense thirst, drowsiness, generalised malaise, parched tongue and dry mucous membrane with decreased urinary output. Temperature rarely rises above 37.8 °C unless there is infection and dehydration. Otherwise the pain and the loss of fluid will often cause hypothermia and signs of impending shock Physical examination. On inspection the abdomen may be distended; and in pyloric stenosis peristalsis will be visible. On palpation abdominal tenderness and rigidity are absent unless strangulation and/or peritonitis are present. On auscultation bowel sounds may be high pitched above the area of obstruction and absent below the area of obstruction.

Diagnostic studies. Diagnosis is based on symptoms and on X-ray studies. • Abdominal X-ray studies will show a distended colon. In some instances a barium swallow or enema may be done to outline the lumen of the bowel. The presence of intraperitoneal air will indicate perforation. • Serum and electrolytes should be monitored frequently to determine fluid and electrolyte balance. • Serum sodium, potassium and chloride concentration are decreased in small bowel obstruction. • An elevated white blood count may indicate strangulation, perforation and infection. • Decreased haemoglobin and haematocrit may indicate bleeding. • Stool should be checked for occult blood. • Sigmoidoscopy and colonoscopy may be done to provide direct visualisation of the obstruction.

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Medical management The goals of management of a patient with bowel obstruction are to: • Relieve the obstruction and promote return to normal bowel function • Minimise pain and discomfort • Restore normal fluid and electrolyte status. The treatment of bowel obstruction is directed towards decompression of the bowel by removal of gas and fluid through insertion of a nasogastric or intestinal tube. Decompression of the bowel will relieve pressure on

the organs, reduce pain, relieve vomiting and the risk of aspiration. A sigmoidoscopy may be done to relieve a sigmoid volvulus. A barium swallow may relieve intussusception. When the bowel is completely obstructed or strangulated, surgical intervention becomes urgent. Surgical intervention may involve resection of the obstructed segment of bowel and an end-to-end anastomosis. In the presence of an extensive obstruction with necrosis, a partial or total colectomy, colostomy, or an ileostomy may be performed. For perioperative care, read Chapters 20, 21 and 22.

Table 40.1  General nursing care plan for a patient after (post) abdominal surgery

Pain Nursing diagnosis

• Altered comfort related to the operation as evidenced by a complaint of pain, sleep disturbance and restlessness

Expected outcome

• No pain • Promote comfort and sleep

Nursing interventions and rationale

• Monitor patient’s pain level on a scale of 0–10 • Administer analgesics as prescribed • Change position frequently to relieve discomfort • Administer sedatives to promote sleep and rest

Evaluation

• Pain controlled • Pain reported to be less than 3 on a scale of 0–10 • Patient is restful and able to sleep

Nausea and vomiting; decreased urine output Nursing diagnosis

• Fluid volume deficit related to NPO (nil per orem) status, NG (nasogastric) suctioning, nausea and vomiting and fluid shift in the GIT, evidenced by inability to take oral fluids due to nausea

Expected outcome

• Maintain normal hydration status • Maintain normal urine output 1400 ml per day • No nausea and vomiting

Nursing interventions and rationale

• Insert an intravenous line and administer intravenous fluids as prescribed to maintain hydration • Monitor and record intake and output • Monitor and record NG suctioning and replace fluids as prescribed • Keep the patient NPO immediately postoperatively to prevent vomiting and until the bowel sounds are heard • Provide mouth care to relieve nausea • Weigh the patient and measure the abdominal girth daily to evaluate abdominal distension • Administer antiemetics as prescribed

Evaluation

• Nausea and vomiting stopped • Urine output 1400 ml per day

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❱❱

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Anxiety Nursing diagnosis

• Anxiety related to knowledge deficit regarding the uncertainty about the outcome of the operation

Expected outcome

• No anxiety

Nursing interventions and rationale

• Reassure and comfort the patient • Listen attentively and answer questions truthfully • Provide simple explanations of the tests and procedures done • Attend to and correct misconceptions regarding the disease condition and surgical operation

Evaluation

• Patient verbalises understanding of the disease process • Anxiety less marked

Fever, secondary bleeding or a purulent discharge from the wound, drains and tubes Nursing diagnosis

• Risk for infection related to intra-abdominal procedures evidenced by elevated temperature, bleeding or a discharge

Expected outcome

• Prevent infection • Maintain normal vital signs

Nursing interventions and rationale

• Maintain aseptic technique when dressing the wound • Monitor temperature 4-hourly to recognise infection early and allow for prompt treatment • Monitor wound, drains and tubes for the amount and type of drainage • Keep a strict record of output • Administer antibiotics as prescribed

Evaluation

• Patient is free from infection • Vital signs are normal • Absence of purulent drainage from the wound, drains and tubes

Inflammatory bowel disorders

Sigmoid colon

The proximal half of the colon still takes part in the absorption of food, while the distal part stores faeces until the time of defecation. Inflammatory bowel disorders include conditions of the large bowel such as appendicitis, diverticulosis, regional enteritis, ulcerative colitis, irritable bowel syndrome, tumours, haemorrhoids and cysts.

Transverse colon

Terminal ileum

Appendicitis Definition

Appendicitis is inflammation of the appendix, a small finger-like projection at the tip of the caecum below the ileocaecal valve in the right lower quadrant of the abdomen. Incidence and causes. Appendicitis develops most commonly between 11 and 30 years of age (teenagers and young adults). More males are affected than females. The appendix normally fills with food and empties

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Caecum Appendix

Inflammation of the appendix

Figure 40.3  An inflamed appendix

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McBurney’s point

Right lower quadrant

nausea and vomiting. Elderly patients often get vague symptoms and delay presenting themselves for help, hence most of them present with a ruptured appendix. Roctus abdominis muscle Umbilicus Left lower quadrant Anterior superior iliac spine Appendix

Figure 40.4  When the appendix is inflamed, tenderness can be noted in the right lower quadrant at McBurney’s point

Objective data. There is low-grade fever and local tenderness on palpation at the right lower quadrant of the abdomen. Diagnostic tests. Blood investigations include a full blood count which reveals an elevated white cell count above 11 000 mm3 with the neutrophil count above 75%. Abdominal X-rays show dilated loops of bowel indicating paralytic ileus, air or fluid levels in case of obstruction and free air consistent with perforation.

Medical management inefficiently because its lumen is very small and therefore is prone to obstruction. The common causes of obstruction of the lumen of the appendix are faecal mass (faecalith or faecal stones), foreign bodies, kinking of the appendix, intramural swelling from lymphoid hyperplasia, and fibrous conditions of the bowel wall, tumours of the caecum or the appendix and external occlusion of the bowel by adhesions.

Pathophysiology Obstruction of the appendix results in an inflammatory reaction which leads to oedema and distension. Pressure is applied on the intramural blood vessels which leads to vascular engorgement, resulting in gangrene of the appendix. In addition, the mucosal wall ulcerates, becomes infected and ruptures, which spreads infection to the peritoneum; hence the associated peritonitis or abscess formation.

Assessment and common findings Subjective data. Appendicitis commonly starts with a persistent, continuous, periumbilical pain. Initially the pain feels like an intermittent discomfort but then shifts to the right lower quadrant of the abdomen where it becomes localised. The patient will prefer to lie with the right leg flexed. The pain may also vary according to the location of the appendix, for example, pain may be felt at the lumbar region if the appendix is curled around behind the caecum. Pain on defecation may indicate that the tip of the appendix is resting on the rectum, while pain on micturition indicates that the tip is resting on the bladder or ureter. On rupture of the appendix, pain becomes diffuse and abdominal distension ensues related to the accompanying paralytic ileus and peritonitis. The abdominal pain described above may be accompanied by anorexia,

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This usually involves immediate surgical removal of the appendix through a laparotomy or laparoscopy. Drainage of the abscess may be indicated if this complication has developed. Before surgery intravenous therapy should be given to correct fluid and electrolyte imbalance and to administer prescribed antibiotics for infection. If the appendix has not perforated at the time of surgery, the patient’s recovery is usually smooth and they are discharged within 5–7 days, or even earlier.

Nursing management The goals of nursing management are to allay anxiety, relieve pain, prevent systemic infection, correct fluid and electrolytes balance, restore and/or maintain optimal nutrition and prepare the patient for surgery.

Specific preoperative care Once diagnosis of appendicitis has been confirmed: • Administer prescribed analgesics and antibiotics for pain and infection respectively. Assess the patient for the effect of these drugs by observation and by asking the patient the extent of pain. • Monitor and record vital signs to detect infection early and response to treatment. • Withhold oral feeds and if paralytic ileus or peritonitis has developed, insert a nasogastric tube and keep the patient on continuous drainage while awaiting surgery. • Ensure adequate fluid replacement as the patient may be vomiting. • Explain all procedures and activities to the patient to allay anxiety. For perioperative care for abdominal surgery, see Chapters 20, 21 and 22.

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Diverticular disease Definition

Diverticular disease occurs clinically as diverticulum, diverticulosis and diverticulitis. Diverticulum is a saclike dilatation or an outpouching of the mucus layer of the bowel that extends through a defect in the muscle layer. Many diverticula may occur without inflammation and are referred to as diverticulosis. When diverticula get infected they are called diverticulitis.

Causes Diverticula may occur anywhere along the gastrointestinal tract and may vary in number from a few to several hundreds. They are frequently found in the sigmoid colon. Most colon diverticula are acquired and are caused by increased pressure within the lumen or poor muscle tone in the wall of the colon. Diverticular disease is common in developed countries and almost non-existent in developing countries. Diverticulitis occurs when food and bacteria retained in the diverticulum cause infection and inflammation. It may be acute or chronic. A congenital predisposition is also suspected as one of the causative factors of diverticular diseases, especially if it is present in people younger than 40 years of age. Lack of dietary intake of fibre, a decrease in physical activity, and poor bowel habits such as neglecting the urge to defecate, the ageing process, and stress have also been implicated.

Pathophysiology A diverticulum occurs when the mucosal or submucosal layer herniates through the muscle wall of the gut due to increased pressure in the lumen, or poor muscle tone. This occurs in areas where blood vessels pass through the bowel wall. Diverticula measure up to 1 cm and are attached to the intestinal lumen by necks of varying sizes. Hardened faeces may be present in the diverticula with no symptoms or may result in inflammation (diverticulitis) which may extend to the adjacent bowel wall, causing irritability and spasticity of the colon. Unless complications develop, a diverticulum is not a problem. Complications such as diverticulitis, perforation and/or haemorrhage may occur. Perforations are frequently walled off by the peritoneum and heal without surgical intervention, or may result in abscess formation, which may extend to adjacent structures such as the bladder, causing fistulae such as vesicosigmoid fistula, but may also involve the skin, perineal area, and small bowel. The formed abscesses may perforate, leading to peritonitis and erosion of blood vessels resulting in haemorrhage. Diverticula are the most common cause of bleeding in the bowel. Due to chronic local inflammation

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of the diverticula, the large bowel narrows with fibrotic strictures. If untreated, the diverticulitis may result in septicaemia.

Assessment and common findings Subjective data. The history of the patient with diverticulosis reveals: • Bowel irregularity with chronic constipation and intervals of diarrhoea for many years • Narrowing of the bowel may result in narrow flat stools and increased constipation • Complaints of weakness and fatigue; other complaints include anorexia, nausea, bloating and/or abdominal distension • An abrupt onset of crampy pain in the left lower quadrant of the abdomen • A low-grade fever which often denotes acute diverticulitis. Objective data. On physical examination there is abdominal distension. A rigid boardlike abdomen may be palpated if peritonitis is present and bowel sounds may be absent. • If an abscess has formed, tenderness and a palpable mass may be felt. • There may be fresh blood in the stool due to the erosion of the blood vessels by diverticuli. Diagnostic studies • A full blood count may reveal leukocytosis and the erythrocyte sedimentation rate may be elevated. • The diverticuli may be confirmed with a barium enema which reveals narrowing of the colon and thickened muscle layers. A barium enema is contraindicated when signs of peritonitis are present because of the potential for perforation and leaking of barium into the peritoneal space. • X-ray studies will reveal air under the diaphragm in case of perforation. • A CT scan is the preferred diagnostic procedure because it can also reveal abscesses. • Ultrasonography may also be used to confirm the diagnosis. • A colonoscopy may also be performed in the absence of acute diverticulitis or after resolution of acute episode to visualise the colon, determine the extent of the disease and exclude other diagnoses.

Management The goals of management are to relieve pain, prevent complications such as infection and fluid volume deficit, attain normal elimination patterns and relieve anxiety.

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Medical management. Diverticulitis may be treated on an outpatient basis with a high-fibre diet and medication. Medical management focuses on the treatment of acute diverticulitis and complications for which hospitalisation may be required, especially for the elderly and the immunocompromised such as patients on corticosteroids. • The colon should be allowed to rest to enhance recovery. The patient must be kept nil per mouth and parenteral fluids given. • Nasogastric drainage may be indicated if signs of intestinal obstruction such as vomiting and abdominal distension are present. • A 7- to 10-day course of broad spectrum antibiotics may be prescribed for infection. • Analgesics are prescribed for pain, taking care to exclude morphine which increases segmentation and intraluminal pressure. • Antispamodics such as propantheline bromide (ProBanthine®) may also be prescribed to control severe pain. • Normal stools may be promoted by giving bulk preparations such as Metamucil®, stool softeners such as Colace®, warm mineral oils instilled into the rectum, or an evacuant suppository such as Dulcolax®. This will help reduce the bacterial flora in the bowel, improve on the bulk of the stool and soften the faecal mass thereby facilitating the stool transit through the inflammatory obstruction. Surgical intervention may be indicated in patients who have developed complications such as mentioned earlier, or to prevent acute episodes. Two types of surgical procedures may be done, namely: • One-stage resection of the inflamed area • End-to-end anastomosis or a multiple-stage procedure in which a colostomy is performed from the proximal stump, while the distal stump is either closed or brought to the surface as a mucus fistula. Later the colostomy is closed and an anastomosis is performed. Nursing management. During the acute phase: • Bed rest is encouraged but exercise should be instituted as soon as the acute phase subsides, to avoid complications such as constipation. • For pain relief, administer analgesics as prescribed.

Essential health information The patient should be advised to: • Maintain a normal elimination pattern and increase fluid intake, preferably up to a minimum of 2–3 ℓ/day if the cardiac and renal status so allow

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• Establish a schedule/pattern for eating and defecation • Prescribe an exercise programme which should serve to promote bowel movement • Take prescribed bulk laxatives or oil retention enemas to propel the stool through the colon, and avoid straining when passing stools • Reduce weight if obese • Avoid all factors that increase intra-abdominal pressure. These include bending, straining when passing stools, vomiting, lifting and tight or restrictive clothing.

Prevention Patients at risk of complications such as the elderly and the immunocompromised should be encouraged to maintain normal bowel elimination and avoid raising the intraluminal and intra-abdominal pressure as mentioned earlier. The nurse must be able to recognise signs of intestinal obstruction, namely, more intense abdominal pain, tenderness and rigidity, fever, tachycardia and hypotension.

Inflammatory bowel disease Definition

Inflammatory bowel disease (IBD) refers to two chronic inflammatory gastrointestinal diseases, namely, regional enteritis or Crohn’s disease, and ulcerative colitis. While these diseases are different, they have striking similarities: both diseases produce inflammation of the bowel, have no proven causative agent, have a pattern of familial occurrence, and are accompanied by systemic manifestations.

Causes The aetiology of both Crohn’s disease and ulcerative colitis is unknown, but familial occurrences have been observed suggesting that heredity plays a role. Other associated causes include genetic factors that have been implicated in predisposing patients to autoimmune reactions, which are thought to be triggered by environmental agents such as food additives, tobacco, radiation and pesticides. Infectious agents are also thought to play a role, for example Chlamydia, atypical bacteria and mycobacteria. Psychogenic factors are thought to exacerbate the onset and severity of both conditions.

Regional enteritis (Crohn’s disease) Definition

Regional enteritis, also called Crohn’s Disease, is a recurrent granulomatous type of inflammatory response that is progressive, persistent, and often disabling. Regional enteritis can affect any area of the gastrointestinal

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tract. In the majority of cases, it is restricted to the small intestine, particularly the terminal portion of the ileum. In some it affects the large intestine and in others, both the small and large intestines. The incidence is higher among adolescents and young adults. People of European origin are at higher risk, especially the so-called Ashkenazi Jewish population.

Pathophysiology Regional enteritis begins with inflammatory oedema and thickening of the mucosa, which later develops into ulcers. Characteristic multiple, sharply demarcated granulomatous lesions surrounded by normal mucous membrane follow. These lesions are interspersed between normal segments of the bowel, thus they are called skip lesions. The disease affects the full thickness of the intestinal wall with the submucosal layer being affected most, because of marked fibrotic changes in it, while the smooth muscle layers of the bowel are relatively spared from the disease process. Fissures and crevices develop on the affected area with surrounding oedematous submucosal tissue assuming the appearance of a cobblestone. The loops of the diseased bowel sometimes adhere to each other, causing obstruction. These changes interfere with bowel motility. Eventually the bowel wall becomes thickened and inflexible with a narrowed lumen assuming the appearance of a lead pipe or rubber hose. The adjacent mesentery becomes inflamed and the regional lymph nodes enlarge while lymph channels become engorged with abscess formation. Complications such as intestinal obstruction, strictures, internal and external fistulae, perforation and abscesses develop. The most common type of fistula that develops is the enterocutaneous fistula, which occurs between the small bowel and the skin, though these can occur between the bowel, the bladder, the vagina and urethra.

Assessment and common findings Thorough history and physical examination are usually helpful in the diagnosis of regional enteritis. Clinical manifestations of regional enteritis develop slowly, often in exacerbations and remissions and according to the location of the lesions. Subjective data. The principal symptoms include: • A colicky pain in the right lower quadrant. Pain gets worse after meals because of stimulation of the peristaltic wave. There is also abdominal tenderness and spasm. Because of the pain related to meals, the patient avoids food, leading to nutritional intake

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below body requirements, resulting in malnutrition, anaemia and weight loss. • Intermittent or chronic diarrhoea. Objective data • Low-grade fever is usually found among the symptoms. • Symptoms often extend beyond the gastrointestinal tract; for example, there may be arthritis, skin lesions such as Erythema nodosum, ocular lesions such as conjunctivitis, and mouth ulcers. Diagnostic studies • Haematological studies. A full blood count reveals leukocytosis related to inflammatory reaction, anaemia, elevated erythrocyte sedimentation rate, and low haematocrit and albuminaemia. • The stool should be examined for ova and parasites. • Endoscopic studies. A proctosigmoidoscopy can be done to determine the location of the lesion and obtain a biopsy specimen of the affected tissue. • Radiological studies. The most conclusive test is a barium swallow that shows the typical ‘string sign’ of terminal ileum, indicating the narrowing of the lumen of the bowel. A barium enema may also be done and often shows the cobblestone appearance of the bowel. The barium enema may also show fistulae and fissures.

Management Management of regional enteritis aims at: Arresting the inflammatory process • Anti-inflammatory agents such as corticosteroids, sulphasalazine, and antibiotics such as metronidazole are given to treat the inflammatory process. • Immunosuppresive drugs such as azathioprine (Imuran®), and its active derivative, 6-mercaptopurine, may also be used. • A monoclonal antibody such as infliximab may be prescribed in pursuit of the tumour necrosis factor (TNF-ß). Surgical interventions include resection of the diseased bowel, drainage of abscesses, and repair of fistulae as indicated. Promoting comfort and healing. During acute exacerbations of the disease, the inflamed bowel may be allowed to rest by giving total parenteral nutrition while food cannot be tolerated or absorbed from the intestine. A bulk-free oral diet should be introduced slowly, thus allowing the often-affected ileum to heal.

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Maintaining adequate nutrition and fluid. A bland, bulk-free, highly nutritious diet that will not trigger undue peristalsis must be given with additional calories for energy, vitamins – especially A and C – as well as proteins for healing and anabolism. The patient’s appetite should be stimulated by serving small frequent meals. An analgesic could be given before meals. Preventing of complications. The nurse must observe the patient for signs of intestinal obstruction such as increased abdominal pain, tenderness and rigidity. Systemic manifestations such as arthritis must be assessed and reported.

Ulcerative colitis Definition

Ulcerative colitis is a condition in which intermittent inflammation and ulceration of the mucosa of the colon and rectum occur. The disease process may also extend to the submucosal layer and often starts at the rectum and the sigmoid area extending proximally up the descending colon. There are three types of ulcerative colitis and these are according to the severity of the disease. They are mildchronic, chronic-intermittent and acute fulminating. The more severe fulminant form of ulcerative colitis affects about 15% of the people and is characterised by severe bloody diarrhoea, fever, and acute abdominal pain. People suffering from fulminant ulcerative colitis are prone to development of megacolon and systemic toxicity.

Incidence The incidence of ulcerative colitis is high among Caucasians and Jewish people. The disease can affect all age groups but the incidence is highest between 20–50 years of age, often beginning between 20–25 years. The disease is accompanied by systemic complications, a high mortality rate, and a 10–15% incidence of cancer of the colon.

Risk factors Laxatives, narcotics, anticholinergics and hyperkalaemia are reported as contributing factors to the more severe form of ulcerative colitis.

Pathophysiology Ulcerative colitis often presents as diffuse inflammation of the colonic mucosa with oedema and multiple areas of desquamation and necrosis. The inflammatory process is often continuous. Ulceration is superficial but may extend

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over a large area. Characteristic lesions form in the crypts of Lieberkühn found in the base of the mucosal layer and eventually form crypt abscesses. These lesions contain leukocytes, lymphocytes, red cells, and cellular debris. Pinpoint mucosal haemorrhages form and culminate into abscesses. Tongue-like projections (pseudopolyps) also develop. Secondary infection produces further inflammation. The bowel eventually narrows and shortens and the wall thickens and becomes inflexible as fibrotic scar tissue forms. Complications of ulcerative colitis are toxic megacolon, perforation and haemorrhage.

Assessment and common findings Objective data. Ulcerative colitis often follows a pattern of remissions and exacerbations. Diarrhoea is the most typical sign, with 10–20 bowel movements a day. Nocturnal diarrhoea occurs in severe attacks. Due to the ulceration of the mucosa, the stools often contain blood and mucus. The amount of blood in the stool depends on the size of the vessels that are eroded. Severe rectal bleeding may occur if a large blood vessel is eroded. Pallor may result, depending on the duration and the amount of rectal bleeding. Mild pain and rebound tenderness may be felt in the left lower quadrant. Other signs and symptoms are anorexia, weight loss, weakness, vomiting, diarrhoea and bleeding which may result in dehydration. Skin lesions such as Erythema nodosum, ocular lesions such as uveitis, joint abnormalities such as arthritis, and liver disease may develop. On physical examination, tachycardia, hypotension and tachypnoea, fever and pallor may be detected related to bleeding and infection. Dehydration and weight loss may be observed related to diarrhoea, anorexia and vomiting. Bowel sounds may be absent and the abdomen distended and tender. Diagnostic studies • Haematological studies. Blood may be detected in the stool and low haemoglobin and haematocrit with leukocytosis may be detected in the blood cell count. • Radiological studies. X-rays may be done to exclude obstruction of the bowel. Barium studies may show irregularities of the mucosal wall, fistulae, megacolon and shortening of the bowel. CT scan, MRI and ultrasound may reveal abscesses and changes around the rectum. • Endoscopic studies. Sigmoidoscopy and colonoscopy are usually done to confirm the diagnosis of ulcerative colitis.

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Management Management of ulcerative colitis depends on the severity of the disease and includes measures to control acute symptoms and prevention of recurrence. Medical management. Mild symptoms are controlled by avoidance of caffeine, lactose in milk, highly spiced foods and gas-forming foods. Fibre supplements may be given to control diarrhoea. The same drugs used in Crohn’s disease can be used for ulcerative colitis, though corticosteroids should be used selectively and cyclosporine may be used as an immunosuppressant for severe colitis. Surgical intervention is indicated if the patient does not respond to conservative treatment. Removal of the rectum and entire colon and creation of an ileostomy or ileal anastomosis may be performed. Nursing management. This is aimed at relieving pain, controlling diarrhoea, improving nutrition, relieving anxiety and enhancing coping mechanisms. See also Table 40.1.

Anorectal disorders Haemorrhoids Definition

Haemorrhoids are vascular masses of dilated superior and inferior haemorrhoidal veins that form a plexus, or a cushion, in the submucosal layer of the lower rectum. They may be external, occurring outside the external sphincter, or internal, occurring above the internal sphincter. Internal haemorrhoids are classified by size. The size of the haemorrhoids determines the nature and the severity of symptoms and the appropriate treatment.

Causes The causes include: chronic constipation or diarrhoea. prolonged sitting/standing, hereditary factors, alcoholism, pregnancy, portal hypertension, infections of the anal area, rectal surgery, loss of muscle tone due to old age, anal intercourse, heavy lifting.

Pathophysiology The superior haemorrhoidal veins do not contain valves and are therefore vulnerable to overdistension when a person is in an upright position. Increased intra-abdominal pressure causes engorgement in the vascular tissue lining the anal canal. With age there is deterioration of the anchoring connective tissue, allowing the loosening of the blood vessels from the surrounding connective tissue, with protrusion or prolapse into the anal canal. When the supporting tissues weaken, usually due to age or straining when passing stools, the venules become dilated and also

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40.1 Grading scale for haemorrhoids The grading scale for haemorrhoids is: • First-degree. The haemorrhoids bulge into the lumen of the anorectal canal but do not protrude through the anus. • Second-degree. There is a prolapse of the haemorrhoids out of the anus with defecation or straining. The haemorrhoids return spontaneously to their normal anatomic position after defecation. • Third-degree. There is prolapse of the haemorrhoid out of the anus with defecation or straining and manual reduction to its normal anatomic position is necessary. • Fourth-degree. The haemorrhoids prolapse out of the anus; it is irreducible with a risk of strangulation.

the blood flow through the veins of the haemorrhoidal plexus is impaired. External haemorrhoids rarely bleed but may become thrombosed or rupture, and cause bleeding with defecation. The amount of blood lost may be small but if continuous, may lead to iron deficiency anaemia. Internal haemorrhoids are uncomfortable and cause pain if strangulation or prolapse occurs.

Assessment and common findings Subjective data. Haemorrhoids may be asymptomatic unless complications occur. External haemorrhoids seldom bleed or cause pain unless a vein ruptures. Objective data. There will be some or all of the following symptoms: • A sensation of incomplete faecal evacuation • A visible palpable mass if haemorrhoids are external • Constipation and anal itching • Bleeding during defecation, with bright red blood on the stool due to injury of mucosa covering the haemorrhoid • Infection or ulceration and mucus discharge • Pain in external haemorrhoids due to thrombosis of haemorrhoids • Constipation or diarrhoea, which aggravates the symptoms. Diagnostic tests • History, visualisation by external examination and the use of an anoscope or proctoscope (anoscopy and proctoscopy) • Barium enema or sigmoidoscopy, to rule out more serious colonic lesions causing rectal bleeding.

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Longitudinal muscle Sigmoid colon

Rectal valves

Internal haemorrhoids External haemorrhoids Figure 40.5  Haemorrhoids and removal by ligation with a rubber band

Nursing management

Other treatment options

Haemorrhoids can be conservatively managed if the symptoms are not severe. Conservative management involves: • Preventing constipation by eating a high-fibre diet • Avoiding prolonged periods of standing or sitting • Taking warm sitz baths, 2–3 times daily for up to 2 weeks to help reduce the discomfort and swelling associated with haemorrhoids • Inserting soothing anal suppositories as prescribed 3 times daily • Applying warm compresses for comfort • Controlling itching by improved anal hygiene measures and control of moisture.

• Ligation of haemorrhoids with a rubber band. See Figure 40.5. This method is used for treatment of internal haemorrhoids. It may be done in the outpatient clinic with no anaesthesia. Anoscopy is done. The haemorrhoid is grasped and drawn through a double sleeved cylinder that slips a latex band over the base of the haemorrhoid. The band constricts the blood circulation causing necrosis. After a period of time, the haemorrhoid sloughs away. • Sclerotherapy. A sclerosing solution of 5% phenol in oil is injected into small bleeding internal haemorrhoids, producing an intense inflammatory reaction. This is a palliative treatment and repeated injections may be necessary. • Cryosurgery. Liquid nitrogen or radiation is used to destroy the local tissue which sloughs off with necrosis. It is an expensive procedure. The healing process may be long, requiring periodic anal dilatation where this is constricted.

Surgical management Severe haemorrhoids may be excised. Haemorrhoidectomy is indicated when the following conditions exist: • Thrombosis from strangulation • Prolonged bleeding • Complicated prolapses • Intolerable itching • General unrelieved discomfort • Intense pain.

Specific postoperative care Postoperatively, the rectum may be packed to absorb drainage. The packing should be removed on the first or second postoperative day. Rectal bleeding and drainage should be assessed and any excessive bleeding reported. Provide privacy when performing nursing procedures to avoid embarrassment. The following specific measures can be implemented: • Provide support by placing a pillow under the buttocks for comfort and relief of pain caused by pressure • Give pain medication before a bowel movement to reduce discomfort as the first bowel movement postsurgery may be dreaded by the patient • Give a stool softener such as docusate sodium (Colace®) as ordered. A retention enema may be given if there is no bowel movement 2–3 days post-surgery.

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Essential health information • Emphasise the importance of strict personal hygiene as well as prevention of constipation and straining when passing stools. • Encourage a high-fibre diet with additional fruit and vegetables. Bran may be added to the diet to ease the passage of stools. • Emphasise the importance of regular exercises to encourage normal bowel action. • Ensure that the patient drinks at least 2–3 ℓ of fluid a day to encourage bowel action. • Advise the patient to apply ice or warm compresses or prescribed analgesic ointments to provide comfort around the anal area. • Apply strict anal hygiene after each bowel action. • Discourage the regular use of laxatives. Firm, soft stools dilate the anal canal, and decrease stricture formation.

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• Determine the patient’s normal bowel habits, identify predisposing factors and educate the patient about changes necessary to prevent the recurrence of symptoms. • Emphasise the need for thorough cleaning of bath tubs or containers used for sitz baths.

Anal fissures, abscesses and fistulae Anal fissures, abscesses and fistulae are common problems that develop from trauma or infection in the anorectal area.

Definition An anal fissure is a linear painful ulceration or tear of the anal epithelium, typically located in the posterior midline. It may be primary or secondary.

Causes Primary fissures are idiopathic and occur mainly in young and middle-age adults. Secondary fissures are associated with passing hard stools in chronic constipation, trauma, or chronic ulceration that result from IBD. Fissures may also occur during childbirth with perineum straining. Tuberculosis, syphilis, and Crohn’s disease may also be contributory causes. Anal abscesses result from inflammation of anorectal tissue evidenced by a localised area of foul pus formation and pain. The abscess is caused by an obstruction of an anal gland by faeces. It may be superficial and accompanied by swelling, redness and tenderness. It may be deep and result in toxic symptoms, fever and lower abdominal pain. Many of the abscesses result in fistulae. An anal fistula is an abnormal tube-like passage from the skin outside the anus into the anal canal. It is often preceded by an anal abscess and is also associated with IBD, cancer, or a foreign body. There is a purulent drainage from the opening, or stool leakage which stains undergarments. Itching and pain are also present. Anal fistulae are a complication of Crohn’s disease and can be treated by performing a fistulotomy or fistulectomy.

Pathophysiology

however cause bleeding if healing does not occur. Infection may also set in, causing anal abscesses. Widespread infection may develop in patients who are immunocompromised. Pain is a primary feature of anal fissures and abscesses because of the pressure exerted on the somatic nerves in the perianal area. Constipation is inevitable because the patient avoids bowel action for fear of pain.

Management The nature and the severity of the problem will determine whether intervention is necessary. Extensive surgery (sphincterotomy) may be necessary to repair a fistula, while incision and drainage of the abscess may be indicated where conservative management fails. Medical management. This includes administration of stool softeners and analgesic ointments to relieve pain. Specific antibiotic therapy may be necessary for abscesses. Temporary faecal diversion may be necessary to achieve bowel rest to allow the fistula to heal. Nursing management. Nursing interventions for anal disorders mainly focus on improving the patient’s comfort by giving analgesics and local topical applications as ordered for pain, sitz baths to promote comfort, relieve pain, support cleanliness, and reduce oedema around the anal area.

Essential health information Education should focus on maintaining anal and personal hygiene, avoiding constipation by maintaining a high-fibre diet, increased fluid intake (2–3 ℓ a day) and prevention of recurrences. It is also important to instruct the patient on how to do perineum strengthening exercises.

Conclusion Disorders affecting the intestines and rectum range from mild to life-threatening. Some can be acute while others can be chronic. Most are preventable. The nurse has the responsibility to provide education to the patient and family regarding the disorders of the lower gastrointestinal tract, including diet and lifestyle modification.

Most anal fissures are superficial and therefore heal spontaneously in response to therapy. The fissure may,

Suggested activities for learners Activity 40.1 Discuss the assessment findings of irritable bowel syndrome (IBS) in relation to the pathophysiology. Activity 40.2 Design a nursing care plan for a patient who has undergone an appendectomy.

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41

Management of the disorders of the accessory organs of digestion

learning objectives

On completion of this Chapter, the learner should be able to: • describe the aetiology, pathophysiology, clinical manifestations, therapeutic and pharmacological interventions in patients presenting with disorders of the accessory organs of digestion in the gastrointestinal system in a variety of clinical settings • assess patients suffering from disorders of the accessory organs of digestion • interpret assessment data including results of diagnostic tests in patients suffering from disorders of the accessory organs of digestion in the gastrointestinal system • plan, implement and evaluate scientifically correct nursing care that is based on assessment findings for patients presenting with disorders of accessory organs of digestion in a variety of clinical settings • manage emergencies and complications related to disorders of accessory organs of digestion in the gastrointestinal system. key concepts and terminology

ascites

The accumulation of serous fluid in the peritoneal or abdominal cavity.

asterixis

Involuntary flapping movements of the arms and hands associated with metabolic liver dysfunction.

Budd-Chiari syndrome

Hepatic vein thrombosis resulting in non-cirrhotic portal hypertension.

cholecystectomy

Removal of the gallbladder.

cholecystitis

Inflammation of the gallbladder.

cholecystoduodenostomy

Anastomosis between gall bladder and duodenum to relieve obstruction at the distal end of the common bile duct.

cholecystogastrostomy

Anastomosis between the gallbladder and the stomach.

cholecystojejunostomy

Anastomosis of the gallbladder to the jejunum to divert bile flow.

cholecystostomy

Incision into the gall bladder (usually to remove gallstones).

choledolithotomy

Incision into the common bile duct for removal of stones.

cholelithiasis

Stones/calculi in the gallbladder.

cirrhosis

A chronic progressive disease of the liver with destruction of parenchymal cells.

cryoablation

Treatment of malignant lesions of the liver involving exposure of the tumour to temperatures below –200 °C and subsequent thawing. The procedure is done via a probe through which nitrogen liquid flows.

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fetor hepaticus

A musty, sweet and slightly faecal odour of the breath due to accumulation of digestive by-products that the liver is unable to degrade in chronic liver disease.

fulminant hepatic failure

Severe impairment of liver function associated with hepatic encephalopathy.

fulminant viral hepatitis

A clinical syndrome that results in severe impairment or necrosis of liver cells and potential liver failure.

hepatic encephalopathy

A neuropsychiatric manifestation of liver damage, and a terminal complication in liver disease.

jaundice

A yellowish discolouration of mucous membrane, skin and sclera resulting from increased circulation of unconjugated bilirubin.

orthotopic liver transplantation

Grafting of a donor liver into the normal anatomic location of the recipient’s liver after removal of the diseased liver.

paracentesis

Needle puncture of the abdominal cavity to remove ascetic fluid.

portal hypertension

An increase in venous pressure in the portal circulation due to obstruction of venous flow through the liver.

steatorrhoea

Bulky, loose and fatty stool characteristic of improper fat metabolism.

prerequisite knowledge

• Anatomy and physiology of all the body systems with special focus on the accessory organs of digestion • Microbiology, parasitology, pharmacology • Biochemistry and biophysics. medico-legal considerations

The nurse has the obligation to assess the patients presenting at the health facility thoroughly and meet the full spectrum of their bio-psychosocial needs to be able to make nursing diagnoses and provide relevant nursing care. They should also keep accurate records. ethical considerations

The nurse is legally and ethically bound to inform the patient about their diagnosis and care. The nurse must also document the teaching and instructions given to the patient and family. Failure to inform and to document information given can be the basis for malpractice and litigation. essential health literacy

The functioning of the accessory organs of digestion such as the liver and pancreas can be compromised by a patient’s lifestyle. Because of their close anatomic proximity with one another and the gastrointestinal system and interrelated metabolic functions, disorders of one accessory organ may result in the dysfunction of the other accessory organs as well as the gastrointestinal system. It is important to teach patients the correct way to use chemicals in the home, how to minimise exposure to chemicals at work, and the dangers of incorrect drug usage. Toxic hepatitis can be prevented by carefully reading and following instructions on safe use of cleaning agents and solvents. Excessive use of alcohol and over-thecounter medication can cause extensive damage to the liver and pancreas and diseases that develop in this manner are chronic with poor prognosis.

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Introduction The liver, pancreas, gallbladder and its bile ducts are called accessory organs of digestion in the gastrointestinal system. The gallbladder is located under the liver, along with parts of the pancreas and intestines. The liver and these organs work together. The functions of the accessory organs are to: • aid digestion through the delivery of hormones and enzymes in the blood and into the small intestine • help with the metabolism of absorbed nutrients. The pancreas functions as an endocrine gland. Insulin is a hormone secreted by the beta cells of the Islets of Langerhans in the pancreas. The main function of insulin is to facilitate glucose metabolism. The liver detoxifies chemicals and is instrumental in the synthesis, metabolism and storage of important nutrients. The biliary tract provides bile salts to emulsify fats and to neutralise the acidic stomach contents and render these amenable for digestion and breakdown by pancreatic enzymes. The aim of this Chapter is to provide information on the disorders of the accessory organs of digestion.

Classification of disorders of the accessory organs of digestion Disorders of the accessory organs of digestion include obstruction, inflammation, infection and malignancy; and are classified according to the organ affected as follows: • Disorders of the liver • Disorders of the pancreas • Disorders of the biliary tract.

Risk factors for the disorders of the accessory organs of digestion The risk factors include the following: • Exposure to hepatotoxic substances such as industrial chemicals and infectious agents like bacteria and viruses • Exposure to blood and blood products contaminated with viruses such as hepatitis B and C • Invasive procedures such as blood transfusions and dental procedures that may transmit viruses, for instance hepatitis B and C • Lifestyle behaviour and habits such as excessive consumption of alcohol • Excessive use of certain prescribed and over-thecounter medication and herbal remedies • Trauma and illness.

Nursing assessment and common findings A complete history of the patient with hepatobiliary and pancreatic disorders must include current problems

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and symptoms, lifestyle patterns, environmental and occupational factors.

Subjective data On history taking, the patient may report any of the following symptoms: • Abdominal discomfort and/or pain. The nurse should establish details about the pain (whether acute, colicky or dull, its onset whether sudden or gradual, and its location whether in the right upper quadrant for liver disease, left upper quadrant, epigastric or umbilical in pancreatic disease, and epigastric or right upper quadrant in gallbladder problems). The pain may be colicky, especially with biliary tract problems. The pain may be referred and related to movement when breathing. • Abdominal distension, tenderness and/or rigidity related to ascites from portal hypertension and retention of sodium and water and associated peritonitis in cholecystitis and pancreatitis. • Generalised oedema. • Anorexia, nausea and vomiting. • Fatty foods intolerance and steatorrhoea or claycoloured stools, which are associated with cholecystitis and liver diseases due to abnormalities of bile secretion and/or flow. • Altered bowel patterns as evidenced by constipation or diarrhoea related to sympathetic dominance in the bowel. • Dark yellow urine related to increased bilirubin and/ or haemoglobin content from increased haemolysis of red blood cells in liver diseases. • Easy bruising, epistaxis or melaena stool related to failure of the liver to produce vitamin K-dependent clotting factors such as prothrombin. • Haemorrhoids and bleeding related to congestion of anorectal veins. • Pruritus associated with yellow discolouration of the skin and mucous membranes (jaundice) related to failure of the diseased liver to conjugate bilirubin, increased haemolysis and obstruction to the flow of bile into the gastrointestinal tract. • Extreme fatigue due to anorexia, nausea and vomiting, as well as failure of the liver to metabolise glucose for energy, especially in stressful situations such as in illness, for example failure of glycogenolysis and gluconeogenesis processes. • Change in level of consciousness, such as inactiveness, apathy, forgetfulness, drowsiness, confusion, irritability, flapping tremors (asterixis) and depression, related to neurological intoxication with ammonia

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(hepatic encephalopathy), as the liver cannot convert ammonia into urea. • Fetor hepaticus, which is faecal breath accompanied by an unpleasant taste in the mouth. This is attributed to abnormal amino acid metabolism and abnormal bacterial action in the intestine. The patient may also report any of the following behaviours associated with their lifestyle: • Alcohol abuse, which is often associated with both liver and pancreatic diseases • Excessive use of either prescribed or over-the-counter drugs, for example anaesthetic agents, painkillers, oral contraceptives, illicit drugs and antidepressants • Exposure to toxins and/or unusual food products, such as Jamaican bush tea, Amanita phalloides in mushrooms, and seafood • Sexual practices that may have exposed the patient to viral hepatitis, especially hepatitis B, as this can be transmitted sexually. The patient’s environmental or occupational history may reveal any of the following: • Exposure to unhygienic waste disposal or accidental immersion in polluted water • Eating raw or steamed shellfish from polluted water • Exposure to hepatitis B while travelling in countries where hepatitis B is endemic • Occupational exposure to blood products while working in the healthcare field, particularly the operating theatre and trauma/casualty unit • Exposure to a family member with viral hepatitis, which is transmittable • History of recent disruption of the skin or mucous membrane integrity with a potential to transmit the hepatitis virus in blood tests, transfusion of blood products, intravenous therapy, intravenous drug therapy, dental procedures, ear piercing, tattooing.

• Malnutrition in patients with a history of substance abuse, such as alcohol or drug abuse. • Dupuytren’s contractures of the hands, which is evidenced by a shortening and thickening under the skin of the palm that causes the middle fingers to be bent. The palms of the hands may also be reddened from vascular congestion. • Small vascular lesions called spider naevi in the arms, shoulders, chest and back. These do not appear below the waistline in liver diseases and would appear around the umbilicus and in the loins in pancreatitis. These lesions are related to portal hypertension and congestion of collateral circulation. • The abdomen may be distended, tense, shiny and bulging at the flanks. A prominent venous collateral system is obviously seen on the stretched abdominal skin in liver diseases especially cirrhosis. • Purpura from lack of vitamin K-dependent clotting factors and increased haemolysis by the spleen, as well as hair loss and gynaecomastia from oestrogen abnormalities. • Neurological signs related to intoxification of the brain with ammonia. These include apathy, decreased level of consciousness, disorientation, confusion, lethargy, deteriorating finger coordination. • Anxiety, anger and/or hostility. On palpation the following may be found: • Muscle guarding and rebound tenderness as evidenced by facial grimacing and tensing due to peritoneal inflammation • Hepatomegaly that can be palpated along the costal margin on the right upper quadrant as the patient inhales • The liver can then be felt protruding below the costal margin • Splenomegaly may present, due to congestion from portal hypertension.

Objective data

Diagnostic tests

Physical assessment mainly includes inspection, palpation and percussion. On inspection the following may be noted: • Fidgety movements, tense facial expression or groaning with pain. • Jaundice, which is a yellow discolouration in the skin and mucous membrane including the sclera. With dark-skinned individuals, jaundice is better observed in the nail bed or in the gums and sclera rather than in the skin. • Muscle wasting or weight loss with chronic liver disorders, but fluid retention may result in oedema.

Diagnosis of the disorders of the hepatobiliary tract and pancreas requires multiple procedures that may be tiring and emotionally draining for the patient. To gain cooperation and alleviate anxiety and fatigue, it is necessary to thoroughly explain these procedures to the patient. The diagnostic procedures include blood tests, radiological and endoscopic studies and liver biopsy.

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Blood tests Tagged red blood cell scan is a procedure where a radiopaque substance is attached to red cells and injected into a patient’s vein. An image of the liver is taken with

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41.1  Preparation for liver biopsy • Preparation of the patient for liver biopsy includes the following: Coagulation studies done prior to the procedure. An informed consent must be secured and baseline vital signs such as blood pressure, pulse and respiration established. The patient should be asked to relax and must be supported throughout the procedure. The skin area must be cleaned with an antiseptic and injected with a local anaesthetic. The patient should also be asked to hold their breath after expiration, during needle insertion and aspiration of tissue to immobilise the chest wall, thereby avoiding severe damage to the liver and related complications, such as pain and bleeding. • After the procedure, the patient should be allowed to rest for about 4 hours before being discharged. During this time, blood pressure, pulse, respiration, and possible signs of bleeding must be monitored every 15 minutes, then every 30 minutes, and finally at hourly intervals. • Monitor possible referred pain on the right shoulder caused by irritation of the liver capsule. Once the patient’s condition has stabilised, they can be discharged. The patient must be advised not to do any heavy lifting or strenuous activity for 1 week, to reduce the risk of bleeding. • Alternative ways of doing liver biopsies may be adopted if the patient has low platelets or prolonged prothrombin time, because these often accompany advanced liver disease that may involve the spleen and may lead to severe bleeding.

a camera that detects emitted radioactivity. This test is used for detection of haemangioma and benign tumours of the liver. It is effective because the tagged red cells accumulate around the tumour. Radiological and endoscopic procedures Ultrasound or sonography is a widely-used test to establish the presence of masses such as tumours and cysts. Ultrasound is non-invasive and relatively cheap. It can also detect dilatation of bile ducts due to obstruction by tumours or stones. This test is of no help in hepatitis.

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Computerised axial tomography (CAT or CT) can be used to detect masses including gallstones. It is the best test to assess the extent of liver tumours and images of the entire abdomen. It can also be used to diagnose advanced liver cirrhosis when the liver is shrunken and nodular. It is, however, expensive and more difficult to perform. Magnetic resonance imaging (MRI) can be used to detect images of internal organs. It is slightly more sensitive than tomography for evaluation of certain tumours. Endoscopic retrograde cholangio pancreatography (ERCP) is used to visualise bile ducts and the gallbladder. A fibreoptic tube is inserted into the oesophagus up to the small intestine and the common bile duct. A dye is injected into the bile duct right up to the smaller bile ducts in the liver and the pancreas. A series of X-rays are then taken. This is the most sensitive test for visualising bile ducts, because it can detect gallstones that could not be detected by ultrasound and tomography. Light sedation is usually ordered to prepare the patient for this procedure. The patient should be starved to avoid vomiting during insertion of the tube. Liver biopsy Liver biopsy is the removal of a small amount of tissue from the liver through needle aspiration. This is done by introducing a needle through the skin (percutaneous) into the liver along the right midaxillary line between the ribs. Liver biopsy can be done as asn outpatient procedure. Indications include confirmation of the diagnosis of liver disease, such as chronic hepatitis, Wilson’s disease, glycogen storage diseases and familial haemochromatosis and cancer.

Specific tests for liver diseases Haematological studies include: • Antibodies. Antibodies against viruses are tested in blood for the diagnosis of viral hepatitis. For blood tests for hepatobiliary and pancreatic functions see Table 41.1. • Autoantibodies. Autoantibodies against proteins from mitochondria and certain antinuclear antibodies are used to diagnose primary biliary cirrhosis.

Common nursing diagnoses These are discussed in the general nursing care plan in Table 41.2.

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784  Juta’s Complete Textbook of Medical Surgical Nursing Table 41.1  Routine blood tests for hepatobiliary and pancreatic functions

Test

Function tested

Normal values

Significance

Special preparation

Aminotransferase (ALT)

Enzyme activity

Male: 0–29 µ/ℓ Female: 0–22 µ/ℓ

• Exclusively found in hepatocytes • Indicates hepatocyte death and damage from inflammation or other causes

None

Aspartate aminotransferase (AST)

Enzyme activity

Male: 0–25 µ/ℓ Female: 0–21 µ/ℓ

• May also be elevated in cardiac or muscle cell death • Usually two or more times elevated than ALT in alcoholic hepatitis

None

Alkaline phosphatase (ALP)

Enzyme activity

68–212 µ/ℓ

• Produced in cells • lining biliary tract, bone, liver, kidney and intestine • Elevated in biliary • Obstruction by gallstones and cancer

None

Gamma glutamyltranspeptidase (GGTP)

Enzyme activity

Male: 8–37 µ/ℓ Female: 5–24 µ/ℓ

• Found exclusively in parts of hepatocytes and bile duct cells • May be elevated in normal individuals or alcohol drinkers without structural liver disease

None

Serum bilirubin

Concentration

Total: 2.0–7.0 µmol/ℓ Direct/conjugated: 0–8.5 µmol/ℓ

• Elevated in most liver diseases, eg acute liver damage, advanced cirrhosis including bile duct obstruction and haemolysis

Protect specimen from ultraviolet rays

Serum enzymes

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Test

Function tested

Normal values

Significance

Special preparation

Blood ammonia

Concentration

Male: 14.7–5.3 µmol/ℓ Female: 11.2–48.2 µmol/ℓ

• Elevations of ammonia correlate with the degree of hepatic encephalopathy

None

Prothrombin time (PT)

Clotting time

12–16 seconds

• Prolonged when blood concentrations of some clotting factors manufactured in the liver are low • Found in significant liver damage • Also in vitamin K deficiency, acquired blood clotting disorders, and some drugs, eg warfarin

None

Platelet count

Quantity of cells

150–44 × 109/ℓ

• Low in patients with cirrhosis or very severe or acute liver disease

None

Full blood count

Quantity of individual blood cells

Red blood cells: Male: 4.5–6.5 × 1012/ℓ Female: 3.8–5.8 × 1012/ℓ

• Anaemia with low haematocrit in liver diseases

None

White cell count

Quantity of cells

4.0–11.0 × 109/ℓ

• Decreased white cell count in patients with cirrhosis but also increased with acute inflammatory liver diseases, such as amoebiasis

None

Serum protein electrophoresis

Concentration of blood’s major proteins, eg albumin, alpha globulins, gamma globulins

Serum albumin: 40–55 g/ℓ Alpha globulin: 1.5–2.5 g/ℓ Gamma globulin: 4.3–7.5 g/ℓ

• Less plasma proteins, eg albumin and globulins (alpha 1, alpha 2, and beta) produced in a diseased liver

None

Other blood tests

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786  Juta’s Complete Textbook of Medical Surgical Nursing Table 41.2 General nursing care plan for patients with disorders of the accessory organs of digestion Fatigue and weakness Nursing diagnosis

• Activity intolerance related to decreased energy levels due to disease process manifested by pallor, muscle weakness, tiredness and weight loss

Expected outcome

• Activity tolerance improved • Muscle strength and normal body weight gained

Nursing interventions and rationale

• Promote rest and allow for uninterrupted periods of relaxation during the acute phase of illness to facilitate recovery and reduce metabolic demands • Teach the patient to monitor activities that provoke fatigue and encourage participation in planning care • Increase activity slowly as tolerated with intervals of rest to conserve energy and patient’s strength and prevent an increase of weakness • Encourage the patient to eat all the meals • Weigh daily to assess weight gain

Evaluation

• The patient exhibits interest in activities • Fatigue is reported less frequently • Gradual weight gain is evident as indicated in the daily weighing schedule

Aversion to eating, nausea and vomiting Nursing diagnosis

• Altered nutrition, less than body requirements, related to disease process manifested by severe anorexia, nausea and vomiting, abdominal distension and weight loss

Expected outcome

• Abdominal distension, and appetite improved • Nausea and vomiting stopped and normal weight gain maintained

Nursing interventions and rationale

• Assess the patient’s appetite and adequacy of intake to plan appropriate interventions • Identify the patient’s likes and dislikes and serve food that can be tolerated, and that has a low fat content • Ensure meals are served attractively • Engage a dietician to provide appropriate guidance to address nutritional requirements, eg high carbohydrates, low protein and fat with adequate vitamins • Serve small meals frequently • Do oral care before meals to remove foul tastes • Administer antiemetics as prescribed Monitor fluid and solid intake and output strictly to ensure a balance thereof • Monitor weight daily for loss secondary to poor appetite • Educate the patient about the nutritional requirements and foods to avoid that are likely to cause nausea

Evaluation

• Patient reports no nausea and vomiting • Appetite is improved • Weight gain is satisfactory • Patient verbalises an understanding of adequate nutritional requirements and aspires to the intake thereof

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Diarrhoea or constipation Nursing diagnosis

• Altered bowel pattern related to disease process manifested by diarrhoea or constipation

Expected outcome

• Bowel action normal and normal stool passed regularly

Nursing interventions and rationale

• Give adequate amounts of fluids orally or intravenously if vomiting presents and persists • Maintain adequate intake of solids with adequate fibre to ensure bulk and normal stool formation; be certain to reduce protein and fat in the diet as these may not be tolerated and may result in steatorrhoea • Monitor vital signs so that possible high fever and its causes are promptly addressed to avoid diaphoresis that may result in dehydration, causing constipation • Administer stool softeners or antidiarrhoeals as prescribed • Avoid the use of laxatives in the treatment of constipation • In case of diarrhoea, monitor electrolytes and replace according to levels

Evaluation

• The patient reports a normal stool of correct consistency • Vital signs are normal

Pain, abdominal distension, pruritus Nursing diagnosis

• Altered comfort, sleep pattern disturbance and impaired skin integrity related to disease process manifested by reported pain, ascites and itching

Expected outcome

• Pain, abdominal distension and itching relieved

Nursing interventions and rationale

• Assess the degree of pain to establish the baseline from which to evaluate the response to treatment • Nurse in a position of choice for the patient’s cause and location of pain • Provide relaxing baths, backrubs, fresh linen, and a dark and quiet environment to ease the patient’s discomfort • Administer prescribed analgesics to relieve pain • For pruritus: use warm (not hot) soaking baths, avoid clothes made of wool as these may irritate the skin, use cool non-restrictive clothing that does not cling, maintain a cool environment, apply emollient creams and lotions to soothe the skin, use superfat soaps that will not dry the skin, avoid activities that promote sweating, keep the patient’s nails very short to prevent scratching, give prescribed antihistamines to control itching and use diversional therapy to reduce the patient’s perception of pruritus • For abdominal distension: a nasogastric tube may be used to drain the abdominal contents. The patient should be encouraged, if possible, to walk about so that flatus can be passed. The doctor may need to do a paracentesis to remove the peritoneal fluid in ascites

Evaluation

• Should sleep well and comfortably • The patient to report that pain is controlled • Abdominal distension is relieved • The skin is intact and the itching is controlled

Yellow discolouration of the skin, purpura and petechiae Nursing diagnosis

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• Risk of anxiety and depression related to knowledge deficit and change of body image due to skin discolouration manifested by yellow discolouration of the skin and eyes, Ecchymosis, withdrawal and reluctance to participate in care

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Expected outcome

• Patient informed about the disease process and therefore knowledgeable about the disease process

Nursing interventions and rationale

• Provide information about the disease, its possible cause, pathophysiology, planned management and prognosis, and also clear the misconceptions so that the patient and family understand the reason for the yellow discolouration of the skin and eyes, or the bruising with minimum pressure, the itching and the reason for many investigative procedures • Provide soothing baths for the pruritus • Encourage participation in their care • Teach the patient about symptoms of recurrence • Explain the importance of avoiding alcohol consumption, over-the-counter medication and herbal remedies • Allow free discussion and provide honest answers to questions • Allow the patient and family to participate in the care • Teach them about infection control and prophylaxis in relation to transmission and treatment regimen; explain procedures and results of tests done • Teach about diet restriction • Address the risk of contracting viral hepatitis through multiple sex partners and the importance of using condoms • Explain the importance of follow-up • Refer the patient for counselling and assistance to stop drinking alcohol if this is the problem

Evaluation

• The patient to communicate freely about the disease process and participate in their care • The patient verbalises an understanding of follow-up care and expresses willingness to comply with the follow-up regimen and abstain from alcohol, and work towards stopping alcohol consumption if addicted • The patient is able to explain transmission methods and how these can be prevented

Halitosis and loneliness Nursing diagnosis

• Social isolation due to management interventions, change in body image, stigma of having an infectious disease and bad breath manifested by withdrawal from social interactions

Expected outcome

• Halitosis improved and the patient presenting with an odourless breath

Nursing interventions and rationale

• In case of halitosis, provide information about the pathophysiology of liver diseases • Encourage oral hygiene to promote comfort • Educate the patient and family about isolation procedures in the management of some diseases, to maintain family support • Create a supportive environment that will allow the patient to express feelings about the disease and plan appropriate interventions • Include patients in their own care plan and encourage participation to increase self-esteem and independence • Encourage communication and answer questions truthfully and honestly • Encourage the family to visit the patient and provide measures for barrier nursing to prevent infection

Evaluation

• The patient verbalises an understanding of the necessity of isolation and adapts positively to the change in skin colour and halitosis • Patient participates in self-care and oral care

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Specific disorders of the accessory organs of digestion Disorders of the liver The liver is the largest glandular organ of the body. It weighs about 1.36 kg, is reddish brown in colour and has two large sections called the right and the left lobes, of unequal size and shape. The liver lies on the right side of the abdominal cavity beneath the diaphragm. Blood is carried to the liver via two large vessels called the hepatic artery and the portal vein. The hepatic artery carries oxygen-rich blood from the aorta. The portal vein carries blood containing digested food from the small intestine. These blood vessels subdivide in the liver repeatedly, terminating in very small capillaries. Each capillary leads to a lobule. Liver tissue is composed of thousands of lobules, and each lobule is made up of hepatic cells which are the basic metabolic cells of the liver. The functions of the liver are to: • Produce substances that break down fats • Convert glucose into glycogen • Produce urea, which is the main substance of urine • Make certain amino acids, that are the building blocks of proteins • Filter harmful substances from the blood, such as alcohol • Store vitamins A, D, K and B12 and minerals • Maintain normal glucose level in the blood • Produce cholesterol Right lobe of liver

• Filter the blood coming from the digestive tract, before passing it to the rest of the body • Detoxify chemicals • Metabolise drugs • Make proteins important for blood clotting and other functions.

Conditions of the liver Hepatitis. Inflammation of the liver, usually caused by viruses like hepatitis A, B, and C. Hepatitis can have noninfectious causes too, including heavy drinking, drugs, allergic reactions or obesity. Cirrhosis. Long-term damage to the liver from any cause can lead to permanent scarring, called cirrhosis. The liver then becomes unable to function well. Liver cancer. The most common type of liver cancer, hepatocellular carcinoma, almost always occurs after cirrhosis is present. Liver failure. Liver failure has many causes including infection, genetic diseases, and excessive alcohol. Ascites. Accumulation of fluid in the peritoneal cavity resulting in a distended and heavy abdomen. Gallstones. If a gallstone becomes stuck in the bile duct draining the liver, hepatitis and bile duct infection (cholangitis) can result. Hepatic vein Diaphragm

Hepatic artery Portal vein Bile draining to intestines Gallbladder Figure 41.1  The blood supply to the liver

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Haemochromatosis. Haemochromatosis allows iron to deposit in the liver, damaging it. Primary sclerosing cholangitis. A rare disease with unknown causes, primary sclerosing cholangitis causes inflammation and scarring of the bile ducts in the liver. Primary biliary cirrhosis. A rare disorder, in which an unclear process slowly destroys the bile ducts in the liver. Permanent liver scarring (cirrhosis) eventually develops.

Risk factors The liver is the chemical factory of the body. However, there are activities and events that put it at risk. These include: • Exposure to hepatotoxic substances, eg industrial chemicals and medication • Alcohol • Exposure to blood and blood products contaminated with viruses such as hepatitis viruses • Blood transfusion • Circulatory problems. The most common and significant symptoms of the disorders of the liver are: • Jaundice resulting from increased unconjugated bilirubin concentration in the blood • Cholestasis, which is a reduction or stopping of bile flow or stagnation of bile • Portal hypertension and varices resulting from circulatory changes within the diseased liver producing gastrointestinal haemorrhage, sodium and fluid retention • Hepatic encephalopathy or hepatic coma, a disorder in which the brain function deteriorates due to toxic

substances accumulating in the blood because the liver cannot remove them • Nutritional deficiencies that result from the inability of the diseased liver cells to metabolise certain nutrients, resulting in impaired functioning of the central and peripheral nervous systems, and bleeding tendencies. Acute liver diseases occur suddenly and are of short duration. They may resolve spontaneously, become chronic or fatal. Chronic liver disease may last more than 6 months. Fulminant hepatic failure is a severe type of liver failure caused by some acute liver diseases.

Management The therapeutic goal in the treatment of acute liver disease is to provide professional support for the disease to resolve spontaneously and prevent it from becoming chronic. In chronic liver disease, the goal of management is to either cure or prevent the disease advancing to cirrhosis.

Jaundice Definition Jaundice is a yellow discolouration of the skin, mucous membrane and the sclerae of the eyes caused by high levels of unconjugated or conjugated bilirubin in the bloodstream due to an alteration in normal bilirubin metabolism or flow of bile through the hepatic or biliary duct systems.

Pathophysiology Normally, damaged or old red blood cells are mainly removed by the spleen from the circulation. During this process, the haemoglobin splits into the haem and globin. The haem is broken down in the liver into conjugated bilirubin to be finally excreted as part of bile. If this Coronary ligament

Right lobe

Left lobe

Falciform ligament Ligamentum teres Gallbladder Figure 41.2  Anterior view of the liver

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process is hindered, excess conjugated and unconjugated bilirubin passes into the bloodstream and is deposited onto the skin, the mucous membranes, sclerae and other body fluids and tissues causing a yellow discolouration. The urine may also be very dark because of the excess bilirubin.

Types of jaundice Haemolytic jaundice results from an increased destruction of red blood cells, resulting in an increased amount of unconjugated bilirubin in the blood. The liver fails to excrete the bilirubin as quickly as it is formed. Haemolytic jaundice is caused by blood transfusion reactions, sickle cell crisis and haemolytic disorders. Obstructive jaundice is caused by an obstruction in the bile ducts, which then impedes the flow of bile through the liver and the biliary tract. The obstruction may be intrahepatic or extrahepatic. In both obstructions, the bile is reabsorbed into the blood and carried through the body, causing jaundice. It is also excreted in the urine giving it a foamy, deep orange colour. The stools become clay-coloured or fatty because of non-entry of bile into the intestine. The patient complains of an itchy skin. Dyspepsia and intolerance to fatty foods is due to impaired digestion caused by absence of intestinal bile. An intrahepatic obstruction is due to swelling or fibrosis of the liver’s canaliculi and bile ducts. This can be caused by damage from tumours of the liver, an inflammatory process, hepatitis or cirrhosis. Certain medicines called cholestatic agents may cause intrahepatic obstruction by causing thickening of the bile or stasis. Examples of these are phenothiazines, androgens, oestrogens, and certain antidepressants. Extrahepatic obstruction is caused by obstruction of the common bile duct by a gall stone, carcinoma of the head of the pancreas, and sclerosing cholangitis. Hepatocellular (hepatic) jaundice develops within the liver. It results from excessive serum bilirubin due to either defective uptake of bilirubin by the liver or defective excretion as well as conjugation of bilirubin within the liver. In hepatocellular disease, the liver cells or hepatocytes are damaged and leak bilirubin, thereby increasing the circulating levels of both conjugated and unconjugated bilirubin. Conjugated bilirubin is water soluble and is thus excreted in the urine. The common causes of hepatocellular jaundice are cirrhosis, hepatitis and carcinoma of the liver. Both liver disease and biliary obstruction create multiple defects, resulting in a mixed hyperbilirubinaemia. Hyperbilirubinaemia or increased serum bilirubin levels result from several inherited disorders, such as

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Gilbert’s syndrome, Dubin-Johnson syndrome or Rotor’s syndrome. Benign cholestatic jaundice of pregnancy is thought to be due to unusual sensitivity to the hormones of pregnancy, and is accompanied by retention of conjugated bilirubin.

Assessment and common findings Subjective data

• Mild jaundice without dark urine suggests uncon­ jugated hyperbilirubinaemia caused by haemolysis or Gilbert’s syndrome rather than hepatobiliary disease. • A severe jaundice with dark urine indicates a liver or biliary disorder. Patients often notice the dark urine before skin discolouration. • Dyspepsia, intolerance of fatty foods and steatorrhoea may indicate less bile in the intestine to help digest dietary fat. • Nausea and vomiting that precedes jaundice may indicate acute hepatitis or common bile duct obstruction by a stone. • Abdominal pain or rigors indicate acute hepatitis. • Anorexia and malaise occur in many conditions and may suggest alcoholic liver disease or chronic hepatitis. • Weakness and weight loss occur in hepatocellular disease. • In obstructive jaundice, the skin is itchy due to presence of bile products in the circulation. • Prolonged jaundice from cholestasis produces a muddy skin colour and fatty yellow deposits in the skin.

Objective data Diffuse lymphadenopathy suggests mononucleosis in acute jaundice and lymphoma or leukaemia in chronic illness. Diagnostic tests include imaging in diagnosing infiltrative and cholestatic disorder, as is with an abdominal ultrasound. CT and MRI scans are often used to detect metastatic and liver lesions. These may also reveal bloated bile ducts which imply mechanical obstruction. • Peritoneoscopy (laparoscopy) can be used for direct inspection of the liver and biliary tree. • Percutaneous transhepatic cholangiography (PTC) is useful in revealing extrahepatic obstruction. • Liver biopsy can be used to diagnose intrahepatic cholestasis. • Laboratory findings are as presented in Table 41.3.

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792  Juta’s Complete Textbook of Medical Surgical Nursing Table 41.3  Laboratory findings in jaundice

Category

Laboratory findings

Obstructive intrahepatic jaundice

Conjugated bilirubin is elevated, alkaline phosphatase is elevated, no enlargement of bile ducts seen on scan or ultrasound

Extrahepatic (bile duct obstruction) jaundice

Conjugated bilirubin elevated, alkaline phosphatase elevated, scan or ultrasound shows enlargement of bile ducts; no urobilinogen in urine

Hepatocellular jaundice

Transaminases (ALT, AST) elevated. Conjugated and unconjugated bilirubin is elevated

Haemolytic jaundice

Mild elevation of total bilirubin, unconjugated is more than conjugated

Management

Pathophysiology

The goal of management is to eliminate the underlying cause/disease. Possible interventions include: • Surgical removal of an extrahepatic obstruction • Choledochostomy, which is an exploration of the common bile duct to differentiate between a choledocholithiasis and a tumour.

Viral hepatitis causes a diffuse inflammatory infiltration of liver tissue. The pathophysiological changes in the liver are similar in the various types of viral hepatitis. There is liver damage during acute infection that is mediated by cytotoxic cytokines and natural killer cells that cause lysis of the infected cells. The liver cells may become swollen and there may be necrosis thereof. Bile flow may be interrupted leading to cholestasis. In most cases of uncomplicated hepatitis, healing of the hepatocytes occurs in 3–6 months, with normal liver function and no hepatic necrosis. Alternatively, damage to liver cells may occur resulting in alterations in the functioning of the hepatocytes, caused by the virus and the immune response. The changes in the hepatocytes are not always related to the virus itself but are associated with increased levels of serum alkaline phosphatase and an elevated bilirubin level. Chronic hepatitis may occur with all types of viral hepatitis. Once damaged, the liver will not be able to perform its normal functions efficiently.

Nursing management • Provide regular soothing baths to relieve pruritus and prevent scratching and skin excoriation. • Administer prescribed medication timeously. Oral cholestyramine resin may provide relief by binding with the bile salts to facilitate elimination through the intestines. Antihistamines may be prescribed to provide relief from itching. • Provide emotional support as jaundice may affect the patients’ body image as it interferes with their appearance. It may also cause physical, social and emotional isolation. • Allow the patient to voice their feelings and concerns by providing an environment of acceptance. Unconditional support by family members and the health team is important, as the patient may be preoccupied with their physical appearance and suffer a low self-concept. • Answer all questions truthfully and honestly to help patient cope with the altered physical appearance.

Hepatitis Definition Hepatitis is an inflammation of the liver, and may be caused by viruses, bacteria or any toxic substance. Hepatitis caused by viruses is called viral hepatitis. The types of infectious viral hepatitis are A, B, C, D, and E (see Table 41.4). Hepatitis types F and G are rare and are caused by bacteria such as Streptococci, Salmonella and E. coli. Viral hepatitis is the most common liver disease.

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Assessment and common findings Subjective data

Many patients are anicteric with mild and flu-like symptoms such as low-grade fever, severe anorexia with a strong aversion to cigarette and cigarette smoke, nausea, heartburn and flatulence. In hepatitis A, the onset is acute with mild symptoms, in hepatitis B the symptoms are severe with an insidious onset and in hepatitis C the symptoms are mild or absent. The clinical manifestations of viral hepatitis may be described in three phases as indicated in Table 41.5.

Management The overall goals of nursing management are to: • relieve discomfort • promote return to normal liver function • prevent complications.

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Chapter 41 – Management of the disorders of the accessory organs of digestion  793 Table 41.4  Major human hepatitis viruses

Virus

Genetic material

Mode of transmissions

Disease

High-risk groups

Secretions with infective agent

Hepatitis A

RNA

Faecal-oral route due to poor sanitation and ingestion of contaminated food or water, or direct contact with infected person Incubation 2–6 weeks

Acute hepatitis

Travellers, staff and patients in custodial care institutions, eg prisons, nursing homes

Faeces, blood

Hepatitis B

DNA

Parenteral, sexual intercourse, mother-to-infant transmission Incubation 4–24 weeks

Acute or chronic hepatitis

Sexual partners of hepatitis B virus carriers, intravenous drug users, patients and staff in custodial care settings, or patients on haemodialysis and healthcare workers in contact with blood

Blood, serous fluid, saliva, semen, vaginal discharge, urine, stools, pleural fluid, nasopharyngeal washings

Hepatitis C

RNA

Exposure to contaminated blood and blood administration equipment, mother to infant, sexual intercourse Incubation 2–20 weeks

Acute or chronic hepatitis

Travellers to endemic areas, people receiving frequent blood transfusions, drug users, organ transplant recipients

Blood and semen

Hepatitis D

DNA

Blood super infection or co-infection with chronic HBV Incubation 3–20 weeks

Acute or chronic hepatitis

Same as hepatitis B virus

Blood

Hepatitis E

RNA

Faecal-oral route due to poor sanitation, ingestion of contaminated food and water Incubation 2–9 weeks

Acute hepatitis

Immigrants and travellers to hepatitis E virusinfected areas

Stools

(For nursing management of viral hepatitis, refer to the nursing care plan in Table 41.2)

Pharmacological management The goals of pharmacological management are to reduce the viral load, the rate of disease progression, and prevent drug resistance. There are no specific drug therapies for the treatment of acute viral hepatitis. Most medication is metabolised in the liver, and therefore only essential drugs should be given. Analgesics should be given with caution.

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Interferon has been administered with success in patients with chronic hepatitis. Interferon and lamivudine (Epivir®), a reverse transcriptase, have also been found to be effective in the treatment of hepatitis B virus (HBV), Adefovir (Dipivoxil®) has been used especially in patients with active viral replication and elevations in either alanine aminotransferase (ALT) or aspartate aminotransferase (AST). For the treatment of hepatitis core antigen (HBC), a combination therapy of ribavirin and alpha-interferon may be used. This combination treatment is used in the management of patients with coexisting HIV, but the

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794  Juta’s Complete Textbook of Medical Surgical Nursing Table 41.5  Clinical manifestations of viral hepatitis

Preicteric phase

Icteric phase

Posticteric phase

• Precedes jaundice and lasts from 1–21 days. This is also the maximum infectivity period • Anorexia, nausea, abdominal discomfort, vomiting, constipation or diarrhoea • Anorexia severe due to cytokines or chemicals produced by the liver. Food is repugnant to the patient

• Characterised by jaundice which results when bilirubin diffuses into tissues. Lasts 2–4 weeks • Darkening of urine due to excess bilirubin excreted by the kidneys • Stools are fatty, clay-coloured and show a decrease in urobilinogen • Anorexia persists with weight loss and strong aversion to fatty foods

• Jaundice disappears • Malaise and easy fatigue may continue for some time • Urine returns to normal colour • Stool returns to normal colour • Appetite improves

Subjective data: • Weight loss • Distaste for cigarettes if the patient is a smoker • Aversion to fatty food • Loss of sense of smell or decrease thereof • Fatigue, cough and joint pains • Malaise, headache, fever and skin rashes

Subjective data: • Abdominal discomfort and pain in the right upper quadrant • Increasing pruritus due to accumulation of bile salts • Fatigue

Objective data: • Elevated serum alanine aminotransferase (ALT) • Elevated urine bilirubin levels • Presence of viral antibodies, antigens and viral particles

Objective data: • Hepatomegaly with tenderness • Laboratory studies show elevated conjugated bilirubin levels and decrease in urobilinogen

treatment may further reduce the CD4 cell count and increase the patient’s risk for anaemia.

Toxic and drug-induced hepatitis There are many agents that can cause liver damage. These agents include drugs, alcohol, industrial toxins and plant poisons.

Pathophysiology Toxic and drug-induced hepatitis are similar to viral hepatitis in the pathophysiological changes in the liver and clinical manifestations. However, the changes produced by the toxins in the liver vary, and the changes are dependent on the specific hepatotoxin. A major cause of toxic hepatitis is the use of acetaminophen, especially when used with alcohol, anticonvulsants or antituberculous drugs. People who are repeatedly exposed to toxic substances may develop cirrhosis. Those experiencing sensitivity reactions may show eosinophilia, fever, arthralgia and faulty lipid metabolism.

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Objective data: • Values return to normal

Clinical manifestations Early manifestations include anorexia, nausea, vomiting and lethargy. Chemical manifestations include elevated ALT and AST levels. Later manifestations include jaundice, hepatomegaly, hepatic tenderness, dark urine, elevated serum bilirubin levels, and elevated urine bilirubin levels. Symptoms can be more intense for the severely toxic patient. In prolonged exposure, recovery is unlikely. The patient may become very toxic and prostrated. Vomiting may be persistent with blood-stained vomitus. Clotting abnormalities may be severe with haemorrhages occurring beneath the skin. The gastrointestinal symptoms become severe, leading to vascular collapse. Delirium, coma and seizures may develop and the patient may die unless a liver transplant is performed.

Management The management of toxic and drug-induced hepatitis is mainly supportive. Gastric lavage and cleansing of the bowel may be indicated as first aid treatment to remove the

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hepatotoxins from the intestinal tract. Specific treatment for specific hepatotoxins may be used; for example, in paracetamol overdose, acetylcysteine is an antidote and can be given within 16 hours of ingestion. However, a liver transplant may still be necessary. Healthy

Essential health information The patient is advised to keep a healthy lifestyle, instructed to avoid the use of alcohol or drugs, not to take any overthe-counter medication or herbal medicines without first consulting their doctor or nurse. Advice and education regarding healthy eating habits and a balanced diet is an important aspect of care.

Cirrhotic

Autoimmune hepatitis Autoimmune hepatitis occurs in patients who have no known risk factors for the development of viral hepatitis. It is a chronic necro-inflammatory liver disorder associated with circulating autoantibodies and high serum globulin levels. The causes of autoimmune hepatitis are unknown but it is associated with a genetic predisposition to autoimmunity that develops after exposure to some environmental agents. It is less common than chronic viral hepatitis. It may occur at any age and is common in women between the ages of 15 and 40 years.

Alcoholic hepatitis Alcoholic hepatitis may be acute or chronic due to necrosis of the parenchymal cells that results from alcohol abuse. Alcoholic hepatitis often results in cirrhosis.

Assessment and common findings Symptoms of alcoholic hepatitis occur following a bout of heavy drinking. Symptoms include nausea, anorexia, abdominal pain, splenomegaly, hepatomegaly, jaundice, ascites, fever and encephalopathy. The laboratory results may reveal anaemia, leukocytosis and elevated serum bilirubin. A liver biopsy will be done to confirm the diagnosis. Alcoholic hepatitis has a poor prognosis, especially in people who fail to control their drinking. Management includes a high vitamin and high carbohydrate diet with folic acid supplements.

Cirrhosis of the liver Definition Cirrhosis is a chronic progressive disease that is characterised by extensive degeneration and destruction of the parenchymal cells of the liver.

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Figure 41.3  A healthy and a cirrhotic liver

Pathophysiology Cirrhosis is the final stage of many types of liver injuries. In cirrhosis, the liver varies in appearance. The most prominent feature is a nodular consistency with bands of fibrous scar tissue and small areas of regenerating tissue. The fibrotic changes in the liver distort the hepatic structures, resulting in the obstruction of the splanchnic veins and portal blood flow. This obstruction causes problems such as fluid retention, increasing oedema, ascites and hydrothorax. The portal pressure increases, and this together with congestion of splanchnic veins, results in splenomegaly and altered functioning of the spleen, which can cause leukopenia, thrombocytopenia and anaemia. Portal hypertension increases venous pressure, vascular haemostasis, haemorrhoids, varicose veins and oesophageal varices. The liver fails to metabolise oestrogen, causing gynaecomastia (enlarged breasts) in males.

Causes of cirrhosis Cirrhosis has many causes, the most common being chronic alcoholism and viral hepatitis. • Alcoholic liver disease. Alcoholic cirrhosis develops after a long time (more than a decade) of heavy drinking. The amount of alcohol that can injure the liver varies from person-to-person. Alcohol has a potential to affect the liver by blocking the normal metabolism of protein, fats and carbohydrates. • Infections. These include hepatitis B, C and D. Infections with hepatitis C virus cause inflammation of the liver and low-grade damage to the liver cells that

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796  Juta’s Complete Textbook of Medical Surgical Nursing Table 41.6  Types of cirrhosis

Type

Causative factors

Pathophysiology

Alcoholic cirrhosis (nutritional portal)

• Chronic consumption of excessive amounts of alcohol and malnutrition

• There is accumulation of fat in the liver cells; massive collagen formation occurs • The liver is large and firm in the early stages and becomes small and nodular with areas of necrosis in later stages; alteration in physiology is seen in later stages • If alcohol abuse continues, scar formation occurs throughout the liver • Fatty liver and alcoholic hepatitis will resolve if the patient stops alcohol consumption

Postnecrotic cirrhosis

• This is a complication of viral, toxic or autoimmune hepatitis

• Liver has nodules • There is scar tissue formation in the liver • The liver is decreased in size, and is fibrous

Cardiac cirrhosis

• This is a complication of right heart failure in patients with cor pulmonale, constrictive pericarditis and an inefficient tricuspid valve

• Liver is swollen • Fibrosis occurs in patients with long-standing congestive heart failure • Changes are reversible if congestive heart failure is treated

Primary biliary cirrhosis

• Inflammation of the smallest bile ducts in the liver resulting in biliary obstruction • Cholangitis

• The liver is enlarged and firm with nodules • Impairment of bile drainage occurs due to inflammation and scarring of bile ducts • Skin pigmentation • Jaundice occurs because bile remains in the liver cells and spills over into the bloodstream • Scar tissue develops throughout the liver • Pruritus occurs

Non-specific metabolic cirrhosis

• Metabolic problems • Infiltrative diseases • Gastrointestinal diseases • Infectious diseases

• Liver is enlarged and becomes firm • Portal or liver fibrosis may develop

can lead to cirrhosis over several decades. Hepatitis B virus is the most common cause of cirrhosis, and hepatitis D infects the liver, but only in people who already have hepatitis B. • Autoimmune hepatitis. This causes inflammation, damage and scarring of the liver. • Non-alcoholic steatohepatitis. Fat builds up in the liver and eventually causes scar tissue. • Exposure to certain chemicals and drugs. Severe reactions to prescription drugs, prolonged exposure to environmental toxins, parasitic infection, such as schistosomiasis, and repeated bouts of heart failure with liver congestion can all lead to cirrhosis.

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• Bile duct obstruction. When the bile ducts are blocked, bile stagnates and damages liver tissue. Primary biliary cirrhosis is caused by inflamed, blocked and scarred bile ducts, and secondary biliary cirrhosis may happen after gallbladder surgery if the ducts are inadvertently tied off or injured. • Inherited diseases. Certain diseases interfere with the way the liver produces, processes, and stores enzymes, proteins, metals and other substances necessary for the body to function. Examples of these are inherited diseases such as haemochromatosis, alpha-1 antitrypsin deficiency, Wilson’s disease, galactosaemia and glycogen storage diseases.

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Chapter 41 – Management of the disorders of the accessory organs of digestion  797 Table 41.7  Clinical manifestations of cirrhosis

Clinical manifestations of cirrhosis

Basis

Early manifestations • Anorexia, nausea and vomiting, dyspepsia, change in bowel habits (diarrhoea or constipation) • Abdominal pain which is described as a dull, heavy feeling in the right upper quadrant or epigastrium • Fever, lassitude, slight weight loss, enlargement of the liver and spleen; the liver is palpable • Prolonged clotting time

• Occur as a result of the liver’s altered metabolism of carbohydrates, fats and proteins • Pain due to rapid enlargement and stretching causing tension of the liver capsule and spasm of the biliary ducts and vascular spasm • Inflammatory process and failure of the liver to synthesise proteins, clotting factors and other substances and manifestations of portal hypertension

Later manifestations • Jaundice – minimal or severe, depending on the degree of damage to the liver • Pruritus may accompany jaundice

• This results from the compression of the bile ducts by overgrowth of connective tissue and also from the functional derangement of liver cells decreasing the ability of the liver to conjugate and excrete bilirubin • Pruritus is due to accumulation of bile salts under the skin

• Skin lesions are common in cirrhosis, namely, spider angiomas, which are small dilated blood vessels with a red centre point and spider-like branches occurring on the nose, cheeks, upper trunk, neck and shoulders; and palmar erythema

• Due to an increase in circulating oestrogen, as the damaged liver fails to metabolise steroids and hormones

• Endocrine disturbances such as amenorrhoea, atrophy of testicles, gynaecomastia, parotid hypertrophy, loss of axillary and pubic hair, impotence with loss of libido, vaginal bleeding in older females

• Due to probable abnormal hormonal metabolism in the liver, resulting in manifestations of oestrogen excess, and androgen deficit

• Peripheral oedema (of ankles and sacrum) and ascites

• Oedema results from a decrease in colloidal oncotic pressure from impaired synthesis of albumin, and increased portocaval pressure from portal hypertension

• Emaciation and ascites

• Due to malnutrition and portal hypertension • In cirrhosis, there is an elevation of blood pressure in the liver; proteins move from the blood vessels into the lymph space; when the lymphatic system is unable to carry the excess proteins and water, these leak through the liver capsule into the peritoneal cavity; the osmotic pressure and the protein pulls additional fluid into the peritoneal cavity to cause ascites • Hypoalbuminaemia results from the inability of the liver to synthesise albumin; the hypoalbuminaemia results in a decrease in colloidal oncotic pressure • Hyperaldosteronism is due to the inability of the damaged hepatocytes to metabolise aldosterone; the increase in aldosterone results in an increase in the reabsorption of sodium by the renal tubules, resulting in water retention

• Abdominal striae with prominent abdominal wall veins

• Collateral vessels bypass the scarred liver to carry portal blood to the vena cava

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Clinical manifestations of cirrhosis

Basis

• Peripheral neuropathy

• Due to failure of the liver to metabolise thiamine, folic acid and cobalamin

• Oesophageal varices occur at the lower end of oesophagus as tortuous veins that are enlarged and swollen; the collateral veins are highly fragile and bleed easily

• Portal hypertension causes dilation of collateral veins in the oesophagus

• Gastrointestinal bleeding

• There is hypoprothrombinaemia and thrombocytopenia; portal hypertension, oesophageal varices, and peptic ulcers are common in alcoholics

• Haemorrhoids

• Internal haemorrhoidal veins dilate with the pressure of portal hypertension

• Splenomegaly

• Results from the backing up of blood from the portal vein into the spleen

• Anaemia

• Due to inadequate red blood cell production and survival of the cells, poor diet, poor metabolism and absorption of folic acid and bleeding from varices

• Other haematological problems are thrombocytopenia, leukopaenia, coagulation disorders which are manifested by bleeding tendencies, such as epistaxis, purpura, petechiae and menorrhagia

• The liver is unable to produce prothrombin resulting in coagulation disorders

• Renal failure

• Rapidly failing hepatic function, occasionally precipitated by urinary volume depletions

• Infections

• Leukopenia due to an enlarged overactive spleen; hypoproteinaemia, and bacteria in portal blood bypass the liver and are not removed by the Kupffer’s cells

• Recurrent symptoms of hepatitis

• Chronic viral, toxic or alcoholic hepatitis progressing to cirrhosis may have inflammatory exacerbations

• Hepatic encephalopathy and coma

• The liver is unable to remove ammonia that accumulates to levels toxic to the brain

Assessment and common findings

Diagnostic evaluation

A variety of signs and symptoms may be seen in patients with cirrhosis and these reflect the diminishing capacity of the liver to function normally. The patient may show any or all of the signs and symptoms in Table 41.7. The onset of cirrhosis is insidious but occasionally there is an abrupt onset of symptoms. The most common early symptoms occur in the gastrointestinal tract, while later symptoms may be severe and result from liver failure and portal hypertension. Other late symptoms include skin lesions, haematological disorders, endocrine disturbances and skin neuropathies.

Liver function studies indicate abnormalities in liver function. There is an increase of enzyme levels, namely: • Asparate aminotransferase (AST) • Alanine aminotransferase (ALT) • Alkaline phosphatase (ALP) • Serum glutamate pyruvate transaminase (SGPT) • Serum glutamic oxaloacetic transaminase (SGOT).

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In addition: • Prothrombin time will be elevated. • Protein metabolism tests will reveal a decrease in total protein, decreased albumin and increased globulin levels.

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• Cholesterol levels are decreased, indicating abnormalities in fat metabolism. Other possible diagnostic tests include: • Ultrasound to measure the difference in density of parenchymal cells and scar tissue • Liver biopsy to confirm diagnosis • Liver scan and MRI and radioisotope scans to determine liver size, hepatic blood flow and obstruction • Stool tests for occult blood • Full blood count to detect anaemia, leukopenia or thrombocytopenia as these may be a result of splenomegaly.

Management The two main goals of treatment with cirrhosis of the liver are to: • Maximise liver function by improving the diet, discouraging alcohol intake, controlling infection, and encouraging adequate rest • Control disabling symptoms. The three most feared complications of cirrhosis are ascites, bleeding oesophageal varices and hepatic encephalopathy. All known hepatotoxic drugs must be removed from the therapeutic regimens and all dosages of drugs thought to be metabolised by the liver must be lowered and given with extreme caution. Corticosteroids may be given in postnecrotic and posthepatic cirrhosis to reduce the clinical manifestations and improve liver function.

Nursing management • Monitor for encephalopathy by assessing the patient’s general behaviour and orientation to time and place. • Monitor vital signs and overall status to detect deterioration of baseline functioning. • Monitor for speech and report any deviations from normal. • Monitor blood pH constantly, as well as ammonia levels because the liver is unable to convert accumulating ammonia into urea for excretion by the kidneys. Reduction of ammonia levels can be achieved by: –– eliminating or restricting protein intake as ordered –– decreasing metabolism of endogenous proteins by increasing carbohydrate intake –– giving small, frequent, attractive meals to improve appetite –– encouraging fluid intake (if not restricted) and giving laxatives and enemas or oral cathartics as ordered to decrease production of ammonia

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• •

• • •

–– encouraging good oral hygiene to increase appetite –– administering antibiotics as prescribed to kill bacteria in the gastrointestinal tract –– managing haemodialysis as prescribed. Protect the patient from injury because the altered mental status increases the potential for injury. Carefully balance fluid intake to maintain kidney perfusion without overloading the cardiovascular system. Strict intake and output records must be kept to monitor renal function. Maintain central venous pressure monitoring to determine fluid status. Focus family education on correct diet, and on medication that should be taken, as well as avoided. Alert the family to observe and report any changes in the patient’s behaviour.

Pharmacological management Narcotics and sedatives should not be administered as these are detoxified by the liver. If sedatives are necessary; only drugs that can be excreted by the kidney should be used, such as, phenobarbital or chlordiazepoxide. If indicated, medication can be given to reduce serum ammonia levels, for example lactulose, antibiotics, glucose, or benzodiazepine antagonists.

Essential health information Cirrhosis is a chronic illness, therefore the patient and family must adhere to follow-up care after discharge from hospital. The patient and family should be advised to: • avoid over-the-counter medication, as some could be hepatotoxic • avoid alcohol consumption to prevent further liver damage • eat a balanced diet • avoid spicy, rough foods as well as activities that increase portal pressure such as coughing, sneezing, retching, vomiting and straining when passing stools • be alert for symptoms of complications and know when to seek professional help • avoid medication such as Aspirin®, as this may precipitate haemorrhage if peptic ulcers, oesophageal or gastric varices are present.

Complications of cirrhosis and their management Hepatic encephalopathy Hepatic encephalopathy is a major complication of cirrhosis, which is due to rising levels of toxic substances normally metabolised and excreted by the liver, mainly ammonia and aromatic amino acids. Hepatic encephalopathy may occur gradually or quickly and result

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800  Juta’s Complete Textbook of Medical Surgical Nursing Table 41.8  Stages of hepatic encephalopathy

Stage 1

Stage 2

Stage 3

Stage 4

Prodromal

Impending hepatic encephalopathy

Stuporous

Coma

• Slow response to stimuli • Short attention span • Irritability and tremors • Changes in sleep pattern • Slight asterixis • Depression or euphoria

• Apathy • Disorientation to time • Slurred speech • Decreased inhibition • Inappropriate behaviour • Decreased reflexes • Ataxia • Asterixis • Lethargy • Anxiety

• Stupor, but can be aroused • Disorientation to time and place • Confusion • Anger, paranoia • Incoherent speech • Asterixis • Increased reflexes

• Absence of intellectual functioning • Loss of deep tendon reflexes • Fetor hepaticus • Hyperventilation • Elevated temperature, pulse and respiration • Unconsciousness

Table 41.9  General nursing care plan of a patient with cirrhosis of the liver

Anorexia and weight loss Nursing diagnosis

• Altered nutrition, less than body requirements due to disease process, manifested by poor appetite, nausea, vomiting, weight loss

Expected outcome

• Improved appetite, weight gain and maximised liver function

Nursing interventions and rationale

• See Table 41.2 • Patient is weighed to gain baseline data which is needed to plan effectively for nutritional needs • Decrease roughage to prevent irritation and possible bleeding of oesophageal varices

Evaluation

• See Table 41.2

Pitting oedema of legs, and ascites Nursing diagnosis

• Fluid volume overload due to disease process and secondary to fluid retention manifested in oedema and ascites

Expected outcome

• Oedema and ascites reduced

Nursing interventions and rationale

• Restrict sodium intake to control oedema • The patient to be taught the rationale for sodium restriction to gain cooperation • Strict bed rest until ascites has been relieved to decrease metabolism and energy consumption; activity will depend on the patient’s energy level, level of consciousness, and coordination • Administer diuretics as prescribed

Evaluation

• Oedema resolved • Decrease in abdominal girth

Tiredness Nursing diagnosis

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• Exercise intolerance, evidenced by demonstrated lethargy and verbal expression of tiredness by the patient

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Expected outcome

• Patient energetic and able to participate effectively in activities of daily living

Nursing interventions and rationale

• If necessary, limit visitors to ensure adequate rest • Provide a balanced diet and regulated exercise • Drink allowed amounts of fluid

Evaluation

• Patient able to participate in the activities of daily living

Pruritus Nursing diagnosis

• Altered comfort and body image due to disease process, evidenced by itchiness

Expected outcome

• Itching relieved

Nursing interventions and rationale

• Patient to be given cool medicated baths twice a day • To be dressed in cool light cotton clothes to prevent sweating

Evaluation

• Patient to report no itching and to have a restful comfortable sleep

Fever and chills Nursing diagnosis

• Risk of infection related to disease process manifested by an increase in temperature, pulse and respiration

Expected outcome

• Maintain normal vital signs

Nursing interventions and rationale

• Maintain 4-hourly record of temperature, pulse and respiration to detect early signs of infection so that treatment can be implemented as soon as possible • Ensure the use of universal precautions to prevent infection, ie proper hand washing, observance of aseptic technique with all procedures undertaken, good respiratory care, eg deep-breathing exercise to prevent accumulation and stasis of secretion and prevent risk of pneumonia • Restrict visitors to decrease risk of cross-infection

Evaluation

• No evidence of localised and/or systemic infections as indicated by normal vital signs • White blood cell count within normal limits

Difficulty in breathing Nursing diagnosis

• Ineffective breathing pattern related to ascites that exerts pressure on the diaphragm, immobility and accumulation of secretions in the respiratory tract due to disease process manifested by dyspnoea

Expected outcome

• Normal respiration

Nursing interventions and rationale

• Nurse the patient in High Fowler’s position to assist respiration • If the patient is on strict bed rest, turn and change position frequently to prevent stasis of secretions and to relieve pressure on the diaphragm • Deep-breathing exercises should be encouraged by enlisting the help of the physiotherapist to prevent atelectasis • Monitor and record respirations 4-hourly • If possible, encourage ambulation and mild activity to prevent weakness of muscles

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Evaluation

• The patient is able to breathe easily • Breath sounds are progressively clear throughout lung fields • Vital signs are normal

Restlessness Nursing diagnosis

• Risk for injury related to diminished sensory perception secondary to peripheral neuropathy and low level of consciousness, restlessness, confusion and seizures related to the disease process

Expected outcome

• Patient safe and no falls • Patient conscious and well oriented

Nursing interventions and rationale

• Assess level of consciousness and cognition and record this to establish a baseline data to compare progress • Assess numbness and tingling sensation of lower extremities to determine risk of injury • Provide a safe environment and nurse patient in a cot bed, and avoid the use of tight bedclothes that restrict movement because these reduce circulation and exert pressure

Evaluation

• Patient well oriented, aware of time, place and self • No falls reported

Weakness, purpura, bleeding easily even when attending to activities of daily living, eg brushing of teeth Nursing diagnosis

• Risk of haemorrhage related to altered clotting mechanisms manifested by bruises and bleeding when brushing teeth • Risk of anaemia manifested by bleeding, pallor and undue weakness

Expected outcome

• No haemorrhage noticed • Haemoglobin, and platelet count levels normal

Nursing interventions and rationale

• Monitor bleeding in stool, urine, skin and mucous membrane • Monitor vital signs 4-hourly • Instruct the patient to use a soft bristled tooth brush or cotton swabs for oral care to prevent bleeding • Avoid injections as the patient has decreased clotting ability and may bleed at injection sites • Monitor haemoglobin and platelet levels as ordered • Administer blood and blood products as prescribed • Provide stool softeners to avoid straining when passing stools • Administer vitamin K as prescribed to promote coagulation • Check patient’s body daily for purpura, haematomas or petechiae • Maintain a safe environment and avoid knocks and bumps • Avoid spicy, hot foods that can cause bleeding of oesophageal varices

Evaluation

• No bleeding marked • Haemoglobin and platelet levels within normal limits

Depression Nursing diagnosis

• Ineffective coping related to knowledge deficit

Expected outcome

• Adequate and relevant information to the family and patient • about the disease process • provided

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Nursing interventions and rationale

• Assess the patient and family’s understanding of diagnosis and discuss the facts about the illness to correct any misunderstanding • Help patient to establish a positive self-esteem by involving them in goal-setting and decision-making • Give positive feedback and support in times of relapse • Identify the patient’s or family’s coping strategies and give appropriate support • Listen attentively and give correct and honest answers at all times • Allow the patient to express feelings of fear, anxiety, and powerlessness and demonstrate empathy at all times • Encourage the family to support the patient at all times; see Table 41.2 • Evaluate ability to use coping strategies to deal with illness

Evaluation

• Family support and increased knowledge of disease process as evidenced by involvement in self-care activities • Patient making positive statements about self and realistic statements about future goals

in alterations in the state of consciousness, behavioural and personality changes, and changes in intellectual and neuromuscular function. The changes are graded in four stages according to severity (see Table 41.8 for stages of hepatic encephalopathy). The nursing care plan of a patient with cirrhosis is based on the general care plan in Table 41.2.

Gastrointestinal bleeding Haemorrhage as a complication is related to bleeding tendencies secondary to altered clotting factors and rupture of oesophageal or gastric varices.

Nursing interventions For early detection of clinical features of bleeding: • Monitor vital signs 4-hourly. • Assess level of consciousness 4-hourly. • Monitor and measure gastrointestinal secretions and record output, for example emesis and stools. • Monitor haematocrit and haemoglobin and report. Activities that increase intra-abdominal pressure that could lead to rupture and bleeding of oesophageal or gastric varices should be avoided, such as constipation and straining while passing stools, coughing and sneezing. In addition: • Give small meals frequently. • Assist the patient at all times with all activities. • Assist with procedures and therapy needed to stop the bleeding. • Support the patient emotionally, as they will most probably be exhibiting a lot of anxiety. • Employ measures to control the bleeding.

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• Monitor respiratory status which may be affected by anxiety. • Treat respiratory complications as indicated. • Inform the family of the treatment’s progress to allay fear and anxiety. • Monitor closely for recurrence of bleeding and haemorrhage as bleeding can recur.

Ascites One of the most frequent complications of cirrhosis of the liver is ascites, which results partly from portal hypertension. Ascites also results from decreased hepatic synthesis of albumin, obstruction of hepatic lymph flow, and increased levels of aldosterone due to incomplete metabolism in the liver. The fluid that accumulates in the peritoneal cavity is rich in albumin.

Nursing management This focuses on bed rest, restriction of sodium in the diet, diuretics and paracentesis. Bed rest. This is important as ascites initially produces diuresis, which increases fluid excretion. The patient should be nursed in an upright position to relieve pressure on the damaged liver. An upright position is associated with activation of the rennin-angiotensin-aldosterone system and the sympathetic nervous system, which results in reduced renal glomerular filtration, sodium excretion and a decreased response to loop diuretics. Diet. Salt must be avoided in order to reduce fluid retention. The patient must be supported through the process of adjusting to food without salt. Salt substitutes may be used, but those containing ammonia must be avoided. The family must be part of this dietary modification and must be encouraged to support the patient. There must be an

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accurate assessment and control of fluid and electrolyte balance. Intake and output must be monitored. Drugs. Oral diuretics may be used. diuretic is furosemide (Lasix®). To and sodium loss from long-term spironolactone (Aldactone®), which blocking agent, may be used.

The most common prevent potassium use of diuretics, is an aldosterone-

Paracentesis. This is the removal of fluid from the peritoneal cavity. Plasma expanders such as intravenous albumin should be given simultaneously. In chronic and resistant ascites, insertion of a peritoneo-venous shunt may be done where ascitic fluid is reinfused into the venous system. However, this treatment modality is seldom used due to complications.

Portal hypertension The structural changes in the liver from the cirrhotic process are accompanied by the compression and destruction of the portal and hepatic veins and sinusoids. These changes result in obstruction of blood flow through the damaged liver, resulting in increased blood pressure throughout the portal venous system. Other presenting signs may be splenomegaly, ascites, systemic hypertension, and oesophageal varices.

Causes The causes of portal hypertension are unknown. However, the most common cause is cirrhosis of the liver. Cirrhosis Liver

Portal vein

Stomach

Pancreas

results from scarring of a liver injury caused by hepatitis, alcohol abuse, or other causes of liver damage. The scar tissue in cirrhosis blocks the flow of blood through the liver. Other causes of portal hypertension include: • blood clots in the portal vein • blockages of the veins that carry the blood from the liver to the heart • a parasitic infection called schistosomiasis.

Assessment and common findings Subjective and objective data Encephalopathy or confusion and forgetfulness caused by poor liver function. Gastrointestinal bleeding evidenced by black, tarry stools or blood in the stools; or vomiting of blood due to the spontaneous rupture and haemorrhage from varices. On physical examination of the abdomen or the anus there will be a presence of ascites, dilated veins or varices. Diagnostic studies • Blood tests will reveal reduced levels of platelets, decreased clotting factors and low white blood cell count (the cells that fight infection). • X-ray tests and endoscopic examinations may also be used.

Management Treatment focuses on preventing or managing the complications, especially the bleeding from the varices. Diet. The patient is advised to maintain good nutritional habits. Medication. Beta blockers may be prescribed alone or in combination with endoscopic therapy to reduce the pressure in varices and further reduce the risk of re-bleeding. The drug lactulose can help treat confusion and other mental changes associated with encephalopathy. Endoscopic therapy. Banding (a procedure in which a gastroenterologist uses rubber bands to block off the blood vessel) and sclerotherapy (a procedure in which a solution is injected into the bleeding varices to cause them to scar) can also be done. Surgery. Liver transplant is done in cases of end-stage liver disease.

Large intestine

Devascularisation. Devascularisation is a surgical procedure that is done to remove the bleeding varices. This procedure is done when a transjugular intrahepatic

Figure 41.4  Portal venous systems

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portosystemic shunt (TIPS) is not possible or is unsuccessful in controlling the bleeding. Paracentesis. In this procedure the accumulation of fluid in the abdomen (ascites) is directly removed. Other treatment options. Decompression procedures such as TIPS and distal splenorenal shunt (DSRS) can be done. TIPS involves placing a stent or tubular device in the middle of the liver. The stent connects the hepatic vein with the portal vein. DSRS connects the vein from the spleen to the vein from the left kidney in order to reduce pressure in the varices and control bleeding. Radiology procedures will depend on the severity of the symptoms and on how well the liver is functioning.

Essential health information The patient is advised to keep a healthy lifestyle; to avoid the use of alcohol or unprescribed drugs.

Hepatorenal syndrome This is a serious complication of cirrhosis and is characterised by renal failure, oliguria and ascites. The blood pressure may be high, and the patient presents with anorexia, weakness and fatigue. This complication has a poor prognosis and may be an end stage of liver disease and is suggestive of impending death.

Liver failure Liver failure occurs when a large portion of hepatocytes dies or ceases to function. The liver can fail with sudden or acute loss of liver cell function in an otherwise healthy body. Liver failure can also occur gradually in patients with cirrhosis. Liver failure can be acute or chronic. The most severe type of acute liver failure is known as fulminant hepatic failure. Chronic liver failure occurs as a result of cirrhosis.

Fulminant hepatic failure Fulminant hepatic failure is acute liver failure, characterised by severe impairment of liver function, with hepatic encephalopathy occurring within 8 weeks of the first symptoms.

Causes Fulminant hepatic failure is caused by the following factors: • Acute viral hepatitis. The most common cause is viral hepatitis, in particular HBV, but it may also occur in HAV, and less frequently HCV. It may also be caused by hepatitis D, E, and yellow fever.

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• Drugs and toxins. This can include an overdose of paracetamol, halothane, sulphur-containing drugs, isoniazid, poisonous plants, aflatoxins, non-steroidal anti-inflammatory drugs. • Shock to the liver. This could be caused by haemorrhage, sepsis, heat stroke, heart failure, severe dehydration. • Other causes. These include Wilson’s disease or autoimmune hepatitis.

Assessment and common findings • Jaundice, ascites, oedema and the signs and symptoms of encephalopathy • Blood ALT and AST activities markedly elevated as a result of massive hepatocyte necrosis • Elevated bilirubin concentration in the blood and prolonged prothrombin time • Decreased albumin concentration in the blood as its synthesis also decreases • Kidney and lung failure may occur with the patient becoming susceptible to infections • Encephalopathy may progress to coma if the liver function does not improve. Brain oedema may lead to irreversible brain damage and death. Depending on the degree of liver failure, treatment may involve liver transplantation.

Liver abscess Definition Liver abscesses can be classified into two categories, namely, amoebic and pyogenic. Amoebic liver abscess (amoebiasis) is caused by Entamoeba listolytica while pyogenic abscesses are caused by organisms such as E. coli, Klebsiella pneumoniae, Staphylococcus, Streptococcus and Pseudomoneas. Systemic candidiasis with multiple hepatic abscesses has developed in patients with depressed immune functioning, such as those with neutropenia or leukaemia.

Pathophysiology Amoebic liver abscesses are large and singular and are usually secondary to infections in the biliary system, portal venous system, hepatic arterial or lymphatic systems. Pyogenic abscesses occur as a single large abscess or multiple small and/or microscopic abscesses. Pyogenic organisms may also be introduced to the liver by penetrating injuries or by direct continuous extension. In most instances bacteria are immediately destroyed but in others these gain momentum and cause infection.

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The organisms cause necrosis of the liver tissue and abscess formation. In amoebic abscesses, the vegetative form of the organism moves from the gut to the small portal vessels and into the hepatic tissue where it becomes activated. The leukocytes also migrate into the infected area and form an abscess cavity filled with a liquid that contains living and dead leukocytes, liquefied liver cells and bacteria (pus). If the liver abscesses are not identified, they continue to grow in size and can perforate the pleural cavity, the peritoneal cavity, or the pericardial cavity. Fistulas may also develop from the abscess to other abdominal organs or through the abdominal wall.

Assessment findings Subjective data

The patient with an amoebic liver abscess will give a history of a bloody mucoid diarrhoea, general abdominal pain and rectal tenesmus.

Objective data On physical examination the patient will be very sick, dehydrated and hypotensive. The major clinical features of liver abscess are caused by the infection rather than by changes in hepatic functioning. These include: • Fever and chills with a temperature of between 38.8 °C and 41.1 °C • Diaphoresis • Cough • Malaise, anorexia, nausea and vomiting, and possible weight loss • Difficulty in breathing due to pressure on the diaphragm • Severe abdominal pain and tenderness in the right upper quadrant of the abdomen. Other signs that result from hepatic dysfunction are: • Hepatomegaly • Jaundice and pruritus • Splenomegaly • Abdominal distension and ascites.

Diagnostic evaluation Blood tests will reveal leukocytosis, elevated erythrocyte sedimentation rate due to the infection and moderate elevation of serum alkaline phosphatase (APT), minimal elevation of serum transaminases (AST and ALT) from damaged liver cells. Blood culture may also be done to identify the causal organism. • Hyperbilirubinaemia and hypoalbuminaemia will be indicative of impaired liver function.

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• Possible radiological studies include hepatic radioisotope scans, ultrasound scanning and computed axial tomography (CT) scans to confirm the diagnosis.

Management

Medical management Intravenous antibiotic therapy will be initiated. The specific antibiotic used will be determined from the culture and sensitivity of the aspirate of the drained abscess. Open surgical drainage may be necessary especially for pyogenic abscesses. The aspirate should be sent to the laboratory for culture and sensitivity testing. Metronidazole (Flagyl®) is usually the drug of choice for the treatment of amoebic abscesses. Acetaminophen is used to control fever; and fluid and electrolytes are replaced intravenously.

Nursing management Nursing management focuses on: • assisting with nutrition • controlling discomfort including dealing with pruritus and pain • assisting with medical treatment • helping the patient to attain appropriate knowledge for self-management. Other nursing care measures involve careful assessment of vital signs because of the danger of general sepsis. Respiratory care is important to limit pulmonary complications related to hepatic abscess. Please note that the general nursing management of the patient in the acute stage will be the same as for the patient with severe infection.

Cancer of the liver Tumours of the liver may be primary or secondary (metastatic) in origin. Primary tumours are relatively rare and may arise from the hepatocytes, the bile ducts, connective tissue or the blood vessels and may be benign or malignant (see Table 41.10). Metastatic tumours of the liver are very common and arise from the breast, lungs and gastrointestinal tract, particularly the colon. Hepatocellular carcinoma is the most common primary liver cancer, and is often associated with chronic liver diseases including chronic hepatitis B or C. Metastatic tumours of the liver occur due to its high rate of blood flow, size and its portal drainage input from the major abdominal organs. Melanomas and tumours of the gastrointestinal tract, lung and breasts cause greater liver metastases than do tumours of the prostate, thyroid or skin.

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Table 41.10  Classification of primary tumours of the liver

Origin

Benign

Malignant

Hepatic cell

Adenoma

Hepatocellular carcinoma

Connective tissue

Fibroma

Sarcoma

Blood vessels

Haemangioma

Haemangioendothelioma

Bile ducts

Cholangioma

Carcinoma of the bile ducts

The cancer spreads to the liver by: • direct extension from nearby organs • the hepatic arterial system • the portal venous system. The surface of the liver may be seeded with metastatic cells as a result of peritoneal migration.

Assessment findings Objective data

The clinical manifestations in patients with primary (benign and malignant) and secondary (metastatic) tumours are often the same. Early manifestations are often vague, and it is often difficult to differentiate carcinoma of the liver from cirrhosis because many of the clinical manifestations, for example weight loss, ascites, peripheral oedema, hepatomegaly, and portal hypertension are similar. Other common manifestations include: • A dull abdominal pain and tenderness in the epigastrium or right upper quadrant region • Nausea with minor temperature elevation • Vomiting • Weakness • Pulmonary emboli may occur.

Diagnostic studies • Liver scan • Computed axial tomography and magnetic resonance imaging scans • Hepatic arteriography • Endoscopic retrograde cholangiopancreatography (ERCP) • Liver biopsy • In primary hepatocellular cancers, alpha-feto-protein (AFP) is a marker; its presence helps to distinguish primary cancer from metastatic cancer • Metabolic derangements such as polycythaemia, blood sugar disorders, and high levels of calcium may be present • Leukocytosis and anaemia may also be present

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• Jaundice may be present if bile ducts are the primary sites or if the tumour obstructs a major duct.

Stages of liver cancer These are classified as follows: • Stage I consists of a single tumour no longer than 2 cm in size, with no progression into the blood vessels. Patients with Stage I cancer have the best prognosis. • Stage II is a more advanced disease with involvement of the blood vessels. Cancer in the blood vessels provides a route for malignant cells to move to other sites and has a negative effect on prognosis. • Stage III indicates disease progress in which the tumours are large and may include lymph nodes and blood vessels. Prognosis for survival is usually less than a year. • Stage IV disease reflects widespread significant malignant lesions, including vascular invasion and lymph node involvement. Prognosis is poor. Few patients survive more than a year after transplantation or surgery. The prognosis for patients with liver cancer in general is very poor. The cancer grows rapidly and death may occur within 4–7 months as a result of hepatic encephalopathy or massive blood loss from gastrointestinal bleeding.

Nursing and collaborative management Palliative care is the main treatment of cancer of the liver. Management is similar to liver cirrhosis. If the tumour is localised to one portion of the liver, a lobectomy may be performed. If the tumour is too advanced, surgery is not recommended. Surgical excision of the entire tumour offers the best chance of survival. • Radiation therapy. Liver tumours can be treated with external beam radiation. The procedure can be done percutaneously, laparoscopically through an open incision, intravenously, or through intraarterial injection of antibodies that are tagged with radioactive isotopes that attack tumour-associated antigens. Percutaneous or laparoscopic placement of

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a high intensity source for interstitial radiation therapy can be used for tumours that are resectable as well as for palliative purposes. Complications may include infection, bleeding, skin burns, and arrthymias. • Cryosurgery. This is the placement of cryoprobes directly into the liver. It can be used for patients whose tumours are unresectable but with no signs of metastasis. Liquid nitrogen flows through the probe to freeze the affected liver tissue. • Chemotherapy. This is used to improve the quality of life and prolong survival, and may be used as adjuvant therapy following surgical resection of tumours. A variety of chemotherapeutic agents can be administered systemically or regionally. Commonly used chemotherapeutic agents are 5 fluorouracil (5-FU) and leucovorin. Regional chemotherapy includes portal vein or hepatic artery perfusion with 5-FU or other chemotherapy drugs. The hepatic arterial infusion therapy would be done under general anaesthesia. • Liver transplantation. This is recognised as an option for patients with liver cancer that has not spread beyond the liver.

Liver transplantation Definition Liver transplantation is a surgical procedure involving the total removal of the diseased liver and its replacement with a healthy liver in the same anatomic position (orthotopic liver transplantation). This is also accompanied by the reconstruction of the hepatic vasculature and biliary tract. Liver transplantation is a therapeutic option for patients with irreversible liver disease for which no other form of treatment is available. Liver transplantation is performed to improve the quality of life for end-stage liver patients. Liver transplants are not recommended for patients with advanced, widespread malignant disease.

Indications for liver transplantation • • • • • • • • • • •

Irreversible advanced chronic liver disease Chronic viral hepatitis Drug and alcohol induced liver disease Congenital biliary abnormalities Wilson’s disease Fulminant hepatic failure Metabolic liver diseases Primary biliary cirrhosis Inborn errors of metabolism Hepatic cancer with no metastasis Sclerosing cholangitis.

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Types of liver transplants Two types of liver transplants can be performed, namely: 1. Orthotopic liver transplant. This is a common type where the recipient’s own liver is removed entirely. 2. Auxiliary liver transplant. This procedure involves leaving part or all of the recipient’s liver in place and grafting in a healthy whole or partial liver, either from a cadaver or a live donor.

General preoperative and postoperative care During the period of evaluation and planning for the transplantation, the transplant team members must support and educate the family of the donor, and that of the recipient. Concerns should be addressed and the patient assured of confidentiality. The waiting period is a stressful period for all concerned and the families involved will need a great deal of support and empathy from the team. Ascites, fluid and electrolyte disturbances, and malnutrition must be treated before surgery to increase chances of a successful outcome. Postoperatively the patient will require highly-skilled care in the intensive care unit or a specialised unit. The critical aspects of nursing care following liver transplantation are: • Monitoring for infection • Assessing neurological status • Monitoring pulmonary, cardiovascular, renal and metabolic functions • Monitoring for signs of haemorrhage • Monitoring drainage, electrolyte levels, fluid output including urine, bile and drainage from surgical tubes • Monitoring for signs and symptoms of rejection • Monitoring liver function tests including the coagulation profile • Monitoring chest X-rays and electrocardiograms.

Clinical alert! Monitoring for signs and symptoms of infection, rejection and liver dysfunction is critical and should be done throughout the patient’s life. On discharge, the family must be informed about the signs for infection and rejection so that they can contact the hospital immediately should these occur.

Postoperative complications Immediate postoperative complications are bleeding, obstruction of the biliary anastomosis, impaired biliary drainage and impaired respiration as a result of prolonged

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anaesthesia, over-handling of the diaphragm, immobility and post-operative pain. Other potential complications are vascular thrombosis and stenosis. Subsequent major postoperative complications are infection and rejection. A transplanted liver is perceived as a foreign antigen by the body and therefore triggers an immune response that leads to the activation of T-lymphocytes, which attack and destroy the implanted liver. The administration of immunosuppressant drugs such as cyclosporine has been used successfully in liver transplantation, thus increasing the 1-year and 5-year survival rates. A major side effect of cyclosporine is nephrotoxicity, which is related to the dose administered. If the dose is decreased, the renal dysfunction can be reversed. The advantage of cyclosporine is that it does not suppress bone marrow and does not impede wound healing. Other immunosuppressant drugs are azathioprine (Imuran®), corticosteroids and rapamycin. Newer agents used are interleukin-2 receptor antagonists. Other factors that have improved the rate of success are advanced surgical techniques, better selection of potential recipients and donors, and improved management of underlying liver disease before surgery.

glucose into the cell to be metabolised, thus preventing hyperglycaemia; while glucagon increases the blood sugar level if this falls too low, preventing hypoglycaemia. The release of glucagon into the bloodstream is also stimulated by the ingestion of high concentrations of amino acids as would be the case after a high protein meal. In this instance, glucagon also stimulates gluconeogenesis, which is the conversion of non-glucose substances such as amino acids, into glucose in order to make more glucose available to the tissue. Disorders of the pancreas may involve interference with digestion and/or glucose utilisation. These may include inflammatory (acute and chronic pancreatitis), neoplastic (parenchymal, ductal and islet cell), traumatic (blunt and penetrating) or genetic (cystic fibrosis and hereditary and familial pancreatitis) disorders.

Acute pancreatitis Definition Acute pancreatitis is an inflammatory process with varying degrees of pancreatic oedema, fat necrosis and haemorrhage. Acute pancreatitis can be a medical emergency with life-threatening complications.

Disorders of the pancreas The pancreas is a glandular organ that secretes digestive enzymes (internal secretions) and hormones (external secretions). It is a yellowish organ about 17.8 cm long and 3.8 cm wide. The pancreas lies beneath the stomach and is connected to the small intestine at the duodenum. The pancreas contains enzyme-producing cells that secrete two hormones: insulin and glucagon. Insulin and glucagon are secreted directly into the bloodstream and together they regulate the level of glucose in the blood. Insulin lowers the blood glucose level by carrying

Healthy

Normal pancreas

Liver

Pancreatitis Stomach Pancreas (tail)

Gallbladder Pancreas head

Figure 41.5  The position of the pancreas

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Inflamed pancreas

Duodenum Figure 41.6  An inflamed pancreas

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Causes and incidence Acute pancreatitis is strongly linked to alcohol use and abuse and biliary tract diseases, such as cholecystitis with gallstones (cholelithiasis). Other causes include: • trauma from: –– biliary tract surgery –– vagotomy and retroperitoneal node dissections –– diagnostic procedures such as endoscopic retrograde cholangiopancreatography –– blunt and penetrating trauma causing rupture of the pancreas –– ischaemic episodes –– viral infections, such as hepatitis, mumps and coxsackie virus B –– a penetrating duodenal ulcer –– cystic fibrosis • Kaposi’s sarcoma • some metabolic disorders, eg hyperlipidaemia, anorexia nervosa, hypercalcaemia, hyperthyroidism and renal failure • some drugs, eg corticosteroids, thiazide diuretics, oral contraceptives, sulphonamides, tetracyclines, azathioprine, mecaptopurine and non-steroidal antiinflammatory drugs • idiopathic causes are also implicated in 20% of cases. Children have a low incidence of pancreatitis related to hereditary factors, such as autosomal dominant traits, and in association with hyperlipidaemia, ascariasis in the biliary tract, trauma and steroid therapy.

Pathophysiology The mechanisms causing pancreatitis are unclear, but it is believed to be premature activation of pancreatic enzymes. The mechanism by which alcohol affects the pancreas is also unclear but it is associated with increased production of hydrochloric acid which decreases the pH and stimulates production of the hormone secretin. This hormone then stimulates pancreatic secretion. Obstruction of the pancreatic duct is also thought to occur in alcohol abuse due to precipitation of highly concentrated pancreatic secretory proteins because of decreased water and bicarbonate content in the pancreatic juices. Alcohol is also implicated in the causation of regurgitation of duodenal contents into the pancreatic duct, thereby stimulating the proteolytic enzymes. Direct toxic effects on the acinar cells of the pancreas are also thought to occur with alcohol abuse. The pathophysiological effect of all these mechanisms is inflammation of the pancreas, resulting in oedema

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of varying degrees, necrosis, and haemorrhage of the pancreas with complications in other organs that may be life-threatening.

Assessment and common findings Subjective data

The patient with acute pancreatitis may present with any of the following: • History of alcohol abuse, biliary tract diseases, peptic ulcers or abdominal surgery on the stomach, duodenum, or biliary tract or trauma and the use of thiazides, oestrogens, corticosteroids, azathioprine, sulphonamides and opiates. • Severe abdominal pain in the mid-epigastric region or left upper quadrant. The pain may be referred to the back because of the retroperitoneal location of the pancreas. The onset of pain is usually observed 24–48 hours after a heavy meal or alcohol intake and is not relieved by antacids. The patient may assume a foetal position in an attempt to relieve the pain. • Persistent vomiting of gastric or bile-stained contents that does not relieve the pain. • Abdominal distension and rigidity (board-like abdomen) if peritonitis is present. • Ecchymosis around the umbilicus (Cullen’s sign) and on the flanks (Grey Turner’s sign) due to seepage of blood from the haemorrhagic pancreas or development of disseminated intravascular coagulopathy (DIC) as a complication. • Fever due to systemic inflammatory reaction. • Hypotension, tachycardia, cardiac failure due to hypovolaemic shock, related to loss of protein-rich fluid into tissues and peritoneum from inflammatory exudation and haemorrhage. • Respiratory distress/dyspnoea may develop due to pulmonary oedema related to release of inflammatory mediators such as histamine, bradykinin, kallikrein, which cause capillary vasodilatation and increased permeability. • Signs of cardiac dysfunction due to the tendency of the diseased or ischaemic pancreas to release a myocardial depressant factor. • Signs of renal failure, for example oliguria due to decreased renal perfusion.

Objective data On physical examination there may be: • Restlessness, anxiety, diaphoresis and a thready pulse due to pain and shock • Abdominal tenderness and guarding • A poorly defined palpable mass

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• Bowel sounds may be increased or diminished due to decreased peristalsis • Pulmonary crackles on auscultation due to pulmonary oedema.

Diagnostic tests Blood tests will show the following: • Elevated serum amylase and lipase three times their normal limits within 24 hours. Serum amylase returns to normal in 48–72 hours while lipase can remain elevated for 7–14 days. • Full blood count reveals anaemia and leukocytosis due to bleeding. • Hypocalcaemia is usually mild because calcium gets deposited in areas of fat necrosis. • Hyperglycaemia due to damage of the Islets of Langerhans with decreased secretion of insulin, while stress hormones are stimulated by severe pain and physiological changes associated with acute pancreatitis. • Elevated serum bilirubin. • Elevated urea and creatinine occurs if renal failure ensues. Other signs: Urine amylase is also elevated and remains elevated for longer than serum amylase. There may be glycosuria; bulky, pale and foul-smelling stools due to biliary tract diseases; the fat content of stool may increase from 20% to 50% and in some instances up to 90%.

Nursing diagnoses • Abdominal pain and discomfort related to abdominal distension, tension of the oedematous pancreas within the tough capsule, peritonitis and muscle spasms from tetany, including pressure of the oedematous pancreas on the coeliac plexus • Ineffective breathing pattern related to pulmonary oedema • Fluid volume deficit related to anorexia, vomiting, gastric suction, diaphoresis, failure to take food orally because of pain, haemorrhage and fluid shift from increased capillary permeability, including cardiac failure • Altered nutrition related to anorexia, vomiting and failure to take food orally because of pain • Hyperglycaemia or hypoglycaemia related to involvement of Islets of Langerhans and exaggerated glucose production by stress response • Pruritus related to jaundice in biliary tract disease as a causative factor • Fever related to inflammatory response • Oliguria related to dehydration and renal failure

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• Ineffective management related to knowledge deficit with regard to preventive measures and dietary restrictions.

Management

Nursing management The goals of management are to: Relieve pain. The patient should be placed in a comfortable position, often lying on the right-hand side to relieve tension on the abdomen with the head elevated to 45°. The knees may be drawn up. Assess pain level before and after administration of analgesics using available pain scales. Analgesics such as pethidine should be given as prescribed. Morphine and its derivatives are avoided because it is known to cause spasms of the sphincter of Oddi, which may aggravate the reflux of bile and pancreatic juices. Reduce pancreatic activity. Reduction of pancreatic activity is essential to avoid release of the enzymes that cause autodigestion. The patient should be kept nil per mouth and put on nasogastric suction to prevent abdominal distension, vomiting and further stimulation of the pancreas by the acid contents of the stomach entering the duodenum, and of secretin and pancreozymin that stimulate the pancreas. Avoid exposing the patient to the smell or visualisation of food to avoid the cephalic phase of gastric stimulation. Food should be reintroduced slowly as the symptoms subside and bowel tone returns, normally within 7 days, and should start with clear fluids, progressing to a simple diet. Avoid fats, caffeine and alcohol in the diet as these stimulate gastric acid. Relieve pain as mentioned earlier, as pain may stimulate pancreatic secretion. The following medication can be given as prescribed: • IV plasma and 0.9% saline until vital signs satisfactory and urine output more than 30 ml/hour. If shocked, three units of plasma and 1 ℓ of 0.9% saline over first hour, and then at least 6 ℓ of fluid/24 hours • Pethidine 100 mg and prochlorperazine 12.5 mg 4-hourly intramuscularly for pain relief.

Surgical management Exploratory laparotomy may be indicated if the diagnosis is uncertain. Drainage and debridement of necrotic tissue may be done in cases of acute pseudocyst, abscesses or biliary tract diseases. Restore lost plasma volumes and electrolytes. Monitor blood pressure, pulse and respiration including central venous pressure for fluid deficit and as guidance for fluid replacement. Monitor urine output, specific gravity,

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nasogastric aspirates, skin turgor and mucous membranes for moisture. Monitor electrocardiogram for dysrhythmias related to electrolyte imbalances, especially potassium and calcium. Calcium gluconate may need to be given. Acid– base imbalances may accompany electrolyte imbalances therefore arterial blood gases should be monitored as prescribed. Replace electrolytes when necessary. Monitor haemoglobin and haematocrit for blood loss. Measure abdominal girth and weigh daily. Give parenteral fluids and blood transfusion as prescribed to maintain fluid volume and prevent renal failure. Monitor blood glucose 4-hourly and electrolytes frequently according to existing abnormalities. Avoid parenteral fluids with glucose. Administer insulin as prescribed and titrated according to blood glucose. Antiemetic agents such as metoclopramide (Maxolon®) can be prescribed for nausea and vomiting. Continue nasogastric drainage to prevent abdominal distension. Administer total parenteral nutrition as prescribed. Prevent complications. Monitor respiratory rate, rhythm and depth of breathing including air entry, breath sounds, pulse oximetry and arterial blood gases. Position the patient in Fowler’s position for ease of breathing. Give oxygen when necessary. The patient may need to be transferred to the intensive care unit if breathing deteriorates. Renal function should be monitored for early detection and treatment of prerenal failure, for example monitor urine output according to the patient’s weight (0.5 ml/kg/hour), age, fluid administered, monitor its specific gravity, osmolarity, urea and creatinine. Monitor temperature and give prescribed prophylactic antibiotics for infection. Give oral hygiene for a mouth that may be dry and crusted from nil per mouth and anticholinergic drugs that may have been given.

Essential health information • Advise the patient to abstain from alcohol to prevent recurrence of the disease. Refer the patient to support groups such as Alcoholics Anonymous (AA), or the South African National Council on Alcoholism and Drug Dependence (SANCA) if alcohol abuse continues to be a problem. • Advise the patient to follow a diet that is high in carbohydrates and low in fats and proteins, and to avoid stimulants such as coffee. The patient must take small meals frequently rather than heavy meals. • Teach the patient how to monitor blood glucose and to understand the factors that indicate pancreatic tissue failure, such as abnormal stools. • Advise the patient of the importance of follow-up to monitor for continued alcohol abuse and recovery.

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The family must be involved to support the patient in adhering to restrictions and follow-up.

Chronic pancreatitis Definition Chronic pancreatitis is a progressive destruction of pancreatic tissue resulting in gradual fibrosis and calcification of the pancreas.

Causes of chronic pancreatitis Causative factors for chronic pancreatitis include: • Repeated attacks of acute interstitial pancreatitis • Gallstones, hyperparathyroidism and occasional hyperlipidaemia • Cancer of the ampulla of Vater, duodenum and pancreas • A diet that is poor in protein content and very high in fat • A history of prolonged use of alcohol. The incidence of chronic pancreatitis is greater in alcoholics than in non-drinkers. Hereditary predisposition exposes some individuals to the effects of alcohol.

Pathophysiology Prolonged use of alcohol causes calcification of pancreatic tissue resulting in fibrosis and obstruction of the pancreatic duct and the common bile ducts including part of the duodenum. Proteins may also precipitate in the ducts enhancing the obstruction. The affected glandular tissue atrophies, and pseudocysts and abscesses develop. Fat and protein digestion is impaired due to malabsorption that develops as the disease progresses.

Assessment and common findings Subjective data

Recurrent episodes of pain, which may alternate with severe acute attacks, are experienced, and are accompanied by vomiting and low-grade fever. As the disease progresses the attacks become severe, frequent and of longer duration. Analgesics often do not provide pain relief though this may be associated with addiction after long use of such drugs. The location of the pain is the same as in acute pancreatitis. Due to pain and associated decreased dietary intake including vomiting, the patient experiences significant weight loss. The stool becomes frequent, frothy and foul smelling with a high fat content (steatorrhoea). Jaundice may occur because of the constriction of the common bile duct as it passes through the head of pancreas.

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Objective data With diagnostic tests, serum amylase and lipase are not significantly elevated. There may be increased serum bilirubin, mild leukocytosis and an increased erythrocyte sedimentation rate. A glucose tolerance test may reveal hyperglycaemia or diabetes mellitus indicative of Islets of Langerhans destruction. Urea and electrolytes may reveal hypocalcaemia. A secretin stimulation test is a reliable test to diagnose chronic pancreatitis. For this test, the patient is given secretin intravenously and gastric and duodenal secretions are withdrawn separately for analysis of the volume and bicarbonate content which are often reduced in the absence of adequate secretin. The stool reveals steatorrhoea. Arteriography and X-ray may indicate fibrosis and calcification. Endoscopic retrograde cholangiopancreatography (ERCP) followed by insertion of a contrast medium may be used to visualise the pancreatic and common bile ducts. Gross dilatation and microcysts may be visualised. Computed axial tomography, magnetic resonance imaging and ultrasound may also reveal cysts.

Nursing diagnoses • Knowledge deficit regarding reduction of pancreatic activity • Altered comfort related to pain • Nutritional and fluid deficit below body requirements due to decreased food intake and vomiting.

Nursing management The goals of management are to: Prevent and manage acute attacks. To prevent acute attacks, the patient should be given a bland, low-fat diet in small frequent servings daily (six times a day) because of fat intolerance. Antacids and anticholinergic drugs may be given to reduce acid, which stimulates pancreatic activity. For example, ranitidine and cimetidine can be given as histamine receptor blocking agents. Alcohol consumption should be completely discouraged. All stimulants such as caffeine should be excluded from the diet. The patient should try to manage stress but may need psychological counselling to assist with this. Hyperlipidaemia and hyperparathyroidism as causative factors must be treated. The free flow of pancreatic juice and release of pressure in the pancreatic duct may be promoted surgically. The pancreas may finally be transplanted if a donor is available, and the patient qualifies in terms of not having self-destructive habits such as alcohol abuse. Relieve pain and discomfort. Careful assessment and management of pain is required so that the patient does not become dependent on the drugs. The patient

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may need large, frequent doses of analgesics. It may be necessary to undertake a surgical procedure if medication does not help. The nurse should be familiar with these procedures so that they can answer the patient’s questions and prepare them. Surgical procedures include: • Elimination of obstruction of the duct • Diversion of gastric juices (gastroenterostomy) • Division of the autonomic nerve fibres • Transcutaneous nerve stimulation. Surgical management is, however, a risk in most patients with chronic pancreatitis, because they may be malnourished and debilitated. Manage exocrine and endocrine insufficiency. Pancreatic enzymes are replaced by giving pancreatin (Viokase®) and pancrelipase (Cotazym®), which contain amylase, lipase and trypsin. These medicines are coated to avoid breakdown or deactivation by gastric juices. Bile salts may be given to promote absorption of fat-soluble vitamins A, D, E and K and prevent further fat loss. The endocrine function of the pancreas must be closely monitored for the development of diabetes mellitus. The nurse should watch for signs such as polydipsia, polyuria, polyphagia, weakness and weight loss, and report these to the doctor. If diabetes mellitus develops, the patient should be treated by diet modification, oral hypoglycaemic agents, or insulin. Eliminating alcohol cannot be over-emphasised.

Pancreatic cysts Definition Pancreatic cysts are fluid-filled sacs resulting from local inflammation and necrosis. Cysts are walled off by fibrous tissue and are referred to as pseudocysts.

Causes of pancreatic cysts Pancreatic cysts are usually a complication of acute pancreatitis. Occasionally it may result from chronic pancreatitis, trauma or congenital anomalies. Typically, cysts are located adjacent to the pancreas rather than within it. Most of the cysts are found in the region of the pancreatic tail.

Pathophysiology Inflammation, vascular dilatation and increased permeability lead to local accumulation of fluid that eventually gets walled off by fibrous tissue forming a cyst. As the cyst increases in size, it causes pressure symptoms such as pain. Due to their retroperitoneal position and growth in size, the pancreatic cysts may impinge on and displace adjacent structures, such as the stomach or left

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colon. The cysts eventually rupture, spilling their contents into the abdominal cavity, causing chemical peritonitis.

Assessment and common findings Subjective data

Subjective data will reveal a history of acute pancreatitis, trauma to pancreas and gallstones. Pain and vomiting may occur.

Objective data The diagnosis of pancreatic cysts is usually confirmed by ultrasound, computed axial tomography and endoscopic retrograde cholangio-pancreatography (ERCP).

Nursing diagnoses • Altered comfort related to pain • Altered skin integrity around stoma following surgical drainage, related to excoriation by enzyme-containing drainage.

Management Pain is managed as in acute pancreatitis. Surgical drainage is usually done internally through the gastrointestinal tract or externally through the abdominal wall.

Nursing management To avoid irritation by pancreatic enzymes, the nurse must be vigilant to protect the skin around the stoma and observe for any signs of irritation for early treatment. Ointments must be applied on the skin around the stoma. Pancreatic secretions may be suctioned to avoid skin contact with digestive enzymes. Avoid disconnection of the suction tubing. A stomatherapist may be consulted to ensure adequate drainage while protecting the skin.

Carcinoma of the pancreas Definition Carcinoma of the pancreas is a malignant tumour of the pancreas.

Incidence Pancreatic cancer is responsible for 5% of worldwide deaths from cancer annually. Although cancer of the pancreas is the fifth leading cause of death in the US, it does not show on the African list of the top ten cancers. It usually occurs between the ages of 50 and 70, and affects more men than women. The cause/s of pancreatic cancer is/are not known.

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Risk factors • Cigarette smoking • A high-fat diet • Exposure to industrial chemical carcinogens such as gasoline, benzidine, beta-naphthylamine and drycleaning solvents.

Pathophysiology Cancer may arise in any part of the pancreas, that is, the head, body or tail. Approximately 75% of pancreatic cancer occurs in the head. As cancer of the head of the pancreas develops, obstruction of the common bile duct occurs, resulting in obstructive jaundice and dilatation of the gallbladder. Islet cells may or may not be involved and if affected, their function may be increased resulting in hyperinsulinism.

Assessment and common findings Subjective data

Assessment findings of pancreatic cancer are the three classic symptoms, namely, abdominal pain, weight loss and jaundice. The character of pain is related to the location of malignancy. The pain has an insidious onset, dull in nature and located in the right upper quadrant if the head is involved, and left upper quadrant in the case of body and tail involvement. The pain in all cases radiates to the back. It is worse in a supine position and it is relieved by lying down with the legs drawn up, or sitting forward. Cancer of the body of the pancreas impinges on the coeliac ganglia, resulting in pain. The pain also gets worse with ingestion of food. Cancer of the pancreatic tail will cause pain only when it has metastasised. Jaundice may appear with accompanying pruritus. Progressive weight loss is also seen due to anorexia, nausea and vomiting which are late signs. Low-grade fever may be present.

Objective data Moderate hepatomegaly and an enlarged gallbladder may be palpated depending on the extent of metastasis.

Diagnostic tests Cytological evaluation of gastric juices may reveal malignant cells. Secretin stimulation tests show decreased volume of pancreatic juices with normal bicarbonate and enzyme content. Carcinoembryonic antigen (CEA) will be elevated in a significant percentage of patients with advanced

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cancer, but this may not be reliable for diagnosis because this antigen is elevated in other cancers as well. Therefore, this test is used to evaluate the response to treatment and disease progression, rather than diagnosis. Ultrasonography, CT scanning and laparoscopy form reliable tests for confirming the cancer because these tests are capable of identifying solid tumours and changes indicative of lymphatic spread. Pancreatic arteriography may show occlusion of the coeliac axis and the superior mesenteric artery. The endoscopic retrograde cholangiopancreatography (ERCP), will demonstrate obstruction or narrowing of a major pancreatic duct and saccular dilatation of the smaller peripheral ducts. Percutaneous transhepatic cholangiography can also be performed to identify obstruction of the biliary tract by the pancreatic tumour.

Nursing diagnoses • Altered comfort related to pain • Fluid and nutrition below body requirements related to anorexia, nausea and vomiting due to disease process and cancer therapy • Impaired skin integrity related to jaundice and pruritus, including reaction to cancer therapy • Inability to cope related to knowledge deficit with regard to diagnostic and surgical procedures and depression • Altered self-concept related to change in role function.

Management The goals of nursing management in cancer of the pancreas are to: • ensure and maintain appropriate fluid and nutritional intake to meet body requirements • relieve pain and promote comfort • control pruritus and maintain skin integrity • promote coping abilities.

Medical management This may include pain management with prescribed analgesics. The delay in the diagnosis of pancreatic cancer makes it impossible to simply excise the tumour surgically. Pancreatic cancer is usually extensively metastasised to the liver, biliary tract, lungs and bones by the time it is diagnosed. Intraoperative radiotherapy in high doses may be chosen for treatment because pancreatic tumours are reported to be resistant to standard radiation therapy. Intraoperative radiation also has the advantage of causing minimal injury to other tissues while also relieving pain. Chemotherapy using fluorouracil may be undertaken. A pancreatoduodenectomy may be performed to remove the cancerous head of the pancreas, whereby the common bile

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duct, the stomach and remaining portion of the pancreas are sutured to the side of the duodenum and jejunum.

Nursing management See Table 41.2 for the nursing care plan for disorders of the accessory organs of digestion.

Tumours of the pancreatic islets Islet cell tumours are tumours that affect the Islets of Langerhans and other endocrine cells found in the pancreas. Islet cell tumours are often benign and located in the tail and body of the pancreas. The metastatic tumours are often associated with other endocrine disorders such as pituitary dysfunction; hence these are called multiple endocrine adenomas.

Pathophysiology Tumours of the pancreatic Islet cells depend on the type of cells affected, namely, the alpha, beta, delta and gastrinproducing cells (G-cells). For example, a tumour of the alpha cells will result in hyperglucagon syndrome, that of the beta cells (insulinoma) results in hyperinsulinism, and that of the delta and gastrin secreting cells cause ZollingerEllison syndrome, an ulcerogenic tumour associated with hypersecretion of the gastric acid and development of ulcers and bleeding in the stomach.

Assessment Hyperinsulinism results in hypoglycaemia, below 1.6 mmol/ℓ. The patient may experience unusual hunger, nervousness, sweating, headache and faintness. Severe cases of hyperinsulinism may develop seizures and cause the patient to lose consciousness, because the brain is dependent on a continuous supply of glucose. Hyperglucagon syndrome results in hyperglycaemia resulting in signs of diabetes mellitus, namely polyuria, polyphagia, polydipsia, and weakness. Zollinger-Ellison syndrome with oversecretion of gastrin will produce clinical manifestations of gastric and duodenal ulcers.

Nursing diagnoses These will be similar to those of peptic ulcers presented in Chapter 39.

Management Symptoms related to hypoglycaemia disappear on administration of glucose orally or parenterally. The treatment of the alpha and beta cell tumours is primarily the partial or total removal of the pancreas. As gastrin-secreting tumours tend to appear in multiples, pancreatectomy does not help. A total gastrectomy may

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41.2  The transportation of bile The transportation of bile is as follows: • When the liver cells secrete bile, it is collected by a system of ducts that flow from the liver through the right and left hepatic ducts. • These ducts ultimately drain into the common hepatic duct. • The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct, which runs from the liver to the duodenum (the first section of the small intestine). • However, not all bile runs directly into the duodenum. About 50% of the bile produced by the liver is first stored in the gallbladder, a pearshaped organ located directly below the liver. • Then, when food is eaten, the gallbladder contracts and releases stored bile into the duodenum to help break down the fats.

be done to eliminate the source of acid. Antacids have been used successfully for the Zollinger-Ellison syndrome. However, this necessitates strict adherence to treatment because of the risk of recurrence of ulceration and severe bleeding if the treatment is not taken as prescribed.

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Pancreas

Gallbladder Liver

Stomach

Common hepatic duct

Cystic duct Common bile duct

Pancreatic duct Duodenum

Figure 41.7  The biliary system

Stomach Gallbladder

Disorders of the biliary tract The biliary system consists of the bile ducts, gallbladder, and associated structures that are involved in the production and transportation of bile. The function of the biliary system is to drain waste products from the liver into the duodenum and to help in digestion with the controlled release of bile. Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts) that is secreted by the liver cells to carry away waste and to break down fats during digestion. Bile salt is the actual component which helps break down and absorb fats. Bile, which is excreted from the body in the form of faeces, is what gives faeces its dark brown colour. Conditions of the biliary tract are significant because they are fairly common and often lead to obstruction of the biliary tree, which may affect the flow of bile and pancreatic juice. These disorders include cholecystitis, cholelithiasis and cancer of the biliary tree. The former two conditions are closely linked because cholelithiasis often leads to cholecystitis. Biliary tract diseases affect more women than men, and the incidence increases with age.

Left hepatic duct

Right hepatic duct

Common bile duct

Pancreatic duct Duodenum

Pancreas

Figure 41.8  The gallbladder

Disorders of the gallbladder The gallbladder is a small pear-shaped organ that stores and concentrates bile. The gallbladder is connected to the liver by the hepatic duct. It is approximately 7.6–10.2 cm long and about 2.5 cm wide. The function of the gallbladder is to store bile and concentrate it. Bile is a digestive liquid continually secreted by the liver. The bile emulsifies fats and neutralises acids in partly digested food. A muscular valve in the common bile duct opens, and the bile flows from the gallbladder into the cystic duct, along the common bile duct, and into the duodenum (part of the small intestine).

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Cholecystitis Definition Cholecystitis is inflammation of the gallbladder, that may be acute or chronic.

Causes of cholecystitis Acute cholecystitis almost always follows stone impaction of the cystic duct (calculous cholecystitis), resulting in gallbladder distension, that in turn leads to decreased blood supply, decreased lymph drainage, and a good medium for bacterial proliferation. Calculous cholecystitis affects 90% of patients. Cholecystitis without stones (acalculous cholecystitis) is less common and it follows: • major surgery, severe trauma and burns, making its diagnosis difficult • tortion of the cystic duct causing obstruction • multiple blood transfusions • primary bacterial infections of the gallbladder which may have reached the biliary tree through the blood and lymphatic circulation, bile ducts or from adjacent organs; common causative organisms for the infectious process are Escherichia coli, Streptococci, Salmonellae, Staphylococci and Enterococci • neoplasms • extensive fasting and frequent weight fluctuations • anaesthesia and narcotic analgesics • hyperalimentation • hypotension and mechanical ventilation with positive end expiration pressure (PEEP).

Pathophysiology Inflammation of the gallbladder results from irritation by the concentrated bile from stasis. The mucosal lining becomes oedematous, hyperaemic, and ischaemic due to venous congestion and lymphatic stasis leading to marked gallbladder distension with bile and/or pus. The gallbladder is thought to be amenable to ischaemic effects, which results in necrosis and sloughing of the mucosal layer. The whole process may cause gangrene and perforation of the gallbladder. Severe scarring of the gallbladder may result in deficient functioning.

Assessment and common findings Subjective data

The symptoms depend on the severity of the obstruction, inflammation, and gallbladder distension. • Pain is the usual symptom, and is located in the epigastric, subscapular or right upper quadrant areas. The onset of pain is sudden and increases steadily reaching a peak in 30 minutes. The pain is often

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precipitated by a fatty meal with initial complaints of indigestion. This pain does not respond spontaneously, nor does it respond to potent analgesics. Seventy-five per cent of patients will have experienced biliary colic previously, especially if the cause is calculous. • Nausea and vomiting is observed in 50% of individuals. • Intolerance for fatty foods will be reported.

Objective data • Extreme tenderness will be observed on palpation of the right costal margin. Murphy’s sign will be elicited when the patient fails to breathe deeply on inspiration. • Jaundice will be observed in 20% of patients. • Fever of about 38–38.5 °C will be observed in some patients. A higher fever would indicate peritonitis. • Laboratory findings reveal leukocytosis between 12 000 and 15 000 per mm3. • Aminotransferase and alkaline phosphatase will be at abnormal levels. • Abdominal X-ray will reveal an enlarged gallbladder. Calcium gallstones may be visible. • Ultrasonography can expose gallbladder stones and thickening of the gallbladder wall. • Cholescintigraphy (radionuclide imaging) is accurate in detecting acute cholecystitis. This test relies on the ability of the liver to extract a rapidly injected contrast medium (radionuclide), which is excreted into the bile ducts. Cystic duct obstruction is also revealed by this test when the evidence is clinically obscure.

Management Medical management includes surgical or non-surgical treatment. Surgical treatment includes cholecystectomy in which the gallbladder is removed by laparotomy or laparoscopy. A detailed management of acute cholecystitis will be discussed under cholelithiasis.

Chronic cholecystitis Definition Chronic cholecystitis refers to persistent inflammation of the gallbladder.

Causes of chronic cholecystitis Chronic cholecystitis may be a sequel of acute cholecystitis or may result from repeated attacks of acute cholecystitis or chronic irritation of the gallbladder by stones which are almost always present. Cholecystitis may be associated with acute pancreatitis and rarely with carcinoma of the gallbladder. It attacks middle aged and older obese women. The female to male ratio is 3:1.

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Assessment findings Subjective data

The manifestations of chronic cholecystitis are similar to those of acute attacks with certain exceptions. For example, the pain is less severe, the temperature is not as high, and the leukocyte count is lower. The patient may complain of vague symptoms of discomfort, dyspepsia, fat intolerance, heartburn, and flatulence. These symptoms may have been experienced over a long period including repeated attacks of acute episodes.

Objective data Ultrasonography is largely used to diagnose chronic cholecystitis. Radionuclide imaging can also be used as a supplementary diagnostic procedure based on nonvisualisation of the gallbladder. Chronic cholecystitis may be difficult to differentiate from other diagnoses, such as angina pectoris, chronic pancreatitis, oesophagitis, hiatal hernia, peptic ulcer, pyelonephritis and spastic colitis – hence the need for the afore-mentioned diagnostic procedures.

Management Management for chronic cholecystitis will be discussed under cholelithiasis. Other management strategies of chronic cholecystitis include conservative measures such as weight reduction, use of anticholinergics, analgesics and antacids. When these do not relieve symptoms, surgical removal of the gallbladder may be done.

Cholelithiasis Definition Cholelithiasis is the presence of gallstones often associated with inflammation of the gallbladder (cholecystitis).

Causes of cholelithiasis Three factors are thought to contribute to the formation of gallstones, namely abnormalities of the composition of bile, stasis of bile, and inflammation of the gallbladder. These may be associated with the following factors: • Obesity, multiple pregnancies and oral contraceptives. These cause stasis of bile flow and excretion of increased amounts of cholesterol by the liver into the bile. Oestrogen further reduces the synthesis of bile acid in women. • Malabsorption disorders associated with ileal disease or its resection, which interferes with the absorption of bile salts. • Drugs that lower serum cholesterol levels also increase cholesterol excretion into the bile, for example clofibrate.

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• Starvation and rapid weight loss, which cause bile to become as thick as sludge with thick gallbladder mucoprotein and trapped cholesterol crystals. • Diabetes mellitus because of its interference with fat metabolism. • Vagotomy because it decreases motility of the gallbladder and thus causes stasis of bile. • Inflammation of the gallbladder, which alters the absorptive characteristics of the mucosal layers, resulting in excessive absorption of water. • Chronic haemolytic disorders such as sickle-cell disease, which result in increased bile pigments that form stones. • Cirrhosis of the liver, which alters the formation of bile and causes stasis of bile. • Obstruction of the biliary tract, which causes stasis of bile.

Pathophysiology The actual cause of gallstones is unclear but it is associated with alteration in the balance that keeps cholesterol, bile salts, and calcium in solution resulting in precipitation of these substances. Two major types of gallstones are known to occur. Predominant stones (75%) are those primarily composed of cholesterol. The rest (25%) are black or brown stones made of calcium salts and bile pigments (bilirubin). There may also be stones of a mixed composition. Stones of bile pigments and bile salts are thought to form from unconjugated pigments in the bile that precipitate stone formation, as would be seen in liver, biliary tract, and haemolytic diseases. Cholesterol stones develop in response to the solubility of cholesterol. For example, cholesterol solubility depends on the amount of bile acids and lecithin or phospholipids in bile. In cases where bile acid is depleted and cholesterol is increased, the bile is oversaturated with cholesterol, which precipitates and forms stones. Cholesterol laden stones also irritate the mucosal layer causing inflammation (cholecystitis). The result of gallstones is obstruction of bile flow and inflammation and dilatation of the gallbladder. Obstruction may also affect the pancreas as mentioned in earlier sections of this Chapter.

Assessment and common findings Subjective data

Most patients would be without symptoms when the gallstones are less than 8 mm in diameter. Such stones may be detected incidentally while the patient is undergoing procedures for other gastrointestinal problems. When these stones pass into the bile ducts, symptoms begin to show. The symptoms depend on the size of the stones

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and the area of obstruction. Such symptoms may be abdominal distension, epigastric fullness, and vague to severe pain in the right upper quadrant that is aggravated by a fatty meal. Definitive symptoms occur with obstruction of the cystic duct, which will cause dilatation and inflammation of the gallbladder. The clinical manifestations are as discussed below. • Pain and biliary colic described as excruciating in the right upper quadrant, radiating to the back or right shoulder. The pain is associated with vomiting, diaphoresis, tachycardia and prostration. A heavy meal may be a precipitating factor for the biliary colic. It usually persists for 2–8 hours. The pain is thought to be due to the contraction of the gallbladder in an attempt to release bile against resistance of obstruction. • Fever due to inflammation. • Marked tenderness in the right upper quadrant on deep inspiration resulting in shallow breathing. • Marked pruritus due to jaundice. • Intolerance for fatty foods causing anorexia, nausea and sensation of fullness because of lack of bile in the intestine for digestion. • Bleeding tendencies due to failure to absorb fat-soluble vitamin K, resulting in failure to produce prothrombin.

Objective data A palpable abdominal mass may be felt at the region of the ninth right rib and tenth costal cartilages. On inspection jaundice will be seen especially in the mucous membranes of the eye and mouth due to obstruction of the common bile duct.

Diagnostic studies • Urine testing will reveal dark amber urine that foams when shaken due to the presence of bilirubin. • Stools will be fatty and clay-coloured (steatorrhoea) due to bile pigments not reaching the duodenum. • Abdominal X-ray may be employed to diagnose calcified gallstones or other diseases. • Ultrasonography (ultrasound) is the preferred diagnostic tool because of its accuracy and the rapidity with which it can diagnose gallstones and distended common bile duct, including its ability to diagnose liver dysfunction. To facilitate the efficacy of this procedure the patient should be starved overnight so that the gallbladder is distended on examination. • Cholescintigraphy or radionuclide imaging can be used to diagnose cholecystitis. During this procedure the patient will be given a radioactive substance intravenously. This agent is taken up by hepatocytes

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and excreted into the biliary tract quickly. Pictures of the biliary tract and gallbladder will be taken. This procedure is expensive and takes a long time to perform and it exposes the patient to radiation. It may be used in cases where ultrasonography is not conclusive. • Cholecystography may be used if an ultrasound facility is not available, or the ultrasound results are inconclusive. This procedure can be used to test the ability of the gallbladder to fill, concentrate its contents, and contract and empty the concentrated bile. To assess this, a contrast medium containing iodine will be injected into the patient, taken up by the liver, and excreted into the gallbladder where it is concentrated. Twelve hours later, X-rays will be taken and if the gallbladder is normal, it will fill with the radio opaque substance, and if there are gallstones, these will show as shadows. The presence of gallstones may prevent the visualisation of the gallbladder, while jaundice may indicate liver dysfunction. This would mean that the liver may fail to excrete the contrast medium into the gallbladder in the test. In preparation for this procedure, the patient must have been assessed for allergies to iodine or seafoods that contain iodine. The patient should be starved to prevent contraction and emptying of the gallbladder during the test. • Cholecystography may be useful in the evaluation of patients who have had dissolution therapy. • Percutaneous transhepatic cholangiography: In percutaneous transhepatic cholangiography, a contrast medium is injected directly into the hepatobiliary tree. The high concentration of the dye promotes visualisation of a clear outline of the hepatic ducts within the liver, the entire length of the common bile duct, the cystic duct, and the gallbladder. This procedure is useful even if the liver is diseased and it can assist with distinguishing between jaundice caused by liver disease and that caused by obstruction of the biliary tract. This diagnostic procedure can also diagnose gastrointestinal symptoms of a patient who has had the gallbladder removed, to locate stones in the biliary tract, and for the diagnosis of cancer involving the biliary system. In preparation, the patient must fast, be well sedated and be put in a supine position on the X-ray table. The site to be punctured must be cleaned with an antiseptic, anaesthetised with local anaesthesia, and a small incision made through which the needle will be inserted. Bile will be withdrawn as an indication of the correct position in the biliary tract and a contrast medium is injected. On completion, as much bile as possible will be withdrawn to avoid chemical peritonitis from bile spillage. The nurse must

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therefore observe the patient for signs of peritonitis, abdominal bleeding and sepsis.

Nursing diagnoses • Pain and discomfort related to inflammation, biliary obstruction and pruritus are caused by jaundice • Fever related to inflammation • Easy bruising with tendencies to bleed associated with failure to absorb fat-soluble vitamin K • Nutrition below body requirements related to intolerance for fatty foods and failure to reabsorb fatsoluble vitamins (A, D, E, K) • Altered breathing related to shallow breathing to guard against aggravating pain. Management

Medical management The goal of medical treatment is to reduce the incidence of acute episodes of biliary colic and cholecystitis by removing the cause of cholelithiasis through pharma­ cological therapy, endoscopic and surgical procedures, as well as conservative modalities.

drugs, such as ursodeoxycholic acid (UDCA) and chenodeoxycholic acid (chendiol or CDCA). These drugs inhibit the synthesis and secretion of cholesterol resulting in desaturation of bile, reduction in the size of bigger stones, and dissolution of smaller ones. This treatment is usually effective in 6–12 months and is of advantage to patients who refuse surgery or for whom surgery is a risk. A solvent, such as mono-octanoin or methyltertiary butyl ether (MTBE) can also be infused directly into the gallbladder through a tube or catheter to dissolve stones that were not removed at the time of surgery.

Procedures to remove gallbladder stones Endoscopic procedures: Stones can be removed by the insertion of a catheter that has a basket attached to it through an endoscope to retrieve the gallstones. This procedure may result in complications such as perforation, bleeding and infection.

Extracorporeal shock-wave lithotripsy

See Table 41.2 for the nursing care plan for patients with the disorders of the accessory organs of digestion.

Extracorporeal shock-wave lithotripsy is a non-invasive destruction of gallstones using repeated shock waves run through a fluid-filled bag. The stone fragments then pass spontaneously through the duodenum where they are removed by endoscopy or dissolved with oral bile acid or solvents.

Conservative treatment

Intracorporeal lithotripsy

Conservative treatment involves nutritional and supportive therapy using pharmacological treatment. Nutritional therapy may be the main mode of treatment for patients who only present with dietary intolerance to fatty foods with vague gastrointestinal symptoms. Supportive treatment in the form of rest, intravenous therapy, nasogastric suction, analgesia and antibiotics, has brought some remission in gallbladder inflammation. This treatment also helps to decrease the symptoms and allow for complete evaluation in readiness for surgery. Dietary therapy includes low-fat fluids immediately after an acute episode. A variety of supplements high in protein and carbohydrates can be mixed in skimmed milk. Cooked fruit, rice, lean meat, mashed potatoes, bread, coffee or tea may gradually be added as the patient tolerates them. Consideration and emphasis on foods that are contraindicated must be made, for example eggs, cream, pork, fried foods, cheese, rich dressings, gasforming foods and alcohol as these trigger the episodes of acute cholecystitis.

Intracorporeal lithotripsy involves performing an ultrasound or a pulse laser hydraulic lithotripsy which is applied through an endoscope directly to gallstones to crush them. The small stone fragments are then irrigated and aspirated out.

Nursing care

Pharmacological management Pharmacological management involves dissolving small radiolucent cholesterol gallstones using systemic

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Surgical management Surgical treatment of gallbladder diseases may be an emergency or elective procedure according to the acuteness of the symptoms. The goals of surgical treatment of cholelithiasis and cholecystitis are to: • Relieve persistent symptoms • Remove the gall stones • Treat acute cholecystitis. Possible surgical procedures include the following:

Laparoscopic cholecystectomy In this procedure a small incision is made through the abdominal wall slightly above the umbilicus. The abdominal cavity is insufflated with carbon dioxide to assist in the insertion of the laparoscope and visualisation of abdominal organs. Additional punctures are made

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to insert forceps for grasping the gallbladder and for dissection of the gallbladder. It is important for the nurse to inform the patient preoperatively that a laparoscopic procedure may be converted to an open abdominal surgery (laparotomy) if problems arise, for example perforation and/or bleeding. Postoperative problems may be irritation of the phrenic nerve and diaphragm resulting in difficulty with breathing. Therefore the patient must be allowed to assume the most comfortable position that will allow deep breathing while respiration is monitored halfhourly in the first 6 hours postoperatively.

Surgical cholecystostomy This is an incision and drainage of the gallbladder performed when the patient’s condition contraindicates more extensive surgery or the acute inflammatory condition is severe. This may be an intermediate procedure followed by abdominal incision for cholecystectomy when the patient’s condition improves. In this procedure, the fundus of the gallbladder is incised and drained, and stones are removed, after which a drain is left in situ for drainage of bile to prevent bile from leaking into and irritating the surrounding area. The gallbladder should be assessed postoperatively for remaining gallstones, and elective cholecystectomy may be indicated if there are any. The patient may have to remain on a low-fat diet for 4–6 weeks. It is also advisable for the patient to lose weight if they are obese.

Cholecystectomy This procedure involves excising the gallbladder and ligating the cystic duct and the associated blood vessels. Cholangiography may also be done to explore the common bile duct for the presence of gallstones, which may also be removed. A T-tube must be inserted for drainage of bile, but this tube may also assist with an open route for follow-up cholangiography and non-surgical removal of stones if found. The T-tube necessitates extensive patient education (see Box 41.3). Common complications following cholecystectomy • Destruction of the bile ducts due to erroneous identification of the ducts and overzealous ligation. This problem may be identified during surgery but can be identified postoperatively by leakage of bile and formation of a fistula. It must be corrected surgically. • Haemorrhage due to damage to the liver and failure to clamp bleeding vessels. This can be detected by close monitoring of vital signs in the immediate postoperative period. • Bile leakage due to damage of the cystic duct or retention of gallstones. Hence the T-tube is inserted

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41.3  Care of the T-tube Care of the T-tube at home should be done as follows: • Clamp the tube when eating to allow for fat digestion • Measure and record drainage • Cleanse the skin around the drain • Change the dressing • Assess for infection • Assess pattern of drainage, for example copious or scanty • Seek help if the temperature is above 37 °C, there is general malaise, or purulent discharge.

for drainage. Leakage of bile may cause peritonitis evidenced by fever, severe abdominal pain and abdominal rigidity. The same diagnostic studies as done initially will be employed to trace the cause and location of the problem and repair it. • Jaundice may occur due to missed gall stones, stenosis of the sphincter of Oddi, a missed tumour in the area of the ampulla, and necrosis of the liver after interruption of its blood supply during surgery. Assessment of the skin and mucous membrane for yellowish discolouration in the postoperative period will assist in early detection and correction of the causative problem. • Pancreatitis may result from trauma and fibrosis of the common bile duct. This complication increases the mortality rate. • Subphrenic abscess related to surgical damage to the liver, rupture of small bile ducts and leakage of bile. Spiking fever 5–8 days postoperatively may indicate this problem. A drain may prevent the problem. For general postoperative care after abdominal surgery, refer to Chapter 40.

Cancer of the biliary tract Cancer of the biliary tract involves malignancy of the biliary tree.

Incident and causes Cancer of the biliary tract is a rare problem accounting for less than 1% of all gastrointestinal cancers. It mainly affects women over 65 years of age. The causes are unknown, but it is thought that there may be a link between occurrence of cancer and gall stones, although the exact link is not known. The most common type is adenocarcinoma associated with chronic gall stones.

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Pathophysiology

Management

The onset is insidious and metastasises by direct extension through the blood and lymphatics. It occurs anywhere in the gallbladder.

Surgery for cholecystectomy or treatment to maintain the patency of bile flow is suggested. Also, provide supportive care to both the patient and family.

Assessment and common findings

Conclusion

The symptoms are similar to those in cholelithiasis and cholecystitis. Intermittent pain in the upper abdomen causes: • Anorexia • Nausea and vomiting • Weight loss • Jaundice.

The role of the accessory organs of digestion is primarily metabolism. The disorders of any or all of the accessory organs can cause various problems in the maintenance of normal energy storage.

Suggested activities for learners Activity 41.1 Discuss the pathophysiology of cirrhosis of the liver and draw up a nursing care plan for a patient with liver cirrhosis.

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42

Management of disorders of the endocrine system

learning objectives

On completion of this Chapter, the learner should be able to: • describe the causes and pathophysiology of endocrine disorders • describe the clinical manifestation of endocrine disorders • relate the pathophysiology to the clinical manifestations of endocrine disorders • describe the therapeutic and pharmacological management of endocrine disorders • accurately interpret assessment findings including the results of diagnostic studies • effectively plan, implement, and evaluate scientifically correct nursing care of patients with endocrine disorders in a variety of clinical settings: –– carry out a nursing assessment of the patient with an endocrine disorder; including pre- and postoperative assessment –– specify nursing diagnoses for the patient with an endocrine disorder –– draw up an individualised care plan for a patient with an endocrine disorder –– implement nursing care for a patient with an endocrine disorder –– evaluate the results of care for a patient with an endocrine disorder • effectively manage emergencies and complications related to endocrine disorders • describe the health information that should be provided for patients with endocrine disorders. key concepts and terminology

acromegaly

Inappropriate growth or enlargement of bony parts of the body, especially the lower jaw.

adrenocorticotrophin hormone (ACTH)

A hormone secreted by the anterior lobe of the pituitary gland, which controls the secretion of adrenal corticol hormones.

antidiuretic hormone (ADH)

A hormone secreted by the posterior lobe of the pituitary gland, which controls the concentration of body fluids.

diabetes mellitus

A disorder of fat, carbohydrate and protein metabolism characterised by hyper/ hypoglycaemia, degenerative vascular changes and neuropathy.

dwarfism

Stunted growth.

eicosanoids

Biologically active lipids synthesised from arachidonic acid, eg prostaglandins and prostacyclines.

exophthalmos

Bulging/protruding eyeballs or enlargement of the eyeballs.

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gestational diabetes mellitus (GDM)

Type of glucose intolerance seen during pregnancy.

gigantism

Excessive growth due to over secretion of pituitary growth hormone.

gluconeogenesis

Formation of glucose from new sources such as amino acids and the glycerol part of fats. This process occurs in the liver.

glycogenesis

Formation of glycogen from glucose or conversion of glucose into glycogen. This process is promoted by insulin.

goitre

Enlargement of the thyroid gland due to a deficiency of iodine in the diet.

hirsutism

Excessive body hair.

hormone

A chemical substance synthesised and secreted by a specific organ/tissue and transported by blood to the site of the body where its action is required.

hyperthyroidism

A disease caused by over production of thyroxine due to overactivity of the thyroid gland.

hypothyroidism

A disease caused by a deficiency of thyroxine due to underactivity of the thyroid gland.

myxoedema

Condition characterised by slow metabolism and non-pitting oedema caused by very low or non-production of thyroxine by the thyroid gland.

Receptors

Structures found on the cell walls of target cells that bind to hormones and subsequently initiate specific chemical processes within the target cells.

steroid hormones

Type of hormone synthesised from cholesterol. The only examples in the body are the gonadal hormones and the adrenocorticotrophic hormones.

Syncope

Brief loss of consciousness. A faint.

thyroid crisis/ storm

Sudden rise in the production of thyroxine that occurs due to manipulation of the thyroid gland during thyroidectomy.

Thyroxine

Hormone secreted by the thyroid gland.

thyroidectomy

Surgical removal of the thyroid gland.

prerequisite knowledge

• Anatomy and physiology of the endocrine system including biochemistry thereof. essential health literacy

People should be aware of the role of hormones, and thus the endocrine glands, in the maintenance of a healthy body. Risk factors for endocrine disorders such as sedentariness and obesity as well as the effects of some drugs, eg cortisone, should also be known. Among sports people the temptations to use performance-enhancing substances such as anabolic steroids, which increase stamina and muscle mass, are rife. However, these drugs disrupt the natural hormonal balance within the body and are potentially very dangerous.

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Chapter 42 – Management of disorders of the endocrine system  825

Introduction Disorders of the endocrine system are mostly related to overactivity or underactivity of the endocrine glands. Problems are caused by imbalances in production of the hormones or alteration in the body’s ability to use the hormones. This Chapter aims to provide you with the knowledge to effectively manage the care of patients with endocrine disorders. Aspects to be covered include: • Overview of anatomy and physiology of the endocrine system • Chemistry of hormones and how these function • Classification of disorders of the endocrine system • Risk factors for disorders of the endocrine system • Assessment and common findings • Specific disorders of the endocrine system.

Overview of the anatomy and physiology of the endocrine system The endocrine system consists of the endocrine glands, which secrete chemical substances called hormones. The glands are also known as ductless glands and include the pituitary gland, thyroid gland, parathyroid gland, adrenal gland, the Islets of Langerhans, and the gonads (ovaries and testes). These glands are known as ductless glands because they secrete specific hormones directly

into the bloodstream. They are clearly differentiated from the exocrine glands, which secrete through the ducts onto epithelial surfaces: sweat glands are an example of the exocrine glands. The hypothalamus provides a link between the endocrine system and the nervous system. Through the influence of the hypothalamus on the pituitary gland the nervous system controls the secretion of the pituitary hormones, which in turn regulate the secretion of all the hormones in the body. Hormones are generally secreted according to the need for their actions, that is, secretion is stimulated when action is needed, and inhibited once the desired effect is achieved.

Chemistry of hormones Hormones are chemical messengers. They are secreted directly into the bloodstream by the endocrine glands to be transported to the target cell, tissue or organ. Hormones may be composed of amino acids (protein-based) or lipids (fatty-acid-based). The lipid hormones or steroids are synthesised from cholesterol (which is produced by the liver) combined with proteins, ie lipoproteins. In addition to the hormones produced by the endocrine glands, other chemical mediators or hormonelike substances (also known as local hormones), which also influence cellular function, are produced by the

Pituitary gland Pituitary gland

Parathyroid gland

Thyroid gland Parathyroid gland Pancreas (islets of Langerhans)

Adrenal glands Testes

Adrenal glands

Ovaries

Figure 42.1  Location of the major endocrine glands of the body in females (left) and males (right)

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body. These substances are generally involved in the body’s response to injury eg coagulation, inflammation and allergy. This group includes: • Eicosanoids, containing arachidonic acid and phospholipids, eg prostaglandins, which are involved in the anti-inflammatory response • Cytokines, which are also involved in the inflammatory response • Histamine, involved in the immune response • Complement, involved in the anti-inflammatory response • Bradykinin, involved in coagulation. The functioning of the target cell, tissue or organ is influenced by hormones in one of two ways: 1. Amino acid-based hormones bind to receptors on the cell membrane of the target organ or tissue. The action of binding activates a second messenger such as the cyclic adenosine monophosphate (cAMP). In turn cAMP activates protein kinases within the cell. These protein kinases influence the function of the cell, for example secretions of enzymes may be increased or decreased. 2. Steroid hormones are able to enter the target cell by diffusing across the cell membrane. Once inside the cell they bind to intracellular receptors. The combination of hormone and intracellular receptor causes gene activation and the synthesis of specific proteins by the target cell (see Figure 42.2).

Hormone binds to receptor on cell wall

receptor

hormone Binding activates a second messenger (cAMP) inside the cell

cAMP

Activation of protein kinases

Function of the cell is altered Effects a) Amino acid-based hormones Steroid hormones and eicosanoids are able to diffuse across the cell membrane

Once inside the cell the hormone binds to an intracellular receptor

Classification of disorders of the endocrine system Most endocrine system disorders are related to overactivity or underactivity of the specific gland and can therefore be classified according to the gland/structure affected.

Gene activation follows intracellular binding of hormone and receptor

Risk factors for the disorders of the endocrine system Heredity

Congenital disorders and family history increase the risk for the disease. The disease is transmitted as a recessive genetic trait.

Synthesis of specific proteins by the cell

Sedentary life Lack of activity leads to obesity which is related to endocrine disorders.

Environmental factors These include stress from surgery, trauma, and emotional and/or occupational stress.

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b) Steroid hormones

Effects

Figure 42.2 Schematic diagram showing the chemistry of hormonal action

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Chapter 42 – Management of disorders of the endocrine system  827 Table 42.1  Classification of disorders of the endocrine system

Gland

Disorder

Pituitary gland

Hypopituitarism, hyperpituitarism, pituitary tumours, diabetes insipidus, SIADH – syndrome of inappropriate anti-diuretic hormone

Parathyroid gland

Hyperparathyroidism, hypoparathyroidism

Thyroid gland

Hyperthyroidism, Grave’s disease, toxic nodular goitre, thyroid crisis/storm, thyroiditis, hypothyroidism, thyroid cancer

Adrenal gland

Addison’s disease, adrenocortical insufficiency, Cushing’s syndrome, hyperaldosteronism, pheochromocytoma, adrenal virilism, adrenal hyperplasia

Pancreas Islets of Langenhans

Diabetes mellitus type I

Gonads (testes and ovaries)

Hypo- and/or hypersecretion of gonadal hormones is generally due to a problem of pituitary or adrenal secretion

Age The onset of endocrine diseases such as diabetes is closely related to age; for example, diabetes mellitus type I usually occurs before the age of 30, and type II over the age of 30.

Drugs Some drugs affect the function of the endocrine system adversely, for example corticosteroids may cause glucose intolerance and suppression of the pituitary ACTH synthesis.

Injury Head injury, brain tumours, intracranial haemorrhage and cerebral hypoxia interfere with secretion of hormones, thereby putting the patient at risk of endocrine disorders.

Malignancy A malignancy of any of the endocrine glands or of the brain would put the patient at risk of endocrine disorders.

Assessment and common findings As hormones are responsible for all cell activities in the body, assessment is usually intense. Assessment findings can be obtained through accurate history taking, physical examination, and diagnostic studies.

Subjective data Chief complaint and presenting symptoms The nurse obtains a history from the patient about their present health status. Anything that could indicate an endocrine disorder is noted: • Recent unexplained weight loss or weight gain • Increased thirst (polydipsia) and/or increased food intake (polyphagia)

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• Smell of acetone, or sometimes apples, on the breath (ketosis) and/or nausea • Increased urination especially at night (nocturia) • Tiredness, fatigue • Sudden weakness and drowsiness • Delayed wound healing • Constipation or diarrhoea • Sleep disturbance • Abdominal pains, such as cramps • Pruritus or itching • Recurrent vaginitis, indicated by itching and discharge • Myopia (short-sightedness), blurred vision • Numbness, tingling sensations • Irritability, and/or sexual difficulties, such as impotence, increased or decreased libido. Personal history The nurse should obtain information about the following: • Onset of symptoms – whether acute or gradual • Any recent stressor such as illness, trauma, surgery, or emotional stress • Age and social history, such as occupation, lifestyle • Diet, exercise and sleep pattern. Past medical history This should include a history of previous and present medication, previous illnesses and hospitalisations. Family history This should include information on diabetes mellitus, gout, hypertension, cancer and obesity within the family.

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Objective data Physical examination The nurse should consider the patient’s general appearance, physical growth, body size and development in relation to the patient’s age. Physical growth and development is mediated by hormones and many endocrine disorders adversely affect growth and development as well as body mass. The nurse should also assess the patient’s weight, height, facial features and posture, and note any report of weight loss or gain as these may also be affected by hormone imbalances. A head-to-toe examination must be done to assess the following: • Hair. For texture, amount, pattern and distribution. Note any alopecia or hirsutism. • Head. For contour, any changes in shape, symmetry of facial features, eg are the features in the right place? Are the features the same on each side of the face? Appearance and size eg any enlargement or deformity of the skull and facial bones. A round moon face may indicate Cushing’s syndrome. • Eyes. For size, protrusion, visual acuity, nystagmus, and oedema around or underneath the eyes. There may be exophthalmoses and diminished or blurred vision. • Mouth. Note the size and shape of the jaw. Inspect the colour of the mucous membrane; check teeth for alignment and condition (for example, any caries). Check the size of the tongue, which may be red and enlarged. • Nose. Inspect the mucous membrane for swelling and colour. Listen for noisy air entry and laboured breathing. The patient may report a history of nosebleeds or easy bruising. • Nails. For any changes in growth, texture and clubbing of fingers. • Neck. Palpate the thyroid gland for enlargement, lumps, roughness and hardness. Any enlargement or nodules may indicate a thyroid problem, eg goitre. Inspect distended neck veins and forceful pulsation of the carotid artery if present. Listen to the patient’s voice as there may be hoarseness, high pitch or volume of speech in thyroid problems, particularly if the thyroid is enlarged. Ask the patient to swallow and observe any difficulty or pain during swallowing. Look for scars related to previous surgery or trauma, for the midline position of the trachea. In addition, review all body systems as follows: • Cardiovascular system. There may be an abnormal pulse rate and rhythm, eg tachycardia and/ or atrial fibrillation (rapid irregular heartbeat) in hyperthyroidism, postural hypotension if the blood

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•

•

•

•

•

•

pressure is low as, for example, in Addison’s disease, which involves hyposecretion of the adrenal glands, or bluish discolouration on the nails and the nail beds and cold extremities, which may be related to cardiac failure due to severe hyperthyroidism. Also, on auscultation, there may be the presence of palpitations and syncope related to changes in position. Respiratory system. Inspect the chest for symmetry and general appearance. Note the respiratory rate, depth, and quality. There may be deep rapid respiration (Kaussmaul’s), indicating acidosis; a fruity breath odour or acetone breath indicating respiratory excretion of ketones; or altered breath sounds and shortness of breath, indicating inadequate ventilation, pneumonia and fluid overload, which may be related to cardiac failure in severe hyperthyroidism. Gastrointestinal tract. Inspect the abdomen for shape and size. There may be polyphagia, polydipsia, abdominal distension, pain and tenderness and decreased bowel sounds. There may be changes in bowel habits and appetite evidenced by diarrhoea or constipation with clay-coloured stools or steatorrhoea, nausea, and vomiting. Integumentary. Feel for temperature. The skin may be warm, flushed and dry with poor turgor (scaly, sweating with enlarged pores), poorly healing skin wounds and infections. There may be hyper- or hypopigmentation including jaundice with unexplained puncture holes and myxoedema in hypothyroidism. Neurological. There may be localised or generalised weakness, altered level of consciousness evidenced by irritability, lethargy, drowsiness, confusion, altered reflexes and possible coma. Back pain, tremors and loss of sensation may be reported. Mild depression and emotional instability may also be evident. Genitourinary system. There may be evidence of polyuria with dark yellow or tea-coloured urine, nocturia and calcium formation in urine. Vaginal discharge, perineal irritation, impotence and decreased libido may also be reported. Musculoskeletal system. There may be aching and cramping, muscular weakness or numbness and tingling sensations. There may also be acromegaly of the head, hands, feet or face; dwarfism or gigantism in hyperpituitarism.

Diagnostic findings See Table 42.2

Common nursing diagnoses • Alteration in acid–base balance and electrolyte imbalance related to dehydration

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Chapter 42 – Management of disorders of the endocrine system  829 Table 42.2  Summary of diagnostic findings in endocrine disorders

Study

Purpose

Nurse’s responsibility

Urinalysis

To determine the levels of glucocorticoid metabolites and ketosteroids and aldosterone

Obtain a urine specimen for routine ward tests

Radioactive iodine uptake

To assess the rate of iodine uptake by the thyroid

Obtain a 24-hour urine specimen and ensure that the patient has not eaten seafood within 2 weeks, not had an X-ray or taken oestrogen within the same period

Radioactive iodine uptake

To assess the rate of iodine uptake by the thyroid gland

Explain the purpose of the examination to the patient, keep NPO for 8 hours, ask about use of medication that can cause bleeding or nonsteroidal anti-inflammatory agents (NSAIDs)

Thyroid scan

To detect the size, shape and activity of the thyroid gland

Explain the procedure to the patient

Skull X-ray, CT or MRI

To assess the structure of the pituitary gland and rule out tumours

Explain the procedure to the patient and clearly indicate what the patient is expected to do

Blood tests

To assess for acid–base balance, electrolyte balance (which may be abnormal due to endocrine imbalance), glucose in case of suspected diabetes or adrenal hypersecretion, and hormone levels

Explain the reasons for the tests

Visual testing

To assess for visual problems such as loss of peripheral vision in pituitary tumours

Explain the reason for the test to the patient and describe what the test involves

Neurological tests

Reflexes, sensation and mobility to tests for neuropathy in suspected diabetes mellitus

Explain the tests and the reason for the tests to the patient

Osmolality studies

Radiological studies

• Altered nutritional status as evidenced by weight gain related to polyphagia or weight loss related to nausea, vomiting and anorexia or increased metabolism • Altered elimination pattern related to the disease process evidenced by polyurea, diarrhoea or constipation • Knowledge deficit about the disease process as evidenced by self-esteem disturbance, anxiety and an inability to participate in self-care

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• Ineffective individual coping related to a new diagnosis as evidenced by denial of the need for self-care and inability to comply with treatment regimen • Anxiety due to self-esteem and body image disturbance related to changes in physical appearance and diagnosis of chronic illness • Sleep pattern disturbance related to nocturia and polyuria as evidenced by insomnia and restlessness • Risk for poor sexual function and disturbance related to the disease process as evidenced by decreased libido and impotence.

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Specific disorders of the endocrine system Disorders of the pituitary gland The hypothalamus is the common pathway directing input to the pituitary gland from all other areas of the central nervous system (CNS). The hypothalamus thus regulates the activities of both the anterior (adenohypophysis) and the posterior (neurohypophysis) lobes of the pituitary gland. Hormones secreted by the hypothalamus bind to specific cell membrane receptors that stimulate or inhibit the release of pituitary hormones. The disorders of the pituitary gland are characterised by hyposecretion or hypersecretion of the pituitary gland. Table 42.3 gives the hormones that are secreted by the anterior pituitary lobe (adenohypophysis) and the posterior pituitary lobe (neurohypophysis).

third percentile and growth velocity is less than or equal to 4 cm per year.

Causes The causes are unknown but are related to pituitary tumours, low or decreased growth hormone secretion, defective growth hormone action, impaired skeletal response to growth hormone, primary or secondary hypothyroidism, and diabetes mellitus in the patient.

Assessment and common findings There is growth retardation, but all structures are normal in proportion. There will be delayed or failure to begin pubertal development and possible emotional depression. There may also be a family history of short stature.

Hypopituitarism

Diagnostic studies

This is a condition where there is an endocrine deficiency syndrome due to partial or complete loss of anterior pituitary lobe functioning. The onset is often insidious and may not be recognised by the patient.

• Growth hormone studies will reveal low levels of growth hormones • X-rays and a CT scan should be done to confirm bone status.

Dwarfism

Management

This condition is characterised by an abnormally short stature due to decreased functioning of the anterior pituitary gland, specifically the secretion of the growth hormone. The height of the individual is less than the

This includes replacing the lacking pituitary gland hormones, and possible surgical removal of any tumours. Irradiation of the tumour, if malignant, may be carried out.

Table 42.3  Hormones secreted by the anterior and posterior lobes of the pituitary gland

Lobe of pituitary gland

Hormone secreted

Function of hormone

Anterior lobe of the pituitary gland

Growth hormone

Promotes growth

Corticotrophin

Controls secretion of adrenocortical hormones which in turn affect protein, fat, and carbohydrate metabolism

Thyrotrophin

Controls the rate of secretion of thyroxine by the thyroid gland responsible for most of the chemical activities in the entire body

Gonadotrophic hormones: follicular stimulating hormone, luteinising hormone, and luteotrophic hormone

Control growth of gonads and reproductive activities

Antidiuretic hormone

Controls the concentration of body fluids

Oxytocin

Promotes uterine contraction during and after childbirth Promotes milk flow for infant feeding

Posterior lobe of the pituitary gland

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Nursing care

Surgical treatment

This is directed at the proposed treatment, for example replacement of lacking hormones, surgical or radiation therapy in the case of malignant tumours.

Surgical management usually includes hypophysectomy to remove the tumour.

Hyperpituitarism

Tumours of the pituitary gland result in hyper- or hyposecretion of the affected part of the pituitary gland.

These conditions are characterised by over-production of the hormones of the anterior pituitary gland.

Acromegaly and gigantism These are syndromes of excessive secretion of growth hormone. Gigantism begins in childhood, resulting in excessive growth of the individual (some of whom can reach over 2m in height) whereas the onset of acromegaly occurs in adulthood.

Causes Hyperpituitarism, leading to gigantism (childhood onset) or acromegaly (adult onset) may be caused by hyperplasia, adenoma, or tumour of the anterior pituitary gland, which causes excessive secretion of growth hormone.

Assessment and common findings • Change in facial features with nose enlargement, lip thickening, bulging of the forehead and enlargement of the hands and feet • Headaches and visual changes • Deepening of the voice caused by thickening of the vocal cords • Thoracic kyphosis from the weight of the body bulk • Enlargement of the tongue and salivary glands, spleen, liver, heart and kidneys • Elevated blood pressure • Snoring, sleep apnoea and respiratory failure • Acne, sweating, and oiliness of the skin • Backache and arthralgia from bone enlargement • Peripheral nerve damage, evidenced by carpal tunnel syndrome • Impaired glucose tolerance, resulting in the clinical features of diabetes mellitus • Changes in fat metabolism resulting in hyperlipidaemia • Lethargy and fatigue • Osteoporosis, evidenced by bone pain and possibly spontaneous fractures • Electrolyte changes, polyuria, calcium excretion and elevated blood phosphate.

Diagnostic studies • Immunoassay of hormone levels will show evidence of excessive growth hormone • CT scan of the skull and MRI may show evidence of a tumour/adenoma.

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Pituitary tumours

Assessment and common findings These include: • Visual defects – tunnel vision is a common finding • Headache • Somnolence • Increased intracranial pressure • Seizures • Behavioural changes, eg confusion and aggression • Hydrocephalus and papilloedema • Disturbed sleep pattern, eg excessive sleepiness, appetite and temperature fluctuations such as hot flushes.

Management The preferred treatment for pituitary tumours is surgery to remove the tumour. Following removal of the tumour radiation therapy may be used to prevent regrowth. Inoperable pituitary tumours are treated with radiation therapy.

Pituitary surgery The surgical approach is usually made through the frontal bone, depending on the situation and the size of the tumour. A trans-sphenoidal approach may be selected but this carries the risk of bacterial contamination from the nasopharynx.

Nursing management following pituitary surgery Nursing care is very much the same as for a patient who has undergone a craniotomy. However, in addition a careful watch must be kept on the urinary output in order to detect diabetes insipidus. If the patient passes large volumes of diluted urine, fluid replacement with a suitable intravenous fluid (Ringer’s lactate or normal saline) should be implemented. Nursing care includes the administration of pituitary hormones as prescribed, and the general nursing care of a patient following surgery for removal of the tumour, radiation therapy or both.

Diabetes insipidus Diabetes insipidus is a disorder of the posterior lobe of the pituitary gland. It is due to a deficiency of sufficient antidiuretic hormone (ADH) to concentrate body fluids,

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or the inability of the kidney to respond normally to ADH. It is characterised by polyuria, polydipsia and cell dehydration.

Causes This condition is caused by central brain or pituitary tumours, head trauma, encephalitis, meningitis, hypophysectomy or cranial surgery. It may also be hereditary.

Assessment and common findings • Confusion • Seizures and loss of consciousness with weight gain and oedema • Hyponatraemia from fluid excess.

Management

• Lack of ADH or an inactive kidney response to ADH results in insufficient water reabsorption by the kidney. • The kidney excretes excessive amounts of dilute urine (polyuria) which then stimulates the perception of thirst (polydipsia).

Treatment is aimed at correcting the underlying cause: • Restrict fluid intake and keep a record of the intake and output. • Maintain sodium chloride infusion as prescribed to replace serum sodium. • Administer diuretics to increase free water clearance. • Administer an enema to draw out excess water. • Monitor neurological status and electrolyte balances.

Assessment and common findings

Disorders of the parathyroid gland

• Polyuria of 2 ℓ or more of urine per day • Very dilute urine with specific gravity of 1.005 or less and osmolality of 200 mmol/ℓ or less • Polydipsia where the patient will drink 2 ℓ or more per day • Sleep pattern disturbance related to polyuria and polydipsia • Hypovolaemia • Hypotension and tachycardia • Poor skin turgor, with dry mucous membranes • Irritability and mental instability.

There are four parathyroid glands, which are situated on the anterior lobes of the thyroid gland. These glands secrete parathormone (PTH), which plays an important role in calcium metabolism and resultant metabolic bone development. The PTH helps maintain the homeostasis of serum calcium concentration. This process is regulated by a feedback mechanism that either stimulates or inhibits the release of parathormone: a low concentration of calcium will stimulate its release, a high concentration of the same will have an opposite effect.

Pathophysiology

This condition occurs when there is excessive secretion of anti-diuretic hormone by the pituitary gland. In this condition patients do not pass dilute urine; they tend to retain fluids.

Maintenance of this homeostasis is achieved by the following actions: • PTH stimulates restoration of bone, thereby releasing calcium and phosphate from the bones into the bloodstream. • PTH acts on the intestines to accelerate the absorption of calcium. • Parathormone also acts on the kidney tubules to increase their excretion of phosphorus and reabsorption of calcium. • Vitamin D, and calcitonin secreted by the thyroid gland, are also involved in calcium metabolism. • The normal calcium levels of 9–10 mg/dl are maintained by the above-mentioned mechanism. • Failure to maintain this balance results in hyperparathyroidism or hypoparathyroidism.

Causes

Hyperparathyroidism

This is usually caused by a malignancy or tumour pressing on the pituitary gland. It may also be caused where malignant cells from the lungs synthesise and release ADH. In some instances, this is related to medication such as thiazide diuretics, vincristine, and antidepressants.

This condition occurs when there is an increased secretion of PTH. It may be primary or secondary. The increased PTH in return causes rapid absorption of calcium from the bones, producing abnormally high levels of calcium in the blood, referred to as hypercalcaemia. The clinical manifestations of primary and secondary

Management of diabetes insipidus • Vasopressin replacement, for instance, desmopressin (DDAVP®) • A low-sodium and low-protein diet • Thiazide diuretics are used if diabetes insipidus is nephrogenic • Replacement of fluids over a period of 48 hours to avoid cerebral oedema.

Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

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Chapter 42 – Management of disorders of the endocrine system  833 Table 42.4  Tests for hyper- and hypoparathyroidism

Diagnostic test

Hyperparathyroidism

Hypoparathyroidism

Calcium

Increased more than 10 mg/dl

Decreased less than 6–12 mg/dl

Phosphate

Decrease falls below 1.8 mg/dl

Increased more than 5.4 mg/100 ml

Magnesium

Decreased

Increased

Chloride

Increased

Decreased

Uric acid

Decreased

Increased

PTH radioimmunoassay

Increased in most parts

Decreased

Creatinine

Decreased

Increased

Calcium

Increased

Decreased

PH

Alkalosis

Serum

24-hour urine specimen

Radiology X-ray

Demineralisation and decreased bone density

Increased bone density

Renal radiological studies Excretory urogram

Presence of renal calculi

Parathyroid ultrasound

Enlargement of one or more parathyroid glands

hyperparathyroidism are the same, namely those of hypercalcaemia. • Dehydration • Drowsiness, coma • Confusion • Muscle weakness and fatigue • Abdominal pains • Nausea and vomiting • Thirst, lethargy and slow thought processes.

Primary hyperparathyroidism Primary hyperthyroidism occurs spontaneously and is unrelated to any other condition. The most common cause of primary hyperparathyroidism is adenoma of one of the parathyroid glands. Genetic predisposition has also been recorded as being a possible cause. The condition is more common in women than in men, and the incidence increases with age.

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Secondary hyperparathyroidism This condition occurs in situations where there is resistance to the metabolic action of PTH as in disorders such as chronic renal failure, malnutrition presenting with vitamin D deficiency and rickets, osteomalacia and intestinal malabsorption syndrome.

Nursing assessment and common findings The most common physical findings are related to the musculoskeletal system: these are bone and joint pains including pseudo gout, chronic lumbar pain, muscular atrophy and weakness. Pathological fractures of ribs, vertebrae and long bones may also occur. Other signs and symptoms are as follows: Gastrointestinal system • Anorexia • Constipation leading to faecal impaction • Epigastric pain • Peptic ulcers.

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Renal system • Nephrolithiasis (kidney stones) • Urinary output changes including polyuria and calcium deposits. Nervous system • Depression or psychosis • Psychomotor disturbances • Personality disturbances • Increased drowsiness, stupor and coma.

should also enquire about alcohol consumption, recent neck surgery, or irradiation. Common findings include the decreased levels of the parathyroid hormone that account for a variety of physical symptoms in this condition. Please note that tetany is the chief symptom of a lowered serum calcium level (see Figure 42.3).

Other symptoms include cataracts and integumentary changes such as osteoporosis.

Nursing management Pharmacological and patient education interventions play a significant role in the treatment of this condition. • Monitor intake and output as the patient may be on an intravenous infusion of isotonic sodium chloride and diuretic agents to promote excretion of excessive calcium. • Provide analgesics as prescribed to relieve pain thus making mobility easier. • Administer the following medication as prescribed: – Aluminium hydroxide gel to bind phosphate and increase the reabsorption of calcium – Calcitonin to decrease the rate of bone resorption. • Educate patient regarding limiting (avoiding) foods that contain calcium, and the importance of regular follow up to monitor bone density. Surgeons may proceed with surgical removal of the tumour causing hyperparathyroidism.

Hypoparathyroidism This condition occurs when there is a decreased secretion of parathormone.

Causes • The onset may be slow or sudden. It may occur suddenly when there has been accidental removal of the parathyroid glands, or as a result of irradiation of the thyroid. • It may develop slowly in idiopathic atrophy of the parathyroid glands. • It may also occur in any condition that causes hypomagnesaemia as in alcoholism or malabsorption syndrome.

Assessment and common findings Nursing history will focus on identifying the underlying causes as well as the presenting symptoms. The nurse

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Figure 42.3  Tetany/Carpo-pedal spasm

Common signs and symptoms of hypocalcaemia • • • • • • • • •

Tachycardia Low blood pressure Cardiac dysrhythmias Tingling and numbness sensations Twitching and seizures Cramps Tetany Positive Trousseau’s sign Positive Chvostek’s sign.

Management Management options in hypocalcaemia related to hypoparathyroidism include the following measures to increase blood calcium levels: • Administer parathormone replacement and vitamin D to improve the reabsorption of calcium. • Administer aluminium hydroxide gel as prescribed to bind the phosphate in the gastrointestinal tract and to enhance the excretion of excess phosphate. • Administer calcium salts orally or parenterally. Calcium salts must be infused slowly. Rapid infusion may cause hypotension, bradycardia and cardiac arrest. Tissue necrosis occurs if a calcium infusion extravasates into the surrounding tissues. • Educate the patient regarding correct nutrition. Include advice on a diet high in calcium, such as milk products, and foods low in phosphates, such

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Chapter 42 – Management of disorders of the endocrine system  835

as spinach. Red meat should also be restricted in the acute phase as it contains a lot of phosphate, which will hamper the absorption of calcium.

Disorders of the thyroid gland The thyroid gland secretes the hormones that control the metabolism in the body. These are triiodothyronine (T3) and thyroxine (T4). Thyroid disorders can therefore result in the disruption of normal bodily functions. The main abnormalities of the thyroid gland are hyperthyroidism, hypothyroidism, and goitre.

Hyperthyroidism Hypersecretion of the thyroid hormone causes hyperthyroidism (or thyrotoxicosis). The most common form of hyperthyroidism is Grave’s disease. Another cause is toxic nodules on the thyroid gland.

Grave’s disease Grave’s disease is an autoimmune condition where the T3 and T4 are elevated because of abnormal stimulation of the thyroid gland by circulating immunoglobulins. The condition is also characterised by a diffuse enlargement of the thyroid gland (goitre) and the patient presents with a variety of signs and symptoms affecting all body systems: • Nervousness • Emotionally hyper-excitable, irritable, apprehensive • Restless (inability to sit still) • Often suffering from palpitations, atrial fibrillation as well as tachycardia at rest and on exertion • The high levels of thyroid hormone in the circulation stimulate cell metabolism, resulting in a high metabolic rate – an increased appetite accompanied by progressive weight loss • The patient is flushed and warm, with moist skin • Abnormal muscle weakness and amenorrhoea are present. Other signs denoting cardiovascular system involvement include myocardial hypertrophy and heart failure. This condition is more common in females than in men and it is believed to be familial.

Toxic multinodular goitre This condition usually occurs after a long history of goitre. Small, discrete, independent nodules develop, which secrete thyroid hormone. When hyperthyroidism occurs, the condition is described as a toxic adenoma.

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Thyroid crisis/storm This is a rare complication of hyperthyroidism and may occur before surgery or early during the postoperative period. The causes are: • An increase in the circulating amount of thyroxin in the bloodstream, resulting in increased metabolism • An incomplete removal of the thyroid gland or as a complication of surgery where the thyroid gland releases thyroxin into the bloodstream as the gland is being removed. Thyroid crisis/storm is a medical emergency. Symptoms include: • Hyperpyrexia of 41 °C and an increased heartbeat of up to 200 beats per minute • The heart system rapidly becomes overworked and the patient presents with acute left ventricular failure • Apprehension and restlessness. Treatment must commence promptly once the condition is diagnosed. The nurse must utilise measures to reduce temperature immediately, including the use of a hypothermic blanket. • Appropriate drugs are given to reduce the heartbeat. Provided the patient is not presenting with cardiac failure, propanalol is the drug of choice. If left ventricular failure is present, antithyroid drugs such as Lugol’s Iodine are used, as propanalol is unsuitable for a patient in cardiac failure. • Hydration is maintained by means of an intravenous infusion utilising appropriate fluids, eg 5% dextrose saline solution. • Sedatives eg benzodiazepines such as diazepam are given to reduce restlessness.

Assessment and common findings Subjective data The nursing history should focus on collecting data about alarming changes in any of the systems, as the thyroid hormone plays a role in regulating metabolism and organ function throughout the body. Relevant questions include the following: • History of thyroid disorders in the family including pre-existing goitre • Exposure to head and neck radiation or recent surgery • Use of any medication that could contain derivatives of the thyroid hormone • Weight loss despite a good appetite • Any nervousness, irritability, emotional instability, fatigue, insomnia or heat intolerance, excessive sweating and itchiness

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• • • • •

Any breathlessness or dyspnoea on exertion Any palpitations Any diarrhoea, nausea and polyuria Any decreased libido, impotence and amenorrhoea Any muscle weakness.

Objective data • Exophthalmos and infrequent blinking or an inability to close the eyes • Hyperactivity and restlessness • Rapid speech and body movements • Pyrexia: the skin may be hot and moist, and there may be a fine tremor of the outstretched hands • Tachycardia • The skin is thin and hair is sparse and dull, and the nails are brittle • Elevated blood serum T3 and T4 • Sleeping pulse of above 80 beats per minute indicates thyrotoxicosis.

Management Treatment modalities in hyperthyroidism are threefold, namely: 1. Anti-thyroid drug therapy 2. Surgery 3. Radioactive iodine therapy.

Other nursing considerations • Nurse the patient in a quiet and well-ventilated room. • Ensure that the patient gets enough rest, and restrict the number of visitors the patient receives. • For those with exophthalmos, protect the eyes from trauma by providing dark glasses. • Give iodine solutions as prescribed with fruit juice or milk and administer with a straw to avoid staining the teeth. • Provide a diet high in proteins, calories and vitamins. • Discourage foods rich in caffeine. • Provide emotional support to the patient and family. • Observe for signs of complications of hyperthyroidism.

Surgical intervention Where drug therapy has failed, surgery is indicated. Drug therapy is sometimes given initially to reduce the size of a goitre and prevent it from pressing on the structures of the neck, followed by surgery. • A subtotal thyroidectomy may be done for most patients in this category, including patients with a large and unsightly goitre that is causing pressure symptoms. • When malignancy exists, then a total thyroidectomy will be done. • Postoperative care aims at early identification and prevention of complications, namely, haemorrhage, hypocalcaemia, hypothyroidism, and recurrent

Table 42.5  Antithyroid drugs and the nurse’s role

Drug

Action

Nurse’s role

Propylthiouracil 300–600 mg daily or carbimazole 30–40 mg daily

Inhibits the synthesis of thyroid hormone

Educate the patient about the side effects, including agranulocytosis, and to report any fever or sore throat

Other iodides such as Lugol’s Iodine

Blocks the release of T3 and T4

Educate the patient on the side effects, including conjunctivitis, rhinitis, skin rash, bronchitis, as well as laryngeal oedema and drooling

Beta-adrenergic blockers, eg propanolol

Relieves symptoms of hyperthyroidism such as tachycardia

The drug should be given as prescribed until the thyroid hormone levels are normal

Radioactive iodine (RAI)

Destroys thyroid tissue

Educate the patient regarding: • Not eating for 3–4 hours after administration to allow optimum absorption of the iodine • Drinking at least 2 ℓ of fluid over 24 hours after administration of iodine to flush out the freecirculating medication Inform the patient of the possibility of delayed radioactive elimination from the body, which could be up to 1 week following therapy

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laryngeal nerve palsy. In the initial postoperative phase bleeding leading to airway obstruction is the most significant complication and the emergency trolley must be kept in readiness by the bedside. • Acute hypocalcaemia indicated by laryngospasm and carpo-pedal spasm is another very significant complication. A syringe of calcium chloride or calcium gluconate solution must be kept at the bedside to be given in this instance. • In the case of accidental severing of the recurrent laryngeal nerve the patient presents with upper airway

obstruction, particularly if the problem is bilateral. This is an emergency necessitating the insertion of a tracheotomy to maintain the airway. Such a tracheotomy is usually temporary, but if both nerves have been severed, may have to be permanent. • The first 24 hours are the most significant in terms of acute complication. Early ambulation and a return to normal activities can be encouraged from the second day onward.

Table 42.6  General nursing care plan for a patient post sub-total thyroidectomy/total thyroidectomy

Potential for airway obstruction Nursing diagnosis

• Risk of altered air entry related to neck oedema secondary to surgery

Expected outcome

• Airway remains clear with no strain on the suture line

Nursing interventions and rationale

• Nurse patient in Fowler’s position to facilitate breathing and reduce neck swelling • Support head between two sandbags to reduce strain or tension on the sutures • Keep clip removal/suture removal set at bedside in case of an emergency to remove suture or clips

Evaluation

• No signs of any airway obstruction on return from theatre

Bleeding Nursing diagnosis

• Risk for bleeding and haematoma in neck following surgery

Expected outcome

• Early detection and management of bleeding

Nursing interventions and rationale

• Monitor vital signs frequently – a low blood pressure and restlessness may indicate bleeding; however, the nurse should note that it is the position of the bleeding that is significant – a small blood clot will not lower blood pressure but may obstruct the airway • Observe for obvious bleeding from the wound • Be alert for signs of laboured breathing and/or stridor, both of which may indicate airway obstruction • Keep clip removal/suture removal set at bedside in case it is necessary to remove suture or clips; if the patient’s breathing becomes laboured the clips or sutures should be removed to allow any blood or blood clot to escape and thereby releasing pressure on the trachea. The open wound should be covered with sterile gauze that has been soaked in sterile saline and the patient should be returned to theatre

Evaluation

• No evidence of bleeding after 4–6 hours

Tetany Nursing diagnosis

• Risk of tetany related to possible accidental removal of one or more parathyroid glands

Expected outcome

• Calcium concentration in the bloodstream normal

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Nursing interventions and rationale

• Observe the patient closely for signs of tetany as a sudden drop in blood calcium levels may result in laryngospasm and airway obstruction • An ampoule of calcium chloride or calcium gluconate, together with a syringe and needle can be kept at the bedside; should the patient develop tetany, the nurse should administer the prescribed calcium slowly and observe the response; the patient is then referred for immediate medical attention and possible transfer to the intensive care unit

Evaluation

• No evidence of hypocalcaemia/tetany after 6–8 hours

Restlessness, hyperpyrexia, elevated blood pressure Nursing diagnosis

• Risk of thyroid crisis related to handling of the thyroid gland and release of hormone into the blood

Expected outcome

• No thyroid crisis

Nursing interventions and rationale

• Monitor vital signs regularly; half-hourly intervals are recommended until the risk of thyroid crisis has passed (24–48 hours)

Evaluation

• No evidence of thyroid crisis after 6–8 hours

Loss/hoarseness of voice Nursing diagnosis

• Risk of damage to the recurrent laryngeal nerve

Expected outcome

• No laryngeal nerve damage

Nursing interventions and rationale

• Observe the patient for any difficulty in breathing, dysphagia or hoarseness • A tracheostomy set should be kept at the bedside in case it becomes necessary to carry out an emergency tracheostomy – eg when airway obstruction is due to oedema or to laryngospasm following severing of one or both recurrent laryngeal nerves during surgery

Evaluation

• No hoarseness or loss of voice after 6–8 hours

• Once drains and clips have been removed wound healing occurs rapidly and the incision scar eventually disappears into the folds of the neck.

Hypothyroidism Hypothyroidism is caused by a deficiency of thyroid hormone, and is characterised by a slow metabolic rate.

Causes Hypothyroidism may be primary, resulting from a variety of thyroid disorders; or secondary, as a result of either pituitary or hypothalamic dysfunction. • Underactivity of the thyroid can also be due to inflammation of the gland – thyroiditis – or destruction of a large number of cells that produce thyroxine • Underactivity may also be due to autoimmune factors such as in Hashimoto’s disease • Genetic defects also account for congenital hypothyroidism, which results in cretinism: this condition

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is caused by a lack of the thyroid hormone in utero and during early infancy • Cretinism is mainly characterised by failure to grow, as well as mental defects.

Congenital hypothyroidism: Cretinism Pathophysiology

This condition develops during intrauterine life or the neonatal stage due to: • Maternal deprivation of iodine • Genetic enzyme defects • Congenital absence of the thyroid gland.

Assessment and common findings • The child may become sluggish a few weeks after birth and may suck poorly when feeding. • There will be failure to thrive due to poor feeding. • Later on, retarded physical and mental growth becomes apparent.

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Adult hypothyroidism: Myxoedema In this condition all body processes become slow. Levels of T3 and T4 are low. The level of TSH may be high indicating that the defect is in the thyroid. A low TSH level indicates that the problem could be with the pituitary gland or the hypothalamus.

Assessment and common findings • Insidious and slow onset • Decrease in appetite with an increase in weight due to the low metabolic rate • Sluggishness in both physical and mental activities • There may be cold intolerance, fatigue, impaired memory and sleeping for longer periods • Constipation, flatulence and abdominal distension may be noted • A husky voice, depression, coarse skin and brittle hair and nails may also be found • A swollen face and eyelids may be present, or there may be bagginess under the eyes • The thyroid gland may be enlarged. If untreated, myxoedema may result in psychosis or even unconsciousness. The diagnosis is confirmed by the clinical picture, and low plasma levels of the thyroid hormone, accompanied by high TSH levels.

Treatment and nursing management • Hypothyroidism is treated by hormone replacement therapy using thyroxine – treatment is life-long. • The dosage of thyroxine is gradually increased and a balance maintained to prevent either hypothyroidism or hyperthyroidism. • It is important to educate the patient and family regarding compliance with the daily medication, particularly if the patient is elderly. • The nurse should give advice regarding skin care, for instance, suggest applying skin lotions or creams to prevent cracking and peeling. • The nurse should also advise the patient to make follow-up appointments to ensure that a euthyroid state is achieved and maintained.

Carcinoma of the thyroid gland Carcinoma of the thyroid gland is very rare and accounts for about 1% of all cancers. It is more common in females than in males, and more common in the younger age group of between 20–40 years. There are five common types of thyroid carcinomas: 1. Papillary adenocarcinoma. This presents with a palpable lump that causes hoarseness and difficulty

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2.

3. 4.

5.

in swallowing. It often spreads to the lymph nodes and may be fatal due to the lymphatic spread to the trachea. Follicular adenocarcinoma. This is a rapidly growing lump that causes pressure symptoms on the trachea or oesophagus. Anaplastic carcinoma. This is the most vicious form of thyroid cancer. Lymphomatous carcinoma. This arises from lymphatic cells in the thyroid and may be related to systemic lymphatic malignancy. Medullary carcinoma. Lymphomatous and medullary carcinoma often spread to the lymph nodes and infiltrate the trachea and larynx, and may also cause stricture of the oesophagus.

Treatment and nursing management The treatment of choice is surgery, and a total thyroi­ dectomy may be performed. Surgery is often sufficient to halt the disease; however, in the case of aggressive tumours or tumours that metastasise, radiation therapy is used. Radioactive iodine may also be used.

Disorders of the adrenal gland The adrenal glands are situated above the kidneys. Each gland has a cortex and a medulla. The adrenal cortex produces hormones called adrenocorticoids/corticosteroids, which include the following steroids: mineralocorticoids (aldosterone), glucocorticoids (cortisol/hydrocortisone), and the sex hormones (androgens, progesterone and oestrogen). The adrenal medulla has special nerve cells which secrete two hormones: adrenaline and noradrenaline. The disorders of the adrenal glands are divided into the clinical features produced by hypofunction or hyperfunction of the gland.

Adrenal hypofunction Addison’s disease This condition is also known as primary adrenocortical insufficiency, and it is an insidious and progressive disease resulting from adrenocortical hypofunction. It is a rare disorder and its causes are unknown. The disease is related to atrophy of the adrenal cortex, destruction of the gland by diseases such as tuberculosis, neoplasms, or inflammatory necrosis. Addison’s disease is characterised by reduced levels of all three classes of steroids, ie glucocorticoids, mineralocorticoids and androgens. Other possible causes include fungal infections, cancer, sepsis, anticoagulation therapy, and surgical removal of both adrenal glands.

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Pathophysiology

Medical management

• An alteration in electrolyte balance characterised by increased urinary sodium excretion and potassium retention • Increased sodium secretion in saliva, sweat and the gastrointestinal tract also occurs • This causes low blood concentrations of sodium and chloride with high serum potassium • This leads to severe dehydration, increased plasma potassium levels, decreased circulatory volume, hypotension, and circulatory collapse.

Initial management consists of steroid replacement combined with management of dehydration and shock. This includes: • Hydrocortisone 100 mg over 30 seconds • Infusion of 1 ℓ made up of dextrose 5%, sodium chloride 0.9% with hydrocortisone added over 24 hours • Continuous infusion of normal saline 0.9% until dehydration and hyponatraemia are corrected • Restoration of blood pressure and management of shock with vasopressors, fluids and plasma infusion • Oxygen therapy • Anti-infective therapy with appropriate prescribed broad-spectrum antibiotics, eg amoxicillin.

Assessment and common findings • Shock and cortisol insufficiency related to malfunctioning of the adrenal cortex accompanied by stress evidenced by hypotension, dizziness and fainting as well as circulatory collapse • Hyperglycaemia resulting from insufficient carbohydrate metabolism caused by the absence of cortisol • Weakness due to neuromuscular dysfunction • Lowered resistance to infection caused by the decreased adrenal output of cortisol • Low cardiac output and circulatory failure due to dehydration • Hyperpigmentation due to excessive stimulation of melanocytes by corticotrophin and melanocyte stimulating hormone as well as increased pituitary Adreno-CorticoTrophic Hormone (ACTH) production related to decreased cortisol levels • Gastrointestinal disturbance evidenced by weight loss, anorexia, vomiting, nausea and diarrhoea • Decreased cold tolerance • Dizziness and syncope attacks.

Diagnostic tests These include blood for haematology and chemistry, 24-hour urine specimen, adrenal insufficiency test, ACTH response test, and radiological studies. Diagnostic findings include the following: • Blood chemistry. Low serum sodium ( 5 mmol/ℓ), elevated BUN (blood urea/nitrogen) (>  6.7  mmol/ℓ), low blood glucose and low plasma bicarbonate ( 90/60 mmHg • Pulse 60–100 beats per minute • Urine output 1 ml/kg/hr • Normal skin turgor • Skin firm and pink with moist mucous membranes

Nursing interventions and rationale

• Monitor serum osmolality as per laboratory results to guide fluid replacement • Maintain intravenous line to replace fluid as prescribed to ensure normal hydration • Monitor intake and output accurately • Monitor vital signs and report abnormalities • Monitor electrolytes to identify imbalances and replace according to results

Evaluation

• Normal hydration and circulation 12 hours

Ineffective breathing pattern Nursing diagnosis

• Poor ventilation as evidenced by respiratory acidosis • Electrolyte imbalance related to dehydration as evidence by metabolic acidosis, hyper/ hyponatraemia and hyper/hypokalaemia

Expected outcome

• Optimal ventilation and oxygenation maintained • Normal acid–base balance restored

Nursing interventions and rationale

• Maintain a patent airway; monitor respiration hourly for rate, depth, odour and breath sounds • Administer oxygen as required to promote oxygen uptake and delivery to the tissues • Monitor arterial blood gas levels to ensure the type and degree of acid–base imbalances • Monitor electrolytes and replace according to the results obtained

Evaluation

• Acid–base balance is normal • Serum electrolytes within normal limits within 4–6 hours

Confusion and impaired mental status Nursing diagnosis

• Altered mental state as a result of high or low blood glucose level evidenced by drowsiness and restlessness

Expected outcome

• Blood glucose level within normal range

Nursing interventions and rationale

• Administer injectable insulin or oral hypoglycaemic agents as prescribed • Encourage and supervise prescribed diet and exercise • Administer glucose replacement as prescribed for hypoglycaemia • Assess neurological status and nurse in cot bed if appropriate • Avoid stressful situations at all times, especially when confused

Evaluation

• Blood glucose levels remain within normal limits within 12–24 hours

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Increased food intake, weight loss, nausea and vomiting Nursing diagnosis

• Altered nutritional status related to disease process as evidenced by weight gain or weight loss, nausea and vomiting

Expected outcome

• Maintenance of normal body weight • Adequate food and fluid intake

Nursing interventions and rationale

• Weigh the patient daily • Provide a well-balanced, nutritious diet • Provide snacks in between meals • Serve food attractively • Administer mouth care frequently • Eliminate nauseating odours from the environment • Serve small amounts of food frequently • Encourage eating with others

Evaluation

• Normal body weight maintained • Intake of food and fluid is adequate by discharge

Increased body temperature Nursing diagnosis

• Risk of infection related to inadequate secondary defences as evidenced by skin infections and poor healing of wounds

Expected outcome

• The patient is free from infection, vital signs are normal, white cell count is normal and blood culture results for infection are negative

Nursing interventions and rationale

• Assess the patient for infection • Ensure that good hand washing technique is used when caring for the patient • Limit the use of invasive treatments/procedures or discontinue immediately when no longer needed • Adhere to aseptic technique when inserting IV lines or catheters and provide good skin care • Use a pressure relief mattress to help prevent skin breakdown for those who are on prolonged bed rest

Evaluation

• No evidence of infection within 24–48 hours

Risk of injury Nursing diagnosis

• Altered peripheral nerve function related to disease condition

Expected outcome

• Sensation is normal in extremities

Nursing interventions and rationale

• Massage extremities to improve circulation • Give advice regarding foot hygiene and the wearing of soft, well-fitting shoes

Evaluation

• No evidence of peripheral neuropathy

Knowledge deficit Nursing diagnosis

• Ineffective individual coping related to the new diagnosis and lack of knowledge and understanding of the condition evidenced by denial and lack of appropriate self-care as well as non-compliance with treatment regime

Expected outcome

• Patient is able to manage own condition independently Compliance with treatment

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Chapter 43 – The management of diabetes mellitus  851

Knowledge deficit Nursing interventions and rationale

• Compile a teaching plan for the patient dealing with the disease process, the need for selfcare and follow-up • Provide treatment instructions in simple terms • Refer newly diagnosed patients to diabetes educators • Inform the patient about hospital and community resources such as the dietician and diabetic clinic; support groups can also be identified

Evaluation

• Patient verbalises understanding of the disease process and the importance of self-care

Exercise Exercise is as important as diet in managing DM because it lowers blood glucose levels, helps to maintain normal cholesterol level and increases circulation. Exercise results in reduced weight, which improves blood glucose control by improving the body’s insulin sensitivity. In addition, the risk of developing heart and blood vessel disease is greatly reduced. It is advisable to develop individualised exercise programmes that should be followed consistently. The programme should consider the age and condition of the patient, their ability to carry out the exercises regularly, and also how well the blood glucose is controlled. The risks and benefits of such a programme should be explored and discussed with the patient. Exercise is contraindicated when the patient is hyperglycaemic and has ketosis, because these will exert a physiological stress on the body, resulting in progressive hyperglycaemia. The exercise programme should begin with mild exercises that gradually increase until the required level is reached. Exercise should be done at the same time every day and at a time when blood glucose is at its highest, which is after a meal. It is therefore necessary that blood glucose be checked before exercises. Recommended exercises include walking up the stairs instead of using a lift, brisk walks, cycling or swimming. A MedicAlert® bracelet should be worn, and every diabetic who is engaged in exercising should always have emergency supplies for managing hypoglycaemia, such as glucose sweets. Intake of carbohydrates should be increased by up to 15 g during moderate exercise, and for vigorous exercise (jogging, playing tennis) complex carbohydrate intake should be increased by 40 g about 30 minutes before the exercise.

Insulin therapy As indicated earlier, insulin lowers the blood glucose after meals by facilitating the uptake of glucose by cells.

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Between meals or during fasting periods, insulin inhibits the breakdown of stored glucose, protein, and fats. In type I DM, the pancreas produces little or no insulin, making replacement with exogenous insulin necessary. In type II DM, insulin is administered on a long-term basis to control blood glucose if diet and oral medication have not succeeded. Blood glucose level determines individual insulin doses. Self-monitoring of blood glucose level is therefore mandatory during insulin therapy. Insulin preparations differ according to source, concentration and time course of action. Human insulin is the insulin of choice because of its reduced antigenicity. Human insulin is produced by recombinant DNA technology. Animal sources include pork insulin as this closely resembles human insulin. Insulin differs in onset (speed of effect), peak (time of greatest action), and duration (how long it acts). Insulin derivatives are therefore classified into short-acting, intermediate acting and long-acting insulin.

Specific clinical problems related to diabetes mellitus Hypoglycaemia Hypoglycaemia is a state of low blood glucose that occurs when the blood glucose level falls below 3.3 mmol/ℓ. It is caused by administration of excessive insulin or oral hypoglycaemic agents, too little food intake while on insulin therapy, skipping a meal after administering insulin, or excessive exercises taken by a diabetic person without a concomitant increase in the intake of food. Other causes of hypoglycaemia include: • Abdominal surgery, which allows more rapid loss of glucose via exposed surfaces in the stomach and small intestines • Tumours of the pancreas • Liver disease • Disorders of the pituitary gland and adrenal cortex

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852  Juta’s Complete Textbook of Medical Surgical Nursing Table 43.3  Classification of insulin according to time of action and duration of action

Insulin type

Onset

Peak

Duration

Rapid acting: eg Humalog (insulin lispro injection) Regular

Immediate 15 minutes–1 hour

1 hour 2–3 hours

2–4 hours 3–6 hours

2–4 hours 3–4 hours 15 minutes–1 hour

4–10 hours 4–12hours 2 peaks 3–4 hours 8–12 hours

3–6 hours 10–16 hours 2 peaks 12–18 hours 16–24 hours

6–10 hours

None

18–20 hours

Intermediate acting: eg NPH Lente Premixed, ie a combination of short and intermediate acting insulins Long acting: eg Ultralente

• Drug addiction and alcoholism, which cause hypoglycaemia because glycogen stores become depleted, resulting in increased levels of insulin.

Pathophysiology Hypoglycaemia is classified as fasting hypoglycaemia or reactive hypoglycaemia. • Fasting hypoglycaemia occurs as a result of excessive insulin production, decreased glucose production by the liver, hormone deficiencies, tumours of the non-islet cells of the pancreas, and autoimmune diseases. It is associated with central nervous system (neuroglycopaenic) symptoms, which are mental confusion, seizures, and coma. • Reactive hypoglycaemia occurs 3–5 hours after meals. It is caused by an idiopathic delay in insulin secretion or a rising post-prandial glucose level, due to rapid gastric emptying. In type II diabetes, the pancreas is unable to keep up with rising levels of postprandial glucose. The result is delayed insulin hyper-secretion resulting in hypoglycaemia. It is associated more with adrenergic symptoms of hypoglycaemia.

Clinical manifestations The clinical manifestations of hypoglycaemia are described according to sympathetic and central nervous system manifestations, and they are described according to the severity of hypoglycaemia as follows: • Mild hypoglycaemia. The drop in blood glucose stimulates the sympathetic nervous system, resulting in a surge of adrenaline. The symptoms are anxiety, irritability, palpitations, diaphoresis, tremors and hunger. • Moderate hypoglycaemia. This results in impaired function of the central nervous system causing poor

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concentration, headache, confusion, numbness of the lips, slurred speech, double vision and drowsiness. • Severe hypoglycaemia. This impairs the central nervous system to the extent that the patient needs assistance. The manifestations are disorientation, decreased level of consciousness and difficulty arousing from sleep, progressing to complete loss of consciousness and seizures. Symptoms of hypoglycaemia may occur suddenly, and its course can be dangerous if it is not treated. The symptoms vary from person to person according to the level to which the blood glucose falls and the rate at which it falls. The diagnosis of hypoglycaemia is made on the accurately documented Whipple’s triad, which consists of appropriate signs and symptoms, documented subnormal blood glucose, and the return to normal blood glucose with ingestion of carbohydrates/glucose.

Management • Immediate oral administration of approximately 15 g of a fast-acting sugar, such as: – Commercially prepared glucose tablets (Glucagon tablets) (3–4 tablets) – Fruit juice or regular non-diet soda (125 ml). Do not add sugar to fruit juice, even if it is unsweetened, because it will increase the blood glucose sharply, resulting in hyperglycaemia later – Hard sweets, for example Life Savers® (6–10) – 2–3 teaspoons of sugar or honey. • Monitor the symptoms as well as blood glucose levels and repeat the treatment if symptoms persist for more then 10–15 minutes after the treatment, and the blood glucose level remains in the range of 3.9–4.1 mmol/ℓ.

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Chapter 43 – The management of diabetes mellitus  853 Table 43.4  Oral hypoglycaemic medication for type II diabetes

Class and specific agent

Actions

Adverse effects

First-generation sulphonylureas Chlorpropamide

• Stimulates the beta cells of the pancreas to secrete insulin • Mild diuretic

• Hypoglycaemia • Hyponatraemia in the elderly • Photosensitivity • Weight gain, gastrointestinal and haematological defects • Increased risk of hyperglycaemia with infection, fever, surgery, trauma, injury

Second-generation sulphonylureas Glipizide

• Increased tissue response to insulin • Decreased glucose production by the liver stimulates beta cells to secrete insulin • Mild diuretic

• Same as for first generation • sulphonylureas

Biguanides (Metformin®)

• Increased tissue response to insulin • Decreased hepatic production of glucose • Decreased absorption of glucose from small intestines • Decreased triglyceride and low-density lipoprotein levels

• Gastrointestinal symptoms include nausea, vomiting, diarrhoea • Lactic acidosis (rarely)

Alpha-glucosidase inhibitor Arcarbose Meglitinides Repaglinide

• Delays digestion of complex • carbohydrates and certain sugars thereby decreasing the postprandial rise in blood glucose • Stimulates insulin secretion via closing or inhibition of ATP sensitive potassium channels in beta cells

• Gastrointestinal symptoms like flatulence, cramps, abdominal distention • Hypoglycaemia • Weight gain

Thiazolidinediones Rosiglitazone

• Increased insulin action at the receptors and post receptor level in hepatic and peripheral tissue • Decreased insulin resistance • Decreased triglyceride levels

• Hypoglycaemia only in the presence of insulin or sulphonylureas • Weight gain, oedema, transient anaemia

• Give the patient a snack containing protein and carbohydrate, for instance cheese or peanut butter on whole-wheat bread, cream crackers or milk with crackers/bread, after the resolution of the hypoglycaemic event. • If the patient is unconscious, glucagon 1 mg may be administered subcutaneously or intramuscularly as prescribed. Glucagon promotes the breakdown of stored glycogen in the liver into glucose. It may take up to 20 minutes for the patient to regain consciousness following the administration of glucagon. • 10% dextrose (100–150 ml) bolus dose may be administered intravenously in hospital or in a casualty department to patients who are unable to swallow or who are unconscious while monitoring the blood glucose level until it is at least 4 mmol/ℓ.

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Nursing diagnoses • Risk of injuries related to seizure secondary to hypoglycaemia • Risk of injury related to decreased level of consciousness (LOC) secondary to hypoglycaemia • Knowledge deficit related to the disease process, diagnostic testing, indicators of hypoglycaemia and therapeutic regimen.

Nursing goals • Within 20–30 minutes of administering therapy the patient should: –– Be alert, verbalising orientation to time, place and person –– Be free of seizures –– Demonstrate normal blood glucose levels.

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• A patient that is knowledgeable about hypoglycaemia, the indicators, diagnostic testing and therapy before discharge.

Family members should be included when teaching is done, for they may have to assist the patient if they become unconscious.

Nursing interventions

Hyperglycaemia

• Administer fast-acting carbohydrates/glucose orally. • If incoherent, unconscious, and unable to take carbohydrates orally, administer prescribed subcutaneous and/or intramuscular glucagon or 10% dextrose bolus doses intravenously. • Monitor and document blood glucose levels every 30–60 minutes to detect response to interventions. • When the patient is awake, obtain history regarding recent food intake or lack of food intake, exercise, and medication. • Refer for review of anti-hyperglycaemic medication if food intake has been found to be adequate. • Monitor symptoms at frequent intervals, for example level of consciousness, seizures, airway adequacy and vital signs. • Nurse in a padded cot bed, with the side rails up to prevent injury during seizures. • Notify the doctor when seizures occur, and do not leave the patient unattended during seizures. • Assess the patient’s knowledge regarding the disease process and management thereof. • Evaluate the patient’s current diet and the hypogly­ caemic event to identify causes and knowledge deficit. Give health education according to identified needs.

Hyperglycaemia refers to an elevated blood glucose level. Hyperglycaemia is a potentially life-threatening complication of DM. Hyperglycaemia may or may not be associated with ketosis (ketones present in blood and urine)

Essential health information The patient should be informed about the causes of hypoglycaemia, indicators, diagnostic testing and therapy. All patients with DM should carry a hypo kit consisting of 1 mg glucagon at all times to manage sudden hypoglycaemia. Also make sure that the patient is able to do their own blood glucose testing and administer injectable insulin just prior to a meal if this is prescribed, and recommend that they wear a MedicAlert® bracelet to indicate that they are diabetic and on insulin (if this is the case), with the dosage and frequency. Discourage the patient from using high-calorie and high-fat food to treat hypoglycaemia, because the highfat snacks may slow down the absorption of glucose. However, do emphasise the importance of: • Regular, consistent and healthy eating • Complying with medication requirements • Exercise • Between meal and bedtime snacks.

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Hyperglycaemic hyperosmolar nonketotic syndrome (HHNKS) HHNKS is a life-threatening complication of type II DM characterised by hyperglycaemia and hyperosmolarity, resulting in alterations of the sensorium. HHNKS often occurs in elderly patients who have had no previous history of DM. Patients with undiagnosed or inadequately treated type II DM are also at risk of HHNKS. Stressors such as infection, trauma, or therapeutic procedures such as dialysis increase the demand for insulin and may precipitate the acute onset of HHNKS. The ingestion of medicines such as Metformin® that provoke insulin insufficiency can cause HHNKS. These include thiazide diuretics, beta-blockers, steroids and phenytoin. In HHNKS, glucose accumulates in the bloodstream because the available insulin is not adequate for the facilitation of its transport into the cells. Hyperglycaemia causes serum hyperosmolarity of 343 mOsm/ℓ with resultant osmotic diuresis and simultaneous profound dehydration. Serum glucose level can be more than 13.9 (35) mmol/ℓ, and the patient may lose about 8–9 ℓ of body fluid, resulting in severe intracellular dehydration, and body cell shrinkage. The blood becomes thick (increased viscosity) with a pH reading of 7.3 as the ECF (extracellular fluid) decreases, causing the blood flow to be slow, resulting in increased risk for thrombo-emboli.

Assessment and common findings Some findings are: • A deteriorating mental status from confusion to coma, seizures, hypovolaemic shock and signs of electrolyte imbalances • A history of anything from days to weeks of polyuria and polydipsia • Possible complications of renal failure and myocardial infarction due to decreased renal blood flow and increased cardiac workload respectively

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• Cerebro-vascular accident (CVA) may result from decreased cerebral blood flow or thromboemboli • Dysrhythmias, arterial thrombosis, multiple organ failure may occur.

Diagnosis This can be made as follows: • High blood glucose of > 13.9 (35) mmol/ℓ • Urea and electrolytes which may reveal elevated sodium (Na+) level: 7–10 mEq per kg body weight, decreased levels of potassium (K+), 3–5 mEq per kg body weight, chloride (Cl–), phosphorus (P) and magnesium (Mg) • Serum osmolarity of 343 mOsm/ℓ or higher • Signs of severe dehydration.

Management Management focuses on fluid replacement and correction of glucose level and electrolyte abnormalities. • Normal saline or 5% dextrose in 0.45% saline can be administered rapidly intravenously, at a rate of 200–300 ml/hr until the blood glucose drops to 35 mmHg, 50% glycerol 1 g/kg must be given orally (beware in diabetics). IVI 20% mannitol can be given IVI over 45 minutes if glycerol is not tolerated. An Nd:YAG laser peripheral iridotomy (PI) must be performed as the cornea clears. The laser makes an opening through the iris to relieve the pressure in the posterior chamber. It creates flow of aqueous from the posterior chamber into the anterior chamber of the eye. A prophylactic YAG PI must also be done in the other eye to prevent angle closure.

•

•

In this condition, the IOP is raised due to closure of the angle of filtration. The trabecular meshwork is occluded by the iris, which is pushed towards the cornea, thus obstructing the outflow of aqueous humour.

Acute closed-angle glaucoma This is an ophthalmic emergency. The condition has an acute onset with severe nauseating pain in and around the eye and rapid loss of vision. The pupil may be middilated or oval shaped. If not treated adequately and early the patient will become blind.

Emergency treatment Patient must lie on their back. Give analgesia and antiemetic intravenously if possible, and call the ophthalmologist. Decrease IOP medically with topical IOP-lowering drugs (timolol 0.5%) and dexamethasone qid. Systemic carbonic anhydrase inhibitor (acetazolamide) is given in a tablet (500 mg stat) and IVI (500 mg) form.

Patient teaching in glaucoma • It is important to discuss the medication programme with the patient and family because drug therapy is lifelong. Compliance with treatment and follow-up

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• •

is critical to control progression of the condition and prevent further damage of the optic nerve. Side effects of the medication should be discussed with the patient. If there is poor compliance due to side effects, this should be brought to the doctor’s attention to change to a different class of medication. Once vision is lost, nothing can bring it back, but with medication the vision that is still present can be saved. Patients must not stop the medication if their vision does not improve, because by doing so they might lose more vision. All family members over 40 should also be screened for glaucoma. In patients with poor vision, time must be spent to make sure they are able to instil their drops by themselves, otherwise a caregiver must be taught how to do it.

Specific systemic diseases that affect the eye Systemic viral infections These include measles, mumps, rubella, herpes zoster and herpes simplex Clinical manifestations include conjunctivitis, keratitis, extraocular muscle palsy. The treatment is antivirals. Complications, especially in congenital rubella, are cataract, glaucoma and squint.

Clinical alert! Please note that viral infections such as herpes simplex can get worse if treated with steroids.

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Systemic bacterial infections

Refractive errors

Systemic bacterial infections frequently affect the eye. Tuberculosis causes conjunctival ulceration, phlyctenular conjunctivitis and uveitis. Treatment consists of antitubercular treatment. Syphilis presents with interstitial keratitis, anterior uveitis, secondary glaucoma and optic neuritis or atrophy. Treatment consists of treating the systemic infection.

Refraction is the bending of light rays in the eye in order to focus the image on the retina. Patients complain that they cannot see far objects (nearsightedness/myopia) or near objects (farsightedness/hyperopia). Spectacles can correct these problems, and contact lenses can also be used for cosmetic reasons.

Systemic diseases

Myopia is nearsightedness, where the axial length of the eyeball is longer or even larger than average, which causes the light rays to be focused in front of the retina. The patient will complain of being unable to see distant objects clearly. The onset of myopia may be at birth but it more often manifests during teenage school years. Correction is by prescribing concave (minus) lenses, which move the image back onto the retina. These lenses make the eyes look smaller.

Connective tissue disorders • • • • •

Rheumatoid arthritis Systemic lupus erythematosis (SLE) Juvenile idiopathic arthritis Uveitis Peripheral ulcerative keratitis.

Metabolic diseases • Diabetes mellitus. Fluctuating refractive error, diplopia, rubeosis iridis, snowflake cataract. Treat by lowering the glucose level. • Hyperthyroidism/Graves’ disease. Thyroid eye disease (proptosis, diplopia, lid retraction, exposure keratopathy, optic neuropathy due to severe proptosis). Treat by surgical or chemical removal of the thyroid. The patient should not smoke. In the acute stage, steroid or radiotherapy can be used to reduce inflammation. The reconstructive phase would involve orbital decompression surgery, muscle surgery if diplopia persists, and lid surgery to correct the lid retraction. • Sarcoidosis. Anterior and posterior uveitis, kera­ toconjunctivitis sicca, conjunctival nodules, pul­ monary lymphadenopathy. Treatment is with steroids and then methotrexate. • Neurological. Multiple sclerosis can cause optic neuritis that causes sudden onset of blindness in one eye. • Myopathies. These include myasthenia gravis (excessive fatigue of muscles), ptosis and diplopia. Treatment is with neostigmine.

Nutrition and the disorders of the eye Deficiencies in vitamins, especially vitamins A and C, have been associated with eye conditions such as xerophthalmia, night blindness, lid oedema, chemosis and corneal ulceration. Alcoholism gives rise to nystagmus, poor conjugate gaze, as well as nutritional optic neuropathy. Treatment consists of replacing the lacking vitamins, and protein in cases of alcoholism (plus abstinence from alcohol and rehabilitation if necessary), and encouraging a healthy lifestyle that includes fresh fruit, vegetables and exercise.

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Myopia

Hyperopia This is farsightedness, where the eyeball is shorter or smaller than average, which causes the light rays to be focused at a point behind the retina in an unaccommodating eye. The patient will complain of being unable to see near objects clearly. Correction is by convex (plus) lenses, bringing the focus forward. These lenses make the eyes look bigger.

Nearsightedness/myopia: focus point is in front of the retina

Concave lens moves focus point backwards onto the retina (–) Farsightedness/hyperopia: focus point is behind the retina

Convex lens moves focus point forward onto the retina

(+)

Figure 52.6  Refractive errors

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Astigmatism This is an irregular curvature of the cornea. Most optical surfaces are equal and symmetrical in all meridians. In astigmatism, the cornea often lacks this perfection and may be more curved in one meridian. The patient will complain of blurred vision, sometimes with a ghost image. Correction is with cylindrical (toric) lenses in combination with spherical (plus or minus) lenses.

Presbyopia This condition occurs in people 40–45 years old, who complain of an inability to see near objects that they could see before. They have to hold books further away to read. This is due to loss of accommodation, caused by the lens becoming harder and less pliable. The condition can be corrected with over-the-counter convex (plus) lenses (reading spectacles): • 40–45 years old: +1.00 • 45–50 years old: +1.50 • 50–55 years old: +2.00 • Over 55 years old: +2.50 or higher People with pre-existing refractive errors need prescription spectacles, and can use either bifocal or multifocal spectacles.

Common nursing diagnoses These include the following: • Altered vision. This could be blurred, double or no vision caused by a refractive error, squint, cataract or other diseases such as diabetes mellitus. • Photophobia. This may be as a result of inflammation, eg conjunctivitis, keratitis or uveitis. • Itching. This could be caused by conjunctivitis or blepharitis. • Irritation/discomfort. This may be caused by a foreign body, dry eye syndrome, conjunctivitis and uveitis. • Lacrimation. This may be caused by a foreign body or any irritant in the eye. Lacrimation is the physiological response to remove the irritant. • Discharge. This could be purulent or watery, moderate or copious, and usually indicates infection or an obstruction in the lacrimal passage. • Various degrees of discomfort, irritation or pain. This may be due to irritation related to infection or a foreign body. The pain can be moderate in uveitis and very severe with acute angle-closure glaucoma and corneal ulcer. Dull pain is experienced in inflammation of the choroid or the optic nerve. • Bloodshot eye/hyperaemia. This usually denotes irritation or infection.

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Clinical alert! The basics of eye care include eye swabbing, irrigation and the instillation of medication.

Prevention of blindness Every ocular condition, if neglected, will lead to blindness or severe visual impairment. The following are the main causes of blindness in Africa: • Cataract • Glaucoma • Age-related macular degeneration • Corneal opacities • Diabetic retinopathy • Childhood blindness • Trachoma • Onchocerciasis. Also known as river blindness, this is a disease caused by the parasitic worm Onchocerca volculus. It is transmitted to humans via the bite of the blackfly, which breeds in rivers and is infected with this worm. Symptoms in humans include severe itching, bumps under the skin and gradual blindness. It is treatable with ivermectin.

52.3 Guidelines for the care of visually impaired patients Some general guidelines in the care of people with visual impairment are the following: • Be patient. • Explain every activity to the patient. • Maintain privacy throughout, even though the patient’s vision is poor and they may not be aware of this. The nurse must remain respectful of the visually impaired. • Provide the necessary assistance without patronising the patient. • Always aim at maximising independence. • If admitted to the ward, care must be taken to guide the patient by taking them by the arm and leading them to their bed and to the bathroom.

Essential health information Health education is of paramount importance for the prevention of blindness. Prophylactic measures to prevent the complications of rubella include vaccination or the prevention of exposure of young girls to German measles before the childbearing period. In the newborn, instillation of prophylactic ointment will further prevent ophthalmia neonatorum. Correct monitoring of oxygen

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Chapter 52 – Management of disorders of the eye and vision  1063 Table 52.6  Eye swabbing, irrigation and the instillation of medication

Activity

Indication

Method

Eye swabbing

To clean the eye of discharges prior to irrigation or instillation of medication

1. Check the doctor’s prescription to verify what is to be done and how often 2. Explain the procedure to the patient 3. Assist the patient to assume a comfortable position 4. The patient must sit upright with the head slightly tilted backwards, or lie down 5. Wash hands and wear fitting gloves 6. Gently wipe the lower eyelid with clean gauze without applying too much pressure from the nasal side outwards while the patient is looking up 7. Gently wipe the upper lid from the nasal side outwards while the patient is looking down 8. Wet the gauze with sterile water or saline when the discharge too sticky or hard 9. Leave the patient comfortable 10. Remove gloves and discard used supplies appropriately 11. Record the condition of eye, the procedure done and the response of the patient

Eye irrigation

To wash the conjunctival sac in case of a chemical injury to the eye. Ringers lactate, or saline or tap water may be used

Same as above up to point 8: 1. Insert a drop of local anaesthetic into the eye as prescribed by the doctor 2. Separate the eyelids with the forefinger and thumb 3. Take a 5 ml syringe and draw it full of sterile water or saline 4. Have a kidney bowl ready under the cheek to catch the water 5. Gently squeeze the syringe from a distance of 2.5 cm from above the eye, and rinse the discharge out of the eye. Start from nasal side outwards. Repeat this process by asking the patient first to look up, then to the right, then left and then down. Repeat filling the syringe till the eye is cleared of all chemicals. A minimum of 1 ℓ of water or saline must be used. 6. If the chemical was an acid or an alkali, the irrigation must continue till the pH is normalised. This can be checked with the pH monitor that is usually present on a urine dipstick. Normal pH is between 7 and 7.3 7. Dry the eye gently with dry gauze, and make the patient comfortable 8. Remove gloves and discard used supplies and equipment appropriately 9. Record the condition of eye, the procedure done and the reaction of the patient

Instillation of medication

To introduce drops into the eye

1. Ask the patient to sit upright with the head slightly tilted backwards and looking up. The patient can lie down when they put in their own drops. 2. Pull the lower lid a little bit away from the eyeball and down to form a pocket while instructing the patient to look up. 3. Instill the prescribed medication into the lower pocket created between the lower lid and the eyeball 4. Ask the patient to gently close the eye without squeezing 5. Ask the patient to apply their index finger to the inside corner of the eyelid by the nose and press gently. This must be done for 2 minutes. This prevents systemic absorption and improves absorption by the eye 6. If inserting another medication, wait 2 minutes before instilling the second drop.

❱❱

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Activity

Indication

Method 7. Record the medication instilled, the condition of the eye and the reaction/response of the patient 8. Make the patient comfortable

Hot compresses for eyelid infections

To instill eye ointment into the eye

1. Repeat steps 1 and 2 of the previous point 2. Make sure the ointment is slightly heated in your hand to ensure easy expelling 3. Remove the cap and gently squeeze a 2.5 cm long section of ointment into the lower fornix of the eye. 4. Ask the patient to gently close the eye 5. Always put the ointment last if there is other medication as well

To apply a hot compress to the eye

1. Soak two clean gauze squares in hot water (not boiling) and apply it to the lid for 5–10 minutes, 3 or 5 times a day. The eye must be closed 2. Repeatedly soak the gauze in hot water to maintain adequate heat. The warm compress should allow the clogged gland to open and drain white or yellow discharge. If the gland opens, gentle massage around the stye or chalazion may help drainage

for premature babies under the birth weight of 1 500 g is mandatory to prevent the retinopathy of prematurity. In addition, good health and nutrition; prompt attention to eye infections; early detection of cataracts, glaucoma and squints; and careful monitoring of systemic diseases, especially diabetes mellitis and hypertension, will prevent blindness in both the young and old. Whenever possible, the nurse should emphasise the importance of adequate safety measures at home and in industry. The use of protective goggles when grinding steel or chopping wood is essential. Avoiding uncontrolled fireworks and dangerous toys such as pellet guns, bows and arrows, and catapults is very important. These are all common causes in the loss of an eye. The community as a whole needs to be educated about safety and first aid measures to undertake in case of serious accidents.

Rehabilitation of the visually impaired The patient must be able to cope with the activities of daily living, including feeding, identification of clothing and dressing, and should be able to identify money. Orientation and mobility are essential, and the patient must know how to use aids such as a white stick properly. The care and engagement of a guide dog as an aid to mobility requires specialised training for both the patient and the animal. The patient will need to learn new communication aids, such as Braille, talking books, tape aids and how to use the telephone. The patient may need assistance to begin socialising in the home and community once again and may need to be referred to a support group or a social worker.

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Ethical and legal issues relating to visual impairment and the provision of eye care In dealing with conditions related to the eye, the nurse must observe all the ethical and legal aspects that apply. They must obtain informed consent for all surgical procedures and tests before these are performed. The nurse must respect the patient’s confidentiality and must not discriminate against visually impaired people. The patient has a right to information and must therefore be kept informed about their condition, prognosis and all activities undertaken during treatment.

Clinical alert! People in the community should know that blindness is preventable, therefore they should seek immediate intervention should they experience any problem with their eyes. Certain blinding eye diseases can be treated or controlled if detected early. It is recommended that neonates have their eyes examined shortly after birth and before they leave the hospital to confirm the presence of a red reflex. Every child under the age of five should have a red reflex test and vision screening done with every routine clinic visit, and school-going children should be tested every 2 years. Healthy adults should get their eyes tested by the age of 40, then every 2–4 years. After 65, this should be every 1–2 years.

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Conclusion The eye is a very important organ for our existence. It is through the eye that we are able to appreciate ourselves, others and the environment around us, therefore it is imperative that we look after our eyes and preserve the sight we have for as long as possible. When working in dusty places or where small chips of wood or specks of

stone or bone are likely to be in the air, or when travelling in the sun, correct protective equipment such as goggles or other forms of glasses/spectacles should be worn. People who read a lot need to have their eyes checked periodically to ensure that the lens can still refract light accordingly and that the eyes are not strained unduly.

Suggested activities for learners Activity 52.1 The eye is very delicate and its care is important. Working in pairs, learners should carry out a full eye examination on each other. This should include the following: 1. History taking 2. Physical examination, including the use of a ward ophthalmoscope 3. Measurement of visual acuity using the Snellen chart. 4. Produce a record of the results and submit this to the facilitator. Activity 52.2 You are working in a peripheral clinic and you have examined this patient who is 70 years of age and is complaining of blurred vision. 1. Indicate all that you are likely to find with this patient. 2. Make a recommendation for the nursing management of this patient.

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53

Management of elderly patients

learning objectives

On completion of this Chapter, the learner should be able to: • identify the common health problems of the elderly person • assess and manage the common problems of the elderly patient in a variety of healthcare settings • give information to families and the general public concerning the care of the elderly • give support and advice to the family of the elderly patient. key concepts and terminology

ageing

The normal process of growing older as it occurs over time.

dehydration

Condition caused by inadequate fluid levels in the body due to inadequate intake or excessive output.

delirium

An acute confusional state. Commences with disorientation, but may progress to altered level of consciousness, coma and death.

dementia

Syndrome characterised by alterations in higher cognitive functioning, progressing to inability to carry out the basic activities of daily living.

depression

Affective disorder common in old age, characterised by negative mood and outlook.

elder abuse

Physical or emotional harming of an elderly person.

geriatrics

The study of old age, including physiology, pathology, diagnosis and management of conditions common in old age.

gerontology

The study of older people within their environment.

life expectancy

The average number of years that a person is expected to live.

lifespan

The maximum number of years that a healthy individual can be expected to live in the absence of disease or disability.

orientation

The ability to recognise time and place.

polypharmacy

The taking of multiple medicines at the same time.

presbycusis

Decreased ability to hear high-pitched sounds.

presbyopia

Decreased visual accommodation, characterised by long-sightedness.

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prerequisite knowledge

• Anatomy and physiology of the human body • Social sciences • Systematic and needs approach to care for the medical and surgical conditions. medico-legal considerations

The anatomical and physiological changes in the elderly expose them to risks in their daily lives. Of importance is the abuse that they are prone to suffer. Currently the only mechanism that exists to protect older people from abuse is found in the Mental Health Care Act 17 of 2002. Organisations such as the Human Rights Commission and Age-in-Action, in conjunction with its member organisations, have adopted the Rights of the Elderly charter based on the 1991 United Nations Declaration of the Rights of the Elderly, which supports the rights of the elderly to independence, participation, care, self-fulfilment and dignity. This forms the basis for the acceptable response to providing for the needs of older people in a humane society. HEAL is a South African telephone helpline that offers advice and support for older people, their families and professionals when elder abuse is suspected. Legislation relating to the reporting of elder abuse and to the protection of the abused people varies in different parts of the world. Reporting of abuse to the elderly has become compulsory in countries such as the USA, the UK and Israel, similar to that required for abused children or those in need of care. Formal channels for providing protective shelter or the opportunity to assess the older person are also available in various countries, and should be adopted worldwide. ethical considerations

The older patient is cared for in a variety of settings, from community facilities and primary healthcare clinics to hospitals and frailcare facilities, including their homes. Special attention to rehabilitation and the management of chronic diseases and disabilities is needed. The cultural aspects and belief systems also need to be taken into account by the nurse. If this is not done, it is unlikely that the patient will comply with their prescribed treatment regimen, be it medication or lifestyle adaptation. Caring for older people provides many ethical dilemmas and often requires the nurse to become the spokesperson and protector. The four fundamental ethical principles are autonomy, non-maleficence, beneficence and justice. These include the right of the person to decide what will be done to their person and life (autonomy), not to have harm done to them or be deprived of care (non-maleficence), to promote and do that which is good and moral (beneficence), and to ensure fairness, in that each person receives that which is their right or due (justice) to them. The right to privacy and confidentiality is also inherent in the rights of all patients and is not negated by their age or mental state. These all raise a number of issues. The competency of the older person to make decisions for themselves is related to their mental competency at the time the decision needs to be made. This includes informed consent for treatment or participation in research, the ability to sign legal documents such as wills, the validity of a living will or the right to refuse treatment. The refusal by a person to undergo specific treatment does not imply that nursing care is no longer required. The nurse is critical in assisting the person to attain comfort and maintain dignity where curative care is not appropriate. Specific nursing acts, such as the application of restraints or giving nasogastric feeds to a patient who refuses to eat, require that the nurse consider the rights of the patient and their family. Maintaining life through artificial feeding, intravenous therapy and ongoing antibiotics is an emotional and moral decision. The legal status of euthanasia and the validity of living wills are currently being debated in southern Africa, while issues relating to ‘do not resuscitate’ policies still need debate among healthcare practitioners. The guidelines and practices should not be different when dealing with the elderly, although a common-sense approach is required when making decisions concerning invasive treatment or heroic attempts to maintain life at all costs.

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essential health information

Older people are not a homogeneous group and are often active and healthy. Each person’s individual needs must be considered. Diseases, symptoms and disabilities need to be treated with the same consideration as those encountered in younger people. Activities of daily living and self-care are important aspects of patient education in the care of the elderly. Measures to maintain optimum health, mobility and quality of life should be emphasised. Measures to ensure safety in the home and to prevent accidents are an important aspect of health education for both patient and family. The patient and their family need education about how to take medication, to look out for and report side effects, and the importance of compliance. Support for the carer of a person with a chronic condition is critical for the welfare of the older person and the carer themselves. Adequate supervision and support of other categories of staff in hospitals, frailcare facilities and at home limits the risk of abuse, particularly exploitation, theft of money and property, mental and physical abuse, and neglect.

Introduction Changes in healthcare have meant that people are living longer, and that more and more elderly people will need care. The elderly are the survivors of physical degeneration and many illnesses. As a result, they may have a number of chronic problems that require attention either as a part of their normal existence or in addition to the illness for which they are seeking attention. When they do fall ill, the presentation of symptoms often differs from those of younger patients because of the normal physiological changes of ageing.

The demographic impact of ageing The growth in the number and proportion of older people in southern Africa and other African countries has been rapid. There are a number of factors causing this: • Immunisation programmes to prevent diseases • Improved medical science and management of diseases that would previously have resulted in premature death • Improved education and living standards • Better control of chronic disorders, such as diabetes and hypertension • Acknowledgement that not only are the elderly equally entitled to treatment, but that they have every chance of recovery. Southern Africa is not yet considered to be an ageing society. According to the Mid-Year Population Estimates of 2011 (Statistics South Africa, 2011), approximately 7.7% of the population, or ± 4 million, are aged 60 or older. Of these, approximately ± 800 000 are aged 75 and older.

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The increase in deaths caused by changing disease patterns and violence is having a significant impact on older people in sub-Saharan Africa. The burden of caring for orphans and the terminally ill has shifted to pensioners, who, although needing care and attention themselves, provide both financial and physical care to these vulnerable groups. However, the proportion of people reaching old age will probably decline because of reduced life expectancy resulting from HIV and Aids. These changes affect the allocation of healthcare resources, and nurses and other healthcare professionals must ensure that the health of the elderly is given the attention it deserves.

Overview of anatomy and physiology Ageing is a normal physiological process. However, the changes that occur with age do not usually become significant until a person is well over 50 years of age. The elderly are often divided into the following categories: • The young old (60–74 years) • The old (75–85 years) • The very old (over 85 years). The changes that occur affect all the systems of the body. Those that are most significant are described in Table 53.1. As a result of these changes, nursing care and medical treatment need to be adapted. Some common medical consequences of ageing are the following: • Common diagnostic signs and symptoms, such as a fever as a sign of infection or chest pain during a myocardial infarction may be altered.

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Chapter 53 – Management of elderly patients  1069 Table 53.1  Physiological changes and associated health problems in the elderly

Physical changes in appearance and body composition mainly affecting the musculoskeletal and skin systems Posture

This is more stooped, with increased flexion of knees and hips, and the head tilted forward; loss of bone mass and structure results in narrowing of intervertebral spaces, structural deformities, joint pain and altered mobility

Skin

Loss of elasticity and reduced subcutaneous fat layer results in a wrinkled appearance; skin becomes thinner; areas of discolouration and spots occur, which may become malignant; hair distribution changes and becomes thinner and coarser

Weight

Total body water and fat decrease, resulting in decreased body mass

Respiratory system Chest

The thoracic cage is more rigid due to increased muscle and connective tissue rigidity, resulting in poor ventilation and increased chest infections

Cough mechanism

This is less effective due to rigidity and decreased ciliary function and increased respiratory infections

Lung capacity

Capacity is altered due to reduced elasticity of lung tissue, resulting in poor lung expansion, dyspnoea on exertion; inspiratory and expiratory volume decrease

Ventilation

The number and size of alveoli decrease, and oxyhaemoglobin saturation is reduced

Cardiovascular system Heart

Heart valves become thicker and more rigid, and myocardial hypertrophy may occur; cardiac output decreases by up to 40%, and the heart rate slows with altered ability to respond to stress and activity; increased irritability of the myocardium makes the heart more susceptible to factors resulting in arrhythmias

Blood vessels

Reduced elasticity and increased calcium and plaque formation occurs; venous valves become less efficient and veins dilate, resulting in sluggish blood flow and increased peripheral resistance, hence increased blood pressure

Blood pressure

This increases as a result of reduced cardiac function and increased peripheral circulatory resistance

Gastrointestinal system Mouth

Teeth become more brittle and loose, with gums receding, particularly where teeth have been lost, impacting negatively on chewing

Taste

Reduction in taste buds and decreased salivary production alters taste and therefore food intake and nutrition

GIT

Impaired muscular functioning results in decreased peristalsis and risk of aspiration, poor absorption and nutrition being significantly altered

Intestines

Reduced peristalsis and altered diet and mobility may result in constipation; formation of diverticuli occurs in about 35% of older people

Liver

This decreases in size and function, affecting the ability to metabolise and excrete drugs, hence the high risk of metabolic diseases and abnormal reaction to medication

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Physical changes in appearance and body composition mainly affecting the musculoskeletal and skin systems Genitourinary system Kidneys

Size and functioning are significantly reduced; glomerular filtration rate decreases progressively to 50% at age 90, resulting in decreased excretory efficiency, affecting creatinine clearance and the ability to excrete electrolytes and metabolites selectively, hence the risk for renal diseases

Bladder

Capacity may decrease or become irritable, or may become more atonic, resulting in retention or incontinence

Prostate

Benign hypertrophy occurs in older men, resulting in altered patterns of micturition

Pelvic floor

Reduced hormone levels and less effective musculature result in poor support of uterus and bladder, which may be reversed through exercise and hormone replacement. Poor pelvic floor muscle tone may result in incontinence of both urine and faeces, and the prolapse of pelvic structures

Reproductive organs Male

Hormone level and sperm are reduced; libido is unchanged, but responses may be slower and erection difficult to sustain

Female

Hormone production (oestrogen) is significantly reduced, resulting in atrophy of the vagina and endometrium; cervix becomes thicker

Neurological system Brain

Slight decrease in size, with reduced blood flow, results in the inability to regenerate neurons; fatty deposits and senile plaques and tangles develop, with or without memory impairment; heat regulation (production and loss) is impaired due to hypothalamic changes

Peripheral nerves

Deep tendon reflexes decrease, with slowing of reaction times; the baroreceptor reflex is altered, affecting blood pressure control

Neurotransmitters

These are altered, resulting in an increase in potential for depressive conditions; diseases such as Parkinson’s disease are due to reduced dopamine

Endocrine system Structure of glands

Structural changes in the pituitary, thyroid and adrenal glands result in decreased hormone production. Thyroid function is most commonly affected, as well as oestrogen, progesterone and testosterone

Pancreas

Insulin release and effectiveness is impaired, although production appears unaffected

Musculoskeletal system Bone

Bone loss is due to calcium absorption, hormonal changes and increased reabsorption rate; osteoporosis occurs and fractures are common

Muscles

Muscle cells lost are not replaced, and atrophy occurs, leading to reduced proportion of muscle to body weight

Joints

Cartilage becomes eroded and synovial membrane becomes more friable; wear and tear on the joints results in arthritic changes with poor mobility and articulation

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Chapter 53 – Management of elderly patients  1071

Physical changes in appearance and body composition mainly affecting the musculoskeletal and skin systems Sensory system Vision

Presbyopia occurs due to increasing rigidity of tissues in the eye; lenses may be relaxed and discoloured due to increased pressure resulting in cataract formation; visual acuity changes due to decreased pupil size and poor depth perception; arcus senilis appears around the iris

Hearing

Presbycusis occurs and tone discrimination is impaired due to atrophy and sclerosis of the tympanic membrane and changes to the ossicles in the middle ear; cerumen production increases. All these result in impaired hearing.

Immune system Immunity

This is less effective due to reduction in T-cell production and decrease in natural antibodies

• Dosages of medicines often need to be adjusted as they remain active in the body for longer periods due to alterations in metabolism and reduced renal function. • Drug interactions occur more commonly because of polypharmacy. • Rehabilitation following surgery or illness is slower because of reduced capacity to build and repair tissue and muscle. • Adaptation to new or different lifestyles is affected by changes to vision and hearing, as well as changes to general mental and physical functioning. • Falls occur more commonly because of changes in posture, stability and slower reflexes. In summary, the common medical problems that occur in older people are the following: • Cardiac disease • Hypertension • Depression • Chronic obstructive pulmonary disease (COPD) • Degenerative joint disease • Diabetes mellitus • Poor hearing • Poor vision • Cognitive deterioration. Functional impairment of older people can be classified into the following categories, originally described as the ‘giants of geriatric medicine’: • Immobility • Instability • Incontinence • Intellectual impairment • Iatrogenesis.

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Iatrogenic conditions are those that are unintentionally caused by medical intervention. These include common problems such as the following: • Side effects of medication (eg confusion and incontinence) • Dehydration because of restraints or aperients • Falls that result from oversedation or inappropriate medication, or unsteadiness on one’s feet. These risks can be identified if one is aware of the physical and physiological changes which take place in older people and changes to their home environment as they get older. As nurses working in a multidisciplinary environment, it is important to understand the functions of all team members, including the elderly and their families. It is equally important to understand the need to adapt care according to the unique needs of each patient. Nurses are in an excellent position to identify many of the causes of impairment, because they are able to obtain information and history from the patients over time and in settings in which patients are more willing to confide in someone they trust.

Community-based nursing Over 90% of older people live independently in the community, with or without some form of social or nursing assistance. In most developed countries, there are extensive networks of support services funded by state or welfare organisations. This differs in underdeveloped countries, where there are proportionally fewer older people, who tend to work until much later in life and normally remain within the family – often because there are few alternatives.

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International trends, which are mirrored in southern Africa, encourage communities to take responsibility for the care of the disabled and frail within families, according to the economic and cultural influences of the community. Institutional frailcare is provided for those who are significantly dependent. The role of the nurse is being extended in conjunction with the roles of the social worker and other members of the team.

Detection and screening A large percentage of older people attend service clubs and social centres or live in retirement communities. These provide an excellent opportunity for the primary healthcare nurse to provide basic screening clinics, counselling, health advisory services and relevant healthcare.

Screening procedures • A simple but effective screening programme with an evaluation of health status can be undertaken, based on a systematic history and limited physical examination. See Box 53.1 for the information required. • The nurse needs limited equipment, such as sphygmomanometer and stethoscope, urine testing strips, a haemoglobinometer, a glucometer (inexpensive and accurate) and scales. • An otoscope, Snellen chart, and gloves and lubricant for rectal examinations should also be available. As hearing impairment is not uncommon in older people, it is important to find a consultation area that allows for privacy. The aim of the screening is the following: – Clinical assessment to identify and treat or refer remediable problems – Functional assessment to evaluate the functional abilities and limitations of the patient and advise or refer appropriately – Intellectual assessment to evaluate mental state and intellectual impairment, and advise or refer appropriately.

Assessment A full assessment should be undertaken every 6–12 months, with additional follow-up where indicated. The assessment consists of finding out about the patient’s home circumstances, their access to various facilities and any support services being used. The relevant past medical and surgical history is obtained, with special attention being paid to the medicines that have been prescribed, how they are being taken, what other medication is being used, including over-the-counter and natural herbal preparations, alcohol and ‘swaps’ from friends and neighbours.

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It is a good idea to request that patients bring all their medication with them to the clinic, as it is not uncommon for them to be taking duplicate medication because of different names used for the same thing. It is also common to find medication being taken for problems that patients have forgotten to mention during the history taking, such as thyroid medication, analgesics or sedatives. The history is completed with questions about body functions and habits. The remainder of the assessment is based on the nurse’s observations. As instability and immobility are common problems, it is important to examine the state of the patient’s feet and to watch them walking. An overall impression of mental functioning may indicate the need for a limited mini-mental examination. This is based on a list of 10 questions as shown in Box 53.2. There is currently research to establish the impact of culture and language on evaluating mental function, but this is still being validated. If the patient scores less than 7/10, a full mental state evaluation should be done, either by the psychiatric nurse, or the patient can be referred to the psychiatric or geriatric services. This would provide a baseline for future comparison. Depression is very common in the elderly, who respond well to treatment. Various depression assessment scales are available. Sudden weight gain could be indicative of fluid retention related to cardiac failure, while weight loss could indicate underlying pathology such as a malignancy or metabolic disorder. Disorders of the thyroid are common in older people, but often have a different presentation from that in a younger person. These should be ruled out. Blood pressure should be taken first while the patient is lying or sitting, followed immediately by taking it with the patient sitting or standing. A drop of more than 20 mmHg in the systolic pressure is indicative of postural hypotension, a common medication side effect which can result in dizziness and falls. If the blood pressure is raised (> 140/90 mmHg), it should be checked again after resting for 30 minutes. If there is no improvement, the patient should have their blood pressure checked again in a week. Significant hypertension (> 170/110 mmHg) should be referred for immediate treatment as there is a strong correlation between hypertension and other circulatory diseases, such as stroke and cardiac disease. Guidelines for managing and referring people with hypertension have been developed by the health authorities, and can be found in the essential drug programme (EDP) guidelines. The risks attached to hypertension are described later in this Chapter.

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53.1 A screening instrument for older people Name: Address: Age: Religion: Occupation:

First assessment date: Dwelling type: Access to the dwelling: Toilet access: Bath access: Stairs/lift:

Additional services received: Domestic: Homehelp: OT/physio

Living conditions: No of occupants:

Relevant past medical/surgical history: Medication (past and present): Sedation: Painkillers: Allergies: Chronic medication: General examination: Inspection: Palpation: Auscultation:

Degree of mobility/independence: Bathing: Dressing: Vision: spectacles: Hearing: right/left: Mouth: Feet:

Bowel habits: continent/incontinent/constipated

Bladder function: Urgency/frequency/continent/incontinent Incontinence aids used: Urine is passed how many times per night?:

Nutritional status:

Sleep pattern:

Chest: Lungs: Cigarettes per day:

Mental state: Memory: Language/speech defects:

Observations: Weight: Blood pressure: Lying: Repeat after 10 mins Haemoglobin: Blood glucose: Urinalysis: Skin: dehydration: Broken areas: oedema

Assistance/aids for activities of daily living Meals on Wheels: Shopping or other: Bath: Toilet: Hearing aid: Dentures: Other:

Standing:

Aids & appliances: Walking: Toileting:

Other conditions or circumstances Cough: Alcohol use: Mood: Exposure to hazards: Social work: Tel no: Referred by: GP: Hospital:

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53.2 Short mental assessment instrument (orientation in terms of identity, time and place) (Note: there are many different versions of this questionnaire) 1. What is your name? 2. How old are you? (Check date of birth for confirmation) 3. What is your home address? 4. When is your birthday? 5. What day of the week is it today? 6. What is today’s date? 7. What season is it? 8. What time is it? (approximate) 9. Where are you now? 10. What is my job? Score 1 point for each correct answer.

Where shortcomings are identified, alternative support and care are utilised, but if they are lacking, the nurse is challenged to improvise. Polypharmacy and incorrect use of medication contribute toward more than 50% of hospital admissions, falls, confusion and the general debility of older people. The vast number of generic equivalent medicines that are available may result in patients taking duplicate medication, often with catastrophic consequences. Where people shop around for healthcare, they are less inclined to tell the doctor, nurse or pharmacist that they have medication from other sources. This may also result in dangerous drug interactions. A home visit is often the only way to establish the true picture. The nurse is responsible for monitoring the use of medication in the home and for taking steps to ensure that the patient understands the importance of compliance. Being aware of the possibility of adverse drug reactions, such as confusion from digoxin, is also a nursing function.

Counselling and support Owing to the altered renal threshold, urinalysis is not a good indicator of blood glucose levels. The presence of blood or albumin in the urine requires further monitoring and referral according to the clinic protocols. Blood glucose is measured using testing strips or glucometer readings, where available. The importance of controlling diabetes is discussed later in this Chapter. As with younger patients, a cough lasting more than one month requires further investigation, particularly if it is associated with weight loss or haemoptysis, as both tuberculosis and malignancies occur in older people. Certain medication may also cause a persistent cough, which resolves when the treatment is changed. Finally, it is important to recognise that most older patients tend to under-report their limitations and problems, while those in the earlier stages of mental impairment tend to exaggerate their abilities. It is important to obtain a collateral history if the examination and the history do not correspond, and a home visit may be indicated.

Evaluation and monitoring It is recognised that by the time patients leave the hospital or consulting room they remember only a small portion of the instructions and advice given to them. If you add impaired memory or anxiety, this problem increases significantly. Older people are inclined to overestimate their coping abilities, often in an attempt to protect their independence. Community nurses are in an ideal position to evaluate home circumstances, support systems and coping skills.

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The older person with chronic disabilities or diseases requires regular counselling and support to facilitate effective management and adaptation to this, as do their family or carers. As with other problems, the response to a chronic problem may range from denial to obsessive concern or total disregard. The nurse has a relevant role in enabling appropriate behaviours, including lifestyle and dietary advice. If the disability has resulted in reduced functioning, the nurse is in a position to facilitate support services and devices. Table 53.2 provides a list of some of the resources available in the community. These are not limited to the developed sectors of the community, but are also often available through many informal channels. A local resource manual, when available, is an invaluable aid for all healthcare providers. People with illnesses such as stroke, diabetes, Parkinson’s disease and cancer find referral to support groups, as well as support and counselling from the nurse in the community, invaluable. Carers of people with dementia require extensive support as these patients are particularly demanding and difficult to care for. Active listening and respite care provide constructive support for carers.

Provision of care in the community Care provision in the community is provided directly or indirectly by nurses. Direct care takes many forms. Basic procedures are not restricted to the elderly and commonly include dressings, catheter management, management of leg ulcers and bathing. More specialised care, such as

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Chapter 53 – Management of elderly patients  1075 Table 53.2  Community resources

Health services

General practitioner Primary health centre District/community nursing Community physiotherapy Community occupational therapy Hospice and Cancer Association volunteers and nurses Podiatry

Welfare services

Social workers Service centres Meals on Wheels Home help services

Voluntary services

Visiting the housebound Shopping and library services Laundry services St John’s Ambulance: home care, visiting Red Cross: home care, food parcels, clubs Church groups Lifeline Neighbours

Support groups

Stroke clubs, Parkinson’s support group, ARDA (for dementia patients and their families)

This list is not exhaustive, but provides a guide for some of the services available. Regional welfare organisations may have booklets about what is available in the area. psychotherapy and intravenous antibiotic therapy, is now also being provided. Indirect care is offered in the form of teaching and the support of unqualified carers or family members. • The chronic nature of frailcare means that basic care and funding are often not available from either public health services or medical schemes. Families therefore use the most affordable alternatives. The nurse working in the community is in a position to teach carers to provide safe and appropriate care. • This teaching may relate to specific procedures, such as personal hygiene, nasogastric feeding, management of dialysis and assisted respiration or traction. • Rehabilitation following hospitalisation or a traumatic episode such as a stroke is often also required. This is not an exhaustive list, and indirect care is equally likely to be found in all sectors of the community, particularly as health service resources are reduced. The provision of care provides a major challenge to nurses as patients require the development of a caring and supportive infrastructure. Nurses are responsible for teaching the patient, family and carers to undertake the

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tasks required, often improvising in terms of equipment and methods. This emphasises the importance of learning the principles of care and carrying out procedures, as these are the essential elements of the learning/teaching process.

Supervision of care In many instances, the family will engage another person to provide care for a frail person at home if they are unable to do so themselves. Many of these carers have no training, and require supervision and instruction. Ancillary healthcare workers are being trained to provide basic care such as bathing, feeding and dressing. They are also instructed in the importance of referring to professionals where appropriate. This is more likely to take place if they know the community nurse in their area. The important aspects that need to be monitored are medication use, management of bladder and bowels, skin care, mobility and nutrition. Elder abuse is not uncommon in circumstances where a career is inadequately trained, or the patient is demanding due to illness. All healthcare professionals have a duty to report suspected abuse to the relevant authorities.

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Case management The development of case and disease management as a form of healthcare cost containment was developed in the USA, and is now used extensively in many parts of the world. It is no longer confined to the private sector and managed healthcare organisations. The principle is the provision of efficient, effective care, utilising resources only where this is in the best interests of the patient. This includes the cost-effective planning, organising and monitoring of home-based healthcare following a hospital admission. Discharge planning should begin soon after the patient is admitted to the ward if it has not been done prior to admission, as is the case in planned hospitalisation. This requires the nurse to assess and make assumptions about the likely state of the patient on discharge, their support systems, and the available rehabilitation and community support. Family and community support services are then planned and organised to prevent patients remaining in hospital for longer than is medically necessary. The resources available vary according to the region or circumstance, and community-based professionals are the mainstay of this process. Case management may be done by professionals other than nurses, but nursing supervision is often required where care is provided in the home.

Hospital-based nursing Older people previously constituted a large percentage of all adults in hospital. The elderly often remain in hospital for longer than younger people because of the delayed processes of healing and recuperation. An aspect that requires early attention is discharge planning, as suitable arrangements for rehabilitation and recovery may take time, extending the length of admission. This requires a multidisciplinary approach. Box 53.3 outlines an approach to discharge planning. The pressure on hospitals to admit patients further emphasises the need for early discharge, and this process is often undertaken prior to admission where time allows.

The older patient in the emergency unit Older people often present with atypical signs and symptoms. Acute onset confusion or a fall may be the only presenting symptom in a patient who has had a myocardial infarction. Nausea and vomiting or acute onset confusion may be the presenting symptom of a urinary tract or lower respiratory tract infection, and urinary retention the result of excessive medication taken for cold and flu symptoms. Trauma, often fractures or lacerations, is common­ place in older people. A fractured femur may present with an immobile or painful knee and no history of

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a fall, particularly in patients with postmenopausal osteoporosis. In a busy trauma unit, reduced vision and hearing in an older patient often result in incorrect answers being given, along with disorientation and anxiety. As a result, the patient may be incorrectly labelled as ‘difficult’ or ‘confused’. The risk of pressure sores is increased in frail and malnourished patients who lie on a hard surface, such as a trolley, for long periods awaiting attention. The inability to communicate or mobilise effectively may aggravate preexisting dehydration, or the patient wetting themselves and being labelled ‘incontinent’. Anaemia, either due to acute or insidious blood loss or nutritional deficiency, may contribute to a number of symptoms, such as confusion, angina, shortness of breath and general failure to thrive.

Postoperative nursing care The older person requiring surgery may be admitted earlier than younger patients to allow the doctors to evaluate their anaesthetic risk and management. The surgical procedures are unlikely to differ from those that are done on all other patients, but in certain instances the age of the patient may influence the choice of procedure, such as the fixation of a fractured femur with a sliding pin and plate to enable earlier mobilisation. Concurrent medical conditions will influence the choice of anaesthesia. For example, patients with COPD may be given a spinal anaesthetic to reduce the risk of postoperative respiratory infections. Local or regional anaesthetic may be used for a similar reason. The postoperative risks remain high because of possible fluid and electrolyte imbalance or adverse drug reactions due to impaired renal function, reduced cardiac output and decreased tissue perfusion. It is not unusual for the older patient to develop transient confusion lasting one or two days postoperatively as a result. Table 53.3 lists some of the common causes of postoperative confusion in the elderly. The immobility that occurs during surgery and the immediate postoperative period place older patients at risk for developing pressure sores, deep-vein thrombosis and pulmonary embolus. This is due to decreased circulation, possible underlying cardiac disease and hypovolaemia. Another risk factor in older people is hypothermia resulting from the combination of the anaesthetic agents and impaired thermoregulation. A very common complication is constipation and faecal impaction as a result of immobility, reduced bowel mobility and altered diet and medication, particularly opioid analgesia. Appropriate monitoring and nursing intervention are essential. Pressure sores that result as a

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53.3 Guidelines for discharge planning Discharge planning sheet Case manager:

Tel/ext no:

1. Has the family/carer been informed and have they been included in the planning? Yes No Who: Date:

Transport: own/hospital Date/time: Arranged by:

2. Team members informed: Physiotherapy, social worker, speech therapist, Meals on Wheels, district nurse, home help and general practitioner By whom: Date:

Aids supplied: By whom:

3. Does the patient have sufficient medication, dressing, etc? Where will the patient go for new supplies? 4. Have instructions been given for procedures and equipment, eg catheter management, nebulisers, etc? By whom? 5. Have instructions being given about medication to be taken, the route, time, to whom, etc? Name: Purpose: Times to be taken: Special instructions: 6. Have instructions been given about the follow-up appointment? Date: Time: 7. Has the patient or carer been given a copy of this discharge planning sheet? Signature: Date:

postoperative complication of immobility, incontinence and bed rest will require extensive nursing care and hospitalisation, and will have an impact on rehabilitation. These can also be avoided through appropriate monitoring and regular basic nursing intervention in the immediate postoperative period.

General nursing care The atypical presenting signs and symptoms that are common in older people, combined with multiple underlying chronic diseases, may delay or obscure the initial diagnosis. It is essential that the nursing observations and diagnoses are shared with other healthcare professionals. Labelling patients as ‘demented’ or as having had ‘a stroke’ is detrimental to care planning and results in incorrect medical diagnoses or an extended stay in hospital, as well as a loss of dignity.

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Disorientation and anxiety when coupled with sensory deprivation may result in patients becoming very fearful of their surroundings. This lack of cooperation and the difficulty of dealing with the patient in these circumstances can also result in the labelling described above. Fluid balance, hydration and elimination may contribute to increased demands for nursing care. Owing to reduced cardiac and renal function, patients may easily become fluid overloaded, while environmental factors such as cot sides, intravenous infusions and diuretics may result in urinary urgency and frequency. The resultant incontinence is usually transient and is preventable by careful monitoring and attention to the environment and nursing care. The overuse of diuretics may also result in dehydration, further renal impairment and electrolyte imbalance. Daily weighing of patients on diuretics is an

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1078  Juta’s Complete Textbook of Medical Surgical Nursing Table 53.3  Common causes of postoperative confusion in the elderly patient

Problem

Possible contributing factors

Hydration

Cardiac failure leading to overhydration or dehydration due to altered renal function or fluid retention

Circulation

Blood loss, resulting in hypovolaemia, hypotension and anaemia, myocardial insufficiency, eg arrhythmias or infarction

Electrolytes

Impaired renal function, leading to electrolyte imbalances, diuretic use, volume overload

Renal

Decreased renal function, resulting in poor urinary output, electrolyte imbalances and fluid overload

Oxygenation

Underlying lung disorders, compromised circulation and low haemoglobin; pulmonary embolism and atelectasis

Malnutrition

Physical constraints; poor preoperative nutrition, resulting in anaemia or hypoalbuminaemia

Hypothermia

Poor thermoregulatory control with reduced shivering reflexes, or exposure

Constipation

Medication, including analgesics and anaesthetic agents, immobility and underlying diseases, eg Parkinson’s disease, hypothyroidism

Pain/trauma

Inadequate analgesia as patient is unable to verbalise pain; inappropriate pain control

Disorientation

Strange surroundings, compounded by sensory deficits and noise and sleep pattern disturbances; physical restraints

Pre-existing dementia

The presence or absence of dementia must be ascertained by means of information from the family as well as a mental state assessment

Drugs

Analgesics, sedatives

Infection

Respiratory tract; urinary tract; wound infection

acceptable means of assessing the level of hydration as an alternative to skin elasticity, which is inaccurate in older people. As with surgical patients, the potential for developing constipation and pressure sores also occurs in medical patients, and prevention, detection and treatment of these conditions is a nursing function.

Rehabilitation Rehabilitation is the process of regaining the ability to become self-caring and is not restricted to the recovery of function following a particular illness or episode, such as a stroke or amputation. It may also be required following any medical, surgical or mental illness or traumatic episode. In order for rehabilitation to be effective, it is essential that an individualised, structured programme be developed. Following a functional assessment of the older person and their home circumstances, the multidisciplinary team, in conjunction with the patient and family, set out realistic goals and aims. These should be broken down into a series

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of achievable short-term goals. As nurses spend the most time with the patient in the hospital, they are instrumental in ensuring that the plan is carried through consistently. This may relate to feeding and breathing techniques, dressing, mobilising, and transferring and positioning, particularly after a stroke. Outside the hospital, the nurse may be the only professional available to teach the patient and family. They do not take the place of the physio- or occupational therapist, but act in a nursing role in lieu of the therapist. Because elderly people are likely to benefit from assessment and rehabilitation interventions, they should be referred for physiotherapy, occupational therapy and speech therapy in the community services, where available.

Chronic and long-term care The provision of chronic and long-term care takes place in various environments, including the home and private or state-funded frailcare centres, or less often in special units attached to hospitals. The challenge to the nurse is

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Chapter 53 – Management of elderly patients  1079 Table 53.4  General nursing care plan for the elderly patient

Problem/ need

Nursing diagnoses

Expected outcomes

Nursing interventions and rationale

Evaluation

Dyspnoea

Altered breathing pattern related to the effects of ageing, especially on exertion, evidenced by abnormal rate and rhythm of breathing and difficult breathing

Normal breathing pattern

Encourage mild exercise and build up exercise tolerance over time Encourage the patient to pace activities to minimise fatigue Encourage deep breathing and coughing to maintain lung capacity

Breathing pattern normal Patient carries out activities of daily living

Decreased cardiac output

Altered circulation related to the cardiovascular effects of ageing evidenced by increased blood pressure

Optimal cardiac output

Monitor blood pressure and cardiac function Give antihypertensive medication as prescribed Encourage mild exercise and build up exercise tolerance over time Encourage patient to pace activities to minimise fatigue

Blood pressure and pulse within normal limits Patient carries out activities of daily living

Reduced integumentary function and integrity

Potential skin breakdown related to loss of skin thickness and elasticity as well as poor circulation to the skin

Skin integrity and condition is maintained

Maintain hygiene of the skin Provide regular care to pressure areas to prevent decubitus ulcers Inspect pressure areas regularly Provide protection for the skin Avoid/prevent minor injuries to the skin

No skin breakdown noted

Anorexia

Altered nutrition due to anorexia related to indigestion, heartburn and abdominal discomfort evidenced by reluctance to take food/ eat and loss of weight

Food intake normal

Offer small balanced meals that are easy to eat and digest Offer food several times a day Monitor intake and output Weigh patient on a weekly basis to monitor weight gain or loss

Nutritional intake is normal Optimum body weight is maintained

Dehydration

Risk of fluid volume deficit related to inadequate intake of fluids evidenced by dry skin and mucous membrane

Normal hydration Vital signs normal Food and fluid intake adequate

Record all intake and output Serve frequent small meals Encourage additional fluids between meals Monitor and record vital signs

Optimum hydration is maintained Intake of food and fluid is adequate Vital signs are normal

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Problem/ need

Nursing diagnoses

Expected outcomes

Nursing interventions and rationale

Evaluation

Constipation

Altered elimination pattern due to constipation related to reduced bowel tone and inadequate fluid intake

Normal bowel activity is maintained

Record all bowel actions Encourage a diet containing adequate amounts of fibre Encourage adequate fluids over a 24-hour period

Bowel function is normal

Urinary/faecal incontinence

Altered elimination pattern due to frequency and/or reduced tone of pelvic floor muscles

Patient remains continent of urine and faeces

Encourage patient to urinate at 2-hourly intervals to reduce overflow Record all bowel actions Encourage a diet that is nonirritating to the bowel; avoid rich and spicy foods Maintain hygiene of the patient Reassure the patient to allay embarrassment and anxiety

Continence of urine and faeces is maintained

Immobility

Self-care deficit related to immobility due to loss of muscle strength and degenerative changes of the joints

Normal mobility is maintained

Encourage regular exercise and movement Encourage a diet that contains adequate amounts of calcium Administer vitamin and mineral supplements as prescribed

Patient remains mobile Patient carries out activities of daily living

Confusion/ delirium/ dementia

Altered mental state due to physiological changes and/or changes in brain function

Normal orientation and mental function is maintained

Supervise and monitor patient, particularly if the patient wanders Ensure safety of the patient Apply restraints only if necessary and as prescribed Constantly orientate patient to reality Constantly reassure patient and explain all procedures

The patient is orientated to time and place Restlessness and anxiety are reduced

Fear and anxiety

Risk of fear and anxiety related to disorientation and unfamiliar environment Knowledge deficit related to ageing and its problems

Promotion of calm Patient is knowledgeable about condition

Explain all symptoms, problems and treatments to the patient Answer questions and provide as much information as possible Arrange for the medical practitioner to talk to the patient and the family

The patient is calm and confident regarding condition

to ensure that the older person is allowed to remain as independent as possible, and be considered as a person or resident with compromised function or chronic disability, not as an ill patient. It is likely that the level of functioning and feeling of well-being will fluctuate and needs to be considered when developing care plans.

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The role of the nurse in this setting is that of educator, supervisor and expert support for the person and their carers. It is not easy for the nurse to acknowledge that many of the tasks that are uniquely nursing in a hospital environment may be undertaken by others in the home setting. The unique nursing role is related to providing

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expertise and transferring skills to ensure that a competent level of care is provided. In developing a relationship with the family and carers, the aim is to ensure that a mutually cooperative relationship develops that benefits the patient. In a healthy relationship, the carer will be confident about referring to the nurse for assistance and advice, and not feel at risk of being criticised. The problems that commonly occur in this setting relate to the loss of functional independence due to physical or mental impairment. These are very stressful for the patient as well as the carers, as there is no break from the cycle of care. Unlike the hospital environment, the difficult patient cannot be discharged, and burnout of the carers is well documented. This also extends to nurses and care assistants in frailcare facilities. Community nurses and nursing management have a responsibility to ensure that carers are given adequate time away from the demands of the patient in order to reduce the risk of elder abuse. The provision of respite care is included in the National Policy on Older Persons. This provides short admissions of frail people being cared for at home to enable the carers to have a break from the responsibility of providing care. It also provides an opportunity for professional staff to reassess the patient in terms of rehabilitation and care planning. The most common problems that occur in this setting are reduced mobility, impaired respiratory function, incontinence, dementia and depression. These are usually the result of underlying disease processes, which may require special attention in the elderly.

Palliative and terminal care The concept of terminal care in the elderly is not restricted only to the later stages of malignant life-threatening illnesses, but also to the normal life cycle. Furthermore, there are many principles of palliative care that can be applied to the elderly without such an illness, such as pain control and dealing with bereavement and isolation. The older generations have strong ties to traditional value systems and beliefs. The nurse needs to respect these and work within their framework. The transcultural nursing approach permits a structured approach to evaluating the life world of the patient, and to negotiating that which is in their best interests. End-stage organ failure, such as cardiac failure, chronic respiratory diseases and renal failure, require intensive nursing skills to maintain functional independence as long as possible, preventing complications such as pressure sores, dehydration and constipation, and enabling the provision of personal comfort. Acute episodes such as pneumonia are reminders that death will occur at some

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point, and that all people need to prepare for such an eventuality. The fear of isolation is a reality, particularly where the illness results in distressing or unsociable symptoms. The helplessness and guilt of the carer and the family may result in the terminally ill person being left alone for long periods. The family who has emigrated or moved from a rural to an urban area also leads to the elderly being left without direct family support at a time when they are feeling vulnerable. Additional attention and support services from the remaining community need to be harnessed by the nurse who is in regular contact with the older person. Support and guidance are needed for others living with terminally ill people, such as in a home for the aged or frailcare. These people may also need bereavement counselling. The staff in frailcare facilities also need the opportunity to mourn for the loss of people for whom they have provided care over a long period. Remembrance circles afford the family of the deceased and fellow residents and staff an opportunity, under the guidance of a trained nurse, social worker or qualified counsellor, to pay their respects, mourn appropriately and close a chapter in their lives.

Malignant diseases Malignancies, including the leukaemias, occur in the elderly in the same way as in younger people, but the progression of the disease may differ. Treatment depends on the individual patient, their disease profile and level of functioning. The severe side effects of chemotherapy could place the older patient at greater risk if they have other diseases, for example cardiac failure, and the benefits must be considered against these risks. Age should not be the only factor in the decision-making process. Radiation or other palliative treatment may be given to control distressing symptoms.

Palliative care Palliation is a holistic approach to patient care that aims to prolong meaningful living without active, curative treatment, focuses on pain control without affecting alertness, and provides emotional and spiritual support. It is a term that is commonly used in the hospice movement, but is equally applicable to elderly people with lifealtering conditions or reaching the last stages of life.

Pain control The emphasis on pain control has provided nurses and other professionals with extensive knowledge about the effective management of pain. The challenge is to use this knowledge to support those with chronic pain caused by

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non-life-threatening diseases such as arthritis, as well as the terminally ill person. The side effects and risks of analgesics, such as constipation, sedation, confusion, dry and itchy skin and a dry mouth, can be reduced and managed through appropriate nursing observation and intervention. It may be appropriate in certain instances to have medication prescribed to relieve the side effects, but this is not normally accepted practice. Confusion in older people may be caused by pain, dehydration, infection or the analgesics and other medication being used for symptom control. For more detail on pain management, see Chapter 14.

Impaired mental functioning care Impaired mental functioning occurs frequently in the elderly and may be the first indication of an underlying medical or psychiatric problem. Psychogeriatrics is the psychiatry of the elderly. The problems that arise are commonly found in the community, hospital and institutional setting, and need to be correctly identified as many are reversible, while the remainder require skilled nursing and care planning. Any person who has had a lifelong mental illness, such as schizophrenia, will continue to do so in old age, although it may become less pronounced. The care and treatment focuses on the ability to maintain a safe independent life, with or without additional support.

Illnesses such as depression, agitation and anxiety disorders, dementia and delirium are common, while psychotic episodes and other disorders should not be ruled out.

Confusional states It is essential to distinguish between the various types of confusion and the onset and progression of mental impairment.

Delirium Delirium is an acute confusional state that may be caused by a number of underlying medical, physical or psychological problems. Table 53.5 provides a useful checklist for identifying the possible causes, and uses the mnemonic DIMTOP. About 53.5% of postoperative patients and 40% of older people will develop delirium during their stay in hospital. In many instances, this may present before tachycardia or fever as a sign of an underlying problem. Predisposing factors that increase the likelihood of a patient developing delirium are underlying disease of the brain, advanced age (over 80 years), and impaired hearing and vision. An accurate history will indicate a recent onset, particularly with night-time disturbances, and is based on the observations of the people caring for them. It is also important that when taking the history or reporting the problem the nurse is aware of a sudden change or

Table 53.5  Reversible causes of acute confusion

Drugs

Sedatives and tranquillisers Oral hypoglycaemics Steroids and L-dopa Antihypertensives and digoxin Alcohol

Infections

Commonly respiratory or urinary tract, but may be any infection

Metabolic

Uraemia, hypo- or hyperglycaemia Dehydration from diuretics, diarrhoea or poor fluid intake Hypothermia

Trauma

Intracerebral or subdural haemorrhage Fractures

Oxygen deficit

Anaemia, cardiovascular and respiratory disorders, eg pneumonia and myocardial infarction Postoperative and nocturnal hypoxia Strokes and epilepsy

Psychological and perceptual

Changes to the environment Sensory deprivation Depression

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deterioration in a demented patient, which could be acute confusion superimposed on the chronic condition. Once the reversible cause has been identified, the acute symptoms resolve over a period of time, possibly as long as two weeks. The most common cause (some sources quote up to 40%) of confusion is the use of medication, followed by infection. All patients with acute onset confusion should have their urine tested to exclude a bladder infection, and a physical evaluation to exclude a chest infection.

Dementia Dementia is a syndrome that results in impaired memory, personality and intellect in an alert patient. The incidence increases with advancing years, and occurs in 5% of 65-year-olds, 20% of 80-year-olds, and 40% of 90-yearolds. In old-age homes, as many as 50% of the residents may be demented. Recent advances in medical science have enabled certain types of dementia to be diagnosed through advanced X-ray imaging techniques, but the diagnosis is made more often following a history and functional assessment. The causes of dementia are numerous, and include Alzheimer’s (70%), multi-infarct dementia (20%) and alcohol (5%). Other causes such as Aids, vitamin E and vitamin B12 deficiency, tumours, infections (including neurosyphilis) and normal pressure hydrocephalus may respond to treatment and must be excluded. The assessment is based on mental functioning, a functional assessment and a social assessment. Differentiation between normal forgetfulness (benign senescent forgetfulness) and dementia is essential. A person with Alzheimer’s disease will present initially with short-term memory impairment; personality changes such as paranoia, apathy or aggressiveness; intellectual impairment such as language difficulty or disinhibition; shoplifting; inability to manage finances; and emotional changes, such as reduced sensitivity towards others. Physical changes include weight loss, change in gait and sudden signs of ageing. A mini-mental state examination (MMSE) is used commonly to assess mental functioning, but may be unsuitable for illiterate or non-westernised people. A more suitable method of assessment is currently being evaluated. An MMSE score of less than 24 points out of 30 is normally indicative of dementia. The various types of dementia will present with different symptoms of impairment. Classically the Alzheimer’s patient will have an excellent long-term memory and blunted personality, which may be misinterpreted as depression, while the alcoholic dementia patient will have well-preserved personality and social skills and

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an ability to confabulate (make up explanations), which may mislead the person doing the assessment. Collateral history obtained from the caregiver is important to corroborate the patient’s story. While the deterioration in most types of dementia tends to progress constantly (although the rate of progression appears to be slower if onset is at an older age), multi-infarct dementia progresses in a step-wise manner. This patient may remain stable for long periods if the underlying cause of the cerebral infarcts is controlled. Because the disease progresses gradually and silently, the patient’s partner may not realise the degree of impairment until an acute episode occurs, such as following hospitalisation or a fall. Careful questioning, particularly about social skills and handling of finances, will alert the professional to the insidious onset over a long period of time. The progression of dementia may be described in stages according to the amount of functional impairment, and accurately describe the normal progress of the disease: • Stage 1 . Mild: distracted and forgetful, hygiene adequate, conversation limited but relevant, difficulty in coping in a new environment, may become depressed • Stage 2. Moderate: ‘happy wanderer’, does not know own address (may give one from distant past), accident-prone and forgetful, may sleep in day clothes, possibly smells of urine, personal hygiene poor, unable to handle finances or simple tasks, may also become repetitive and aggressive, with loss of sexual inhibitions • Stage 3. Moderate with physical limitations: may become bed- or chair-bound if not mobilised regularly, needs help with dressing and completing routine tasks such as running a bath • Stage 4. Severe memory and intellectual impairment: may be doubly incontinent, conversation is rambling and incoherent, makes no effort to cook or find food; weight loss occurs in spite of eating well • Stage 5. Late stage: has become bed- or chair-bound, loses ability to smile or hold head up; vocabulary limited to a few words or non-existent. The management of the demented person requires a multifaceted approach. The carer should be reminded that care depends on the four don’ts: 1. Don’t restrict. Patients become aggressive and agitated and fight against any limitations. 2. Don’t enter into conflict. If the patient is convinced they are right, circumvent the issue or distract them rather than correct them.

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3. Don’t judge. Dementia is a disease, not a crime – the patients should not be subjected to punishment for their mistakes. 4. Don’t evict. Feeling secure is a key to management. Try not to change the environment unless no alternatives are available. The patient needs personal care, a safe physical environment and, particularly in the early stages when they are very anxious or depressed, supportive care. In the later stages, the care becomes more supportive as the physical and emotional needs increase. As one of the problems is uncontrolled behaviour and night wakening, prudent use of sedatives may be indicated. Antidepressants, anxiolytics and sedatives may be prescribed, but the nurse should be aware that the medication may have an adverse effect on the patient, causing hyperactivity. In Lewy body disease, a recently identified type of dementia, phenothiazines and other psychotropic drugs are contraindicated as they may cause rapid deterioration. Hypersexuality and loss of inhibition occurs, with this being more problematic in male dementia patients. The use of certain sedatives or hormone therapy may be required if the uncontrollable patient is placing other people at risk. The use of reality orientation – a focused time/place orientated approach – is promoted as an approach to keeping the demented person in touch with reality. It has been suggested that these programmes may slow down the symptoms, but proof of this is inconclusive. Urinary and faecal incontinence are managed by regular timed toileting, as it is not bladder function that is impaired but the ability to control micturition. The use of indwelling catheters is contraindicated as the demented person does not understand what it is and may cause trauma to the bladder in trying to remove it. Because of the long-term nature of the illness, the family and caregivers require extensive support and counselling. The nature of the illness, the likelihood of it being passed on genetically (unproven at this stage), and the need for information and constant demands for attention need to be the focus of the nursing interventions. Burnout of carers is common, and respite care or the use of community resources to provide backup and free time should be the focus of the support to be arranged. It is not uncommon for spouses to resist all help, but the importance of sustaining the care over a long period of time should be stressed. Extensive research about Alzheimer’s disease is under way, and new drugs are available which claim to slow down the dementia process if given in the early stages. The challenge is therefore to identify the patients who

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could benefit from these newer forms of treatment. There are no known ways of reversing the process.

Depression Depression is very common in older people for a number of reasons. The loss of income, function, status, independence and family contributes to a feeling of hopelessness and despair. Postoperative depression is also common. Suicide contributes significantly to the causes of death in men over 60 years. Symptoms of depression include insomnia and early morning waking, loss of energy, poor appetite, constipation, bouts of tearfulness, social withdrawal and personal disinterest. In severe cases, pseudo-dementia may mask the depression. It is important to distinguish between normal reactive depression, which occurs following bereavement or similar loss, and endogenous depression. The older person who has suffered a personal loss must be assisted in working through it and may need a short course of antidepressants if there is no improvement, with therapeutic counselling and environmental adjustments. The person with endogenous depression responds well to various forms of therapeutic intervention, and should be provided with these, irrespective of their age. Electroconvulsive therapy is again becoming popular in certain circumstances where responses to moderate doses of antidepressants are unsatisfactory, as it avoids the potential side effects associated with drugs, particularly at higher doses.

Care of specific conditions The common medical conditions are normally treated in the same manner as for younger people, but there are some special considerations, as discussed below.

Cardiovascular disease Cardiovascular disease, lipid disorders and hypertension occur commonly in older people, not only because of the inherent risk factors such as age, genetic risk and gender, but also because of the cumulative effects of environmental factors and coexistent diseases. The influence of migration and lifestyle changes, such as diet, smoking and alcohol consumption, has resulted in all population groups being equally at risk for these conditions. Cardiovascular diseases, such as congestive cardiac failure, myocardial infarction and arrhythmias, occur frequently due to a combination of age-related changes as well as the sedentary lifestyle of many older people. Ageing also makes older people particularly susceptible to the adverse effects of medicines, such as digoxin combined with diuretics, which cause hypokalaemia.

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Symptoms such as confusion, arrhythmias and nausea may occur. The evidence for treating all patients at risk for stroke or myocardial infarction with two aspirin daily as antiplatelet therapy is well documented. Patients must be observed for signs of bleeding, such as nose bleeds and occult blood in the stools, as they may be taking other medication with a similar effect, such as non-steroidal anti-inflammatories (NSAIDS). This may result in iron deficiency anaemia. In addition, patients with atrial fibrillation should be treated with warfarin, which requires careful monitoring of the PT or INR. Anaemia may present with a variety of symptoms or exacerbate underlying conditions. The frequency and severity of angina attacks may increase due to reduced oxygenation, and shortness of breath in COPD and congestive cardiac failure may be aggravated. Cerebrovascular accidents or strokes are devastating and life threatening. The special considerations are discussed in more detail under ‘Stroke’. Special nursing care is required at all stages, with the correct positioning of the patient being important during the acute stage if one is to improve or shorten the rehabilitation process. Besides general physical care, counselling of people who are at risk of developing a stroke should be intensive. Hypertension, diabetes, atrial fibrillation, smoking, obesity, hyperlipidaemia and a sedentary lifestyle are all contributory risk factors which can be managed by the patient if they have accurate information.

Hypertension Evidence has been overwhelming in recent years that the treatment of hypertension in the elderly reduces the risk of cardiovascular disease. Isolated systolic hypertension (systolic blood pressure of > 160 mmHg with a diastolic blood pressure < 90 mmHg) accounts for approximately 60% of hypertension in the elderly. It is associated with a significantly increased risk of death or disease from cardio- and cerebrovascular diseases. Treatment is aimed at reducing the systolic blood pressure to 140 and diastolic blood pressure to 90 by means of exercise, diet and relaxation techniques. Drug treatment is based on a series of three readings over a period of weeks. Weight loss, limiting salt intake and exercise such as walking form the basis of non-drug intervention. Any person with a systolic blood pressure of more than 160 mmHg after three weeks of non-drug interventions must be referred for treatment. Occasionally one will come across a patient with very high blood pressure who is resistant to treatment. Aggressive treatment should be handled cautiously as

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lowering the blood pressure to ‘normal’ levels may lead to postural hypotension, dizziness and falls.

Chronic obstructive pulmonary disease (COPD) The years of cumulative damage to the lungs as a result of smoking and/or industrial and environmental pollutants contribute to the high rate of COPD in the elderly. This group of diseases includes emphysema and chronic bronchitis. Unfortunately, the damage is usually irreversible, and these patients are prone to superimposed bacterial infections, which may require hospitalisation for intravenous antibiotic therapy. Asthma, after 40 or more years, is also less responsive to treatment, and may become irreversible after many years if inadequately treated. Although the chronic and acute management of asthma differs from COPD, the resultant shortness of breath, anxiety and impact on quality of life is similar. The shortness of breath that these patients experience may significantly affect their lifestyle. Exercise tolerance is limited. As the frequency of breathlessness increases, patients become less active to conserve their energy. A steady programme of exercises can build up exercise tolerance and activity levels, although overall lung function cannot be improved through rehabilitation. Domiciliary care includes counselling and support; the use of medication, particularly inhalers; and advice on coping with the illness. Nebulisers for home use may be prescribed, and low-dose long-term oxygen therapy (LDOT) is becoming common. Oxygen is usually prescribed for up to 20 hours per day, at 4 ℓ/minute with a 28% mask or cannula. This requires regular monitoring of oxygen saturation levels and patient compliance. LDOT reduces the number of infections and hospitalisation, and improves long-term survival. Chronic respiratory diseases may occur in conjunction with other diseases. There are medicines commonly used to treat respiratory symptoms, such as bronchodilators, which may be contraindicated in the presence of certain cardiac diseases. Information on these contraindications or access to information relating to the medication should be available.

Degenerative joint and bone disease Wear and tear on the joints may lead to osteoarthritis and other degenerative diseases that have an impact on functional ability and mobility. Attempts to manage chronic pain may trigger a cascade of side effects, either from the medication or from depression. Non-steroidal anti-inflammatory drugs, commonly used in pain management, should be used cautiously in

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older people due to the risk of adverse drug reactions and drug interactions. Limited mobility may affect the ability of the individual to provide self-care, such as aspects of personal hygiene and basic housework. Specific diseases such as polymyalgia rheumatica occur more frequently in older people. The symptoms include lethargy and muscle pain and stiffness, particularly in the morning. The diagnosis needs to be considered as patients tend to respond very well to lowdose corticosteroid therapy. Rheumatoid arthritis tends to become less severe with increasing age, but patients need assistance in adapting to the limitations caused by the damage to the joints. Polyarticular gout is often mistaken for rheumatoid arthritis, and responds well to therapy. Surgical replacement of severely affected joints has a high success rate in all age groups, and contributes significantly to improving the quality of life of the chronically disabled older person. Osteoporosis results in reduced bone mass, and occurs mainly in postmenopausal women. It is less common in black women, who appear to have a greater bone mineral density, which is thought to be associated with greater levels of physical activity. A family history, smoking, chronic use of corticosteroids, low calcium intake and low levels of activity increase the risk of developing osteoporosis. Vertebral fractures and fractures of the femur and wrist are more likely to occur. Pain often accompanies vertebral compression fractures, and nurses need to counsel those with osteoporosis, and also take an active role in promoting methods of preventing this disease, including the use of hormone replacement therapy and other non-hormonal medication that improve bone mineral density.

Diabetes mellitus Type 2 diabetes mellitus (formerly referred to as noninsulin-dependent diabetes mellitus) occurs commonly in the elderly. It is important that glycaemic control is achieved as complications associated with poorly controlled diabetes are significant. Cerebrovascular events, amputations following gangrene and loss of vision are the most common complications, all resulting in severe loss of functional independence. Reduction of weight, a diet that is low in fat and excludes refined carbohydrates, and exercise significantly reduce dependence on medication, although these alone are seldom sufficient for adequate glycaemic control. The introduction of a diet based on the glycaemic index is rapidly becoming the basis of weight and glycaemic control. The glycaemic index (GI) is a ranking

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of carbohydrates based on their immediate effect on blood glucose (blood sugar) levels. Carbohydrates that break down quickly during digestion have the highest glycaemic indices. The blood glucose response is fast and high. Carbohydrates that break down slowly, releasing glucose gradually into the bloodstream, have low glycaemic indices. By concentrating on low GI foods or combining them with higher GI foods, it is possible to improve the control of blood glucose levels. The use of insulin, either during an acute episode such as an infection or surgery, is used more frequently for Type 2 diabetes than in the past, irrespective of age. Older patients who cannot achieve adequate glycaemic control with oral hypoglycaemics are commonly placed on daily doses of long-acting insulin, either as a supplement to oral medication or as an alternative. Nurses need to understand the reasoning behind the combination therapy and their role in monitoring and educating the patients. When one is confronted with a patient who is unable to achieve reasonable glycaemic control but is keeping to the treatment regimen, it is important to look for an underlying cause. This is often a chronic fungal foot infection, intertrigo, a low-grade infection in a leg ulcer or a similar cause. Treatment of the infection will result in improved control of blood sugar levels. Regular monitoring of blood pressure is important as hypertension associated with Type 2 diabetes is common, and significantly increases the risks of developing cardioand cerebrovascular diseases. Impaired bladder function is associated with diabetes, and may result in repeated urinary tract infections and overflow incontinence, caused by a hypotonic bladder. Peripheral vascular disease and impaired circulation place older people with diabetes at particular risk as they are unable to care for their feet satisfactorily, leading to trauma or infections.

Thyroid disorders The signs and symptoms that accompany hypothyroidism, such as fatigue, memory loss, decreased hearing, depression, constipation and hair loss, are often ascribed to ‘old age’, so it is important to consider thyroid disease in the elderly presenting with these symptoms. Thyroid replacement therapy usually has very good results. Hyperthyroidism may present as unexplained cardiac failure, atrial fibrillation or psychiatric symptoms such as agitation or dementia. Loss of appetite and unexplained weight loss are common. The clinical signs may be extremely subtle in the elderly. Antithyroid drugs and radioactive iodine are the preferred forms of treatment.

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Poor hearing and poor vision The ear is responsible for hearing and maintaining balance. It is estimated that up to 40% of people over 75 years have some hearing impairment, which may be the result of sensory or conductive impairment. Presbycusis is the more common form of sensory impairment in older people, and results in reduced ability to discriminate between sounds. Poor hearing as a result of wax build-up may also present as dizzy spells. This is treated by softening the wax by initially instilling suitable drops for three days before irrigation. If the eardrum cannot be visualised, medical advice should be obtained before syringing the ears. Ear buds should be avoided as these may result in the wax becoming impacted against the drum. Tinnitus is very distressing for the sufferer as it presents as buzzing, hissing or ringing in the ears, especially when trying to sleep. It also reduces the ability to hear. Drug therapy has not proven effective and there is currently no simple remedy. Unlike spectacles, hearing aids are not suitable for every type of hearing loss, and require correct fitting followed by support and training in the use and care of the appliance. Many people are unable to use a hearing aid. When speaking to hearing-impaired people, consider the pattern of hearing loss. As the highest and lowest frequencies are normally affected, speech should be slower and direct, but avoid shouting as this tends to raise the pitch. As a significant amount of comprehension relates to what someone can see, the lighting in the room may affect communication, and the speaker should not stand with the light source behind them. Sight is also commonly compromised in older people. The common disorders which affect vision are the following: • Presbyopia (changes in the ability to focus due to normal degenerative changes) • Cataracts • Glaucoma • Senile macular degeneration • Diabetic retinopathy. The incidence of cataracts and glaucoma in Africa is particularly high and often results in blindness, particularly in rural areas where health services are limited. Both respond very well to treatment, either medical or surgical as appropriate. The risk of diabetic retinopathy can be reduced by maintaining good glycaemic control. The nurse as educator is a key person in this field, both for the patient and the lay care worker.

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The combination of an inability to adapt to glare, loss of peripheral vision and reduced accommodation are the reasons most older people stop driving at night. The reduction of vision may also result in elderly people becoming disorientated and confused. The older person who is in hospital or removed from their normal environment may present as confused or wandering. The sensory impaired person may be labelled as demented due to inappropriate answers and will tend to withdraw from society out of fear of ridicule. The sudden loss of or deterioration in sight is a medical emergency, and requires immediate referral. This loss may be complete or partial, and could be the result of retinal artery occlusion, temporal arteritis or a detached retina.

Dehydration Owing to the altered thermoregulatory capacity of the older person, in conjunction with medicines such as diuretics and herbal remedies or physical limitations, the risk of dehydration is significantly increased. Older people are often less likely to feel thirsty because of reduced capacity to concentrate urine, along with a reduced fluid intake. Furthermore, because of increased incidence of urinary urgency, older people are inclined to restrict their fluid intake. Where the elderly person is unable to reach water, either due to restraints, physical impediment or distance, the risk is also increased. When dehydration occurs, there is a risk of confusion, as well as the potential to develop urinary tract infections and pressure sores. Symptoms of dehydration in older people are a warm, dry skin, concentrated urine, constipation, weight loss and, in severe cases, confusion. The technique of pinching a fold of skin is not a good indicator of dehydration as the skin loses elasticity with age. The task of the nurse is to ensure that the patient is able to reach fluids if there are physical constraints, as well as educating the elderly and their caregivers in the importance of adequate hydration.

Epilepsy This disorder is often misdiagnosed in the elderly, but occurs commonly after strokes as a result of anoxia, hypoglycaemia, the presence of brain tumours or as an adverse effect of certain drugs, such as certain antidepressants, antipsychotics and theophylline. The seizures may present in different ways. The classical description is that the person is unaware of what they are doing and may engage in unusual repetitive actions. These episodes are often diagnosed as transient ischaemic attacks, and the nurse needs not only to observe the episode, but also to record and report the person’s behaviour immediately afterwards. Anti-epilepsy drugs are effective in controlling these seizures if diagnosed.

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Syncopal attacks (fainting spells), which may also be misdiagnosed as seizures, or transient ischaemic attacks may be the result of a cardiac arrhythmia. A full cardiac and neurological assessment is required.

Dizziness The causes of dizziness are varied, and it is a frequent complaint in older people. Drug treatment should be limited to true vertigo, where there is a sense of the ‘room turning’. Even this may cause unwanted side effects in older patients, including hypotension. Withdrawing or adjusting the dosage of medication, such as diuretics and drugs which cause postural hypotension, may resolve the problem. True vertigo may be accompanied by nausea. This may be a symptom of Ménière’s disease (which also has hearing loss and tinnitus), viral labyrinthitis or occasionally due to drugs such as aspirin or indomethacin. Cardiac arrhythmias or heart block may also present as dizziness or syncope, and are diagnosed by checking the rate and regularity of the pulse or by ECG. Prolonged coughing, anaemia or hypoglycaemia may cause dizziness. Excessive straining to pass urine results in micturition syncope in older men, which causes dizziness or fainting. Impacted ear wax is well recognised but easily missed as a cause of dizziness and is readily treatable. The correct method of removing wax is described elsewhere in this Chapter. The role of the nurse is patient education and reassurance as very few other medical interventions are effective.

Falls Instability is described as one of the giants of geriatric medicine. The combination of altered posture; changes in gait; decreased sensory function such as vision, hearing and balance; and increased potential for adverse effects of drugs may lead to older people tripping and falling. Decreased bone density results in fractures, particularly of the hip and wrist. Research has shown that elderly people are more likely to fall at night and in institutions, although this may be secondary to the reason for which they were admitted to care originally, such as a stroke or visual impairment. Repeated falls are often a sign of impending deterioration in general health, and such people should be closely monitored. The nursing interventions include identifying risk factors that could result in a fall, advising older people about environmental hazards, including inappropriate footwear, and teaching them how to get up following a fall. Discussion should also take place about how to call for assistance in such an instance.

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This is especially important as many elderly people either live alone or with equally old spouses, and the consequences may be catastrophic. A person who is unable to get up may remain on the floor for an extended period, and may become hypothermic and develop pneumonia, both of which have a high mortality rate.

Thermoregulation Heatstroke

The incidence of heatstroke is unknown, but given the changes in thermoregulation and the impaired recognition of thirst, heatstroke in Africa is not unlikely. The importance of adequate fluids must be stressed.

Hypothermia Hypothermia is defined as a body temperature below 35 °C. It occurs commonly in the community but is usually misdiagnosed, particularly in countries with warmer climates. The patient may present with mild confusion but no signs of infection. Severe hypothermia is accompanied by a very slow pulse rate. The absence of shivering is not uncommon in the elderly. A history of alcohol misuse, extended exposure or use of phenothiazines should alert the nurse to the possibility of hypothermia. It is essential that every emergency facility has a lowreading thermometer (25–40 °C), which should be used if the normal thermometer reading does not register. The most accurate reading is obtained rectally. As a matter of principle all patients with hypothermia should be rewarmed slowly with cardiac monitoring in place. Controlled external warming using a space blanket and a warm (not hot) electric blanket may be used in mild cases, but caution is required as too rapid rewarming may result in cardiac arrhythmias and death. Older people who complain of being continually cold do not necessarily have hypothermia. An assessment of the medication being taken as well as thyroid function testing should be done to exclude these as probable causes.

Immobility Loss of mobility severely threatens the older person’s autonomy and quality of life. It is described as the inability to move independently, with or without a walking aid. It refers to those who become bed- or chair-bound as well as those unable to venture outside their home. It may be the result of physical limitation, such as breathlessness, angina, pain, vertigo, instability, painful feet or claudication. It can also result from psychological factors such as fear of the surroundings, anxiety, depression, forgetfulness, loneliness or fear of falling.

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There may also be environmental barriers such as illfitting shoes, stairs and rough ground. Immobility resulting from diseases such as cardiac failure, COPD and degenerative disorders can be improved in most circumstances. The rehabilitation following one or more falls becomes increasingly difficult as the person loses self-confidence. The assistance of a physiotherapist is essential in regaining walking skills. Impaired balance, Parkinson’s disease and arthritis require a multidisciplinary approach, with achievable small goals to prevent demotivation. Satisfactory transfers and walking require a well-lit environment and the availability of suitable aids and appliances as appropriate. Using chairs, towel rails in bathrooms and other light furniture is dangerous. Railings must be securely fitted. The supply of suitable appliances, such as walking frames and sticks, is sometimes limited, but they are less costly than the expense involved in providing homecare or institutional care to a housebound person, or the surgical repair following a fractured femur. The nurse should be aware of the need for suitable appliances, the methods of obtaining them, and the education of the patient and caregivers in this aspect of care.

Leg ulcers Reduced skin elasticity combined with poor peripheral circulation and chronic hypoxia may lead to the formation of varicose ulcers following relatively minor trauma to the lower leg. The presence of diabetes or cardiac failure with pedal oedema also affects the healing processes. Treatment of leg ulcers varies according to current policies and the improved products available, but clinical practice should be evidence-based. The treatment of venous and arterial ulcers differs. Anaemia and inadequate dietary intake of vitamins and protein will inhibit the healing process. Significant protein loss takes place through the wound exudate, and dietary supplements may be required. The basic nursing care entails the provision of rest and elevation of the affected limb, moist wound-care methods, observation for signs of infection and advice concerning nutrition and exercise.

Nausea and associated symptoms Nausea is common in older people and may be the result of a number of underlying causes. Acute onset of nausea may be due to a urinary tract infection, middle ear infection, constipation or gastric upset. It is not uncommon for nausea to accompany chest pain in cases of severe angina, or as an early sign of a respiratory infection. This requires a full assessment and treatment of the underlying cause.

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Heartburn or dyspepsia may be associated with chronic nausea, and may be due to a variety of causes, including hiatus hernia, gastric ulcer and oesophagitis. While these complaints are sometimes overlooked, persistent symptoms require investigation, and these patients should be referred for medical attention. In the later stages, the patient may present with difficulty in swallowing, which could be due to an oesophageal stricture. Chronic nausea may also be a symptom of drug toxicity, particularly digoxin and aminophylline. COPD patients who regularly use nebulisers and inhalers often complain of nausea and sore throat, and should be advised to gargle after using the medication.

Parkinson’s disease This neurological disorder is progressive and is usually a disease of older people. Medication is effective, although the introduction of particular drugs may be delayed in the earlier stages until symptoms and functional limitations become an obstacle. Regular monitoring of functional capacity is important as the efficacy of medication diminishes over time, so dose alterations or additional medication may be required. Surgery has also recently become an option, limited to particular circumstances and to those who can afford it. The long-term care problems are loss of function and mobility, with eating problems and mental impairment (and depression) in the later stages. The combination of medication and immobility may result in urinary incontinence and constipation. With careful nursing, it is possible to retrain a patient who has become incontinent following catheterisation, but this process takes up to three months. With the assistance of the physiotherapist it is also possible to remobilise many patients who have become immobile due to a period of hospitalisation. The joint rigidity that is part of Parkinson’s disease affects the ability to dress and bath, while the tremor may limit independence. Appliances are helpful in assisting patients retain their independence. Parkinsonism is a common side effect of certain medication in older people, particularly major tranquillisers and drugs used for nausea. It is important to distinguish between these symptoms and the disease, as it is possible to treat the symptoms with good effect if identified early and the offending drug is withdrawn.

Pressure sores Pressure sores are also known as decubitus ulcers, and prevention is a nursing function. It is also important to teach family and caregivers the principles of prevention. Various scoring systems are used to assess the risk of developing pressure sores, usually relating to the mobility

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of the patient, their mental state and continence, their nutritional state and the degree of bed rest. These are useful in highlighting people at risk. Environmental factors, such as poor lifting techniques or torn linen, may be the cause of the initial injury to the skin, which results in an ulcer. Alternatively, continuous pressure may prevent circulation to the underlying tissue, resulting in deep tissue damage that becomes noticeable only after a few days. As the skin of older people tends to lose its moisture and elasticity, preparations containing alcohol for skin or pressure care should be avoided. Plain aqueous cream rubbed in gently (so as not to damage underlying skin) or warm water and soap with gentle drying, in addition to regular positional changes, form the basis of pressure care. Wheelchair- or chair-bound patients must also be assisted and encouraged to change position at least every two hours. Where pressure sores develop, it is important to evaluate the current practice in the hospital and treat the patient accordingly. An important principle is not to change the form of treatment too often. Moist wound healing is most effective, and appears to result in a reduction in pain. Wound-cleansing agents should not cause damage to the new skin. The use of Eusol solution is no longer recommended. Accurate recording of the site, size and appearance of the ulcer is important to enable other team members to assess the sore. The stages of pressure sores are described as follows: • Stage 1 . Intact skin, red mark which does not fade • Stage 2. Superficial abrasion, blister • Stage 3. Full thickness skin loss, with or without necrosis • Stage 4. Full thickness skin loss with extension, including underlying muscle with or without sinus formation and necrosis.

Prevention of incontinence Incontinence is the common factor causing older people to need institutional care. It can be prevented or limited if a number of basic precautionary steps are taken. There are also many causes of transient incontinence that can be remedied by taking simple precautions and actions. The normal ageing process results in older people needing to pass urine once or twice during the night. Nighttime frequency is normally due to detrusor instability or excessive evening fluid intake. Daytime frequency that is not accompanied by night-time symptoms may be due to excessive fluid intake, caffeine or poor toileting habits. Medication may also account for unusual micturition patterns.

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53.4 Reversible causes of incontinence Reversible causes of incontinence are as follows: • Delirium/acute confusion • Infection of urinary tract • Atrophic vaginitis • Pharmacological preparations: sedation, other medication • Endocrine disorder: diabetes, hypercalcaemia • Restricted mobility and excessive fluid intake • Stool impaction and small bladder.

Senile vaginitis is the result of low oestrogen levels in postmenopausal women, resulting in urgency and frequency. Frequency that occurs during the daytime and nighttime may be due to detrusor instability (unstable bladder), which responds well to bladder retraining and the use of medication. An enlarged prostate gland may cause bladder outlet obstruction in older men, resulting in a poor urinary stream or frequency as a result of incomplete bladder emptying. Outlet obstruction may require a prostatectomy or, if minor, may be controlled by medication. Transient incontinence after prostatectomy commonly lasts for approximately 6 weeks, although the incidence is unknown. Pelvic floor exercises and bladder retraining are partially effective in controlling the symptoms, although appliances may be required during the rehabilitation phase. In the hospital environment, the combination of intravenous therapy, medication and high beds may result in a patient wetting themselves. If this is repeated, it is possible that the patient is labelled incontinent and an indwelling catheter ordered in response to a request from the nursing staff. If a patient is confused, regular toileting is needed. Awareness by the nurse of the reversible causes will enable early intervention and treatment. Postoperatively or during an acute illness a catheter may be needed for monitoring urinary output. This should be removed as soon as possible. Following a cerebrovascular accident, the majority of patients are able to regain their bladder control soon after regaining consciousness. The assistance of the physiotherapist in teaching the patient to bridge (lifting their hips off the bed) plays an important part in being able to use a bedpan. However, it is essential to remember that defecation is difficult when the patient is lying flat or at an angle on a bedpan. The use of a commode will encourage the return of normal bowel habits. This is also true following orthopaedic surgery.

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Older patients are often reluctant to drink adequate fluids as they believe this will increase the need to pass urine. Adequate fluid intake is required to prevent urinary frequency, as concentrated urine is a bladder irritant, while inadequate hydration increases the likelihood of constipation. The nurse needs to explain the importance of adequate hydration. Urinary alkalinising agents such as Citro-Soda®, used to relieve urinary symptoms, should be used cautiously, as they may mask urinary tract infections, or lead to diarrhoea and renal calculi. Patients with indwelling catheters need to be educated about reducing the risk of urinary tract infections. This includes bowel management, the use of vitamin C to maintain a urinary pH of below 7, drinking adequate fluids, and maintaining a ‘closed’ bag system.

Stroke A stroke is the result of ischaemic or haemorrhagic cerebral episodes that result in decreased perfusion to a part of the brain. This is followed by cerebral oedema, and may result in confusion, coma or death. The stroke is usually accompanied by paralysis or loss of sensation of one side of the body (hemiplegia or hemiparesis), and speech and swallowing disturbances if the right side is affected. Where the stroke affects the left side, the patient is more likely to suffer from an inability to recognise the affected side, making rehabilitation more difficult. A transient ischaemic attack (TIA) is defined as a stroke-like episode that lasts less than 24 hours. Not all TIAs present with a hemiplegia or hemiparesis, but could manifest as facial paralysis or slurred speech. The prevention of TIAs and further strokes requires that patients are given accurate information and education.

Risk factors for initial or repeated strokes in older people include hypertension, smoking, cardiac arrhythmias such as atrial fibrillation, obesity and diabetes. All of these may be controlled by weight reduction, complying with medication regimens, or avoiding the trigger factors. The mortality rate from strokes is the same in men and women over 60, although the incidence in men is higher. The nursing care of a stroke patient depends on the phase of the stroke. If the patient is unconscious, the normal routine care is provided, including the maintenance of a patent airway, nutrition and hygiene. The correct positioning of the affected limbs should begin in this phase, as this may reduce the rehabilitation period. This entails positioning the patient on alternate sides with correctly placed pillows to support their limbs. Once conscious, as the early rehabilitation phase begins, the role of the nurse changes as they provide the continuum of care in the absence of the other therapists and team members. Depression following a stroke is common and may require antidepressants. The need for urinary catheterisation should decrease once consciousness has been regained as the risk of urinary tract infections increases with catheterisation. Approximately half of stroke patients may require an indwelling catheter for up to six weeks, while fewer than 20% still require one after six months. Following discharge from hospital, the patient’s family and community care staff provide care with the support and guidance of the nurse. As with dementia, the effect of a stroke is devastating for the caregivers, and the same principles apply to the provision of respite care, support services and counselling. Stroke clubs are found in most communities, which enable the patient and the family to share their frustrations and solutions, improving their ability to come to terms with the change in lifestyle.

Table 53.6  Types of elder abuse

Physical abuse

Physical neglect

Assault Rough handling Burns Sexual abuse Unreasonable physical restraint

Dehydration Malnutrition Poor hygiene Soiled or inappropriate clothing Medication given incorrectly or omitted Lack of medical attention

Psychological abuse

Material abuse

Verbal and emotional abuse Threats Isolation Confinement

Financial neglect Exploitation and misuse of funds/pension Theft Withholding income

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Elder abuse Abuse is not limited to any one age group, culture, income, social class or gender. Elder abuse is a problem that has been in existence for as long as there have been vulnerable frail or older people. The emergence of elder abuse as a social problem is due to recognition of the problems that occur, the empowerment of the elderly, and improved case finding and reporting systems. While the rights of the elderly person are protected in the South African Constitution, no mechanism exists as yet to ensure that these rights are respected or that protection is available. There is a distinction between abuse and neglect, with the term ‘abuse’ being used to describe the wilful infliction of injury or punishment on or theft from a person, and neglect being the failure or refusal of the caregiver to provide the essentials required to avoid physical or mental distress or safety. Significant research findings show that physical elder abuse is most common where the caregiver is not trained or provided with support, and is more likely to occur if the patient is very dependent. It is not uncommon for a previously abused spouse to become abusive towards the newly dependent partner. Physical neglect is usually due to a lack of knowledge and circumstance, although emotional neglect is more common in institutional settings. Abuse may be intentional or unintentional, active or passive, as indicated in Table 53.6. The use of excessive sedation occurs in institutional settings where it is used to enable staff to cope, particularly in situations where low staff ratios are the norm. Restraints are another form of physical abuse commonly found in hospitals or institutions, which results in patients becoming aggressive and frustrated, especially if they suffer from intellectual impairment. Inappropriate sedation may also result in a cascade of problems leading to incontinence, pressure sores and infections. It is important that every organisation that deals with the elderly acknowledges that elder abuse exists, and that it develops guidelines for dealing with complaints as they arise. It is important that the findings of these investigations be made available to the complainant, their family and the caregivers. Where the complaint is found to be valid, the steps taken should provide reassurance to the older person and reinforce the fact (to the caregiver) that abuse is not acceptable. It also assists the abused person to come to terms with their fears of further abuse. It is equally important, that where a complaint is unfounded, the information is also made available, enabling the person against whom the complaint has been made to continue working. Counselling and support by the nurse, both for the elderly person and the caregiver, helps to re-establish trust.

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53.5 Guidelines for investigating elder abuse Guidelines for investigating elder abuse are the following: • Use a multidisciplinary team approach: different team members may be needed in each situation. • Be aware that abuse occurs in all economic and social settings. • Educate professionals concerning: –– recognition of symptoms of abuse –– methods of assessing situations and patients –– management techniques –– legislation relating to abuse –– obligation to report abuse. • Educate the elderly and their families concerning: –– awareness of abuse –– methods of reporting –– counselling –– rights of the elderly • Ensure that there is an agreed-upon system and methods of dealing with complaints in an institution. Suggestions include the following: –– There is an ‘open door policy’ where senior staff are always available to hear reports of abuse. –– Procedures for reporting are known to residents, family and staff. –– There are procedures for investigations that ensure accuracy of information and protection of rights (privacy, confidentiality, fairness). –– There is a mechanism to allow the older person’s statement to be given in the form of a legal affidavit to protect them from intimidation; this would then be admissible in a disciplinary hearing. • Enforce institutional inquiry and disciplinary procedures. • Give feedback to complainant, family and relevant staff. • Take every complaint seriously and investigate it fully. If fairness prevails and feedback is given, staff and residents become confident in the management of the home.

Conclusion The elderly comprise a specific group of patients within the health services with unique needs and problems. The management of elderly patients requires dedication, vigilance and an in-depth understanding of this group. Effective management of the elderly patient can contribute immeasurably to the health and longevity of the patient.

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Suggested activities for learners Activity 53.1 Visit an old-age home and/or frailcare centre. Find out what the most common problems are among the residents and how the staff manages these problems. Activity 53.2 Visit a community clinic where elderly patients consult. Interview at least two older people to find out what they know about their problems and the medication they are using. Identify those medicines which are prescribed as well as any others the patients are using, particularly self-prescribed medicines, and herbal and alternative remedies. Activity 53.3 Work out a diet and exercise programme for a frail elderly patient. Describe your assessment of your patient and identification of their needs, and relate your assessment to the diet and exercise programme that you will develop for this patient.

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54

Management of people with disabilities

learning objectives

On completion of this Chapter, the learner should be able to: • assess the rehabilitation needs of the person with a disability and their carers and family • plan and implement a programme of care for the person with a disability based on these assessed needs • provide appropriate support and education for the person with a disability as well as their family/significant others to facilitate autonomy, responsibility and accountability • effectively coordinate the care and management of the person with a disability and their rehabilitation • act as an advocate for the person with a disability • refer the person for care and support in the community. key concepts and terminology

ability

The way in which a person interacts with their environment.

disability

The lack of ability to perform a task that is usually accepted as being within the range of the average person who has not sustained a physical or pathological injury.

functioning

The degree to which the person can manage normal activities of daily living and cope within their environment.

habilitation

The process of teaching a person how to function independently within the limitations of an inherited or genetic deficit that has been present from birth.

handicap

The extent or severity of the impairment for a given person to function independently with and/or without assistive devices, resulting from an impairment or disability. This is unique to each person even if the same disability is present.

impairment

The World Health Organization, defines impairment as any loss or abnormality of psychological, physiological or anatomical structure or function. People with disabilities might have all or some of the impairments associated with their disability.

rehabilitation

The process of developing a person to their fullest physical, psychological, social, vocational and educational potential, consistent with their physiological or anatomical impairment and environmental limitations. This is a continuous process which can be affected by the progress of pathology or by ageing.

rehabilitation nursing

The diagnosis and treatment of responses to actual or potential health problems stemming from impaired functional ability and altered lifestyle in individuals and groups. The retention of information and the application thereof and informed decision-making will affect the success of this phase.

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Introduction This Chapter introduces the concepts and philosophy involved in managing and assisting the person with a disability, whether their disability was caused by disease processes, pre-birth or during birthing, or by trauma. The rights of an individual with a disability to care, treatment and rehabilitation in order to develop and maintain and alter daily functionality, so that they can lead an independent or partially independent life within the context of their disability, are inherent in the right to become a contributing member of society. Chapter 2 of the Constitution of South Africa is very specific about the care people with disabilities are entitled to. The nursing care and rehabilitation of the person with a disability does not require new nursing skills, but rather a different application of those skills and a fresh approach to care. Part of that approach is that the person must be at the centre of the team and a key player in any decisionmaking regarding their care. The key goal of nursing management is for the person to achieve autonomy and to assume full responsibility for their ongoing care. It is therefore important that specific strategies be developed to support the person with a disability and to transfer the driving force (agency) from the professional nurse to the person with a disability in the process of becoming a contributing member of society. People with disabilities can and do become contributing members of society, and this contributes to their own wellness physically, psychologically and socially once they have taken over the role of ‘selfmanagement’ within the context of their limitations.

Historical overview Disability under democracy (1994–2017) Since the achievement of democracy, the South African government has had a focus on people with disabilities that is inclusive and noteworthy. The earnestness of the transformational policies and white papers for people with disabilities relates to the seriousness of the government in establishing a just and equitable society for all its citizens. It is an agenda that includes all previously marginalised and vulnerable groups of society, such as people with disabilities, as was encapsulated in the aim of the Reconstruction and Development Programme. The commitment to developing a paper on disability reflected the seriousness of the inclusive approach, which led to the creation of the first disability programme in the Office on the Status of Disabled Persons (OSDP) in the Presidency. On 3 December 1997, the White Paper on an Integrated National Disability Strategy (INDS) was released. The OSDP was tasked to monitor the implementation of the INDS in all government departments, and to ensure the

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management and mainstreaming of all disabilities across all sectors in the country. The vision of the INDS is: ‘A society for all, one in which people with disabilities are actively involved in the process of transformation.’ The INDS was paralleled by the United Nations Standard Rules for the Equalization of Opportunities for Persons with Disabilities and the Disability Rights Charter developed by Disabled People South Africa in consultation with others in the disability sector and organisations representing people with disabilities. The INDS became the benchmark for all future legislation, programmes and projects on disability in South Africa. The fundamental approach of the INDS is based on a social model addressing the needs of those with disabilities and integrating them with the approach used for all citizens. This model is inclusive of sections 1, 2 and 3 of the White Paper on Disability, and Chapter 2 (the Bill of Rights) of the Constitution of the Republic of South Africa, 1996, which outlaws discrimination on the basis of disability and guarantees the right to equality for people with disabilities. The Promotion of Equality and Prevention of Unfair Discrimination Act, passed in 2000, gives effect to the equality clause in the Bill of Rights, and defines ‘discrimination’ as: any act or omission, including a policy, law, rule, practice, condition or situation which directly or indirectly (a) poses burdens, obligations or disadvantage on; or (b) withholds benefits, opportunities or advantages from any person on one or more of the prohibited grounds.

Equality In 2007, South Africa ratified the outcomes of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) and its Operational Protocol without reservation. The country therefore committed itself to respecting and implementing the rights of people with disabilities related to various articles. Unfair discrimination was tested in the Constitutional Court related to the preservation of a person’s human dignity. The Court endorsed the view that: at the heart of the prohibition of unfair discrimination lies recognition that the purpose of our new constitutional and democratic order is the establishment of a society in which all human beings will be accorded equal dignity and respect regardless of their membership of

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particular groups (Prinsloo v Van der Linde & Another, 1997(3) SA 1012 CC/1997 BCLR 759). The Equality Court in Port Elizabeth emphasised the importance of human dignity when it upheld that: there is no price that can be attached to dignity. There is no justification for the violation or potential violation of the disabled person’s right to equality and maintenance of his dignity that was tendered or averred by the respondent … the Court therefore found the discrimination to have been unfair (WH Bosch v The Minister of Safety and Security & Minister of Public Works, Case no. 25/2005 (9)). The Baseline Country Report to the UNCRPD, approved by Cabinet in April 2013, highlights that systemic inequalities and the violation of rights are still experienced on a daily basis by people with disabilities and their families. It acknowledges that: weaknesses in the governance machinery of the State, and capacity constraints and lack of coordination within the disability sector, have detracted from a systematic approach to the implementation of the UNCRPD. The continued vulnerability of people with disabilities, particularly children with disabilities as well as people with psychosocial disabilities, residing in rural villages, requires more vigorous and better co-ordinated and targeted intervention.

The Baseline Report recommends that government accelerates the country’s national agenda for the realisation of rights of people with disabilities by, among others, doing the following: 1. Strengthening baseline information for every article of the UNCRPD; 2. Strengthening the implementation of its mainstreamed legislative and policy framework; 3. Targeting interventions in a coordinated and integrated manner through transversal policy and legislation as well as monitoring mechanisms; 4. Strengthening its national disability rights machinery, including creating more enabling environments for organisations of people with disabilities;

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5. Strengthening accountability and monitoring through the introduction of disability rights-based indicators into the governmentwide M&E system, and above all: 6. Accelerating implementation of policies and programmes that aim to provide equal access to people with disabilities, including disability-specific programmes aimed at addressing barriers to participation. (Item 1.2.2 from the White Paper on the Rights of Persons with Disabilities) Care for people with disabilities in South Africa has developed considerably, so that their rights include the acknowledgement of the potential of each person to develop and to be self-sustainable on a physical, psychological and social level. Healthcare institutions have altered their care regimens to adapt to the needs of the individual instead of providing a generalised care regime as happened in the past. Comprehensive care for people with disabilities is available in both state and private healthcare facilities. These units deal not only with the acute phase of disabling injuries, but provide a complete rehabilitation service as well. In addition, there are several communitybased organisations, such as the QuadPara Association of South Africa, the National Council of and for Persons with Disabilities, Blind SA, the South African National Council of the Blind and the National Association for Cerebral Palsy. Such associations offer peer guidance and will support those with disabilities so that they can live as independently as possible.

The development of rehabilitation Rehabilitation developed when it was realised that people who had sustained major injuries or who had disabling pathologies became less functional and lost the potential for future independence. People with disabilities were kept in the curative setting for longer periods of time, which made secondary complications such as decubitus ulcers more likely, which again prolonged their stay in hospital or even led to their death. After discharge, most were sent to long-term accommodation facilities that catered for people with both mental and physical disabilities. This system did not cater for or encourage eventual independence, but focused rather on the physical care of individuals. Two world wars, polio outbreaks, industrial revolutions, and the development of the motor car with its high accident rate have all had a tremendous impact on rehabilitation. The survival rate of people with disabilities

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has increased as medical science has advanced, nursing care has progressed and the infrastructure for immediate care has developed as part of evidence-based practices and best practice guidelines. Medical research and nursing development have increased the knowledge base of how to care for those with disabilities through the involvement of the rehabilitation team and of their families/significant others. Using the above approach, rehabilitation is less complicated than is generally believed, and can readily be put into practice with the cooperation of a wellorganised and motivated healthcare team at curative and primary healthcare level, with rehabilitation as a focus. Throughout this Chapter, recommendations and suggestions are made for changes within existing systems to give those with disabilities better opportunities in life.

Rehabilitation Rehabilitation is the process of developing a person to their fullest physical, psychological, social, vocational and educational potential, consistent with their physiological or anatomical impairment and environmental limitations. The process is guided and initiated by the rehabilitation team. However, maintaining the goals and objectives for progress and the maintenance of optimum health is the responsibility of the individual. Rehabilitation can only be achieved if the person understands the consequences of their disability and the effect it will have on daily functioning on a physical, psychological and social level. The person, and preferably also their immediate family/significant others, needs to develop an accurate perception of their condition and an understanding of what needs to be done to live effectively and as a contributing member of society within the given parameters. Successful rehabilitation is a continuous process. For example, if surgery was involved, the preoperative information sessions should have been directed at alleviating fear and giving information about the process to be followed postoperatively and during the recovery and rehabilitative phases. It is essential that the rehabilitation team meet the person (and, preferably, their immediate family) before the surgery to explain what will happen after the surgery. It will be necessary to continuously explain the nature of the surgery and the disability, as the person and possibly their immediate family may still be in denial and may not fully comprehend the effects of the acquired disability and its effects on the person’s life. To be able to give the correct care, the nurse needs to understand the extent of the person’s disability or impairment and the outcome thereof. Specific terminology is used to describe the various aspects of disability; you should become familiar with this terminology so that

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you can communicate effectively. Read the following carefully.

Functioning Functional ability is grouped as follows: • Grasping and exploring • Crawling and walking • Attention and perception • Language and thinking • Manipulating and changing surroundings. Most activities of daily living are categorised as above. Manipulating the surroundings and acquiring assistive devices to perform tasks will help to fulfil functional expectations.

Ability This refers to the way in which the person interacts with their environment. In rehabilitation, it is important to judge a person’s performance appropriately, ie according to their ability within the framework of their limitations. For instance, a quadriplegic may need help getting up and getting dressed in the morning, but might be able to work on their computer once seated.

Impairment The World Health Organization defines impairment as any loss or abnormality of psychological, physiological or anatomical structure or function.

Temporary or permanent impairment The long-term planning for a person with a functional disability (and, preferably, their family/significant others) will focus on setting short- and long-term goals. Irrespective of the period of the dysfunction, the person (and, preferably, their immediate family/significant others) must still be prepared physically, emotionally and mentally for what to expect and how to maintain independence.

Simple or complex impairment An integrated approach to rehabilitation will ensure that any assistive devices needed for independence will be specific to the disability. Assistive devices must be adapted or replaced as the person’s independence level changes. For example, the weight of the wheelchair may need to be changed as the person’s strength changes – a lightweight wheelchair might be more appropriate at a later stage in the disability, due to the person either gaining strength within the context of their recovery or reaching a plateau in the gaining of ability in the context of their disability.

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Disability Disability is the lack of ability to perform a task that is usually accepted as being within the range of the average person. Disability can be determined according to the following criteria: • The nature of the impairment, eg its intensity or severity • The age of the person • The emotional attitude of the person • Cultural and social expectations • Cognitive abilities • Environmental factors • Family perceptions of the problems and future expectations • Attitudes of rehabilitation staff • Attitude of the person.

Habilitation This refers to the process of teaching the person how to function independently within the limitations of an inherited or genetic deficit. Those born with a disability have never experienced this function, and so cannot be rehabilitated. This person has had to learn to function independently with the help of others from birth, and is therefore habilitated. Independence can be acquired if the rehabilitation team uses an approach where the person’s needs guide the process towards independence.

Nursing assessment and common findings Assessing the person with a disability is essential to seeing the disability in the context of that person’s existence within a family and society as a contributing member. Physical, environmental, social and psychological factors can contribute to well-being.

Subjective data Initial history taking will reveal the extent of the person’s acquired injury. Aspects which need to be taken into account are discussed below.

Previous history Find out about any previous medical and/or surgical history with a view to identifying any potential problems that may complicate the course of recovery and rehabilitation. Of particular importance are underlying medical conditions such as cardiovascular disease, diabetes mellitus or asthma, which may be exacerbated by the disability and complicate the rehabilitation process. It is also important to find out about old injuries and operations, as the disability may exacerbate old problems.

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54.1 The healthcare team in relationship with the person with a disability The healthcare team must develop a lifelong therapeutic relationship with the person with a disability, and, preferably, their immediate family/ significant others, to ensure that secondary complications are addressed as soon as they occur. Secondary complications usually develop as a result of the initial injury: an effect of being paralysed could be developing decubitus ulcers (pressure sores), which arise due to the person not having the ability to do pressure relief or not knowing to ask someone to lift or turn them because of their lack of sensation. Secondary complications are preventable if the person, and, preferably, their immediate family/ significant others, is made aware of potential problems and contacts the rehabilitation team quickly. For example, if a person in a wheelchair gains weight, they need to push the extra weight and need to increase the strength in their arms accordingly.

Current medication Ask whether the person was taking any medication at the time of the disabling injury. Medication that is taken on a chronic basis, such as asthma or antihypertensive medication, will need to be continued, but the dosages may need to be adjusted within the context of the current acquired disability. A disabling injury, like any other injury, evokes the physiological stress response, which may alter the person’s response to medication. It is also important that the multidisciplinary team be aware of any medication the person is taking.

Family history Take a family history and cover any medical conditions that may be present among family members, such as diabetes mellitus, cardiovascular disease, genetically influenced diseases, and psychiatric conditions, such as depression. Hereditary conditions such as diabetes may easily be brought to the fore by the stress of a disabling injury.

Social history Obtain detailed demographic and psychosocial information, as it is necessary to have a full understanding of the person’s circumstances for successful rehabilitation. In addition to routine demographic information taken on admission to the healthcare facility, the following may help with rehabilitation planning:

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• • • • • • • •

Cultural affiliation and background Educational level and professional qualifications Occupation and work history, including income Family structure and social network, Marital status and, if cohabiting, sexual partner Type of housing Access to transport Religious affiliation.

•

Lifestyle Detailed information on lifestyle is also essential to enable the team to manage the rehabilitation programme holistically. Specific information to be obtained includes: • Habits, particularly drinking of alcohol and smoking • Sports and other recreational activities • Diet and food preferences.

•

Psychological state The psychological state of the person with a disability is relevant to the healthcare team, as this can determine the success or failure of the rehabilitation programme. A motivated and positive person will have a far greater chance of successful rehabilitation and reintegration into society than one who is negative, self-pitying or angry. A variety of emotions might be experienced, such as anger, fear, sadness and hope. Relationships might change or experience strain. It is essential for the person with a disability to become aware that they will have to learn to cope with the acquired disability. During the initial assessment, the nurse should start to assess the person’s psychological state by noting attitude, behaviour and expressed feelings, or the lack thereof. All this information is essential to enable the multidisciplinary rehabilitation team to deal with the person holistically and to manage rehabilitation within the context of the person’s individual circumstances. Emotions such as depression, anxiety or anger must not be seen as negative: these emotions show that the person understands their disability and its limitations. Psychotherapy can assist with verbalisation and dealing with these emotions.

•

•

Objective data A full physical examination should be carried out to determine the person’s general state of health and to pinpoint any specific physical problems. The physical examination should include the following: • A full head-to-toe survey during which any obvious external abnormalities and/or lesions will be noted. The nurse should also note the condition of the skin, including colour and perfusion, as well as the presence of any skin lesions or injuries. The nurse should also

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•

•

note the person’s general nutritional state, as this can hamper the healing process and influence a feeling of overall wellness. Examination of the cardiovascular system is done by palpating all major pulses, determining the systemic blood pressure and listening for heart sounds. Any parameters that deviate from the norm should be noted and reported. The effects of the acquired disability must be taken into consideration when this is done. Cardiomyopathy adds additional physiological strain on the healing of the person. The lung fields should be auscultated for breath sounds. Air entry should be equal, and there should be no adventitious sounds heard in the lung fields. The nurse should also observe the person’s breathing while resting their hands on either side of the chest to test for symmetry in the movements of the chest wall during breathing. The person’s respiratory rate and depth should be noted. Paradoxical breathing can indicate diaphragmatic breathing for certain levels of spinal cord injury. Tracheal deviation from the suprasternal notch can indicate a prolapsed lung. Cyanosis wheezes and crepitation might relate to some existing or acquired lung pathology. The abdomen is palpated to detect any masses or hepatosplenomegaly. The abdomen is also auscultated for bowel sounds. The presence or absence of bowel sounds is important in the person with a spinal injury, as paralytic ileus frequently follows a spinal cord injury, or an abdominal impact injury, such as those higher than a cervical six spinal cord injury, where the intercostal muscles will become dysfunctional. Abdominal distension must be observed and measured. Percussion sounds will indicate the potential underlying abnormality, eg timpani for air, dullness for fluid or masses. A basic neurological survey is done by checking the level of consciousness and all reflexes, including pupil reflexes. The nurse will be assisted by the neurological examination or Glasgow Coma Scale. The cough and gag reflexes are significant, as their presence or absence will determine whether the person can be fed orally during the acute phase following injury. If possible, the nurse should also carry out a basic assessment of motor and sensory function. When oedema of the spinal cord decreases, the sensory level may alter – reporting on this progress is essential. The sensation levels can be determined while the person is undressed for a full wash. The nurse should determine whether the person can move all limbs or not, and whether there is any muscle weakness present. It is essential to determine this,

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even before the person is removed from the fracture board (if admitted on this from the prehospital setting). • The general condition of the eyes, hair, nose, mouth, teeth, tongue, ears, nails and external genitalia is assessed, and any abnormalities, obvious lesions or discharges are noted. Protruding, bleeding, asymmetrical appearance, and leaking of fluid can indicate underlying symptoms of the impact of an injury or developing pathology, such as a tumour. • Routine diagnostic tests include urinalysis, bloods for urea, electrolytes and full blood count, electrocardiograph, and chest X-ray. Blood gases, bloods for liver functions as well as sputum and urine for microscopy and culture may also be useful. Further specific diagnostic tests will depend on the condition of the person and will be requested by the doctor. Routine haemoglucose and haemoglobin tests are within the scope of certain categories of nurses. Nurses must use sensory assessment such as touch, inspection, smell and visual analysis to interpret what they experience from the person. • Medical and nursing information concentrates on the person’s physical condition. The physiotherapist and occupational therapist collect information related to functionality. The social worker, key worker or discharge coordinator will collect data related to social or vocational aspects. The family/significant others must be involved to understand the impact of the injury and relate to their own emotions, which can be guided by a psychologist or advanced psychiatric nurse.

Points to consider following disability, trauma and/or other emergencies Grieving The shock of losing one’s independence and the effects of an altered body image following an accident or disabling illness may start the grieving process, which is a way of dealing with the emotions evoked by the situation. In some cases, the person might only become aware of the effect much later due to sedation or ventilation, and they might not initially be able to comprehend the effects of the injury. Mostly, the person will become aware of the disability when they cannot move, see or cannot as they had before the accident. Family members/significant others experience similar emotions, and dealing with these emotions effectively while the person is in a critical phase prepares everyone for eventually playing a supportive role.

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Giving information Questions from the family/significant others must be answered honestly and accurately, without giving false hope. However, information about the prognosis should be given only by the person’s doctor. Thereafter the nurse reinforces what has been said by the doctor, answers any questions and supports the person at all times. It may happen that the person with the disability or the family will ask for the same information from different members of the healthcare team in order to fully understand the prognosis or outcome.

Depression This is often a response to a permanent injury. A psychologist or other counsellor, or even another person with similar disabilities living in society, should be brought in to talk to the person, even if they are still being ventilated. Working through the trauma can help with the healing process. Psychotropic medication can enable the person to have more rest, which will aid the physical healing process. Note that the person’s psychological state can affect how quickly they will progress and stabilise.

Body image Developing a strategy for learning to live with dysfunction is a process, and although an altered body image may never be accepted, the person can learn to live with it.

Dependence Coping with dependence and pleasing a partner who is suffering with the same loss can be a slow and tiring process. Role changes and determining physical, psychological and social needs can take years to master. It is therefore essential that the healthcare team be available once the person has been discharged.

Teamwork It is important to remember that the entire team is important in the rehabilitation process, and that communication within the team on the optimal functional goals for the person is essential. Each member must realise their limitations within their scope of practice to develop the person to their full potential.

Legal protection The rights of people with disabilities are enshrined in the Constitution of South Africa, especially in Chapter 2 (the Bill of Rights), and other policy documents. The Department of Health has a national policy on rehabilitation that emphasises the rights of every person with a disability to receive rehabilitation before and after discharge from hospital or other medical facilities.

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The United Nations Convention on the Rights of Persons with Disabilities, Article 25, pertaining to Health for people with disabilities, of which South Africa is a signatory as of September 2008, states the following: States Parties recognize that people with disabilities have the right to the enjoyment of the highest attainable standard of health without discrimination on the basis of disability. States Parties shall take all appropriate measures to ensure access for people with disabilities to health services that are gender-sensitive, including health-related rehabilitation. In particular, States Parties shall: (a) Provide people with disabilities with the same range, quality and standard of free or affordable health care and programmes as provided to other people, including in the area of sexual and reproductive health and population-based public health programmes; (b) Provide those health services needed by people with disabilities specifically because of their disabilities, including early identification and intervention as appropriate, and services designed to minimize and prevent further disabilities, including among children and older people; (c) Provide these health services as close as possible to people’s own communities, including in rural areas; (d) Require health professionals to provide care of the same quality to people with disabilities as to others, including on the basis of free and informed consent by, inter alia, raising awareness of the human rights, dignity, autonomy and needs of people with disabilities through training and the promulgation of ethical standards for public and private health care; (e) Prohibit discrimination against people with disabilities in the provision of health insurance, and life insurance where such insurance is permitted by national law, which shall be provided in a fair and reasonable manner; (f) Prevent discriminatory denial of health care or health services or food and fluids on the basis of disability.

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The scope of practice of all three categories of nurses, especially that of the professional nurse, dictates the nurse’s responsibilities towards people with disabilities. The scope of practice specifically states that the nurse must remain the advocate for any person with a disability in their care. Once discharged from the healthcare facility, a person with a disability must have acquired the knowledge to see to their own care, or someone should have been trained to look after them. It is the duty of the healthcare team (and mostly that of the professional nurse) to see to postdischarge care, and to ensure that the infrastructure for follow-up care has been arranged before discharge.

The rehabilitation process Planning and implementing the rehabilitation process The perception exists that rehabilitation is a separate and isolated component of nursing care. However, it is an integrated process of information sharing and evaluation of the perceptions of the individual, the family and the significant others about what is happening to the individual physically, psychologically and socially. Rehabilitation starts with the first contact between the person and the healthcare services, including the prehospital phase.

54.2 Rehabilitative care Note on rehabilitation Initially it may be difficult for the person with a disability to focus on rehabilitation when most of their energy is taken up with building up physical strength, attending physiotherapy sessions and learning to use prescribed assistive devices. During this phase, the healthcare team should remain positive and encouraging. Guiding the person with a disability will strengthen their internal locus of control.

The philosophy of rehabilitation The basic philosophy at the core of rehabilitation is that the person has the right to become the expert in their own healthcare management. To do this, the person must have the necessary information to understand their condition so that any limitations on independence are clear, and so that the implication of not taking certain actions or interventions is understood. Decisions on self-care actions should be based on a fundamental knowledge of self-care needs.

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When does rehabilitation start?

The rehabilitation team and its members

Rehabilitation starts when the person is admitted to the care of the healthcare team. It might relate to the prehospital phase when they are treated at the site of the accident or during the progress or reversal of a pathophysiology. Initially, until the person is physiologically stable, information-sharing, prevention of secondary complications and the support of the family/ significant others might be the main focus. The healthcare team will discuss strategies with the person with a disability and the family/significant others while waiting, for instance, for the person to be weaned off a ventilator. It is therefore essential that the process of rehabilitation be introduced on admission to the healthcare institution and continue for the person’s lifetime because of physiological ageing and the progress of the pathophysiology that caused the initial disability. Initial psychological rehabilitation can commence even with the person on a ventilator. Physical, psychological and social rehabilitation are ultimately integrated, and can begin in a way that suits the person. However, the initiating of rehabilitation will be dictated at times on the basis of understanding the person’s previous lifestyle and home circumstances. A suitable member of the healthcare team must visit the person’s home to assess living arrangements and life circumstances. Again, it should be stressed that, depending on the specific disease process or trauma, the full impact of the disability may not be immediately clear, and it may be progressive. Information related to the outcome of the disability must therefore be clearly communicated and re-emphasised, because of the possibility that the person does not fully grasp, or may be denying, the implications of the disability.

Rehabilitation nursing is practised in many settings, including acute care, home/community health, and longterm care facilities. In all these settings, it is the direct care nurse who provides the backbone of care and is able to provide information, education and support to the person and their family/significant others to assist in planning their future. This is the essence of case management. As rehabilitation progresses, the person’s reliance on the ‘umbrella’ of the rehabilitation team lessens. Once an acquired disability exists, the healthcare team’s role may diminish, but it does not disappear.

54.3 Six goals of rehabilitation 1. To achieve maximal functional potential and selfsufficiency 2. To achieve and maintain an acceptable quality of life 3. To ensure that the person’s specific needs are addressed 4. To promote adaptation and adjustment of both the person and their family to a changed life 5. To prevent complications and promote optimal well-being 6. To return the person to successful functioning within the community as a contributing member of society.

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As rehabilitation progresses, so the patient’s reliance on the ‘umbrella’ of the rehabilitation team lessens

Figure 54.1  The healthcare team

The role of the rehabilitation team is initially to assess the person to determine the potential remaining ability by taking a thorough history and physical assessment and performing diagnostic tests. The team must meet and set goals for short- and long-term outcomes. In order to obtain the full cooperation of the person with a disability and their family/significant others, the process of setting goals needs to be understood within the context of the achievement of ultimate functionality in the context of the disability. Each member of the team is responsible for working with a specific aspect of the remaining abilities of the disabled person. For example, the physiotherapist will strengthen the muscles of the arm, and the occupational therapist will teach the person to eat unassisted. Team meetings must include the person and at times their family/significant others. Healthcare team advocacy is essential in order to ensure that the transition of care from one medical team speciality to another will have the ultimate benefit in therapy for the person with a disability.

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Nurse

Occupational therapist

The nurse performs the following functions: • Provides direct care • Maintains the functions of activities of daily living and prevents secondary complications, eg skin breakdown, bladder infection, mouth ulcers • Reinforces the use of skills taught and practised in therapy sessions • Coordinates the daily schedule and team activities • Creates a therapeutic environment • Acts as advocate for the person and their family • ‘Accompanies’ the person through activities aimed at enabling them to overcome the need for help • Supports the family and/or the significant others.

The occupational therapist performs the following functions: • Helps with optimal restoration of function for participation in activities of daily living (work, school, community, recreation) • Assists with activities of daily living and with recommendations in order to live independently • Deals with joint function and protection, coordination, endurance, body mechanics and positioning • Deals with adapting and adopting assistive equipment and prosthetic devices • Evaluates the home environment, home management, prevocational activities and social skills.

However, nursing is much more than the simple functions on this list. It is an interpersonal, comprehensive service to people at all stages of life, ill or well, encompassing a dynamic systematic process of management, clinical care and teaching. In this way, the nurse can effect change that facilitates prevention of illness, disability and suffering, and promotes the regaining of wellness. When it is not possible to regain wellness, it is the nurse’s function to facilitate a peaceful, dignified death.

Speech and language therapist

Doctor

The social worker/discharge coordinator performs the following functions: • Assists with personal issues such as work • Assesses coping history and current adaptation to disability • Assesses availability of family members and support networks • Provides counselling and support • Deals with housing, living arrangements, employment and education • Deals with financial resources • Deals with transportation • Expedites discharge • Acts as liaison between the person, the family and community resources.

The doctor performs the following functions: • Establishes a medical diagnosis and prognosis • Provides medical management such as traction or surgery • Requests and interprets special investigations, and alters treatment accordingly • Prescribes treatment, medication, and therapeutic aids in collaboration with other members of the healthcare team • Directs the progress of the treatment plan in collaboration with the healthcare team.

Physiotherapist The physiotherapist performs the following functions: • Helps the person with the functional restoration of mobility through the application of specific exercises • Deals with range of motion, strength, reflexes, tone, posture, gait, orthotic or prosthetic fit and function, and sensorimotor function • Uses heat/cold, hydrotherapy, electrical stimulation, massage, joint mobilisation and exercise in therapy • Provides training in mobility using orthoses, prostheses, crutches, canes, walkers and wheelchairs.

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The speech and language therapist performs the following functions: • Provides therapy to enhance or restore verbal and written language, articulation, speech fluency and interactive communication • Provides therapy to improve cognitive deficits, memory, and comprehension.

Social worker/discharge coordinator

Psychologist The psychologist performs the following functions: • Evaluates and treats psychological and neuropsychological impairments associated with disability • Assesses emotional and cognitive status • Provides counselling to both the person and family members.

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Dietician The dietician performs the following functions: • Advises on the correct diet for ideal weight maintenance or diets related to underlying or pre-existing pathologies, such as diabetes and food allergies • Advises on foods that will prevent digestive complications.

Alternative medicine practitioner The alternative medicine practitioner performs the following functions: • Assists with relaxation • May help promote physiological activity, eg elimination • Treats with alternative medicine, which will be complementary to current pharmacotherapy. Each member of the team has a specific role to play and each must understand the roles of the others. Coordinating duties will avoid duplication and ensure time is used optimally. The overall goal of the rehabilitation team is to maximise the person’s residual function by using every remaining ability to its fullest possible extent.

Factors influencing rehabilitation Pain Each person’s pain threshold is different, and the nurse should assess the pain and the external and internal factors that contribute to it. Pain or discomfort will cause the person to lose concentration and energy if it is persistent. The person can be taught how to deal with pain. Pain scales must be used to measure the pain, such as the 0–10 scale and smiley faces.

Depression and anxiety Depression influences the rehabilitation process, and for this reason it is important for the nurse to be aware of the person’s mental state. The Hospital Anxiety and Depression Scale was developed in the spinal unit at Stoke Mandeville Hospital to assist with monitoring depression. This system uses a score showing high or low anxiety, indicated by column A, or a depressive state, indicated by column D. Self-perceptions and feelings are also indicated on the questionnaire. Similar scales have been adapted for use in rehabilitation units throughout the world. The scale can also be used outside the healthcare institution. It is an easy scale for a nurse to use to determine why a person with a disability is not progressing psychologically or physically within the context of their functioning. In South African rehabilitation units, the tendency is for the nurse to observe and report on the general mental and emotional state of the person, while the detailed assessment of the person’s psychological assessment

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54.4 Methods to cope with pain Pain can be the most debilitating effect of disability and can contribute to further dysfunctionality. It is therefore essential that pain management form an integral part of the daily management of the person with a disability. Suggestions to help the person with a disability cope with pain: • Relaxation training must be practised continuously, and will become easier with time. • Pace activities. • Listen to your body and use the time when the pain is absent. • Measure the time by the increase of the pain during an activity. • Use positive self-statements. • Use positive thinking to cope with pain. • Pleasant activities, such as hobbies and interests, should be scheduled into your daily routine. • Get involved in activities that are not strenuous, but which can occupy you constructively. • Talk less about pain. • Keep your mind occupied. Using non-drug methods of alleviating pain can help in assessing physical abilities and emotions. However, analgesics may also be necessary.

is done by the clinical psychologist attached to the rehabilitation team. Research has found that social support decreases once the person is discharged, so it is extremely important to refer the person to an appropriate community organisation or service for support and further treatment – research has found that coping strategies and group membership are more important than factors such as functional independence and marital satisfaction. However, it is important that a post-discharge service be implemented once the person with a disability is discharged. The psychological pacification and security of a team of experts on standby can alleviate some stresses in order for the person to concentrate more on priorities related to daily functioning.

Care and management during rehabilitation Points to consider Care and management should take the following points into consideration: • It should be team-centred.

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• It should be specific to the person’s needs. • The person should set and regulate the pace of rehabilitation; however, they are guided by the team if need be. • When possible, accountability should rest on the person’s shoulders. • Goals should be set for the person within the context of the pathology, not plans for the disease process. • Reasons should be supplied if goals are not achieved, and re-planning should take place to meet them. • It should be a process that continues after discharge and can be revised as needs change. • The process should be regularly evaluated with the person, the family/significant others and the rehabilitation team, preferably in the home setting. • It should be speciality service-oriented – the team member best suited for achieving specific goals should play the largest role in the process. • It should incorporate all aspects of existence in planning and goal-setting. The main objective of such services is to achieve behavioural change to help manage the consequences of disability.

Safety during physical transfers and at home Assisted transfer from bed to wheelchair/other assistive device, from wheelchair to bath, or from bed to commode are regular activities when caring for a person with disabilities. However, they must be allowed to control this process and take responsibility for safe transfer. The following are some points to consider and suggestions for safe transfer: • The assistant must ensure the correct hoist/lifting device/sliding board is available and in working order. • The assistant must understand and be prepared to lift the person, who may be a dead weight if unable to offer any assistance. • The assistant must be able to use the correct lifting methods so as to protect their own back. • The person should be encouraged to inspect the environment to eliminate any risk before transfer. • The person should issue verbal instructions to the assistant before the transfer begins. • The assistant should then repeat the instruction to ensure understanding and so that the person is prepared for the transfer. • The assistant should be aware of high-risk transfers, such as into the bath. It is advisable to place a notice in bathrooms to remind everyone of the temperature of the water.

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Note that there is a particular danger of injury during transfer, and the assistant and/or person must inspect their skin at least three times a week for scrapes and bruises.

Activities of daily living It is important for the person to achieve an optimum degree of independence in the routine activities of daily life, such as dressing, eating, grooming, personal hygiene and toileting. Exactly how much can be achieved depends on the extent of the person’s disability. Rehabilitation team members make use of remaining abilities and work out ways to enable the person to achieve the goal of carrying out the activities of daily living. For example, if there is some arm movement, the person is encouraged to hold their own cup or spoon and to eat by themselves as far as possible. As recovery progresses, the person is encouraged to extend the range of tasks that they are able to carry out.

Skin care Skin care and care of pressure areas are of vital importance and must remain so for the rest of the person’s life. During the acute phase, the healthcare team gives very careful attention to the skin and to pressure areas and ensures that the person’s position is changed regularly. During the rehabilitation phase, the person or caregiver must be shown how to care for the skin and pressure areas. It is important to explain how to inspect the skin for red patches, blisters or other changes in skin colour that may give warning of an impending pressure sore/ decubitus ulcer. If a red area develops, the person must be kept off it. The paralysed person must be turned from side to side and not positioned on their back, as they will sit on their bottom during the day when sitting in a wheelchair. Initially the person must be turned every 2 hours; the time intervals may be increased by 30 minutes if no red areas develop.

Bladder care Many people with disabilities, especially those with a spinal injury, cerebral palsy or other neurological disorder, have difficulty emptying their bladders. In these cases, bladder care must be undertaken. Such care is important both for social acceptance and to prevent a bladder or kidney infection due to urine stasis. Two possible problems are a flaccid (atonic) bladder and a spastic bladder. 1. The flaccid bladder is able to retain large volumes of urine, but must not be allowed to become overfull or the person will develop hydronephrosis with ascending urinary tract infection. The recommended method for draining this type of bladder is intermittent

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catheterisation every 3–4 hours. Initially the person will have an indwelling catheter. Subsequently the indwelling catheter is clamped and released at 3–4-hourly intervals, and finally the routine will be to have intermittent catheterisation carried out every 3–4 hours. Initially this is done by the nursing staff, but ultimately the person or caregiver will have to do it at home, and therefore the person and/or caregiver must be taught how to do intermittent catheterisation and how to prevent infection due to catheterisation (refer to Chapter 7). 2. The spastic bladder is unable to hold large volumes of urine and therefore leakage occurs between catheterisations, which are uncomfortable and socially unacceptable. It is possible to have a permanent indwelling catheter in situ and there are many catheters on the market that have been developed especially for this purpose – such a catheter is changed on average every six weeks. People with indwelling catheters need to be taught basic catheter care to keep the urethral meatus clean and to prevent urinary tract infection. Alternatively, males may wear a condom drainage system (urinary sheath) in between intermittent catheterisations to drain the overflow. Females who do not have a permanent catheter can carry out intermittent catheterisation more frequently, eg every two hours instead of every four hours. Supra-pubic catheters are one of the systems on the increase. Once the insertion is done and the area healed, the change of the catheter will use the same method as for a urethral change of the urinary catheter. The genitals are free from sexual obstruction and infection declines.

Urinary tract infections Urinary tract infections (UTIs) are common for those who do not have the ability to empty their bladders and thus retain residual urine in their bladders. UTIs are also common for people with an indwelling urinary catheter, because ascending infection travels up the catheter into the bladder. The person should be advised as follows to limit infection: • Drink at least 8 glasses of water per day. • Take a prophylactic dose of vitamin C or cranberry juice or cranberry tablets. • Monitor the colour and smell of the urine – if it becomes dark it might be an indication of dehydration or that there is an infection present. • Note any small deposits (floating objects) in the urine glass or catheter bag or any sensation of pressure, lower abdominal pain, burning micturition or urine

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bypassing the catheter – any of which could indicate infection.

54.5 Care of the urinary catheter Care of the urinary catheter should be done each day when the genitals are washed. To do this, gently pull on the catheter and wash the exposed part of the catheter closest to the genitals with soap and water, then dry it and allow it to migrate back to its original position. If urinary sheaths (external urinary drainage devices) are used, they must be replaced daily after the genitals have been washed and dried. If the person uses a leg catheter bag that gets changed at night, the catheter bag can be rinsed through with a mild solution of white vinegar or bleach. These solutions will help to kill the bacteria in the urine bag. Ensure that the section where the end of the catheter bag connects with the urinary catheter is stored in a mild bleach solution. A recommendation is to clean the tap of the leg bag and insert the tip of the night bag into the pipe below the tap. The cap of the catheter bag should always be used to re-cap the catheter bag.

Bowel management In order to avoid faecal incontinence or constipation, and for social acceptance, the person should be advised as follows: • Follow a high-fibre diet, including adequate amounts of fresh fruit, vegetables, dried fruit and nuts, whole grains, cereals and bran (unless contraindicated by a dietician). • Take plenty of fluids. • Follow a fixed routine for bowel movements (eg every day on waking, take a hot drink, which will stimulate peristalsis; following the hot drink, sit upright on the toilet to evacuate the bowel) • Take care not to exceed 30 minutes on the toilet, as this can cause the development of haemorrhoids. • Take a mild bulk aperient if constipated. • Retain bowel and eating routine even when travelling.

Mobility Mobility will depend on the exact extent of the person’s disability or injury. Initially the aim is to prevent complications of immobility, such as contractures and joint stiffness, which will interfere with the person’s ability to mobilise. During this early stage, the limbs are positioned in a natural functional manner, and muscle

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tone is maintained by means of a passive range of motion exercises. If splints are used, caution must be taken not to keep them on for too long as they can cause friction and skin breakdown. Splints must be loosened and repositioned every two hours. Passive exercise is combined with active exercise for muscles and muscle groups that are functional. As soon as the person is stable, mobilisation is started with the help of the physiotherapist. The use of appropriate aids to mobility such as crutches, walking frames or a wheel chair will be determined by the extent of the person’s disability, and the person will need to learn how to mobilise using these aids. Mobility could also include the use of public transport or driving. Many people with a disability drive, but it is usually necessary to have the controls modified. Lists of mechanics who are able to do the necessary modifications are usually available through the community-based organisations for people with disabilities. It may be worthwhile noting that it is usually only cars with an automatic transmission that can be modified.

Social issues There is a variety of social and economic issues that will need to be considered during rehabilitation: • Work. The aim of rehabilitation is to enable the person to return to their previous occupation. If the disability is such that the person cannot do this, a work fitness assessment and aptitude test may need to be done and, if necessary, occupational retraining. The occupational therapist can carry out a workplace visit to discuss arrangements with the person’s employer to facilitate the return to work. • Financial issues. Other social matters include aspects such as grants, pensions and compensation. If the person is no longer able to work, they may need to access their pension contributions from their employer or apply for a disability grant. The type of grant that the person qualifies for will depend on the nature of the disability and how it was acquired. The social worker should be asked to assist with this. • Sports and recreation. These are important aspects of social life, and the rehabilitation team should try to ensure that the person can still participate in these activities. There are many sports clubs in South Africa that accept members with disabilities, and wheelchair sport is organised at many levels in this country.

Accommodation The suitability of the person’s accommodation should be assessed. Aspects that must be considered include access to the home, access to rooms within the home, access to

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the bathroom, and the ability to do things in the kitchen. For example, is it possible for the person to get into the garden? In many instances, it is necessary to adapt the home to make the environment more suitable. The occupational therapist should be available to do a home visit to assess the home environment and make recommendations. Sometimes it may be necessary for the person to move to another type of accommodation.

Psychological issues A disability requires considerable adjustment and adaptation, and the stresses and strains can be severe. One of the biggest adjustments for the person is the loss of independence and privacy. Relationships may be strained by the stress of adjusting to a disability; unfortunately, some relationships do not survive. Sexual dysfunction as a result of disability adds to the strain on an intimate relationship, and couples should be referred for specialist help to overcome sexual dysfunction. Disability also causes distortion in the individual’s body image, which may lead to a loss of confidence, especially in social situations. The person with a disability may feel like they stand out and may feel that everyone is staring at them. Withdrawal and depression often follow if the person is not constantly encouraged to remain positive and reminded that they are a worthy human being with a positive contribution to make to society. The relationship with self, others and the environment is prominent in the thoughts of the person with a disability, and it can take years for some to come to terms with their disability.

Essential approach to goal planning The scientific process is embedded in goal planning; assessment, planning, implementation and evaluation form part of the process of goal setting and planning. Goal planning is based on four principles: 1. Involvement of the person 2. An emphasis on needs and strengths rather than on weaknesses and disabilities 3. Setting specific goals and realistic targets 4. Recognising that comprehensive rehabilitation requires a multidisciplinary approach so that the expertise of the whole team can be utilised. A series of goal-planning meetings should be held in which the person and all members of the healthcare team participate. These meetings establish which needs must be addressed and detail the steps that will be taken, as well as identifying who or what will be involved in reaching

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the goals that have been set. This is often a process of negotiation and compromise. The team leader is responsible for explaining the needs to be worked on and why. The person with the disability is encouraged to voice their own wishes and priorities. Shortly before the person is discharged, the key worker goes through their needs assessment again. A ‘before’ chart, which highlights the person’s achievements and provides an opportunity for them to be acknowledged, is prepared. The key worker is not just a coordinator, but also acts as the person’s advocate where necessary. The goal-planning review committee meets regularly to evaluate the change process, consider the experiences of key workers and suggest improvements. This not only acts as a safety net within the rehabilitation programme, but also serves to highlight gaps in rehabilitation and unmet needs, and ensures that the person has access to rehabilitation resources. The achievements are communicated with the service delivery facility to which the person with a disability is discharged. Goal-planning increases engagement in rehabilitation, which should eventually decrease periods of hospitalisation and reduce readmission rates. The intense education of the person with a disability to take accountability on the physical, psychological and social levels ensures that the rehabilitation team become observers instead of participants. The above process can be carried out for all disease processes and in all healthcare situations. The system also reduces conflict within the rehabilitation team, and highlights the person’s achievements at a time when much of the rehabilitative effort focuses on their losses. It enables the person to have direct involvement and control over their own rehabilitation.

continue to be worked on, or disregarded, or reformulated as new goals.

Preparing to go home After being in hospital for many weeks or months with a disabling condition, going home may seem like a great event. However, it takes a great deal of careful preparation – the person must learn the skills they will need to take care of themselves. It will also take time to adapt the home and for their family/significant others to adapt to the needs of the person with a disability. Much of the stay in hospital is concerned with preparations for ‘discharge’, for going home, rather than with medical treatment. Reintroducing the person with a disability can be a great strain on the household, and the role, responsibilities and tasks need to be agreed on. Adjustment may take a long time.

The discharge planning process

A set of goals, both long- and short-term, will be set by the team, with the agreement of the person with a disability. A daily programme and a discharge process will form part of the therapeutic actions that are carried out immediately.

Discharge planning begins on admission. It is a logical, coordinated process of decision-making and other activities involving the person, the family/significant others, and a multidisciplinary team of health professionals working together to facilitate a smooth, coordinated transition of the person from one environment to another. The rationale for discharge planning is cost containment, continuity of care, and quality of life. It is the person’s right to expect such planning, and the responsibility of the registered nurse is to ensure that the process is instituted according to their scope of practice. The transitional environment may be an acute care facility, a chronic care or rehabilitation hospital, a nursing home, or the person’s home. The goal or purpose of discharge planning is to assist the person to make a smooth transition from one healthcare setting or level of care to another, without sacrificing the progress that has already been achieved. The process of discharge planning will ensure the provision of other healthcare needs that may still be unmet. It should ensure the ultimate physical, psychological and social development of the person with a disability within the context of their potential.

Implementation

Readiness for discharge

The person and the team will achieve the goals set by means of a daily activity programme. The team will withdraw over time in order to monitor the person with a disability to continue on their own with the set goals and outcomes.

The following checklist should be at hand when a decision is taken as to whether the person is ready for discharge: • Do they understand their condition and the process of recovery or deterioration? • Have they reached their ultimate potential within the parameters of the disability or are the goals set in such a manner that they can be achieved? • Can they carry out activities of daily living or, alternatively, effectively instruct someone else to do the needed activity on their behalf?

Planning

Evaluation Periodic meetings between the person, the team, and the family/significant others will determine progress and the establishment of further goals. Goals not achieved will

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Chapter 54 – Management of people with disabilities  1109 Table 54.1  General nursing care plan for the rehabilitation of a person with a disability

Inability to carry out activities of daily living Nursing diagnosis

• Self-care deficit related to the nature and extent of the person’s disability

Expected outcome

• Independence in activities of daily living is achieved

Nursing interventions and rationale

• Make use of remaining abilities to work out ways to carry out activities of daily living • Encourage the person to extend the range of self-care activities • Implement measures to prevent contractures and deformities due to immobility, as these will hamper rehabilitation • Position the limbs in a natural functional manner and support with pillows • Carry out passive range-of-motion exercises • Carry out assisted mobilisation using appropriate aids with the help of the physiotherapist • Ultimately, teach the person independent mobilisation, such as getting in and out of a bed and chair

Evaluation

• Person is able to carry out self-care activities independently

Skin integrity Nursing diagnosis

• Risk of breakdown of skin integrity related to immobility due to specific disability

Expected outcome

• Skin integrity is maintained

Nursing interventions and rationale

• Pay attention to skin and pressure areas at regular intervals • Change person’s position regularly • As recovery proceeds, teach the person how to carry out skin care

Evaluation

• No breakdown in skin integrity is noted

Urinary retention Nursing diagnosis

• Altered urinary elimination related to retention due to flaccid bladder

Expected outcome

• Optimum urinary elimination is maintained

Nursing interventions and rationale

• Take care of indwelling urinary catheter • Clamp and empty the catheter every 4 hours as prescribed • Remove the indwelling catheter and carry out intermittent catheterisation at 4-hourly intervals • Ultimately, teach the person how to carry out intermittent catheterisation independently so they can do this at home

Evaluation

• Urinary elimination is normal • No evidence of urinary infection

Urinary incontinence Nursing diagnosis

• Altered urinary elimination pattern related to incontinence due to spastic bladder

Expected outcome

• Optimum urinary elimination is maintained

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❱❱

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Nursing interventions and rationale

• Take care of indwelling urinary catheter • The person will be permanently catheterised. Change the catheter weekly • Males can make use of condom drainage • Alternatively, intermittent catheterisation can be carried out more frequently, eg every 2 hours as opposed to every 4 hours

Evaluation

• Urinary elimination is normal • No evidence of urinary infection

Constipation and/or faecal incontinence Nursing diagnosis

• Altered bowel elimination related to faecal incontinence and/or constipation

Expected outcome

• Normal bowel elimination is maintained

Nursing interventions and rationale

• Encourage adequate fluids • Encourage the person to take adequate fibre in their diet • Teach the person to follow a fixed daily routine for bowel movements • Give a mild aperient if constipated • Record all bowel movements

Evaluation

• Person has a bowel action regularly

Socioeconomic issues Nursing diagnosis

• Altered pattern of social and community function related to disability

Expected outcome

• Person is able to function optimally within the family and the community

Nursing interventions and rationale

• Implement activities geared towards enabling the person to return to work • If a return to work is not possible, implement vocational training • Assist the person to access pensions, grants • Assess the person’s home and environment; modifications to the home may be needed, or the person may have to move

Evaluation

• Person is functional within the family and community

Depression and anxiety Nursing diagnosis

• Altered mental state related to psychological reaction to disability and its consequences

Expected outcome

• Person is positive regarding rehabilitation and future prospects

Nursing interventions and rationale

• Refer person for counselling if any signs of depression are noted • Give mild sedatives and/or antidepressants as prescribed in the initial stages • Expert sexual counselling may be needed in cases of sexual dysfunction following spinal cord injury • Constantly encourage and support the person

Evaluation

• Person demonstrates positive attitude and outlook regarding future

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Chapter 54 – Management of people with disabilities  1111

• Has someone been trained to look after them if they cannot carry out their activities of daily living for themselves, or has the person been discharged to a facility where they will receive the necessary care? • Has financial compensation been arranged? This could be a disability grant from the government, workman’s compensation from the employer or, alternatively, a claim through the Road Accident Fund if the disability was as a result of a motor vehicle accident. • Has the person had contact with other people with the same disability? • Has the person joined a support organisation for their specific disability or, alternatively, have the organisation’s contact person and contact numbers been given to the person? • Does the person have sufficient medical supplies and medication, and was the facility where consumables must be obtained identified? • Does the person have emergency contact numbers in case they experience a difficult situation? • Does the person have dates for follow-up visits to the rehabilitation team, and the contact numbers of each department as well as the reference person in that department?

Returning to work A person with a disability should be reintegrated into the community and resume work as soon as possible, provided the nature of the disability allows this. It is essential that the person with a disability become a contributing member of the society. The reintroduction to work follows a thorough assessment of the person’s readiness to return to work in collaboration with the psychologist, the occupational therapist and the social worker. Every effort should be made to ensure that the person is able to return to their previous employment for psychological and socioeconomic reasons. The employer needs to be involved in the process to facilitate any adaptations that may be needed. The person may need to be retrained and reallocated within the company. Wherever possible, the person should return to work rather than relying on a disability grant, and this is the responsibility of the rehabilitation team as well as the person concerned.

Understanding medication If medication is still needed, the person must know the reasons for medication use and any side effects. This information should be provided in writing and the person’s knowledge tested prior to discharge. Medication might be adapted once the person is discharged and it

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may take time for it to take effect. A period of time of about a week needs to be given in order to see the effects of the medication. During the rehabilitation phase the person should take full responsibility for their medication, while the nurse becomes the supervisor to ensure that essential tasks are carried out and treatments taken.

Depression after discharge Depression could become worse after discharge. The expert care from the rehabilitation team is not always available when problems occur. The same emotional effect can be part of the experience of the family/ significant others. The person may become frustrated with their carer, who may not be as efficient as the hospital staff. Frustration can add to depression, and verbal or physical conflict. The person still has their own preferences and the carer must constantly be aware that the person is not sick, but merely needs assistance. The carer becomes the extension of the person’s ability to perform certain tasks, and this should be respected. Necessary physical exposure and loss of privacy can lead to problems with body image, and this can contribute to depression when the person has not yet accepted their altered body image. It may take some time for the person to develop or reinstitute coping mechanisms. In the meantime, the carer needs to be aware of the signs of depression and alert the medical team when necessary.

Reassessment and follow-up It may take some time to reintroduce the person into everyday activities of life. It is therefore essential for them to come back to the hospital or rehabilitation centre for short periods to assess whether everyone, including the caregiver and family/significant others, is coping. Each member of the rehabilitation team must reassess the person’s physical, psychological and social wellness at each follow-up visit, or preferably within the context of their own home. The interval between reassessments can be extended as circumstances and support structure allow. Every person should be assessed at least annually.

Essential health information As discussed throughout this section, one of the primary goals of rehabilitation is for the person to regain their independence and to be accountable for their own progress on a physical, psychological and social level. One of the ways this can be achieved is by providing all the necessary information about the nature of the disease or injury, about how to look after their body, and about how to take their place in a society that will label them as

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‘disabled’. Family and significant others must understand that the choices made might not be clear to them but that it is essential that the person with a disability take accountability for their choices. Most rehabilitation units run training sessions as part of the rehabilitation process, and supply information packs. It is often possible for family members/significant others or caregivers to attend such sessions. Typical topics for a person with a spinal injury might include: • The spinal cord • Skin care and pressure sores • Managing spasms and pain • The bladder • Bowel management • Diet • Sexuality and relationships • Building confidence • Looking after your wheelchair

• • • • • •

Cushions Driving Money and benefits Preparing to go home Life after leaving hospital Employment.

Conclusion The nurse working with people with disabilities should remember that the main objective of rehabilitation is to enable the person to return to the community and function independently and as a contributing member of society. This can be achieved only by allowing the person to become the expert in their own healthcare management and by allowing rehabilitation to proceed at the pace set by the person. Some of the goals will be met over time and others need to be adapted in order to be met within the parameters of the disability.

Suggested activities for learners Activity 54.1 1. Carry out a long-term case study on a person newly diagnosed with a disability, and follow up on the person for intervals of 6–9 months following discharge. Concentrate on the following aspects: • How the disability was acquired • Type and extent of the disability • Residual function • Care plan and rehabilitation programme • Response of the person to the programme • Psychosocial aspects • Impact on the family and significant others • Discharge planning and referral • Progress at home and in the community. 2. Visit a rehabilitation facility in your area. Pay particular attention to the following aspects: • Programmes offered at the facility • Role of the community. 3. Contact a disability support group in your area. Pay attention to the following aspects: • Programmes and facilities offered • The role of the community. 4. Assess the psychological and social needs of the person with a disability.

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55

Principles and standards of care of the sick child in hospital

learning objectives

On completion of this Chapter, the learner should be able to: • explain the behaviour displayed by hospitalised children • identify and accurately assess the needs of hospitalised children and the support their families require • effectively plan, implement and evaluate the physical, emotional and psychosocial care provided to hospitalised children and their families • effectively integrate play into therapeutic procedures planned for hospitalised children • identify possibilities for children to participate in decision-making relating to their care • accurately assess pain in hospitalised children, and effectively implement methods of pain management. key concepts and terminology

analgesia

Pain-reducing medicinal substances.

autonomy

Functioning independently.

child

According to the United Nations, a child is anyone under the age of 18. In the context of the discussion hereunder, a child is anyone 5 years old or younger.

development

As applied in the discussion below, development is related to the child’s increased understanding or psychological maturity.

family

A social unit where people are in a relationship and provide emotional, psychological, physical and economic support.

growth

An increase in the child’s physical size.

hospitalisation

A term used to describe an act of keeping a sick person in hospital for the purposes of treatment.

informed consent

Permission that is granted after full explanation of the subject, issue and procedure.

milestones

A series of sequential events to mark achievement or progress. For example, in child development, the child achieves the ability to hold the head steady, to respond to social engagement, to crawl, to stand.

pain

Subjective description or exhibition of discomfort.

play therapy

Pleasurable interventions usually administered in the form of games.

prerequisite knowledge

• Social sciences in healthcare • Basic nursing care.

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medico-legal considerations

It is difficult to measure the intensity of psychological damage that is caused by hospitalisation in a child. Nurses and everybody else in the healthcare facility have a duty to ensure that this is reduced to a minimum. Where possible, parents or at least the first caregiver must remain with the child when admitted into hospital to avoid emotional upheaval experienced by the child when they have to be left behind. Painful procedures must be done quickly, but must be explained each time they are to be done. Children are prone to accidents because of their immaturity and this risk is heightened in hospital, therefore those charged with their care must ensure their safety. They must be cared for in a cot bed and the rails must be kept up at all times when they not being attended to. All harmful objects, materials and substances must be kept (or locked away) out of the reach of children. Under no circumstances must they be allowed to play with sharp objects or matches.

Introduction Specific hospital care for children only emerged around the mid-19th century. Before that time, dispensaries gave advice and medicine for parents to look after their children at home and when this was not possible or they were too ill for this, they were looked after in adult general wards in the hospital. When child care developed to the extent that it was realised that children should, in essence, be cared for separately from adults, children’s hospitals came into existence. The first ones were sterile units with rigid routines, and very little or no contact was allowed between hospitalised children and their parents. As the science of child development gained momentum, paediatricians and psychologists soon realised that it was not good to separate sick children from their parents during hospitalisation as this was identified as the most distressful period for the children when they needed their parents most. Towards the end of the 19th century, attitudes towards parental participation in their children’s care underwent changes, because research provided abundant evidence of the adverse effects of separation on the child. Three phases were described following hospitalisation: initially the child protests at being left in the hospital, seeing this as desertion. Then despair and withdrawal follow when protest is found to be fruitless. During this stage, the child becomes uncharacteristically quiet, but uncooperative. The appearance of the parent at this stage is often marked by a return to the protest behaviour. Finally, the child becomes detached and uninterested. This is when the child has given up on the parents and pretends that everything is fine. Prolonged separation from parents could have grave and far-reaching effects on the child’s character and mental development. Based on these findings, efforts are again afoot to encourage parents to keep their sick children at home. Integrated management of childhood illnesses (IMCI) is an approach recommended by the United Nations

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International Children’s Fund (UNICEF) and the World Health Organization (WHO) to assist in the care of the sick child. This Chapter seeks to outline principles and standards of care for sick children aged 5 years and younger, to ensure that the child’s stay in hospital is not prolonged unduly, parental care is not disrupted, and the family is kept as a unit, even at the time of hospitalisation.

Foundations of the child care charter for children in hospital Almost every developed country in the world has a legal statute that recognises children’s rights and selfdetermination. The Children’s Act 38 of 2005 and the United Nations Charter (1989), emphasise that in all actions concerning children, the best interests of the child shall be of primary consideration. In 1968, the Association for the Care of Children in Hospital (ACCH) was started in the USA and Canada. The organisation monitors children’s rights, and seeks to foster and promote the health and well-being of children and families in healthcare settings by means of education, planning for children in hospital and research into children’s well-being. In 1988, a corresponding European organisation, the European Association for Children in Hospital (EACH), agreed on the following 10-point charter: 1. Children shall be admitted to hospital only if the care they require cannot be equally well provided at home or on a daily basis as an outpatient. 2. Children in hospital shall have the right to have their parents or parents’ substitutes stay with them at all times. 3. Accommodation in hospital should be offered to all parents and they should be helped and encouraged to stay with the sick child. Parents should not incur additional costs or suffer loss of income as a result of being away from work while staying with the sick child. In order to share in the care of their child, parents should be kept informed about ward routine and their active participation encouraged.

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4. Children and parents shall have the right to be informed in a manner appropriate to age and understanding. Steps should be taken to mitigate physical and emotional stress. 5. Children and parents have the right to informed participation in all decisions involving their healthcare. Every child shall be protected from unnecessary medical treatment and investigation. 6. Children shall be cared for together with children who have the same developmental needs and shall not be admitted to adult wards. There should be no age restriction for visitors to children in hospital. 7. Children shall have full opportunities for play, recreation and education suited to their age and condition, and shall be in an environment designed, furnished, staffed and equipped to meet their needs. 8. Children shall be cared for by staff whose training and skills enable them to respond to the physical, emotional and developmental needs of children and families. 9. Continuity of care should be ensured by the team caring for children. 10. Children shall be treated with tact and understanding and their privacy shall be respected at all time. In a study that aimed to establish which aspects of care are important for children with cancer, children and parents most frequently mentioned social competence and amusement to be important for the child, while nurses most often mentioned information, continuity and emotional support as the most important aspects for the child. These results confirm that the 10 standards of care included in the Charter are the most important aspects for children and parents.

Determinants of children’s reactions to hospitalisation There is much that adults in a family can do to make hospitalisation a pleasant experience for the child. Unless the child has been hospitalised before, they will try to imagine what will happen to them in the hospital, most probably without their family, so it is a good idea to talk about hospitalisation if it is going to happen. If the child attends a nursery school, it is important to let the teachers know so that the hospital, nurses and doctors can form part of the child’s play in a safe environment. At home, there must be conversations held with the child about illness, visits to the clinic, and the importance and benefits of treatment and care that is given by hospital staff. The child must participate in the preparation for the planned hospitalisation, including planning toys or books

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the child will take to the hospital, and where possible schedule a visit to the ward where they can see other children and meet the ward staff before being admitted. The child should be encouraged to discuss their fears so that parents can try to allay them wherever possible. How a child reacts to hospitalisation depends on the following: • Their age • Preparation for hospitalisation • Previous illness-related experiences • Support of the family and health providers • The child’s emotional status. There are three major stresses that have an impact on children when they are hospitalised: 1. Separation from family 2. Loss of control of self and the environment 3. Body injury inflicted by various treatment modalities, eg injections. Between the ages of 1 and 3 years, children are very worried about being separated from their parents, hence it is only after the age of 3 years that children may attend nursery school. The period away from home is also not long – it could be 4–6 hours. After the age of 3, children may become more fearful about what is going to happen to them. Studies have found that children’s needs depend on whether the situation is threatening or not. For instance, painful procedures or restrictive treatments such as oxygen therapy make the hospital environment threatening. During non-threatening situations, the child’s greatest need is for activity, while having control is the greatest during threatening situations.

Children’s needs during non-threatening and threatening situations Children have special needs, especially when in distress, and it is important for the nurse to know what they are during non-threatening and threatening situations. Children under threatening situations tend to lose control and may need their parents and familiar objects for security.

The role of the nurse in the admission of a child to hospital The nurse can play a role in making hospitalisation a time of growth rather than a negative experience. They have an obligation to do the following: • Provide information and prepare the child and family for admission. • Involve parents in the care of the child.

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1116  Juta’s Complete Textbook of Medical Surgical Nursing Table 55.1  Needs during non-threatening and threatening situations while in hospital

Needs during non-threatening situations

Needs during threatening situations

Activity/play

Control

Experiences/exploration

Information

Parent’s presence not crucial

To have parents nearby

Participation

To hold on to something familiar

Praise and recognition • Encourage and make it possible for parents to stay with the child. • Maintain the home routine as far as is possible. These factors are integrated into the discussions below.

Admission to hospital In order to instil confidence in the child and the family, the nurse must know how to carry out the admission procedure skilfully and smoothly. They must also be prepared to meet the emotional needs of the child and family.

Practice alert! Empathy in dealing with fears of both the child and family can make the admission procedure stimulating rather than merely a task to be completed.

Preparation before admission A child must be prepared for hospitalisation by, if possible, doing the following: • A tour of the paediatric unit by the child and the family before admission is advisable and this will also enable the parents to meet the people who will be caring for their child and also for the child to see other children in hospital. • For the parents, it is recommended that they know the physical layout of the hospital before the child is admitted, because this will relieve them of the stress of not knowing how to find facilities such as outpatients, consulting rooms and admission area. On the admission day, the child and the family are taken to the child’s room, introduced to the other children in the room and a little later to those in the ward. The admission procedure should be explained carefully, but information which might not be understood by the child must be avoided, and must not be discussed with the parents or

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caregiver in the presence of the child. The parents should be encouraged to do as much for their child as possible. The nurse must try not to appear rushed: a soft voice and quiet approach are less frightening for the child. If the nurse looks anxious, this will cause worry for everyone. The nurse must be available to answer questions that might arise. When there is a good relationship between the nurse and the family, the child will relax and benefit from such a relationship.

Focused nursing assessment A number of important areas must be assessed to identify nursing diagnoses and plan the care for the individual child.

Subjective assessment This information is sought to determine the reason for admission. Although the greatest amount of verbal communication is usually carried out with the adults, the child must not be excluded during the interview. By periodically paying attention to younger children through play, or by occasionally directing questions or remarks to them, makes children participate in the interview. Older children should be actively included as informants themselves. Parents or caregivers must be ready to provide information about the illness, such as the nature of the complaint, when it started, whether any treatment was given, etc. They also must give a history of the family health to exclude conditions that are hereditary, and must also provide information about the child’s habits, eg when the child sleeps, what and when they eat, and elimination patterns, so that care can be aligned with this information.

Objective assessment This can be difficult to accomplish and may need the help of a family member to calm the child down. The nurse should do basic physical assessments such as the vital signs, weight, height, head circumference and skin condition to exclude pyrexia that may be present with

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55.1 Warning! Attempts to make friends with children before they have had an opportunity to familiarise themselves with a stranger will only increase their anxiety. A helpful tactic is to continue to talk to the child and family, and allow the child to observe from a safe position. For instance, if the child has brought a special doll, it is helpful to ‘talk’ to the doll first. Asking simple questions such as: ‘Does your doll have a name?’; ‘Where does the doll live?’ This may ease the child into a conversation.

Clinical alert! Learn as much as possible about the child in the first interview. infections, and to ascertain nutritional status. It is also necessary to establish psychosocial milestones, which should be compared to the physical findings to establish progression and potential for coping with the admission.

Principles and standards of care Developing a paediatric nursing care plan is similar to developing an adult plan. Nursing care plans are guides that need continual evaluation to determine whether the goals for the individual child are being met. The care plan is the result of the nursing process. It states specifically what is to be done for each child in accordance with their developmental stage and problems, and keeps the focus on the child, not on the condition or the therapy. Assessing the child must therefore include knowledge of growth and development processes, so that the plan is child-specific. The nurse must work with members of the family and plan interventions that best meet the defined problems.

Role of the nurse in child care The nurse has the following roles: • Healthcare planning • Family and child advocacy • Disease prevention/health promotion • Providing essential health information • Support/counselling • Therapeutic role • Coordination/collaboration • Research.

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Participation of the family Children need their family (or primary caregivers) with them in the hospital all the time. If the parents are admitted to the hospital together with the child, then the child feels secure and safe, and responds better to treatment. The presence of parents in hospital also provides an opportunity for the healthcare provider to share information with the family, such as the correct way to deal with health problems. In return, the parents are able to share knowledge of their child’s habits, which can help to maintain the child’s routine.

Parental participation When a child is hospitalised, the whole family is affected. Parents may: • blame themselves for the child’s illness because they did not recognise the symptoms earlier, which may have delayed treatment, or possibly feel that they did not provide the necessary preventive measures • experience fear of the unknown because they are unfamiliar with the hospital setting, and are not knowledgeable about the procedures, treatment and outcomes of the disease/illness • be anxious about the costs of hospitalisation. The nurse must realise that developing a trusting relationship with the parents is often at the centre of helping the child. The nurse must listen, acknowledge feelings and support the family. During the last decades, the role of parents and nurses has shifted greatly. Today the role of the nurse is that of giving information, educating children and families, preparing children for procedures, and assisting and supporting children and families to cope with hospital care. That of the parents is to provide for the child’s physical and emotional care, as well as encouraging and supporting the child throughout hospitalisation. A new phenomenon is the ‘Cared-by-parent’ units. In these units, the nurse’s role is to assess the family’s needs and develop interventions to meet them. In this way, families are supported to carry out their caring task within the hospital. This is educative to the parents as they practise care under the nurses’ supervision. Some of these interventions are discussed below.

Interventions to enable parent participation It has been found that parents vary in the extent to which they wish to participate in the care of their child. It is therefore important not to force parents to participate, but

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to encourage and support them at all times in whatever decision they have made in the following ways: • All parents (or primary caregivers) should be offered accommodation in the hospital or the ward. Most suitable is for parents to sleep in the child’s room. Neonates, severely sick children and adolescents need their parents to stay in the ward but not necessarily in the same room. • Encourage parents to stay with the child in the hospital. Where necessary, parents should arrange for special leave from the workplace so that they can be with their child. Many constitutions recognise child illness as a family responsibility. • Assist parents in obtaining information concerning the condition of the child and the treatment plan. Explain all procedures. • Orientate the family to the hospital routine and explain the ward routine and rules. Encourage parental involvement in the care of the child. • Offer temporary assistance so that parents can have a break in the care of their child. • Reinforce positive parenting, such as body contact. For optimum participation, parents should follow a preparation programme that entails: • a study visit to the hospital, to the X-ray or equivalent department, and all other areas of high activity before the child is admitted into that hospital • being present when unpleasant procedures are done on their child • demonstration of the entire procedure on a doll before it is done on the child, so that they can see what the procedure entails • presenting an album describing the procedure by means of photographs of children who have previously undergone the procedure • providing parents with pamphlets that have information about the procedure prior to the scheduled admission or procedure so that they can help prepare the child. Experience has shown that by following a parent preparation programme, children cope much better with the hospital situation.

Sibling participation Siblings are also affected when a family member is hospitalised. They may experience anger, resentment, jealousy and guilt because attention is focused on the sick family member. Siblings may feel neglected, their routine may be disrupted, and their needs may not receive the necessary attention. The nurse can assist the parents in identifying and meeting the needs of the siblings while looking after their sick child by:

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• keeping siblings informed about the child’s illness and progress • allowing siblings to visit the hospitalised child • allowing older siblings to assist with care of the sick child if they so wish.

Child’s participation

Participation in decisions Informed consent refers to the legal and ethical requirement to clearly, fully and completely inform the patient about their illness, treatment and care. Depending on their age and understanding, it is important that the child be informed about their illness, the proposed treatment and care or research being conducted, so that they can agree with decisions made. By including children in the decision-making process and gaining their acceptance, children are treated with respect and are empowered to have an input in the management of their lives. There are a few empirical studies of children’s participation in decision-making that illustrate children’s capabilities of making rational choices in hypothetical situations. One study shows that 14-year-olds are as competent as adults in making certain decisions, and that 9-year-olds often make the same choices as adults, although they are not capable of arguing to the same extent. Other studies have shown that children who are hospitalised are frequently more competent in making decisions than those with no experience of medical care (Alderson, 1990). These studies highlight the need to allow children to be part of the decision-making process.

Communication with children Children need information about themselves to be able to take an interest in self-care. The manner of imparting the information should be simple, honest and reassuring, and done at a level appropriate to the child’s cognitive and psychological development.

Preparation prior to investigations Most preparation methods emphasise three major objectives to preparing a child for hospitalisation. These are the following: 1. Providing information about the approaching event 2. Encouraging the child to express any feelings of anxiety 3. Establishing a relationship of trust with the child. Information about the event should be provided to the child because vague, undefined events are more upsetting than those that are known and understood. In the absence of accurate information, children of all

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ages develop fantasies and distorted ideas. Preparation programmes generally involve some or all of the following components: • Giving the child the information about what will be done • Letting the child handle equipment that will be used • Having the child practise the procedure on a doll • Introducing the child to medical personnel and letting them speak to the child in the presence of the familiar nurse • Discussing fears and feelings, and answering the child’s questions, genuinely ensuring that meaning is not distorted • Helping the child to reconstruct the information given and thereby come to understand the child’s perception of the whole hospital situation. Various methods can be used in the preparation process, including the following: • Playing with a doll • Hospital tours to areas like X-rays, laboratories, kitchen, nursery and even school, if the hospital has one • Storytelling, pamphlets and photo albums; younger children (3–12 years of age) tend to benefit from programmes utilising dolls, puppets and handling equipment, whereas older children will benefit more from verbal explanations, diagrams and audio-visual aids, such as pictures, videos and slide shows. Preparation programmes must be designed to meet the developmental needs of each individual child, since children have different concerns and cognitive abilities at each developmental stage. The above measures are extended below.

Puppet shows By imparting information about the procedure, the puppet show helps the pre-school child (3–4 years) to understand a frightening situation. The puppet show is usually 15 minutes long, and shows a puppet being hospitalised, and includes admission and surgical procedures. Puppets incorporated into the performance include an ambulance, doctor, anaesthetist, nurse, parents, siblings and the child. The play is designed to familiarise the child with hospital equipment, routines and personnel. After the show, the child is encouraged to talk about it and to manipulate the puppets and equipment.

Pictures, videos and slides Where puppet shows are not possible, a variety of videos, slides and pictures that show what is going to happen

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during hospitalisation can be used. Slide shows can be used to illustrate details for older children and also allow time for questions. Problems are discussed with the child during or after the show. Photo albums with pictures help the child to see what is going to happen in reality and also give the child an opportunity to understand that other children have gone through the procedure previously, hence the pictures. An important requirement is that the photos be taken from the same hospital where the child is hospitalised, which makes them more realistic and familiar.

Handling equipment Play therapy is frequently used for children between 3 and 11 years of age. This is usually combined with the use of equipment involved in the procedure. During the play therapy session, the child and the therapist act out the procedure using either the real equipment or miniature ‘mock-up’ equipment. During play, children are given the opportunity to act out, draw or describe events that they will experience in the hospital. Play also gives the child an opportunity to act out fantasies and anxieties, and to express fear and anger caused by the hospital visit.

Play in hospital Play is therapeutic at any age, and through this universal medium, children learn what no one can teach them. They reveal much about themselves during play because it provides an avenue to release tension and stress. Consequently, nurses need to understand how to use play as therapy. Play therapy allows the child to do the following: • Express emotions and release unacceptable impulses in a socially acceptable way. • Experiment and test fearful situations, and to assume and vicariously master the roles and positions that they are unable to perform in the real world. • Communicate and alert the observer about the needs, fears and desires that they are unable to express with their limited language skills. • Be observed, allowing the nurse the opportunity to obtain a better understanding of the child’s struggles, fears, and feelings. • Have something to do during the long waiting times in the hospital, which can be boring. Some hospitals have well-established child-life programmes or play therapy units supervised by play therapists/specialists. The playroom can offer the child a ‘free zone’ where there are no frightening procedures performed. The play therapy unit can also be used for giving information and for preparing the child for investigations and treatments.

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Play is not just the responsibility of those who are assigned to it, nor is it confined to certain times or shifts. Play does not need expertise in manual dexterity, art or music. To be of assistance, the nurse must always be alert and prepared to understand the needs of the child in relation to play.

Time period The efficacy of preparation also appears to be related to the time when it is given. Older children (7–12 years of age) seem to benefit from preparation presented one week in advance, whereas younger children adapt to immediate preparation, eg the night before surgery.

Other considerations in preparing the child for admission • The child’s previous experience of healthcare. Preparation programmes are especially important to children whose last hospital experience was unpleasant. • Family factors including parents’ presence or absence, as well as attitudes to nurses and the hospital. Highly anxious parents can transmit their emotional state to the child, which intensifies the child’s own fears. Because of the importance of the parent– child relationship, parents must participate in the preparation. They, too, need accurate information and appropriate reassurance.

Continued schooling Some hospitals have their own schools from Grade 0 with accredited teachers. The hospital school can offer education and contact with the child’s normal school, and can help the child to keep their hopes for the future alive.

Pain in children Many years ago, it was thought that infants did not feel pain because of an immature nervous system in which the nerves were not completely myelinated. Nowadays, there is little doubt that neonates and infants feel pain or, more specifically, react to obnoxious stimuli with distress indicative of pain. The child in pain is often misunderstood because of the nurses’ misconceptions about the child’s reaction to pain – the younger the child, the more defenceless they will be against it. It seems that the younger the child, the less adequate the control for pain is. Several myths related to children’s pain and its treatment have obstructed sound knowledge development in this direction. The following describe differing perceptions of pain:

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• Nurses in general underestimate the amount of pain experienced by children. If the nurses’ own children have suffered a painful episode, then this appears to provide experience in pain management for them and influences decisions regarding the administration of analgesics. • The greater the educational background of the nurse, the higher the dose of opioids/analgesia selected. Nurses with a greater knowledge of opiate analgesics appear more comfortable with administering them in higher doses. • Pre-verbal children receive larger amounts of nonopiates and lower doses of opiate analgesics than older children. Children fear pain and its treatment but, unfortunately, nurses tend to underestimate and undertreat pain in children. One of the reasons for inadequate management of pain is a lack of understanding of what pain is because it is subjective, and children have difficulty communicating the pain they are experiencing. An operational definition of pain by the International Association of the Study of Pain (IASP) is ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage’ (Kumar and Elavarasi, 2016) (see Chapter 14). IASP further states that ‘pain is a subjective experience and each individual learns the application of words through experiences related to injury in early life’.

Common misconceptions among nurses related to pain in children These include some of the following misconceptions: • Infants cannot feel pain. • Children do not feel as much pain as adults. • A sleeping child cannot be in pain. • Children always tell the truth about pain. • The best way to administer analgesics is by intramuscular injection. • Children cannot describe and locate their pain. • The child is not crying because of pain, but because they are being restrained. • Parents know all the answers about their child’s pain. • Opiates are not safe for use in children.

Principles of pain assessment in children Since pain is both a sensory and an emotional experience, several assessment strategies should be used to gather information about pain, including the following: • Ask the child about the pain. • Ask the parents about the pain.

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• Use pain rating scales. • Evaluate behavioural changes. • Evaluate physiological changes.

Questioning the child about pain Children’s verbal statements and descriptions of pain are the most important aspects in assessing pain. However, young children may not know what the word ‘pain’ means and may need help in describing it, using familiar language. Asking children to locate the pain is also helpful, and play can provide other means for helping children to reveal discomfort. When asking children about pain, the nurse must remember that children might deny pain because they fear receiving an injectable analgesic, or because they believe they deserve to suffer as punishment for being naughty. Suggested questions for obtaining information about pain from the child include the following: • Tell me what pain is. • Tell me about the hurt you have had before. • What do you do when you hurt? • Do you tell others when you hurt? • What do you want others to do for you when you hurt? • What don’t you want others to do for you when you hurt? • What helps the most to take away your hurt? • Is there anything special that you want me to know about you when you hurt?

Questioning the parents about the child’s pain Parents (or primary caregivers) know the child best and are sensitive to changes in the child’s behaviour. Parents’ ability to recognise pain in their child varies. Some parents may never have seen their child in severe pain. However, others are aware that certain behaviours signal pain. In addition, parents usually know what comforts the child, such as rocking, stroking, talking or feeding. To better assess the child’s pain, the nurse can interview the parents about their child’s previous pain experiences. Ideally, this interview occurs before the child is in pain, such as on admission to the hospital. Parents need to realise that their knowledge of their child is important in providing quality care. Questions to ask the parents about their child’s pain include the following: • Describe any pain your child has had before. • How does your child usually react to pain? • Does your child tell you or others when they are hurting? • How do you know when your child is in pain?

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• What do you do to ease discomfort for your child when your child is hurting? • What does your child do to get relief when hurting? • Which of these actions work best to decrease or take away your child’s pain? • Is there anything special that you would like me to know about your child and pain?

Pain rating scales Pain rating scales provide a subjective, quantitative measure of pain. Although various pain scales exist, not all of them are appropriate for children in all age groups. For the most valid and reliable pain intensity rating, a scale that is suitable for the child’s age, ability and performance is selected. The same scale is used for subsequent assessments to avoid confusing the child with different instructions. Ideally, children are taught to use the scale before pain is experienced, such as preoperatively. If the nurse familiarises the child with the scale, this will make it easier to use the scale in actual pain.

Examples of useful pain rating scales for children Examples include the following: • Faces scale. The scale consists of six cartoon faces ranging from a smiling face for no pain to a tearful face for worst pain. Several variations of face scales exist. See Figure 14.4. • Oucher. This consists of six photographs of a child’s face representing ‘no hurt’ to ‘the biggest hurt you could ever have’. This also includes a vertical scale with numbers from 0 to 10. (See pain scales in Chapter 14.) • Colour tool. Using a body figure and crayons, the child can show the location and intensity of the pain. Different intensities of pain are marked with different colours. Most children tend to choose red or black for the worst pain. (See Figure 14.5 and Table 14.5.)

Responses when in pain Behavioural changes

Behavioural changes are common indicators of pain and are especially valuable in assessing pain in non-verbal children. Children’s behavioural responses to pain change with age. Temperament affects coping style, and children with more positive moods may appear to be in less pain than they actually are. The child’s cultural background may also play a role in their response to pain. Depending on the type and location of pain, children may display behaviours that indicate local body pain, for instance pulling the ears for ear pain. Children who experience

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chronic pain or report pain often develop effective behavioural coping strategies, such as thinking about pleasant events.

Physiological changes Physiological responses indicating pain include flushing or pallor of the skin; sweating; an increase in blood pressure, pulse and respiration; restlessness; and dilatation of the pupils. However, these signs vary considerably and may be produced by emotions such as fear, anger or anxiety.

Pain management The reason for assessing pain is to relieve it, which is a basic need and the right of all children. Total pain relief should always be the goal. A combination of pharmacological and non-pharmacological interventions may be used. In this Chapter, the pharmacological treatment of pain will not be discussed.

Non-pharmacological pain management A number of non-pharmacological techniques exist, the most specific of which require children’s understanding and cooperation. In the selection of a pain reducer, it is best to use a strategy familiar to the child or to describe several strategies and let the child select the most appealing. Parents may be familiar with the child’s coping skills and could therefore be helpful in the selection of better pain-reducing modalities. Ideally, children should learn a specific strategy before pain occurs or before it becomes severe.

General pain management strategies General pain management strategies include: • Forming a trusting relationship with the child and the family • The use of general strategies to prepare the child for painful procedures • The use of comfort measures when the child is in pain, such as cuddling, feeding

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• Performing painful procedures in a treatment area away from the child’s ‘safe’ place such as the child’s room or bed • Staying with the child during a painful procedure • Encouraging parents to stay with the child all the time • Involving parents in learning specific nonpharmacological strategies of relieving pain • Educating the child about the pain • Giving the child a doll, which becomes ‘the patient’, and allowing the child to do everything to the doll that is being done to them.

Specific non-pharmacological pain management strategies Examples of useful non-pharmacological strategies are hot or cold applications, massages, trans-electrical nerve stimulation (TENS), acupuncture, relaxation techniques such as listening to music, breathing and blowing away pain, positive self-talk, biofeedback, guided imagery, hypnosis, and distraction and diversional therapy. (See also Chapter 14 for pain management.)

Conclusion Hospitalisation during childhood is an unpleasant experience for both the child and the family, and it needs careful management to ensure that activities undertaken during this period do not have negative effects on the child. Nurses therefore need to be knowledgeable on measures which may be applied to minimise the emotional untoward effects. Of importance is for the nurses to realise that children who are ill, frightened, fatigued and/or in pain need the support of their family to make psychologically healthy adjustments to hospitalisation. In the society that we live in, some of the recommended measures given above may not be practical, but allowing the parents to stay with the child while in hospital is mandatory. This immediately increases the child’s confidence and the child can thus withstand many painful procedures, even without the necessary preparation.

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Suggested activities for learners Activity 55.1 Child care poses a problem to young nurses, as the sick uncooperative child may be seen as ‘difficult and spoiled’. Consider the following scenario: Sibongile is 3 years old and has been admitted to the paediatric ward with pneumonia. On admission, she was quite sick and distressed, and when her mother had to leave, she cried and kicked the nurses and ran after her. That first day she had to be put in a closed cot bed because if let free, she ran towards the door in the direction her mother had gone, and this distressed her even more, because she was quite sick. The nurse thought Sibongile was ‘wild’, and instructed the mother not to visit for a while to allow the child to ‘settle’. When the mother opposed this suggestion, the nurse reassured her that Sibongile’s reaction was normal, and that the child would meet with the other children in the ward, and would be fine. She also said that the ward could not cope with this type of behaviour, and so the mother did not visit for 4 days. In the meantime, Sibongile was sent for a chest X-ray, put in an oxygen tent and had to be restrained to ensure that she received the benefit of the treatment. Antibiotics were given intramuscularly. An intravenous fluid therapy was instituted to ensure good hydration. When her mother visited 4 days later, Sibongile was much better. 1. What measures would you have taken to make Sibongile’s stay in hospital a less traumatic experience? (The aim of this exercise is to ensure that learners are innovative and can introduce new approaches to patient care.) 2. Working in pairs, do an audit on the admission procedure in the paediatric wards in the hospital where you work to ensure that it is in keeping with the rights of a hospitalised child. Analyse the audit and write a proposal to introduce the concept of a ‘Cared-by-parent’ unit.

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56

Palliative care nursing and end-of-life care

learning objectives

On completion of this Chapter, the learner should be able to: • provide effective symptom management for chronically or terminally ill patients in a variety of healthcare settings • provide effective psychological support for carers, patients and families • refer the patient appropriately, if necessary • manage pain effectively in the chronically or terminally ill patient. key concepts and terminology

anorexia

Loss of appetite and/or interest in food.

anxiolytic

Drug that reduces anxiety.

carcinoid syndrome

Systemic syndrome associated with certain tumours, characterised by skin flushing, cyanosis, abdominal cramps, diarrhoea, valvular heart disease and arthropathy.

Cheyne-Stokes breathing

Breathing pattern characterised by alternating periods of rapid and slow respirations, sometimes with a period of apnoea during slow respiration.

dyspareunia

Pain or discomfort during sexual intercourse.

dysphagia

Difficulty in swallowing.

dysphoria

Altered mood characterised by sadness and grief encountered during the grieving process following the death of a loved one.

extrapyramidal signs

Disorder of movement characterised by abnormal gait, tremors and abnormal movements associated with certain medication, eg antipsychotic agents.

fungating wound

Wound characterised by overgrown granulation tissue which appears fungus or cabbage-like.

hepatomegaly

Enlargement or swelling of the liver.

lymphangitis

Painful inflammation of the lymphatic vessels.

mucositis

Inflammation of the oral mucous membrane.

oesophagitis

Inflammation of the oesophagus.

opioid

Analgesic agents derived from opium.

palliative care

The active and total (holistic) care of patients and families by a multidisciplinary team, especially when the patient is no longer responsive to curative treatment.

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plexopathy

Disorder of one or more of the nerve plexuses characterised by pain, weakness and paraesthesia of the affected area.

pruritus

Unpleasant skin sensation which the patient tries to relieve by scratching.

subphrenic

Literally, below the diaphragm – a subphrenic abscess is found below the diaphragm, between the liver and the diaphragm.

prerequisite knowledge

• Anatomy and physiology of the all the systems in the body • Applied social sciences • Pharmacology • Basic nursing care. medico-legal hazards

Palliative care is an essential service for relieving the pain and suffering of patients and their families. Patients at the end of life are prone to falls from delirium and restlessness where respiration is difficult or sedation may be heavy. To avoid this, patients should be nursed in a cot bed. ethical considerations

By its very nature, palliative care is central to human rights issues in healthcare. The control and management of pain and other uncomfortable symptoms are key to good basic nursing care to ensure that the patient’s dignity is upheld and that the patient remains comfortable and supported throughout the process of illness. It is also important to respect, protect and preserve the patient’s self, possessions and wishes, especially at the end of life, when most are very vulnerable. It is for this reason that patients coming into the health facility need to be encouraged and supported to give their ‘living will’ in writing or verbally while they are still aware of their surroundings. essential health literacy

Death, although a normal process in the life of all individuals, is still feared by most. Conversation about death is taboo in many families, as people realise a lasting loss in death. The community needs to be prepared and supported when death is inevitable. Most importantly, communities need to know about services that are available for those with life-limiting conditions to ensure that the uncomfortable symptoms are controlled, that pain is managed and that, at the end, the person dies with dignity. Conversation about death in families must be had well before death is imminent. The issue of what the person desires for their end of life must be discussed or written as a living will. The dying person must not be allowed to die alone. Relatives, where possible, must remain with them, hold their hand and comfort them in the best manner that they can.

Introduction The word ‘palliative’ derives from the Latin pallium, meaning ‘cloak’. Symptoms are cloaked with treatments that aim to promote comfort. It is patient-centred total care, focusing on quality of life and support for the patient and their family. Palliative care is the active and total care of patients with any life-limiting disease and is available even when the disease is no longer responsive to curative or life-prolonging treatment. Palliative care complements primary care and should be started at any time from the diagnosis of a terminal (or chronic) illness. As the disease progresses, the rendering of palliative care will increase.

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According to the World Health Organization (WHO), palliative care is an approach to care that is aimed at improving the quality of life of patients and their families facing problems associated with life-threatening illness by preventing and relieving physical, psychosocial and spiritual suffering, early identification, impeccable assessment and management of pain as well as providing support to the family members/significant others to ensure that when the time comes, the patient is able to die peacefully, and with respect and dignity. The aim of this Chapter is to introduce the nurse to the principles, perspectives and philosophy of palliative care.

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56.1 The history of palliative care In the early 1950s, Cicely Saunders, who originally trained as a nurse and social worker and who later became a doctor, worked to improve the care of terminally ill cancer patients. In 1967, she founded St Christopher’s Hospice to care for cancer patients and also to educate professionals in the care of the terminally ill. This institution has remained the centre of palliative care education, although many other centres have followed suit, promoting an approach that ensures: • quality care for patients and their families • a range of services to help to provide optimum and total care in hospitals and the community • education of professionals • evidence-based practice • research and evaluation.

Coupled with home-based care, effective palliative care is becoming an essential component of the care of the chronically and/or terminally ill patient in the community, as well as in the more traditional hospital or hospice.

Clinical alert! Good symptom management remains the hallmark of good nursing care for any patient.

In the year 2000, the British professor, Derek Doyle, said that South Africa lagged behind in palliative care. Unfortunately, this has been the case, in both urban and rural communities. However, recently there has been a move toward educating professionals in this discipline in technikons and universities. As more professionals become skilled in palliative care, the greater will be the benefits for patients. This will also influence other professionals and encourage them to seek the same education. Palliative care training should be accessible to all professionals as it is an important part of their work, whatever their discipline. Palliative care becomes applicable early in the course of the illness in conjunction with other therapies that are implemented to prolong life, such as chemotherapy and radiation therapy, and includes those investigations needed to better understand and manage distressing clinical symptoms.

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Approach to palliative care Palliative care is best provided by a multidisciplinary team in order to facilitate effective palliation. The team should consist of medical practitioners, nurses, dieticians, psychologists, clergymen, physiotherapists, pharmacists, clinical social workers and community care workers, the family, and where possible, the patient. As the patient has important decisions to make and faces many challenges, including those in their normal life pattern, the team approach is important in maintaining emotional stability. This is not only beneficial for the patient, but also for the family and the multidisciplinary team, because the team members provide support for one another. The multidisciplinary team aims to provide: • relief from distressing symptoms experienced by the patient • emotional, social and spiritual support for patients with terminal illness • support to bereaved relatives through counselling • support and advice for personnel caring for these patients • continuous education programmes on the provision of palliation.

Attitudes to death and dying In many cultures, open and honest communication about death and dying is taboo and because of this, healthcare providers find it difficult to disclose a terminal prognosis. In many instances, doctors and nurses fail to deal with their own reactions to death and dying, which may affect and exacerbate the patient’s difficulties in dealing with a

56.2 Guiding principles of palliative care According to the World Health Organization, the guiding principles of palliative care are as follows: • Ensuring that a patient’s remaining days are as comfortable as possible and that dignity is maintained up to the last moment • Affirming life while regarding dying as a normal process • Providing relief from pain and other distressing symptoms • Integrating the physical, psychological and spiritual aspects of patient care • Offering a support system to help the patient live as actively as possible until death • Offering a support system to help the family cope during the patient’s illness and during bereavement • Enhancing the quality of life, and positively influencing the course of the illness.

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terminal illness. Failure to disclose to a patient that they are dying may be a way of self-protection for the healthcare provider, because they then do not have to get involved in aspects of care related to the dying process. This may cause family members to become frustrated because they can sense that healthcare providers are hiding information from them. It is also possible that family members may be responsible for colluding in withholding bad news in an attempt to protect their loved one from further hurt. Patients will react in different ways on being informed of the prognosis – some may become bewildered, resentful, withdrawn and socially isolated, and bottle up their feelings, while others may need to know more about the way ahead. The attitudes of both the patient and the healthcare provider about death and dying will have been shaped by their experiences and societal beliefs, and both patient and healthcare provider will draw on these experiences and beliefs when faced with death.

Communication Effective communication is an integral part of palliative care nursing. There must be open, two-way communication in which patients are kept informed about matters affecting them, and where patients are able to express their emotions and anxieties. Effective communication must also extend to family members. Once a disease reaches an advanced stage, it becomes imperative for healthcare providers to give the patient as much information as possible in a way that is understood, so that both the patient and family are empowered to manage the day-to-day challenges facing them, and to adapt successfully to the terminal diagnosis. Non-verbal communication, such as therapeutic touching, is a crucial way of communicating, particularly with patients who are dying and who can no longer respond verbally.

56.3 Benefits of effective communication The benefits of effective communication are as follows: • Patients become knowledgeable and therefore empowered by information. • Patients become active and effective participants in health matters affecting them and contribute towards their own care. • Patients can make informed decisions that are realistic and appropriate. • Patients who are well informed can adapt to changes and demands due to their illness. • Patients and relatives are empowered to be in control of the situation when properly informed.

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Both patient and family must be given time to understand the information that is being given to them, and they must be allowed an opportunity to freely express their needs, fears, concerns and anxieties. The nurse must listen attentively to any concerns and try to empathise with the patient. The nurse should have adequate knowledge of the subject being discussed so that they can answer truthfully and knowledgeably. The nurse should consider the following points to enhance communication: • Sit facing the patient and lean forward slightly so as to be at eye level with the patient, but try to make the eye contact comfortable. Your tone of voice should show care and concern, and you should assume a posture that conveys interest, friendliness, attention and respect. • Show genuine interest in the patient as a person and be willing to become involved during times of stress and discomfort. • Be aware that verbal and non-verbal language may have different meanings to different people. • Listen empathetically and carefully, but remember to remain objective. • Provide privacy and a non-threatening environment that is free of distractions. Assure the patient that anything they say will remain confidential. • Arrange the seating so that the patient and family feel comfortable – try to make sure that an appropriate distance is maintained between you and the patient. • Modify the length of interaction to suit the patient’s ability to tolerate close interpersonal contact and their concentration span. • Be honest and give consistent information. • Try to be at ease and relaxed when communicating and do not give false reassurance. Encourage family members to become part of the team by involving them in decision-making. • Acknowledge the patient’s and family’s feelings, fears, concerns and anxieties. • Allow the patient and family to express their views and opinions without judgement. • Encourage a feeling of friendship rather than a strictly professional relationship.

Nursing assessment and common findings Comprehensive assessment of the terminally ill patient Terminally ill patients experience considerable suffering, and therefore comprehensive assessment is the basis for good symptom control.

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Pain Nursing diagnosis

• Discomfort and disturbed sleep due to pain as well as other distressing signs and symptoms associated with terminal illness

Expected outcome

• Pain and discomfort are controlled

Nursing interventions and rationale

• Assess pain adequately to establish baseline data • Administer analgesics as prescribed and whenever necessary • Apply other relevant supporting therapies to relieve pain to enhance the effect of prescribed analgesia

Evaluation

• Patient is pain free and gets adequate rest and sleep

Poor appetite Nursing diagnosis

• Inadequate nutrition and weight loss due to poor food intake following radiation therapy or chemotherapy or as a result of the illness itself; dysphagia due to tumours that may apply pressure on the oesophagus

Expected outcome

• Improved nutrition • Patient understands anorexia and its causes

Nursing interventions and rationale

• Maintain good oral hygiene • The mouth should be kept moist and lubricated • Provide small servings of bland meals regularly to promote appetite and to encourage eating • Make sure that food is attractively presented and involve the patient in deciding on the menu • Encourage the patient to rinse their mouth with a bland solution 3- to 4-hourly, as well as before meals • Prepare meals so that food does not lose its nutritional value • The patient should be allowed to feed themselves as far as possible, as this provides a sense of independence • Serve meals at room temperature • Reinforce positive behaviour by congratulating the patient when meals have been eaten • Provide for rest periods before and after meals • Allow sufficient time for the meal to be eaten, especially for those who require assistance • Encourage the intake of nutritional supplements such as Complan, Ensure or Build-Up in between meals • A small amount of alcohol such as a glass of sherry before meals may stimulate the appetite • Serve food that does not use up energy to eat, such as soft food • Encourage family members to be around during meal times so that they can be involved in feeding their loved one • Avoid fluid intake with meals, as this causes a sense of fullness that may reduce the patient’s food intake • Ensure that the environment is clean before meals are served; dressings should be changed, and smelly and dirty dressings removed and hygienically disposed of

Evaluation

• Food intake is adequate • Weight loss is halted or is minimal

Nausea and vomiting Nursing diagnosis

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• Fluid volume deficit related to gastrointestinal fluid loss due to vomiting ❱❱

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Expected outcome

• Maintenance of fluid status, nutritional status and body weight

Nursing interventions and rationale

• Avoid foods and beverages that could irritate or stimulate the intestinal tract and cause nausea and/or vomiting • Avoid foods that have a strong odour, are highly spiced or are fatty, because they may aggravate the patient’s nausea • Serve small meals and restrict fluid intake during meals to avoid over-distending the stomach • Distressing procedures should not be performed close to mealtimes • If vomiting continues, alternative means such as parenteral nutrition can be considered • Sips of clear cool fluids or ice chips may be given to promote comfort • Prescribed antiemetics should be administered to suppress vomiting

Evaluation

• Hydration is normal • Nausea and vomiting are minimised

Diarrhoea Nursing diagnosis

• Fluid volume deficit related to excessive fluid loss in stools • Potential impaired skin integrity (rectal)

Expected outcome

• Diarrhoea is reduced within 7 days

Nursing interventions and rationale

• Try and identify the cause of diarrhoea and manage that • Keep the patient clean, dry and comfortable • Use gloves to change soiled linen or diapers • Cleanse buttocks gently with a mild non-alkaline soap and water with every change to promote comfort as diarrhoea stools may be very irritating to the skin • Apply protective ointment such as aqueous cream or buttock cream as prescribed to irritated or excoriated areas to facilitate healing • Observe skin elasticity, mucous membrane integrity and mental status to assess hydration • Monitor vital signs 4-hourly • Observe and record all stools, ie colour, consistency, odour and frequency • Urine specific gravity should be done twice daily to assess hydration • If tolerated, fluid intake should be encouraged • If an IV line is in situ, the infusion should be carefully monitored and all intake and output should be recorded

Evaluation

• Absence of diarrhoea • Fluid status within normal limits

Painful gums and mouth Nursing diagnosis

• Altered nutrition due to changes in the oral mucous membrane and pain in the gums

Expected outcome

• Intact oral mucous membrane within 7 days

Nursing interventions and rationale

• Assessment of oral mucous membrane should be carried out twice daily and more frequently if mucositis occurs • Consult other members of the multidisciplinary team, eg dietician and dentist, to plan other strategies to employ in the management of painful gums. • Oral and dental hygiene should be carried out meticulously • Use a soft toothbrush or tooth sponges if there is a risk of bleeding; discourage brushing and flossing

❱❱

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• To keep the mouth clean, rinse with warm saline or sodium bicarbonate in water before and after meals, in between meals and at bedtime • Keep the mouth moist and lubricated with an application of glycerine to the tongue and lips to promote comfort • Lip moisturisers, eg petroleum jelly, should be applied to keep the lips moist and prevent drying • Allow the patient to have frequent sips of cold water; if the patient is very ill, use a spray bottle to spray cold water into the mouth • Give the patient ice cubes to suck • Discourage the patient from using commercial mouthwashes as some can leave an unpleasant taste in the mouth and some contain alcohol, which will irritate the mucous membrane • Spicy and acidic foods should be avoided • Food and fluids should be taken at moderate temperatures • Tobacco and alcohol should be avoided • Humidify the room in very dry areas • Provide the patient with foods that can be easily chewed Evaluation

• Patient reports no pain in the gums • Mucous membrane is intact and shows no signs of irritation

Disfigurement Nursing diagnosis

• Risk of altered self-image related to changes in role responsibilities and to disfigurement

Expected outcome

• Patient maintains self-respect and dignity

Nursing interventions and rationale

• Explain the prognosis and progress of the disease to the patient and family to facilitate complete understanding of the condition and acceptance of the changes that will take place

Evaluation

• Patient and family understand the condition and cope with changes

Anxiety and depression Nursing diagnosis

• Altered mood caused by debilitation related to the disease process and knowledge deficit, evidenced by withdrawal, lack of interest in family responsibilities, lack of self-care and hopelessness

Expected outcome

• Patient is knowledgeable about the disease process and participates in self-care; patient takes an interest in family matters

Nursing interventions and rationale

• Explain the disease process to the patient and family so that they have a clear idea of what will happen • Explain every procedure to be undertaken so that the patient not only cooperates, but participates with understanding • Encourage the family to involve the patient in family matters and allow them to make a contribution so that they can regain a sense of worth • Ensure that pain is controlled effectively and that the patient gets enough sleep and rest

Evaluation

• Patient’s mood is normal

Generalised itchiness Nursing diagnosis

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• Altered skin integrity and discomfort due to dryness ❱❱

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Expected outcome

• Maintenance of normal condition of the skin within 10 days

Nursing interventions and rationale

• Use tepid water with mild, non-perfumed soap when bathing and pat the skin dry, paying attention to areas within body folds • Avoid vigorous rubbing with a towel as this over stimulates the skin causing more itching and may rub off the outer layers of skin causing damage, especially if parts of the skin are inflamed • Lubricate the skin immediately after bathing with an emollient that traps moisture • Avoid exposure to very warm environmental temperatures as this causes vasodilatation and sweating • Avoid alcohol, hot foods and hot liquids as these induce sweating and will intensify itching • Where possible, use cotton clothing rather than synthetics as the latter may exacerbate itching • Keep the patient’s room cool and humidified • Avoid vigorous scratching of affected areas – gentle rubbing may help • Nails should be kept short and trimmed to prevent skin damage • Hot-water bottles, electric blankets and heating pads should not be used • Avoid tight clothing over affected areas

Subjective data

Common nursing diagnoses

The nurse should take a careful history from the patient to determine the full extent of the patient’s symptoms and their effect. Symptoms that should be noted include pain, coughing, difficulty in breathing, hiccoughs (hiccups), itchy skin, wounds that smell, depression, confusion, weakness, change in body image, anorexia, constipation, nausea and vomiting, diarrhoea, mucositis. During the history taking the nurse should use the opportunity to establish rapport with the patient and the family. The process of assessment can itself be a therapeutic tool, as it conveys compassion and acknowledges the patient as a person.

Diagnoses can include the following: • Inadequate nutrition resulting in possible malnutrition and weight loss related to anorexia and mucositis, dysphagia • Fluid volume deficit caused by diarrhoea and vomiting, which in turn results in altered nutrition • Depression and hopelessness caused by thoughts of impending death, functional losses and possible social withdrawal • Pruritus related to dry skin secondary to dehydration • Ineffective airway clearance related to a decreased ability to expectorate secretions secondary to weakness, pain and an increased viscosity of mucus • Self-care deficit related to fatigue, weakness, sedation, pain and decreased sensory-perceptual capacity • A disrupted family life, caused by the patient’s inability to continue in their normal family role, and concerns about how the family will cope after the patient’s death • Altered comfort related to acute and chronic pain due to disease progression

Objective data The gathering of objective data involves a physical examination and relevant investigations. However, when a patient’s condition is terminal, they should not be subjected to exhaustive and intense investigations. Any investigations considered at this stage of the disease should be performed only in order to assist with the relief of suffering rather than for diagnostic purposes. Blood may be taken for the following: • Full blood count • Urea and electrolytes • Liver function tests. X-rays may be done to ascertain the presence of metastasis in other parts of the body, such as the lungs, bones and brain. Once a patient has been assessed, any problems can be categorised according to their importance.

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High risk for disturbed self-concept related to changes in role responsibilities and disfigurement due to the disease process.

Management of specific symptoms A wide range of symptoms may cause considerable suffering in patients at the end of their lives. The intensity of the symptoms may interfere with their normal daily functioning. Even if the stage of the condition has been reached where no further active treatment can be given, symptom control is the cornerstone of good palliative

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care. Poorly controlled symptoms result in impaired quality of life, despair, withdrawal, fear of being a burden to the caregivers, decreased energy, fear of loss of control and dignity, and a complicated bereavement for those left behind. The nurse must be knowledgeable about the use of non-pharmacological means of managing these symptoms, while medication must be given as prescribed.

Respiratory symptoms Cough Coughing is the physiological reflex employed to clear irritants, and foreign or particulate material from the respiratory tract. Coughing can be caused by physical or chemical stimulation of receptors in both the upper and lower respiratory tract, and also in the pleura, pericardium and diaphragm.

Contributory factors Contributory factors are aspiration; the presence of tumours such as endobronchial tumours, extrinsic bronchial compression tumours; oesophageal reflux;

sputum retention or increased respiratory secretions; chronic bronchitis and bronchiectasis; sinusitis and postnasal drip; bronchospasm (asthma, chronic obstructive pulmonary disease); pulmonary tuberculosis; streptococcal pneumonia; and pulmonary fibrosis.

Nursing management • Avoid smoke and fumes, and encourage the patient to stop smoking. • Humidify the atmosphere. • Place patient in a position of least discomfort (usually sitting in a semi-recumbent position).

Clinical alert! Nebulised lignocaine causes decreased sensitivity of the gag reflex, and patients should avoid drinking or eating for an hour after lignocaine nebulisation. The use of lignocaine in asthmatics may initiate bronchospasm.

Table 56.2  Pharmacological management of symptoms affecting the respiratory tract

Symptom

Pharmacological management

Cough due to bronchospasm

Often responds to bronchodilators and/or inhaled or systemic corticosteroids

Cough due to oesophageal reflux

This warrants a trial of H2 receptor antagonists, eg ranitidine or proton pump inhibitors

Dry, irritating non-productive cough

Cough suppressants may be used, eg: - Codeine 10–20 mg 4-hourly - Dextromethorphan 25 mg 3 times a day - Morphine – start at 2.5 mg 4-hourly - Demulcents, eg simple linctus - Nebulised lignocaine 3 ml of a 2% solution (without epinephrine), 3–4 times per day

Productive cough in a patient who is able to cough effectively

Nebulised saline (2%) Physiotherapy and postural drainage Inhalations using menthol eucalyptus or Friar’s balsam A chemical mucolytic may be of some benefit in loosening tenacious secretions: – Acetylcysteine (Solmucol®) – Mesna (Mistabron®) – Bromhexine (Bisolvon®) – Expectorants, eg ammonium chloride; iodides

Terminal care: productive cough in a patient who is unable to cough effectively

Codeine 8–30mg 4-hourly Dextromethorphan 15–30 mg 4–6-hourly Sedation: benzodiazepines or other tranquillisers Antipsychotic agents such as haloperidol

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Breathlessness/dyspnoea Dyspnoea is one of the most distressing symptoms for patients and significant others, especially when it occurs in the home setting.

Contributory factors Contributory factors include anxiety, fear, depression, pain, pulmonary infections, pulmonary metastasis, anaemia, generalised weakness, airway obstruction, replacement of lung tissue by cancer cells, tumour embolism, aspiration pneumonia, chemotherapy causing lung fibrosis, surgery such as pneumonectomy or lobectomy.

Nursing management Depending on the general condition of the patient, the nurse can implement the following interventions: • Teach the patient relaxation and breathing exercises. • Encourage the patient to assume a position that will facilitate ventilation, and if not able to assume such a position, the patient should be assisted to do so. • Control room temperature and air circulation. • Consult the physiotherapist. • Give oxygen therapy if dyspnoea is associated with hypoxaemia, which may be helpful. • Supply a cool stream of air to the face, which may be as effective as oxygen via a mask.

Pharmacological management A combination of an opioid and an anxiolytic is very effective. • Opioids. If the patient is unaccustomed to opioid (opioid naïve), start with 2.5–5 mg oral morphine solution 4-hourly and, if necessary, titrate the dose upwards. Morphine improves the quality of breathing and decreases anxiety. For a patient who is unable to swallow, opioids can be given subcutaneously, sublingually or rectally (morphine slow-release tablets can be used rectally). • Anxiolytic. Examples of these are the following: – Lorazepam (0.5–1 mg orally or 1 mg sublingually 6–8-hourly) – Diazepam (2.5 mg tds up to 5 mg tds)

– Midazolam (15–30 mg/24 hours by continuous subcutaneous infusion) is the parenteral benzodiazepine of choice. • Other pharmacological management options. These depend on aetiology, eg: – Corticosteroids – Hyoscine butylbromide – Bronchodilators.

Increased pulmonary secretions Saliva and secretions associated with pulmonary infections or chronic bronchitis build up and pool in the mouth, pharynx, larynx, trachea and main bronchus, causing a condition sometimes described as a ‘death rattle’. This noisy, bubbly breathing is often more distressing to the family members and caregivers than to the patient. Contributory factors Contributory factors include prolonged immobility, excessive weakness resulting in exhaustion and an inability to cough, chronic bronchitis, pulmonary infections. Nursing management This includes the following care: • Change the patient’s position frequently to loosen secretions. • Position the patient such that postural drainage is facilitated, eg in the semi-prone position. • Suction secretions through the mouth and nose. Pharmacological management In the terminal stages of Aids, patients who are too weak to cough effectively should be given anti-secretory (anti-cholinergic) drugs to reduce secretions. To achieve optimal effect, these should be started earlier rather than later.

Hiccoughs Hiccoughs (or hiccups) are caused by an involuntary contraction of the diaphragm, which causes inspiration associated with glottic closure. Prolonged episodes of hiccoughs can occur in a patient with advanced illness and can result in significant distress, which can cause interference with sleep, eating, talking and resting.

Table 56.3  Pharmacological management to reduce pulmonary secretions

Option

Dose

Hyoscine butylbromide

20–120 mg orally in divided doses or by continuous subcutaneous infusion

Antihistamines, eg diphenhydramine

25–50 mg 4–6-hourly

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Hiccoughs may also aggravate nausea and pain caused by bone metastasis. Causes of hiccoughs include the following: • Diaphragmatic irritation which can be due to infiltration by tumour cells into the oesophagus, stomach, lung, pleura and peritoneum • Inflammation or infection such as subphrenic abscess • Hepatomegaly, gastric distension or obstruction, gastric outlet obstruction caused by a tumour • Oesophagitis • Phrenic nerve irritation; intracranial disease such as a cerebral tumour • Metabolic diseases, for instance in uraemia.

Nursing management The aim of management is to reduce gastric distension by: • providing an aerated drink or peppermint water • introducing a nasogastric tube to remove the gas or excess gastric contents. Various ‘home cures’ include the following: • Stimulating the vagus or pharynx by drinking from the ‘wrong’ side of the glass, massaging the external auditory meatus, sneezing or stimulating the nasopharynx with a nasal swab or nasogastric tube • Elevation of the Paco2 by holding the breath or re-breathing into a paper bag.

Pharmacological management This includes the following treatment: • Treat the underlying cause • Reduce gastric distension with metoclopramide 10–20 mg 8-hourly • Chlorpromazine 25–50 mg orally 6-hourly • Baclofen 5–10 mg orally 8–12-hourly • Nifedipine 10–20 mg orally 12-hourly (twice a day)

• For hiccoughs due to intracranial disease, consider phenytoin or carbamazepine • Haloperidol in small doses is also very good for hiccoughs.

Dermatological symptoms Pruritus Pruritus (itching) is an unpleasant skin sensation that initiates the desire to scratch.

Contributory factors Contributory factors are adverse drug reactions, allergies, wet macerated skin, carcinoid syndrome, scabies, lice, Hodgkin’s disease, liver dysfunction, multiple myeloma, non-Hodgkin’s lymphoma, opioids, polycythaemia, renal dysfunction, obstructive biliary disease, thyroid disease, dehydration, heat, psychiatric illness such as boredom, anxiety and stress.

Nursing management See the general nursing care plan in Table 56.1. Some of the medication mentioned in Table 56.4 are sedating and are usually only administered at night. Nonsedating antihistamines are more expensive, but are an alternative for patients who can afford them. Topical agents used to manage dry skin and pruritus. These are the following: • UEA with 1% menthol • Eurax cream (crotamiton), a scabicide with antipruritic properties; calamine lotion • Hydrocortisone 1% cream • Hydrocortisone in menthol 1:3 • Antihistamine cream • Phenol 0.25%.

Table 56.4  Oral pharmacological agents used for the management of dry skin and pruritus

Pharmacological preparation

Example

Dose

Antihistamines

Diphenhydramine Chlorpheniramine Hydroxyzine Promethazine

25–50 mg tds 4 mg tds 25 mg tds 10 mg tds or 25 mg nocté

Corticosteroids

Prednisolone

From 5 mg daily

H2 receptor antagonists

Cimetidine (in conjunction with H1 antihistamine)

400 mg daily

Non-steroidal anti-inflammatory drugs

Ibuprofen

400 mg nocté

Thalidomide

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50–100 mg nocté

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Malodorous wounds A wound that smells bad, especially an ulcerating or fungating wound, is a most distressing symptom. Common sites include carcinoma of the breast, vulva, cervix and rectum. Malodorous fungating wounds may result in isolation of the patient and further distress.

Neurological and psychiatric symptoms Depression

Some of the causes are the following: • Colon or rectal malignancy • Kaposi’s sarcoma, bedsores • Fungating tumours, such as carcinoma of the breast or oral lesions • Perineal infections • Vaginal infections • Cervical carcinoma • Malignant melanoma.

Patients who are suffering from a serious illness commonly experience periods of intense sadness and anxiety accompanied by depressive symptoms. These feelings are experienced over short periods of time, but may persist if they are not resolved. Patients with advanced illness who are depressed may have persistent dysphoria, loss of selfesteem, and feelings of hopelessness, helplessness and worthlessness. Prompt treatment of depression may significantly improve their quality of life and enable them to have more energy to achieve their final goals before they die. The diagnosis and treatment of depression in the terminally ill is essential. It is never appropriate to assume that depression is simply an ‘understandable’ reaction to the situation.

Nursing management

Contributory factors

Nursing care includes the following treatment: • Adhere to the principles of aseptic technique when dressing the wound. • Cleanse and dress regularly with prescribed solutions and creams. • Dressings should be done 1–2 hours before meals are served. • Skin care around the wound should be gentle. • Give a high-protein and high-calorie diet to promote wound healing. • Irrigate the wound with metronidazole solution. • Apply non-adherent dressing; cavities should be packed with an absorbent non-adherent dressing, eg alginate (Kaltostat®). • Apply enough absorbent pads to control drainage. • Agents to control bleeding, odour and infection should be used as prescribed.

Contributory factors include diagnosis of cancer or an incurable illness, fatigue, chronic pain, disfigurement, progression of the disease/recurrence, and dependency on others.

Pharmacological management Treatment includes the following: • Regular cleansing with a recommended or prescribed solution • Metronidazole gel: KY jelly or intrasite (desloughing) gel mixed with crushed metronidazole tablets applied topically to wound • Metronidazole cream: one large tub (500 ml) of UEA cream mixed with 20 (400 mg) metronidazole tablets applied topically to wound • Metronidazole powder: crushed metronidazole tablets sprinkled over wound when a dry dressing is preferred • For severe cases: oral metronidazole 400 mg bd is prescribed for as long as is necessary.

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Nursing management Help the patient in the following ways: • Foster self-esteem; accept the patient as they are. • Help them to focus on positive accomplishments. • Keep self-help strategies simple. • Be sincere and show empathy towards the patient. • Spend time with the patient by providing a nonthreatening one-on-one relationship, particularly when the patient becomes withdrawn. • Respond to, and acknowledge, their emotional changes such as anger and sadness. • Provide physical, social and emotional support by proper referrals, eg to a psychologist, psychiatric or social worker. • Include family members in counselling sessions. • Involve the patient in activities that are achievable so that they can experience a feeling of success.

Pharmacological management • The treatment of depression and anxiety in a patient with advanced disease should be as active and rigorous as with any other medical illness. • Depression responds well to psychotherapy and medication, eg venlafaxine (37.5–150 mg per day); amitriptyline (start with 25 mg and increase to 150 mg nocté); fluoxetine (start with 10–20 mg daily and increase to 80 mg daily).

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• Even when a patient has a poor prognosis and may live for only a few weeks, it may be appropriate to try a low dose of a psychostimulant, such as methylphenidate (from 10 mg) or corticosteroid, eg dexamethasone (from 2 mg daily) to increase cognitive function. • For patients with associated agitation or anxiety, risperidone (from 0.5 mg daily) may be helpful.

Acute confusion and delirium Confusion and delirium have many features in common, which manifest especially among the elderly when dementia might also be present. For the majority of patients, this occurs during the terminal phase and is usually mild. It is important to take measures to ensure that the family is not left with unpleasant memories because the patient’s confusion may interfere with valuable opportunities for communication.

Contributory factors There are many contributory factors, such as hypoxia, intracranial tumour, seizures, liver disease, heart failure, severe depression/anxiety, stroke, uncontrolled pain, shock, advanced metastatic disease, fever, urinary retention and/or faecal impaction, malnutrition (vitamins B1, B6, B12 deficiency), drug and alcohol withdrawal, dehydration, hypovolaemia, infectious processes such as respiratory and urinary infections, fluid and electrolyte imbalances such as hypercalcaemia and hyponatraemia, and drugs, eg opioids, sedatives, antidepressants, antiemetics, stimulants, NSAIDS and corticosteroids.

Nursing management The nurse should do the following: • Provide a pleasant, safe and uncluttered environment. • Orientate the patient to time, place and person regularly. • Place an orientation device in the patient’s room, eg family pictures, a calendar and clock, or even some treasured items from home that will provide reassurance. • Avoid harsh or sudden lights or noises; lights should not be totally switched off at night as darkness might worsen the problem; a night-light may be helpful. • Nurse the patient in a padded cot bed or a bed at a low level, or place the mattress on the floor if necessary to prevent injuries and falls and so that the patient can climb on and off with ease. • Evaluate coping skills and help the patient to acquire new coping mechanisms. • Reinforce newly learned coping skills.

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Pharmacological management All patients with delirium should be treated initially with haloperidol and other antipsychotic drugs. Benzodiazepines should only be used if other measures fail. Give the following treatment: • Haloperidol (from 2.5 mg orally daily and increase as needed) • Chlorpromazine (from 10–50 mg tds) • Risperidone (0.5–1 mg bd). For severe agitation at the end of life, give the following: • Midazolam 15–30 mg/24 hours via continuous subcutaneous infusion or 2.5–5 mg stat subcutaneously or orally (repeat as needed) • Haloperidol 5–10 mg subcutaneously or ivi; repeat every 30 minutes until patient calms down or 5–40 mg/24 hours via continuous subcutaneous infusion • Benzodiazepines such as diazepam 2.5–5 mg tds; lorazepam 1 mg sublingually.

Anxiety It is not uncommon for patients with advanced disease to present with anxiety. This may also coexist with depression but may be caused by other reversible conditions such as hypoxia, medication or withdrawal from drugs, alcohol or caffeine.

Contributory factors Contributory factors include diagnosis of cancer; decisionmaking; fear of pain; fear of the unknown; fear of rejection; hypoxia; impending death; hypoglycaemia; depression; failed treatments; lack of understanding about disease and prognosis; grief and loss; social issues; medication such as isoniazid, corticosteroids, theophylline; withdrawal from alcohol, caffeine, drugs.

Nursing management Treatment includes the following actions: • Encourage the patient to verbalise feelings and concerns. • Establish a non-threatening, relaxed atmosphere. • Teach the patient relaxation exercises to provide a distraction. • If necessary, refer for psychological counselling. • Listen actively and with empathy. • Be direct and supportive, and offer reasonable hope.

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Pharmacological management Give the patient the following: • Clonazepam (0.5 mg tds up to 3–6 mg/day in divided doses) • Diazepam (2.5–5 mg tds) • Lorazepam (from 0.5–1 mg to 6 mg in divided doses) • Buspirone (15–45 mg in divided doses) • Venlafaxine (from 37.5 mg bd to 75 mg bd).

Generalised symptoms Fatigue/weakness Fatigue is associated with advanced illness and end of life. Its presence when the disease is advanced impacts on the patient’s quality of life because it interferes with carrying out activities of daily living. Fatigue and weakness also impact on the patient’s sense of well-being, mood and relationships with family and friends.

Contributory factors Contributory factors include anxiety; depression; anaemia; infection; insomnia; pain; nutritional deficiencies, such as iron, B12, folate and protein-energy malnutrition; prolonged immobility; some cancer treatments, eg chemotherapy and radiotherapy.

Nursing management Give the following support to the patient: • Help the patient with their activities of daily living so that they can conserve energy. • Implement an exercise programme that is suitable to the patient’s physical and psychosocial status; provide passive exercises to prevent formation of contractures. • Refer for physiotherapy and occupational therapy as necessary. • Explain to family members that their loved one is not ‘giving up’ or ‘not fighting’. • Explain that the patient has no control over their strength, especially in advanced illness. • Have adequate support and cushioning on the bed to reduce the need for uncomfortable position changing. • Teach relaxation and distraction techniques.

Pharmacological management Give the patient corticosteroids, such as dexamethasone; 2–6 mg/day may be given as a temporary measure to improve fatigue.

Sexuality and altered physical appearance/ body functions With many life-threatening conditions, patients will experience some changes to their physical appearance and mental state, which may impact on their view of

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their own sexuality. Sexuality has different meanings for different people. It may be regarded as the physical closeness and intimacy experienced with others. Sexuality may include one’s view of oneself as a sexual being and it may include gender identification. Sexuality is not only about sexual intercourse and reproduction: body image, closeness and intimacy are also important aspects of sexuality. Sexuality is an aspect that is often overlooked and not discussed with the patient and family members because of embarrassment. It is often uncomfortable for caregivers to discuss how changes in body image impact on sexuality. Caregivers feel embarrassed about discussing sexual topics and obtaining a sexual history for the following reasons: • There are negative societal stereotypes about sexuality and chronic illness. • There may be misconceptions as well as individual prejudices about sex. • It may be incorrectly assumed that when a person is old and/or unwell, sexuality is no longer important. Factors that may contribute towards a feeling of inadequacy include the following: • Weakness and fatigue • Dyspareunia • Oestrogen deficiency • Disfigurement as a result of surgical intervention • Loss of hair due to chemotherapy and radiotherapy • Progression of the disease such as growing tumours and fungating skin lesions • Depression and anxiety • Fears about the cancer being contagious • Pre-existing sexual and marital problems • Impotence as a result of medication such as CNS depressants, anticholinergics or hormonal therapy.

Nursing management Provide the following care: • Assess psychological and psychosocial factors impacting on sexual function. • Encourage the patient to articulate their fears, feelings, concerns and misconceptions. • Respond honestly to the patient’s questions to enhance trust. • Help and encourage the patient to mourn the loss of a body part, eg removal of a breast following the presence of a fungating lesion. • Offer simple explanations, reassurance and advice on overcoming physical problems and handicaps. • Do not force the patient to readily accept their new body image, but give them time to come to terms with physical changes.

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When oral feeding is impossible, it may be necessary to explore other feeding routes to ensure that the patient’s nutritional status is maintained. Even though it is important to maintain the patient’s nutritional and hydration states, the route of choice for feeding should not cause distress. It may be necessary to begin tube feeding or parenteral nutrition through a central venous line. It is futile to try and make patients eat when they refuse to do so.

• Ensure that there are open avenues for family members/ significant others to seek information, explore and verbalise their feelings and needs. • Provide privacy so that the patient can engage in the discussion without being embarrassed or holding back because other patients are listening. • Maintain open non-judgemental communication with the patient and family members. • Refer patients and relatives to any available agencies that can offer other means of support, eg clergy, psychologists, or social workers. • Assist patients in the selection of cosmetics and clothing that increases their sense of attractiveness, eg wigs or scarves for alopecia, and breast prosthesis for mastectomies. • Create an environment where patients and partners can verbalise their concerns about altered sexuality and explore alternatives to their usual sexual expression. • Always control pain where this is present.

Contributory factors

Pharmacological management

Constipation

Treatment includes the following: • Treat the underlying cause wherever possible. • Women with vaginal mucosal atrophy can be treated with small doses of topical oestrogens or adequate lubricants before intercourse. • Vaginitis caused by chemotherapy or radiotherapy requires intensive local hygiene and douching, and the use of metronidazole vaginal suppositories. • For men, testosterone deficiency can be treated with systemic replacement therapy (except in cases of prostate cancer).

Constipation is the passing of hard stools at irregular or infrequent intervals, usually accompanied by a feeling of discomfort or pain during defecation. If undetected and left untreated, constipation can result in faecal impaction.

Anorexia Anorexia means loss of appetite or the physiological desire to eat. A patient’s lack of appetite will impact on their nutritional status. Prolonged anorexia will result in malnutrition and cachexia.

Some contributory factors are altered sense of taste, nausea and vomiting, dysphagia, malabsorption, fatigue and depression, mucositis, pain and anxiety.

Nursing management See the general nursing care plan In Table 56.1.

Pharmacological management of anorexia See Table 56.5 for pharmacological treatment of anorexia.

Contributory factors There are numerous contributory factors, such as anxiety; dehydration; depression; hypercalcaemia; hypokalaemia; inadequate dietary intake of roughage; immobility and weakness; changes in eating habits; fear of incontinence; impaired peristaltic activity following neurotoxic chemotherapy; abdominal tumours; neurogenic phenomena secondary to metastasis such as spinal cord compression; painful anorectal conditions; inconvenient toilet access and abnormal position; and medication such as analgesics, opioids, antidepressants, non-steroidal antiinflammatory drugs and antiemetics. The most common cause, however, is opioid use.

Table 56.5  Pharmacological management of anorexia

Pharmacological agent

Example

Dose

Appetite stimulants

Megestrol acetate (also recommended for weight gain) Corticosteroids, eg dexamethasone, prednisone Periactin® (cyproheptadine), may also stimulate the appetite

80–156 mg bd 2–4 mg daily 10–20 mg daily

Antiemetics (if nausea contributes to the anorexia)

Metoclopramide for nausea of gastrointestinal origin Haloperidol for drug-induced nausea Cyclizine with corticosteroid (dexamethasone) for nausea related to raised intracranial pressure

4 mg bd or tds 10–20 mg tds 1–2.5 mg nocté g tds

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Chapter 56 – Palliative care nursing and end-of-life care  1139 Table 56.6  Oral antiemetics

Antiemetics

Dose

First-line oral antiemetics Metoclopramide Cyclizine Haloperidol

Start with 10–20 mg daily; increase to max 120 mg/24 hours 50 mg tds 1–5 mg daily

Second-line oral antiemetics Hyoscine butylbromide Dexamethasone Prochlorperazine

20 mg tds 2–4 mg daily 5–10 mg tds

Consequences Some of these are the following: • Perianal problems such as haemorrhoids and anal fissures • Abdominal distension • Abdominal pain • Bowel obstruction • Anorexia • Nausea and vomiting • Faecal impaction • Faecal leak or overflow incontinence • Spurious diarrhoea and tenesmus.

Nursing management Help the patient in the following ways: • Consult a dietician to advise on diet. • Encourage oral fluid intake. • Increase dietary fibre if appropriate. • Teach the patient to respond immediately to the urge to defecate. • Advise the patient to go to the toilet at the same time each day. • Establish an exercise regimen with the patient, but if active exercises are tedious, gentle passive exercise can be done. • Allow the patient to use the bathroom rather than a bedpan or commode, if their condition enables this.

• Ensure privacy at all times to enable the patient to talk about subjects that might cause embarrassment. • Consult other members of the healthcare team, such as the physiotherapist, occupational therapist and pharmacist, for advice.

Nausea and vomiting Nausea is the sensation of an urge to vomit, frequently accompanied by other symptoms such as cold sweats, excessive salivation and tachycardia. Vomiting is the coordinated expulsion of gastric contents through the mouth. When dealing with patients who are terminally ill, nausea and vomiting are frequently encountered. Prolonged nausea and vomiting can result in serious electrolyte imbalance and will affect the patient’s nutritional and hydration status. Nausea and vomiting are also physically and emotionally devastating symptoms for the patient and family/significant others.

Contributory factors Some contributory factors include anxiety and fear, pain, poor oral hygiene, gastric irritation, infection and fever, cerebral tumours, hypercalcaemia, uraemia, increased intracranial pressure, constipation, diarrhoea, and drugs such as opioids or antibiotics.

Table 56.7  Antiemetics administered subcutaneously

Antiemetic

Dose

Haloperidol Cyclizine Hyoscine butylbromide

2.5–15 mg/24 hours 50–100 mg/24 hours 20–120 mg/24 hours

Other options: Dexamethasone Octreotide Ondansetron

2–4 mg/24 hours 150–300 µg/24 hours 4–8 mg/24 hours

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Nursing management See the general nursing care plan in Table 56.1.

Pharmacological management The palliative management of nausea and vomiting often requires a combination of different antiemetics working at different levels. Antiemetics need to be given on a regular schedule so that the patient does not re-experience the problem. Determining the cause of the nausea and vomiting will inform the use of antiemetics. Parenteral antiemetics can be given as oral medication. This is the preferred route. However, severe vomiting may require that antiemetics be given via a parenteral route. In this case, the ideal method is a continuous subcutaneous infusion via a portable battery-operated syringe driver.

Diarrhoea Diarrhoea is an increase in faecal water content accompanied by an increase in the frequency of defecation. The greatest hazard of diarrhoea is dehydration with electrolyte imbalance. Diarrhoea can result in isolation, withdrawal, increased dependence, maceration of perianal skin, malodour and a generally poor quality of life.

Contributory factors Some contributory factors are anxiety; faecal impaction; infection; malabsorption due to intolerance of certain foodstuffs; external radiation therapy to the abdomen; internal radiation to the uterus, cervix and vagina; tumours of the gastrointestinal tract; surgical resection of the bowel; chemotherapy; medication such as antibiotics; hyperosmolar dietary supplements; or tube feedings.

Clinical alert! Please take notice of the following important aspects when antiemetics are given via a parenteral route: • Dexamethasone does not mix well with other drugs when used in a syringe driver. Always administer separately. • In areas where there is no access to a syringe driver, antiemetics can be given subcutaneously as stat doses 2–3 times a day. The insertion of a ‘butterfly’ needle subcutaneously on the anterior chest wall provides a port for repeated injections. The site should be covered with a transparent dressing and can be changed every 3–4 days or as needed. • Rectal suppositories are another alternative in patients who do not have concomitant diarrhoea or anorectal disease. • Extrapyramidal side effects are more likely in patients with Aids.

Pharmacological management See Table 56.8 for the pharmacological treatment of diarrhoea.

Clinical alert! Some clinicians avoid combinations of morphine, codeine and loperamide as they all have the same mechanism of action via opioid receptors in the intestinal tract. However, codeine or morphine have been prescribed in combination if loperamide alone is ineffective.

Nursing management See the general nursing care plan in Table 56.1. Table 56.8  Pharmacological management of diarrhoea

Oral antidiarrhoeal agents

Dose

Loperamide: drug of first choice

4 mg stat, 2 mg after each loose stool up to 32 mg over 24 hours

Codeine phosphate: a less costly alternative to loperamide

30–120 mg 4–6-hourly

Morphine elixir: an alternative to codeine Hyoscine butylbromide: an antispasmodic which may reduce bowel activity and colic Bulking agents, eg ispaghula husk or psyllium to thicken the stool Cholestyramine for patients with secondary malabsorption Kaolin-pectin preparations

From 5 mg 4-hourly titrated upwards to 20 mg tds

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Mucositis Mucositis is an inflammation of the oral mucosa and intraoral soft tissue structures due to the cytotoxic effects of therapy. It not only interferes with the patient’s comfort, but it also affects food and fluid intake. Mucositis can be so severe that the patient may be unable to drink. This may heighten the distress of both the patient and family members.

Contributory factors Some contributory factors are dehydration, infection, exposure to tobacco and alcohol, malnutrition, immunosuppression, poor oral hygiene, anxiety, depression, chemotherapy, radiation therapy to the head and neck area, reduced mastication.

Nursing management See the general nursing care plan in Table 56.1.

Pharmacological management Pharmacological treatment includes the following: • Prophylactic antifungal therapy is advised for all patients at risk of stomatitis. • Chlorhexidine or povidone-iodine can be used regularly as a mouthwash. • Treat infection using specific antimicrobial therapy if the causative organism is known. Antibiotics for bacterial infection are selected on the basis of culture results but should also cover Gram-negative organisms. Severe pain from mucositis should be managed using systemic analgesics according to the WHO analgesic ladder. It may even be necessary to manage pain with parenteral opioid analgesics in severe mucositis. See Chapter 14 for more details.

Pain Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain is always subjective and it is one of the most common symptoms in terminal illness or life-threatening diseases. Pain in terminal illness is mainly caused by tumour infiltration, diagnostic and treatment procedures, and other concurrent disorders that occur with failing body systems. The aim of palliative care is to relieve pain or sufficiently control it so that it does not interfere with the patient’s ability to function or impact on the quality of life. Good pain control requires accurate and detailed assessment of every different pain experienced. Many

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patients with terminal illness have more than one pain and each one requires assessment. Assessment of pain should include the patient’s perception of pain, which includes the following: • Mood • Morale • The meaning of pain for the patient, including guilt for actions in the past, as well as a negative and depressed outlook. It is important to remember that depression is often ignored and untreated, and that it exacerbates the experience of pain. The goals in palliative care are that the patient should be pain free at night, at rest and on movement. In advanced disease there will be multiple pains, with multiple causes and mechanisms. Explanation of the causes of pain reduces fear and so reduces pain, as well as improving compliance. Pain control requires knowledge of the different types of pain. Managing the chronic pain seen in palliative care requires a different therapeutic approach to that used to control acute pain. Nurses need to be aware of this approach and have knowledge of the different treatment modalities.

Causes of pain in advanced disease These include the following: • Tumour infiltration of soft tissue, viscera, bones • Pressure on nerves and nerve endings by tumours • Treatment, eg chemotherapy-related mucositis • Debility, eg constipation, muscle tension/spasm • Concurrent disorders, eg spondylosis, osteoarthritis • Neuropathic compression and/or infiltration • Plexopathy.

Principles of opioid use in palliative care nursing It is important to remember that there are myths and fears about opioid use, believed by both professionals and patients. Professionals often worry about addiction, respiratory depression, excessive sedation and confusion in patients on opioids. Patients fear impending death, decreased options for future pain relief and side effects. However, as long as the dose and its titration are correct, addiction does not occur when morphine is used for pain relief. If the cause of pain is removed, eg by using a nerve block or radiotherapy, the dose of opioid can be reduced. For further details on pain management, see Chapter 14 of this book.

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Classification

Agent

Dosage

Local anaesthetics

Lignocaine Benzydamine Hydrochloride mouthwash

2% viscous: 15 ml 4-hourly, rinse and expel 10% spray: 2 sprays 2–3-hourly to affected area Gel: apply to affected area as required 5–30 ml 3–4-hourly

Benzocaine

Lozenges: suck 1–2 tds Spray: 2 sprays 2–3-hourly

Topical NSAIDS

Benzydamine

0.15% solution, 15 ml 4-hourly, rinse and expel Ointment: apply to affected area as required

Topical salicylates

Choline salicylate

Apply gel with gentle massage 4–6-hourly

Coating and protective agents

Sucralfate suspension

15–30 ml as a mouthwash 2–4-hourly, rinse and expel

Diphenhydramine

Diphenhydramine elixir and Kaopectate® (equal parts) solution

15–30 ml 2–4-hourly, rinse and expel

Diphenhydramine elixir, aluminium hydroxide antacid, lignocaine viscous (equal parts) solution

15–30 ml 2–4-hourly, rinse and expel

Anecdotal evidence shows that a solution containing combinations of morphine with any of the above preparations is effective

Lignocaine viscous 2% mixed with a 15-mg ampoule of morphine sulphate; rinse and expel OR Benzocaine gel mixed with a 15-mg ampoule of morphine sulphate applied topically

Topical morphine

End-of-life care

Denial: Stage 1

Impending death naturally affects everyone involved with the patient: the family, caregivers and friends, and of course the patient themselves. Caregivers should be particularly careful of how they treat the patient during this time and of what they say. The patient’s family easily becomes aware of every little thing that is said or done to their loved one. Remember that even when patients have reached a stage when they are not aware of their surroundings, they should still be cared for with dignity and respect. Each patient will react differently to the terminal phase, which will depend on factors such as their previous experiences with illness, their current physical condition, and other psychosocial issues. However, according to Dr Elizabeth Kubler-Ross, the dying person will experience five stages in coping with the knowledge of terminal illness, namely denial, anger, bargaining, depression and acceptance.

Denial is a useful psychological defence mechanism that may be used by the patient to block threatening reality by ignoring it. It is often the first reaction to approaching death and/or any sad news. It is a necessary short-term reaction from which the patient will gradually recuperate, thus enabling the patient to adapt to changes and approaching death. A patient may overcome this phase easily, depending on how the news is conveyed, how much time there is to assimilate it, and the mechanisms they have used previously to cope with stressful situations.

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Anger: Stage 2 When the patient realises that impending death is a reality, they are likely to react with anger – anger that this is happening to them and resentment that others are alive

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and well. The thought of the loss they will experience angers them, such as loss of their loved ones, their possessions, independence and life. They will also feel powerless and unable to control their own life. Short-term anger is to be expected, but if this persists, caregivers need to take steps to deal with it. One method is to encourage expression of the feelings of anger. If the patient does not do this, they may become agitated, uncooperative, withdrawn or depressed. Prolonged anger will impact on the patient’s ability to act rationally, make constructive decisions and adapt positively to necessary changes. Sometimes the patient’s anger will be projected onto innocent people who simply want to help, eg family members and healthcare providers. The family may withdraw their eagerness to help because of their own lack of understanding.

Bargaining: Stage 3 Bargaining is an attempt by the patient to delay the inevitable by making certain promises and/or agreements with their god/higher power, and these tend to remain a secret between the patient and their god.

• Fear of the unknown and of not knowing what will happen to them after death. It is the responsibility of the healthcare provider to ensure that the rights of the dying patient are upheld and respected.

56.4 Rights of the dying patient The rights of the dying patient are as follows: • To be treated as a living person until the time of death • To die with dignity • To be treated with respect – their name, person and belongings. • To be involved in their own care and decisionmaking • To be free from pain • To be assisted in retaining realistic hope • To be allowed to verbalise their feelings and emotions • To be kept up to date with open, honest and truthful information • Not to die alone.

Depression: Stage 4 Depression is the patient’s way of reacting to the losses that the illness has brought. If identified quickly, depression can be treated and the patient’s response to antidepressants is usually good. However, this may be difficult to pick up early, particularly if the patient hides their negative feelings. Many factors can contribute to depression, such as the loss of freedom as a result of constant hospitalisations and financial burdens.

Acceptance: Stage 5 Acceptance is the phase reached when patients have accepted the knowledge of their impending death and are resigned to it. Usually, they have overcome the feelings of anger and depression. However, even though patients may have come to terms with their death, they will not be without fear. The most common fears are the following: • Not being able to help themselves • Dying all alone and not being found • Leaving their loved ones behind • Not knowing how their loved ones will cope when left alone • Not having done enough for their family • Being penalised for failing their family • Exposure of their changed body image, eg presence of stoma, removed breast • Leaving planned projects unattended and incomplete

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Support of the patient and significant others when death is inevitable, including the bereavement period Dying should be viewed as a journey that the dying person has to walk alone, but a journey that can be supported by others. As death approaches, it is usual for those close to the dying person to offer help and support. Death is the final act of life, and the healthcare provider has a special opportunity to offer care, assistance and comfort to the dying person. Healthcare providers should also extend the support to the patient’s family/ significant others. Much has been written about control and management of symptoms. It must be remembered that the dying person has the same basic needs as that of other patients, so the healthcare provider should do the following: • Provide sufficient water for drinking purposes if it can be tolerated. • Feed according to the patient’s needs and nutritional demands. • Provide for elimination needs, and keep records of intake and output. • Provide for skin care and promote comfort, massaging pressure areas, padding bony prominences and assisting with changing positions. • Attend to personal hygiene to promote comfort.

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• Ensure that the patient is able to rest in a neat, orderly and peaceful environment. • Provide affection and support to allay anxiety and promote a trusting nurse–patient relationship. • Offer respect even at the hour of death. • Help with relief from fear, doubt and feelings of guilt. • Provide assurance that the patient’s loved ones and friends who will be left behind will be comforted and cared for. • Communicate with the patient’s loved ones and friends. • Refer the patient for pastoral counselling to ensure fulfilment of spiritual needs. • Communicate with the patient even when they are in a coma by explaining the procedures to be performed, sitting in silence with the patient, holding their hand and/or stroking their hair. As the time of death comes closer, support and companionship become even more important. At this time, even healthcare providers may feel powerless as death is rapidly approaching, but the patient may be at peace during this period, especially if they have accepted their death and know that no miracle can be performed to reverse the situation.

Early signs of impending death The early signs of death are the following: • Increased sleepiness, with the patient sleeping almost all the time • Increased anorexia and loss of desire to drink even fluids • Wasting • Confusion • Unfinished business – symbolic language • Less frequent speech, which may stop altogether • Oedema due to fluid build-up as the body fails to absorb fluids • Waxy pallor of the skin – more noticeable in white individuals.

Advanced signs of impending death Advanced signs of death are the following: • Coma or semi-coma; however, the patient may become aware of the presence of family members • There are signs of respiratory distress, followed by Cheyne-Stokes breathing. • Tips of ears, nose, fingers, toes and lips become cyanosed, cold and mottled. • Sometimes the skin may darken with the decrease in circulation.

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• The skin may feel cold and clammy. • There may be oliguria and/or anuria. • Breathing may become noisy as a result of secretions pooling in the pharynx and hypopharynx – often referred to as the ‘death rattle’. • The face becomes ashen grey. • Pre-terminal restlessness or agitation may occur, especially if the patient has unfinished business. • Eyes become sunken, starry and glazed. • There is possible urinary and faecal incontinence.

Clinical signs and symptoms associated with decreased survival time The following signs and symptoms are associated with decreased survival time: • Poor performance status, eg the patient stays in bed for 50% of the day • Rapid loss of weight or wasting • Progressive cachexia, with loss of 30% lean body mass • Neurological manifestations such as fatigue, lethargy and confusion • Rapid progression of the disease • Hypoxia manifested by confusion and restlessness • Noisy tachypnoea or death rattle • End organ failure.

Psychosocial factors associated with decreased survival time Some factors include the following: • Physical or emotional exhaustion of social support • Increased demands on the caregivers by the patient • Patient becomes hopeless and wants to give up • The patient desires death and verbalises this wish.

The role of the nurse During this time, the role of the nurse is to focus on the following care: • Ensure that the patient is allowed unrestricted visiting around the clock. • Allow and encourage the family/significant others to deliver some of the necessary care if they so desire. • Comfort the patient and family. • Offer emotional support. • Do not give false hope. • Maintain and respect the patient’s privacy even when unconscious. • Treat the patient with courtesy and respect. • Continue to reassure and communicate with the patient even in the absence of a response. • Honour the patient’s cultural customs and religious principles.

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• Continue to visit and stay with the patient, helping if the patient is anxious. • Attend to all the patient’s basic health needs; during the last hours, the patient may refuse to eat and at this stage must not be forced to do so. • When verbal communication is no longer possible, sit with the patient and hold their hand as a way of demonstrating that you still care. • Simplify medication by stopping those that are no longer beneficial, and administer only essential drugs such as analgesics, antiemetics, anxiolytics and antisecretory drugs. • Administer medication sublingually, rectally and/or by subcutaneous injection if the patient is unable to swallow. • Encourage family members to show their support through their presence.

Support for family The death of a loved one is one of the most intense stressors that a family has to go through, therefore it is extremely important to provide support. Because the family/significant others have been involved with the care of their loved one, their own social support system may have diminished, resulting in the isolation of the family. Because of this, and because feelings of grief may start long before the death of the loved one, bereavement support should be initiated before this happens and must continue until the family is able to cope with their loss. How long this period lasts will vary from family to family. Bereavement counselling aims to do the following: • Give people the opportunity to talk about events leading up to the death and the death itself. • Reassure the people that the feelings of anger, disbelief, sadness, pain and loss are normal when one has lost a loved one. • Assist and allow the bereaved to express their feelings of loss. • Enable the bereaved to accept their loss and to face the future and start living actively again. Healthcare providers should understand that death is handled differently within different cultures and that cultural beliefs must be respected. For Africans, death is not an issue of easy acceptance, even if there has been good communication between the healthcare team and family members. Terminal illness is seen as a failure of modern Western medicine, particularly when a patient has been on treatment for some time. Depending on the belief in their cultural customs and even if the patient

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is critically ill, the family may request discharge of the patient so that a traditional healer can be consulted. The family may even request discharge while the disease is still treatable, especially when no known causative factors can be identified. In these cases, it is believed that a traditional healer or sangoma will be able to identify the cause by virtue of the power vested in them by the ancestors. In African culture, the approaching death of an elderly person requires that the adult children and grandchildren be at the bedside to hear the last wishes of the dying person and also to give them a clear path to allow their soul to depart. The final wishes of the dying person must be honoured so that no bad luck befalls the family. The dying person’s last words supersede the written will. The death of a loved one is a stressful event and the family may behave irrationally and make unrealistic demands on healthcare providers. The healthcare provider should do the following: • Guide and offer support. • Encourage the family to vent their emotions. • Sit down with the family and use them as a therapeutic tool. • Show empathy, understanding and respect. • Encourage family members to stay with the patient and communicate with them even if the patient cannot respond – emphasise that the patient will be aware of their presence. • If the death vigil becomes overwhelming and exhausting, encourage relatives to take turns so that they can have resting periods. • When death occurs, allow family members to stay with the body for some time if there is no pressure of bed occupancy. • Allow relatives to perform last rituals according to their culture, such as washing the body. When death occurs, the family/significant others will express their grief in a variety of ways – with sadness, crying, guilt, apathy, or anger directed at the healthcare team. Grief may bring on physical symptoms, such as chest pains, chest tightness, inability to breathe, hyperventilation and fainting.

Reactions to the death of a loved one The family’s loss may result in some or all of the reactions discussed below.

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Disruption of normal life This could be caused by denial, disbelief, despair, acute emotional pain, auditory hallucinations of the voice of the deceased, insecurity, guilt, loneliness, numbness and shock. This stage usually lasts for seven days or less.

groups, where they will be able to reflect and debrief on the situations they have to cope with.

This will result in anxiety, anger, apathy, disrupted activities, guilt, insomnia, inability to concentrate and an overwhelming sadness. Dysphoria may be prolonged over several weeks, but from the third week onward the bereaved should start to adapt to their loss. From that time and as dysphoria diminishes, normal activities will be resumed, new goals will be established, and a sense of hope restored.

Support groups should be able to call on other caregivers as needed, such as pastoral services for spiritual support and upliftment, clinical psychologists, social workers or psychotherapists to provide individual or group counselling. Caregivers providing care at home must also be supported so that they can be temporarily relieved of their duties, even if only for a few hours, so that they can take time off from providing for the daily activities and needs of the dying person. Ideally, a support system should be made accessible for each caregiver so that they do not become exhausted.

Support for healthcare providers

Home care for the terminally ill patient

Group support for healthcare providers in a palliative care setting offers the opportunity to reflect, debrief and grow as a person. Stressful as it may be to care for the terminally ill, it is also very rewarding for the following reasons: • Symptom relief can be achieved. • Psychological adjustment can be facilitated. • Patients and family offer inspiration. • Personal development can be achieved by facing one’s limitations personally and professionally. • There is a sense of belonging and working in a supportive team where shared decisions and responsibilities are undertaken.

Because some patients associate hospitals with death, they prefer to be cared for in their own homes, where the surroundings and people are familiar, and where they feel they still have some control over their own lives. If possible, this should be allowed. Home care should be provided by or under the supervision of a registered healthcare provider. The care provided at home differs from that provided in a hospital or other institution.

Dysphoria

Caring for the caregivers Caregivers working with terminally ill patients have to deal with an enormous amount of stress and sometimes suffer from ‘compassion fatigue’ for the following reasons: • They have to break bad news to family members or patients almost every day. • They have to cope with situations where a medical cure has failed. • They are repeatedly exposed to the death of people with whom they have formed a relationship. • They have to remain calm and objective when the patient and/or family members express their anger, grief and any other negative feelings. • They experience emotional conflicts. • Their personal belief systems are sometimes challenged as they deal with multicultural patients. For these reasons, it is important for caregivers who provide palliative care to form and attend support

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The advantages and disadvantages are as follows: • For home care to be successful, the ‘lay caregiver’ – who is often a family member – should have the following attributes: – They should be fit and healthy, and able to cope with looking after a seriously ill person (their physical and mental condition must allow them to assume this responsibility). – The caregiver should be fully informed about medication administration, observation and the management of possible side effects. – The patient must be able to receive continuous nursing support through frequent/daily home visits. – The caregiver must be able to communicate closely with the family so that when new problems arise, they are kept fully informed. – It is also useful if the caregiver is aware of support groups in the area. • Even when home care works well, there may be times when a major crisis erupts that requires the patient to be hospitalised. In these instances, it must be possible for the patient to be admitted without delay.

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• Although providing care for a terminally ill person at home may be rewarding, it can also be stressful for the caregiver because of the following reasons: – The patient has to be looked after for 24 hours a day every day. – The caregiver may lack the necessary experience to care for a terminally ill person. – They most probably have other responsibilities, for instance caring for children or employment. – There may be limited social support for when the burden becomes overwhelming. – The physical, emotional, social and economic burdens may become overwhelming at times. – The emotional strain may be particularly difficult if the relationship between the caregiver and the patient is a very close one. – The patient may have experienced some personality changes due to the illness, and may be difficult to deal with, or may be forgetful and unable to recognise close family. – The caregiver may become resentful because they are unable to leave the home to have time to themselves. If the caregiver is not emotionally strong, these mixed feelings can take a heavy toll.

Advantages of home care Advantages of home care include the following: • The patient and family feel that they have more control over their lives. • The family are more relaxed and confident in their own home. • It is less expensive to care for a loved one at home, unless highly technical equipment has to be used. • The family can deal with one person and can form a relationship with them. • Care can be provided in a comfortable and familiar environment, which is less threatening for both the family and the patient. • There are no restrictions on visiting and the family has easy access to their loved one.

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Barriers to effective home care The following barriers exist: • Sometimes the presence of the healthcare provider may be viewed as an intrusion on the family’s privacy. • The healthcare provider displays a lack of sensitivity, and disregards the family’s wishes. • The normal routine is disrupted when healthcare providers are not able to visit at a fixed time. • There may be personality conflicts between the patient, the healthcare provider and the family • There may be financial pressures as medical expenses may prove to be stressful for the family. • There will be a loss of privacy caused by various members of the multidisciplinary team making home visits. • A sense of alienation may be experienced by the healthcare provider at home. Support group and infor­ mation services should be available to reduce this. For home care to be successful for the dying patient, it should comply with the following criteria: • Care must be patient centred. • All stakeholders who will be providing home care must be well informed. • A multidisciplinary team approach should be used. • Comprehensive management of symptoms must be done after assessment. • Referral to relevant resources must be planned and initiated early.

Conclusion Good nursing and palliation of unpleasant symptoms is an essential aspect of end-of-life care. The effective management of pain and other symptoms can contribute a great deal to the patient’s quality of life and also to the peace of mind of the patient’s family.

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Suggested activities for learners Activity 56.1 Working in groups, discuss the following aspects of communication: 1. The importance of good communication. 2. How does ineffective communication impact on the patient and family/significant others? 3. Measures to be implemented to enhance effective communication. Activity 56.2 Working in pairs, develop an education plan for level-two learners in which you explain the measures that should be implemented in the following scenario: You are working in an oncology unit where a few of the patients are terminally ill. What measures would be appropriate for the following problems? 1. Anorexia 2. Mucositis 3. Breathlessness 4. Malodorous wounds 5. Fatigue 6. Pain 7. Preterminal restlessness. Activity 56.3 Disclosure of terminal illness evokes various emotional reactions from the patient. In your groups, identify and discuss the emotional reaction experienced by a terminally ill patient. Activity 56.4 What are the signs that would lead you to recognise that the patient is dying?

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57

Disaster nursing

learning objectives

On completion of this Chapter, the leaner should be able to: • develop a disaster plan for a healthcare institution and the clinical units within it • effectively plan and implement disaster and emergency drills • competently assist and care for victims during a disaster • explain an evacuation in cases of fire and/or a bomb threat in a healthcare institution • facilitate rehabilitation and provide healthcare education in a disaster situation. key concepts and terminology

casualties

The victims of a major incident or disaster.

damage

Harm or injury to property or a person, resulting in loss of value or the impairment of functionality.

disaster

An incident that cannot be dealt with by routine capacity of a service.

disaster planning process

A chronological set of steps that must be followed in order to establish a disaster plan that meets the actual needs of the area of responsibility and is based practically on the capacity of the staff.

evacuation

Moving patients out of a building during a disaster for the purposes of safety.

hazard

Any one object or situation which could potentially be harmful to a person’s life, health, property or the environment.

impact

The action of one force coming into contact with another body; a force striking an environment/society.

preparedness

The state of having been made ready or prepared for use or action, especially in a disaster situation.

risk

The potential of a hazard to occur.

triage

The method of sorting patients to determine who must be treated and transported first in order of priority – to achieve the best for the most.

prerequisite knowledge

• First aid • Microbiology and parasitology • Homeostasis in relation to fluid and electrolyte balance • Shock • The role of the nurse in disaster nursing • The nursing process.

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medico-legal considerations

Disasters are laden with hyperactivity and panic. Nurses who participate in disaster nursing must be well trained so that mistakes are kept to a minimum. Nurses must be careful, and ensure that they give correct treatments to patients and act professionally to avoid litigation. Nurses must be careful on decisions taken, being aware of legal wrangles that may follow the disaster incident, hence the importance of belonging to an association. In a disaster situation, if not well coordinated, the rescue team might miss survivors, thus increasing their vulnerability. The disaster scene might not be safe with worse to follow, thus putting the rescue team as well as survivors in danger. ethical considerations

• In most disasters, some degree of triage is involved. This means taking decisions based on the initial assessment of a patient, which may often seem harsh. Some victims with unsalvageable injuries will be left to die, while others with survivable injuries receive priority care, thus causing an ethical dilemma for the staff involved. In order to deal with this dilemma, very good guidelines should be developed both for triage itself and for the care of each category of patient. • The rights of the victims to receive care must not be ignored. Even those who will not receive life-saving care due to the severity of their condition should receive compassionate nursing care and comfort, and should also have their respect and dignity maintained. • Relatives who come to be with the injured or identify their dead must be able to do so in privacy. • Care should be administered based on clinical needs and not influenced by other discriminatory criteria. This is specifically applicable in conflict and war situations. • It is unethical for the nurse to abandon victims in disaster situations unless it is very clear that no further sustainable actions can be done for them or the environment. • A nurse remains accountable for their actions during a disaster, and these will be evaluated according to the ‘reasonable nurse’ principle. The nurse’s actions during a disaster should conform to what a reasonable nurse with the same level of knowledge would do in the same circumstances. • A nurse’s actions must be guided by the Scope of Practice, but they must be willing and able to improvise and adapt according to the disaster situation. • Nurses must be able to perform the actions competently since they remain accountable for their actions. essential health literacy

A disaster scene is a potentially dangerous place, and the community needs to know that they cannot freely walk around this area. Their assistance must be solicited. Those wanting to assist must await clear instructions on what to do, where to go and when. Victims must not be given anything to drink or eat as surgery under general anaesthesia may be necessary.

Introduction There are different philosophies, approaches, perspectives and skills involved in the management of major incidents and disaster situations, and nurses need to be competent in the specific skills and techniques required. A sound knowledge of the rationale and protocols that underpin disaster management strategies is encouraged. Nurses should be able to identify disaster planning needs and priorities, participate in planning, implement disaster plans and manage a disaster situation.

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Overview of disasters Definition of a disaster The World Health Organization defines a disaster as the following: 1. A serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses which exceed the ability of the affected community or society to cope using its own resources (ISDR). 2. A situation or event, which overwhelms local capacity, necessitating a request to national or international level for external assistance (CRED).

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The Disaster Management Act 57 of 2002 defines a disaster as: a progressive or sudden, widespread or localised, natural or human-caused occurrence which: (a) causes or threatens to cause— (i) death, injury or disease; (ii) damage to property, infrastructure or the environment; or (iii) disruption of the life of a community; and (b) is of a magnitude that exceeds the ability of those affected by the disaster to cope with its effects using only their own resources; In practical terms, a disaster is therefore an incident that cannot be dealt with by the routine capacity and resources of the specific health services. Irrespective of the cause of the incident and the demands created by it, if it cannot be dealt with by the routine resources of the institution concerned, it is often referred to as a disaster. Disaster nursing is often seen as a separate entity, but it basically entails the adaptation of existing knowledge and skills in nursing large numbers of patients, sometimes in improvised circumstances. Isolated aspects that need to be highlighted include the nursing method, safety and control, and improvisation. The primary aim of nursing in disasters and emergency situations is to save human lives and limit suffering of the people involved.

Disaster models A disaster can be analysed with reference to two functional methods, namely: 1. The time-based model 2. The geographical or space model.

The time model This model analyses a disaster on the basis of chronological passage of time, eg before (pre-disaster state), during (the disaster itself) and after (post-disaster state). The model involves the following stages: • Threat stage. This stage occurs in the pre-disaster state, generally once the person becomes aware of an event that constitutes a possible threat to their functioning, eg a weather warning for an approaching system or the diagnosing of a highly communicable disease in the area. This stage is characterised by contingency planning, precautionary measures and a review of disaster plans.

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• Warning stage. This stage is when the potential cause of a disaster becomes an actual threat to people. It can be seen as a development in the pre-disaster stage when a disaster becomes highly probable. Warnings like this often last for a very short time, eg rising storm clouds that indicate impending heavy rain and floods. This phase is characterised by panic reactions on the part of those likely to be affected and dramatic attempts to escape the danger. • Impact stage. This is defined as the period in which the overwhelming force of disaster is present. The impact is felt during the disaster itself and can last for a short time to an extended period, such as an epidemic or a flood situation. • Isolation stage. A period of isolation arises once the disaster force is stabilised. During this stage, the survivors are solely dependent on each other until external help arrives. This is the early phase of the post-disaster state and can last from seconds to days depending on the nature of the incident and the geographical area in which it takes place. • Rescue stage. This stage continues in the post-disaster state. Chronologically it begins once action is taken to restore the balance. Rescue action includes freeing the victims, providing medical assistance and bringing possessions to safety. The initial rescue is carried out by the community until help reaches the scene. • Rehabilitation stage. This stage may start with an early impact and continues through the post-disaster state. It includes physical, psychological and medical rehabilitation and reconstruction. Attempts are made to reconstruct the area. This stage can last several years or even decades before a new balance is established. In South Africa, the Disaster Management Act 57 of 2002 combines these phases as follows: • Pre-disaster phase: prevention, mitigation, preparedness and early warning • Post-disaster phase: response, recovery, rehabilitation and reconstruction.

The space model This model analyses the geographical area of a disaster situation, dividing it into concentric zones of varying sizes. These zones will be discussed below. • Total impact area. This area is seen as the epicentre of the force that caused the disaster, ie where the force was at its worst. Damage and injuries sustained in the area are usually life threatening or fatal. • Fringe impact area. In this area, the force of the disaster is still clearly discernible, but the effects are less catastrophic. It includes, for example, areas

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which were affected partially but were not completely destroyed. Rescue action is usually focused on this part of the disaster scene, since it is here that injured people in serious condition are likely to be found, and who can then be treated and saved. • Filter area. In this area damage is limited, and is often due to the secondary causes of a disaster. Injuries are generally minor, and secondary rescue action can be focused on this area. The relief teams that initially reach the impact area usually come from the filter area. • Organised community. The organised community may be defined as the groups that react to the disaster and offer organised relief. This includes the resources of a specific community’s civil organisations, such as the fire brigade, ambulance services, first aid services, police services and hospitals. A number of communities may often become involved in the emergency relief, particularly in the case of natural disasters. • Organised region. The region involved in organising relief may vary according to the extent of the disaster. Neighbouring towns may send relief, provinces can be involved and the entire country may also send relief.

Classification of disasters Various classification systems using various criteria are used to grade a major incident or disaster.

Governance classification From a legal point of view, disasters may be classified in accordance to the provisions of governance. The Disaster Management Act gives authority to the different tiers of government to classify an occurrence as a disaster, depending on the extent of the effect, and then empower such institutions to implement measures and use resources to counter the effects: • A local disaster affecting a single local authority and managed by the local municipality alone with assistance of municipalities in the area • A provincial disaster affecting more than one local authority in the same province that cannot be managed by the local authorities alone in the area • A national disaster that a single province cannot deal with effectively. This classification designates the primary responsibility to a specific sphere of government.

Functional classification The aim of functional classification is to analyse the incident in accordance with fixed criteria, and then

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to base the classification on the extent of the incident. This classification may be used to determine whether the community will be able to deal with the incident itself, or whether it will be necessary to elicit the help of the entire country. On the basis of such a functional classification, requests may be addressed to government to have the incident or area declared a disaster area.

The number of casualties and the seriousness of their injuries/condition • Minor disaster or major incident. A disaster may be classified as minor in relative terms if there are 25–99 casualties (dead or alive), or if there are between 10 and 49 casualties requiring in-patient hospital treatment. • Moderate disaster. This is where there are 100–999 casualties, alive or dead, or 50–249 casualties whose injuries require in-patient hospital treatment. • Major disaster. This is where there are 1  000 casualties, alive or dead, or more than 250 casualties requiring in-patient hospital treatment.

Other classifications Disasters can also be classified according to criteria which determine the extent to which relief is required. These must be considered collectively when classifying a disaster as a community, regional/local, national or international disaster. • Level I. The disaster can be managed and contained by local emergency responders and agencies. This level of incident is referred to as a major incident rather than a disaster. • Level II. The disaster can be managed and contained by regional emergency responders and agencies. • Level III. The disaster requires the assistance of national agencies in order to manage and control it. • Level IV. This type of disaster requires international interventions to support the national government. Classifying disasters in this way enables health authorities to get a general indication of the extent of their initial reaction, thus a minor disaster will probably be managed at a local level by a community hospital, while a moderate disaster will necessitate mobilising the facilities of an entire region, and a major disaster necessitates action on a national scale. • The location. If a disaster is spread over a large area, it usually involves a number of healthcare services, with the result that each one will receive only a few patients. However, if a disaster takes place in a restricted area with the same number of casualties, the burden on a single health service/establishment will

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be more intense. The management of a disaster will depend on whether the area is urban or rural, and the resources available to manage the disaster. • The rescue and transportation of casualties. The rate and ease with which casualties are rescued and transported from a disaster scene determines the rate at which help will be required and/or the rate at which casualties will arrive at a health service. • The cause. The cause of a disaster will have an influence on the kind of relief that may be required and the extent of the services to be mobilised.

•

•

Causes of disasters The causes of a disaster can be divided into two main groups, namely: 1. Natural disasters. Resulting from natural events, these disasters generally cover larger areas and the number of casualties is relatively low compared with the area involved. Examples of natural disasters are earthquakes, volcanic eruptions, floods, tornados, drought and famine, fire and communicable diseases. 2. Man-made disasters. These are disasters that occur as a result of human action. They usually cover a smaller area, but injuries tend to be more serious than in the case of natural disasters. Examples are transport incidents such as an accident, eg train, bus, overloaded minibus, explosions and fires, poisoning, stampedes and riots, radiation and harmful substances in which people’s actions are the direct cause of the disaster.

Basic principles in disaster management The aim of disaster planning is to reduce or prevent death, suffering and loss of property, and to ensure the survival of human beings as well as the environment. There are eight basic principles of disaster management which are aimed at preventing disasters from escalating into catastrophes that could threaten the survival of human beings and their habitat. • Principle 1: Disaster prevention. Careful assessment of the risks and proper identification of disaster-causing situations are necessary. Dangers can be eliminated and the disaster averted through preventive action. • Principle 2: Reducing the number of casualties. Timeously removing or reducing possible victims can mitigate the effects of the disaster. Plans should be made to evacuate the population where a warning was received on time, and deliver timeous health services. • Principle 3: Preventing further casualties or escalating the incident. This can be done by eliminating secondary disasters, eg by first assessing an area for further risks.

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•

•

•

Injuries to rescue workers can be prevented and vaccinations administered in time. Principle 4: Saving and rescuing victims. Victims must be located as quickly as possible to ensure that they are safe or, if necessary, to rescue them from structures or forces that could further harm them. Specialised equipment and expertise are often required for rescuing and extricating casualties. Principle 5: Delivering emergency care to the injured. Triage (sorting) should be applied to ascertain who should be treated first, ranging from the most to the least severe injuries. Life-saving emergency care must be carried out as quickly as possible, such as securing a patient’s airway, ensuring breathing and controlling haemorrhage. Principle 6: Transporting the injured to hospitals or healthcare facilities. Transportation to facilities should commence in an orderly fashion and according to priority. All available means of transport can be used, such as by road, rail and air transportation, according to the needs and priorities of the patients. Principle 7: Delivering definitive care. Patients should be classified according to the seriousness of their conditions/injuries. Priority should be given to delivering life-saving care to victims with a viable prognosis. Principle 8: Rehabilitation. The rehabilitation process is aimed at meeting the physical, psychological and emotional needs of the survivors.

The disaster planning process The disaster planning process may be defined as a series of logical, chronological steps that need to be taken when setting up a functional plan for the management of incidents, which on account of their nature and extent cannot be managed by routine measures and must therefore be functionally regarded as a disaster. The plan should be: • flexible to make provision for various kinds of incidents that may vary in cause and extent • comprehensive in order to provide for the optimal use of all resources and address all risks • coordinated to ensure that all activities are aimed at effective problem solving with maximum effect • detailed so that all role players are well informed about their roles and functions. The process entails four consecutive steps of the nursing process.

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Step 1: Assessing the need This step entails carrying out a detailed assessment to determine which risks must be planned for. It is essential that the specific geographical area of responsibility be determined, for which planning must be done. The assessment process should include assessing the risk of disaster in the area and the availability of facilities and resources to manage the disaster.

Step 2: Planning to meet these needs It is essential to do detailed planning in order to establish how the specific healthcare service envisages satisfying the needs in a disaster. It is important to determine who will be responsible for drawing up a disaster plan. A small core committee of key people should be formed to coordinate the planning. The functions of the disaster planning committee are to do the following: • Determine the kind of disaster plan that is most appropriate for the specific institution. • Identify the areas to be used in a disaster. • Allocate staff to each area. • Determine the functioning of each respective area. • Determine what supplies are needed. • Coordinate and manage the activities.

Determining the most appropriate disaster plan for the specific institution An appropriate model for each facility should be identified even though various combinations of the models can be put together to effect a plan. The disaster planning models include those discussed below. The phased method. This may be defined as a phased reaction where various hospitals are activated sequentially as required. For example, on receiving the report of the disaster, one or more hospitals closest to the scene are activated and another hospital some distance away must

go on standby. As soon as the assessment of the scene is done, further hospitals or healthcare facilities may be activated. This model is suited for metropolitan areas where there are numerous hospitals available. The action plan model. This may be regarded as an allor-nothing disaster plan. The moment an emergency report of a disaster is received and confirmed, all routine is stopped and all available resources are mobilised. This model is suited to the smaller hospitals or those in highrisk areas, such as in a conflict zone. The ad hoc model. This may be seen as a vague, basic structure in which the actual situation determines the detail. It is concerned with specifications relating to the exact incident taking place. The ad hoc model is used particularly in very small institutions. The steps described below should be followed for planning the needs of patients within a healthcare facility.

Identifying areas in the facility to be used for a variety of activities The first step in creating a disaster plan is to identify areas within the facility that could be used. Considerations in allocating space should be given to the following: • Where the patients will be offloaded and received • Where triage (sorting) will be carried out • Where each of the three triage priorities will be managed • How the flow of casualties is to take place • Where patients will be admitted. Parking area. A clear parking area for emergency vehicles must be identified, with preferably a circular route. A roofed-over area close to the entrance for the reception and sorting of patients must be identified. The parking

Phase

1

2

3

Hospital A

Go on standby

Activate disaster plan

Activate additional temporary facilities

Hospital B

Go on standby

Activate disaster plan

Activate additional temporary facilities

Hospital C

Go on standby

Activate disaster plan

Activate additional Create temporary temporary facilities tented facilities

Go on standby

Activate disaster plan

Hospital D

4

5

Activate additional temporary facilities

Figure 57.1  Example of a phased response to a notification of a possible disaster

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and all identified areas must be on the same floor level to facilitate flow as well as the movement of identified gurneys (hospital trolley/stretchers for carrying patients) and wheelchairs. Areas should be familiar to staff, and caution should be taken not to use totally new areas during emergencies. A clear pattern of flow must be created, preferably with a unidirectional flow chart. Specific treatment areas. Specific areas where patients will be treated according to the seriousness of their conditions must be identified. Personnel are also accordingly assigned to each of the areas. The examples of the specific treatment areas are discussed below. • Receiving and triage area. The drop-off zones should have separate areas for walking patients and uninjured survivors. The areas must have good lighting and methods of crowd control. • Critical resuscitation area. This is the area where critical patients (Priority 1) will be treated. Usually the emergency department or part thereof is used for resuscitation. The resuscitation area must have adequate space for active resuscitation, airway care and shock treatment. • Serious treatment area. This is the area used for stabilising serious (Priority 2) patients, and there must be sufficient space. A part of the emergency department or another area nearby may be used. Some hospitals use a ward close to the receiving area from which patients can be easily evacuated when preparing the area as a serious treatment area. • Minor injuries area. This is an area where patients with minor injuries (Priority 3) are treated. There must be adequate seating space for patients awaiting treatment as well as space for specific treatments. In proportion to all casualties, this category forms the biggest group, and a large area should be used. Such an area must make provisions for tetanus prophylaxis, suturing of lacerations, the application of plaster of Paris for closed fractures and the dressing of wounds. The space should be adequate enough to accommodate a mobile X-ray facility that may be used in this area to take some of the load away from the radiology department. Private rooms for emotional support should also be provided in this area to help victims work through their psychological trauma. Religious workers, psychologists, psychiatrists, social workers and various other skilled counsellors can be utilised in this role. • Deceased area. A storage area for the deceased out of the public eye must be provided. Existing mortuary facilities can be used to store bodies, or a wellventilated room with an exposed cement floor can be utilised while awaiting transfer to a forensic pathology

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mortuary. The corpses can be placed directly on the cement floor so that they do not take up hospital trolleys and beds. Special attention must be given to the legal requirements relating to the identification of bodies and maintaining dignity. If applicable, a decent private area must be created where bodies can be identified and shown to the next of kin. • Unresuscitatable area. This triage category is only activated when the number of casualties totally overwhelms the available resources. In such a situation, casualties with no prognosis are provided with comfort and allowed to die. A private area staffed by experienced personnel should be established. Comfort and pastoral support must be available to these patients, and next of kin must be able to spend time with them. Legal experts may also be required to take instructions pertaining to the last will of victims. • Admission wards. Specific ward(s) from which current patients are moved to other wards may be identified for admitting disaster casualties. The identified wards should be evacuated once the disaster plan is activated. The advantages of admitting all disaster casualties to specific wards are the following: –– It makes administration easier. –– Additional staff can be concentrated in these areas. –– It facilitates flow to theatres. Such wards should be as close as possible to the emergency department level to make provision for power cuts to the lifts. • Discharge and reuniting area. A specific exit thoroughfare must be created for handling all patients who are or have been discharged. This includes inpatients who have been discharged to make room for disaster casualties, and disaster victims who have already been treated and do not need to be admitted. The discharge point should include a place for reuniting the survivors with their families, a place for enquiry management and a bereavement area.

Allocating staff A specific head or coordinator must be appointed for each area, with at least two replacements who will take over in the absence of the coordinator. All three of them should be involved in the disaster planning committee’s sessions on the specific function. Allocation of staff must be finalised in advance, and the need based on estimates of the facility’s emergency service capacity. Key staff should be allocated to the area according to the job titles to ensure that staff turnover is addressed. Non-key staff are mobilised and then report to a central point where they are allocated and provided with action cards. Methods must be identified for informing and mobilising staff.

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The following may be used: • The list method. Each person on the list is personally contacted and summoned. This method is time consuming, but suited to contacting key staff. This method can also be used where messengers have to be sent due to non-functioning communication systems. • The fan-out alert (cascade) system. Each person is responsible for informing two further people and these two people in turn are responsible for informing two additional people in a predetermined plan. This method is extremely fast and efficient, regardless of the method of communication. However, it cannot be stopped once activated. • The siren/loudspeaker system. A siren or loudspeaker is used to summon staff in a small community. This method may be particularly efficient in situations with little means of communication, but often causes panic. • Other communication means. Other sophisticated means of communication such as radio pagers, group cellphone calls and coded messages over the hospital intercom can also be used, but will result in problems if communication systems are down, so a backup plan is necessary. In major disasters, public radio and television broadcasts can be utilised to alert personnel to report for duty. Following mobilisation, a clear reporting procedure for staff must be determined. Specific reporting points must be identified, with clear controls for determining who is present, so that key absences can be identified immediately and arrangements made for replacements. Staff must report to the specific service points to which they have been assigned.

Determining the functioning of each area The disaster planning committee must, in cooperation with representatives from each area, determine the functioning of each respective area. According to the information, a clear plan of action must be drafted for the area. This plan should thus be chronological, simple and written in such a way that instructions are clear. The procedure is then translated into action cards that are handed to each person. Each action card should indicate the following: • Who should execute the tasks (category of worker) • What the person must do in chronological order • Where the person must carry out the tasks • With what resources the tasks must be carried out • Where the person gets the equipment, drugs, keys, etc • How the tasks must be executed. The action card design should be simple, clearly indicate where the person can get help if problems arise (eg

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Clinical alert! Where a disaster situation is reasonably expected to last for a longer period of time, it is essential that a shift system, for example 8 hours on duty and 8 hours off, be implemented to prevent all staff from being deployed without replacements. It may be necessary to provide rest areas, because it is possible that staff might not be able to return to their homes due to inaccessible roads or other dangers.

specific phone numbers) and include a clear layout sketch of the area. The card should also indicate what the person should do once the task is completed, and where to report for further assignments. Action cards can be drafted by the department and then given to the disaster planning committee to ensure that each action correlates with that which is being carried out by the facility. After being approved, a set of action cards must be kept centrally in each department in a clearly marked disaster box or file, or on the notice board. All coordinating staff should be provided with a clearly marked tabard or jacket indicating their role, eg ‘Triage officer’.

Planning supplies Supplies that are required must be realistically determined on the basis of estimates. Estimated supply levels must correlate with the estimated patient numbers and the capacity of the service. The emphasis should, however, be on identifying the resources available rather than on stockpiling mass supplies, eg how one can access 500 vacolitres immediately when these are required, rather than storing them somewhere. If the supplies are stored, a strategy/system must be implemented, which rotates the supplies into circulation before they expire.

Coordination and management Activities should take place in a coordinated way. Instructions on action cards must correlate with the actions of other areas. An operational room should be designed so that all the key management members are present in one room to ensure that the actions run smoothly and are coordinated. The operational room should be equipped with the necessary communication facilities and also have access to a radio network that links the institution to other hospitals in the area, the ambulance service, disaster management, etc. Such radio network links can be supplemented with telephone lines, intercom links and messengers.

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Records of statistics relating to the number of patients involved on the disaster scene, the numbers referred to the specific facility, the numbers received and admitted, the deceased and those discharged are essential for decisions on classification of the disaster and whether or not to alert additional relief, or whether or not to activate an additional phase of the multiphase disaster plan.

Step 3: Implementation of the plan The implementation of the disaster plan should begin with identifying a specific contact point from where the plan can be activated. The emphasis is on identifying a contact point, such as a switchboard, rather than a contact person, such as the nursing service manager personally. The contact point should be provided with a written proforma document containing the necessary information to be obtained and, on the basis of that information, a delegated authority to implement certain activities and actions. A clear action plan must also be available at the contact point and can be mounted on the wall, together with the proforma document. The proforma document will vary among institutions. However, it should contain the following information: • The particulars of the person who calls in and their contact details • Details of the major incident or disaster (this will deter­ mine whether the disaster plan should be activated, or whether the facility should remain on standby) • The exact location of the incident • The type of incident • Hazards such as chemical leakages or contaminated casualties • Access routes to the incident • The estimated number of patients involved • The nature of the casualties/patients • Emergency services that are already on the scene and specialised services required. If not already on the scene, it is essential to immediately send a skilled person such as a nurse, doctor or emergency care practitioner to the disaster area or scene to evaluate or assess the actual situation from a medical perspective. It is the primary function of this assessor to evaluate the scene, to determine the medical impact, and to pass on important information to the hospital(s) concerned to enable informed decisions about the nature of the actions to be taken. The assessor‘s secondary function is to triage patients according to the extent of their injuries. The final function is to assign casualties to specific hospitals according to the extent of their injuries or condition. In some instances, medical relief teams may be required on the disaster scene. It is essential that such

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a team is properly trained, well organised and well equipped, including personal protective equipment. The relief teams can be sent to situations where transportation cannot take place immediately, such as where the number of casualties exceeds transport capacity, or transport is delayed due to inaccessible routes or other reasons. Such a team may also be deployed to provide surgical capabilities and accompany critical patients in ambulances or aircrafts.

Receiving patients A faultless system must be designed to receive patients. They must be numbered on arrival to ensure that there is no opportunity for confusion. The most common method is to use already numbered disaster files with corresponding numbered identity tags, and on arrival the numbered tag is attached to the person and the corresponding file issued. The contents of the files will vary among institutional systems. However, all files should include clinical notes, prescriptions and request forms for diagnostic procedures. Corresponding numbered transparent bags must be provided for clothing and possessions removed from casualties, as well as corresponding numbered bags for valuables or money. A safe storage box, eg a large locked post box, can be provided directly at the entrance where the bags containing the valuable items can be posted and later documented in a more controlled situation. After identification (numbering), the patients must be triaged (sorted) or re-triaged immediately according to the seriousness of their condition. The use of a colour-coded triage method must be used, as shown in Table 57.1. The colour-coded triage tag must be attached to each individual patient. This can be done using triage tags or standard patient nametags pre-marked with strips of coloured insulation tape. The colour code is then attached to the patient’s arm and adapted every time they are re-triaged. The Emergency Medicine Society of South Africa (EMSSA) in collaboration with the National Department of Health recommends the use of the cruciform triage tag (Figure 57.2) and approved the triage sieve system (Figure 57.3) for use in disaster triage.

Triage systems The most appropriately trained person carries out the triage. As primary triage (triage sieve) is done according to a triage algorithm, it is not necessary to use a highly qualified person primarily, therefore a trained enrolled nurse can do primary triage.

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1158  Juta’s Complete Textbook of Medical Surgical Nursing Table 57.1 Triage according to colour-coded priority classification

Priority

Classification

Colour code

Priority 1

Critical

Red

Priority 2

Serious

Yellow

Priority 3

Minor

Green

Dead

Deceased

Black or blue Pr

ior

Pri

ity

1C

rit

ori

ty

2S

ou

s:

y3

rit

io Pr

eri

ica

l:

Clinical alert! Triage merely entails sorting according to clinical parameters. Triage officials must thus not become involved in emergency care, because this can lead to congestion and can further delay patient care. The routes from the triage area to the various treatment areas can be indicated by means of permanent or temporary direction indicators, such as coloured arrows attached to the walls by means of adhesive. In this way, with a minimum amount of instruction, temporary porters can be deployed to ferry patients to specific areas according to the colour of their tags.

Re

d

Ye ll

ow

or

in

M s:

rie

ju

In e Gr

Deceased: Blu

en

e

Figure 57.2  Cruciform triage tag

Walking?

Yes

Priority 3 Minor

Injured

No Not injured

Dead

Survivor reception centre No Breathing?

No

Open airway

Breathing?

Yes

Respiratory rate

Yes 9 or less 30 or more

in 120 m ec*) >2s (CRT

Over

10–29

Pulse rate

Priority 1 Critical

Under 120 min (CRT ≤ 2 sec*)

Priority 2 Urgent

* Capillary Refill Time (CRT) is an alternative to pulse rate, but is unreliable in the cold or dark: if it is used, CRT of > 2 seconds indicates PRIORITY 1.

Figure 57.3  The triage sieve system

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TRIAGE SORT STEP 1: Calculate the GLASGOW COMA SCORE (GCS) A: Eye opening

B: Verbal response

C: Motor response

Spontaneous

4

Orientated

5

Follows command

6

To voice

3

Confused

4

Localise pain

5

To pain

2

Inappropriate

3

Withdrawal to pain

4

None

1

Incomprehensible

2

Flexion to pain

3

No response

1

Extension to pain

2

No response

1

Glasgow Coma Score = A + B + C STEP 2: Calculate the TRIAGE SORT SCORE X: C  onvert Glasgow Coma Score

Y: Respiratory rate

Z: S  ystolic blood pressure

13–15

4

10–29

4

≥ 90

4

9–12

3

> 29

3

76–89

3

6–8

2

6– 9

2

50–75

2

4–5

1

1–5

1

1– 49

1

3

0

0

0

0

0

Triage Sort Score = X + Y + Z STEP 3: Assign a triage PRIORITY 12

=

Priority 3 – Minor

11

=

Priority 2 – Serious

≤ 10

=

Priority 1 – Critical

0

=

Dead

STEP 4: Upgrade PRIORITY, dependent on the injury/diagnosis

Figure 57.4  The triage sort system

However, secondary triage (triage sort) requires a skilled, well-qualified clinician who could apply clinical judgement (see Figure 57.4).

• Discuss the department’s entire disaster procedure. • Simulate the procedure without wasting equipment or disturbing the actual patients.

Step 4: Evaluating the effectiveness of the plan

This serves as a training opportunity, and also to assess the detailed disaster actions for the specific department.

Continuous assessment must be carried out to evaluate the effectiveness of the plan and to ensure staff preparedness. The methods described below can be used.

Table-top exercises

Departmental exercises • Arrange small controlled situations to enable a specific hospital department to test their actions. This can be done theoretically or practically. • Set up organised rosters where a member of the disaster planning committee visits a department at an assigned time.

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• Create theoretical situations and present a scenario for the staff to manage. • Provide time to go through the scenario and then to formulate actions. • Compare the actions described with the disaster plan, and identify problems and shortcomings. The emphasis should be on learning, and not on fault finding.

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Communication exercises • This exercise is to test the flow of communication used to activate staff or to inform departments. • Send a feedback form in advance to all the departments. • A message is then sent through the system, and all departments must record the time they received it. • The feedback forms can be used to determine communication hitches and the time it takes to mobilise staff. • Such an exercise can also be held after hours to determine the availability of staff. • The activation plans can then be adapted to enhance the flow of communication.

Disaster exercises • Full exercises with moulaged casualties are useful to evaluate the total integration of systems; this may, however, be difficult to carry out as it will disrupt the organisation. • The most important actions are the detailed review of the exercise and adapting plans to incorporate the findings.

Post-event review A post-event review following an incident should be carried out: • Conduct a thorough review of all the actions taken. • Assess the actions constructively and critically. • Adapt plans to incorporate decisions.

Managing the disaster scene The actions carried out at the disaster scene aim to evacuate the patients as effectively as possible from danger, to stabilise them and then to transport them to the appropriate facilities in the most orderly and safe way possible. The nurse has various roles in the management of a disaster scene: they may be involved actively in the curative aspects of resuscitation and patient care, be required to accompany a critically ill patient who is transported to another facility, or even be deployed in a preventive capacity and be involved in community health issues such as immunisation programmes, counselling, water provision and food preparation. Nurses can also be used in the rehabilitation of the victims and help in addressing their long-term needs.

Organising the scene The basic steps of organising the health aspects of a disaster scene can be summarised as the following: • Command • Safety • Communication

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• • • •

Assessment Triage Treatment Transportation (Advanced Life Support Group, 2002).

The same basic steps can also be applied within a healthcare institution during a major incident or disaster.

Command The aim of establishing command is to obtain control in an orderly fashion as quickly as possible in order to effectively direct all activities towards saving lives and property. Command is vested in specific organisations, such as the police and the fire brigade. Other various control elements are involved, such as the fire chief, who will be in control of the fire brigade, and the medical chief coordinator, who will control the medical services. Nurses deployed to the disaster scene should thus report to the medical coordinator directly on arrival to receive instructions about tasks to be carried out.

Safety Safety includes individual safety, safety on the scene, and the safety of patients. The nurse should adhere to the safety measures in place on the scene and should not approach the incident when hazards are known to exist without clarifying access with the safety personnel, such as the fire brigade.

Communication Establishing effective communication on the scene and from the scene is a priority in order to request appropriate help and to inform hospitals of the numbers and nature of casualties evacuated.

Assessment Assess the disaster scene as comprehensively as possible and determine the impact of the incident on the health service. This assessment by a dedicated health assessor is essential to guide the activation and preparation of hospitals and to prevent the over- or under-reaction of healthcare facilities. The assessor should also be able to guide the distribution of casualties to the various facilities within the area.

Triage The most competent person available must carry out the triage. The aim is to keep mortality and morbidity as low as possible and to achieve the best outcome for most of the survivors. Primary triage is done on scene using a basic triage algorithm. Secondary triage is done as soon as the

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RECEPTION Off-loading of patients Parking area IDENTIFICATION Disaster files Numbering of patients TRIAGE Entrance lobby

PRIORITY 1 Critical Casualties Resuscitation facilities

Intensive care

Admission wards

PRIORITY 2 Serious

Outpatient clinics

Burns unit/ward

PRIORITY 3 Minor injuries

DECEASED/MORIBUND

Information centre Recreational hall

Hospital Terminal care

Admission wards

Theatre

Discharge centre Nursing home

Information centre Recreational hall

Mortuary

Government mortuary Identification

Figure 57.5  Hospital disaster plan

casualties are assembled at a casualty clearing station using more detailed clinical indicators and applying clinical judgement. Triage is repeated at every link in the evacuation process, and casualties are re-triaged on arrival at t he hospital.

Treatment Treatment is implemented on scene by the various role players involved. This includes basic first aid by bystanders and survivors, and emergency care by ambulance and rescue staff. The aim of treatment is to resuscitate and stabilise casualties sufficiently so that they can endure the journey to a hospital or other facility (Advanced Life Support Group, 2002).

• To execute advanced resuscitation procedures if there is a delay in evacuation, and to carry out emergency surgical procedures if required • To treat patients in temporary facilities such as field hospitals where transport is not readily available or where hospitals are destroyed • To accompany critical patients while being transported by road, rail or air, and to free the ambulance and emergency personnel for rescue work. It is, however, essential that such a team is properly equipped, provided with appropriate protective equipment, and trained to function in austere conditions.

Medical team

Setting up a fixed medical post or casualty clearing station

This team may be made up of doctors, nurses and other emergency care workers. The functions of the teams of professional personnel who are sent from the hospital to a disaster scene may be summed up as follows: • To care for patients on the scene prior to being transported if there is a delay

It may be necessary to establish an area near the disaster scene where casualties are assembled and re-triaged, and to provide optimal care to victims before they are transported away. The aim of a medical post is to resuscitate and stabilise patients only. Setting up a post is particularly valuable in the following circumstances:

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• When the number of victims exceeds the transport means • Where the victims are being freed over a long period • In exceptional circumstances when the victims have to be transported long distances to the nearest hospital.

departing transport and, where possible, the receiving hospital informed of the victims who are en route. Traffic control points should be established to enhance the flow of vehicles.

Disaster nursing

When setting up a post, attention should be given to finding the most functional and safe area available. It could be a nearby building, a tent, a train carriage or simply an open area. The following principles must be taken into account when setting up such a facility: • It must be safe and clearly marked, especially in conflict situations, with the protective signs of the Geneva Convention (Red Cross, Red Crescent or Red Diamond symbols). • It must be within reach of and accessible from the disaster scene, preferably within carrying distance. • It must be protected and able to be cordoned off. • It must be of an adequate size based on the assessment of the number of casualties expected. • It must have adequate lighting and protection against the elements. • It must be accessible to emergency vehicles for the evacuation of victims. • It must be able to facilitate control, triage and documentation; and there must be a single entrance through which only patients can enter the area. • It must have separate areas for different triage priorities which are appropriately marked, eg a red flag for critical patients, yellow for serious, etc. • It must have adequate staff allocated per area. • It must have effective equipment, such as collapsible supports on which stretchers can be placed, effective lighting, and resuscitation apparatus, etc. • It must have a single exit route to facilitate coordinated evacuation.

Disaster nursing is often seen as a separate entity, but it basically entails the adaptation of existing skills to enable nurses to treat large numbers of patients, sometimes in improvised circumstances. Specific important aspects are highlighted in the sections below.

Transportation

Improvisation

Patients must be transported according to priority to ensure optimum survival. It might, however, be necessary to transport lower-priority patients first while the critically ill ones are still being stabilised. Various methods of transport can be used, such as ambulances, improvised ambulances like bakkies (light delivery trucks), minibuses, helicopters, disaster buses and fixedwing aircraft. The use of trains can also be considered, especially following train collisions in places not easily accessible by road. A specific person must be appointed to allocate victims to specific means of transport and to allocate casualties to specific hospitals. The patients, as well as the priority classification, should be noted down in each

By adapting basic needs and by improvising skills, one can still deliver effective nursing care, even in the most basic circumstances. Improvisation may be necessary for certain procedures, such as suctioning, wound dressings and sterilisation. The following are some hints on improvisation: • Collapsible table trestles that are often used in church halls can be used to support stretchers or spine boards to create treatment facilities in a temporary casualty department. • Cardboard boxes lined with tinfoil make ideal emergency incubators for newborn babies. A brick that has been warmed in a fire can be used as the heat source, while taking care not inflict burns.

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Nursing method The method of nursing will have to be adapted to care for large numbers of patients. The greater the need, the less individualised care one will be able to offer. Task allocation coupled with basic nursing skills remain the most effective, because less specialised tasks can be allocated to unskilled helpers. Clear priorities of nursing care must be set by the nurse.

Safety and control Attention must continually be given to the safety of staff, volunteers and the patients. Control of scheduled medication must be increased in the disaster stations as the chaos may create an opportunity for malpractice and overdosing. Only one person per area should be in charge of scheduled medication. It is important to document who gave the medication and to which patient (the disaster numbers of unknown (as yet unnamed) patients will suffice). Where children are involved in a disaster, special measures may be needed to prevent them from wandering off, especially in the case of unaccompanied toddlers, and to protect vulnerable children from dangers such as child traffickers.

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• Outdoor camping headlights can be used by doctors for emergency surgery during total power failures. • Household pressure cookers can be used to sterilise dressings, while boiling instruments remains an effective way of sterilisation. • Household bleach containing hypochlorite can be used as an antiseptic, disinfectant or for purifying water. (Four drops of hypochlorite per litre of water that is left to stand for 30 minutes makes water safe for human consumption.)

Nursing in emergency situations Nurses are often confronted with emergency situations within the hospital services. Such situations can be regarded as internal disasters because they occur within the health facility, as opposed to external disasters which take place outside the institutions. Examples of such internal disasters are fire and bomb threats.

Nursing during a hospital fire Hospital fires start as small incidents that can rapidly develop into gruesome infernos, engulfing patients, staff and equipment.

57.1 Pitfalls to avoid in managing the disaster scene Common pitfalls to avoid are the following: • Ineffective command and unclear guidance for coordinated actions • Non-adherence to safety warnings and ineffective personal protective equipment • Inadequate communication before, during and after the disaster • Incorrect notification and reporting of a disaster • The inability to find all survivors on a disaster scene • Incompetence in the techniques of basic or advanced life support during a disaster • Failure to develop an effective disaster plan for the healthcare institution or unit • Insufficient emergency drills so that staff members are not ill-informed and are prepared to take necessary action when the real disaster presents itself • Poor administrative procedures, resulting in inadequate record-keeping during a disaster • Inadequate identification of victims • Inadequate procedures for dealing with relatives, the media and bystanders.

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Causes of hospital fires A fire requires the following three basic elements to occur: 1 Fuel (combustibles) 2 Heat 3 Oxygen. The three elements are referred to as the components of the fire tetrahedron (see Figure 57.6). • Fuel or combustible material. This is any combustible material in the healthcare facility, from linen, curtains, flammable liquids, such as alcohol-based hand cleaning solutions, to storerooms of dressings and protective clothing. • Heat. Adequate heat to raise the fuel or combustible material to ignition temperature can cause fires. Multiple sources of heat are present in healthcare facilities. These include cigarette butts, heaters for the environment, fluids, electrical motors driving various pieces of equipment, sparks from an electrical short circuit, maintenance equipment such as welding torches, and chemical reactions in oily rags. • Oxygen. Oxygen is required to sustain combustion. Not only is this element present in the atmosphere, but often in the healthcare facility in a higher concentration. • An exothermic chemical chain reaction occurs when the other three elements combine.

Heat

Chemiclal

Oxygen

Fuel

Figure 57.6  Fire tetrahedron

Classification of fires Hospital fires are divided into three classes according to the material that is on fire, and the extinction methods are classified accordingly: 1. Fire due to dry flammable material: wood, paper, linen or rubbish

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2. Fire due to flammable liquids: oxygen, alcohol, lubricants, oils, paint and other flammable liquids 3. Fire due to current-bearing electrical equipment.

Methods used for extinguishing a fire Fires are extinguished by breaking the combustion triangle, which can be done by eliminating one of the elements. The methods that can be used to extinguish the fire are described below. • Smothering. In smothering, the principle is to prevent the oxygen from getting to the fire, for example: –– replacing a lid on a burning pot of oil in the hospital kitchen –– placing a wet blanket over a patient with burning clothes –– using a carbon dioxide gas extinguisher sprayed over the fire. • Starving. The fire can be starved by removing all flammable material that feeds it, for example: –– if a cigarette butt catches alight in a waste-paper basket, carry the bin out of the building to avoid the fire spreading –– if a linen cupboard is burning, remove the remaining linen – the fire will stop once the burning linen is consumed. • Cooling. The fire will stop if all burning material is cooled to below a point at which the material ignites. The most common cooling method involves using water.

Extinction media Table 57.2 shows the various extinction media with their advantages and disadvantages.

Improvised extinction media in hospitals These are as follows: • A bucket of water from the sluice room to extinguish a burning waste-paper basket • A bucket of sand or soil from a pot plant to extinguish burning cooking oil in the kitchen • A woollen blanket to smother the flames on a patient whose clothes are on fire • Wet blankets to cover a person moving through a high-risk area during a fire.

A fire plan for a hospital ward A clear notice detailing where a fire must be reported to should be positioned alongside all the telephones in the hospital. The alarm must be activated immediately after the fire is discovered. The fire can be reported internally, eg to the switchboard, or externally directly to the fire brigade. Local staff, such as the security department, maintenance staff, the nursing service manager and oxygen control and air-conditioning departments, should be informed immediately and must also react to the alarm. The following actions should be taken in case of fire: • Close (but do not lock) all the doors and windows to prevent smoke from spreading to other areas, and to restrict airflow to the fire and slow down the spreading of the flames. • Doors should remain closed to limit smoke spreading but unlocked to facilitate evacuation. • Close off all oxygen supply to the area. • Try to put out the fire if possible. • If the fire cannot be controlled, evacuate the patients and staff to safety immediately.

Table 57.2  Extinction media and their advantages and disadvantages

Media

Advantages

Disadvantages

Water

• Is most generally available • Is the best cooling agent • Is effective on burning solid material • Penetrates easily and cools the underlying material

• Is a good conductor of electricity • Is dangerous in the vicinity of a live electrical current • Can cause permanent damage to electronic and other sensitive apparatus

Dry-powder fire extinguisher

• Effective on burning liquids • Can be used on electrical fires

• May not cool the burning material sufficiently, and the fire may flare up again • Forms sticky crusts on warm or burning substances

Carbon dioxide gas extinguisher

• Suited for small liquid fires and electric fires

• The extinguisher is not suited to use outside and in windy conditions • Has a limited cooling feature and thus fires can flare up again

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Use of extinguishing agents. Use dry-powder and carbon dioxide extinguishers as follows: • Take up a position in which escape from the fire is not restricted. • Adopt a crouching position to avoid the smoke and heat. • Bring the extinction medium as close as possible to the fire before activating it. • Break the seal on the extinguisher. • Remove the seal and then remove the safety pin. • Hold the hose/nozzle firmly and direct it towards the base of the fire. • Activate the extinguisher as indicated on the label. • Move the hose nozzle quickly from side to side in a sweeping motion, driving fire backwards. Use water fire hoses as follows: • Roll out the fire hose; it is usually approximately 30 m long. • Grip the spout firmly and open the tap. • Open the valve on the tip of the hose and direct the stream towards the base of the fire. • Move the hose quickly from side to side in a sweeping motion, driving the flames backwards. • A jet of water from the fire hose can also be used to protect patients and staff against heat during escape. Direct the jet towards the roof to create a tunnel of water through which patients and staff can escape.

Nursing during the emergency evacuation of patients When danger cannot be brought under control, it is essential to evacuate patients from the danger area, or even to evacuate the entire building. Reasons for evacuation are the following: • A fire that gets out of control and threatens the safety of the entire building • Possible structural collapse of the building as a result of fire or another structural challenge such as an earthquake • A confirmed threat of explosion such as a bomb/ explosive device found in the building that cannot be safely diffused in time • Contamination of the building by a harmful substance, or even a virulent organism.

Types of evacuation Partial evacuation

This entails moving patients from one or more areas of the hospital, such as a ward, to another safer part of the hospital.

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Partial horizontal evacuation Patients are moved on the same floor level to an area of safety with access to an exit should the fire spread further.

Complete evacuation The entire hospital is evacuated. Moving in smoke-filled areas. Perform the following tasks: • Instruct the victims to move in crouched positions or crawl as close to the floor as possible. • Provide wet cloths to cover the nose and mouth to limit inhalation of warm air and smoke. • Provide patients and staff with smoke filter masks if available. • As floors collapse in the middle, instruct the victims to move along walls and to hold hands to prevent people from getting lost in the smoke. • Advise victims to walk sideways like crabs to maintain balance and prevent falls over uneven areas. • Open doors sideways from a position of safety to protect against flames bursting from the other side when the door is opened. • When opening doors, use the back of the hand to test for heat on the other side, as it is more heat sensitive. • Ensure that the evacuating group is both led and followed by a staff member. The safety of patients in a fire. Ensure safety in the following manner: • Help/pull the patients out of bed and lie them down in the recovery position on blankets on the floor to prevent smoke inhalation (warm air and smoke usually rise). • Cover them with woollen blankets. • For those who cannot move themselves, drag them on a blanket to an area of safety close to an exit. • Leave traction splints in position, and only detach them from the rails and frame. • Suspend oxygen therapy for fear of fuelling the fire; manual ventilation can be used. • Close infusions or place infusion under the patient’s body to use body weight to maintain infusion.

Complete and vertical evacuation Patients are moved to another floor level. Evacuation should always be to a lower-level floor and the ground floor. Only evacuate to an upper level if there are no alternatives.

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57.3 Management of exits in a fire emergency Fire escape and emergency exits should be managed in the following manner: • Access to emergency doors and fire escapes should be unimpeded at all times. • If an emergency door needs to be locked, the key must be mounted alongside the lock in a glasscovered container and attached to a chain so that it can be retraced in a smoke-filled area with poor visibility if it is dropped. • Ensure that emergency doors to fire escape stairwells are equipped with automatic closing mechanisms. This will ensure that the door reverts to its closing position once a person has entered the stairwell and thus ensures that a minimum amount of smoke enters the stairwell. • After entering a stairwell, close the doors, but do not lock them.

Evacuation order. Perform the following tasks: • Evacuate the floor on which the fire was detected first, followed by the floors above and below the fire. • Then evacuate the rest of the building from the top to avoid trampling on the fire escapes. • Send mobile patients down the fire escape first. • Carry recumbent patients down the stairs on chairs or stretchers; in an emergency situation patients can be dragged on blankets down the stairs. • Do not use lifts due to the danger of fire and shortcircuiting.

Intensive care units Evacuate patients according to prognosis. Patients with the best prognosis are evacuated first. Disconnect all apparatus and retain only if essential. Ventilate the patients manually.

Assembly points Assembly points are areas outside the hospital that are a safe distance from the complex. Places such as a recreation hall at the nurses’ residence or staff carports can be used as a reception area where patients can be assembled and sorted (triaged). The following procedure should be followed: • Establish a control mechanism for department/ward assembly for determining whether all patients and staff have indeed left the department. • Indicate with notices where staff and patients of various wards must gather for control purposes. • Report all those who cannot be accounted for to the fire chief. • Continue basic nursing and provide comfort throughout. • Triage patients for evacuation to other hospitals or alternative centres of care.

Special areas within and around the hospital Children’s wards and nurseries

Carry babies on the back or use baby evacuation pinafores (see Figure 57.7) or homemade bags that can carry more than one baby at a time. For children who are walking, play the game of ‘Follow the leader’ to lead them out of the ward without causing panic.

Theatre All theatre lists should be suspended and anticipatory action taken. Patients should be ventilated manually as soon as possible. Anaesthesia should preferably not be reversed, and ventilation should continue. Patients should be covered with woollen blankets for protection.

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Figure 57.7  Nurse wearing an evacuation pinafore

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Nursing during a bomb threat It is essential that during a bomb threat the hospital is systematically and effectively searched in order to take maximum precautions to ensure the safety of all patients and staff.

Receiving the threat The threat is usually received telephonically, and thus the staff should have a basic knowledge of how to react when receiving such a call. A standard bomb threat questionnaire and action list should be positioned at each telephone in the hospital with space to transcribe the physical threat with the number of critical questions that the caller can be asked in order to extract maximum information. The types of questions to try to obtain maximum information about the situation from the caller include the following: • The bomb, the kind of explosive device, when is it going to explode and how it can be diffused • Where the bomb is going to explode • The origin of the call such as the features of the caller, which include speech impediments, language or accent, background noises, and judgement on whether the caller is familiar with the hospital or not. Once the threat is received and noted, a central contact point in the hospital, such as the switchboard or security office, must be informed. A functional procedure that can be implemented immediately must be available at the contact point and the necessary people informed in order of priority.

Searching the hospital Each department in the hospital should be instructed immediately to search its area for suspicious items that do not belong where they are found. Special attention should be paid to service shafts and power distribution boards that are usually locked and are found open. Search all electricity distribution boxes, medical gas valves, rubbish bins, etc. Leave any suspicious item untouched and immediately report it to the central contact point to be inspected by the police. If no suspicious items are found, the central contact point must also be informed. It is standard procedure to mobilise emergency services in the area.

Mobilising emergency services • Ambulance and fire services should be placed on standby. • Police should be called to investigate the bomb threat and for actions that might arise from it.

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• Explosive experts should be mobilised by the police according to their judgement of the situation. • Trained dogs and their handlers may be requested to search the public areas such as toilets, waiting rooms and access points. It is seldom necessary or advisable to immediately evacuate a total hospital during a bomb scare without a clearly identified threat. The decision to evacuate depends mainly on the advice/instructions received from the police or the fire brigade based on such a threat. It must be made clear that during the evacuation a healthcare facility patient may die due to the non-availability of required support systems, therefore the decision to instruct a healthcare facility to evacuate must be taken with caution. However, if a clear threat exists, evacuation may be the only option.

Community health issues in disasters During disaster situations, the role of the nurse in the context of community health becomes extremely comprehensive and includes paying attention to all aspects that can threaten the health status of the survivors. There are a number of specific aspects that need to be emphasised, including emergency nutrition, safe water and safe disposal of waste in order to promote health and safety in the community.

Emergency nutrition Nutrition serves as an integral part of any emergency relief programme. The primary and immediate aim of emergency nutrition is survival. The function of the community health nurse is to supervise the effective planning of emergency nutrition and the safe preparation of food.

Planning emergency nutrition When planning emergency nutrition in a disaster situation, the factors described in the sections below should be considered. The composition of the target group. Consider culture and eating habits, and urban and rural practices within ethnic groups. Storage. Where large quantities of food have to be stored prior to preparation, thorough planning must be done to ensure that it does not decay, especially in situations in which basic services such as electricity and refrigeration are not available. Age composition of those affected. Provision should be made for the average energy needs of the different

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vulnerable groups such as pregnant women, breastfeeding mothers, young children, and the elderly and frail. Available fuel. This determines the type of food that can be rationed, and how many warm meals per day can be served, if any. The guideline is for food with the highest energy value but requiring minimum fuel to prepare. Geographical location and climate of the area. Colder areas will demand warm food and drinks, and higher energy values. Duration of emergency nutrition. The longer the disaster situation exists, the greater the need for food. It is important to enforce a normal mealtime pattern to conserve food. Special feeding. Attention must be paid to the emergency needs of special groups such as diabetics and other patients who require therapeutic diets. Nutritional needs. Food with the highest energy value must be offered. Milk can be used successfully as emergency food for the elderly, since it provides all the basic nutritional requirements. Disposal of waste. Disposal of waste and sewage should be implemented immediately. Flammable waste must be burnt in a safe area and then covered with soil. Garbage that cannot be burned must be buried. Waste pits must be at least 100 m away from the living quarters and kitchen facilities. Pit toilets must be at least 2 m deep, Caution should be taken to ensure that the water table is not penetrated. Safe food preparation. The highest possible standard of food hygiene should be implemented to prevent contamination by harmful organisms. People working with food must be examined for communicable diseases and encouraged to continually decontaminate their hands during preparation of food. Safe and clean containers must be used for the preparation and storage of food and water, and eating utensils must be washed thoroughly after use. The following are essential for food preparation: • All food must be inspected for suitability before use. • Meat must be cooked at a high temperature. • A third heating of food must be avoided. • With electricity failures, frozen products should be used first as they are only considered safe for approximately 48 hours. • Fresh products with a limited shelf life must be used before tinned products.

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• Cooking on an open fire (braai) is simple, safe and suitable in a disaster. • To ensure safe drinking water, treat it before use either by filtering it through sand or boiling it. • Household bleach can also be used to purify water (see above).

Clinical alert! When water and food shortages take on a crisis proportion, triage must be applied and the available resources used for the victims who have the best chance of surviving.

Prevention of an outbreak of communicable diseases • Hygiene of the environment and the personal hygiene of the survivors should be maintained optimally. • Emphasis should be placed on ventilation and to avoid overcrowding and over-occupation of the temporary accommodation areas. • Provide immunisations if applicable. • Identify communicable disease cases immediately, and isolate and treat. • Trace contacts and keep them under observation. • Decontaminate newcomers and their luggage. • Bury bodies deep enough to prevent contamination. Cremation of bodies using pyres is an emergency option.

Psychological consequences of disasters The aim of psychological support is to try to help disaster survivors (including staff members) cope with and reduce the emotional damage caused by a disaster. Emotional trauma is inevitable in disasters and thus psychological support for survivors and healthcare practitioners involved must be an integral part of the disaster plan. People manifest different emotional reactions before, during and after disasters. The phases of reaction are discussed below.

Threat phase: denial This phase is part of one’s normal adaptation mechanism to reduce excessive anxiety in order to maintain equilibrium. The denial of any danger is the most striking feature. Denial continues during the warning stage of disaster and sometimes until the impact phase. Despite the warnings by authorities and specialists about the possibility of a disaster, the person does not believe anything, and responsibility for preventive action is transferred to the authorities.

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Impact phase: shock The victim is suddenly required to digest the denied facts and accept the awful reality. The victim will initially feel alone and powerless. Most victims are bewildered and manifest with panic reactions, emotional numbness, hyperactivity, anger, aggression, interfering, arguing and blaming, and/or lack of concentration. In this instance, nurses should direct and guide them through concise and clear instructions, and provide physical and emotional care including shelter, food and heat.

Post-impact phase: reality returns The victims come to realise the full extent of the disaster through a slow realisation process. The bewildered feelings subside and they begin to experience emotions such as fear, anger, guilt, anxiety, phobias and despondency. Others may complain of insomnia, nightmares, nausea, vomiting, trembling and dizziness. Imaginary problems also appear with secondary reactions such as loss of self-confidence, avoidance, withdrawal and heightened dependence. The victims must be helped to express their feelings rather than repress them to help relive their experience of the disaster. The nurse can help the victims by doing the following: • Listening attentively • Helping the person gradually accept reality • Helping the person gain insight into the crisis • Assisting the victims in finding new ways of dealing with the problem • Assisting the victims in making contact with other victims or next of kin.

Reconstruction phase: emotional wounding This is the phase which deals with the long-term consequences of the disaster. The reactions may last for years and manifest in the form of neuroses,

depersonalisation experiences or psycho-philosophical problems. The victims may feel guilty about how and why they survived while others did not. In this phase, the nurse should support survivors to establish a new equilibrium and adapt to the permanent losses caused by the disaster. It is essential that psychological support is planned for the survivors as well as the staff that are involved. Early support and counselling by professional counsellors must be planned.

Education • Prevention of potential disaster situations in the community is an important aspect in ensuring health and safety of the community. The community should be informed about the identification of potential hazards and encouraged to work towards minimising or eliminating them. • Basic training for the community in first aid and disaster survival is essential. • Healthcare practitioners, including nurses, should be trained in the basic principles of disaster medicine, triage and scene control.

Conclusion In order to participate effectively and efficiently in the work of disaster management, nurses must understand the concept of disaster, how they occur, the types of disasters and the typical reactions of people involved in them. The suffering, destruction and loss of life that occurs as a result of a disaster or emergency situation are shocking and highly traumatic. Actions should thus be directed towards preventing further suffering or at least keeping it to the minimum. Nursing in disaster and emergency situations thus enables nurses to use their knowledge in such a way that effective planning assures maximum safety and survival for patients under their care.

Suggested activities for learners Activity 57.1 Discuss the key points to be considered when developing a generic disaster plan for a healthcare facility. Activity 57.2 Working in groups of five, design a basic disaster plan that is applicable to your unit and hospital. Draw a graphic flowchart or floor plan indicating the flow of casualties through the facility. Activity 57.3 An outbreak of fire or a bomb threat is possible in a hospital, and the evacuation process cannot be executed by trial and error. Simulate an evacuation of a fictitious healthcare facility during an outbreak of fire or a bomb scare. Activity 57.4 Simulate a disaster situation that occurs outside the hospital (role play). Triage the casualties, and simulate their evacuation to a healthcare facility in priority order with a limited number of vehicles.

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Emergency Medicine Society of South Africa 2012. The South African Triage Scale: Adult SATS chart. http://emssa.org.za/sats/ and http://emssa.org.za/ wp-content/uploads/2011/04/Adult-SATS-2015.pdf (accessed 6 December 2017). Hospice Palliative Care Association of South Africa 2012. Clinical guidelines. http://www.hpca.co.za/ item/hpca-clinical-guidelines-2012.html (accessed 4 December 2017). 2014. Legal Aspects of Palliative Care. http://www.hpca. co.za/item/hpca-legal-aspects-of-palliative-care.html (accessed 4 December 2017). Human Sciences Research Council 2013. Non‐communicable diseases. South African National Health and Nutrition Examination Survey Media release no 1. http://www.hsrc. ac.za/uploads/pageContent/3895/01%20 NON-COMMUNICABLE%20DISEASES.pdf (accessed 4 December 2017). 2013. Nutritional status of children. South African National Health and Nutrition Examination Survey Media release no 2. http://www.hsrc. ac.za/uploads/pageContent/3895/02%20 NUTRITIONAL%20STATUS%20OF%20CHILDREN. pdf (accessed 4 December 2017). International Association for the Study of Pain Resources. https://www.iasp-pain.org/Resources (accessed 6 December 2017). International Council of Nurses 2002. Definition of characteristics of nurse practitioners/ advanced practice nurses. Geneva. 2002. Position statement on patient safety. Geneva. Médecins Sans Frontières 2010. Management of HIV-related conditions and antiretroviral therapy in adults and children (7th edition). National Institute of Allergy and Infectious Diseases (US) HIV Replication Cycle. https://www.niaid.nih. gov/diseases-conditions/hiv-replication-cycle (accessed 6 December 2017). Nursing and Midwifery Council (UK) 2015. The Code: Professional standards of practice and behaviour for nurses and midwives. https://www.nmc.org.uk/globalassets/

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sitedocuments/nmc-publications/nmc-code.pdf (accessed 28 November 2017). South African Department of Health Standard Treatment Guidelines and Essential Medicines List. http://www.health.gov.za/index. php/component/phocadownload/category/197 (accessed 6 December 2017). 2000. National Rehabilitation Policy. 2001. South African national guidelines on nutrition for people living with TB, HIV/AIDS and other chronic debilitating conditions. 2010. National Department of Health guidelines. 2010. National HIV Counselling and Testing (HCT) Policy Guidelines. 2011. National Core Standards for Health Establishments in South Africa. 2012. National Antenatal Sentinel HIV & Herpes Simplex Type-2 Prevalence Survey in South Africa. 2012. Standard Treatment Guidelines and Essential Medicines List for South Africa. 2012. Strategic Plan for Maternal, Newborn, Child and Women’s Health (MNCWH) and Nutrition in South Africa 2012–2016. 2013. South African Antiretroviral Treatment Guidelines. 2013. The South African National Antenatal Sentinel HIV Prevalence Survey. 2014. National Tuberculois Management Guidelines. 2014. Regulations setting out the acts or omissions in respect of which the Council may take disciplinary steps. GN R767 in GG 38047 of 1 October. 2014. Saving Mothers: Annual report and detailed analysis of maternal deaths due to non-pregnancy related infections. 2015. Antiretroviral Treatment Guidelines for Children. 2015. National Consolidated Guidelines for the prevention of mother-to-child transmission and the management of HIV in children, adolescents and adults. 2015. National HIV Testing Services: Policy and Guidelines. 2016. National policy on HIV Pre-exposure prophylaxis and test and treat. 2017. Patients’ Rights Charter. Directorate: Nutrition 2007. National Guidelines on Nutrition for people living with HIV, AIDS, TB and other Chronic Debilitating Conditions. 2013. An introduction to the revised food-based dietary guidelines for South Africa. South African Journal

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of Clinical Nutrition, 26(3): S1–S164. (Vorster, HH, Badham, JB & Venter, CS.) 2013. Roadmap for Nutrition in South Africa 2013– 2017. 2013. South African Infant and Young Child Feeding Policy. South African Burn Society http://saburnsociety.co.za/ South African Journal of Clinical Nutrition – Editorial office 2011. The Tshwane Declaration of support for breastfeeding in South Africa. South African Journal of Clinical Nutrition, 24(4): 214. South African Nursing Council 1993. The South African Nursing Council Regulations Relating to the Course in Clinical Nursing Science Leading to Registration of an Additional Qualification, http://www.sanc.co.za/regulat/Regcln.htm (accessed 28 November 2017). 2004. Charter of nursing practice: Draft 1. Pretoria. 2013. Code of Ethics for Nursing Practitioners in South Africa, http://www.sanc.co.za/pdf/Learner%20 docs/SANC%20Code%20of%20Ethics%20 for%20Nursing%20in%20South%20Africa.pdf (accessed 28 November 2017). Statistics South Africa 2011. Mid-year population estimates. Statistical release P0302. https://www.statssa.gov.za/publications/ P0302/P03022011.pdf (accessed 6 December 2017). 2017. Mid-year population estimates. Statistical release P0302. http://www.statssa.gov.za/publications/ P0302/P03022017.pdf (accessed 6 December 2017). UNAIDS Fact sheet – Latest statistics on the status of the AIDS epidemic. http://www.unaids.org/en/resources/factsheet (accessed 6 December 2017). 2014. HIV/AIDS estimates, 2008–2014. Geneva. 2014. 90-90-90. Geneva. United Nations 1989. Convention on the Rights of the Child. http:// www.ohchr.org/EN/ProfessionalInterest/Pages/CRC. aspx (accessed 6 December 2017). 2005. Panel report: Spirituality, religion & social health during 58th World Health Assembly. Geneva.

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Western Cape Department of Health 2011. Guidelines and standard operating procedure for growth monitoring and promotion in the context of the Road to Health Booklet. Cape Town. 2011. Implementation policy guidelines for nutrition therapeutic programme. Cape Town. 2014. Practical Approach to Care Kit (PACK): Primary Care Guideline for Adults (developed by Cornick R & Fairall L and updated by Picken S & Wattrus C of the Knowledge Translation Unit). World Health Organization Blindness and visual impairment prevention. http://www.who.int/topics/blindness/en/ (accessed 7 December 2017). Cancer pain ladder for adults http://www. who.int/cancer/palliative/painladder/en/ (accessed 7 December 2017). Child growth standards: Weight-for-age: Boys. http:// www.who.int/childgrowth/standards/chts_wfa_ boys_z/en/ (accessed 7 December 2017). Definition of Palliative Care. http://www. who.int/cancer/palliative/definition/en/ (accessed 7 December 2017). Health topics: Disabilities. http://www.who.int/topics/ disabilities/en/ (accessed 7 December 2017). Humanitarian Health Action: Definitions: emergencies. http://www.who.int/hac/about/definitions/en/index. html (accessed 7 December 2017). Integrated Management of Childhood Illness (IMCI). http://www.who.int/maternal_child_adolescent/ topics/child/imci/en/ (accessed 7 December 2017). Mother-to-child transmission of HIV. http:// www.who.int/hiv/topics/mtct/about/en/ (accessed 7 December 2017). Tuberculosis country profiles. http://www. who.int/tb/country/data/profiles/en/ (accessed 7 December 2017). 1996. Cancer pain relief with a guide to opioid availability (2nd edition). Geneva. http:// apps.who.int/medicinedocs/en/d/Js22085en/ (accessed 7 December 2017). 2000. Obesity: Preventing and managing the global epidemic: Report of a WHO Consultation (WHO Technical Report Series 894). Geneva. http://www. who.int/nutrition/publications/obesity/WHO_ TRS_894/en/ (accessed 7 December 2017). 2003. Global strategy for infant and young child feeding. http://www.who.int/nutrition/ publications/infantfeeding/9241562218/en/ (accessed 7 December 2017).

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2013. Guidelines for the inpatient treatment of severely malnourished children. Geneva. http://www.who.int/nutrition/publications/ severemalnutrition/9241546093/en/ (accessed 7 December 2017). 2016. Guideline: Updates on HIV and Infant Feeding. The duration of breastfeeding and support from

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health services to improve feeding practices among mothers living with HIV. Geneva. http://www.who. int/maternal_child_adolescent/documents/hiv-infantfeeding-2016/en/ (accessed 7 December 2017). 2017. Fact sheet: Noncommunicable diseases. http:// www.who.int/mediacentre/factsheets/fs355/en/ (accessed 7 December 2017).

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Index Page numbers in italics indicate where you will find information in figures or tables. 12 lead ECG 261 A abdominal aortic aneurysm 666–668 abdominal compartment syndrome 272 abdominal trauma 271–272 ABG see arterial blood gases ABI see ankle brachial pressure index ability, definition of 1094, 1097 abortion 504–506, 504, 507–508 ABPI see ankle brachial pressure index abrasions 277, 286 abscesses brain 904 breast 521 definition of 277 ear 1015 liver 805–806 scalp 267 skin disorders 975 absorption, definition of 712 abuse of elderly 1091–1092, 1091 sexual assault 275–276 accessory organs of digestion 779–822 biliary tract 816–822, 816 classification of disorders 781 nursing assessment 781–783, 784–785 nursing care plan 786–788 pancreas 809–816, 809 risk factors 781 see also liver ACCH see Association for the Care of Children in Hospital accidents 42, 258 accommodation for people with disabilities 1107 ACE inhibitors see angiotensin-converting enzyme (ACE) inhibitors acetaminophen 143, 794, 806 acetylcysteine 606, 794, 1134 achalasia 731, 745–746 achondroplasia 931 acid, definition of 145 acid–base balance 149, 153–154, 153, 164–168, 165, 166 acidosis 145, 156, 165–167, 170, 201 acne 955, 961, 984

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Acquired Immunodeficiency Syndrome (Aids) see HIV/Aids, patients living with acquired valvular heart disease 638–639 acromegaly 823, 831 ACTH see adreno-corticotrophic hormone actinic cheilitis 734 active exercise 175, 179 active transport 145 activities of daily living (ADL) 177, 1105 acute autoimmune inflammatory demyelinating polyneuropathy see Guillain-Barré syndrome acute closed-angle glaucoma 1060 acute confusion 1136 acute delirium 1136 acute gastritis 750–751 acute left ventricular failure 676 acute otitis media 1016–1017 acute pain 229, 242, 247 acute pancreatitis 809–812, 809 acute renal failure (ARF) 446–449, 447 acute respiratory distress syndrome (ARDS) 576, 588–590, 589 acute respiratory failure 567–568 acute rheumatic carditis 635 adaptation need 32, 222 adaptive immunity see specific immunity addiction to morphine 251 Addison’s disease 839–840 adefovir 793 adenocarcinoma 458 adenoiditis 1002, 1030–1031 adenoids 1030–1031 adenosine triphosphate (ATP) 192, 280 ADH see antidiuretic hormone adhesions 277, 293, 421 adjuvant analgesics 248, 249, 249, 999 adjuvant therapy 317, 322 adolescents HIV/Aids 364, 366, 378, 379–383 nutrition 79–80 adrenal gland 827, 839–842 adrenal hyperfunction 840–841 adrenal hyperplasia 842 adrenal hypofunction 839–840 adrenaline 839

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adrenal virilism 842 adrenocorticoids see corticosteroids adreno-corticotrophic hormone (ACTH) 135, 823, 840–841, 842, 911 adult hypothyroidism (myxoedema) 824, 839 adverse events 37 aerosol 552 afferent arterioles 97 agent–host–environment model 3, 3 age-related macular degeneration (AMD) 1046 agranulocytosis 697 AIDS see HIV/Aids, patients living with airborne transmission 44 air conditioning in theatres 403 airway management 262 albinism 961 albumin 970 alcohol 77, 137, 258, 683 alcoholic cirrhosis 795, 796 alcoholic hepatitis 795 alcohol rubs 44 aldosterone 97, 101, 426, 428 alginates (dressing) 292 alkalaemia 145 alkaline phosphatase (ALP) 784 alkalosis 145, 165–168, 202, 602 alkylating agents 320 allergic reactions allergic rhinitis (hay fever) 1002, 1023–1024 respiratory system disorders 558 skin testing 338–339 upper urinary tract disorders 440 allergy, definition of 332 allograft 277, 986, 995 alopecia 294, 325, 955, 962 ALP see alkaline phosphatase alpha-adrenergic antagonists (alpha-blocking agents) 674 alpha-glucosidase inhibitor 853 alpha-interferon 793 ALT see aminotransferase alternative healthcare provision 23–25, 81, 970, 1104 aluminium–magnesium combination 757 alveolar membrane 552 Alzheimer’s disease 887, 909, 1083–1084 amantadine 908 amblyopia 1032, 1057 AMD see age-related macular degeneration amenorrhoea 471, 490–491 American Nurses’ Association (ANA) 5 amino acids 67 aminocaproic acid 700 aminotransferase (ALT) 784 amphogel 757 amplification theory 304 amputation 945–946 amulets 18, 22, 24 amylase 712, 716, 810–811

JCTMSN_BOOK.indb 1184

ANA see American Nurses’ Association anaemia 63, 77, 82–83, 306, 390, 450, 679, 691–695, 692 anaesthesia 401, 406, 407, 860 anaesthetic nurses 401, 405 anaesthetists 401, 403 anal abscesses 778 anal fissures 778 anal fistulae 778 analgesia 860 analgesics adjuvant 248, 249, 249, 999 analgesic ladder 248, 248 burn injuries 999 for children 250 comfort need 143 definition of 412 diverticular disease 773 haemophilia 700 symptoms management 247–248 wound management 292 anaphylactic shock 169 anaphylaxis 332, 338, 339, 342, 342 anaplasia 277, 286, 294 anaplastic carcinoma 839 anaplastic tumour 294 anarthria 860 anasarca 145, 155 anatomical dead space 552 androgenia see hirsutism androgens 321, 839 anencephaly 901 aneurysms 658, 665–666, 666–668, 668 anger, expressing of 26 angina pectoris 649, 652–653 angiogenesis 277, 288 angiography 618, 663 angiotensin-converting enzyme (ACE) inhibitors 232, 622, 675, 676 angiotensin receptor antagonists 675 anhidrosis 955, 962 anions 150–151 aniridia 1032, 1044 ankle brachial pressure index (ABPI/ABI) 663 anophthalmos 1032, 1044 anorectal disorders 776–778, 777 anorexia definition of 277 end-of-life care 1138, 1138 oncology nursing care 325 palliative care nursing 1138, 1138 anosmia 860, 1028 anoxia 255, 552, 1087 ANS see autonomic nervous system antacids 744, 757 anterior uveitis 1050 anthralin 983 anthropometric measurements 84–86, 85, 86

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anthropometry 63 antiallergenics 575 anti-androgen therapy 321, 545 antiarrhythmics 622, 632 antibacterial agents for burn injuries 1000 antibiotics 292, 774 antibodies 332, 783 antibody mediated immunity 334–335 anticholinergics 398, 756, 758, 908 anticholinesterase agents 910 anticoagulants 390, 632, 665, 896, 999 anticonvulsants 249, 450, 692, 898, 899–900, 903 antidepressants 137, 767, 999 antidiarrhoeal agents 767 antidiuretic hormone (ADH) 97, 101, 150, 330, 426, 428, 823 antiemetics 229, 237, 1138 antigens 332 antigen test (P24 test) 362 antihistamines 237, 398, 575, 1133, 1134 anti-hypertensive agents 390–391, 896 anti-inflammatory drugs 283, 292, 750, 774 antimetabolites 320 antimicrobials 575, 973 anti-oestrogens 321 antiplatelet agents 622, 664 antiretroviral therapy (ART) 78, 349, 354, 357, 374, 375, 376–378, 378, 379–383 antiseptics 973 antispamodics 773 anti-tumour antibiotics 319 antitussives 229, 575 antrectomy (subtotal gastrectomy) 731, 759 anuria 97, 110–111 anus 119, 712, 714, 778 anal abscesses 778 anal fissures 778 anal fistulae 778 anxiety 397, 398, 717, 1104, 1136–1137 anxiolytics 398, 1124, 1133 aphasia 860, 887, 1010–1011 aphonia 860, 1006 apical pulse 61, 607, 616 aplastic anaemia 692–693 appendicitis 770–772, 770, 771 appetite stimulants 1138 aqueous humour 1032, 1036, 1059 arcarbose 853 arcus senilis 1045 ARDS see acute respiratory distress syndrome areflexia 860 areolar 515 ARF see acute renal failure aromatase inhibitors 321 arrhythmias 630–635, 630, 631, 632, 633, 634, 635 ART see antiretroviral therapy arterial blood gases (ABG) 165–166, 165, 560, 560

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arterial lines 618 arterial ulcers 670 arteries conditions of 663–666, 663, 666–668, 668, 672–674, 674–675, 676–677 definition of 607, 658 structure and function of 660–661, 661 arterioles 607, 661 arteriosclerosis 649, 651, 662 arteriovenous fistula 658, 662 arterio-venous re-warming 204 arthralgia 679 arthritis 635, 947–949, 947 arthrocentesis 913 artificial airway 571, 572, 574 artificial eyes 59 artificial urinary sphincter implant 464 artificial ventilation 262 asbestos 593 ascabiol (benzyl benzoate) 976 ascites 779, 789, 803–804 ASD see atrial septal defect aseptic meningoencephalitis 905 aspartate aminotransferase (AST) 784 aspiration 412, 552 aspirin 664, 700, 717, 750, 753 assembly points during disasters 1167 Association for the Care of Children in Hospital (ACCH) 1114 AST see aspartate aminotransferase asterixis 779, 782 asthma 596, 601–604, 601, 603, 1085 astigmatism 1032, 1062 ataxia (difficulty in walking) 860, 887, 905–906 atelectasis 255, 420 atheroma 649, 666, 891 atherosclerosis 649, 651, 658 athetosis 860 athrodesis 913 athroplasty 913 athroscopy 913 ATP see adenosine triphosphate atresia 743, 743 atrial ectopic beats (premature atrial contractions) 633, 633 atrial fibrillation 633, 633 atrial flutter 633, 633 atrial septal defect (ASD) 629, 630 atrophic gastritis 751 atrophy 175, 179, 277 audiometric test 1008 augmentation mammoplasty 526 aura 861, 899 auricle 1002, 1005, 1009, 1014, 1016 autoantibodies 783 autograft 277, 986, 995 autoimmune atrophic gastritis 751–752 autoimmune diseases 335, 344–346, 345, 591–592

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autoimmune hepatitis 795 autoimmunity 332, 335 automaticity 607 autonomic nervous system (ANS) 868–869 autonomy 12, 32, 222, 1113 avascular necrosis 939 AV Junctional dysrhythmias 633–634, 634 AVPU method 259 avulsion 273 awareness, impairment of 42 azidothymidine (AZT) 349 azotemia 438 AZT see azidothymidine B babies see children Babinski’s sign 861, 870 back pain, low 950, 952–953 bacterial endocarditis 636–637 bacterial skin disorders 974–976, 975 bacterial vaginosis 496 bacteriuria 107, 460 balanitis 528 barbiturates 137, 899 bartholinitis 492 Bartholin’s cyst 492–493 basal cell carcinoma 732, 979 basal metabolic rate 135, 175 base, definition of 145 Batho Pele Principles 210 bed rest 181, 181, 182 bed sores (pressure sores) 176, 177, 182, 183, 185–186, 287–288, 962, 1089–1090 behavioural techniques to relieve pain 142–143 Bell’s palsy 911–912 belt restraints 48 beneficence 12 benign, definition of 294 benign prostatic hyperplasia (hypertrophy) 278, 528, 541– 543 benzodiazepines 137, 251, 899, 909, 1020, 1136 benzyl benzoate (ascabiol) 976 bereavement 1144–1145 beta-adrenergic blocking agents 390–391, 622, 632, 674, 676, 836 bicarbonate 152 biguanides 853 bilateral medial rectus recession 1054 bile 816–816 bi-level positive airway pressure (BIPAP) 572 biliary tract 816–822, 816 Bill of Rights 10, 1095, 1100 Billroth I gastrectomy 759, 757, 762 Billroth II gastrectomy 759, 757, 762 binocular single vision 1032 biologic response modifier therapy 294, 325 biomedical paradigm 23

JCTMSN_BOOK.indb 1186

biopsy breast tissue 519–520 definition of 294 female reproductive system 482 male reproductive system 534 prostatic cancer 544 renal 433 respiratory system 563 bio-psychosocial needs 28–36 physical needs 29–31, 33 psychosocial needs 31–33, 33 spiritual needs 33–36, 33, 35 theories 29 BIPAP see bi-level positive airway pressure bismuth subsalicylate 756, 758 bladder 102 dysfunction 464–467, 465 pacemaker (neuroprosthesis) 464 people with disabilities 1105–1106 renal stones (urolithiasis) 457 strengthening of 112 trauma 465–466 blepharitis 1032, 1047 blepharospasm 1032 blindness prevention 1062, 1064, 1065 blood ammonia 785 composition of 681, 682 emergency care 261–262 flow through vascular system 661 functions of 681–682 glucose 857–858 groups 682–683, 686 immune system 339 multiple trauma 261–262 prostatic cancer 544 renal system 432 thinners 632 transfusion 336, 687, 690–691, 690 blood pressure cardiovascular system 613–614, 616 definition of 607 homeostasis 156, 169, 169 kidneys 102 renal system 428 blood urea nitrogen (BUN) 156 blood vessels 658–678 arteries 663–666, 663, 666–668, 668, 672–674, 674– 675, 676–677 blood flow through vascular system 661 classification of disorders 662 nursing assessment 662–663 overview of vascular system 660, 660 risk factors 662 structure and function of 660–661, 661, 662 veins 668–674, 671, 674–675, 676–677 BMI see body mass index

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Index  1187

BMT see bone marrow, transplantation body chart, to communicate sites of pain 245–246, 245 body image 55, 415, 1100 body language 358 body mass index (BMI) 63, 85, 87, 87 body mechanics 188, 913 boils see furuncles bolus (intermittent) feeding 90, 729 bomb threats 1167 bone infections 946 injuries 936–941, 936, 937, 940, 941, 942–944, 945– 946 metabolic diseases 949–950 skeletal system 915–916, 916 see also musculoskeletal system bone marrow aspiration and biopsy 686–687 depression 324 lymphatic system disorders 705 suppression 322 transplantation (BMT) 325–326 bowel management 1106 movement disorders 765–770 obstruction 767–770, 767, 769–770 preparation for surgery 392, 396 washout 126 see also large intestine; small intestines boxing gloves restraints 48, 48 brachytherapy (internal radiation) 294, 314–315 bradycardia 607 bradykinin 826, 991 brain abscess 904 injury 267 nervous system disorders 866–867, 866 tumours 906–907 brain stem 866 breast 515–527 abscess 521 anatomy and physiology of 516, 517 bloody nipple discharge 520 breastfeeding 516–517, 517 breast self-examination (BSE) 517, 518–519, 518 cancer of 521–525, 523, 525 fat necrosis 520 fibroadenoma 521 fibrocystic 521 galactorrhoea 520 lactation 516–517 mastectomy 523–525, 525 mastitis 521 nipple fissure 520 nursing assessment 517–520, 518, 519 reconstructive breast surgery (mammoplasty) 525–526 risk factors 517

JCTMSN_BOOK.indb 1187

Tanner staging 516, 517 breastfeeding 64, 78, 129, 356–358, 516–517, 517 breastmilk substitute 63 breast self-examination (BSE) 484, 517, 518–519, 518 breathlessness see dyspnoea bronchial tree 556, 556 bronchiectasis 596, 605–606 bronchitis 576, 578 bronchoconstriction 553, 601 bronchodilators 171, 575 bronchospasm 339, 553, 568, 596, 601–603, 1132 Brudzinski’s sign 861, 897, 903 bruits 426 bruxism 132, 138 BSE see breast self-examination Budd-Chiari syndrome 779 Buerger’s disease (thromboangiitis obliterans) 663, 664 bulla 955, 968 Bullous pemphigus 973 bullying in workplace 952–953 BUN see blood urea nitrogen bunion (hallux valgus) 934 buphthalmos 1032 burn injuries 986–1001 antibacterial agents 1000 classification of 989–991, 990, 992 complications 998–999 drugs commonly used 994, 999 first aid 51 gastrointestinal system 992 immunologic changes 993 intraoperative complications 408 management of patients with 993–994, 994, 995, 1000– 1001 nursing care plan 995–998 pathophysiology 991–992, 992 positioning of patients 1000–1001 psychosocial responses 993 rehabilitation 999 renal system 992–993 respiratory system 992 risk factors 988, 991 statistics on 988 thermoregulatory alterations 993 types of 988–989 wound care 286, 994–995, 998 burrow 955 bursa 913, 917–918 bursitis 947 butyrophenones 398 bypass grafts 664 C CABG see coronary artery bypass graft cachexia 229, 306 CAD see coronary artery disease caecostomy 712 see also urinary diversion

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caecum 119 caffeine 77, 137 calcitonin 164, 832, 834 calcium 73, 76, 152, 152 calcium channel blockers 632, 652, 665, 675, 676, 746 calcium salts 184, 834 calcium stones 457 calculi (sialolithiasis) 460, 739 callus 913 canal of Schlemm 1032 cancer biliary tract 822 breast 521–525, 523, 525 definition of 294, 297 kidneys (adenocarcinoma) 459 larynx 1026–1029 liver 789, 806–808, 807 lungs and bronchi 592–593 mouth 732–733, 741 stomach 760–762, 761 tongue 738 urinary bladder 466–467 see also oncology nursing care ‘cancer syndrome’ see cachexia capillaries 607, 658, 661 carbamazepine 249, 899, 905, 911, 1134 carbohydrates 66–67, 970 carbonic acid buffer 153 carbonic anhydrase inhibitors 1060 carbon monoxide poisoning 989 carboxyhaemoglobin 986, 989 carbuncle 955 carcinogenesis 294, 303–304 carcinogens 294, 301, 303 carcinoid syndrome 1124 carcinoma definition of 295 of pancreas 814–816 in situ 295 of thyroid gland 839 cardiac ablation 624, 632 cardiac catheterisation 617–618 cardiac cirrhosis 796 cardiac cycle 612 cardiac failure 655 cardiac glycosides 622 cardiac output 607, 612 cardiac rupture 655 cardiac surgery 644–646 cardiac tamponade 270–271, 645 cardiac trauma 644–646, 644 cardinal symptom 229 cardiogenic conditions 592 cardiogenic shock 168–169, 645, 655 cardiomegaly 607 cardiomyopathy 624, 639 cardiopulmonary resuscitation (CPR) 255, 264–265, 264

JCTMSN_BOOK.indb 1188

cardiovascular system 607–623 anatomy and physiology of 609–614, 610, 611, 612 causes of disorders 614 classification of disorders 614 drugs used for treatment 622 elderly patients 1084–1085 exercise and 176 faecal impaction and 126 intraoperative complications and 411 nursing assessment 614–619, 619 nursing care plan 620–621 oncology nursing care 325 postoperative nursing and 414 renal failure and 449 risk factors 614 see also coronary artery disease; heart disorders cardioversion 624 caregivers, palliative care 1145–1146 carotid artery disease 659, 662 carotid endarterectomy 887, 896 carpal tunnel syndrome 947, 953 carpo-pedal spasm (tetany) 164, 164, 834, 834 cartilage 915 case management 1076 castor oil 125 casts 921, 923–925, 925 casualties, definition of 1149 casualty clearing station for disasters 1162 cataplexy 132 cataract 1032, 1057–1059 extraction 1054 catarrhal exudate 282 catch-up growth 63, 83 catheterisation 97, 108, 114–118, 114, 117, 1106 cations 150 CAT scan see computed axial tomography (CT/CAT) scan cautious feeding 63, 83 CCF see congestive cardiac failure CDC see Centre for Disease Control and Prevention cell-mediated immunity 334 cells and tissues, disorders associated with 277–293 anatomy and physiology of cells and tissues 279–280, 279, 297 cell death 284 cell injury 284 cell response to injury 281–283 classification of disorders 281 inflammatory response 281–283 nursing assessment 283–284 nursing care plan 285 risk factors 281 tumours 293 wounds 284, 285, 286–293, 286, 288, 291, 293 cellular immunity 334 cellular transformation and derangement theory 302 cellulitis 946 centrally acting sympathicolytics 674

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Index  1189

central nervous system hypertension 676 lymphoma 905 renal failure 449 see also nervous system central venous pressure (CVP) 607, 618–619 Centre for Disease Control and Prevention (CDC) 353, 355–356 cephalgia 861 cerebellum (hindbrain) 866 cerebral angiography 872 cerebral embolism 887, 891 cerebral malaria 906 cerebral palsy 887, 901 cerebral thrombosis 887, 891 cerebrospinal fluid (CSF) 867 cerebrovascular disease 890, 894–897, 895 cerebrum (forebrain) 866 cerumen 53, 57, 59, 1002, 1009 cerumen impaction 1002, 1015–1016 cervix 496–498 cancer 497–498 cervicitis 496–497 chalazion 1032, 1047 chancre 734 charms 18, 22 cheilitis 973 chemical burns 51, 988 chemical restraints 47 chemolysis 458 chemosis 1032 chemotherapy definition of 295 liver cancer 807–808 oncology nursing care 314, 318–319, 320, 321–325 prostatic cancer 545 chest (thoracic) trauma 267–271, 270 chest drain 269, 553, 594 Cheyne-Stokes breathing 1124 Child Care Act 13 children asthma 604 congenital heart valve defects 629 convulsions 900 definition of 1113 eye and vision disorders 1065 glomerulonephritis (GN) 441 HIV/Aids 362, 363, 364, 364, 365, 591 hygiene in 61–62 malnutrition 82–84, 82 meningitis 903 Moro reflex 1015 musculoskeletal system disorders 920 nappies, changing of 62 nutrition 78–79 pain management 244–247, 245, 246, 250 pneumonia 582, 587–588, 588

JCTMSN_BOOK.indb 1189

renal system disorders 430 rheumatic heart disease 635 skin disorders 964 ‘startle reflex’ 1015 tuberculosis (TB) 591 urine sampling 108 children in hospital 1113–1123 admission to hospital 1115–1117 child care charter 1114–1115 disasters 1166–1167, 1166 historical overview 1114 needs of children 1115, 1116 nursing assessment 1116–1117 pain 1120–1122 principles of care 1117–1120 reactions to hospitalisation 1115 standards of care 1117–1120 Children’s Act 394, 1114 chloasma 961 chloride 152, 152 chlorpropamide 853 Choice on Termination of Pregnancy Act 505 choking 264–266, 266 cholecystectomy 779, 821 cholecystitis 779, 816–817 cholecystoduodenostomy 779 cholecystogastrostomy 779 cholecystojejunostomy 779 cholecystostomy 779, 820 choledochojejunostomy 712 choledolithotomy 779 cholelithiasis 779, 818–821 cholestasis 790 cholesteatoma 1002, 1018 cholesterol 63, 68, 651, 662 cholesterol-reducing agents 622 chordotomy 861 chorea 635, 861 chorioretinal scarring 1044 choroid 1032, 1036–1037 chronic asthma 596, 601–604, 601, 603, 1085 chronic bronchitis 596, 604–605 chronic care for elderly patients 1078, 1080–1081 chronic cholecystitis 817 chronic gastritis 751–752 chronic obstructive pulmonary disease (COPD) 596, 604– 605, 1085 chronic obstructive pulmonary disorders 596–606 asthma 601–604, 601, 603 bronchiectasis 605–606 chronic obstructive pulmonary disease (COPD) 596, 604–605, 1085 classification of disorders 597, 597 infective conditions 605–606 inflammatory conditions 601–604, 601, 603 nursing assessment 598–599 nursing care plan 599–600

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obstructive conditions 604–605 pathophysiology of 598, 598 risk factors 597–598 statistics on 597 chronic otitis media 1017 chronic pain 229, 243, 247, 249–250 chronic pancreatitis 812–813 chronic renal failure 449–450, 452 Chvostek’s sign 164 chyle 705, 712 chyme 97, 119, 712 ciliary body 1033, 1036 cimetidine 757 circadian rhythm 134–135 circulating nurses 403, 404 circulation, definition of 608 circulation need 30, 220 circulatory system see vascular system circumcision 24, 34, 528, 538 cirrhosis of the liver 779, 789, 795–796, 795, 796, 797– 798, 798–799, 800–803, 803–805, 804 cisternal puncture 873 clarithromycin 584 clawfoot (pes cavus) 932, 934 cleaners 403 clinical latency 349 clinical thermometers 194, 195, 204 clonic 888 clonus 861 closed cardiac surgery 644 clubbing of fingernails 608, 615 clubfoot (congenital talipes equinovarus) 933–934 coagulation disorders 698–701 co-analgesics see adjuvant analgesics coarctation of the aorta 628, 629, 630 codeine 248, 1140 coeliac disease 728 cognition need 32, 222 coitarche 471 coitus 471 collaboration 211 collagen diseases 591 collectivistic cultures 26 collegiality 211 colloid osmotic pressure 146 colloids 146, 170–171 coloboma 1033, 1044 colon see large intestine colostomy 712 colour tool (pain rating scale) 245 colo-vesical fistula 460, 467 colporrhaphy 485 coma 861 see also Glasgow Coma Scale combination HIV prevention 349 comedo 955 comfort, rest and sleep needs 31, 132–144, 221 chronic renal failure 450

JCTMSN_BOOK.indb 1190

drug therapy 143 management of problems 140–143 nursing assessment 136–138, 139–140 pain, functions of 138–140 pain relief measures 141–143 preoperative nursing 392 sleep, functions of 134–138, 134, 136 sleep disorders 140–141 communication as core competence 210 cultural diversity and 25, 26–27 disasters 1161 emergency care 258 end-of-life care 1127 with hearing-impaired patients 1018 need for 32–33, 222 palliative care nursing 1127 safety and 42 community-acquired pneumonia 587–588, 588, 590 community-based nursing 1071–1072, 1073, 1074–1076, 1075 community-based organisations 17, 90–91, 1096 community care 252–253, 326–328 community health issues 1167–1168 community resources 1074, 1075 community support 383–384 compartment syndrome 274, 931, 939 competence, definition of 206 competencies of professional nurses 206–213 complementary foods 63, 78–79 complementary healthcare 23–24, 81, 970 complete proteins 63 complex partial seizure 888, 899 compresses 973 computed axial tomography (CT/CAT) scan 432, 483, 534, 663, 783, 872 concussion 894 condom catheters 112, 117, 1106 conducting system of the heart 612, 612, 630–635, 630, 631, 632, 633, 634, 635 conduction 193 conductive hearing loss 1002, 1008, 1020 conductivity 608 condylomata acuminate (genital warts) 551 confidentiality 13 confusion 861, 1082–1084, 1136–1136 congenital conditions cretinism 838 external ear 1014 eye 1044 heart defects 627–628 heart valve defects 628–630, 629, 630 hip 933 hypothyroidism 838 lacrimal duct 1044 musculoskeletal system 932–934 nervous system 900–902

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Index  1191

nose 1023 ocular conditions 1053 ptosis 1044 renal system 102 respiratory system 593 sclera 1044 talipes equinovarus (clubfoot) 933–934 upper limbs 934 congestive cardiac failure (CCF) 639–644, 641, 643 conjunctivitis 1033, 1048 connective cells 280 Conn’s syndrome (primary aldosteronism) 841 consent forms see informed consent constipation 94, 97, 121–127, 130, 252, 1138 Constitutional Court 1095–1096 Constitution of the Republic of South Africa 10, 25, 387, 1095, 1100 contact dermatitis 734 contact lens care 59 contact transmission 44 continent ileal reservoir 468 continent vesicostomy 464 Continuing Professional Development (CPD) 208 contractility 608, 640 contractures 175, 182, 183, 186, 277, 293, 931, 940, 986 contrecoup 267, 861 contusion 286, 913, 934–935 convection 193 convulsions 237–238, 240 convulsive conditions 898–900 Coombs test 686 COPD see chronic obstructive pulmonary disease coping skills 32 copper 970 core competencies of professional nurses 206–213 corneal graft/transplant 1054 corneal laceration repair 1054 corneal topography (pentacam) 1041 corneal ulcer 1033 corns 934 coronary artery bypass graft (CABG) 654 coronary artery disease (CAD) 649–657 angina pectoris 652–653 causes of 651 coronary circulation 650–651 myocardial infarction (MI) 650, 653–656 nursing assessment 652 pathophysiology of 651–652, 652 risk factors 651 see also cardiovascular system; heart disorders coronary circulation 611, 611 coronary sinus 608 cor pulmonale 592 corrosive oesophagitis 743 cortex 97, 100 corticosteroids (adrenocorticoids) 321, 699, 753, 774, 799, 809, 839, 840, 1134

JCTMSN_BOOK.indb 1191

cough end-of-life care 1132, 1132 palliative care nursing 1132, 1132 postoperative nursing 417 respiratory system disorders 558, 563–565, 564, 569– 570, 580 symptoms management 231–233, 233, 238 counselling 358–361, 1074, 1075 CPD see Continuing Professional Development CPR see cardiopulmonary resuscitation cranial nerves 868, 868 craniectomy 861 craniotomy 861, 877–879 creams, definition of 973 creatinine 426 critical thinking 206, 211 Crohn’s disease (regional enteritis) 773, 774–775, 778 cromoglycic acid 575 croup (laryngotracheobronchitis) 232, 1003 crush injuries to extremities 274 crust (scabs) 955 cryoablation 780 cryosurgery 777, 807 cryotherapy 471, 497, 515 cryptococcal meningitis 374–375, 376, 905 cryptococcus neoformans 591 cryptomenorrhoea 471, 494 cryptorchidism (undescended testes) 528, 538–539 crystalloids 146, 170–171 CSF see cerebrospinal fluid CT scan see computed axial tomography (CT/CAT) scan culling 679 cultural competence 212 cultural diversity 18–27 alternative healthcare provision 23–25 communication and 25, 26–27 concept of culture 19–20 HIV Counselling 360 hygienic practices 55 importance of 19, 20 influence on health 5 issues in healthcare 20–23 nurses’ interface with 25–26 perspectives on health and illness 23–24 preoperative nursing 391 curative healthcare 16 Cushing’s syndrome 840–841 cutaneous stimulation 142, 253 cutaneous ureterostomy 467, 467 CVP see central venous pressure cyanosis 233–234, 238–239, 553, 567, 615, 955 cystectomy 460, 465, 466–467 cystitis 462–463 cystocele 426, 471, 494 cystography 432 cystoscopy 426, 458, 534 cystostomy 460, 465

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1192  Juta’s Complete Textbook of Medical Surgical Nursing

cystourethrography 460 cysts Bartholin’s 492–493 definition of 955 meibomian 1033 ovarian 503 pancreatic 813–814 cytokines 826 cytology 295 cytolytic hypersensitivity see Type II hypersensitivity cytoplasm 280, 280 cytotoxic hypersensitivity see Type II hypersensitivity D dacryoadenitis 1047 dacryocystitis 1047 dacryocystorhinostomy 1055 Dandy-Walker syndrome 901 dead space 553 death attitudes to 1126 cultural diversity 22 safety of patients’ possessions 49–50 signs and symptoms of impending 1143–1144 debridement 291, 986, 995, 998 debris 277 decarboxylase inhibitors 908 decerebrate 861 decision-making, ethical 13, 13 decompression 861 decongestants (vasoconstrictors) 575 decorticate 861 decubitus ulcers see pressure sores deep-vein thrombosis 420–421, 656, 668–669 defecation 97 defecography 724 definitive care 255, 1153 degenerative conditions, nervous system 907–909 degenerative joint disorders 947–949, 1085–1086 degenerative ocular conditions 1045–1046 dehiscence 277, 292–293, 293 dehydration 76, 128, 146, 157–158, 570–571, 1066, 1087 delayed hypersensitivity 343–344 delirium 861, 1066, 1082–1083, 1082, 1136 dementia 1066, 1083–1084 Democratic Nursing Organisation of South Africa (DENOSA) 15 dendrites 861, 864 DENOSA see Democratic Nursing Organisation of South Africa dental caries 53, 736 dental plaque 735–736 dentures 53, 60 deoxyribonucleic acid (DNA) 280, 297, 302 Department of Education 91 Department of Health 17, 91, 583, 1157 Department of Social Development 91

JCTMSN_BOOK.indb 1192

dependence of people with disabilities 1100 depression 1066, 1084, 1100, 1104, 1111, 1136 dermatitis (eczema) 961, 981–982, 982, 983 dermatological symptoms 1134–1135, 1134 dermis 957–958, 986 dermoid tumours 1051 descriptive ethics 11–12 devascularisation 804 developmental musculoskeletal disorders 932–934 dexamethasone 1140 dextromethorphan 575 DHA see district health authority diabetes insipidus 831–832, 876 diabetes mellitus (DM) 843–859 chronic complications 856–857 classification of 846–847, 847 in elderly patients 1086 essential health information for patients 857–858, 858 heart disorders and 627 hyperglycaemia 854–856 hypoglycaemia 851–854, 853 insulin therapy 851, 852, 858, 858 nursing assessment 847–848, 851, 852 nursing care plan 849–851 pathophysiology of 845–846, 846 preoperative nursing 390 risk factors 847 Type I 845, 846, 847 Type II 845, 847, 847, 853 vascular system and 662 diabetic foot 843, 857 diabetic ketoacidosis (DKA) 843, 855–856 diabetic nephropathy 843 diabetic neuropathy 844, 857 diabetic retinopathy 843, 1056 diagnostic tests 218 dialysate 438, 453–454 dialyser 438, 454 dialysis 426, 450, 452–454, 453, 454 diaphoresis 427, 471 diaphragmatic hernia (hiatus hernia) 593, 748–749, 748 diaphysis 913, 915 diaries, for pain management 246–247 diarrhoea chemotherapy 325 end-of-life care 1140, 1140 palliative care nursing 1140, 1140 safety in nursing practice 127–129, 128, 130 symptoms management 239 diastole 608, 612 diastolic blood pressure 608, 672, 1085 DIC see disseminated intravascular coagulopathy dicyclomine hydrochloride 758 diet see nutrition needs dieticians 1104 diffusion 146, 438, 452–453, 556–557

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Index  1193

digestion, definition of 712 see also accessory organs of digestion digitalis 643 digital rectal examination (DRE) 544 dignity of patients 407 dilatation and curettage 483, 485 diopter 1033 diphtheria 1003 diplegia 861 diplopia 1033 directly observed therapy short course (DOTS) 586 disability see people with disabilities Disability Rights Charter 1095 Disabled People South Africa 1095 Disaster Management Act 1151, 1152 disasters 1149–1169 basic principles in management of 1153 causes of 1153 classification of 1152–1153 community health issues 1167–1168 definition of 1150–1151 disaster nursing 1162–1167, 1163, 1164, 1166 disaster planning process 1153–1159, 1154, 1158, 1159, 1161 education on 1169 emergency situations 1163–1167, 1163, 1164, 1166 managing disaster scenes 1160–1162, 1163 models 1151–1152 psychological consequences of 1169 triage systems 1157–1158, 1158, 1159, 1161–1162, 1168 discharge coordinators 1103 discharge of patients 419–421, 1108, 1111 discrimination 384, 1095 dislocations 914, 935–936 displacement of pupil 1044 disposal of body and body parts 21–22 dissacharide malabsorption 728 disseminated intravascular coagulopathy (DIC) 328, 701 distal splenorenal shunt (DSRS) 804–805 distributive shock 169 district health authority (DHA) 16–17 diuresis 97 diuretics 137, 146, 622, 643, 674, 676 diurnal enuresis 97 diverticular disease 772–773 diverticulitis 712, 772–773 diverticulum 712, 772–773 dizziness in elderly patients 1088 see also vertigo DKA see diabetic ketoacidosis DM see diabetes mellitus DNA see deoxyribonucleic acid DNA topoisomerase inhibitors 320, 321 donor site, definition of 986 dopamine agonists 908 dopamine antagonists 237 dopaminergic agents 908

JCTMSN_BOOK.indb 1193

Doppler studies 618, 663 dorsiflexion 861 DOTS see directly observed therapy short course Doyle, Derek 1126 DRE see digital rectal examination dressings 292 Dressler’s syndrome 656 drug-induced hepatitis 794–795 drug therapy see medication DSRS see distal splenorenal shunt dumping syndrome 762 duodenal ulcers 752, 754 dwarfism 823, 830–831 dysmenorrhoea 471, 487, 490 dyspareunia 471, 487 dysphagia 712, 725, 1006 dysphasia 861 dysphonia 861 dysphoria 1124, 1145 dysplasia 278, 497 dyspnoea 234–235, 235, 239, 553, 566, 1133 dysrhythmias 126, 420, 631–635, 632, 633, 634, 635, 645, 655 dystonia 861 dystrophy 862 dysuria 435, 471, 487 E EACH see European Association for Children in Hospital ear, nose and throat disorders 1002–1031 adenoids 1030–1031 classification of disorders 1004, 1005 communicating with hearing-impaired patients 1018 ear 57, 59–60, 274–275, 1005, 1005, 1009, 1009, 1014–1020, 1021–1022, 1023 external ear 1009, 1014–1016 inner ear 1009, 1014, 1019–1020, 1023 larynx 1026–1029 middle ear 1009, 1016–1019 nose 60, 275, 1005–1006, 1005, 1023–1025, 1023 nursing assessment 1006–1009 nursing care plan 1010–1014 pharynx 1029–1030 risk factors 1005–1006 throat 1005, 1006, 1025–1030, 1026 tonsils 1030–1031 wicking the ear 1015 EBP see evidence-based practice ECCE see extracapsular cataract extraction ecchymosis 679, 955, 968 ECG see electrocardiogram echocardiography 261, 617 echolalia 862 echopraxia 862 ectopic pregnancy 506, 508–509 ectopic testes 538–539 ectropion 1033, 1045

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1194  Juta’s Complete Textbook of Medical Surgical Nursing

eczema (dermatitis) 961, 981–982, 982, 983 Edmonton Symptom Assessment System 246 education on disasters 1169 influence on health 5 of nurses 40–41, 40 of patients 209 schooling in hospital 1120 Efavirenz (EFV) 349 efferent arterioles 97 effusion 914 EFV see Efavirenz eicosanoids 823, 826 elderly patients 1066–1093 abuse of 1091–1092, 1091 anatomy and physiology 1068, 1069–1071, 1071 cardiovascular disease 1084–1085 chronic care 1078, 1080–1081 chronic obstructive pulmonary disease (COPD) 1085 community-based nursing 1071–1072, 1073, 1074– 1076, 1075 degenerative joint and bone disease 1085–1086 dehydration 1087 demographic impact of ageing 1068 diabetes mellitus 1086 dizziness 1088 epilepsy 1087–1088 falls 1088 hearing 1087 hospital-based nursing 1076–1078, 1077, 1078 hypertension 1085 immobility 1088–1089 impaired mental functioning care 1082–1084, 1082 incontinence 1090–1091 leg ulcers 1089 long-term care 1078, 1080–1081 nausea 1089 nursing care plan 1079–1080 nutrition 79–80, 80 palliative care 1081–1082 Parkinson’s disease 1089 pressure sores 1089–1090 rehabilitation 1078 safety in nursing practice 42 skin disorders 985 stroke 1085, 1091 terminal care 1081–1082 thermoregulation 1088 thyroid disorders 1086 vision 1087 electrical burns 51, 281, 989 electric blankets 415 electrocardiogram (ECG) 156, 616–617 electrocochleography 1008 electro-encephalography 872 electrolyte, definition of 146

JCTMSN_BOOK.indb 1194

electrolyte balance 30, 149, 150–153, 151, 152, 159–160, 160–164, 220, 429, 645 electro-myography 872 electronic thermometers 194, 195 electrophysiologic studies 724 elephantiasis 708–709 elimination definition of 98, 712 four mechanisms of 99–100 need for 30, 221 postoperative nursing 417–418, 419 preoperative nursing 392 see also faecal elimination; urinary elimination ELISA test see enzyme-linked immunosorbent assay (ELISA) test emboli 175, 645 emergency care see multiple trauma and emergency care Emergency Medicine Society of South Africa (EMSSA) 1157 emergency situations 1163–1167, 1163, 1164, 1166 see also multiple trauma and emergency care emergency unit 256 emetics 230 emmetropia 1033 emollient 955 emotional trauma 275–276 emotions, expressing of 26 empathy 243, 358 emphysema 597, 604–605 employment impact of integumentary system disorders on 974 people with disabilities 1111 work-related disorders 950, 952–953, 953 empyema 553 EMSSA see Emergency Medicine Society of South Africa Emtricitabine (FTC) 349 encephalitis 888, 903–904 encephalocele 888, 901 encopresis 98, 129 endocarditis 624, 636 endocrine system 823–842 adrenal gland 827, 839–842 anatomy and physiology of 825, 825 chemistry of hormones 825–826, 826 classification of disorders 826, 827 female reproductive system and 474 nursing assessment 827–829, 829 parathyroid gland 827, 832–834, 833, 834 pituitary gland 827, 830–832, 830 risk factors 826–827 thyroid gland 827, 835–839, 836, 837–838 end-of-life care 1125–1126, 1142–1147 anorexia 1138, 1138 attitudes to death and dying 1126 bereavement 1144–1145 body functions 1137 communication 1127 constipation 1138

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Index  1195

dermatological symptoms 1134–1135, 1134 diarrhoea 1140, 1140 fatigue/weakness 1137 five stages in coping 1142–1143 home care 1146–1147 mucositis 1141, 1142 nausea 1139–1140, 1139 neurological symptoms 1135–1137 nursing assessment 1127, 1131 nursing care plan 1128–1131 opioids 1141 pain 1141 physical appearance 1137 psychiatric symptoms 1135–1137 respiratory symptoms 1132–1134, 1132 rights of dying patients 1143 sexuality 1137 signs and symptoms of impending death 1143–1144 support of patients and significant others 1143–1146 vomiting 1139–1140, 1139 endometriosis 471, 499–500 endometritis 499 endophthalmitis 1033, 1050 endoscopic retrograde cholangiopancreatography (ERCP) 783, 814 endoscopies 561–562, 713, 721–723 end-stage renal disease (ESRD) see chronic renal failure enemas 126 energy therapies 24 enteral nutrition 63, 90–91, 728 entropion 1033, 1045 enucleation 1033, 1055 enuresis 98, 110 enzyme-linked immunosorbent assay (ELISA) test 362 enzymes 64, 320, 321, 713, 715–716 epidermis 957–958, 986 epididymis 528, 530 epididymitis 540 epidural anaesthesia 407 epilepsy 237–238, 888, 898–900, 1087–1088 epiphysis 914 episcleritis scleritis 1049 epispadias 528, 538 epistaxis 1003, 1025 epithelial cells 280 Epstein-Barr virus 300, 710, 905 equality 4–5, 1095–1096 equipment incidents 43 ERCP see endoscopic retrograde cholangiopancreatography erectile dysfunction (impotence) 528, 545, 546, 548–550 Eriksson’s developmental theory 10 ERV see expiratory reserve volume erythema 955 erythema marginatum 635 erythrocytes see red blood cells erythropoeisis 679, 691 erythropoietin 102, 428–429

JCTMSN_BOOK.indb 1195

eschar 293, 987 escharotomy 987 esomeprazole 999 ESRD (end-stage renal disease) see chronic renal failure essential amino acids 64, 67–68 ethical issues 11–14, 13, 210, 211, 358, 393–395, 395 ethics, definition of 1 European Association for Children in Hospital (EACH) 1114–1115 evacuation of patients 1149, 1165–1166, 1166 evaporation 193 evidence-based practice (EBP) 41, 206, 210 evisceration complications related to wounds 278, 293, 293 eye surgical procedures 1033, 1055 excisional biopsy 305 excoriation (erosion) 956 excretory urography 432 exenteration 1033, 1055 exercise ECG (stress test) 616–617 exercise needs see mobility and exercise needs existentialism (meaningfulness) 33, 222 exophthalmos 823 expectorants 230 expiratory reserve volume (ERV) 553, 563 external ear 1009, 1014–1016 external fixator 925–926 external radiation 314 external respiration 553 extracapsular cataract extraction (ECCE) 1054 extracorporeal shock-wave lithotripsy 820 extradural bleeding 891 extradural haematoma 267, 888 extrapyramidal signs 1124 extreme drug-resistant tuberculosis (XDR-TB) 585 exudate 282 exudative diarrhoea 127 eye and vision disorders 1032–1065 Aids and 1057 anatomy and physiology of eye 1036–1037, 1037, 1038 blindness prevention 1062, 1064, 1065 care of visually impaired patients 1064 cataract 1057–1059 classification of eye conditions 1038 congenital abnormalities of the eye 1044 congenital ocular conditions 1053 degenerative ocular conditions 1045–1046 diabetic retinopathy 1056 elderly patients 1087 emergency care 274 ethical issues 1065 glaucoma 1059–1060 hot compresses 1064 hygiene of 56–57, 59 hypertensive retinopathy 1056 inflammatory conditions of the eye 1046–1052 irrigation of eye 1063

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1196  Juta’s Complete Textbook of Medical Surgical Nursing

legal issues 1065 loss of an eye 1053 medication 1063–1064 neonates 1065 nursing assessment 1038–1041, 1040 nursing care plan 1042–1043 nutrition and 1061 ophthalmologists 1053 refractive errors 1061–1062, 1061 rehabilitation of visually impaired 1064 retinopathy 1056 retinopathy of prematurity (ROP) 1056–1057 risk factors 1038 safety in nursing practice 42 squint 1057, 1057 surgical procedures 1054–1056 swabbing of eye 1063 systemic diseases 1061 trauma to eye 1053, 1053 eye contact 26 eyrthmoderma 983 F faces pain rating scale 245 faecal analysis 119, 123, 721, 724 faecal elimination (defaecation) 97–100, 118–131 anatomy and physiology of gastrointestinal tract 118– 121, 119 characteristics of normal/abnormal faeces 121, 123 common problems 122–131, 123, 128 composition of faeces 119 factors that influence 120–121, 122 impaction 126–127 incontinence 129–130 normal process of 119 nursing care plan 130 faith-based organisations 17 fallopian tubes 501–504 falls 47, 1088 family 21, 32, 1113, 1117, 1144–1145 famotidine 758 FAS see foetal alcohol syndrome fat embolism 938 fatigue 235–236, 239, 679, 1137 fat necrosis 520 fats 65–66, 68–69, 970 FBC see full blood count febrile convulsions 202, 204–205, 237, 238 female reproductive system 471–513 abortion 504–506, 504, 507–508 anatomy and physiology of 474, 474 cervix 496–498 chemotherapy 325 classification of disorders 475–476, 476–477 ectopic pregnancy 506, 508–509 essential health education 484–485 fallopian tubes 501–504

JCTMSN_BOOK.indb 1196

hysterectomy 509–510, 511–513 infertility 510, 513 menstruation 474–475, 475, 486, 490–491 nursing assessment 477–483, 479, 480 nursing care plan 487–489 nursing diagnosis 485–486 ovaries 501–504 risk factors 477 surgical procedures 483–484, 485 uterus 498–501, 500 vagina 494–496, 494 vulva 491–494 fentanyl 252 fetor hepaticus 780, 782 FF see formula feeding fibre 67 fibreoptic colonoscopy 723 fibroadenoma 521 fibrocystic breast 521 fibroscopy 713 fidelity 13 films (dressings) 292 filtration 146 finger restraints 48, 48 fire emergencies 1163–1167, 1163, 1164, 1166 first aid 51 first-generation sulphonylureas 853 fissure 956 fistula 460, 471 fistulectomy 764 fistulotomy 764 five Cs of HIV testing 361–362 ‘five rights’ of medication 38, 209, 249–250 five stages in coping 1142–1143 flaccid 862, 914 FLACC scale for assessment of pain 245, 246 flail chest 268 flat foot (pes planus) 934 flatulence 130–131 floaters 1033, 1045 “floor” nurses see circulating nurses Florence Nightingale Pledge 13 fluid balance 30, 149–150, 149–150, 157–159, 160, 220, 429 foams, dressing with 292 focal 862 foetal alcohol syndrome (FAS) 77 folic acid deficiency anaemia 694 follicular adenocarcinoma 839 folliculitis 961, 975 food allergy testing 339 food safety during pregnancy 77 food security 64 foot acquired disorders 934 congenital deformities 933–934 forebrain see cerebrum

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Index  1197

foreign bodies in external ear canal 1016 foreskin (prepuce) 529, 531, 534, 537–538 formula feeding (FF) 148, 357 fourth-generation HIV tests 362 fractures 936–941, 936, 937, 940, 941, 942–944, 945–946 definition of 914 emergency care 273 nose 1025 ribs 267–268 skull 267 FRC see functional residual capacity Freud’s psychoanalytic theory 10 frostbite 51 FTC see Emtricitabine full blood count (FBC) 685–686, 686, 785 fulminant hepatic failure 780, 790, 805 fulminant viral hepatitis 780 functional residual capacity (FRC) 553 functioning 1094, 1097 fungal infections 976, 978 fungating wound 1124 furuncles 956, 961, 975 furunculosis 1015 G GAG see glycosaminoglycon gait 862 galactorrhoea 515, 520 gallbladder 816–822, 816 gallstones 789 see also cholelithiasis gamma glutamyltranspeptidase (GGTP) 784 gammopathies 332, 335, 346 ganglionic blocking agents 675 gangrene 665 gas exchange 553, 556–557 gas gangrene 939–940 gastrectomy 731, 761, 761 gastric ulcers 752, 754 gastritis 750–752, 751 gastroesophageal reflux disorder (GERD) see reflux gastrointestinal motility study 724 gastrointestinal system 712–730 anatomy and physiology of 714–715, 715 bleeding 803 burn injuries 992 chemotherapy 324–325 classification of disorders 717, 717 functions of 715–716, 716, 717 nursing assessment 717–720, 720–724, 720–725 nursing care plan 726–728 nutritional disorders 725, 728–730 risk factors 717 see also faecal elimination; lower gastrointestinal tract; upper gastrointestinal tract disorders gastrostomy 731, 744 gastrostomy tubes 728 ‘gate control’ theory 142, 242

JCTMSN_BOOK.indb 1197

GDM see gestational diabetes mellitus gels 973 gender-based violence 350 general anaesthesia 407 general assistants 403 general symptom, definition of 230 gene therapy 326 genital hygiene 57, 60–61 genital warts (condylomata acuminate) 551 genitourinary system see renal system genu valgum 931, 933 genu varum 931, 933 geographical model of disasters 1151–1152 GERD (gastroesophageal reflux disorder) see reflux geriatrics 1066 German measles (rubella) 961 gerontology 1066 gestational diabetes mellitus (GDM) 844, 847 gesturing 26 GGTP see gamma glutamyltranspeptidase gigantism 824, 831 gingivitis 735 Glasgow Coma Scale (GCS) 255, 260, 266–267, 869–870, 870, 879–880 glaucoma 1059–1060 glipizide 853 globalisation 2 glomerular filtrate 98, 101 glomerulonephritis (GN) 441–444, 443 glomerulus 98, 101 glossectomy 713 glossitis 679 gloves 45 glucagon 809, 844 gluconeogenesis 809, 824 glycaemic index (GI) 844, 1086 glycogenesis 824 glycogenolysis 844, 846 glycolysis 844 glycosaminoglycon (GAG) 440 glycosuria 844 GN see glomerulonephritis goal planning 1107–1108 GOBI-FFF principle 5 going home see discharge of patients goitre 824, 835 Goldmann Applanation tonometer 1040 gonads (ovaries and testes) 825, 827 gonioscopy 1041 goniotomy 1054 gonorrhoea 550 Goodpasture’s syndrome 343 gout 948–949 gowns 45 grafting 278, 292, 995, 998 grand mal epilepsy 888, 899 granulation 278

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1198  Juta’s Complete Textbook of Medical Surgical Nursing

Grave’s disease 835 gravida 471 Gretter, L E 13 grieving 1100 grooming needs see hygiene and grooming needs growth faltering 64 growth monitoring and promotion 64 guarding 471, 724, 756 Guillain-Barré syndrome 906, 911 gums 735 guttate (drop-like lesions) 983 gynaecomastia 528 H habilitation 1094, 1098 haemangiomas 1051 haematemesis 230, 567 haemathrosis 679 haematocrit (Hct) 156, 679, 685, 987 haematological studies cardiovascular system 619, 619 oncology nursing care 305 ulcerative colitis 775 haematological system 679–702 agranulocytosis 697 anaemia 691–695, 692 blood groups 682–683 blood transfusion 687, 690–691, 690 classification of disorders 683, 683 composition of blood 681, 682 disseminated intravascular coagulopathy (DIC) 701 functions of blood 681–682 haemophilia 699–701 haemorrhagic and coagulation disorders 698–701 leukaemia 697–698 malignant conditions 697–698 multiple myeloma 698 nursing assessment 684–687, 686 nursing care plan 688–689 polycythaemia vera 696 red blood cells (RBCs) 691 risk factors 683–684 sickle cell crisis 695–696 thrombocytopenia 698–699 white blood cells (WBCs) 696–698 haematoma 255 extradural 267, 888 intracerebral 267 intracranial 267 intradural 267 subarachnoid 267 subdural 267, 888, 891, 894 haematometra 472 haematopoiesis 679 haematuria 98, 111, 679 haemochromatosis 789 haemoconcentration 987

JCTMSN_BOOK.indb 1198

haemodialysis 454 haemodilution 987 haemodynamic monitoring 608, 617 haemoglobin (Hb) 154, 680, 685, 686, 987 haemolysis 332, 680 haemolytic anaemia 694 haemolytic jaundice 791, 792 haemophilia 680, 699–701 haemoptysis 553, 566–567 haemorrhage haemorrhagic disorders 698–701 nervous system disorders 891, 894–897, 895 peptic ulcers 756 postoperative nursing 419–420, 423 wounds 292 haemorrhagic exudate 282 haemorrhoids 776–778, 777 haemostasis 288, 680 haemothorax 255, 270 hair 56, 58–59, 59, 958 hairy leukoplakia 738 halitosis 53, 56, 732 hallucination 862 hallux valgus (bunion) 934 haloperidol 251, 999, 1134, 1136, 1139 hand hygiene 44, 53, 55–56, 58, 121 handicap 1094 handkerchiefs 565 hay fever (allergic rhinitis) 1002, 1023–1024 hazard 1149 Hb see haemoglobin HCl see hydrochloric acid Hct see haematocrit head circumference in children 84 head trauma 266–267 health, definition of 1–2 health-belief model 3–4 healthcare delivery systems 16–17 health–ill health continuum 2–3 health promotion 1, 4 hearing 42, 1020, 1023, 1087 hearing aids 59–60 heart attacks see myocardial infarction heartburn 94–95, 731 heart disorders 624–648 acquired valvular heart disease 638–639 arrhythmias 630–635, 630, 631, 632, 633, 634, 635 bacterial endocarditis 636–637 cardiac surgery 644–646 cardiac trauma 644–646, 644 cardiomyopathy 639 classification of disorders 626, 626 conducting system 630–635, 630, 631, 632, 633, 634, 635 congenital heart defects 627–628 congenital heart valve defects 628–630, 629, 630 congestive cardiac failure (CCF) 639–644, 641, 643

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Index  1199

infections and inflammatory conditions 635–639, 637 myocarditis 637–638 nursing assessment 627 pericarditis 638 rheumatic heart disease 635–636 risk factors 626–627 septal defects (holes in septum of heart) 628 septic emboli 637, 637 structure and function of heart 609–614, 610, 611, 612, 626 see also cardiovascular system; coronary artery disease heat stroke 190, 202, 1088 height of patients 84, 85–86, 85, 86 Heimlich manoeuvre 255, 265, 265 Helicobacter pylori bacteria 750, 753, 756 helidac 756 hemianopia hydrocephalus 888 hemi-glossectomy 713 hemiplegia 862 Henderson, Virginia 3, 5, 7, 9 HEPA filter system see High Efficiency Particulate Air (HEPA) filter system heparin 669, 672, 999 hepatic encephalopathy (hepatic coma) 780, 790, 799, 800 hepatitis 789, 792–795, 793, 794 hepatitis B virus 300, 793, 795 hepatocellular (hepatic) jaundice 791, 792 hepatocellular carcinoma 807 hepatomegaly 1124 hepatorenal syndrome 805 hernia 767 herpes simplex 300, 734, 961, 977 herpes zoster (shingles) 961, 977 heterograft 987 HFV see high frequency ventilation HHNKS see hyperglycaemic hyperosmolar nonketotic syndrome hiatus hernia (diaphragmatic hernia) 593, 748–749, 748 hiccups (hiccoughs) 412, 420, 1133–1134 high-context communication style 26–27 High Efficiency Particulate Air (HEPA) filter system 403 higher cognitive functions 868 high frequency ventilation (HFV) 572–573 hilum 98, 101 hindbrain see cerebellum hip fracture 941, 945 Hirschsprung disease 768 hirsutism (androgenia) 824, 956, 962 histamine 2-antagonists 757 histoplasmosis 591 HIV/Aids, patients living with 349–385 adolescents 364, 366, 378, 379–383 ART management 354, 357, 374, 375, 376–378, 378, 379–383 breastfeeding 78 children 362, 363, 364, 364, 365 clinical staging 365–366, 367–373, 373–374

JCTMSN_BOOK.indb 1199

community support 383–384 competencies of professional nurses 207, 212 counselling 358–361 cryptococcal meningitis 374–375, 376 discrimination 384 epidemiology of HIV/Aids 353–354, 354 eye and vision disorders 1057 HIV-associated dementia 904 Kaposi’s sarcoma 300 male reproductive system 551 morphine 250 mother-to-child transmission 356–358, 364–365, 367, 375, 376–378 neuroAids 904–906 nursing management 366, 369–373, 373–374 nutrition 80–81 pathophysiology of HIV/Aids 354–358, 355, 357 prevention 366, 373 Primary Health Care 374 respiratory system 576, 587–591, 588, 589 stigma 384 testing services 359, 361–365, 363, 364–365, 366 tuberculosis (TB) 374, 375 hoarseness 1003, 1006, 1027 Hodgkin’s disease 710 holistic paradigm of health and illness 23 home care 326–328, 1146–1147 Homen’s sign 185, 185 homeostasis 145–174 acid–base balance 149, 153–154, 153, 164–168, 165, 166 classification of disorders 155, 154 definition of 148 electrolyte balance 149, 150–153, 151, 152, 159–160, 160–164 fluid balance 149–150, 149–150, 157–159, 160 intravenous therapy 172 kidneys 102 nursing assessment 155–157, 155 recording of intake and output 171–172 renal system 428 risk factors 155 shock 168–171, 168, 169, 170 hordeolum 1033, 1047 hormones body temperature 193 cancer 302 definition of 824 hormonal therapy (chemotherapeutic drugs) 320, 321 hormone replacement therapy (HRT) 302, 491 kidneys 101 prostatic cancer 545 Hospital Anxiety and Depression Scale 1104 hospitalisation, definition of 1113 hot compresses 1064 HPV see human papillomavirus

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human immunodeficiency virus see HIV/Aids, patients living with human papillomavirus (HPV) 482 humidification 569, 571 humoral immunity 334–335 Huntington’s chorea 908–909 hybridisation theory 304 hydrocele 528, 539–540 hydrocephalus 900–901 hydrochloric acid (HCl) 713, 751 hydrocolloids (dressings) 292 hydrogels (dressings) 292 hydronephrosis 456 hydrophilic bead (dressings) 292 hydrophilic colloids 767 hydrotherapy 987, 998 hygiene and grooming needs 30–31, 53–62, 221 cultural diversity 21 factors that influence 54–55 female reproductive system 484 infants 61–62 maintenance of 57–62, 57, 59 neonates 61–62 nursing assessment 55–57 nutrition and 81 patients unable to help themselves 57–61, 57, 59 hyperaldosteronism 841–842 hyperbilirubinaemia 791 hypercalcaemia 163–164, 329–330 hypercholesterolaemia 624 hyperemesis gravidarum 64 hyperglycaemia 854–856 hyperglycaemic hyperosmolar nonketotic syndrome (HHNKS) 844, 854–855 hyperhidrosis 956, 962 hyperkalaemia (potassium excess) 146, 161–162, 165 hyperlipidaemia 624 hypermenorrhoea 472 hypernatraemia (sodium excess) 160 hyperopia 1033, 1061, 1061 hyperparathyroidism 832–834, 833 hyperpigmentation 956 hyperpituitarism 831 hyperplasia 278, 286 hyperpyrexia 190 hypersensitivity 332, 335, 341–344, 342 hypersomnia 132 hypersomnolescence 132 hypertension 608, 627, 662, 672–674, 674–675, 676–677, 1085 hypertensive retinopathy 1056 hyperthermia 204 hyperthyroidism 824, 835–837, 836, 837–838 hypertonic 146 hypertrichosis 962 hypertrophic gastritis 752

JCTMSN_BOOK.indb 1200

hypertrophy (benign prostatic hyperplasia) 278, 528, 541– 543 hypervolaemia 146 hyphaema 1033 hypnologic hallucination 132 hypoalgesia 862 hypocalcaemia 98, 164 hypoglycaemia 851–854, 853 hypokalaemia 146, 162–163 hypomenorrhoea 472 hyponatraemia 161 hypoparathyroidism 833, 834, 834 hypopigmentation 956 hypopituitarism 830–831 hypopyon 1033 hyposecretory agents 757–758 hyposensitisation 344 hypospadias 528, 538 hypotension 414, 419–420, 608 hypothalamus 191–192, 825, 830, 866–867 hypothermia 190, 202–203, 204, 1088 hypothyroidism 824, 837–839 hypotonic 146 hypovolaemia 146, 157–158, 168 hypovolaemic shock 168–169 hypoxaemia 281, 412, 416, 567–568 hypoxia 98, 230, 281 hysterectomy 472, 485, 501, 509–510, 511–513 hysterosalpingoscopy 482–483 hysteroscopy 482 I IASP see International Association for the Study of Pain iatrogenic 472, 486 IBD (inflammatory bowel disease) 773–776 IBS see irritable bowel syndrome ICD tube see intercostal drainage (ICD) tube ICN see International Council of Nurses ICPs see integrated care pathways identification of patients 50–51 ileal (intestinal) conduit 467–468, 467 ileo-caecal valve 119 ileostomy 764 ileo-vesical fistula 460, 467 IMCI see integrated management of childhood illnesses immersion syndrome see near-drowning/immersion syndrome immobility, of elderly patients 1088–1089 immune system 332–348 autoimmune diseases 335, 344–346, 345 burn injuries 993 classification of disorders 335–336 gammopathies 335, 346 HIV/Aids and 355 hypersensitivity 335, 341–344, 342 immune response failure theory 302–303 immunodeficiency 335–336, 346, 347, 707

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Index  1201

immunotherapy 344 importance of 333–334 nature of 334–336, 335 nursing assessment 337–339 nursing care plan 340–341 pathophysiology 336–337, 337 preoperative nursing 390 risk factors 336 immunosuppressive medication 707, 910 impaired cerebral circulation 891 impaired mental functioning care 1082–1084, 1082 impairment 1094, 1097 impetigo 961, 975 impotence (erectile dysfunction) 528, 545, 546, 548–550 improvisation during disasters 1163 incisional biopsy 305 incisions 278, 286, 485 incompetent cardiac valve 624 incomplete proteins 64, 68 incontinence 98, 108, 110–112, 1090–1091 indemnity insurance cover 210 Indiana reservoir 468 indigestion see heartburn individualistic cultures 26 INDS see Integrated National Disability Strategy induced abortion 505 industrial fumes 555 inequality see equality infant formula 148, 357 infantile paralysis see poliomyelitis infants see children infections central nervous system 902–904 chemotherapy 322 definition of 278 diabetes mellitus (DM) 857 external ear 1014–1015 female reproductive system 490 HIV/Aids 361 mastectomy 524 mechanical ventilation 573–574 musculoskeletal system 946–949 postoperative nursing 421 preoperative nursing 392 safety in nursing practice 43–45 wounds 292 infertility 510, 513 inflammation acute gastritis 751 definition of 278 eye conditions 1046–1052 inflammatory bowel disease (IBD) 773–776 joint disorders 947–949, 947 of optic nerve 1050 response to injury 281–283 of retina 1050 of uveal tract 1050

JCTMSN_BOOK.indb 1201

of vitreous 1050 influenza 555, 1003 informed consent 353, 386, 393–395, 395, 396, 404, 1113 ingestion, definition of 713 ingrowing toenail 934 INH see isoniazid inhalation injuries 989 inhalers 602, 603 Initial Pain Assessment tool 246 injuries see multiple trauma and emergency care inner ear 1009, 1014, 1019–1020, 1023 inotropic agents 622 insomnia 132 Institute for Security Studies 275 insulin 781, 844, 851, 852, 858, 858 insurance 210 integrated care pathways (ICPs) 225 integrated management of childhood illnesses (IMCI) 1114 Integrated National Disability Strategy (INDS) 1095 integrative healthcare 23–24, 34 integumentary system 955–972, 973–985 acne 984 anatomy and physiology of 958, 959 appendages of skin 958–959 bacterial skin disorders 974–976, 975 classification of disorders 960, 961–962 common skin problems 966, 968, 969–970, 970 dermatitis (eczema) 981–982, 982, 983 functions of skin 959–960 fungal infections 976, 978 loss of skin integrity 960 malignant skin tumours 979–980 nursing assessment 960, 962, 963–964, 964–966, 967 nursing care plan 971–972 nursing diagnoses 970, 972 occupational impact of disorders 974 older patients 985 parasitic skin infestations 976, 978–979 pemphigus 982–983 pruritus 985 psoriasis 980–983 risk factors 960 skin care 55, 966, 969–970, 970 social impact of disorders 974 viral infections 976, 977 intensive care units 1167 intercostal drainage (ICD) tube 269 intermenstrual bleeding 472 intermittent (bolus) feeding 90, 729 internal radiation (brachytherapy) 294, 314–315 internal respiration 553 International Association for the Study of Pain (IASP) 238, 1120 International Cancer Association 15 International Council of Nurses (ICN) 14, 15, 40, 207–208, 212 International Nurse’s Code of Ethics 210

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1202  Juta’s Complete Textbook of Medical Surgical Nursing

interstitial cystitis 460, 463 interstitial lung diseases see autoimmune diseases interstitial space 703 intestinal (bowel) obstruction 767–770, 767, 769–770 intestinal (ileal) conduit 467–468, 467 intracerebral haematoma 267 intracerebral haemorrhage 888, 891 intracorporeal lithotripsy 820 intracranial haematoma 267 intracranial pressure, raised 873–875, 873 intradural haematoma 267 intraoperative nursing 401–411 anaesthesia 406, 407 care of patients in theatre 405–406 care team 403–405 complications 408, 411 essential health information 411 handover 408 nursing care plan 409–410 recovery room care 406–408, 407 return to ward 408 theatre environment 402–403, 403 intraoperative period 401 intraoperative radiotherapy 815 intravenous pyelogram (IVP) 432, 441, 463, 841 intravenous therapy 172 intravitreal injections 1055 intrinsic factor 713 introitus 472, 494 intussusception 767, 767 invasive haemodynamic monitoring 617 iodides 836 ionising radiation 281 iridectomy 1033 iridodenesis 1033 iridodialysis 1033 iron 681, 692, 970 iron deficiency anaemia 681, 693–694 irritable bowel syndrome (IBS) 766–767 irritable colon see irritable bowel syndrome ischaemia 649 islet cell tumours 815 Islets of Langerhans 825, 827 isoniazid (INH) 584, 591 isotonic 146 isthmus 472, 498 itching see pruritus itch mite (scabies) 961, 976 IVP see intravenous pyelogram J Jacksonian seizure 862, 899 jaundice 780, 790–792, 792, 822 ‘jet lag’ 132, 135 joints 915, 917–918, 918 infection 946 movements 179, 180

JCTMSN_BOOK.indb 1202

replacement 926–927 Joint United Nations Programme on HIV and Aids (UNAids) 353, 354 justice 12 juxtaglomerular apparatus 428 K Kaposi’s sarcoma 739, 1057 Kegel exercises 112, 545, 546 keloids 278, 293, 421, 956, 968 keratin 956, 958 keratitis 1033, 1049 keratoconus 1033, 1045 kernicterus 901 Kernig’s sign 862, 897, 903 ketogenesis 844 ketones 844, 855 key populations 350 kidneys anatomy and physiology of 100–101, 100 chemotherapy 325 disorders 441–454 functions of 102 homeostasis 150, 151 King, Imogene 8–9 Koch pouch 468 Krukenberg’s tumour 760 krythoplakia 738 Kubler-Ross, Elizabeth 1142–1143 kyphosis 914 L Labour Relations Act 15 labyrinthitis 1003 lacerations 278, 286 lacrimal gland, absence of 1044 lactation 77, 516–517 lactulose 125 lagophthalmos limbus 1033 lansoprazole 759 laparoscopic cholecystectomy 820 laparoscopic radical prostatectomy 543 laparoscopy (peritoneoscopy) 482, 485, 791 large intestine (colon) 98, 118–119, 119, 714–715 laryngotracheobronchitis see croup larynx 1026–1029 laryngeal oedema 1029 laryngectomy 1003, 1027–1029 laryngitis 1003, 1026 laryngospasm 1029 lateral epicondylitis (tennis elbow) 953 laxatives 125, 126 LEEP see loop electrocautery excision procedure left ventricular aneurysm 655 left ventricular mural thrombus 655 legal issues 10–11, 210, 393–395, 395, 396, 399, 1100– 1101

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Index  1203

leg ulcers 669–670, 1089 leiomyomas see uterus, fibroids length see height of patients lesion 302, 472 leucorrhoea 472, 480 leukaemia 680, 697–698 leukocytes see white blood cells leukocytosis 680 leukopenia 680 leukoplakia 738 leukotomy 862 Lewy body disease 1084 lice see pediculosis lichenification 956 life expectancy 1066 ligaments 914, 915, 917, 919 lignocaine 1132 liniments 973 lipase 713 lipids 68–69 lipolysis 844 liposuction 709 lips 734–735 cancer 734–735 liquid ventilation 573 listening 358 lithotomy 472, 479 liver 789–809 abscess 805–806 biopsy 783 cancer of 806–808, 807 cardiovascular system 615 cirrhosis of 795–796, 795, 796, 797–798, 798–799, 800–803, 803–805, 804 failure 789, 805 functions of 789, 789, 790 hepatitis 792–795, 793, 794 HIV/Aids and 375 jaundice 790–792, 792 risk factors 790 transplantation 808–809 local anaesthesia 143, 407 logrolling of patients 188 loop electrocautery excision procedure (LEEP) 497 loperamide 767, 1140 Lopinavir/Ritonavir (LPV) 350 loratidine 575 lorazepam 999 lordosis 914 lotions 973 low back pain 950, 952–953 low-context cultures 27 lower gastrointestinal tract 764–778 anal abscesses 778 anal fissures 778 anal fistulae 778 anatomy and physiology of 765, 766

JCTMSN_BOOK.indb 1203

anorectal disorders 776–778, 777 appendicitis 770–772, 770, 771 bowel movement disorders 765–770 classification of disorders 765 diverticular disease 772–773 haemorrhoids 776–778, 777 inflammatory bowel disease (IBD) 773–776 inflammatory bowel disorders 770–776 intestinal (bowel) obstruction 767–770, 767, 769–770 irritable bowel syndrome (IBS) 766–767 lower respiratory tract conditions 578–580, 579, 580–581, 581–583, 584, 585–586 lower urinary tract disorders 460–470 cystitis 462–463 drug therapy 464 interstitial cystitis 463 management of bladder dysfunction 464–467, 465 neurogenic bladder 463 nursing assessment 462 pathophysiology 461–462 risk factors 461 surgical procedures 464, 465 urethritis 463–464 urinary diversion 467–469, 467 LPV see Lopinavir/Ritonavir lumbar puncture 872–873 lumbar sympathectomy 665 lumpectomy 515 Lund and Browder chart 990 luteinising hormone-releasing hormone 545 lymphatic system 703–711 classification of disorders 706–707, 706 Hodgkin’s disease 710 lymphadenitis 708 lymphangiectasia (lymphangioma) 709–710 lymphangitis 708 lymphoedema 708–709, 709 lymphoma 710, 1052 lymphomatous carcinoma 839 lymphoscintigraphy 708 Non-Hodgkin’s disease 710 nursing assessment 707–708 pathophysiology 707 risk factors 707 structure and functions of 704–706, 704, 705 lymphoedema 703, 708–709, 709 lyogenesis 844 M macronutrients 64, 66–69 macrovascular complications of diabetes mellitus 856 macula 956 magico-religious paradigm 23 magistrate, consent given by 394 magnesium 152, 152 magnesium oxide 757

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1204  Juta’s Complete Textbook of Medical Surgical Nursing

magnetic resonance imaging (MRI) 305, 432, 483, 519, 724, 783, 872 malabsorption 725, 728–730 malaise 230 male reproductive system 528–550 anatomy and physiology of 530–531, 530 chemotherapy 325 classification of disorders 531, 531 erectile dysfunction (impotence) 546, 548–550 male urethra 531 nursing assessment 532–534 nursing care plan 535–537 penis 531, 532, 534, 537–538 prostate gland 531, 532, 533, 541–546, 547–548, 548–550 risk factors 532 scrotum 533, 538–541 sexually transmitted diseases (STDs) 550, 550–551 testes 530–531, 532, 533, 538–541 malignant, definition of 295 malignant conditions elderly patients 1081 malignant hypertension 676 malignant hyperthermia (MH) 201, 202 malignant skin tumours 979–980 nervous system 906–907 ocular conditions 1051 respiratory system 592–593 malnutrition 64, 79–80, 80, 82–83, 82 malnutrition-related diabetes mellitus 847 malodorous wounds 1135 mammography 519 mammoplasty (reconstructive breast surgery) 525–526 man-made disasters 1153 manometry 724 marginal ulcers 752 masks 45 Maslow’s hierarchy of needs 6, 29, 223 massage 24, 132, 253 mastalgia 515 mastectomy 523–525, 525 mastitis 521 mastoiditis 1003, 1018–1019 mastoid process 1018–1019 maturation 278 McGill Pain Questionnaire (MPQ) 246 MDR TB see multidrug-resistant tuberculosis meaningfulness (existentialism) 33, 222 mechanical dead space 553 mechanical ventilation 571–574, 573, 574 medical aid schemes 17 medically induced coma 862 medical post for disasters 1162 Medical Schemes Act 17 medical superintendent, consent given by 394 medical waste 38 medication

JCTMSN_BOOK.indb 1204

administration of 45–46 during disasters 1163 ‘five rights’ 38, 209, 249–250 medico-legal hazards 37, 396, 399 medulla 98, 100 medulla oblongata 866 medullary carcinoma 839 megacolon 98 megaloblastic anaemia see pernicious anaemia megalocornea 1033, 1044 meibomian cyst 1033 meibomian gland 1033 Meige disease 708 melaena 98, 255 melanin 956, 959 melanomas 1052 meleana 680 menarche 472, 474 Ménière’s disease 751, 1003, 1019–1020 meninges of the brain 867 meningitis 862, 888, 902–904, 905 meningocele 902 meningomyelocele 902 menometrorrhagia 472 menopause 491 menorrhagia 491 menstruation 474–475, 475, 486, 490–491 mercury thermometers 194, 195, 197–198 mesothelioma 593 metabolic acidosis 166–167 metabolic alkalosis 167–168 metabolic diseases of the bone 949–950 metabolism 64, 414 meta-ethics 1111 metaparadigm of nursing 6–9 metaplasia 278, 286, 295 metastasis 295, 304, 304, 472 metastasise 295 metastatic carcinomas 1052 metronidazole 1135 metrorrhagia 472, 491 MI see myocardial infarction microcornea 1033 micronutrients 64, 66, 69–72, 70–72, 73–75, 75, 76, 82–83 micro-organisms 439, 461 microphthalmos 1044 microsurgery 875 microtubule-targeting drugs (plant alkaloids) 319, 320, 321, 325 microvascular complications of diabetes mellitus 856–857 micturition 98, 102–104, 104, 105–107, 107–108, 137, 532 midazolam 999, 1133, 1136 midbrain 866 middle ear 1009, 1016–1019 midwifery 14–15, 207 milestones, definition of 1113

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Index  1205

mind–body interventions 24 minerals 72, 73–75, 76, 80, 290 miotics 1034 misoprostol 758 mitral valve prolapse 625 mittens (restraints) 48, 48 mixed feeding 64, 78 mobility and exercise needs 30, 175–189, 221 active exercise 179 activities of daily living (ADL) 177 bed rest 181, 181, 182 benefits of exercise 176 common clinical problems 182–187, 185, 186 diabetes mellitus (DM) 851 factors affecting mobility 177–178 female reproductive system 484 HIV/Aids 361, 373 joint movements 179, 180 limitations 178 moving patients 188–189 nursing assessment 178–179 passive exercise 179 people with disabilities 1106–1107 physiotherapists 189 relaxation 181 respiratory system 555–556 types of exercises 176, 177 wound healing 290 model, definition of 1 models of healthcare 3–4, 3, 20 modified Parkland formula 993–994 moist wound management 292 moniliasis see oral candidiasis monoclonal gammopathies 346 monometric formulas 729 monoplegia 862 Monroe-Kellie doctrine 873 morals 12 Moro reflex 1015 morphine 248, 250–252, 773, 999, 1133, 1140 mother-to-child transmission of HIV 356–358, 364–365, 367, 375, 376–378 motion sickness 1003 motor function control 867 Motsoaledi, Aaron 78 mouth 56, 60, 732, 733, 734–740, 741 moving patients 188–189 MPQ see McGill Pain Questionnaire MRI see magnetic resonance imaging MS see multiple sclerosis mucosal barrier fortifiers 758 mucositis 1124, 1141, 1142 mucus plug 553 multidrug-resistant tuberculosis (MDR TB) 585–586 multiple myeloma 698 multiple organ dysfunction syndrome 171 multiple sclerosis (MS) 908

JCTMSN_BOOK.indb 1205

multiple trauma and emergency care 255–276 abdominal trauma 271–272 cardiopulmonary resuscitation (CPR) 264–265, 264 classification of emergency conditions 258, 258 compartment syndrome 274 crush injuries to extremities 274 ear injuries 274–275 elderly patients 1076 emotional trauma 275–276 eye injuries 274 fractures 273 head trauma 266–267 nose injuries 275 nursing assessment 258–262, 264–265, 264 nursing care plan 262–263 overview of 257–258, 257 respiratory emergencies 264–266, 266 risk factors 258 sexual assault 275–276 spinal trauma 272, 272, 273 thoracic (chest) trauma 267–271, 270 triage 257 mummy restraints 48 muscle cells 280 musculoskeletal system 913–930, 931–954 anatomy and physiology of 915–918, 916, 917, 918 bed rest and 183–184, 186–187 classification of disorders 918 congenital musculoskeletal disorders 932–934 contusion 934–935 degenerative joint disorders 947–949 developmental musculoskeletal disorders 932–934 dislocations 935–936 emergency care 272 fractures 936–941, 936, 937, 940, 941, 942–944, 945–946 infections 946–949 inflammatory joint disorders 947–949, 947 metabolic diseases of the bone 949–950 modalities of care 921, 923–927, 930 muscular system 916–917, 917, 918 nursing assessment 919–921, 922–923, 924 nursing care plan 927–929 postoperative nursing 414, 418 renal failure 449 risk factors 918–919 sprains 935 strains 935 subluxations 935–936 trauma 934–946 tumours 950, 951 work-related disorders 950, 952–953, 953 myasthenia 862 myasthenia gravis 343, 909–910 mycosis fungoides 973 mydriatics 1034 myeloma 346, 698, 951

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1206  Juta’s Complete Textbook of Medical Surgical Nursing

myelosuppression 295, 324 myocardial infarction (MI) 649, 650, 653–656 myocardial ischaemia 676 myocarditis 625, 637–638 myofascial pain of the neck 953 myomas see uterus, fibroids myomectomy 485, 501 myopathy 862 myopia 1034, 1061, 1061 myringotomy (tympanotomy) 1003 myxoedema (adult hypothyroidism) 824, 839 N naevi 1052 nails 55–56, 958–959 names of patients 49–51 NANDA see North American Nursing Diagnosis Association nappies, changing of 62 narcolepsy 132 narcotic antagonists 575 nasal atresia 1023 nasal care 60 nasal septum deviation 1003 nasogastric tubes 64, 728 nasointestinal tubes 728 National Health Act 10, 17, 21, 50, 393, 394 National Policy on Older Persons 1081 National School Nutrition Programme 91 natural disasters 1153 nausea and vomiting elderly patients 1089 end-of-life care 1139–1140, 1139 morphine 251–252 palliative care nursing 1139–1140, 1139 safety in nursing practice 93, 129 symptoms management 236–237, 237, 239–240 near-drowning/immersion syndrome 265–266 neck, myofascial pain of the 953 needle biopsy 305 neonates see children neoplasia 295 neoplasms classification of 297–298, 298–300 definition of 278 of salivary glands 740 see also tumours neoplastic cell biology 297, 298 neoplastic pericardial tamponade or effusion 328–329 nephrectomy 427, 454, 458–459 nephritis 441 nephroblastoma (Wilms’ tumour) 459 nephrolithotomy 458 nephrons 100–101, 101, 427 nephrostomy 454 nephrotic syndrome 444, 446 nerve cells 280 nervous system 860–886, 887–912

JCTMSN_BOOK.indb 1206

anatomy and physiology of 864, 865 autonomic nervous system (ANS) 868–869 brain 866–867, 866 central nervous system 890–909 cerebrovascular disease 890, 894–897, 895 classification of disorders 890 concussion 894 congenital conditions 900–902 convulsive conditions 898–900 cranial nerves 868, 868 degenerative conditions 907–909 haemorrhage 891, 894–897 higher cognitive functions 868 impaired cerebral circulation 891 infective conditions 902–904 interpretation of sensory information 867 malignant conditions 906–907 motor function control 867 neuroAids 904–906 neurons 864–865, 865 neurosurgery 875–876, 877–879 nursing assessment 869–871, 870, 871, 872–873, 889– 890, 891 nursing care plan 892–894 peripheral nervous system 909–912 pituitary surgery 876 postoperative nursing 414 raised intracranial pressure 873–875, 873 reflex activity 868, 869 risk factors 869, 889 spinal cord disorders 909–911 spinal surgery 876, 879 subarachnoid haemorrhage 891, 897–898 unconscious patients 879–881, 880, 881–885 Neumann, Betty 3 neuralgia 862, 888, 911 neuritis 862 neuroAids 904–906 neurogenic bladder 463 neurogenic shock 169 neurons 864–865, 865 neuropathic pain 230 neuroprosthesis (bladder pacemaker) 464 neurosurgery 875–876, 877–879 neurosyphilis and HIV/Aids 905 neutropenia 680, 697 nevus 1051 NexTemp thermometer 195 NGOs see non-governmental organisations nicotine stomatitis 737 Nightingale, Florence 2, 5, 7, 23 NIMART see Nurse Initiated Management of Antiretroviral Therapy nipple discharge, bloody 520 nipple fissure 520 nitrates 653, 746 nitric oxide 573

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Index  1207

NMC see Nursing and Midwifery Council nocardia 591 nociception 230 nociceptors 241 nocturia 98, 110, 528 nodule 956, 968 non-alcoholic steatohepatitis 795 non-communicable diseases 64, 81 non-essential amino acids 64, 67–68 non-governmental organisations (NGOs) 17 see also community-based organisations Non-Hodgkin’s disease 710 non-judgemental attitude 358 non-maleficence 12 non-narcotic analgesics 248 non-normative ethics 11–12 non-pharmacological therapy for pain 252–253 non-rapid eye movement (NREM) sleep 133, 135–136, 136 non-specific metabolic cirrhosis 796 non-steroidal anti-inflammatory drugs (NSAIDs) 143, 248, 700, 717, 753, 999, 1134 non-verbal communication 358 normative ethics 11 normothermia 190, 191 North American Nursing Diagnosis Association (NANDA) 220, 220–222 Norton Scale 185, 186 nose see ear, nose and throat disorders nosebleed see epistaxis nosocomial infections 439–440 NREM sleep see non-rapid eye movement (NREM) sleep NSAIDs see non-steroidal anti-inflammatory drugs nucleus 280 numerical pain rating scale 244, 245 Nurse Initiated Management of Antiretroviral Therapy (NIMART) 354 Nurses’ Code of Service 14 Nurse’s Pledge of Service 210 nursing competencies of professional nurses 206–213 concepts in 1–17 meaning of 5–6, 207 metaparadigm of 6–9 professional status of 14–16 role of nurses 2–4, 10, 9, 207, 208 scope of practice 207–208 standards of care 208 teamwork 10 theories of 6–9 Nursing Act 10–11, 15, 207, 208 Nursing and Midwifery Council (NMC) 27 nursing process 214–228 definition of 215–216 important facts about 217 questions for 216–217 record-keeping 216, 226 step 1: assessment 217–219, 219

JCTMSN_BOOK.indb 1207

step 2: nursing diagnosis 219–220, 220–222, 223 step 3: planning 223–225, 225, 227 step 4: implementation 225–226 step 5: evaluation 226 theories and 9–908 nutritional disorders 725, 728–730 nutrition needs 30, 63–96, 221 assessment of nutritional status 84–86, 85, 86, 87 common problems 91, 91–95 cultural diversity 21 definition of nutrition 66 in disasters 1168 eye and vision disorders 1061 HIV/Aids 373 hygiene and 81 in lifecycles 76–80, 80 macronutrients 66–69 micronutrients 66, 69–72, 70–72, 73–75, 75, 76 nutritional care plans 86–88, 89, 90–91 recommended dietary allowance (RDA) 75 safety and 81 skin health 970 South African Food-Based Dietary Guidelines 75, 77 for specific conditions 80–83, 82 visual South African Food Guide 75, 76 Nutrition Therapeutic Programme 80, 91 nystagmus 862, 1034 nystatin 999 O OA see optic atrophy obesity 65, 79–80, 651 observation 218 obstruction of urinary tract 440, 456–459 obstructive intrahepatic jaundice 792 obstructive jaundice 791, 792 occupational impact see employment occupational therapists 1103 OCT see optical coherence tomography odynophagia 713, 731 oedema 615, 642 oesophageal diverticulum 746 oesophageal neoplasms/cancer 746–748 oesophageal ulcers 752 oesophageal varices 749, 798 oesophagectomy 747–748 oesophagitis 743–745, 1124 oesophagoenterostomy 731, 747 oesophagogastric hernias 748 oesophagogastrostomy 731, 747 oesophagus 714–715, 741–749, 742, 743, 748 oestrogen 302, 321, 474–475, 516, 545 Office on the Status of Disabled Persons (OSDP) 1095 oils 68–69 ointment, definition of 973 older patients see elderly patients oligomenorrhoea 472, 491

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1208  Juta’s Complete Textbook of Medical Surgical Nursing

oligometric formulas 729 oliguria 98, 110 omeprazole 759 onchocerciasis 1062 oncology nursing care 294–331 adjuvant therapy 317, 322 anatomy and physiology of cells 297 biotherapy (biologic response modifiers) 325 bone marrow transplantation (BMT) 325–326 chemotherapy 314, 318–319, 320, 321–325 classification of neoplasms 297–298, 298–300 definition of cancer 297 emergencies 328–330 gene therapy 326 grading of tumours 298, 300, 301 home and community care 326–328 nursing assessment 304–306 nursing care plan 307–311 pathophysiology of cancer 303–304, 304 photodynamic therapy 326 prevention and early detection of cancer 306, 311, 312 radiation therapy 313–315, 316–318, 319 risk factors for cancer 300–303 staging of tumours 298, 300, 301 surgical management of cancer 311–313 thermal therapy (hyperthermia) 326 oophorectomy 485 oophoritis 472, 502 open cardiac surgery 644 ophthalmia neonatorum 1034, 1048 ophthalmologists 1034, 1053 ophthalmoplegia 862 ophthalmoscopy 1034, 1040–1041 opiates 398 opioids 143, 242, 248–249, 250, 252, 1124, 1133, 1141 opisthotonus 862 opportunistic infections 350, 374–375, 587–590, 588, 589 optical coherence tomography (OCT) 1041 optic atrophy (OA) 1046 optic nerve hypoplasia 1044 optic neuritis 1051 oral candidiasis (moniliasis or thrush) 57, 737–738 oral health 56, 60, 79, 565 oral rehydration therapy (ORT) 76, 129, 148, 158, 714 orbital cellulitis 1046–1047 orchidectomy (surgical castration) 529, 544 orchidopexy 529, 538–539 orchitis 529, 540 Orem, Dorothea 7–8 organ, definition of 280 organ donation 21, 438–439 orientation 862, 1066 oropharynx 714 ORT see oral rehydration therapy orthopnoea 553 orthoptists 1034 orthotopic liver transplantation 780, 808

JCTMSN_BOOK.indb 1208

Ortolani’s sign 931, 933 OSDP see Office on the Status of Disabled Persons osmolality 146, 427, 829 osmolarity 146, 156 osmosis 146, 427, 452–453 osmotic diarrhoea 127 osmotic diuretics 171 osmotic pressure 146 ossicles 1003, 1009 ossification 914, 916 osteitis deformans (Paget’s disease) 949–950 osteoarthritis 947–948, 947 osteoblasts 914, 915, 937 osteoclasts 914, 915, 937 osteogenesis 914, 916 osteogenesis imperfecta 933 osteomalacia 949 osteomyelitis 946 osteoporosis 187, 914, 939, 949, 1086 otalgia 1003 otitis externa 1003, 1015 otitis media 1003, 1016–1017 otoacoustic emissions 1008 otorrhoea 1004 otosclerosis 1004, 1017–1018 oucher pain rating scale 245 ovaries 501–504, 825, 827 cancer 503–504 cycle 474 cysts 503 over-nutrition 65 overweight 65, 79–80, 81 ovulation 474 oxandrolone 999 oxygenation 553, 580 oxygen need 29–30, 220, 568, 569 oxygen saturation 553 P P24 test (antigen test) 362 PAD see peripheral artery disease paediatric urine sampling 108 Paget’s disease (osteitis deformans) 949–950 pain management acute pain 229, 242, 247 assessment of pain 244, 247 children in hospital 1120–1122 chronic pain 229, 243, 247, 249–250 comfort, rest and sleep needs 138–140, 141–143 definition of pain 230, 238, 241, 1113 diaries 246–247 elderly patients 1081–1082 end-of-life care 1141 essential health literacy 253 measurement of pain 244–247, 245, 246 modulation of pain 241–242, 242 non-pharmacological therapy for pain 252–253

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Index  1209

nursing care plan 240 nursing diagnoses 252 palliative care nursing 1141 physiology of pain 241 rating scales 244–247, 245, 246, 1121 threshold 230 tolerance 230 treatment of pain 247–253, 248, 249–250 types of pain 242–243 palliative care nursing 1124–1147 anorexia 1138, 1138 approach to 1126 attitudes to death and dying 1126 body functions 1137 communication 1127 constipation 1138–1139 dermatological symptoms 1134–1135, 1134 diarrhoea 1140, 1140 elderly patients 1081–1082 end-of-life care 1142–1147 fatigue/weakness 1137 guiding principles of 1126 history of 1126 mucositis 1141, 1142 nausea 1139–1140, 1139 neurological symptoms 1135–1137 nursing assessment 1127, 1131 nursing care plan 1128–1131 opioids 1141 pain 1141 physical appearance 1137 psychiatric symptoms 1135–1137 respiratory symptoms 1132–1134, 1132 sexuality 1137 vomiting 1139–1140, 1139 palsy 888 pancreas 715, 809–816, 809 pancreatic cysts 813–814 pancreatitis 821 pannus 931, 1034 pan retinal laser photocoagulation (PRP) 1055 pantoprazole sodium 759 PAOD (peripheral artery occlusive disease) see peripheral artery disease Papanicolaou see Pap smears papillary adenocarcinoma 839 papillitis 1034 papilloedema 862 papillomas 1051 Pap smears 305, 481–482, 497 papule 956, 968 paracentesis 445, 445, 780 paracetamol overdose 794 paradigms 18, 23 see also metaparadigm of nursing paradoxical sleep see rapid eye movement (REM) sleep paraesthesia 862, 914 paralysis 914

JCTMSN_BOOK.indb 1209

paralytic ileus 420, 424, 768 paraphimosis 529, 537–538 paraphrasing, for HIV counselling 358 paraplegia 862 parasitic skin infestations 976, 978–979 parasomnia 133 parasympathetic nervous system 869 parasympatholytics 464 parasympathomimetics 464 parathormone (PTH) 832 parathyroid gland 827, 832–834, 833, 834 parental participation 1117–1118, 1121 parenteral nutrition 65, 90 paresis 862 parity 472 Parkinson’s disease 768, 908, 1089 paronychia 956, 962 parotitis 739 paroxysmal nocturnal dyspnoea 235, 553, 641 pars plana vitrectomy (PPV) 1035, 1055 partial seizure 888, 899 passive exercise 175, 179 paste 973 patent ductus arteriosus (PDA) 629, 629, 630 pathogens 278 patient-controlled analgesia (PCA) 247–248 patient-driven incidents 43 patient management executives (PMEs) 403 Patients’ Rights Charter 13, 25, 210, 363, 387 PBP see protocol-based practice PCA see patient-controlled analgesia PCR see polymerase chain reaction PDA see patent ductus arteriosus pediculosis 961, 976, 978–979 PEEP see positive end-expiratory pressure pelvic floor muscle exercises 112, 545, 546 pelvic inflammatory disease (PID) 502–503 pelvic node dissection 544 pemphigus 982–983984 penetrating wounds 286 penicillin 442, 550, 575 penis 531, 532, 534, 537–538 cancer 538 definition of 529 pentacam (corneal topography) 1041 people with disabilities 1094–1112 body image 1100 care and management 1104–1107 dependence 1100 depression 1100, 1104, 1111 discharge from hospital 1108, 1111 essential health information 1100, 1111–1112 goal planning 1107–1108 going home 1108, 1111 grieving 1100 historical overview 1095–1097 legal protection 1100–1101

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1210  Juta’s Complete Textbook of Medical Surgical Nursing

medication 1111 nursing assessment 1098–1100 nursing care plan 1109–1110 rehabilitation 1097–1098, 1101–1107, 1102 rehabilitation team 1098, 1100, 1102–1105, 1102 PEP see post-exposure prophylaxis Peplau, Hildegard 29 pepsin 713, 716 pepsinogen 713 peptic ulcers 731, 752–760, 752, 754, 757–759 peptidase 713 peptide 713 peptone 713 perception need 31, 221 percussion 559, 564, 719 percutaneous lithotripsy 458 percutaneous transhepatic cholangiography (PTC) 791, 819 percutaneous transluminal angioplasty (PTA) 664 percutaneous transluminal coronary angioplasty (PTCA) 654 Performance Oriented Mobility Assessment (POMA) 178 pericardiocentesis 255, 270 pericarditis 625, 638, 656 perichondritis 1014–1015 perimeter 1034 perineal prostatectomy 543 perineorrhaphy 485 periodontitis 735 perioperative nursing care 386, 388 periosteum 914, 915 peripheral artery disease (PAD) 663–664, 663 peripheral artery occlusive disease (PAOD) see peripheral artery disease peripheral iridectomy (PI) 1054 peripheral nervous system 909–912 peripheral vascular disease (PVD) see peripheral artery disease peripheral vision 1034, 1036, 1040 peristalsis 98, 101 peritoneal dialysis 453–454, 453 peritoneoscopy (laparoscopy) 482, 485, 791 peritonitis 469, 762–763 peritonsillar abscess (Quinsy) 1031 pernicious anaemia 693 persistent hyperplastic primary vitreous humour 1044 personal development 210 pes cavus (clawfoot) 932, 934 pes planus (flat foot) 934 petechiae 680, 956 petit mal epilepsy 888, 899 pH, definition of 146 phacoemulsification (phaco) 1034, 1054 phaeocromocytoma 841–842 phagocytic cells 278 phagocytosis 278, 332 pharmacological agents see medication pharynx 1029–1030 pharyngitis 1004, 1029–1030

JCTMSN_BOOK.indb 1210

PHC see primary healthcare phenolphthalein 125 phenothiazines 398 phenytoin 899 phimosis 529, 534, 537 phlegm 230 phoroptor 1041 phosphate 152, 152 phosphate buffers 154 photochemotherapy 969 photodynamic therapy 326 photofrin 326 photophobia 862, 1034 photoreceptors 1034, 1036 phototherapy 969 physical examination of patients 218 physical needs 29–31, 33 physical restraints 47–49, 47, 48 physiological dead space 554 physiotherapists 189, 568–569, 1103 PI see peripheral iridectomy pica 65 PID see pelvic inflammatory disease pigmentation 956 pinch test 155, 155 pinguecula 1034, 1045 pitting oedema 155–156, 156 pituitary gland 827, 830–832, 830 surgery 876 tumours 831 plant alkaloids (microtubule-targeting drugs) 319, 320, 321, 325 plantar fasciitis 934 plantar reflex 870 plaque 649, 651–652, 652 plasma 682 plasmapheresis 659, 910 platelet count 686, 785 platelets (thrombocytes) 682 platypnoea 554 play therapy 1113, 1119–1120 plethora 680 plexopathy 1125 PMEs see patient management executives PML see progressive multifocal leukoencephalopathy pneumaturia 460 pneumonia 420, 576, 578–582, 579, 580–581, 587–588, 588, 590 Pneumocystis Jiroveci Pneumonia (PJP) (previously Pneumocystis Carinii pneumonia) 587, 588 pneumonitis 554 pneumothorax 269–270, 270, 645 poisoning 51–52 poisons 46–47 poliomyelitis 906 pollution 555, 597, 604 polycystic kidney disease 455–456

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Index  1211

polycythaemia vera 696 polydactylism 932, 934 polydipsia 845 polymenorrhoea 472, 491 polymerase chain reaction (PCR) 362 polymeric formulas 729 polyneuritis 863 polyphagia 845 polypharmacy 1066, 1074 polyradiculitis see Guillain-Barré syndrome polythaemia 680 polyurethane tubes 728 polyuria 98, 106, 110, 845, 846 POMA see Performance Oriented Mobility Assessment pons Varolii 866 poor appetite 92 portal hypertension 780, 790, 804–805, 804 positioning of patients 181–182, 181, 182, 1000–1001 positive end-expiratory pressure (PEEP) 572 positive feedback 358 positive Levine sign 649, 653 possessions of patients 49–50 posterior uveitis 1050 post-exposure prophylaxis (PEP) 350 postinfarction syndrome 655 postmenopausal bleeding 491 postnecrotic cirrhosis 796 postoperative nursing 412–425 common responses to surgery 413–415 complications 416, 419–421 discharge of patients 419–421 essential health information 419 nursing care plan 422–424 nursing management 415–419 preparation of environment 415–416 receiving patients from theatre 415 post prandial 845 postural drainage 564–565, 564 potassium 151, 152 potassium excess (hyperkalaemia) 146, 161–162, 165 renal system 428 potassium sparing agents 643, 674 PPV see pars plana vitrectomy PQRST method of assessing pain 243 pre-exposure prophylaxis (PrEP) 350 pregnancy 77–78, 322, 375, 490, 684 pregnancy-induced hypertension 78 premature atrial contractions (atrial ectopic beats) 633, 633 premedication 386, 392, 394, 396, 398, 875–876 premenstrual tension 490 preoperative nursing 386–400 checklist routine 399 classification of surgery 388, 389 ethical issues 393–395, 395 gynaecological conditions 484 importance of 388 indications for surgery 388

JCTMSN_BOOK.indb 1211

legal issues 393–395, 395, 396, 399 nursing assessment 391–392 phases of surgical experience 388 pitfalls 399 preoperative care 389–393 principles of care 395–400 risk factors 390–391 suffixes for surgical procedures 388 PrEP see pre-exposure prophylaxis preparedness 1149 pre-prandial 845 prepuce (foreskin) 529, 531, 534, 537–538 presbycusis 1066, 1087 presbyopia 1034, 1062, 1066 presenting symptom, definition of 230 Presidency 1095 pressure controlled ventilation 572 pressure sores (bed sores) 176, 177, 182, 183, 185–186, 287–288, 962, 1089–1090 pressure support ventilation 572 prevac 756 preventive approach to pain management 247 preventive healthcare 16 priapism 529 primary aldosteronism (Conn’s syndrome) 841 primary aphthous stomatitis 737 primary biliary cirrhosis 790, 796 primary closed-angle glaucoma 1060 primary healthcare (PHC) 16–17, 207, 583 primary infection (HIV/Aids) 350, 355–356, 583 primary open-angle glaucoma 1059–1060 primary sclerosing cholangitis 789 priority setting 223 privacy 13 private sector healthcare system 17 PRN see pro re nata (PRN) administration of medication profession, definition of 1, 14 professional development 210 professional ethics 1111 professional indemnity 16 professionalism 14 professional status of nursing 14–16 progesterone 77, 474–475, 839 progestins 321 progressive multifocal leukoencephalopathy (PML) 905 prolapse definition of 472 mitral valve 625 rectal 99 uterine 498–499 Promotion of Equality and Prevention of Unfair Discrimination Act 1095 promotive healthcare 16 proprioception 175 proptosis 1034 propylthiouracil 836 pro re nata (PRN) administration of medication 247, 249

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1212  Juta’s Complete Textbook of Medical Surgical Nursing

prostaglandin analogues 756, 758 prostatectomy 529, 542–546, 547–548 prostate gland 529, 531, 532, 533, 541–546, 547–548, 548–550 prostate-specific antigen (PSA) 534, 544 prostatic cancer 543–546 prostatitis 460, 529, 541 protein buffers 153 proteins 66, 67–68, 290, 970 proteinuria 98, 107, 111 prothrombin time (PT) 686, 785 protocol-based practice (PBP) 206 proton pump inhibitors 759 proto-oncogenes 295, 303 provincial health authorities 16 PRP see pan retinal laser photocoagulation pruritus (itching) 332, 472, 985, 1125, 1134, 1134 PSA see prostate-specific antigen psoriasis 961, 980–983 psoriasis plaque 983 psychogenic pain 230 psychologists 1103 psychosocial needs 31–33, 33 bed rest and 184 burn injuries 993 disasters and 1169 oncology nursing care 327 pain management and 252 palliative care nursing 1135–1137, 1144 people with disabilities 1107 postoperative nursing 418–419 preoperative nursing 391, 396–397 psychological safety 31 psychosomatic pain 230 PT see prothrombin time PTA see percutaneous transluminal angioplasty PTC see percutaneous transhepatic cholangiography PTCA see percutaneous transluminal coronary angioplasty pterygium 1034, 1045, 1056 PTH see parathormone ptosis 1034 congenital 1044 public healthcare system 17 Public Services International 15 pulmonary artery 608, 610–611 pulmonary artery catheterisation 618 pulmonary complications of bed rest 183, 184 pulmonary contusion 268–269 pulmonary embolism 420–421, 656, 671–672 pulmonary function tests 563 pulmonary oedema 592, 643–644 pulmonary tuberculosis see tuberculosis pulmonary veins 608, 610–612 pulse 608, 613, 615–616 pulse oximetry 560, 563, 608, 619 pulsus paradoxus 554 puncture wounds 286

JCTMSN_BOOK.indb 1212

pupil sizes 880, 881 puppet shows 1119 purgatives 125–126 purpura 956 purulent (suppurative) exudate 282 pustular psoriasis 983 pustule 956, 968 PVD (peripheral vascular disease) see peripheral artery disease pyelolithotomy 458 pyelonephritis 446 pyelonephrolithotomy 458 pyelostomy 454 pyloroplasty 713 pyometra 472 pyrexia 190, 198–200, 204, 486 pyrosis 713, 755 pyuria 98, 107 Q QSEN see Quality Safety Education for Nurses quality improvement 211 Quality Safety Education for Nurses (QSEN) 40 questionnaires for pain measurement 246 Quinsy (peritonsillar abscess) 1031 R radiation, definition of 193 radiation burns 989 radiation therapy acute gastritis 751 comfort, rest and sleep needs 143–144 liver cancer 807 oncology nursing care 305, 313–315, 316–318, 319 prostatic cancer 544–545 radioactive iodine (RAI) 836 radioallergosorbent test (RAST) 339 radiographic techniques 560–561 radioisotopic techniques 562 radiologic studies 482–483, 720 radiotherapy 295, 322 RAI see radioactive iodine raised intracranial pressure 873–875, 873 range of movement, definition of 175 ranitidine 757, 999 rape 255, 275–276 rapid eye movement (REM) sleep 133, 135–136, 136 rapid HIV tests 362 RAST see radioallergosorbent test Raynaud’s phenomenon 663, 664–665 RBCs see red blood cells RDA see recommended dietary allowance Reach-to-Recovery organisation 328 receptors 824, 826 recommended dietary allowance (RDA) 75 Reconstruction and Development Programme 1095 reconstructive breast surgery (mammoplasty) 525–526

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Index  1213

record-keeping 171–172, 210, 216, 226, 258 recovery room care 401, 406–408, 407 rectal catheter 128–129, 128 rectal prolapse 99 rectal thermometers 194, 195 rectocele 472, 494 rectum 118–119, 714–715 red blood cells (RBCs) (erythrocytes) 428–429, 682, 685, 691 reduction mammoplasty 526 reflective practice 212 reflex activity 868, 869, 888 reflux 731, 743, 750 refractive errors (vision disorder) 1061–1062, 1061 refractory cardiac failure 644 refusal of treatment 50 regeneration, definition of 278 regional anaesthesia 407 regional enteritis (Crohn’s disease) 773, 774–775, 778 Regulation R786 207 rehabilitation burn injuries 999 definition of 1094 of elderly patients 1078 oncology nursing care 327–328 of people with disabilities 1097–1098, 1101–1107, 1102 rehabilitative healthcare 16 team 1098, 1100, 1102–1105, 1102 of visually impaired 1064 rehydration solution see oral rehydration therapy relapsing symptoms 230 relatedness need 32, 222 relaxation 142–143, 181 religion 33, 35, 55, 88, 222, 252, 360 remitting symptoms 230 REM sleep see rapid eye movement (REM) sleep renal system 426–437 acid–base balance 154 anatomy and physiology of 100–102, 100, 101 bed rest and 184, 187 burn injuries 992–993 cardiac surgery 645 chemotherapy 322 classification of disorders 429, 430 common presentations 434 congestive cardiac failure (CCF) 642 diabetes mellitus (DM) 857 functions of gastrointestinal system 428–429 hypertension 676 nursing assessment 430–434 nursing care plan 435–436 renal failure 446–450, 447, 451–452, 452 renal stones (urolithiasis) 456–458 renal transplant 450 renal trauma 455 risk factors 429–430 see also urinary elimination

JCTMSN_BOOK.indb 1213

renin 428 rennin 716 repair of retinal detachment (scleral buckling) 1055 reproductive system see female reproductive system; male reproductive system research 210 resection (recession) of extraocular muscles 1054 residual urine 98, 113 residual volume (RV) 554 resource utilisation 209 respect for patients 407 respiratory system 552–574, 576–595 acute respiratory failure 567–568 anatomy and physiology of 556–557, 556 artificial airway 571, 572, 574 autoimmune conditions 591–592 bronchitis 578 burn injuries 992 cardiogenic conditions 592 cardiovascular system and 616 chronic renal failure 449 classification of disorders 557, 577, 577 common respiratory problems 563–568, 564 congenital conditions 593 congestive cardiac failure (CCF) 640–641 cough 563–565, 564 cyanosis 567 drug therapy 574, 575 dyspnoea 566 emergencies 264–266, 266 end-of-life care 1132–1134, 1132 exercise and 555–556 extreme drug-resistant tuberculosis (XDR-TB) 585 haemoptysis 566–567 HIV/Aids and 576, 587–591, 588, 589 homeostasis 154, 156, 166, 167 humidification 569, 571 lower respiratory tract conditions 578–580, 579, 580– 581, 581–583, 584, 585–586 malignant conditions 592–593 mechanical ventilation 571–574, 573, 574 morphine 251 multidrug-resistant tuberculosis (MDR TB) 585–586 nursing assessment 557–560, 560–563, 563 nursing care plan 569–571 oxygen therapy 568, 569 palliative care nursing 1132–1134, 1132 physiotherapy 568–569 pneumonia 578–582, 579, 580–581, 587–588, 588, 590 postoperative nursing 413–414 risk factors 557, 577 sputum 565–566 thoracic surgery 594, 594 treatment 568–569, 571–574, 572, 573, 574, 575 tuberculosis (TB) 555, 576, 582–583, 584, 585, 590–591 see also ear, nose and throat disorders rest see comfort, rest and sleep needs

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1214  Juta’s Complete Textbook of Medical Surgical Nursing

restatement, for HIV counselling 358 restraining sheet 47, 48 restraints 37, 47–49, 47, 48 resuscitation 255, 257 see also cardiopulmonary resuscitation reticulocyte count 685 retina 1036–1037 retinitis pigmentosa 1034, 1046 retinopathy 1056 retinopathy of prematurity (ROP) 1056–1057 retinoscopy 1041 retractile testes 538 retropubic prostatectomy 543 Revised Trauma Score (RTS) 257, 257 rhesus (Rh) factor 683 rheumatic heart disease 635–636 rheumatoid arthritis 948, 947, 1086 Rh factor see rhesus (Rh) factor rhinitis 1004, 1023–1024 rhinorrhoea 1004 rhinoscopy 1004, 1024 rhizotomy 863 ribonucleic acid (RNA) 280 rights of patients 353, 1143 see also Patients’ Rights Charter rigors 190, 200–201, 204 risks 43–49, 1149 river blindness see onchocerciasis RNA see ribonucleic acid Road to Health booklet 84–85 road traffic accidents 258 Rogers, Martha 3 Romberg’s test 1008 ROP see retinopathy of prematurity Roper, Nancy 29 rotator cuff tendonitis 953 RTS see Revised Trauma Score rubella (German measles) 961 rubeosis iridis 1034 ‘rule of nines’ 987, 990 rupture of intracardiac structures 655 rupture of wounds 421 RV see residual volume rythmicity 608 S safe sex 22, 350, 360, 384, 484–485 safety in nursing practice 37–52 accidents 42 administration of medicines 45–46 as core competence 209 in disasters 1163 evidence-based practice (EBP) 41 falls 47 first aid 51 identification of patients 50–51 importance of 38 infections 43–45

JCTMSN_BOOK.indb 1214

international standards of 40–41, 40 medical waste 38 names of patients 49–51 national standards of 38–40, 39 nutrition needs and 81 people with disabilities 1105 poisons 46–47 possessions of patients 49–50 radiation therapy 315, 319 refusal of treatment 50 restraints 47–49, 47, 48 risk identification and management 43–49 violence 38 safety need 31, 221 saliva 716 salivary glands 739–740 salpingectomy 485 salpingogram 482–483 salt 76 SANC see South African Nursing Council sangoma see traditional health practitioners SA node see sinoatrial (SA) node sarcoidosis 592 Saunders, Cicely 1126 scabies (itch mite) 961, 976 scabs (crust) 955 scalds 51 scales (integumentary system) 956, 968 scalp abscess 267 injuries 267 scarring 284, 289, 293, 956 Schilling test 686 schooling see education sciatica 863, 912 sclera 1036 scleral buckling (repair of retinal detachment) 1055 sclerotherapy 777, 804 scoliosis 914 scope of practice 206, 207–208 scrotum 533, 538–541 scrub nurses 401, 404 sebaceous glands 959 secondary adrenal insufficiency 840 secondary aldosteronism 841 secondary haemorrhage 421 second-generation sulphonylureas 853 secretory diarrhoea 127 security need 31 sedatives 133, 137, 999 selegilin 908 self-awareness 358 self-care deficit theory 7–8 self-concept need 32 self-confidence 32 self-esteem need 32 sensation need 31, 221

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Index  1215

sensorineural hearing loss 1004, 1020 sentinel infections 350 septal defects (holes in septum of heart) 628 septic emboli 637, 637 septic shock 169 sequestrum 932, 946 sero-discordant couples 350 serological tests 305 serous exudate 282 sertraline 999 serum, definition of 680 serum bilirubin 784 serum protein electrophoresis 785 sexual assault 275–276 sexuality 22, 31, 222, 484–485, 1137 sexually transmitted diseases (STDs) 550, 550–551 SG see specific gravity shaving of patient’s face 58 shingles (herpes zoster) 961, 977 shivering 411 shock 147, 168–171, 168, 169, 170, 419–420, 608, 986 short bowel syndrome 728 shoulder bursitis 953 SIADH see syndrome of inappropriate antidiuretic hormone secretion sialolithiasis see calculi sibling participation 1118 sick certificates 419 sickle cell anaemia 695 sickle cell crisis 695–696 sickling test 686 sight see eye and vision disorders sigmoid (ureterosigmoidostomy) conduit 467, 468 sigmoid colon 118–119 significant other relationships 32, 1143–1146 signs 231 silastic urinary catheters 116 sildenafil 549 silicone tubes 728 sinoatrial (SA) node 612, 630 sinus bradycardia 633, 633 sinusitis 1004, 1024–1025 sinus tachycardia 632, 632 skeletal system see bone skin common problems 966, 969–970, 970 incontinent patients 111–112 people with disabilities 1105 preoperative nursing 392, 396, 399 safety in nursing practice 55 skin (surface) thermometers 194, 195 skin grafting see grafting skin integrity need 30, 221 skull fractures 267 SLE see systemic lupus erythematosis sleep disorders 140–141

JCTMSN_BOOK.indb 1215

functions of 134–138, 134, 136 preoperative nursing 396 sliding hernias 748 slitlamp 1034, 1040 slough 278 small intestines 714–715, 716, 764 smoke and inhalation injuries 989 smoking blood vessels 659, 662 bronchopulmonary cancers 301 cancer of lungs and bronchi 592, 593 cardiac disorders 627 chronic obstructive pulmonary disorders 597, 604 coronary artery disease (CAD) 651 during pregnancy 77 respiratory system disorders 555, 558 Snellen chart 1039–1040, 1040 snoring 133, 138 social workers 1103 socioeconomic factors 4–5, 55, 252, 988, 1107 sodium 76, 151, 152 sodium excess (hypernatraemia) 160 soft tissue infection 946 soft tissue injuries see contusion solutes, definition of 147 solvent, definition of 147 somnambulism 133 sordes 53, 60 South African Food-Based Dietary Guidelines 75, 77, 82 South African Food Guide 75, 76, 82 South African Nursing Association 14 South African Nursing Council (SANC) 5, 11, 38, 207, 210, 226 space model of disasters 1151–1152 spacers 602, 603 spasm, definition of 888 spastic, definition of 914 spastic bowel see irritable bowel syndrome spastic colon see irritable bowel syndrome spasticity 863 specific gravity (SG) 99, 156 specific immunity 334 speech and language therapists 1103 spermatocele 529, 539 sphincter 99, 102–103 spina bifida 901–902 spinal anaesthesia 407 spinal cord 241, 867 compression 330, 909 disorders 909–911 spinal surgery 876, 879 spinal trauma 262, 272, 272, 273 spiritual needs 33–36, 33, 35, 252, 391 spirometry 554 spleen 705 splenic flexure 119 splints 925

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1216  Juta’s Complete Textbook of Medical Surgical Nursing

spontaneous abortion 505 sprains 914, 935 sputum 233, 234, 560, 562, 565–566 sputum retention 554 squamous cell carcinoma 733, 979 squint 1034, 1057, 1057 stakeholder engagement 383 standards of care 206, 208, 209–212, 387 standards of patient safety international 40–41, 40 national 38–40, 39 staphyloma of the sclera 1034, 1045 starches see carbohydrates ‘startle reflex’ 1015 status asthmaticus 597, 602–603 STDs see sexually transmitted diseases steatorrhoea 725, 780 stenosed cardiac valve 625 stenosis 743, 743, 767 stereotactic surgery 863, 875 sterilisation 395 Sterilization Act 395 steroids 171, 575, 824, 839, 910 stigma 384 stimulation need 32, 222 stomach anatomy and physiology of 714–715, 716 definition of 732 disorders of 749–760, 749, 751, 752, 754, 757–759, 760–763 stoma ischaemia 469 stomas 467–469, 467 stomatitis 325, 732–737 stools see faecal analysis strabismus see squint strains 914, 935 stress 302, 336, 413, 651, 717, 751, 766 stress ulcers 645–646, 752 stretch marks see striae striae (stretch marks) 956, 965 stridor 559, 582, 1004 stroke 1085, 1091 stroke volume 608, 612 stunting 65 stupor 863 St Vitus’ dance (Sydenham’s chorea) 635 subarachnoid haematoma 267 subarachnoid haemorrhage 888, 891, 897–898 subdural haematoma 267, 888, 891, 894 subluxated lens 1035 subluxations 935–936 subphrenic, definition of 1125 subtotal gastrectomy see antrectomy sucralfate 758 suffixes for surgical procedures 388 sugar 67 sugar–salt solution see oral rehydration therapy

JCTMSN_BOOK.indb 1216

sulphonamide allergy 1060 sunburn 989 superficial gastritis 751 superior vena cava (SVC) syndrome 329 support groups 360, 384, 545 suppuration 278 suppurative (purulent) exudate 282 suprapubic catheterisation 116–117, 117 suprapubic prostatectomy 543 surface (skin) thermometers 194, 195 surgical cholecystostomy 820 surgical management of cancer 311–313 surgical staples and clips 291 suspensions 973 sutures 291 SVC syndrome see superior vena cava (SVC) syndrome swallowing 741 Swan-Ganz catheter 618 sweat glands 959 Sydenham’s chorea (St Vitus’ dance) 635 sympathectomy 664 sympathetic dependent pain 230 sympathetic nervous system 869 sympathicolytic agents 675 sympathicolytics 622 sympathomimetics 171 symptoms management 229–254 convulsions 237–238, 240 cough 231–233, 233, 238 cyanosis 233–234, 238–239 definition of symptoms 231 diarrhoea 239 dyspnoea 234–235, 235, 239 fatigue 235–236, 239 general symptoms management 231–238, 238–240 nausea and vomiting 236–237, 237, 239–240 nursing care plan 238–240 pain management 238, 240 sputum 233, 234 see also pain management synapse 863, 864–865 syncope 824, 863 syndactylism 932, 934 syndrome of inappropriate antidiuretic hormone secretion (SIADH) 330, 832 synechiae 1035 synovial membrane 914, 915, 917 synthetic laxatives 125 synthetic vasopressin 700 syphilis 550 systemic bacterial infections 1061 systemic diseases 1061 systemic lupus erythematosis (SLE) 591–592 systemic viral infections 1061 systems theory 6, 8 systole 608, 610 systolic blood pressure 608

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Index  1217

T T&T see test and treat tachycardia 486, 608 tagged red blood cell scan 783 talons 53, 56 Tanner staging 516, 517 TB see tuberculosis T-cells see T-lymphocytes TDF see tenofovir disoproxil fumarate teams 10, 211, 403–405 teeth 56, 735–736 telephonic consent 394, 395 temperature regulation needs 30, 190–205, 221 burn injuries 993 common clinical problems 198–203, 202 elderly patients 1088 essential health information 203–205 measuring body temperature 194–198, 195, 196, 197– 198, 199, 200 mechanisms of heat production and loss 191–193 normal variations 193 nursing care plan 204 overview of temperature regulation 191 tendinitis 947 tendons 914, 915 tenesmus 99 tennis elbow (lateral epicondylitis) 953 tenofovir disoproxil fumarate (TDF) 350 terminal care 1081–1082 test and treat (T&T) 350 testes cancer 529, 540–541 definition of 529 disorders 530–531, 532, 533, 538–541 gonads 825, 827 torsion 529, 539 testosterone 544, 545 tetanus 888 tetany (carpo-pedal spasm) 164, 164, 834, 834 tetracycline 984 Tetralogy of Fallot 629, 630 TGUGT see ‘timed get up and go’ test theatre reception nurses 404 theatres (in hospitals) 402–403, 403, 1167 thelarche 515, 516 theories of nursing 6–908, 20 therapeutic environment 211 therapeutic procedure incidents 43 thermal burns 988 thermal therapy (hyperthermia) 326 thermometers 194–195, 195, 196–198, 198 thermoregulation see temperature regulation needs thiazolidinediones 853 thoracic (chest) trauma 267–271, 270 thoracic aortic aneurysm 666–668 thoracic surgery 594, 594 thoracocentesis 256, 269

JCTMSN_BOOK.indb 1217

thoracostomy 256 throat see ear, nose and throat disorders thromboangiitis obliterans see Buerger’s disease thrombocytes (platelets) 682 thrombocytopenia 680, 698–699 thrombolysis 659 thrombolytic agents 622, 669, 896 thrombophlebitis 175 thrombus 175 thrush see oral candidiasis thymectomy 910 thymus 705 thyroid gland disorders of 827, 835–839, 836, 837–838 elderly patients 1086 thyroid crisis/storm 824, 835 thyroidectomy 824, 836, 837–838 thyroxine 824, 839 TIAs see transient ischaemic attacks tics 914 tidal volume (TV) 554, 563 time-based model of disasters 1151 ‘timed get up and go’ test (TGUGT) 47 tinea 961, 974, 976, 978 tinnitus 1087 TIPS see transjugular intrahepatic portosystemic shunt tissues see cells and tissues, disorders associated with TLC see total lung capacity T-lymphocytes (T-cells) 345–346, 704, 705, 910 tone (tonus), definition of 914 tongue 737–738 tonic, definition of 888 tonicity of solutions 147 tonometry 1035, 1040 tonsillitis 1004, 1030–1031 tonsils 704, 705, 705, 1030–1031 tonus (tone) 914 tooth decay see dental caries torticollis 914 total lung capacity (TLC) 554 touching 26, 42 toxic hepatitis 794–795 toxic multinodular goitre 835 toxoplasma encephalitis 905 toxoplasmosis pulmonary infections 591 trabecular network 1035 trabeculectomy (trab) 1054 tracheal intubation 264, 265 tracheobronchial 554 tracheo-oesophageal fistulae 593, 743, 743 tracheostomy 1004, 1029 trachoma 1049 traction 926 trade unions 15–16 traditional health practitioners 18, 24–25, 34–36 Traditional Health Practitioners Act 24, 34 traditional medicines 125–126

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1218  Juta’s Complete Textbook of Medical Surgical Nursing

tranquillisers 390, 1089 transfection 304 transient ischaemic attacks (TIAs) 888, 891 transjugular intrahepatic portosystemic shunt (TIPS) 804 transplantation bone marrow 325–326 corneal 1054 liver 808–809 renal 450 transportation, during disasters 1162 transposition of great arteries 628, 629, 630 transrectal ultrasonography (TRUS/TUS) 544 transurethral prostatectomy 529 transurethral resection of the prostate (TURP) 542–543 trauma definition of 256 to external ear 1016 to eye 1053, 1053 musculoskeletal system 934–946 see also multiple trauma and emergency care trauma unit 256 tremors 914 trench mouth 735 Trendelenburg’s sign 933 triage systems 256, 257, 1149, 1157–1158, 1158, 1159, 1161–1162, 1168 trichiasis 1035 trichomoniasis 496 trigeminal neuralgia 911 trigger finger 953 Trousseau’s sign 164 TRUS see transrectal ultrasonography truthfulness 12–13 T-tube 821 tubal surgery 485 tuberculoma 905 tuberculosis (TB) 555, 582–583, 584, 585, 590–591 definition of 576 HIV/Aids and 374, 375 nutrition and 80–81 tuberculosis meningitis 905 tuberculous peritonitis 762 tumours brain 906–907 of conjunctiva 1051 of cornea 1052 definition of 293, 295 of eyelids 1051 female reproductive system 490 grading of 298, 300, 301 of lacrimal gland 1051 of lacrimal sac 1051 of lens 1052 musculoskeletal system 950, 951 of optic nerve 1052 of orbit 1051 of pancreatic islets 815

JCTMSN_BOOK.indb 1218

of retina 1052 of sclera 1052 staging of 298, 300, 301 tumour, nodes, metastasis (TNM) system 300 upper gastrointestinal tract 738–739 of uvea 1052 of vitreous 1052 see also neoplasms TURP see transurethral resection of the prostate TUS see transrectal ultrasonography TV see tidal volume Twycross, Robert 243 tympanic thermometers 194, 195 tympanometry 1008 tympanoplasty 1004, 1019 tympanotomy (myringotomy) 1003 Type I anaphylactic hypersensitivity 341–343 Type I diabetes mellitus see diabetes mellitus Type II diabetes mellitus see diabetes mellitus Type II hypersensitivity 343 Type III hypersensitivity 343 Type IV cell-mediated hypersensitivity 343–344 U ulceration 306, 752 ulcerative colitis 773, 775–776 ultrasonography 482, 519, 534, 723 ultrasound procedures 305, 432–433 UN see United Nations UNAIDS see Joint United Nations Programme on HIV and Aids unconscious patients 863, 879–881, 880, 881–885 UNCRPD see United Nations Convention on the Rights of Persons with Disabilities under-nutrition 65 underweight 65 undescended testes (cryptorchidism) 528, 538–539 UNICEF see United Nations International Children’s Fund United Nations Charter (1989) 1114 United Nations Convention on the Rights of Children 363 United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) 1095–1096, 1101 United Nations International Children’s Fund (UNICEF) 5, 1114 United Nations Standard Rules for the Equalization of Opportunities for Persons with Disabilities 1095 upper airway obstruction 554, 559, 1029 upper gastrointestinal tract disorders 731–764 cancer of the stomach 760–762, 761 classification of disorders 732 emergencies 763 gastritis 750–752, 751 gums 735 lips 734–735 mouth 732, 733, 734–740, 741 oesophagus 741–749, 742, 743, 748 peptic ulcers 752–760, 752, 754, 757–759

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Index  1219

peritonitis 762–763 salivary glands 739–740 stomach 749–760, 749, 751, 752, 754, 757–759, 760– 763 teeth 735–736 tongue 737–738 tumours 738–739 ulceration 752 upper respiratory system see ear, nose and throat disorders upper urinary tract disorders 438–459 cancer of the kidneys (adenocarcinoma) 459 dialysis 452–454, 453, 454 glomerulonephritis (GN) 441–444, 443 kidney disorders 441–454 nephritis 441 nephrotic syndrome 444, 446 nursing assessment 440–441 nursing care plan 451–452 obstruction of urinary tract 456–459 paracentesis 445, 445 pathophysiology 440 pyelonephritis 446 renal failure 446–450, 447, 451–452, 452 risk factors 439–440 signs and symptoms of 440 surgical conditions of the kidney 454–456, 454 ureteritis 452 uraemia 427 uraemic frost 427, 449 urea breath test 724 ureteritis 452 ureterolithotomy 458 ureterosigmoidostomy (sigmoid) conduit 467, 468 ureterovesical reflux 438, 439, 446 ureters 101, 457 urethra 102 urethral trauma 466 urethritis 463–464 urethrovesical reflux 460, 462 urinary bladder see bladder urinary diversion 467–469, 467 urinary elimination 97–118, 131 anatomy and physiology of renal system 100–102, 100, 101 catheterisation 114–118, 114, 117 common problems 108, 109–111, 111–113 micturition 102–104, 104, 105–107, 107–108 nursing care plan 118 urinary incontinence 108, 110–112 urinary retention 98, 113, 418 urinary sheath (condom) 112, 117, 1106 urinary tract infection (UTI) 457, 461, 1106 urine cardiovascular system 616 characteristics of normal 103–104, 105–107, 107–108 emergency care 261 homeostasis 156

JCTMSN_BOOK.indb 1219

postoperative nursing 414 renal system 431–432 urinometer 99 urolithiasis (renal stones) 456–458 urticaria 956, 961 utensils for eating and drinking, volume of 172 uterus 498–501, 500 cancer 501 cycle 474–475 deformities 498 fibroids 500–501, 500, 746 prolapse 498–499 UTI see urinary tract infection uvea 1035, 1036 uveitis 1035, 1050 V vagina 494–496, 494 absent 494 atresia 494 cancer 496 definition of 472 deformities of 494, 495 injuries 494–495, 494 septate 494 vaginal speculum 472, 480 vagotomy 713, 759 valproic acid 899 valvular heart disease 636 valvular incompetence 639 valvular stenosis 629, 639 varicocele 529, 539 varicose veins 670–671, 671 VAS see visual analogue scale vascular system bed rest and 183, 185 overview of 660, 660 vasculitis 672 vasectomy 529, 541 vaso-active drugs 171 vasoconstrictors (decongestants) 575 vasodilators 171, 622, 643, 665, 675 vasopressors 171 VC see vital capacity vector transmission 44 vegetable laxatives 125 vehicle transmission 44 veins conditions of 668–674, 671, 674–675, 676–677 definition of 608 lymph vessels vs 706 structure and function of 661, 661, 662 venipuncture 680, 685 venogram 618 venous return 613 venous stasis ulcers 669 venous ulcers 670

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1220  Juta’s Complete Textbook of Medical Surgical Nursing

ventilation 416–417, 554, 580 artificial 262 high frequency 572–573 liquid 573 mechanical 571–574, 573, 574 pressure controlled 572 pressure support 572 ventricular asystole 634–635, 635 ventricular dysrrythmias 634–635, 634, 635 ventricular ectopic beats 634, 634 ventricular fibrillation 634, 634 ventricular septal defect (VSD) 629, 630 ventricular tachycardia 634, 634 venules 661 veracity 12–13 verbal pain rating scales 244–245 vertigo 1004 see also dizziness in elderly patients vesicle 956, 968 vesicocutaneous fistula 460, 467 vesicotomy 467, 468 vesicovaginal fistula 461, 467 vibration 564 videos for children in hospital 1119 vinca alkaloids 320, 321 violence 38, 258 viral infections integumentary system 976, 977 lymphatic system 707 viral load 350 Virchow’s Triad 669 vision see eye and vision disorders visual acuity 1035, 1039–1040 visual analogue scale (VAS) 235, 244, 245 visual South African Food Guide 75, 76 vital capacity (VC) 554, 563 vital signs, monitoring of 196 vitamins 66, 69, 70–72 A 290, 970, 999 B-complex 290, 970 burn injuries 999 C 290, 970, 999 D 102, 429, 949, 960 E 999 HIV/Aids 80–81 K 290, 970 kidneys 102, 429 multivitamins 999 osteomalacia 949 skin 960, 970 wound healing 290 vitrectomy 1035, 1055 vitreous humour 1035, 1036, 1044, 1045 voluntary organisations 17 volvulus 767 vomiting see nausea and vomiting

JCTMSN_BOOK.indb 1220

VSD see ventricular septal defect vulva 491–494 cancer 493–494 developmental deformities 492 dystrophy 493 vulvectomy 485 vulvitis 492 vulvovaginalis candidiasis 495–496 W waist circumference measurements 84, 85, 673 warts 956, 977 waste, medical 38 wasting 65 water, for nutrition 72, 75, 148 WBCs see white blood cells weakness see fatigue weal 956, 968 weight, measurement of 84–86, 85, 86, 87 birth weight 64 cardiovascular system 616 renal system 431 wellness 2, 4–5 Western blot test 362 Whipple’s triad 852 white blood cells (WBCs) 339, 682, 685, 696–698, 785 White Paper on Integrated National Disability Strategy (INDS) 1095 WHO see World Health Organization wicking the ear 1015 Wilms’ tumour (nephroblastoma) 459 window period 351, 356 women, role of 22 work see employment World Health Organization (WHO) analgesic ladder 248, 248 burn injuries 988 cataract 1057–1059 children in hospital 1114 diabetes mellitus (DM) 847, 848 disasters 1150–1151 on health 2, 4 HIV/Aids 78, 212, 361–362, 374 impairment 1097 infant feeding guidelines 78, 357 nutrition for children 82 oral rehydration therapy (ORT) 129 palliative care 1125, 1126 traditional health practitioners 34 tuberculosis (TB) 582 wounds 284, 285, 286–293, 286, 288, 291, 293 burn injuries 994–995, 998 definition of 278 postoperative nursing 418, 421 wrist restraints 48, 48

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Index  1221

X xanthelasma 1035, 1051 XDR-TB see extreme drug-resistant tuberculosis (XDR-TB) xerosis 974, 1035 X-rays 720

Z zinc 970 Zollinger-Ellison syndrome 753, 815–816 zolpidem 999

Y Yag laser capsulotomy 1055

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JCTMSN_BOOK.indb 1222

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