CHAPTER 1  . is unknown, and healing generally occurs DISEASES AND DISORDERS OF THE  Stomach. spontaneously within 10 days to two weeks.  . Aphthous stomatitis is most common in young  (10 CONTACT HOURS)  . girls and female teenagers. Its cause is unknown,  . but stress, fatigue, anxiety and predispose Learning objectives:  . its development. Treatment is geared to symptom !! Review the of the gastrointestinal relief through the use of a topical anesthetic and The accessory glands and organs consist of the system. reduction of predisposing factors.5 salivary glands, , gallbladder and bile ducts !! Describe diseases of the oral cavity. and the pancreas.9 The major functions of the GI Miscellaneous !! Identify treatment of diseases of the oral system are digestion and elimination of waste  Candidiasis (thrush): Fungal cavity. products from the body.5,9 that causes cream or bluish-white patches !! Explain the types of disorders and diseases of exudates to appear on the tongue, mouth, affecting the esophagus. Diseases and disorders of the GI system can and/or pharynx. Persons at high risk include !! Evaluate treatment initiatives for disorders range from mild annoyances to life-threatening premature neonates, older adults, those and diseases affecting the esophagus. conditions. It is important that the nurse with suppressed immune systems, persons !! Identify pathophysiology of gastric diseases recognize the numerous abnormalities that can taking antibiotics, or persons taking steroids and disorders. occur, and how to most effectively intervene to for a long period of time. For infants, the !! Evaluate treatment initiatives for gastric help the patient return to a state of maximum oral mucosa is swabbed with nystatin after diseases and disorders. health and wellness. feedings because feedings wash away the !! Explain the pathophysiology of peptic ulcer Diseases of the oral cavity medication. The mother should also be disease. The oral cavity includes the gingival or gums, treated to avoid passing the infection back !! Describe treatment measures for peptic ulcer the buccal mucosa (the lining of the inside of the and forth. Older children and adults swish disease. mouth), the area under the tongue, the hard palate nystatin solutions around the mouth for a few !! Differentiate between ulcerative and (roof of the mouth), the area behind the wisdom minutes before swallowing it. Eating yogurt Crohn’s disease. teeth, and the front two-thirds of the tongue. 10 with active cultures may be helpful in treating !! Describe the pathophysiology of the infection.5,9 inflammatory bowel disease. There are a number of infections that affect  Gingivitis: of the gums. This !! Explain treatment initiatives for inflammatory the oral cavity. Their impact can range from condition can be an early warning sign bowel disease. annoying symptoms that are fairly easily resolved of , blood dyscrasias and lack of !! Discuss the of colorectal to major problems that can have long-ranging vitamins. Gingivitis is occasionally due cancer. effects. to the use of hormonal contraceptives. !! Discuss the signs and symptoms of anal Stomatitis More often, it is due to poor oral hygiene, cancer. Stomatitis is defined as an inflammation of the poorly fitting dentures or other irritants. !! Describe the effects of Celiac disease. oral mucosa that may spread to the , palate Signs include redness, painless swelling, !! Explain the pathophysiology of diverticular and buccal mucosa. It is a common infection and bleeding and evidence of gum detachment disease. generally classified as acute herpetic stomatitis or from teeth. Treatment includes elimination !! Differentiate among treatments for aphthous stomatitis.5 of triggering factors (e.g., improving the fit diverticular disease. of dentures), regular dental check-ups, and !! Define intussusception. Acute herpetic stomatitis is caused by infection good oral hygiene. Sometimes oral or topical !! Identify treatment initiatives for of the herpes simplex virus and is common in are recommended.5 intussusception. children aged 1 to 3 years. It is usually self-  Glossitis: Inflammation of the tongue. It !! Explain the pathophysiology of intestinal limiting but can be severe, and even fatal, in can be due to bacterial infection, irritation obstruction. neonates. Symptoms have an abrupt onset and or injury, or a lack of vitamin B. Spicy !! Evaluate treatment initiatives for intestinal include malaise, anorexia, irritability, mouth pain foods, smoking and alcohol intake may obstruction. and fever, which may last for one to two weeks. also promote its development. The tongue !! Identify the pathophysiology of inguinal The patient’s gums are swollen, bleed easily, and becomes red, ulcerated or swollen to the point . the mucous membrane is painful. Ulcers develop that the airway is obstructed. Swallowing is !! Discuss treatment for . in the mouth and throat that eventually acquire difficult and painful, as is chewing. Speech !! Explain the pathophysiology of rectal the appearance of “punched-out” lesions with red becomes impaired. Treatment focuses on prolapse. areolae. Pain usually ceases about two to four eliminating the underlying cause. Regular !! Describe treatment initiatives for days before the ulcers are completely healed. dental checkups are important, and good oral . Note that if a child with stomatitis sucks his hygiene should be encouraged.5 !! Describe the signs and symptoms of intestinal thumb, the lesions will spread to the hand.5  Periodontitis: Inflammation of the gums polyps. Treatment is focused on symptom relief. Salt- accompanied by recession and loosening of !! Explain the etiology of . water mouth rinses, topical antihistamines, the teeth. Often due to poor dental hygiene, it !! Describe the signs and symptoms of anorectal antacids or corticosteroids may be used to is sometimes related to the use of hormonal and . reduce discomfort. Bland or liquid diets may contraceptives and may also be an early Review of the anatomy of the be recommended to reduce the discomfort of sign of diabetes, blood dyscrasias or vitamin gastrointestinal system eating. In extreme cases, when the patient cannot insufficiency. Onset is abrupt. Signs include The gastrointestinal (GI) system consists of two ingest adequate amounts of food and/or liquids, bright red swollen gums and loosening of major parts: the GI tract, also referred to as the intravenous therapy may be indicated.5 the teeth. There may be evidence of systemic 9 alimentary canal, and the accessory organs. The Aphthous stomatitis causes burning, tingling infection, such as the presence of fever and alimentary canal is a long, hollow, muscular tube and minimal swelling of the mucous membrane. chills. Treatment includes initiating and 5,9 that starts in the mouth and ends at the anus. Single or multiple superficial ulcers with white maintaining good oral hygiene, participating 9 The alimentary canal includes the: centers and red borders appear, heal at one in regular dental check-ups, and, if necessary,   Oral cavity. site, but then form at other sites. The cause surgery to remove infected areas and prevent  Pharynx. recurrence.5

Elite Page 1  Vincent’s angina (trench mouth, ulcerative  Trouble moving the jaw or tongue. Lee is a 55-year-old gentleman who arrived in gingivitis): Painful, severe infection of the  Numbness in the mouth. the United States from Asia about 20 years ago. gums. It is caused by bacterial infection.  Loose teeth or dentures that become He is a heavy cigarette smoker and retains some Predisposing factors include stress, smoking, uncomfortable or start to fit poorly. of the dietary habits from his native land. His poor dietary habits and inadequate rest.  Change in the quality of the voice. wife tells him that his voice is “different” and Onset is abrupt. Signs include ulcers  Bleeding or pain of the mouth or . hoarse. Lee comments that he is having difficulty (covered by a grayish-white membrane)  Swelling of the jaw. swallowing. These symptoms began several on the gums, bleeding, fatigue, mild fever,  Feeling that something is caught in the throat. months ago and have become gradually, but , painful swallowing or talking, steadily worse. Lee decides to visit his doctor, Oral cancer is diagnosed in a variety of ways. enlarged lymph nodes. Treatment includes who suspects an esophageal disorder. A biopsy A thorough physical exam is the first step. antibiotic therapy, removal of infected tissue, of esophageal tissue confirms suspicions of a Suspicious areas are biopsied to determine analgesics, hydrogen peroxide and water malignancy. whether malignant cells are present. X-rays mouth rinses, rest and a soft diet.5 of the head, and chest may be taken. Esophageal carcinoma is more common in Cancer of the oral cavity Other diagnostic studies that may be helpful in men older than 50, and the risk increases with Cheri is a 45-year-old manager of an exclusive, diagnosing and staging of oral cancer include:10 age. Almost half of all people diagnosed with upscale women’s boutique. She attends many  Endoscopy. esophageal cancer are older than 70. This type social events related to business and drinks  MRI (magnetic resonance imaging). of cancer is about three and one-half times more about two to three glasses of wine per day. Cheri  CT scan (CAT scan). common in men than in women, and its incidence smokes about half a pack of cigarettes per day as  PET scan (positron emission tomography is highest in African-American men.4 Esophageal well. About a month ago, she noticed a painless scan). cancer is most common in Japan, China, the Middle East and parts of South Africa. In the white patch about 1 cm in diameter on the inside Prognosis depends on the location of the cancer, United States, the disease affects less than five in of her left . Since it wasn’t causing any the stage at diagnosis, and whether there is lymph 100,000 people.5 discomfort, Cheri dismissed it as “unimportant.” node or blood vessel involvement. 10 Treatment However, today she visited her dentist for her depends on the cancer stage and, depending on The major risk factors for the development of regular six-month check-up. He expressed the patient’s age, strength, and general health, esophageal are cigarette concern and recommended that she have her his ability to tolerate certain treatment initiatives. smoking and chronic heavy alcohol consumption. family doctor evaluate the white patch. A biopsy Treatment may consist of radiation therapy, In Asian countries, certain dietary habits, such as showed that Cheri has oral cancer. surgery, chemotherapy, or a combination of these chewing betel nuts and eating pickled vegetables, 4,5 Cheri’s story is not uncommon. Nearly 36,000 initiatives.13 are associated with its development. Americans are diagnosed with oral or pharyngeal Nursing alert! Persons who have had lip or Nursing alert! Recent research indicates that cancer every year. Of these 36,000 people, only a oral cavity cancer are at an increased risk of there may be a connection between certain types little more than half of them will still be alive in developing a second cancer in the head or neck. of human papilloma virus (HPV) and squamous five years. About 8,000 Americans die from oral Patients must have frequent, thorough follow- cell esophageal cancer. More research is needed 4 cancer every year. In fact, the death rate for oral up.10 to validate this indication. cancer is greater than that of cancers that receive Risk of the development of of much more publicity, such as cervical cancer, Disorders of the esophagus the esophagus is associated with obesity and Hodgkin’s lymphoma, skin cancer and thyroid The esophagus is a muscular tube about 10 to 13 gastroesophageal reflux disease (GERD). A cancer. Sadly, the high death rate is not because inches in length and about ¾-inch wide in adults. patient who suffers from GERD, uses tobacco oral cancer is difficult to diagnosis, but because it It connects the pharynx to the stomach and is and is obese is at even greater risk as a result of is so often identified in its later stages.13 composed of several layers. One layer is a thick this combination of factors.4 muscular band that contracts rhythmically to The risk factors for the development of oral propel food to the stomach. The lower esophageal Nursing alert! Chronic GERD can lead to cancer include:10,12,13 sphincter (LES), located at the bottom of the Barrett’s esophagus, a condition in which normal  Use of tobacco products.  esophagus, prevents the reflux of stomach squamous cells of the esophagus are replaced  Frequent alcohol ingestion. 4  contents back into the stomach. with glandular cells. Barrett’s esophagus puts a  Exposure to natural or artificial (e.g., tanning patient at high risk for adenocarcinoma of the beds) sunlight over long periods of time. Esophageal cancer esophagus.4  Infection with human papilloma virus (HPV). Esophageal cancer is an aggressive malignancy (Infection has been linked to some oral with a high mortality rate. Esophageal cancer Signs and symptoms of esophageal cancer are cancers.) is responsible for 1.5 percent to 2 percent of not particularly distinctive initially.  Low intake of fruits and vegetables. cancers diagnosed in the United States, and is the and weight loss are the most common early  Race: Oral cancer affects twice as many sixth leading cause of deaths caused by cancer symptoms. The dysphagia is mild and African-Americans as white Americans. throughout the world. Survival at five years is intermittent at first, but quickly becomes constant. Additional signs and symptoms include Historically, oral cancer occurred much more only about 16 percent. It is estimated that more than 16,000 new cases of esophageal cancer will chest pain, hoarseness, coughing and the feeling 4,5 frequently in men, affecting six men for every 4 that something is caught in the throat or chest. woman. Today, however, the ratio has decreased be diagnosed annually. to two men for every woman. It is believed that There are two main types of esophageal cancer: Unfortunately, there are no specific screening this is due to an increase in the number of women squamous cell carcinoma and adenocarcinoma. guidelines for esophageal cancer. Patients at who smoke.13 significantly high risk, such as persons who Squamous cell esophageal cancer is the more have Barrett’s esophagus, often have periodic Signs and symptoms of oral cancer include:10,12,13 common. However, there have been some recent examination via upper endoscopy.4  A sore in the mouth or on the lip that does changes in the incidence of the two main types Diagnosis is confirmed via endoscopic not heal. of esophageal cancer. At one time, squamous cell examination of the esophagus  A white or red patch in the mouth. carcinoma accounted for more than 90 percent of (esophagogastroduodenoscopy), punch and brush  A lump or thickening in the mouth or on the esophageal cancers. More recent statistics show biopsies of suspicious areas, and exfoliative lip. that the number of is increasing cytologic tests. Magnetic resonance imaging  Problems chewing or swallowing. drastically in the United States.4,5 (MRI) of the chest and thoracic region and

Page 2 Elite CT scans are used to help determine disease  Formation of esophageal strictures. Such United States. It is far less common in children, staging. Unfortunately, the majority of cases strictures can be a late radiation side effect. accounting for less than 5 percent of all upper GI are diagnosed at Stage III or Stage IV involving If there is tissue stenosis of the esophagus, bleeding episodes. Mallory-Weiss syndrome is tumors that invade the outermost layer of the the subsequent shrinkage makes it difficult two to four times more common in men than in esophagus and regional lymph node involvement. for the patient to swallow. Esophageal women.5,15 Sites of metastasis are most often the liver, lung, dilation may be necessary (on more than one Factors that predispose persons to this syndrome stomach, kidney, bone and brain.4,5 occasion) to maintain a patent esophagus. include:15 Treatment usually involves a combination of The effects of surgery, radiation, and  Ulcers. surgery and chemotherapy. Surgical removal of chemotherapy make patients particularly  Infectious . the affected areas of the esophagus and part of the susceptible to compromised nutritional status.  Pregnancy. stomach is usually indicated. Efforts are made to Patients must be closely monitored for nutritional  . maintain a passageway for food by connecting problems, including:4,5  . the upper part of the esophagus to the remaining  Food aspiration: Make sure that the patient  Gall bladder disease. part of the stomach, thus pulling the stomach up is in Fowler’s position for meals. He should  Renal disease. into the chest area. If this is not possible, it may be encouraged to eat slowly to reduce The onset of Mallory-Weiss syndrome usually be necessary for the patient to have a feeding the possibility of aspiration. Some food begins with blood or passing copious gastrostomy.4,5 regurgitation is likely, so his mouth should be amounts of blood through the rectum a few hours cleaned after each meal. After surgery, the patient will have chest tubes, to several days following forceful vomiting.  : A disorder that most a nasogastric (NG) tube, intravenous therapy, The bleeding may range in amounts from mild patients who have undergone surgery an indwelling urinary catheter and supplemental to massive. Excessive bleeding is more likely to experience to some extent. Dumping oxygen as needed. The NG tube will remain in occur when the esophageal tear is near the cardia syndrome occurs when undigested food place for about five to seven days after surgery. and may swiftly lead to death.5 rapidly leaves the stomach and moves into It is used for decompression to facilitate healing the small intestine. Dumping syndrome Treatment depends on the severity of blood of the anastomosis between the stomach and the causes , cramps, tachycardia and loss. Bleeding usually stops spontaneously and esophagus.4,5 light-headedness. It is believed that the simply requires supportive care and monitoring. Because esophageal surgery involves the cause of dumping syndrome is related to the However, severe blood loss or blood loss that is pericardium area, there is an increased risk for smaller size of the stomach after surgery and continuous may require:5,15 cardiac arrhythmias post-operatively. Cardiac diversion of the vagus nerve.  Blood transfusions. status must be meticulously monitored.4  Delayed gastric emptying: In contrast to  Administration of proton pump inhibitors or histamine-2 receptor antagonists. Chemotherapy may also be part of the dumping syndrome, sometimes food moves  Administration of vasoconstrictors to treatment regimen. Current research indicates too slowly through the GI tract after surgery. decrease blood flow in the esophagus. that chemotherapy in combination with Because the patient’s stomach is now in the  Application of esophageal clips at the site of radiation therapy improves outcomes, although chest area that already contains other organs, food may back up from this crowded space. active bleeding. chemotherapy may be used alone. Usual  chemotherapeutic agents are 5-fluorouracil or  Reflux of gastric contents: Patients who have Patients and families should be helped to identify cisplatin.4,5 had surgery for esophageal cancer have had predisposing factors and how to avoid them. the esophageal sphincter removed, making A careful health history should be taken with Radiation therapy in conjunction with reflux a fairly common problem. Patients careful analysis of dietary habits, medications chemotherapy may be used when surgery is should not eat close to bedtime. They should taken and alcohol intake. Patients should avoid not an option because of the patient’s refusal elevate the head of the bed or sleep on several aspirin products and alcohol.5 to undergo surgery or because the patient’s pillows. Medications that function as proton general health is so poor that he is not able to pump inhibitors (e.g. Nexium) may help to Esophageal diverticula tolerate surgery. Radiation may also be used control symptoms of reflux. Esophageal diverticula are out-pouchings or sacs as a palliative measure in advanced cases of of one or more layers of the esophagus. Although Patients and families need significant emotional esophageal cancer. There are a number of adverse they can occur in infants and children, they are support as well as assistance with the patient’s occurrences associated with external beam generally a problem later in life and are more physical needs. Prognosis is generally not good, radiation to the esophagus. Fatigue and skin common in men than in women.5 breakdown are among the most common. Other and, as the disease progresses, information Esophageal diverticula are the result of side effects from radiation may include: 4,5 about home health assistance or hospice may muscular abnormalities caused by congenital or  Potential damage to the heart, lungs and be needed. Organizations that may be of help inflammatory processes. There are three main spinal cord. include the American Cancer Society (www. types of esophageal diverticula.5  or inflammation of the cancer.org), 1-800-227-2345 and the Esophageal 1. Zenker’s diverticulum: Occurs near the esophagus. This can adversely affect Cancer Awareness Association (www.ecaware. upper esophageal sphincter and is the most swallowing, making it difficult for the patient org), 1-800-601-0613. common of the three types. to eat. He may need nutritional supplements Mallory-Weiss syndrome 2. Traction or mid-esophageal diverticulum: if he is not able to maintain adequate nutrient Mallory-Weiss syndrome is characterized by Occurs near the midpoint of the esophagus. intake. esophageal bleeding from a mucosal tear in the 3. Epiphrenic diverticulum: Occurs just above  Esophageal fistula formation. Tissue esophagus as the result of forceful vomiting the lower esophageal sphincter. breakdown from radiation may cause an or retching.5,15 Although such bleeding usually opening between the esophagus and areas occurs after multiple episodes of vomiting Zenker’s diverticulum produces throat irritation adjacent to it. GI contents leak out of the or retching, it can happen after only a single followed by dysphagia and nearly complete opening, which can cause serious infection or episode.15 obstruction. Food regurgitation is common and injury. For example, a fistula to the lung can may even lead to aspiration of food and resulting cause GI contents to move into the lung, and Mallory-Weiss syndrome is responsible for pulmonary infections. Treatment measures may be fatal. about 1 percent to 15 percent of all episodes of include a bland diet, teaching the patient to upper gastrointestinal bleeding in adults in the chew his food thoroughly and eat slowly, and to

Elite Page 3 drink water after eating to “flush out” the out- Pathophysiology/etiology  Upper GI series: Used to identify the pouchings or sacs.5 Under normal conditions, the LES sustains presence of a or motility problems.9 Nursing alert! Severe symptoms or a large enough pressure around the lower end of the Esophageal manometry is another diagnostic Zenker’s diverticulum may require surgery to esophagus to close it, thus preventing reflux of test useful in evaluating GERD. Also called remove the sac.5 gastric and/or duodenal contents. The sphincter relaxes after every swallow to permit food to esophageal motility, esophageal manometry A mid-esophageal diverticulum, which seldom pass into the stomach. In GERD, the sphincter measures the strength and function of the produces symptoms except for occasional does not remain closed. This is generally due esophagus as well as the musculature of the dysphagia and , requires intervention to inadequate LES pressure or if pressure in throat and esophagus. Its most common use is to only if there is risk of diverticulum rupture. the stomach propels gastric contents into the assess the LES in patients with GERD. The test Interventions include administration of antacids esophagus. Stomach contents are very acidic, takes about 45 minutes from beginning to end.14 and measures to prevent reflux such as sitting thus causing pain and irritation when they move The patient is NPR for six hours prior to the upright for two hours after eating, eating small into the esophagus. The esophageal mucosa test. The nostrils and throat are numbed with meals, avoiding tight clothing, and controlling becomes inflamed, which can decrease LES a topical anesthetic. The patient is placed in chronic cough.5 pressure more and more until there is a recurrent 9 an upright position, and a thin, flexible tube Epiphrenic diverticulum is generally cycle of reflux and heartburn. is passed through the nostril, down the throat, accompanied by some type of motor disorder, Risk factors and into the esophagus and stomach while the such as spasm. It is necessary to treat the There are a number of factors that predispose the patient swallows water. Esophageal muscle underlying cause. For example, medications development of GERD. These include:5,9 pressure, movement, coordination and strength may be administered to control spasms. Surgical  Pyloric surgery. are assessed. Esophageal sphincters are also excision of the diverticulum may be required in  Nasogastric (NG) tube intubation for more evaluated.14 5 cases of severe pain or dysphaia. than four days.  Treatment  Hiatal hernia. 1 Gastroesophageal reflux disease  Treatment goals are: Mrs. Dasher is a 75-year-old retired biology  Conditions that increase abdominal pressure,  To control symptoms. teacher. She is taking verapamil, a calcium- such as pregnancy, obesity, persistent  To promote healing of the esophagus. vomiting or coughing.  channel blocker, and a low-dose aspirin daily   To prevent or manage complications. since she suffered a mild heart attack five years  Medications such as calcium channel Symptom control focuses primarily on lifestyle ago. During a routine doctor’s visit, Mrs. Dasher blockers, morphine, diazepam, modifications. mentions that she has been suffering from anticholinergics and meperidine.   Dietary habits: Avoid foods that trigger severe “heartburn” for the past several months,  Alcohol.  GERD symptoms, such as caffeine products, “especially after my fourth or fifth cup of coffee.”  Cigarettes.  chocolate, spicy food, carbonated beverages, Mrs. Dasher needs to be evaluated for GERD.  Orange juice.  Tomatoes. orange juice, alcohol, onions, fatty foods, Gastroesophageal reflux disease (GERD), often  Whole milk. tomato juice and tomato sauce. Avoid eating referred to as “heartburn,” is the backflow  Peppermint. large meals, which put pressure on the LES. of gastric and/or duodenal contents into the  Chocolate. It is better to eat small frequent meals rather esophagus past the lower esophageal sphincter than three large meals. 1,5 (LES). This backflow is not accompanied by Signs and symptoms  Positioning: Patients should not lie down for belching or vomiting.5,9 Many people, even The most common presenting symptom of GERD two hours after eating. Sleep with the head health care professionals, sometimes dismiss is burning pain in the epigastric area, commonly of the bed raised six to eight inches. A flat “heartburn” as a minor annoyance. However, referred to as “heartburn.” The pain may radiate position puts pressure on the LES.5 ongoing reflux may cause inflammation of the to the and chest and even to the neck and  Weight: Obesity increases abdominal 5,9 esophageal mucosa and complications such jaw. Some patients may think that they are pressure, which pushes gastric contents up as esophageal ulcers, strictures, or Barrett’s having a heart attack. The pain often occurs into the esophagus. Even a moderate weight esophagus.5 It is important that all reports of after a meal or when lying down. Patients may loss can help reduce symptoms.1,5 “heartburn” be carefully evaluated. complain of feelings of fluid accumulation in the  Smoking: Nicotine not only relaxes 9 throat. A chronic cough may develop as a result the esophageal sphincter, it promotes Incidence of the reflux of gastric contents into the throat. the production of gastric acid. Smoking Data show that 25 percent to 40 percent of There may also be hoarseness upon awakening in irritates the esophagus and can reduce the Americans report symptoms of GERD at some 5 the morning. effectiveness of digestion by decreasing time in their lives, and 7 percent to 10 percent gastric motility.5 report that they experience symptoms every Diagnosis  Alcohol use: Alcohol increases gastric acid day. It may be that the actual percentage is even Diagnostic tests focus on identifying the production and decreases LES pressure.5 higher because a significant number of people underlying cause of GERD. In addition to a  Stress: Stress itself does not cause GERD. may be self-medicating with over-the-counter careful history and physical, a number of specific However, stress can cause individuals to preparations and never report their symptoms.5 tests are conducted.  drink, smoke or overeat, which can trigger GERD tends to be chronic, and relapse is  Esophageal acidity test: Assesses the GERD symptoms.1,5 common. Thus many patients require long-term competence of the LES and measures 5,9 medication maintenance therapy.16 reflux. Lifestyle modifications can promote healing   Acid perfusion test: Determines whether of the esophagus and control symptoms. Many GERD is often thought of as an “adult” problem. reflux is the cause of the problem and patients, however, also take medications for the Research shows, however, that GERD is actually 9 distinguishes it from cardiac problems. treatment of GERD. These include: common in infants and children. Repeated   Esophagoscopy: Used to evaluate the  Antacids that neutralize acidic gastric vomiting, coughing and respiratory problems extent of the disease and identify pathologic contents.9 may be indicative of GERD in this population. 9 changes.  Foaming agents (such as Gaviscon) that Most infants grow out of GERD by the time they   Barium swallow: Used to identify hiatal prevent reflux.9 are 1 year old and their digestive systems have hernia as a causative factor or esophageal  5  H2 blockers that reduce the amount of matured. 9 stricture as a complication of GERD. gastric acid production.1,9

Page 4 Elite Nursing alert! H2 blockers eliminate  Smoking: Nicotine products stimulate  Endoscopic mucosal resection (EMR): symptoms in about 50 percent of patients, gastric acid production, relax the esophageal During an EMR, the Barrett’s lining is lifted but remission is maintained in only about 25 sphincter and reduce digestion effectiveness. up and a solution is injected under it, or percent of patients.1 Patients should be referred to smoking suction is applied to it. Then the affected  Protein pump inhibitors (PPIs) limit gastric cessation programs. Many patients need the lining is incised and removed through the acid secretion and facilitate rapid resolution help and support of organized programs to endoscope. Complications can include of symptoms and esophageal healing in stop using nicotine products. bleeding or tearing of the esophagus. EMR 80-90 percent of patients. Examples of fairly  Medication: Patients need to be taught about may be performed in conjunction with PDT.11 recently approved PPIs include Prilosec, the medications they take, the importance of Surgical removal of the majority of the Nexium and Kapidex.9,16,17 Kapidex, for taking them, and any medication side effects esophagus may be recommended in cases of example, is a delayed-release capsule that may occur. severe dysplasia or malignancy. The surgery is taken once a day orally for the treatment In addition to helping patients adhere to their extensive, and older or debilitated patients may of heartburn associated with symptomatic, treatment regimen, nurses must be alert, and not be able to tolerate it. Surgery may, however, nonerosive GERD, the healing of erosive teach their patients to be alert, to the possibility offer the best hope of a cure. Surgery generally esophagitis, and maintenance of healed of developing a potentially fatal disease closely involves removal of most of the esophagus and erosive esophagitis. Kapidex is the first PPI associated with GERD: Barrett’s esophagus. pulling a portion of the stomach up into the with a dual-delayed release formulation. It is chest and attaching it to the remainder of the intended to provide two separate occurrences Barrett’s esophagus is a disorder characterized esophagus.11 of medication release.17 by the replacement of “normal” tissue that lines the esophagus with tissue similar to the lining Research into the cause and treatment of Barrett’s Within the last several years, the U.S. Food and of the intestine. This is referred to as intestinal esophagus is necessary. The National Institute Drug Administration (FDA) has approved some metaplasia. Barrett’s esophagus does not produce for Diabetes and Digestive and Kidney Diseases new devices for the treatment of GERD. These signs or symptoms. Its cause is unknown, but it is (http://www2.niddk.nih.gov) and the National include:9 often found in persons with GERD. The disorder Cancer Institute (www.cancer.gov) are involved  Bard EndoCinch system: An endoscopic affects about 1 percent of adults in the United with such research. For information about current device that puts stitches in the LES to make States. It affects men about twice as often as research projects visit www.ClinicalTrials.gov.11 it stronger. This device is inserted for chronic women, and Caucasian men are diagnosed more GERD. Hiatal hernia often than men of other races.11  Stretta system: Electrodes make tiny cuts The word hernia refers to a condition that exists on the LES via an endoscopic device. As the It is estimated that about 10 percent to 15 percent when an internal body part moves or “pushes” cuts heal, resulting scar tissue makes the LES of patients with chronic GERD symptoms into anywhere it does not actually belong.19 Hiatal stronger. develop Barrett’s esophagus. Because there are hernia, also referred to as hiatus hernia, is a  Enteryx: A solution that is injected during an no specific signs and symptoms, physicians may deficiency or defect in the diaphragm that allows endoscopy. It becomes “spongy” to support recommend that patients over the age of 40 who part of the stomach to pass through the opening the LES and prevent reflux. This procedure have a lengthy history of GERD be screened for in the diaphragm into the chest.5 is approved for patients with GERD who Barrett’s.18 There are two types of hiatal hernia: respond to proton pump inhibitors. Why is such a recommendation made for a 1. Sliding hernia: The stomach and the Patient education is very important to the disorder that causes no signs or symptoms? gastroesophageal junction slip up into the control of GERD symptoms and its treatment. The answer is that a small percentage (less than chest.5 Some important teaching topics include the 1 percent annually) of patients with Barrett’s 2. Paraesophageal hernia: A portion of the following:1,5,9 esophagus develop a rare, often deadly form greater curvature of the stomach moves  Positioning: Teach patients to sit upright of cancer called esophageal adenocarcinoma. through the defect in the diaphragm.5 and avoid lying down for two hour after Because of the lack of symptoms, this cancer Etiology eating. Patients should sleep with their heads is often not detected until it is in an advanced Hiatal hernia is generally due to muscle elevated at least six to eight inches. Teach stage.11 them that flat positions place increased weakening that occurs with the aging process. Barrett’s esophagus is diagnosed via an upper pressure on the LES. It may also be due to injury, trauma or be endoscopy and biopsy. After insertion of the  Clothing: Patients need to avoid constricting secondary to esophageal cancer. Increased endoscopic tube, the physician can inspect the clothing, such as tight belts, girdles and other abdominal pressure caused by coughing, lining of the esophagus and note the presence of types of garments that cinch the waist. straining during bowel movements, pregnancy or abnormal lining. However, a biopsy of the lining  Weight: A weight-loss program may be significant weight gain may also contribute to the of the esophagus is necessary to confirm the 5,19 indicated. Extra weight increases abdominal development of hiatal hernia. presence of a malignancy.18 pressure that pushes stomach contents up Incidence into the esophagus. Patients should not There are several treatment options for Barrett’s Hiatal hernia risk increases with age and occurs simply be told to lose weight. They should esophagus with severe dysplasia or malignancy. most often in persons over the age of 40. It occurs have a dietary consult and, as appropriate, be The focus of these options is destroying or more often in women than in men and in persons placed on a medically supervised weight loss removing the section of the lining that has who smoke and who are overweight.5,19 program. dysplasia or is cancerous. Two endoscopic  Diet: It may be helpful to initiate a dietary therapies may be used to treat Barrett’s esophagus Signs and symptoms consult for patients with GERD. Patients under these conditions. A paraesophageal does not usually cause should be counseled to eat small, frequent  Photodynamic therapy (PDT): Photofrin (a symptoms. It is generally found almost meals rather than three large meals and to light-sensitizing agent) and a laser are used “accidentally” during a barium swallow or avoid eating before going to bed. Foods to kill precancerous and cancerous cells. similar diagnostic tests. Because the stomach such as caffeine, chocolate, spicy foods, Photofrin is injected into a vein. Forty-eight is displaced or stretched, there may be feelings citrus juices, tomato sauce and alcohol all hours later, the laser light is passed through of fullness in the chest or chest pain similar 5,7 stimulate gastric acid production and should an endoscope and the Photofirn is activated, to angina. This type of hernia requires be consumed in very limited quantities. thus destroying the affected tissue of the surgical intervention because there is danger of esophagus.11 strangulation of the stomach as it becomes caught above the diaphragm.5 Elite Page 5 A sliding hernia that does not produce symptoms the stomach. When this happens, the body’s does not require treatment. However, if the Gastritis is a common condition characterized immune system reacts to these attacks, and sliding hernia does produce symptoms, they are by inflammation of the lining of the stomach.20 the stomach lining is damaged. This form usually similar to gastric reflux. Such symptoms Gastritis may be acute or chronic. In most people, of gastritis is more common in persons who include heartburn, chest pain due to reflux of gastritis is not serious. However, some people have other autoimmune disorders.20 gastric contents, dysphagia, and bleeding.5,7 may develop gastric ulcers and increases the risk  Various disease processes and events: 20 A potentially severe complication of for stomach cancer. Certain diseases and events can predispose someone to gastritis. The stress of major paraesophageal hernia is severe pain and shock Acute gastritis has an abrupt onset and causes surgery, trauma, burns or severe infections due to incarceration. Incarceration occurs when reddening of the gastric mucosa, edema, can trigger acute gastritis. Chronic gastritis a portion of the stomach is caught above the hemorrhage and erosion. Chronic gastritis is may be associated with pernicious anemia, diaphragm and can lead to gastric perforation and generally common in the elderly and in people kidney or , strangulation and even gangrene of that portion who have pernicious anemia, although either and diseases of the pancreas.5,20 of the stomach. Emergency surgery is necessary acute or chronic gastritis can occur at any age. if this complication occurs.7 Chronic gastritis causes all stomach mucosal Signs and symptoms 5 Diagnosis layers to become inflamed. Signs and symptoms of acute gastritis are abrupt Diagnosis of hiatal hernia is confirmed via Pathophysiology and etiology in onset and include , abdominal various diagnostic studies. A barium swallow When the stomach’s protective layer is weakened cramps, nausea, vomiting and may show a hernia as an outpouching at the lower or injured, gastric digestive juices penetrate the (bloody vomit). These signs and symptoms can 5 portion of the esophagus. However, small stomach and damage and inflame the gastric last from a few hours to several days. may be difficult to detect. Endoscopic studies lining. There are several factors that can damage Chronic gastritis may produce similar signs and allow the examiner to identify hiatal hernias and the stomach’s protective layer and predispose a symptoms or may cause only mild discomfort other gastroesophageal problems.5 person to the development of gastritis.20 such as slight pain or an inability to tolerate fatty  Treatment  Bacterial infection: Helicobacter pylori or spicy foods. Patients with chronic gastritis may (H. pylori) is a common cause of chronic 5 Asymptomatic hiatal hernias may not require not have any signs or symptoms at all. gastritis. It is estimated that 50 percent of any treatment.19 However, sliding hernias may the world’s population is infected with this Diagnosis produce symptoms of gastric reflux similar to bacterium, but the majority of those infected There are several diagnostic tests used to confirm those of GERD. In this case, treatment focuses do not experience any gastric complications. a diagnosis of gastritis. on relieving and controlling symptoms through  However, in some people, bacteria break  Upper gastrointestinal endoscopy: This the use of medications, avoiding constrictive down the gastric protective lining and allows visualization of the stomach lining and clothing, eating small, frequent meals instead 5,20 gastritis occurs. It is not known why some removal of tissue samples for biopsy. of three large ones, and avoiding alcohol, spicy  people are susceptible to gastritis and others  Tests for occult blood: Stools and vomitus foods, tomato juices, citrus juices and nicotine are not, but some experts believe that lifestyle can be tested for the presence of blood, products.5 For details about reducing symptoms 5,10 choices, such as smoking and high alcohol indicating gastric bleeding. produced by gastric reflux see the preceding  intake, may increase the risk of development  Blood tests: Hemoglobin and hematocrit section on GERD. of the problem.20 levels are assessed to determine whether the Surgical intervention is necessary if the hiatal  patient has developed anemia from gastric  Drug use: Regular use of drugs such 5 hernia has the potential to become constricted or as aspirin and other non-steroidal bleeding. strangulated. In this case, the hiatal hernia must antiflammatory drugs (NSAIDs) such as Treatment 19 be “reduced” or put back in its proper place. ibuprofen (e.g., Advil) and naproxen (Aleve) Treatment focuses on eliminating the cause that The surgeon may have to make an incision in the can cause both acute and chronic gastritis. triggers the gastritis. Antibiotics are administered or thoracic area, but may also be able to Such drugs should not be taken more than is to treat bacterial gastritis. Histamine-2 repair the hernia by laparoscopic surgery, which necessary.5,20 receptor antagonists are given to block gastric is much less invasive and shortens the period of  Alcohol use: Alcohol has the potential to secretions. Over-the-counter antacids may be 5 time necessary for recovery. irritate and erode the lining of the stomach, administered to buffer the effects of the acidity Laparoscopic surgery involves making about increasing the risk of gastritis. Ingesting of gastric secretions. If antacids do not provide five or six abdominal incisions about five to excessive amounts of alcohol is more often adequate relief, acid blockers such as cimetidine 10 millimeters in length. Surgical instruments linked to acute gastritis.20 (Tagamet), ranitidine (Zantac) or famotidine  as well as the laparoscope are inserted through  Smoking: Nicotine products irritate gastric (Pepcid) may be prescribed. In the event of the incisions. The surgeon is able to repair the lining and can lead to chronic gastritis. 5,20 severe blood loss, blood replacement may be  5,20 hernia by viewing the internal organs via the  Older age: The risk of gastritis increases with necessary. age because the gastric lining of older adults laparoscope. Patients are usually able to ambulate Lifestyle changes may also be helpful in reducing generally thins with age, and older people are the day after surgery, eat a normal diet and the signs and symptoms of gastritis. more likely to be infected with H. pylori.20 resume regular activities within a week. Heavy  Diet: Patients should avoid foods that trigger 19  Bile reflux disease: Under normal conditions, lifting should be avoided for several weeks. or exacerbate signs and symptoms, such as bile is released from the gallbladder and Nursing alert! There is no complete assurance fatty or spicy foods. Eating small, frequent enters the small intestine where it assists that the condition will not reoccur, even with meals may be better tolerated than three large in the digestion of fats. The pyloric valve surgical intervention.19 meals a day. A dietary consult may be helpful prevents bile from traveling into the in assisting the patient to adopt or maintain a Because of the possibility of reoccurrence, stomach from the small intestine. However, healthy diet.5,20 patients must be taught to recognize the warning if the valve fails to work properly, bile can  Alcohol intake: Patients should limit signs of the life-threatening complication of flow into the stomach, causing irritation, or avoid alcohol, which can trigger or hernia strangulation. These signs include severe inflammation and, eventually, chronic exacerbate signs and symptoms.5,20 chest or , nausea and vomiting, gastritis.20  Smoking: Patients should avoid using or inability to have a bowel movement or pass  Autoimmune gastritis: This is a rare form 19 nicotine products. Smoking increases gastric gas. of gastritis that occurs when the patient’s acid, delays gastric healing and increases the own body “attacks” the cells of the lining of

Page 6 Elite risk of not only gastritis but of gastric cancer poisoning and traveler’s (from Symptoms of hypernatremia include:22 as well.20 contaminated food and unclean water).5,21  Low-grade fever.  Weight: Patients should maintain a healthy  Amebae: Entamoeba histolytica are one of  Flushed skin. weight. Digestive problems are more the most common types of amebae that can  Weakness. common in overweight people than those cause gastroenteritis.5  Lethargy. who are of normal weight.20  Viruses: Viral outbreaks can also cause  Tremors.  Exercise: Exercise helps all body systems to traveler’s diarrhea and spread rapidly through  Confusion. function at their highest potential. Exercise close contact. In fact, 30-40 percent of cases  Seizures. also aids in proper digestion. Patients of gastroenteritis in children are viral in  Coma. should consult with their physicians before nature.21 Symptoms of hypokalemia include:22 beginning an exercise program.20  Medication reactions: Adverse reactions  Weakness, especially in the legs. to drugs such as antibiotics may trigger Gastroenteritis  Leg cramps. gastroenteritis. Other drugs that may trigger A “stomach flu” is prevalent in a small college  Arrhythmias. the problem include aspirin, steroids, town. Denise, a 20-year-old college sophomore,  Rapid heart rate. non-steroidal anti-inflammatory drugs and develops abdominal cramps, nausea, vomiting caffeine.5,21 Treatment and diarrhea, which lasts for about 24 hours.  Food allergies: Food allergies can trigger the In most cases, treatment is supportive until the Denise makes a speedy recovery, and is back gastroenteritis.21 signs and symptoms resolve themselves. Patients attending classes within 48 hours of the onset of  Ingestion of poisons or heavy metals: need rest and nutritional support. Lost fluid and symptoms. Poisonous substances and water contaminated electrolytes can be replaced with broth, ginger Denise’s 1-year-old cousin, Jason, also develops with heavy metals such as lead and mercury ale, ice chips and lemonade as tolerated. Milk and similar signs and symptoms. After several can trigger gastroenteritis.5,21 milk products should be avoided because they hours of vomiting and diarrhea, Jason becomes may exacerbate vomiting and diarrhea.5 Symptoms dehydrated and is taken to the local hospital. He Signs and symptoms of gastroenteritis vary Patients and their families should be taught is admitted and given intravenous fluids. Jason depending on the cause, age and general health of preventive measures to reduce the risk of recovers quickly and is able to go home the next the person affected. Typical symptoms include:5,21 gastroenteritis. These measures include:5,22 day.  Low grade fever (less than 100 degrees F).  Encourage frequent hand washing. Denise’s 85-year old grandfather also develops  Nausea.  Patients should be taught to avoid touching gastrointestinal “flu” symptoms. After  Vomiting. their eyes, nose and mouth because germs are experiencing severe vomiting and diarrhea for  Diarrhea. easily spread via these routes. nearly 24 hours, he becomes severely dehydrated  Malaise.  When traveling to foreign countries, teach and exhibits confusion and decreasing levels of patients to avoid drinking water or eating raw The disease is usually self-limiting with consciousness. He is rushed to the hospital and is fruits and vegetables. complete recovery. However, in severe cases, admitted in critical condition.  Explain the importance of cooking food it may be necessary to seek emergency medical thoroughly and refrigerating perishable foods The preceding examples show that what is often attention. If blood is present in vomit or stool, such as dairy products, mayonnaise and referred to as a mild illness can, in fact, have vomiting or diarrhea lasts more than 48 hours, a cream. devastating consequences. Gastroenteritis is fever greater than 101 degrees F is present, the generally a self-limiting illness characterized by abdomen is swollen, abdominal pain is in the Gastric cancer irritation and inflammation of the stomach and right lower abdominal quadrant or signs of fluid Once the second most common cancer in the intestines, which produces nausea, vomiting, and electrolyte imbalance are present, the patient world, the rates of gastric or stomach cancer diarrhea and abdominal cramping.5,21 The very should seek immediate medical attention.21 have significantly decreased in most developed young and the very old are especially susceptible countries.23 This malignancy affects all races, Nursing alert! Remain alert to the signs and to complications of this disease as are people but there are some unexplained geographic symptoms of dehydration and electrolyte who are in a debilitated state. As shown in the and cultural variations in incidence. There is a imbalance, especially in children, the elderly and introductory examples, the very young and the higher mortality rate in Japan, Iceland, Chile and debilitated patients. elderly can quickly become severely dehydrated Austria. Over the past 25 years, the incidence of and also experience electrolyte imbalances Signs and symptoms of dehydration include:22 gastric cancer in the United States has decreased as a result of vomiting and diarrhea. These  Thirst. by 50 percent, and the death rate is one-third populations must be carefully monitored and may  Poor skin turgor. what it was 30 years ago. require emergency medical intervention to restore  Dry skin. Incidence is actually one-third of what it was fluid and electrolyte balance.5,9  Fever. 30 years ago. Incidence in Hispanic native and  Dizziness. Gastroenteritis, which affects all age groups, is African-Americans is twice that compared to  Weakness. commonly referred to as intestinal flu, traveler’s whites, and generally higher in men over the age  Elevated heart rate. diarrhea or viral .5 In the United States, of 40. Gastric cancer is more common in people  Decreased blood pressure. the disease ranks second only to the common with type A blood compared to those with type  Changes in mental status. cold as the leading cause of lost work time due O blood. Prognosis depends on the stage of the  Seizures. to illness and is actually the fifth leading cause of disease at diagnosis, but the overall-five-year  Coma. death in young children.5 survival rate is about 19 percent.5 Changes in mental status, seizures, and coma Causes About 50 percent of stomach cancers are located require immediate emergency intervention. There are a number of causes of gastroenteritis. in the pyloric area, but any area may be affected. Common electrolyte imbalances that can Here are some of the most common. Gastric cancer travels quickly to regional lymph occur with severe vomiting and diarrhea  Bacteria: There are several types of bacteria nodes, liver and lungs.5 are hypernatremia (elevated sodium) and that cause gastroenteritis. , hypokalemia (low potassium). Electrolyte salmonella and Staphylococcus aureus are imbalances are more common in infants and common examples. They can cause food children and the elderly.

Elite Page 7 Causes whether the stomach is secreting gastric acid Signs and symptoms The exact cause of gastric cancer is not known. properly.5 Typical signs and symptoms include:5,9 However, a number of factors have been  CT scan and/or MRI: Conducted to view  Abdominal pain that can be localized to the identified that are associated with the disease. chest, abdomen and to assess not only right lower quadrant or generalized over the  Diet: Diets high in foods that are pickled, local disease but also to identify possible abdomen. Rebound tenderness is common. smoked or salted seem related to the areas of metastasis.23 Rebound tenderness is elicited when the development of gastric cancer. Red meat,  Endoscopic ultrasound: Conducted to assess nurse or physician removes pressure from the especially if barbecued or cooked “well- preoperative tumor stage.23 abdomen rather than when pressure is applied done,” is linked to an increased risk of Treatment (as in palpation). In other words, the nurse cancer.5,23 applies pressure during palpation, and when Surgery is generally the treatment of choice. The  Smoking: Smoking is associated with an that pressure is released and pain occurs, malignant area(s) are removed, and if the surgeon increased risk for gastric cancer. If smoking rebound tenderness is present. is able to determine clear margins surrounding is discontinued, the risk decreases.23,24  Anorexia. the cancerous area(s), some of the stomach  Bacterial infection: Chronic infection with  Nausea or vomiting. may be left in place. However, depending on helicobacter pylori (H pylori) is associated  Low-grade fever. the extent of the disease, it may be necessary to with a significant risk of gastric cancer.  Elevated white blood cell count with an perform a total gastrectomy. The patient who has It is believed that this infection increases increased number of immature cells. a partial gastric resection may eventually be able gastric inflammation and predisposes the to eat normally. However, the patient who has a CT scan or abdominal sonography may be used development of gastric cancer.23,24 total gastrectomy will have a slow recovery and to visualize the . Diagnosis is based on  Previous gastric surgery: Retrospective the ability to eat a normal diet is limited. After patient history and diagnostic test results. research studies indicate that previous gastric total gastrectomy, patients must eat small meals surgery increases the risk of gastric cancer. Nursing alert! Abrupt termination of abdominal for the rest of their lives.5 It is believed that the surgery changes the pain suggests perforation or infarction of the normal pH of the stomach, which may cause Nursing alert! Factors that are necessary to appendix.5 vitamin B12 absorption are part of gastric potentially malignant changes in gastric Treatment cells.23 secretions. Life-long replacement vitamin and The only treatment for is removal  Genetic predisposition: It is estimated that iron supplements are necessary for patients who of the appendix or appendectomy. Laparoscopic about 10 percent of gastric cancers have a have had gastrectomies.5 appendectomies reduce recovery time and genetic link. 23 Various chemotherapy agents may be enhance the speed of recovery.  Alcohol: Alcohol may cause alterations administered as part of the treatment regimen. in gastric cells that ultimately trigger the Nursing alert! An ice bag may be used for pain Examples of such agents include fluorouracil, development of cancer.5 relief prior to surgery. NEVER apply heat to the paclitaxel and cisplatin. Radiation in combination right lower abdominal quadrant because heat with chemotherapy may be beneficial.5 Signs and symptoms may cause rupture of the appendix. Never give Signs and symptoms are not specific and In 2009, clinical studies of the breast cancer enemas or laxatives because these may also may indicate a number of other conditions. drug trastuzumab (Herceptin) showed that it rupture the appendix.5 Early symptoms include chronic dyspepsia improved the survival of patients with advanced (indigestion), heartburn and epigastric gastric cancer. Adding Herceptin to standard discomfort. Later signs and symptoms include chemotherapy helped patients survive longer than Peritonitis is an inflammation of the weight loss, anorexia, anemia, fatigue and a patients who received chemotherapy alone.25 (the membrane that lines the abdominal cavity feeling of fullness after eating. There may also be and covers the internal abdominal organs. blood in stools.5 Appendicitis Peritonitis can be acute or chronic and is Daniel is a 22-year-old college senior. He and associated with a 10 percent mortality rate.5 Nursing alert! Because early symptoms may not a group of friends are studying for final exams seem serious to patients, they may ignore them or when he begins to complain of pain in the right Causes self-medicate themselves with antacids to reduce lower area of his abdomen and nausea. Daniel’s Under normal conditions, the peritoneum is epigastric or gastric discomfort.5 Patients should friends are not very sympathetic. One of them sterile. Peritonitis occurs when bacteria enter be encouraged to report all symptoms to their comments, “You really overdid it last night! the peritoneum as a result of appendicitis, health care providers as soon as possible. I’ve never seen you drink so much beer at one , peptic ulcer, , Diagnosis party!” As their study session progresses, the abdominal cancers, strangulated obstruction or stab wounds.5 Because a number of other gastric problems can pain becomes worse and Daniel is doubled over mimic gastric cancer, it is necessary to confirm in pain. His friends decide to take him to the Chemical inflammation may also cause the diagnosis via specific diagnostic studies. campus infirmary. The nurse on duty listens to peritonitis. Chemical inflammation occurs with  Esophagogastroduodenoscopy: Allows Daniel’s complaints and finds rebound tenderness events such as perforation of a gastric ulcer or visualization of the esophagus, stomach and over his right lower abdomen. She arranges for rupture of a fallopian tube. At times, it may be (first part of the small intestine). Daniel to be immediately transferred to the local associated with peritoneal dialysis.5 It has a 95 percent diagnostic accuracy, hospital. Daniel has appendicitis. Signs and symptoms provides a permanent color photographic Appendicitis is inflammation of the appendix Signs and symptoms of peritonitis include:5,9 record of any lesions or suspicious areas, and is the most common disease that requires  Abrupt, severe and widespread abdominal and is the primary way to obtain a tissue emergency surgery. It can occur at any age but pain. This pain generally intensifies and specimen for biopsy.5,23 has a peak incidence in late teens and early 20s. localizes in the area of the case (e.g., right  Barium x-rays: These are x-rays of the About 250,000 cases of appendicitis are reported lower quadrant with appendicitis) with gastrointestinal tract (GI) and are obtained 5 every year. accompanying rebound tenderness. to show problems such as tumors, filling  Excessive diaphoresis. defects, loss of gastric flexibility and Causes  Weakness. abnormalities in the gastric mucosa.5 Appendicitis is due to obstruction of the  Pallor.  Gastric acid stimulation test: Determines appendiceal lumen (inside of the appendix) that is  Cold skin. caused by viral infection, stricture, fecal mass or  ingestion of barium.5,9  Hypotension. Page 8 Elite  Tachycardia. the duodenum (the first portion of the small ulcers tend to develop in persons with type O  Fever of 103 degrees F or higher. intestine that connects to the stomach), or the blood.5  Distention of the abdomen. (the portion of the small intestine that’s  Physical trauma, emotional stress and  Decreased intestinal motility. located between the duodenum and the ), the normal processes of aging are also  With accompanying intestinal obstruction, the lowest portion of the small intestine that contributory factors.5 there will be nausea, vomiting and rigidity of connects to the large intestine.5 Approximately  Irritants such as alcohol, coffee and tobacco the abdomen. 80 percent of all peptic ulcers are located in the may increase the risk of ulcer development duodenum.5 by accelerating gastric acid emptying that Diagnosis facilitates mucosal barrier breakdown.2,5 In addition to patient history, the following are Peptic ulcers can have serious, even fatal, used to identify peritonitis:5,9 consequences. In the United States, an estimated Signs and symptoms  Abdominal x-rays: Reveal distension of 14.5 million people have been diagnosed as A gastric ulcer attack usually begins with the small and large intestine due to gas and having PUD, with about 1.6 million people heartburn and indigestion. Eating may both cause edema; if internal organs are perforated, air developing the disease every year.2,5 This disease and relieve pain. For example, eating causes the may be noted underneath the diaphragm. kills an estimated 4,000 and disables about gastric wall to expand and may cause pain as  Chest x-ray: May reveal elevated diaphragm. 328,000 annually.2 the affected area stretches. If eating causes pain,   Blood studies: Reveal leukocytosis. Gastric ulcers develop most often in middle- there may be weight loss. In severe cases, there  25  Paracentesis: Shows the presence of aged and elderly men, particularly those who are may be significant GI bleeding. bacteria, blood, pus or urine. chronic users of nonsteroidal anti-inflammatory Duodenal ulcers also cause heartburn and  Laparotomy: Used to determine the 5 drugs (NSAIDs), alcohol or tobacco. localized mid-epigastric pain. Eating relieves underlying cause of the peritonitis. Pathophysiology this pain. Weight gain is likely because patients Treatment eat to diminish the pain. An unusual sensation Under normal circumstances, a thick layer of Prevention of the disorder is obviously desirable. of hot water bubbling in the back of the throat is protects the stomach from chemical Gastrointestinal inflammatory conditions should characteristic of duodenal ulcers.5 trauma, mechanical trauma and autodigestion. be carefully monitored and treatment initiated This mucus acts as a barrier that prevents harmful Duodenal ulcer attacks usually take place about promptly. Preoperative and postoperative effects of gastric acid and digestive enzymes. two hours after meals or whenever the stomach antibiotic therapy (as appropriate) can help to Prostaglandins also provide a measure of gastric is empty. Attacks may also occur after ingesting prevent the development of peritonitis.5 protection. When the gastric mucosal barrier orange juice, aspirin or alcohol. Such attacks However, if peritonitis arises, it is a medical is damaged or destroyed, gastric ulcers can occur several times a year, then diminish into emergency requiring immediate treatment. develop.2,9 remission.5 Antibiotic therapy, dependent upon the organisms The duodenum is protected by a mucoid alkaline Complications causing the infection, is initiated. Patients are secretion of the Brunner’s glands. This secretion Nursing alert! Ulcers can penetrate the pancreas not to receive food or drink by mouth. Fluids neutralizes the acid chyme. When there is an and cause serious back pain. Perforation of and electrolytes are administered intravenously. excessive production of acid that cannot be the ulcer may occur, causing abrupt, severe Supportive measures include administration of neutralized, duodenal ulcers can develop.5 pain, a rigid abdomen, grunting respirations analgesics, insertion of a nasogastric (NG) tube and diminished bowel sounds.2 Patients should for bowel decompression, and if needed, a rectal Causes seek immediate medical help if these symptoms tube to promote the passage of flatus.5 There are three main causes of PUD. develop. If peritonitis is due to a perforation (e.g., a 1. Infection with Helicobacter pylori (H. perforated fallopian tube) surgery must be pylori): These bacteria are present in the Ulcers may cause significant bleeding that can performed as soon as possible. The goals of gastric mucosa of about 20 percent of lead to hypovolemic shock. Bloody vomitus or surgery are to remove the contents spilled into Americans under the age of 40 and in about stools, low hemoglobin and hematocrit levels, the peritoneum from the perforation and to insert 50 percent of Americans over 60 years of tachycardia and hypotension may signal this drains to facilitate this removal.5 age. Since most people with H. pylori do serious complication. Patients need emergency not develop gastric ulcers, additional (at this medical intervention for severe hemorrhage.2,5 Peptic ulcers time unknown) factors must influence their Angela is a 55-year-old breast cancer survivor. Gastric dumping syndrome is also a potential development. In susceptible persons, the complication of PUD. Dumping syndrome She is self-employed as a management bacteria contribute to the breakdown of the consultant. Her job is quite stressful, and is characterized by , gastric mucosal barrier and facilitate ulcer nausea and vomiting. If an ulcer is close to the she smokes about a pack of cigarettes a day. 2 development. pylorus, the mucosa can become inflamed and For the past several months Angela has been 2. The use of NSAIDs: These drugs facilitate experiencing heartburn and indigestion, edematous, eventually blocking passage into the the formation of ulcers by interfering with the small intestine. This causes stomach distension. particularly after meals. She also notices that secretion of prostaglandins, which provide the discomfort intensifies after drinking orange As secretions build up in the stomach there is some measure of protection of the gastric , indigestion, nausea, vomiting, feelings juice or coffee. She attributes these symptoms to 5 lining. of fullness and abdominal pain. Dumping job stress and is self-medicating with antacids. 3. Effects of certain illnesses: Certain illnesses However, because of her previous diagnosis of syndrome is managed by inserting an NG tube are associated with the development of PUD. to withdraw accumulated gastric secretions and cancer, she becomes concerned and decides to These include , hepatic disease, seek medical help. Her physician orders an upper decompress the stomach. As measures are taken Crohn’s disease, pre-existing gastritis and to heal the ulcer that causes dumping syndrome, GI and small bowel series. She suspects that Zollinger-Ellison syndrome (increased gastrin Angela may have a peptic ulcer. the blockage is decreased or eliminated and production from non-beta islet cell tumors of normal passage from the stomach to the small 5 Definition and incidence the pancreas). intestine is restored.2 Peptic ulcer disease (PUD) is defined as an There are also a number of predisposing factors 2 Diagnosis erosion of the GI mucosa. Peptic ulcers are for PUD. Diagnosis is made by taking a careful patient circumscribed lesions that can develop in the  Blood type is associated with specific types history and evaluating the findings of certain lower esophagus, stomach, pylorus (area of the of ulcers. Gastric ulcers tend to develop in diagnostic tests. stomach that “connects” to the small intestine), persons with type A blood, while duodenal Elite Page 9  Esophagogastroduodenoscopy: Verifies the Ulcerative colitis need to pass stools (even though the bowel may existence of an ulcer and allows biopsy to Cathy is 19 years old and attends a prestigious be empty), accompanied by cramping, pain rule out cancer or H. pylori.5 university on a full basketball scholarship. She and straining. These feelings are referred to as  Barium swallow, upper GI series, and has begun to experience abdominal cramping tenesmus.8 small bowel series: Verifies the presence of and frequent episodes of diarrhea that is bloody Additional symptoms include:5,9 an ulcer. This is most likely the first test(s) and contains large amounts of mucus. She is  Feelings of urgency to pass stools. performed if signs and symptoms are not losing weight and finding it difficult to play her  Weight loss related to . severe.5 best during basketball games. Cathy attributes  Weakness related to possible anemia and  Hemoccult test: Laboratory analysis of a her problems to the stress of keeping up with her malabsorption. stool specimen is conducted to detect the academic studies and the demanding schedule of  Anorexia. presence of occult blood in stools.5 practice and big-league games. She tries to hide  Nausea.  White blood cell count: Elevated counts her condition from her coach and friends but  Vomiting. indicate infection.2 eventually becomes so weak that she faints during  Hematocrit and hemoglobin: Low levels a practice session in the gym. Her coach insists Complications indicate bleeding.2 that she receive immediate medical attention. There are a number of complications associated  H. pylori antibody assay: A positive finding After a diagnostic work-up, Cathy is diagnosed with ulcerative colitis. These include:5,9 indicates infection. However, this test cannot as having ulcerative colitis.  Hemorrhage. indicate how recently the infection occurred.2  Infection. Ulcerative colitis is a chronic, inflammatory  or fistula. Treatment disease that affects the mucosal layer of the  Perirectal abscess. Treatment focuses on destruction of H. pylori colon. It begins in the rectum and sigmoid colon  Toxic . and protecting the lining of the stomach. Experts and extends upward into the rest of the colon.5  Coagulation deficit. in the treatment of PUD recommend treatment The inflammation generally starts at the base of with two antibiotics (e.g., tetracycline, bismuth the mucosal layer of the colon. The surface of the Another complication is fulminant colitis. This subsalicylate or metronidazole) to eliminate H. mucosal layer becomes dark, red and velvety in problem occurs when the lesions associated with pylori.9 Additional treatment measures to heal texture. The mucosa becomes eroded, and ulcers ulcerative colitis penetrate the muscle of the and protect the lining of the stomach include: form. The mucosa is affected by hemorrhage, bowel. The patient experiences abrupt, violent  Administration of proton gastric acid pump edema and exudative inflammation. diarrhea accompanied by rebound tenderness, inhibitors to decrease secretion of gastric form in the mucosa and drain purulent exudates. abdominal pain and toxemia. Fulminant colitis acid.9 Tissue is destroyed, and sloughing of the mucosa may also trigger (toxic dilation  Administration of a prostaglandin analog causes stools to become bloody and filled with of the colon) or perforation of the bowel.8 mucus. As the abscesses heal, scar tissue forms such as misoprostol to inhibit the secretion of Nursing alert! A diagnosis of ulcerative colitis and granulation tissue replaces the muscle layer gastric acid and increase mucus production in increases the risk for future development of 5,9 of the colon. As the muscle layer decreases, the order to protect the lining of the stomach. .5  Administration of histamine-2 blockers colon narrows, shortens and its characteristic to reduce gastric acid secretion and pouches are no longer evident.5.9 Diagnosis anticholinergics to inhibit the action of acid- A number of diagnostic tests are used to diagnose Incidence secreting cells.9 ulcerative colitis. These include: Ulcerative colitis can occur at any age but occurs  Administration of blood products if extensive  Sigmoidoscopy: Because ulcerative colitis primarily in young adults, particularly in women. GI bleeding occurs.5 generally develops in the rectum first, It is also more common among persons of Jewish  Avoidance of caffeine, alcohol, nicotine sigmoidoscopy may be the first diagnostic ancestry.5 There may be a genetic component to products and other items that encourage the procedure performed. Ulcerative colitis both types of IBD. It is estimated that about 10 secretion of gastric acid and irritate the lining shows mucosal friability (inflammation), percent to 20 percent of patients with IBD have of the stomach.9 decreased mucosal detail, mucosal flattening, at least one relative who also has the disease.8  Avoidance of NSAIDs because they irritate evidence of pinpoint hemorrhages and thick Although exact incidence is unknown, research the lining of the stomach.5 inflammatory exudates. Biopsy can help to suggests that 10 to 15 out of 100,000 people may  Avoidance of stressful situations that may confirm the diagnosis.5,8,9 be affected by ulcerative colitis.5 predispose ulcer development.5  Lab studies: Ulcerative colitis may cause Most patients first experience symptoms as decreased serum potassium, magnesium and Nursing alert! In the event of severe GI bleeding, teenagers or young adults. There is a peak albumin levels; decreased white blood cell emergency measures must be initiated. These between the ages of 15 and 30. However, there is count; decreased hemoglobin level; and a include insertion of an NG tube for iced saline also another peak incidence between the ages of prolonged prothrombin time.8,9 lavage, administration of blood products and 50 and 70.5  Stool specimens: The specimen should possibly surgery if perforation is suspected.5 be evaluated for the presence of bacteria, Cause Inflammatory bowel disease parasites and ova. In the case of ulcerative The exact cause of ulcerative colitis is unknown. Ulcerative colitis and Crohn’s disease are both colitis, blood and pus are present but not In addition to possible genetic influences, it is types of inflammatory bowel disease. However, disease-causing organisms.5,9 believed that ulcerative colitis development is they affect different portions of the GI tract.  Colonoscopy: Colonoscopy is performed to related to abnormal immune response in the GI Differentiating between the two conditions can determine the extent of the disease process tract. This response may be linked to food or be problematic in about 10 percent of reported and to assess strictures and polyps, if present. bacteria such as Escherichia coli.5,9 cases.6 Both are identified as inflammatory Biopsy of suspicious areas is performed.5,9 bowel disease (IBD), and both are chronic with Signs and symptoms  Barium enema: May also be performed to periods of exacerbation and remission. However, Ulcerative colitis is usually a chronic disease determine the extent of the disease and the ulcerative colitis is confined to the colon, while with periods of remission and exacerbations. It presence of complicating factors, such as Crohn’s disease can affect the entire GI tract.8 In is characterized by episodes of bloody diarrhea malignancy.5 order to properly diagnose and treat inflammatory that often contains pus and mucus. Patients may Nursing alert! Barium enemas and endoscopies 9 bowel disease, it is important to determine the have as many as 10 to 20 bloody stools per day. are contraindicated if the patient has active signs exact nature of the disease affecting the bowel. The disease often causes feelings of a constant

Page 10 Elite and symptoms or indications of complications (inflammation of the pouch), steadily increased over the past 50 years, now because these can cause bowel perforation.8,9 and pouch failure, which affecting seven out of every 100,000 people. It is necessitates removal of the pouch and most common among adults between the ages of Treatment performing a permanent ileostomy. 26 20 to 40. It is less common in blacks and two to The primary treatment goals are to control  Kock pouch or continent ileostomy: three times more common in persons of Jewish inflammation, reduce signs and symptoms, Usually performed prior to the development ancestry.5,8 replace blood loss, replace loss of fluids, of the IPAA. It is not considered a good electrolytes and other nutrients, and to prevent Cause primary operation. A pouch is formed from a the development of complications.5 The exact cause of Crohn’s disease is not small loop of the terminal ileum and a valve known. However, a genetic link is suspected. Supportive measures are initiated in an effort to from the distal ileum. This results in a stoma For instance, the disease is sometimes found control the disease and avoid surgery. located just above the pubic hairline. The in identical twins, and 10 percent to 20 percent pouch is emptied periodically via a catheter Sulfasalazine (Azulfidine) is the drug of choice of patients with the disease have relatives who that is inserted in the stoma.5,26 and is administered for its anti-inflammatory and have been diagnosed with Crohn’s disease. anti-microbial action. Other drugs with these Special nursing considerations Recent research findings show a mutation in the properties include olsalazine, mesalamine and  Monitor intake and output meticulously. gene NOD2. The gene is found twice as often balsalazide. Steroids such as prednisone and Remain alert to signs of fluid and electrolyte in persons with the disease as compared to the hydrocortisone are given to control inflammation, imbalance.8,9 population in general. This gene is believed and immunodulators or 5-aminosalicylates may  Monitor lab studies for evidence of to change the body’s ability to fight bacterial be administered to decrease the frequency of electrolyte imbalance and decreased infection. As of this writing, there is no realistic exacerbations. Iron supplements may be used to hemoglobin and hematocrit levels.8,9 screening method to check for this mutation.9 correct anemia.5,9   Provide good skin care after each bowel Signs and symptoms movement, gently cleansing the area around Nursing alert! The use of antispasmodics and Early symptoms of Crohn’s disease may be the rectum. Help the patient to turn frequently anti-diarrheal agents may cause toxic megacolon mistaken for bowel obstruction or appendicitis.8 if on bedrest to avoid skin breakdown. Place (dangerous dilation of the colon) and are usually Symptoms include a steady, colic-like pain in the a sheepskin on the bed or use an air mattress contraindicated. Such drugs are used only in right lower abdomen, cramping and tenderness. to help avoid compromise of the skin those patients with controlled ulcerative colitis Signs include weight loss, diarrhea, bloody integrity.8,9 but who have frequent, loose stools.5,9 stools, (the presence of excessive  Provide good patient education about amounts of fat in stools), and the presence of Bedrest, IV fluid replacements and a clear- care of the ostomy if necessary. Patients a palpable mass in the right lower abdominal liquid diet are indicated during acute attacks. need explanations about its care and good quadrant.8,9 Debilitated, dehydrated patients may be given emotional support.5,9 total parenteral nutrition and receive nothing  Explain the importance of regular medical Complications by mouth to rest the intestinal tract, decrease follow-up.5,9 Complications associated with Crohn’s disease diarrhea and restore fluid and electrolyte balance. include:5,9 Crohn’s disease Blood transfusions may be necessary for patients  Intestinal obstruction. 5,8,9 Crohn’s disease (also referred to as regional who experience significant blood loss.  Nutritional deficiency. enteritis and granulomatous colitis) is also an  Fistula of the anus. For patients who do not respond to medications IBD. But unlike ulcerative colitis, which is  Perineal abscess. and supportive measures, surgery may be confined to the colon, Crohn’s disease is an  A variety of , including to the bladder, necessary. It is estimated that about 25 percent to inflammation of any portion of the GI tract that 8 vagina or skin in the area of an old scar. 35 percent of patients need some type of surgery. usually extends through all layers of the wall of  Fluid imbalance. the intestine.8,9 There are several surgical options.  Peritonitis.  Proctocolectomy with ileostomy: The colon, The inflammation associated with Crohn’s rectum and anus are removed and the end of disease has a slow, steady progression. Lymph Diagnosis the small intestine (ileum) is brought through nodes enlarge and hinder lymph flow in the Diagnosis depends on the patient’s history, a stoma in the abdominal wall to allow the submucosa. Obstruction of lymph flow causes physical examination and the findings from various diagnostic studies. drainage of intestinal waste products from the edema, ulceration of the mucosa and the  body. An external bag is worn over the stoma, development of fissues and abscesses, sometimes  Barium enema: This test shows what is which is usually located in the right lower referred to as granulomas. called a “string sign” if Crohn’s disease is abdomen just below the belt line to the right present. This sign is caused by segments of Nursing alert! The pattern of ulcerations in of the naval.26 stricture separated by portions of normal Crohn’s disease is not continuous (referred to as  Restorative proctocolectomy (ileoanal bowel. The narrowing of the bowel (or skipping), compared to the continuous pattern of 5 pouch anal anastomosis or IPAA): strictures) causes the string-like appearance. ulcer lesions found in ulcerative colitis. This is a  Developed about 20 years ago, this procedure  Stool analysis: A test characteristic that helps to differentiate the two 9 eliminates the need for an ostomy bag. shows small amounts of blood in the stools. types of IBD.9  The procedure is performed in two parts.  Small bowel x-rays: X-rays show ulceration, The lining of the small intestine develops oval stiffening and irregular intestinal mucosa.9 The first operation involves removal of  the colon and rectum. The anus and anal shaped elevated patches of lymph follicles called  Blood studies: An elevated white blood sphincter muscles are left intact. The ileum Peyer’s patches. The wall of the bowel thickens, cell count is present, red blood cell analysis is made into a pouch and connected to the and there is narrowing of the affected areas of may indicate anemia, and there may be anus. A temporary ileostomy is performed the intestine. This narrowing causes intestinal decreased levels of potassium, calcium, and obstruction of varying degrees of seriousness. magnesium.8,9 to allow the new pouch to heal. In about 10  to 12 weeks (after the pouch has healed), Loops of the bowel that are inflamed attach  Sigmoidoscopy and colonoscopy: These the temporary ileostomy is closed and stool to other loops, both diseased and normal. The studies may show patchy (discontinuous) passes through the anus. There are several diseased segments of the bowel become thicker, areas of inflammation that help to distinguish possible complications that can occur shorter and narrower.9 it from ulcerative colitis, which causes continuous areas of inflammation.9 after an IPAA is performed. These include Incidence The number of cases of Crohn’s disease has Elite Page 11 Treatment The two “ends” of the normal or unaffected relationship to a diet high in saturated animal fat Treatment focuses on controlling the intestine are joined together (anastomosis). such as found in red meats and processed meats inflammatory process of the disease and reducing A resection may provide many years of (e.g., hot dogs and processed luncheon meats).3,5 signs and symptoms. Supportive measures relief from the symptoms of the disease. Additional risk factors include:3,5 including medications, dietary changes, rest and Unfortunately, the disease can recur at or  Cigarette smoking. stress reduction are the first steps taken. Surgery close to the site of the anastomosis.27    Obesity. is never a first initiative because it does not  Colectomy (removal of the colon) or both  Sedentary lifestyle. provide a cure, and recurrence of symptoms after colon and rectum (proctocolectomy):  Adult-onset diabetes. 5,8,9 surgery is common. Patients with severe disease that affects the  Age (older than 40). colon may need to have the entire colon Initial measures include:  History of ulcerative colitis.  removed. If the rectum is unaffected, the  Administration of medications such as Nursing alert! The average period of time 9 surgeon may be able to join the end of the sulfasalazine to reduce inflammation. between diagnosis of ulcerative colitis and the  small intestine to the rectum, thus allowing  Administration of immunosuppressants to development of colorectal cancer is 11 to 17 9 for passage of stool through the rectum. reduce the response to antigens. 5 However, if the rectum is affected, and years.  Administration of infliximab, an anti-tumor both colon and rectum are removed, the necrosis factor agent for disease that does not Research indicates that the development of patient requires an ileostomy and must wear respond to conventional therapy.5,9 colorectal cancer is linked to alterations in an external bag for the collection of body  Administration of anti-diarrheal drugs to several genes. The majority of colon cancers waste.27 suppress diarrhea. Note that such drugs stem from adenomatous polyps. However, are contraindicated if bowel obstruction is Nursing alert! Even if the diseased section of the other polyps may become malignant, and it is present.9 intestine is surgically removed, the inflammation impossible to say which polyps will become  Administration of an opioid analgesic for the can reoccur in a previously unaffected segment of cancerous. Complete removal of all colon polyps control of both pain and diarrhea.5,9 the intestine.27 About half of adults who undergo dramatically decreases the risk of a causing 3  Reduction of stress. Patients may need a resection have a recurrence of Crohn’s disease malignancy. education regarding stress reduction within five years of surgery.27 Signs and symptoms 9 measures. Special nursing considerations Signs and symptoms of colorectal cancer depend  Encouragement of adequate rest to facilitate  Patients need emotional support as they deal on the location and stage of the malignancy. bowel healing.9 with the effects of Crohn’s disease and its Although disease in its early stages may not  Implementation of dietary changes: Foods chronic nature.5,9 cause any signs or symptoms, the following are that are to be eliminated vary from patient to  Intake and output should be meticulously associated with the disease as it advances. patient. However, foods that are commonly  monitored.5,9  The right (ascending) colon: Black, tarry found to be irritating and thus need to be  Monitor for fluid and electrolyte imbalance.5,9 stools, anemia due to insidious blood loss removed from the diet include dairy products,  Monitor hemoglobin and hematocrit levels.5,9 (which may be the first sign of colon cancer), spicy foods, fatty foods, caffeine and  Promote rest and avoidance of foods that abdominal cramps or pressure, vomiting, carbonated beverages.9 9 trigger attacks.5,9 weakness, fatigue, anorexia and weight loss. Surgery  For patients requiring a resection, arrange for Stool in the right or ascending colon is liquid, Medications and supportive measures are the first a visit by an enterostomal therapist.9 so tumors in this area can actually become 3 interventions for patients dealing with Crohn’s very large before blocking stool movement. Colorectal cancer  disease. Nevertheless, approximately 66 percent  Transverse colon: Tumors in this area can Colorectal cancer is the third most common to 75 percent of patients with Crohn’s disease interfere with the movement of more solid 27 cancer in the United States as well as in stool and can cause cramps and eventually require surgical intervention. Surgery 3,5 Europe. Nearly all colorectal malignancies are 3 is indicated to correct bowel perforation, in the that last for more than several days. adenocarcinomas.5  event of massive hemorrhage, fistulas, acute  The left (descending) colon: Intestinal intestinal obstruction, toxic megacolon, or for Colorectal cancer generally grows slowly and obstruction, abdominal distention, patients who do not respond to medication and often remains localized for a long period of time. pain, vomiting, cramps, rectal pressure, supportive measures.5,27 Early diagnosis before involvement of the lymph constipation, diarrhea, dark red or bright red nodes has about a 90 percent cure rate. The five- blood in stools, and pencil-shaped or ribbon- There are several surgical options for the patient 9 year survival rate for persons with adjacent organ shaped stools. with Crohn’s disease. 5  Sigmoid colon: Passage of bright red blood  or lymph node spread is about 60 percent.  Strictureplasty: When the small intestine via the rectum, changes in bowel habits and Colorectal cancer includes cancers that affect is the area affected by Crohn’s disease, ribbon-like stools.3 portions of diseased intestine alternate with both the colon and the rectum. Colon cancer 28 portions of normal bowel. The affected refers to malignancies that occur below the small Signs and symptoms of rectal cancer include:  areas narrow, forming strictures, which may intestine and above the last six inches of the GI  Diarrhea.  interfere with the passage of digested food. tract. Rectal cancer refers to malignancies that  Constipation. 3  Pain occurs when normal segments of the occur in the last six inches of the GI tract.  Narrow stools (“ribbon” shaped) or a change intestine “push” against the affected areas in in the shape of stools. Incidence  Feeling that the bowel isn’t emptying even an effort to promote passage of digested food. More than 130,000 people are diagnosed with During strictureplasty, the surgeon makes a after bowel movements. colorectal cancer every year in the United States.  lengthwise incision along the affected area(s)  Dark or bright red blood in the stool. It causes more than 50,000 deaths annually and  and then sutures the incision crosswise. This  Abdominal cramps, bloating, gas pains. is the second-leading cause of cancer death in the  Changes in appetite. widens the stricture without removing any 5 United States.  part of the small intestine.27  Weight loss.   Resection: In the event of a particularly Cause and risk factors  Fatigue. long stricture or if there are many strictures The exact etiology of colorectal cancer is not Diagnosis close to each other, the surgeon may need known. However, research shows that there is a In addition to a history and physical, a number to remove the affected area of the intestine. higher incidence of the disease in areas of higher of diagnostic tests are conducted to identify economic development, which may indicate a colorectal cancer. Page 12 Elite  Digital rectal exam (DRE): DRE is and cervical cancer. HPV can also cause and celiac sprue, is a disease that damages the conducted to palpate for any rectal masses. genital warts. small intestine. It is characterized by an inability DRE detects nearly 15 percent of colorectal  Older age: The majority of reported cases of to properly absorb food and an intolerance of cancers.5,9 are diagnosed in persons 50 years gluten, a protein found in wheat, wheat products,  Fecal occult blood test: This test is of age and older. rye and barley. Gluten is found in a wide variety conducted to look for the presence of blood  Multiple sexual partners: Risk of anal of foods but may also be found in everyday in stools.5,9 cancer is greater in men and women who items such as vitamins, lip balms and some  Scopes: Proctoscopy, sigmoidoscopy and have multiple sexual partners throughout medicines.5,31 colonoscopy are performed to visualize their lifetimes. Celiac disease is two-fold disease. It is a disease tumors, detect polyps, remove polyps and  : The risk of anal cancer is greater in 5,9 of malabsorption and an immune reaction to biopsy suspicious tissues and lesions. persons who engage in anal sex. 31   gluten. When gluten is ingested, there is injury  CT scans: CT scans are generally conducted  Smoking: Smoking cigarettes may increase to the villi in the upper portion of the small to identify areas of metastasis. 5,9 the risk of anal cancer.   intestine. This leads to a reduction in surface area  Barium x-rays: These x-rays can show the  Immunosuppressant drugs: Persons who and malabsorption of most nutrients.9 location of lesions that cannot be detected take drugs that weaken the immune system, visually or manually.5,9 such as persons who have received organ Under normal conditions, villi allow absorption  Carcinoembryonic antigen: This is a transplants, may have an increased risk of of nutrients from food into the bloodstream. If blood study used as a tumor marker. It is anal cancer. villi are not healthy, nutrients cannot be absorbed. not specific enough for early diagnosis, but  Corticosteroids: Long-term use of This causes the patient to become malnourished, 31 is used to monitor patients before and after corticosteroids may also increase the risk of no matter how much food is eaten. treatment.5 anal cancer. Causes and incidence  Treatment  HIV infection: HIV infection suppresses the Celiac disease is caused by an intramucosal immune system and increases the risk of anal Surgery is the most effective treatment for enzyme defect that prevents the body from cancer. colorectal cancer. In very early cases, polyp digesting gluten. Tissue toxicity occurs, resulting removal and analysis of adjacent tissues to Signs and symptoms in swift turnover of cells, increased number of determine whether the disease is localized may Signs and symptoms are not specific to anal epithelial lymphocytes and damage to the surface 5,31 be sufficient. Lymph nodes may also be removed cancer and may mimic other problems. Signs and epithelium of the small bowel. to determine whether the cancer has invaded the symptoms associated with anal cancer include:30 Celiac disease is found in people all over the lymphatic system.5  Pain in the anal area. world. More than 2 million persons in the United  Depending on the extent of the disease, colon  Bleeding from the anus or rectum. States have celiac disease, which affects one of  5,31 resection (removal of parts of the colon) may be  A mass in the anal canal. every 133 people in this country.  Anal itching. necessary. In some cases, a permanent stoma with Celiac disease affects women and girls twice as an external collection device may be necessary. Nursing alert! Some patients may assume that often as men and boys. There is a strong genetic Metastatic disease or inoperable tumors indicate these symptoms are not serious and think that association among persons who have the disease. the need for chemotherapy, such as fluorouracil they may be caused by common problems such as For people who have a first-degree relative (e.g., with leucovorin, irinotecan and oxaliplatin. hemorrhoids. Therefore, they don’t seek medical parent, sibling, or child) with celiac disease, the 31 Monoclonal antibody therapy may be initiated help. Encourage patients to always seek medical incidence may be as high as one in 22 people. 30 to inhibit the growth of cancer cells. Radiation intervention for their symptoms. The disease is found primarily in whites and therapy may be used before or after surgery or in Diagnosis persons of European ancestry. It is also more combination with chemotherapy.5 Diagnosis is made depending on the findings common in people with other genetic disorders, such as Down syndrome.31 Anal cancer of a history and physical exam and diagnostic Anal cancer is a rather rare cancer that affects the tests. A digital rectal exam (DRE) is performed, Celiac disease, which may also be autoimmune in anal canal. About 5,290 new cases of anal cancer and an anoscope may be inserted to inspect the nature, seems to occur in people who have other anal canal. Ultrasound may also be conducted, autoimmune diseases such as:31 were expected to be diagnosed in 2009 in the  United States, 3,190 in women and 2,100 in men. and a biopsy of suspicious tissue or masses is  Type 1 diabetes mellitus. performed.30  Thyroid disease. It is estimated that 710 people will have died  from anal cancer in 2009.29 Treatment  Addison’s disease.  Rheumatoid arthritis. Anal cancer is not colorectal cancer. Anal cancer is generally treated using a Unfortunately, many people, including health combination of chemotherapy and radiation. Other conditions associated with celiac disease care professionals, equate anal cancer with Surgery may be performed as well. Very small, include anemia, and 5 colorectal cancer. The rectum is the lowest localized anal cancers may be removed along osteoporosis. portion of the colon. The anal canal houses the with surrounding tissue to determine the size Complications of celiac disease include:5 sphincter that controls the passage of stool from and spread of the disease. Advanced cancers or  Anemia secondary to malabsorption. the body.29 cancers that do not respond to chemotherapy and  Syncope, angina and heart failure due to radiation may require more extensive surgery. Anal cancer is closely linked to human anemia. In these cases, the surgeon may remove the  Bleeding disorders due to vitamin K papillomavirus (HPV) infection, a sexually anal canal, rectum and part of the colon. The transmitted disease. It is believed that HPV deficiency. remaining colon is attached to an abdominal  Intestinal lymphoma. is associated with 90 percent to 99 percent of stoma and an external bag.30 all anal cancers. The infection is most often Signs and symptoms diagnosed in white females.29 Anal cancer is a relatively uncommon cancer. There are a wide variety of signs and symptoms Patients need to be assessed and treated by Risk factors associated with celiac disease. The disease affects health care professionals who have experience in people in different ways because of the amount of A number of factors are linked to an increased diagnosing and treating this cancer. risk of anal cancer.29,30 damage to the small intestine, a person’s age and  HPV infection: HPV infection increases the Celiac disease the length of time the patient has had symptoms 31 risk of a number of cancers, including anal Celiac disease, also referred to as idiopathic without being diagnosed and treated. steatorrhea, nontropical sprue, gluten Elite Page 13  GI effects: Damage to the small intestine  Some non-food products, such as lipstick, of the bowel and exerts high intra-abdominal may cause cramping, recurrent diarrhea, may contain gluten as an additive. Find out pressure during elimination of .9 abdominal distention, weakness and an about the contents of any product that can be When diverticulitis occurs, undigested food increase in appetite without weight gain.9 ingested through the GI tract! If ingredients  and bacteria build up in the diverticular sac.  Hematologic effects: Anemia due to are not provided on the label or package The food and bacteria become a hard mass that malabsorption of folate, iron, and vitamin insert, contact the manufacturer for a product inhibits blood supply to the walls of the sac. B12.5 list.31   This lack of blood makes the sac susceptible to  Malabsorption effects: Loss of calories,  When eating out, ask the waiter if a gluten- bacterial infection and inflammation. This may 31 fat-soluble vitamins (A,D,K), calcium, free menu is available. lead to perforation, obstruction, peritonitis or minerals, electrolytes and malabsorption of Here are some Web sites that persons dealing hemorrhage. Sometimes the inflamed portion fat, carbohydrates and protein.5,9  with celiac disease may find useful. of the colon may adhere to organs such as the  Musculoskeletal effects: Osteomalacia, 5,9  American Celiac Disease Alliance bladder, causing a fistula to form. osteoporosis, tetany and bone pain due to (www.americanceliac.org). calcium loss and vitamin D deficiency.9 is most prevalent in developed or  American Dietetic Association  Neurologic effects: Paresthesia, seizures, industrialized countries, especially the United (www.eatright.org). peripheral neuropathy.5,9 States, England and Australia where low-fiber  Celiac Disease Foundation (www.celiac.org).  Skin effects: Dry skin, eczema, psoriasis, diets are common. Areas where people consume  Gluten Intolerance Group of North America dermatitis, brittle nails.5,9 diets high in fiber, such as Asia and Africa, have a (www.gluten.net). 5,9,32  Endocrine effects: Amenorrhea, rare incidence of the disease.  National Foundation for Celiac Awareness hypometabolism and adrenocortical High-fiber diets make stools soft and easy to 5,9 (www.celiaccentral.org). insufficiency. eliminate from the body. Lack of fiber decreases   Psychosocial effects: Irritability, lethargy, Diverticular disease stool bulk and makes stools harder and more 5,9 and mood changes. Bradley is a 70-year-old retired nurse. He is difficult to pass from the body. If stools are hard, Diagnosis active and healthy, and since his retirement, people strain when eliminating stool during a enjoys traveling throughout the United States. On A number of diagnostic findings lead to the bowel movement. Straining increases colonic a recent visit to his son in Arizona, he suddenly diagnosis of celiac disease. pressure, which may cause the lining of the colon developed left lower abdominal quadrant pain  Esophagogastroduodenoscopy: During this to bulge out through weak areas in the wall of the and bloody diarrhea. Bradley’s son insists on 32 test, tissue specimens are obtained for biopsy. colon. taking him to the emergency room for evaluation. Histologic changes seen include a mosaic- The cause of Bradley’s rectal hemorrhage is Diverticular disease is most common in men like pattern of alternating flat and bumpy determined to be due to diverticulitis. more than 40 years of age and in persons who areas, a nearly total absence of villi, and lack fiber in their diet. Incidence increases with an irregular, blunt, unorganized network of Diverticular disease is characterized by bulging age. However, about 20 percent of patients are 5 blood vessels confirm diagnosis. pouches or diverticula in the GI tract. These younger than 50. About half of older adults   Blood studies: Elevated alkaline phosphatase pouches push the mucosal lining through the develop diverticulosis.5 levels, low cholesterol and albumin levels, surrounding muscle. Diverticula are most often slightly elevated liver enzymes, abnormal found in the sigmoid colon, but can develop Complications blood clotting and anemia.5 anywhere from the proximal end of the pharynx There are several potentially lethal complications  Antibody blood tests: High levels of anti- to the anus.5,9 of diverticular disease that stem from tissue transglutaminase (+TGA) antibody diverticulitis. When the pouches become inflamed, it is or anti-endomysium antibodies (EMA) are  Rectal hemorrhage: Rectal hemorrhage referred to as diverticulitis. Diverticulitis may indicative of the disease.31 due to diverticulitis is relatively uncommon. cause potentially fatal complications, such However, when it does occur, it can cause Treatment as obstruction, infection or hemorrhage. In massive blood loss. It is believed that such The only treatment for celiac disease is diverticulosis, diverticular exist, but do not bleeding is the result of blood vessel(s) 5,32 implementation of a gluten-free diet for the cause any symptoms. Together, diverticulosis in a diverticulum that weaken and burst. remainder of the patient’s life. This involves and diverticulitis are referred to as diverticular Bleeding can range from minimal to severe, 32 eliminating wheat, barley, rye and oats from disease. It is estimated that 10 percent to but it may stop by itself without medical the diet as well as foods that are made from or 25 percent of people with diverticulosis get intervention. However, some persons 32 contain these products. Patients usually notice diverticulitis. experience severe hemorrhage requiring swift sign and symptom improvement within days of Meckel’s diverticulum is diverticular disease of medical intervention, blood transfusion and eliminating gluten from their diets. The small the ileum and is the most common congenital colonoscopy to identify the site and cause of intestine heals within three to six months in 5,32 anomaly of the GI tract. It is characterized by a bleeding. children but may take several years in adults.5,31 “blind tube,” similar to the appendix, that opens Nursing alert! All rectal bleeding, even small Nursing alert! Because this is a significant into the ileum. It is found in about 2 percent amounts, must be medically evaluated as dietary change, patients need dietary consults of the population, usually in males. Meckel’s soon as possible. The cause may be self- and excellent patient education. Initially, the diet diverticulum, if uncomplicated, is asymptomatic. limiting and minor in nature, or quite serious. consists of proteins and is slowly expanded to If complications occur, the patient experiences Encourage all patients to seek prompt include other foods.5 abdominal pain, usually around the umbilicus, evaluation for rectal bleeding!  Here are some tips for patients as they adapt to and dark red . Complications may lead to  Fistula: A fistula, or abnormal opening or their new way of eating, which must continue for peptic ulcer, perforation, peritonitis and bowel connection of tissues between two organs 5 the rest of their lives! obstruction. or between and organ and the skin, can be a complication of diverticulitis. In the case  Read all food labels carefully! Many foods Cause and incidence 5 of infection related to diverticulitis, the contain gluten in varying amounts. Diverticula are most likely due to high pressure  infection may travel outside of the colon,  Ask pharmacists whether prescribed exerted on a portion of the GI wall where blood causing the tissue of the colon to adhere to medications contain wheat or other gluten vessels enter. Diet is believed to contribute to the 31 nearby tissues. This most often involves products. development of diverticular because inadequate tissue of the bladder, small intestine and the fiber diminishes fecal residue, narrows the lumen

Page 14 Elite skin, with a fistula between the colon and of diverticular disease because bowel prep for If patients are taking bulk-forming cathartics such the bladder being the most common. Such colonoscopy is arduous and can put unnecessary as Metamucil, they should be taught to take them a fistula is found in men more frequently pressure on the bowel.5 with plenty of water. If these agents are not taken than women and can lead to severe urinary with enough liquid, they may absorb moisture in Treatment tract infections. Surgery may be necessary to the mouth and throat and swell, thus blocking the If diverticulosis does not produce signs or remove the fistula and the part of the colon esophagus or trachea.5 symptoms, treatment is not usually necessary. that is affected.32 However, if signs and symptoms are present, Additional information about diverticular disease  Intestinal obstruction: Infection may treatment depends on their severity. The first step may be found on the following Web sites: cause significant scarring that may lead to is to increase the amount of fiber in the diet. This  American College of intestinal obstruction. Complete obstruction may reduce or prevent symptoms and prevent (www.acg.gi.org). is a medical emergency requiring immediate complications such as diverticulitis. 32  American Gastroenterological Association surgical intervention.32 (www.gastro.org).  Abscess: Abscess is a localized infection that Fiber keeps stools soft and lowers the pressure  International Foundation for Functional can cause swelling and destruction of tissue. within the colon, thus facilitating movement Gastrointestinal Disorders (www.iffgd.org). A small abscess may be confined to the of feces through the bowel. High-fiber foods colon wall and resolve itself with antibiotic include whole-grain cereals and breads, fruits Intussusception treatment. Failure to respond to antibiotics and vegetables. Fiber products (bulk-forming Shannon is an experienced pediatric nurse who may require an incision and drainage of the cathartics) such as methylcellulose (Citrucel) or recently relocated from a large urban area to a abscess.32 psyllium (Metamucil) may be recommended by small community in another state. After spending  Perforations and peritonitis: Infected health care providers.32 many years specializing in pediatrics, Shannon perforations spread infection from the colon decides to explore a new employment opportunity Some physicians recommend that patients to the abdominal cavity causing peritonitis. as a nurse in a large outpatient family practice avoid nuts, popcorn and seed products such Symptoms include severe nausea, vomiting, setting where she now cares for adult patients as as sunflower, pumpkin and sesame seeds. fever, and abdominal tenderness. Peritonitis well as children. On a warm summer afternoon, These products may enter, block or aggravate is a medical emergency requiring surgery to Mr. Williams arrives for an appointment with his diverticula.32 treat the infection and remove the damaged physician and sits uncomfortably in the waiting portion of the colon.32 Patients with diverticulosis who experience pain, room. He complains of vomiting, diarrhea and mild GI distress or constipation may be placed on colicky abdominal pain. His pain radiates from Signs and symptoms a bland or liquid diet and stool softeners to help the right lower abdominal quadrant to the back The patient with diverticulosis does not usually relieve symptoms and minimize the possibility of and increases after he eats. One of Shannon’s have any symptoms. This is generally true until, the development of diverticulitis. After symptoms colleagues comments, “I’ll bet he has that awful and if, the patient develops diverticulitis. In diminish, high-fiber diets and fiber products may GI flu that’s going around.” Shannon disagrees that case, symptoms may be listed according to be recommended.5,9 and hurries to see Mr. William’s physician. She severity of the problem. tells her, “I’ve seen this a lot in infants. It’s really  Mild diverticulitis: Left lower abdominal Patients whose disease progresses to diverticulitis rare in adults, but I think Mr. Williams has an quadrant pain, mild nausea, gas, low-grade need to take additional measures. Persons intussusception. He needs to be seen now!” fever, leukocytosis and irregular bowel experiencing mild diverticulitis without evidence habits.5,9,32 of perforation need to rest their colons. A liquid Intussusception is a serious, potentially fatal  Severe diverticulitis: Diverticular rupture diet and stool softeners are recommended. condition in which a portion of either the small characterized by abdominal rigidity, left- Antibiotics may be administered to prevent or intestine or the colon moves into another part lower abdominal quadrant pain, high fever, control infection.5,32 of the intestine. This movement is referred to as 5,9 chills, hypotension and shock. About 20 If the diverticulitis is severe, a variety of “telescoping” and can cause a blockage of the percent of patients develop diverticular that interventions may be necessary, depending intestine, thus preventing the passage of food and rupture and cause abscesses or peritonitis.5 fluids as well as cutting off the blood supply to on the problems the diverticulitis is causing. 5,9,33 Minimal to severe rectal hemorrhage may The following interventions may be initiated, the affected portion of the intestine. Fatalities 9 occur from ruptured diverticular. depending on the signs and symptoms present occur most often if treatment is delayed for more  5  Chronic diverticulitis: Constipation, ribbon- and the degree of severity of the disease.5,9,32 than 24 hours. shaped stools and intermittent diarrhea.  Blood transfusions may be needed in the When the bowel segment (the intussusception) Fibrosis and adhesions narrow the lumen presence of severe hemorrhage. moves into another part of the intestine, referred of the bowel, which may cause intestinal  Analgesics are administered to control pain to as invagination, it is moved along the intestine obstruction. Such obstruction causes and relax smooth muscles. via . This movement pulls even more abdominal rigidity and pain, vomiting and  Antispasmodics are administered to manage 5,9,32 bowel along with it. Invagination causes edema, reduced or absent bowel sounds. muscle spasms. hemorrhage, incarceration and obstruction.  Diagnosis  Surgery: Colon resection may be performed If treatment is not initiated within 24 hours, Diagnosis depends on a history and physical to remove affected segment of the colon. strangulation of the affected areas of the intestine  exam, including a rectal digital exam. Many  Surgery: Temporary colostomy may be occurs, resulting in shock, perforation and times diverticular disease, which often produces performed to drain abscesses and remove gangrene.5,9 no symptoms, is identified during an upper infection and give the colon a rest. This procedure may be indicated in the event of Causes and Incidence GI series performed as part of a differential Intussusception is seen most often in infants 5 obstruction, fistula, perforation or peritonitis. diagnosis. between the ages of 6 months to 1 year. It is An upper GI series can confirm (or rule out) Special nursing considerations twice as common in male infants compared to diverticular disease of the esophagus and upper Because diverticular disease is relatively female infants. Although it can affect adults, the bowel. A barium enema can confirm (or rule out) common, especially as people age, nurses occurrence of intussusception in adults is rare.5,33 5 should encourage their patients to consume diverticular disease of the lower bowel. The exact cause of the intussusception is enough dietary fiber. Patients should also be unknown. But because there are seasonal peaks, Nursing alert! Biopsy of affected tissue can also taught to recognize early signs and symptoms in the spring-summer time period that coincides rule out or confirm malignancy. However, biopsy of diverticular disease, even though the disease with enteritis and in the mid-winter period when should not be performed during acute phase itself is often asymptomatic. Elite Page 15 respiratory tract infections are prevalent, there Treatment Mechanical obstruction is due to blockage from may be an association with viral infections.5,33 For children, treatment is generally either foreign objects, such as or fruit pits; In children, a malignant or benign growth in the hydrostatic reduction or surgery. In adults, bowel wall compression due to such problems intestine may trigger the problem.33 however, surgery is always the treatment of as intussusception; or tumors. Non-mechanical 5 obstruction is due to physiologic alterations In adults, several causes of intussusception are choice. such as electrolyte imbalances, the effects of suspected. These include:33 Hydrostatic reduction involves dripping a barium medications that slow peristalsis (e.g., opioids),  Malignant or benign growths in the intestine. solution into the rectum from a height of no more thrombosis or paralytic .5,34  Adhesions in the intestine. than three feet. Fluoroscopy is used to follow the  Surgical scars in the intestine. progression of the barium. The goal is to have Paralytic ileus is a form of small bowel  Motility disorders of the digestive tract. the barium backwash into the ileum, causing the obstruction that develops after abdominal surgery.  Chronic diarrhea. mass to resolve itself. If this is not accomplished, Paralytic ileus causes a decrease or absence of 5 intestinal motility and usually resolves itself Nursing alert! Once a patient has had the patient must have surgery. within two to three days.5 intussusception, he or she is at risk to develop If surgery is necessary, the surgeon first attempts it again. Patients must be taught to remain alert to manually reduce the intussusception by Signs and symptoms for its signs and symptoms and to seek immediate “milking” or stroking the intussusception back Signs and symptoms can begin with pain, nausea emergency medical treatment if they occur!33 through the bowel. If this attempt fails, or if and vomiting and, if untreated, progress to shock, complications such as strangulation, gangrene or Signs and symptoms sepsis and death. They can vary depending on perforation are present, a resection of the affected the location of the obstruction and whether it is As noted in the scenario that introduced this portion of the bowel is performed.5,330 partial or complete. topic, intussusception can occur in adults as well  Small intestine obstruction: Nausea, as children. Because this is a rare occurrence, Intestinal obstruction vomiting, constipation, abdominal distention nurses must be knowledgeable about presenting Intestinal obstruction is a complication of various and colicky pain. Extreme thirst, malaise, signs and symptoms in persons of all ages. GI disorders and diseases. A common condition, and dry oral mucous membranes and it is estimated that at least 1 in 1,000 patients is Nursing alert! In infants and children there tongue may develop. Bowel sounds are diagnosed with this condition annually.34 are four primary signs and symptoms of heard upon auscultation. These may be Intestinal obstruction can be partial or complete intussusception!5 quite loud, and may even be heard without blockage of the lumen in either the small or the use of a stethoscope. There is pain  The first sign of intussusception in an infant large intestine. The site in 90 percent of patients upon abdominal palpation and rebound might be abrupt, loud crying. The infants with intestinal obstruction is the small bowel, tenderness if strangulation of the bowel is pull their legs up to their , become which is usually more serious than large bowel present. Untreated obstruction may cause pale and diaphoretic, and have grunting obstruction. Untreated complete obstruction, hypovolemic shock. If the small bowel is respirations. The pain is intermittent, initially regardless of location, can be fatal within hours completely obstructed, extreme peristalsis occurring at 15- to 20-minute intervals. from shock and vascular collapse.5 As time passes, the episodes occur more may develop as the bowel attempts to move 5,33 Intestinal obstruction can be classified in three its contents through the obstruction. Bowel frequently and last longer. 5  Stomach contents are vomited. Patient categories: contents may be moved toward the mouth, 1. Simple: Intestinal contents cannot and vomitus contains gastric juice, then bile, eventually vomits bile-stained contents or 5 5 move through the bowel, but there are and eventually, the contents of the ileum. fecal material.   The infant’s stools have a “currant-jelly” complications or blood flow alterations.  Large intestine obstruction: Symptoms appearance and contain blood and mucus.5,9 2. Strangulated: Blood supply is cut off to the progress more slowly because the large bowel  The abdomen becomes tender and distended, affected section of bowel. This may be partial can absorb fluid and distend well beyond its and a sausage-shaped mass can be palpated.5,9 or complete. typical size. At first, constipation may be the 3. Close-looped: both ends of a portion of the only sign. Then colicky abdominal pain may Signs and symptoms that occur in adults bowel are blocked, thus isolating it from the develop quite swiftly, producing frequent include:5,33 rest of the intestine. spasms. There is significant abdominal  Urgent need to defecate. distention. Eventually, vomiting occurs. The Obstruction of the intestine causes GI secretions,  Colic-like abdominal pain and tenderness. vomitus may contain fecal matter; continuous gas and swallowed air to accumulate near the  Vomiting. abdominal pain develops, and peritonitis location of the obstruction. Peristalsis increases  Diarrhea. may occur. If the obstruction is partial, these above and below the obstruction as the bowel  Bloody stools. symptoms can occur but in a less severe tries to force its contents through the blockage.  Weight loss. form. Liquid stool may leak around the This damages the intestinal mucosa and leads obstruction.5 In adults, the abdominal pain is localized in the to distention at and above the area of blockage. right lower quadrant and radiates to the back. Distention interferes with venous blood flow and Diagnosis This pain increases with eating. In cases of blocks normal absorption. The inability to absorb In addition to findings from a history and severe intussusception, pain may be agonizing causes the bowel to secrete water, sodium and physical, lab studies may show decreased and accompanied by abdominal distention and potassium into fluids collecting in the lumen.5,35 sodium, chloride and potassium levels due to tachycardia.5 Small bowel obstruction leads to metabolic vomiting and an elevated white blood cell count 5 Diagnosis alkalosis due to dehydration and loss of acidic due to infection (e.g., peritonitis). Barium enema is performed to confirm gastric contents (gastric hydrochloric acid). Diagnostic tests such as CT scans, barium enema, intussusception. Findings show a characteristic Obstruction in the lower bowel causes a loss in upper GI and small-bowel series, and abdominal “coiled spring” appearance. Barium enema also alkaline fluids leading to metabolic acidosis.5 films are conducted. Small bowel obstruction shows the extent of intussusception. Additional Causes findings include alternating levels of fluid and findings include a palpable as gas, sometimes referred to as a “stepladder” In developed countries, the leading cause of well as the signs and symptoms identified in the pattern.5,35 Large bowel obstruction findings small bowel obstruction is adhesions followed preceding section.5,33 include a distended, air-filled colon.5 by malignancy, Crohn’s disease and hernias.35 Large bowel obstruction is generally due to malignancy.5 Page 16 Elite Treatment to abnormal muscular structure around the  Fever. Initially, immediate treatment includes fluid umbilical area.  Tachycardia. resuscitation, correction of electrolyte imbalances  : Occurs at the site of a  Anorexia. and administration of analgesics and anti- previous surgery due to a weakness in the  Vomiting. emetics as indicated. Bowel decompression is abdominal wall, inadequate wound healing or  Infection. accomplished by the insertion of a nasogastric an infection.  Absent or diminished bowel sounds. tube to suction GI contents and avoid  Bloody stools. Causes and incidence aspiration. Antibiotics that are effective against  Shock. There are two types of inguinal hernias: direct gram-negative and anaerobic organisms are and indirect. Each type has different causes. Nursing alert! Remember that strangulation of prescribed.35 1. Indirect : Indirect inguinal the hernia is a medical emergency. In the event Strangulated obstruction requires blood hernias are congenital in nature and are more of intestinal necrosis, the affected potion of the transfusions. Patients must be monitored closely common in males than in females and more intestine must be removed.5,37 for evidence of shock indicated by pallor, common than direct hernias. This is because Diagnosis tachycardia and hypotension. If the patient’s in a male fetus, the spermatic cord and both Upon inspection, a large hernia is evident by condition does not improve or if it deteriorates, testicles descend, under normal conditions, swelling, bulging or the presence of a lump in surgery is needed.5 through the inguinal canal into the scrotum. the inguinal area. A small hernia may just appear Surgical interventions may include removal But if for some reason the entrance of the as an unusual “fullness” in the . Signs and of tumors and other masses, hernia repair or inguinal canal does not close just after birth, symptoms and patient history all help in the bowel resection.35 For large bowel obstruction, a weakness is created in the abdominal wall. diagnosis of inguinal hernia. surgical resection with anastomosis, colostomy or This allows fat or part of the small intestine An important part of the physical exam in a ileostomy may be necessary.5 to move through weaknesses into the inguinal canal, causing an inguinal hernia. In females, male patient is essential to confirmation of the Special nursing considerations an indirect inguinal hernia occurs when the diagnosis. The patient is asked to stand with the  Monitor closely for signs and symptoms female organs or the small intestine slides leg on the same side as the hernia (ipsilateral) of metabolic alkalosis: Changes in levels into the groin through a weakness in the slightly flexed and his weight on the other leg. of consciousness, tetany, twitching, shallow abdominal wall.37 The examiner inserts his/her gloved index finger respirations, cardiac arrhythmias and 2. Direct inguinal hernia: Direct inguinal into the lower part of the scrotum moving the confusion.36 hernias are due to degeneration of the finger through the external inguinal ring to the  Monitor closely for signs and symptoms connective tissue of the abdominal muscles, internal ring throughout the inguinal canal. The of metabolic acidosis: Headache, lethargy, which leads to weakening of the muscles patient is asked to cough. If the examiner notes deep, rapid respirations (Kussmaul’s during adulthood. Direct inguinal hernias pressure against his/her fingertip, an indirect respirations), hypotension, anorexia, stupor.36 only occur in males.37 The hernia passes hernia is present. If pressure is felt against the  Monitor intake and output meticulously: thorough the weak muscles into the groin. side of the finger, a direct hernia is present.5 Record amount and color of NG tube A direct hernia develops as a result of Treatment drainage.5 continuous stress on the muscles.5,37 Sudden  The treatment of choice for infants, adults  Monitor for signs of dehydration: Thick, twists or pulls, lifting heavy objects, straining and healthy elderly patients is herniorrhaphy. swollen tongue, dry oral mucous membranes with bowel movements, weight gain and Herniorrhaphy is a surgical procedure during 37 and poor skin turgor. chronic coughing may all worsen the hernia. which the contents of the hernia sac are replaced Inguinal hernia Nursing alert! Be alert to the possibility of into the abdominal cavity. This procedure is often An inguinal hernia occurs when intra-abdominal incarcerated or strangulated inguinal hernias. performed under local anesthesia in a short-term 5,37 fat or a portion of the small intestine protrudes An incarcerated inguinal hernia is one that unit. Another surgical option is hernioplasty, through a weakened area in the lower abdominal becomes trapped in the groin or scrotum and is during which the weakened area is reinforced or 5 wall. This type of hernia is located in the groin unable to be massaged back into the abdomen. supported with steel mesh, wire or fascia. because the fat or intestine moves through a weak An incarcerated hernia can become strangulated, For elderly or debilitated patients who are not area at the inguinal ring, which is the opening to meaning there is serious interference with normal able to tolerate surgery, a truss may be used to the inguinal canal. An inguinal hernia appears as blood flow to the incarcerated area. This can lead keep the abdominal contents from protruding into 37 a bulge on one or both sides of the groin. to obstruction and necrosis. Strangulated hernia the hernia sac. This is not a curative measure, but is a serious medical emergency.5,37 Inguinal hernias are usually reduced is an option for relieving the discomfort of the 5 (manipulated back into place) without much Signs and symptoms hernia. difficulty. However, the hernia may become Typical signs and symptoms of inguinal hernia Some patients, especially if the hernia is not incarcerated due to adhesions that interfere with include:5,37  causing significant discomfort, may delay intestinal flow or strangulated, meaning that the  A lump or bulge over the herniated area when surgery. They should be cautioned about the hernia becomes twisted or edematous. In the the patient is in a standing position or strains. potential complications of the disorder and be event of strangulation, normal blood flow and The lump or bulge disappears when the taught to recognize the signs and symptoms of peristalsis are impeded and may lead to intestinal patient is lying down. strangulation and bowel obstruction. Ideally, 5,9  obstruction.  Sharp, steady pain in the groin that is patients will respond to the need for surgical exacerbated with lifting, straining or repair before such complications occur. Nursing alert! There are a number of common exercising, and is relieved with rest or being 5,9 sites of hernia. These include: After surgery, patients should be taught how to  in the supine position.  Femoral: Develops when a fatty deposit  Feelings of weakness or pressure in the groin. recognize signs and symptoms of infection and within the femoral canal grows and creates to avoid lifting heavy objects or straining during Strangulation of the hernia, a medical emergency an opening large enough for part of the bowel movements. peritoneum and bladder to move through. that can lead to partial or complete bowel  Umbilical: Common in neonates, but also obstruction, produces the following signs and Inactive colon 5,37 occurs in obese women, or in women who symptoms: Connie is a 50-year-old small business owner.  have had a number of pregnancies. It is due  Severe pain. She recently fulfilled a long-wished-for dream  Redness in the area of the hernia. and opened a craft shop specializing in knitting

Elite Page 17 and embroidery products. Prior to opening her When a person does not drink enough fluids, decaffeinated beverages to avoid interfering shop, Connie worked as a buyer for an exclusive more fluid is absorbed from the intestine and with sleep. Older patients or patients with women’s boutique. Connie is accustomed to a stools become hard and dry. Adequate hydration incontinence should avoid drinking large stressful work situation and to working long as well as a diet high in fiber causes water to be amounts of fluid before bedtime as this hours, but enjoys the challenge of an active pulled into stools by osmosis, thus keeping stools increases the possibility of incontinence. career. soft and facilitating their movement through the Encourage these patients to consume their intestine.9 beverages during the day and early evening. She also has to deal with something just as Nursing alert! Caffeine-containing liquids challenging but a lot less enjoyable: chronic Common causes of constipation include:5,9,38 and beverages that contain alcohol can constipation. Connie has suffered from  Low-fiber diet. contribute to dehydration. Encourage the constipation for most of her adult life and just  Lack of exercise or limits in ability to be intake of hydrating fluids such as water and shrugged it off as “something I have to live with. physically active. beverages that are decaffeinated whenever It’s probably because of my stressful career.”  Certain medications, such as opiates and possible!38 What Connie doesn’t realize is that the stress and antacids, that interfere with bowel motility, Nursing alert! Some patients may be on fluid long hours also contribute to her having little  Conditions or injuries that interfere with restrictions due to other health conditions. Be or no time to exercise, and she usually eats fast neural pathway functioning (e.g., spinal cord aware of overall health status and medically food or skips meals altogether. The constipation injury, multiple sclerosis, stroke or tumors of ordered fluid restrictions when providing seems to be getting worse, and she feels bloated the intestine). patient education. and uncomfortable several days a week. Connie  Metabolic and endocrine disorders.  Eat a diet high in fiber: The most common finally decides to tell her doctor about this  Overuse or abuse of laxatives. causes of constipation are a diet low in problem and seek some relief for an issue that has  Overuse of enemas, which reduce rectal fiber or one that is high in fats such as troubled her for years. sensitivity to the presence of stool. those contained in cheese, eggs and red  Dehydration. Connie is not alone in having to deal with meats. Fiber, the part of fruits, vegetables  Diseases of the colon or rectum. chronic constipation, also referred to as inactive and grains that cannot be digested by the  Ignoring the urge to have a bowel movement. colon, lazy colon, colonic stasis or atonic body, takes on a soft, gel-like texture in  Stress. constipation. Besides causing feelings of bloating the intestines, helping to make stools soft and abdominal discomfort, inactive colon can Nursing alert! Many medications (in addition to and easily eliminated from the body.38 The also lead to .5 those mentioned above) can affect GI functioning. recommended daily dose of fiber is 20 to Certain blood pressure medications, especially What is constipation? 35 grams a day. Unfortunately, Americans calcium channel blockers, and antidepressants, consume only a daily average of five to Constipation means different things to different anti-Parkinson drugs, iron supplements, 14 grams of fiber.38 Good sources of fiber people. Bowel habits vary among people. Some anticonvulsants, antispasmodics and diuretics, include fresh fruits with skins, raw and people believe that unless they have a bowel may cause constipation in some patients.38 course vegetables, and whole grain cereals.5 movement every day, they are constipated. For  Avoid foods that are highly refined: These others, having a bowel movement every other day Diagnosis foods include white rice, Cream of Wheat, is normal. Actually, there is a wide range of what A history of dry, hard, infrequent bowel pasta, candy, cookies and ice cream.5 Avoid is considered to be normal. movements suggests inactive colon. A eating such foods because they do not help proctoscopy may show that the patient has an Normal patterns of bowel movements range from relieve constipation and are often sources of unusually small colon lumen with abnormal as many as three times a day or three times a fat.38 amounts of mucus and the presence of prominent week, depending on the individual. Constipation  Participate in regular exercise as authorized veins.5 is generally defined as having a bowel movement by health care providers. Moderate physical less than three times a week. 5,9,38 Constipation It is imperative that a thorough history and exercise, such as a walking routine, should be can be self-limiting and short-term or chronic physical be conducted to rule out serious disease incorporated into daily activities.5,38 (inactive colon). processes such as malignancies. Testing stool Nursing alert! Persons have different for occult blood, a rectal exam, an upper GI tolerance levels for exercise because of Causes and incidence series, barium enema and colonoscopy may be age and general health. All persons should Constipation is a very common gastrointestinal performed.5 consult their health care providers prior to complaint in the United States. More than initiating an exercise regimen. 4 million Americans complain of frequent Treatment and nursing considerations  Identify medications that might contribute constipation. Persons who report constipation Treatment depends on results of the physical to constipation: As noted in the section (and seek medical intervention) are most often examination, the patient’s age and general pertaining to causes of constipation, many women and adults 65 years of age and older. health, and his/her ability to participate in medications contribute to the problem of Pregnant women also report constipation fairly lifestyle modifications. These initiatives can be constipation. This includes over-the-counter often, as do women after giving birth and persons preventative as well as used for treatment. Here as well as prescription medications. Patients who have just had surgery.38 are the most common interventions for inactive with inactive colon should discuss and colon or chronic constipation. Nursing alert! Elderly patients generally review ALL medications they are taking and  Increase fluid intake: Adequate fluid intake experience reduced intestinal motility and a include, in addition to prescription and over- is critical to maintaining homeostasis and slowing of neural impulses in the gastrointestinal the-counter, herbal supplements, vitamins, avoiding dehydration. Persons should drink tract, which can increase the risk of constipation. minerals and weight-control products. at least eight to 10 glasses of liquid on a This same population often limits the amount of  In cases of severe inactive colon, take daily basis. Fluid helps keep stools soft for fluids they drink to avoid or reduce incontinence. laxatives under the direction of health easy movement through the intestine and Inadequate fluid consumption also increases care providers. Bulk-forming laxatives facilitates passage from the rectum. Advise the risk of constipation as well as dehydration. are considered to be among the safest, patients to drink a hot beverage, such as Patients who are limited in their physical but can interfere with the effectiveness of coffee or tea, or prune juice before or with activity due to age or illness are also at risk for certain other medications.38 That is why it breakfast to help stimulate the bowel.5,9 Some constipation. 9 is so important to consult with a physician patients prefer to drink such beverages in the regarding adding any medication to a evening. In this case, advise them to drink

Page 18 Elite treatment regimen. Examples of bulk- Causes and incidence Children with midgut volvulus undergo surgical forming laxatives include Citrucel and Volvulus may be due to an abnormality of treatment, often with the Ladd procedure. During Metamucil. Stool softeners, which moisten rotation, ingestion of a foreign body or an this surgical procedure a transverse incision is stool, or lubricants, which grease the stool . The specific cause may never be made through the right rectus muscle in the right and facilitate its movement, may also be determined, however. In adults, the most common upper quadrant, which facilitates visualization prescribed.5,38 site of the disorder is the sigmoid colon. In and access to the intestine. The volvulus is corrected in the majority of patients by rotating Nursing alert! If a fecal impaction is present, an children, the small bowel is a more common site. the intestine in a counterclockwise direction.39 oil-retention enema is usually administered prior Other sites include the stomach and the cecum. Sometimes, in adults with sigmoid volvulus, to its removal.5 In patients with cystic fibrosis, volvulus may occur secondary to meconium ileus (an intestinal a non-surgical reduction is successful. A It is important that patients be advised to avoid blockage due to cystic fibrosis).5,39 proctoscope examination is done to check for the the overuse of laxatives. People who believe presence of infarction. A sigmoidscope or long Acute has a significant mortality that they “must” have a bowel movement every rectal tube is carefully, gently inserted to deflate rate of 42 percent to 56 percent.5 There are no day may rely on laxatives to make this happen. the bowel. Success is indicated by passage of gas known racial differences, and males and females 5 Overuse makes the bowel dependent on laxatives 5,39 and swift relief from abdominal pain. to have a bowel movement.38 are equally affected. About 20 percent of cases of volvulus are noted in infants younger than 1 Overuse of enemas is also contraindicated. year. Peak incidence is noted in people between Rectal prolapse is the protrusion of one or more Frequent use of enemas can make the bowel the ages of 40 to 50.5 layers of the mucous membrane of the rectal dependent on enemas to eliminate stool. In tissue slides through the anal orifice.5,40 There are particular, frequent use of sodium biphosphate Signs, symptoms, and complications two types of rectal prolapse: partial and complete. should be avoided because it is a hypertonic Volvulus causes vomiting and a rapid, noticeable 1. Partial rectal prolapse occurs when only the solution that can absorb a significant amount of distention of the abdomen with abrupt onset rectal mucosa and a small mass of radial the colon’s sodium or pull intestinal fluids into of severe abdominal pain. Bloody stools, 5 5,9 mucosal folds are involved. the colon, thus causing dehydration.5 constipation and shock may also occur 2. Complete rectal prolapse occurs when the full Immediate treatment is necessary to prevent life- rectal wall, anal sphincter muscle or bowel To help establish a normal pattern of bowel threatening complications. Such complications evacuation, a person should include maintaining herniation are involved. Complete rectal include strangulation of the twisted portion of the prolapse is also referred to as procidentia.5 a regular time for bowel movements (e.g., in the bowel, ischemia, infarction, perforation and fatal morning after breakfast). Privacy is important. peritonitis.5 Causes and incidence Using a small footstool to enable thigh flexion The exact cause of rectal prolapse is not known, while sitting on the toilet may facilitate bowel Diagnosis but it is associated with conditions that affect evacuation. Patients should also be told to The symptoms of volvulus may mimic other the pelvic floor or rectum. Nearly 50 percent of respond as soon as possible to the urge to have a disorders. The onset of severe pain, abdominal reported cases of rectal prolapse are caused by bowel movement. 5 distention and a palpable abdominal mass chronic straining with bowel movements and 5 suggest volvulus. Appropriate diagnostic studies constipation.40 Nursing alert! Remind patients that there is a include:5,39 wide variation in what is a normal pattern of  X-rays: Obstruction may be evident as Increased intra-abdominal pressure causes 9 bowel elimination. This range can vary from well as the classic double-bubble sign.39 the protrusion of the layers of rectal tissue. 5,9,38 three times a day to three times a week. The double-bubble occurs when duodenal Additional conditions that increase the risk of rectal prolapse include:5,40 Volvulus obstruction leads to gastric and duodenal  Diarrhea. David is a 45 year-old electrician. He has distension with a prominent duodenal bulb  Benign prostatic hypertrophy. just spent a relaxing Sunday with his wife, and air-fluid levels in the proximal duodenum 39  Chronic obstructive pulmonary disease daughter and son. They enjoyed watching his and stomach.  (COPD). daughter play in her first soccer tournament  CT scans: Evidence of intestinal obstruction 5  Cystic fibrosis. and celebrated her team’s victory with dinner may be evident.   Malnutrition and malabsorption. at their favorite restaurant. Later that evening,  Upper GI series: Signs of volvulus include 5,39  Pertussis (whooping cough). David suddenly develops episodes of vomiting incomplete duodenal obstruction.   Pelvic infections. and abdominal distention. He blames it on  Barium enema: Barium enema can show  Neurological disorders. “something I ate” at the restaurant. However, specific areas of the colon that are affected.  Previous trauma to the anal or pelvic area. he soon experiences an abrupt onset of severe In volvulus of the cecum, barium fills the abdominal pain. His wife insists that she take colon distal to the affected area. In sigmoid Many cases of rectal prolapse are not reported, him to the emergency room, where diagnostic volvulus, findings vary in children and adults. making it difficult to determine actual incidence. studies indicate a severe bowel problem, possibly In children, the barium may twist and appear Rectal prolapse occurs most often in children volvulus. as a “point.” In adults, the barium may take under the age of 6 and in adults in their 60s and on the appearance of the “ace of spades,” 70s. Females experience rectal prolapse more Volvulus is a “twisting” of the intestine at least mimicking that configuration from a deck of often than males, with females accounting for 80 180 degrees on its mesentery, a fold of tissue that playing cards.5 percent to 90 percent of cases that are reported.5 attaches the intestine to the back of the abdominal  White blood cell (WBC) count: 5 Nursing alert! In children with cystic fibrosis, wall. This disorder was initially described in Strangulation generally causes the WBC 1832 as an abnormally positioned cecum (the the incidence of rectal prolapse is nearly 20 count to surpass 15,000/ul. If the bowel is percent.40 beginning of the large intestine) noted in two infracted, the WBC count exceeds 20,000/ul.5 autopsies. It was Ladd, however, who published a Potential complications of rectal prolapse include paper in 1932 that described congenital duodenal Treatment varies according to the age rectal ulceration, bleeding, incontinence and obstruction and presented a surgical correction and condition of the patient and whether rectal wall necrosis.5,40 of malrotation. This surgical technique, with complications have occurred. In the event of minor modifications, is actually the foundation a necrotic bowel (as a result of obstruction or Signs and symptoms of surgical treatment to this day, particularly in strangulation), immediate surgical resection and Protrusion of rectal tissue when walking or 5 children.39 anastomosis is indicated. during elimination of stool is the primary sign of rectal prolapse. Other symptoms include:5,40 Elite Page 19  Ongoing sensations of fullness in the rectum. Nursing alert! It is important that prevention the severity of the problem. First-degree  Constipation. of constipation and to avoid straining during hemorrhoids, although they may be painless,  . be taught to all patients. Straining can characteristically cause painless, intermittent  Bloody diarrhea. lead to a number of adverse consequences! bleeding with defecation. The patient may  Rectal bleeding. report bright red blood on the toilet paper or on Hemorrhoids  Lower abdominal pain. stool. Bleeding occurs as the result of injury to Hemorrhoids are varicosities or enlarged veins  Feeling of incomplete evacuation of feces. the mucosa that covers the hemorrhoids. These in the lower part of the rectum and the anus.9,41 hemorrhoids may cause itching if anal hygiene is Nursing alert! Hemorrhoids and/or rectal polyps Internal hemorrhoids cannot be felt and are poor.5,9,41 may exist in conjunction with rectal prolapse.5 found in the inside lining of the rectum. External Second-degree hemorrhoids result in more Diagnosis hemorrhoids are found underneath the skin that surrounds the anal area. These types of severe characteristic symptoms with the addition Nursing alert! Rectal prolapse is often a hemorrhoids are felt when they swell, and they of prolapse, which spontaneously symptom. The underlying cause must be identified may cause itching or pain as well as bleeding. resolves itself after the patient has a bowel and corrected.40 A thrombosed external hemorrhoid is the result movement. These hemorrhoids are usually History, inspection and clinical signs confirm of blood clotting within veins and can cause the painless.5,9 diagnosis. Imaging studies such as a barium 41 patient significant pain. Third-degree hemorrhoids cause ongoing enema may be performed to rule out diseases discomfort and prolapse whenever there is an of the colon and/or rectum or the presence of Internal hemorrhoids are covered by mucosa and increase in intra-abdominal pressure. These third- tumors.40 actually protrude into the rectal lumen. They may prolapse when the patient has bowel movements. degree hemorrhoids must be manually reduced.5 Treatment External hemorrhoids are covered by skin and Thrombosis of external hemorrhoids causes Sometimes, correcting the underlying cause is the protrude from the rectum. These hemorrhoids abrupt and a large, firm lump that can only treatment needed. First, the rectal mucosa are more likely to thrombose than internal be felt by the patient. Such hemorrhoids may 5 may be reduced with gentle digital pressure. The hemorrhoids. cause bleeding that is severe enough to cause patient is placed in a knee-chest position, and Hemorrhoids can be classified according to their secondary anemia. In these cases, the patient a soft, warm, wet cloth may be used to gently severity.9 may complain of fatigue and weakness, exhibit push the mass through the anal opening. Gravity  First-degree hemorrhoids: These are significant pallor and ultimately lead to secondary should facilitate the return of the prolapse to confined to the anal canal. anemia.5,9 its proper place.5 However, the presence of  Second-degree hemorrhoids: These edema of the bowel may make manual reduction Nursing alert! Tell patients that ALL occurrences prolapse when the patient strains (e.g., during problematic. In these types of cases, granulated of rectal bleeding must be evaluated by a health defecation) but reduce spontaneously. sucrose may be applied topically to the mucosal care professional. Rectal bleeding may be a  Third-degree hemorrhoids: These are surface. This may reduce edema and allow for symptom of a serious problem, such as cancer. All prolapsed hemorrhoids but must be manually successful manual reduction.40 too often, people assume that rectal bleeding is reduced after each bowel movement. due to hemorrhoids and fail to report it. In children, prolapsed rectal tissue lessens as the  Fourth-degree hemorrhoids: These child grows. Older patients may require injection hemorrhoids are severe and cannot be Diagnosis of a sclerosing agent that causes a fibrotic reduced. Physical examination confirms the diagnosis reaction and fixes the rectum in its proper place.5 of external hemorrhoids. It is important that a Causes and incidence proctoscopy be performed to diagnosis internal Surgery may be necessary for cases of severe Hemorrhoids are most likely due to increased hemorrhoids and to rule out polyps or other or chronic rectal prolapse. During surgery the venous pressure. Factors that predispose the conditions.5,9 sphincters are strengthened or tightened with wire development of hemorrhoids include:5,9 or by anterior or rectal resection of the tissue that  Prolonged periods of sitting or standing. Treatment prolapsed.5  Straining during defecation (often associated Treatment depends on the type and severity Patient education with constipation). of the hemorrhoids. For hemorrhoids that are  Straining during coughing, sneezing or not severe, lifestyle modifications are often the It is important that patients understand what vomiting. foundation of treatment as well as measures measures to take to avoid rectal prolapse or the  Heart failure. initiated for symptoms relief. The goals of recurrence of the disorder.5,40  Liver disease. treatment are to reduce or eliminate pain,  Prevention of constipation is very important.  Alcoholism. fight swelling and congestion, and to facilitate Teach the patient to drink an adequate  Anal/rectal infections. defecation without straining.5,9 amount of fluid every day and to eat a diet  Rectal surgery. that has adequate amounts of fiber and only One of the first steps is to eliminate constipation  Pregnancy. moderate amounts of fat. and teach patients measures to prevent  Anal intercourse.  If ordered, explain how to take medications constipation and straining during defecation.  Loss of muscle tone (often due to old age). such as stool softeners to help avoid Patients should drink adequate amounts of fluids constipation. Hemorrhoids are quite common. They are more and increase the amount of fiber in their diets by  Explain that rectal incontinence may be a common in whites, those who are of higher increasing their intake of raw vegetables and fruit permanent complication of surgery. socioeconomic status, and those who live in and whole grain cereals. They should take stool  Patients with severe rectal prolapse and rural areas.5 The exact incidence of hemorrhoids softeners as recommended by their health care incontinence should be advised to wear a is unknown because many people do not seek providers.5,9 perineal pad. medical help for the problem. However, it is Nursing alert! Patients should be taught to avoid  Teach patients perineal strengthening estimated that hemorrhoids occur in up to 50 straining during defecation! exercises. For example, the patient should percent of the population by age 50.41 repeatedly squeeze and relax the Patients need to avoid sitting or standing for while sitting in a chair. Signs and symptoms prolonged periods of time. If their jobs often Hemorrhoids may not cause any symptoms cause them to sit or stand for long periods of at all. But symptoms generally increase with time, they should be taught to take breaks when

Page 20 Elite they can stand and move around (if they are although rectal bleeding may occur. Diagnosis Diagnosis sitting for too long) or move about and/or sit for requires visualization via proctosigmoidoscopy or A detailed patient history is obtained, including short periods (if they are standing in one place colonoscopy.9 questions about the patient’s sexual practices. for too long). Patients should be cautioned not to Treatment Nursing alert! It is important to remain sit on the toilet for long periods of time to avoid Polyps are generally removed for biopsy objective, supportive and non-judgmental. venous congestion.9 during procedures such as colonoscopy. Further Sexually transmitted diseases still carry a Local anesthetic agents in the form of lotions, treatment depends on the results of the biopsy. negative stigma, particularly those that are creams or suppositories may be used to decrease Benign polyps generally require no further associated with anal sex. All patients deserve local swelling and pain. Hydrocortisone cream treatment after their removal except for adherence compassionate care delivered to the best of the and suppositories may be used to reduce edema, to screening colonoscopies as recommended health care professionals’ abilities. itching and prolapsed hemorrhoids. Warm sitz by their health care providers. If a malignancy A sigmoidoscopy may be performed that reveals, baths may also provide some pain relief.5,9 is diagnosed, treatment depends on the type of in acute proctitis, shiny, thick, bright red or pink Hemorrhoidecotmy by cauterization or excision cancer and its stage. rectal mucosa that may be ulcerated. In chronic is the most effective treatment and is required for Proctitis proctitis, results may include thickened mucosa, patients experiencing severe pain or bleeding, Proctitis is an inflammation of the rectal mucosa. rectal lumen stricture and loss of normal vascular significant prolapse and itching. However, It can be acute or a chronic condition. Proctitis patterns.5 surgical intervention is contraindicated in persons causes discomfort, bleeding, and at times, the Treatment with diseases of the blood such as leukemia, 5 discharge of pus or mucous. Antibiotics specific for the organisms causing aplastic anemia or hemophilia, GI cancer, or the disorder are administered in the presence of during the first trimester of pregnancy.5,9 Causes There are several factors that lead to the infection. If the proctitis is the result of radiation After surgery, stress to the patient how important development of proctitis. therapy, steroid suppositories or soothing enemas it is to avoid constipation and to ensure good anal  Proctitis can be caused by a sexually may help to relieve symptoms. Tranquilizers may hygiene. Patients should not use harsh soaps over transmitted disease (STD), especially be helpful for patients having difficulty dealing 9 5,9 the anal area or cleanse the area too vigorously. among those who participate in anal with emotional stress. Intestinal polyps intercourse. STDs that can cause proctitis Anorectal abscesses and fistulas Intestinal polyps are masses of tissue that project include , herpes, Chlamydia and An is due to inflammation from the surface of the mucous membrane. They . Amebiasis is of the soft tissue near the rectum or anus. Pus may develop in the colon or rectum where they also a causative factor and can be transmitted collects in the localized area of inflammation. 5,43 protrude into the GI tract. Most polyps do not via anal-oral sex. Inflammation may cause an abnormal opening  cause symptoms except for minor rectal bleeding,  Autoimmune response can also cause in the anal skin that can communicate with the which is not usually detectable by observation proctitis and is associated with disorders such rectum. 5,44 5,43 (occult bleeding). Although most polyps are as Crohn’s disease and ulcerative colitis.  usually benign, they may become cancerous. 5,42  Proctitis may be a side effect of medications, Causes and incidence radiation treatment or the insertion of foreign The development of an abscess may start when Nursing alert! It is important to encourage objects or chemicals into the rectum.5,43 the lining of the anal canal or rectum is torn or patients to undergo screening colonoscopies  In children, the most common example of suffers an abrasion and subsequent infection with as they reach the age of 50 and periodically non-sexually transmitted proctitis is infection Escherichia coli, staphylococci, or streptococci.5 thereafter as recommended by their physicians. with beta-hemolytic streptococcus, the same Additional causes include:5,9,44 Patients with a history of polyps, a family or bacteria that cause strep throat.5,43  Trauma. personal history of colon cancer, or those who  Treatment of internal hemorrhoids. Nursing alert! Patients receiving radiation are having symptoms may need to begin having  Puncture wounds (e.g., from ingested fish therapy, especially for treatment of cancers of the colonoscopies at an earlier age. bones as they are eliminated from the body). cervix or uterus, need to be taught to be alert to  There are several types of polyps, including 5  Pre-existing lesions. the signs and symptoms of proctitis.  polypoid adenomas, villous adenomas,  Systemic illnesses such as ulcerative colitis hereditary polyposis, focal polypoid hyperplasia The risk of proctitis increases with certain factors and Crohn’s disease. that have the potential to irritate the rectal area. and juvenile polyps. As noted, most polyps As the production of pus increases, a fistula These include:5,9 are benign. However, villous and hereditary may develop in the soft tissues beneath the  Food allergies, particularly an allergy to milk. polyps have a significant inclination to become sphincters’ muscle fibers. This is most likely to 5  Chronic constipation. cancerous. occur beneath the muscle fiber of the external  Habitual or overuse of laxatives. sphincter.5 Causes and incidence  Injury to the rectum. Polyps occur as a result of unrestrained cell  Interference with normal muscle control. Anorectal abscesses have a peak incidence growth in the upper epithelium. Factors that  Emotional distress. among adults in their 30s and 40s. However, increase the risk of polyp development include there is also a high rate of occurrence in infants. age, infection, high-fat, low-fiber diet, and Signs and symptoms It is estimated that about 30 percent of patients 5,9,43 heredity.9 Signs and symptoms include: have a prior history of anorectal abscess. Such   Stools that contain blood and mucous. abscesses are two to three times more common in The incidence of polyps for both males and   Constipation. men than in women.5,9 females increases after the age of 70. Juvenile  containing pus. polyps are most commonly found in children  Rectal pain. Nursing alert! Anal fissures in children may be a 44 less than 10 years of age. Villous adenomas are  Pain when having a bowel movement sign of sexual abuse. most commonly found in men over the age of 55. (tenesmus). Signs and symptoms Polypoid adenomas are most prevalent in white  Feeling of rectal fullness. women between the ages of 45 and 60.5,9 Characteristic signs and symptoms of anorectal  Left-sided abdominal cramps. 5,9,44  abscess include: Signs, symptoms, and diagnosis  Intense urge to have a bowel movement.  Rectal pain that is often described as Most patients with polyps are asymptomatic, throbbing, burning, cutting or tearing.

Elite Page 21  esophageal-manometry.htm.  Hard, painful lump that causes discomfort 15. Cuffari, C. (2010). Mallory-Weiss syndrome. Retrieved November 15, 2010 from when sitting. http://emedicine.medscape.com/article/931141-print. DISEASES AND DISORDERS OF THE 16. Vedder, R. L. (2006). Prilosec OTC: Sometimes it all comes down to cost. AJN,  Pus and/or mucous discharge from the 106(3), 60-64. GASTROINTESTINAL TRACT 17. Nursing Center. (2009). Medication update. The Nurse Practitioner: the American rectum. Journal of Primary Health Care, 34(4), 56. Self Evaluation Exercises  18. WebMD. (2009). Barrett’s esophagus: Symptoms, causes, and treatments. Retrieved  Pain with bowel movements. December 27, 2010 from www.webmd.com/heartburn-gerd/barretts-esophagus- Choose True or False for questions symptoms-causes-and-\treatments. 1 through 8 and check Nursing alert! Spasm of the anus is highly 19. WebMD. (2010). Hiatal hernia. Retrieved December 28, 2010 from www.webmd. com/heartburn-gerd/hiatal-hernia. your answers at the bottom of the page. suggestive of an anal fissure.44 20. MayoClinic.com. (2009). Gastritis. Retrieved December 31, 2010 from www. mayoclinic.com/health/gastritis/DS00488. 21. WebMD. (2007). Gastroenteritis. Retrieved January 1, 2011 from www.webmd.com/ Diagnosis digestive-disorders/gastroenteritis. You do not need to submit this self-evaluation 22. Bartelmo, J., & Terry, D. P. (Clinical Eds.). (2008). Fluid & electrolytes made An anorectal abscess is detected upon rectal incredibly easy (4th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams exercise with your participant sheet. & Wilkins. examination. Sometimes the abscess drains by 23. Cabebe, E., C., & Mehta, V. K. (2010). Gastric cancer. Retreived December 26, 2010 forming a fistula. If so, the pain subsides and from http://emedicine.medscape.com/article/278744-overview. 24. National Cancer Institute. (2010). Stomach (gastric) cancer prevention. Retrieved intense itching occurs. The external opening of December 26, 2010 from www.cancer.gov/cancertopics/pdq/ prevention/gastric/ 1. The accessory glands and organs of the HealthProfessional. the fistula looks like a pink or red elevated ulcer 25. National Cancer Institute. (2009). Breast cancer drug helps patients with gastric GI system consist of the salivary glands, cancer. Retrieved December 26, 2010 from www.cancer.gov/clinicaltrials/results/ liver, gallbladder and bile ducts, and the near the anus. Additional signs and symptoms summary/2009/trastuzumab-gastric0609. 26. Crohn’s & Colitis Foundation of America. (2008). Surgery for ulcerative colitis. pancreas. depend on the severity of the co-existing Retrieved January 17, 2011 from www.ccfa.org/info/surgery/surgeryuc. infection. These include chills, fever, nausea, 27. Crohn’s & Colitis Foundation of America. (2009). Surgery for Crohn’s disease. Retrieved January 17, 2011 from www.ccfa.org/info/surgery/surgerycd. vomiting and fatigue.5 28. National Cancer Institute. (2010). General information about rectal cancer. Retrieved True False January 19, 2011 from www.cancer.gov/cancertopics/pdq/treatment/rectal/Patient. 29. Anymothersdaughter.com. (2010). Anal cancer. Retrieved January 20, 2011 from A palpable indurated tract may be noted upon http://anymothersdaughter.com/analcancer.html. 30. Mayo Clinic. (2010). Anal cancer. Retrieved January 20, 2011 from www. 2. Mallory-Weiss syndrome is characterized rectal digital exam, and pus may be evident on mayoclinic.com/health/anal-cancer/DS00852. the examiner’s gloved finger. It may be necessary 31. NIDDK. (2008). Celiac disease. Retrieved January 22, 2011 from http://digestive. by rectal bleeding from a mucosal tear in niddk.nih.gov/ddiseases/pubs/celiac/ the intestine. to perform a proctosigmoidoscopy to rule out 32. NDDIC. (2008). Diverticulosis and diverticulitis. Retrieved January 26, 2011 from 5,9 http://digestive.niddk.nih.gov/ddiseases/pubs/diverticulosis/ other diseases. 33. MayoClinic.com. (2010). Intussusception. Retrieved January 29, 2011 from www. mayoclinic.com/health/intussusception/DS00798/ True False 34. Goldberg, S. M. (2009). Identifying intestinal obstruction: Better safe than sorry. Treatment Nursing2009, 39(9), 13-16. The anorectal abscess must be surgically incised 35. Nobie, B. A. (2009). Obstruction, small bowel. Retrieved January 29, 2011 from http://emedicine.medscape.com/article/774140-print 3. Alcohol increases gastric acid production under caudal anesthesia to promote drainage 36. Rosto, E. (Ed.). (2009). Pathophysiology made incredibly easy (4th ed.). Philadelphia: Lippincott Williams & Wilkins. and decreases lower esophageal sphincter of infected material. Fistulas are treated by 37. NIDDK.NIH. (2008). Inguinal hernia. Retrieved January 30, 2011 from http:// digestive.niddk.nih.gov/ddiseases/pubs/inguinalhernia/ pressure, which can exacerbate symptoms removing the fistula and granulated tissue 38. NIDDK.NIH. (2007). Constipation. Retrieved March 12, 2011 from http://digestive. niddk.nih.gov/ddiseases/pubs/constipation. of GERD. (referred to as a fistulotomy) under caudal 39. Hebra, A., & Miller, M. (2010). Intestinal volvulus. Retrieved March 13, 2011 from anesthesia. Warm sitz baths, analgesics and http://emedicine.medscape.com/article/930576-print. 40. Flowers, L. K. (2009). Rectal prolapse. Retrieved March 13, 2011 from http:// True False antibiotics may also be part of the treatment emedicine.medscape.com/article/776236-print. 41. emedicinehealth.com. (2011). Hemorrhoids. Retrieved March 14, 2011 from www. 5,44 regimen. emedicinehealth.com/hemorrhoids/article_em.htm. 42. merckmanuals.com. (2007). Polyps of the colon and rectum. Retrieved March 14, 2011 from www.merckmanuals.com/professional/sec02/ch021/ch021g.html. 4. Chronic infection with helicobacter pylori Nursing considerations 43. National Center for Biotechnology Information. (2009). Proctitis. Retrieved March (H pylori) is associated with a significant 14, 2011 from www.ncbi.nlm.nih.gov Nurses need to be aware of several 44. Legall, I. (2010). Anal fistulas and fissures. Retrieved March 16, 2011 from http:// risk of gastric cancer. considerations. These include:5,9,44 emedicine.medscape.com/article/776150-print.   Teach the patients the importance of perianal True False cleanliness. This may be an embarrassing topic for some patients. Nurses should 5. Your next-door neighbor is complaining be tactful and objective while providing of right lower abdominal pain. She is information about perianal hygiene. nauseous and has a low-grade fever. A good  Teach the patient to be alert to the signs and way to help relieve the pain is to apply a symptoms of abscesses and fistulas and to heating pad to the right lower abdomen. seek prompt medical attention.  Patients may suppress the urge to have a True False bowel movement for fear of pain. This could lead to constipation and even fecal impaction. Teach the importance of a diet that consists of 6. Crohn’s disease and ulcerative colitis are adequate fluid intake and fiber. Facilitate the names for the same disease. administration of stool softeners as ordered. True False References 1. AboutGERD.org. (2009). Treatment of GERD. Retrieved September 28, 2009 from www.aboutgerd.org/site/about-gerd/treatment/. 2. Barba, K., Fitzgerald, P., & Wood, S. (2007). Managing peptic ulcer disease. 7. Anal cancer is closely linked to human Nursing2007, 37(7), 56hn1-56hn4. 3. Colwell, J., & Gordon, B. (2009). Helping patients combat colon cancer. Nursing papillomavirus (HPV) infection, a sexually 2009, 39(4), 34-48. transmitted disease. 4. Edmondson, D., & Schiech, L. (2008). Esophageal cancer: A tough pill to swallow. Nursing2008, 38(4), 44-50. 5. Harold, C. (Ed.). (2009). Professional guide to diseases (9th ed.). Philadelphia: wolters Kluwer Health/Lippincott Williams & Wilkins. True False 6. King, J. (2007). Does my patient have ulcerative colitis or Crohn’s disease? Nursing2007, 37(3), 7. Lippincott Williams & Wilkins. (2011). Professional guide to signs & symptoms (6th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 8. An important part of the treatment for 8. Day, M.. (2008). Fight back against inflammatory bowel disease. Nursing2008, 38(11), 34-40. celiac disease is an increase in products 9. Munden, J. (Ed.). (2007). Professional guide to pathophysiology (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. containing wheat, barley, rye, and oats. 10. National Cancer Institute. (2010). Lip and oral cavity cancer treatment. Retrieved October 21, 2010 from www.cancer.gov/cancertopics/pdq/treatment/lip-and-oral- cavity/Patient/page1/print. True False 11. National Institutes of Health. (200). Barrett’s esophagus. Retrieved December 1, 2009 from http://digestive.niddk.nih.gov/ddiseases/pubs/barretts. 12. National Institutes of Health. (2010). About oral cancer. Retrieved October 21, 2010 from www.nidcr.nih.gov/OralHealth/Topics/OralCancer/OralCancer.htm. 13. Oral Cancer Foundation. (2010). Oral cancer facts. Retrieved October 21, 2010 from

http://oralcancerfoundation.org/facts/index.htm. 14. OUC San Diego Medical Center. (2009). What is esophageal manometry? Retrieved 8.F 7.T 6.F 5.F 4.T 3.T 2.F 1.T December 4, 2009 from http://health. ucsd.edu/specialties/gastro/motility/procedures/ Answers: Page 22 Elite CHAPTER 2 by 2015, an estimated 20 million people will die (enlargement), especially left ventricular FAMILIAR CHRONIC CASES: from cardiovascular disease (mainly from heart hypertrophy, which further increases the heart’s CARDIOVASCULAR DISEASES AND attacks and strokes). Cardiovascular disease kills workload because of the resulting increased more people than the next-most common causes oxygen demands. STROKE of death combined, including cancer, chronic (10 CONTACT HOURS) Once blood vessels are blocked by plaque or lower respiratory disease, accidents, diabetes, clots, they cannot supply blood to the heart Learning objectives influenza and pneumonia. According to the heart ! and brain, which then become damaged ! Define cardiovascular disease. association, in 2006, more than 80,000,000 !! Identify the prevalence of cardiovascular and weakened and can lead to a myocardial people in the U.S. had one or more forms of infarction, congestive heart failure or disease in the United States and globally. cardiovascular disease. The most common forms !! Discuss the most common types of arrhythmias. Although there are several types of of cardiovascular disease include hypertension, plaque that may result in serious coronary events, cardiovascular disease. 73,600,000; coronary heart disease,16,800,000; ! retrospective analyses have demonstrated that 70 ! Identify the non-modifiable and modifiable acute myocardial infarction, 7,900,000; angina risk factors for developing cardiovascular percent of all fatal acute myocardial infarctions pectoris (chest pain or discomfort caused by and sudden coronary deaths are attributable to disease. reduced blood supply to the heart muscle), ! plaque rupture or erosion. ! Identify the common signs and symptoms of 9,800,000; cerebrovascular accident, 6,500,000; cardiovascular disease. and congestive heart failure, 5,700,000. Although atherosclerosis is the predominant ! ! Discuss how to screen for cardiovascular In 2009, the CDC estimated that 785,000 predictor of cardiovascular disease, there are disease. Americans would have a new coronary heart other potential pathological rationales for each ! ! Discuss the ways to prevent cardiovascular attack, and about 470,000 would have a recurrent of the major specific cardiac diagnosis and disease. attack. To put it into perspective, approximately significant overlapping in each of the most ! ! Discuss the treatment modalities of the every 25 seconds an individual would have a common heart conditions. various cardiovascular diseases. coronary event, and one person would die every ! Coronary artery disease (CAD) ! Describe the two most common kinds of minute. stroke. The most common type of heart disease, coronary !! List common symptoms for stroke. Although cardiovascular disease is the leading artery disease (also called coronary heart disease, !! Identify risk factors for stroke. cause of death, most times it is preventable by or CHD) is the primary cause of acute myocardial !! List the steps used to diagnose stroke. avoiding unhealthy habits, such as a high-fat infarction secondary to atherosclerosis, and the !! Explain why timing is crucial in the treatment diet, physical inactivity and smoking. Every leading cause of death in the United States for of strokes. day, nurses are responsible for patients and both men and women. Over time, CAD can !! Identify tPA and its use in treatment of acute their families who are living with some form weaken the heart muscle and lead to heart failure ischemic stroke, as well as contraindications of cardiovascular disease. However, nurses are and arrhythmias. not immune either, and the daily stressful grind for its use. What causes coronary artery disease? ! of their work can itself create a risk for nurses ! Describe key components of a nurse’s role in Research suggests that coronary artery disease of developing cardiovascular disease or picking treatment of stroke patients. (CAD) starts when certain factors damage the ! up bad habits during the long shifts, such as ! List ways rehabilitation therapy can help inner layers of the coronary arteries. These smoking and a high-fat diet. Nurses can use patients recover from stroke’s damage. factors include: ! the information in this course in their personal ! Identify the Coverdell Registry.  Smoking. ! lives as well as in their work caring for others to ! List the consensus stroke performance  High amounts of certain fats and cholesterol reduce the overall risk of cardiovascular disease measures for stroke treatment developed in the blood. in our nation. through the Coverdell Registry program.  High blood pressure.  PART I: Cardiovascular diseases Pathophysiology of cardiovascular  High amounts of sugar in the blood caused by Introduction diseases insulin resistance or diabetes. The heart is a hollow, muscular organ that Cardiovascular disease is a broad term that is When damage occurs, excess fatty tissues release is responsible for continuously pumping an used interchangeably to describe “heart disease.” compounds to promote the healing process. But adequate supply of blood throughout the body Cardiovascular diseases encompass many heart this in turn causes plaque to build up where the to vital organs for survival. To reduce our risk of conditions that may overlap, such as coronary arteries are damaged. The buildup of plaque in developing cardiovascular disease, it is important artery disease (CAD), hypertension (HTN), acute the coronary arteries may start in childhood. Over that we nurture our bodies with healthy, nutritious myocardial infarction (AMI or MI), congestive time, plaque can narrow or completely block foods; exercise; and avoid harmful substances. heart failure (CHF) coronary artery disease and the coronary arteries, which reduces the flow of arrhythmias. According to the World Health Cardiovascular diseases are mainly caused by oxygen-rich blood to the heart muscle. Plaque Organization (WHO), Centers for Disease a buildup of plaque (atherosclerosis) inside also can crack, which causes blood cells called Control and Prevention (CDC) and the American the coronary arteries. Over time, the plaque platelets to clump together and form blood clots Heart Association (AHA) (2009), cardiovascular diminishes blood flow and oxygen to the at the site of the cracks. This narrows the arteries disease is the leading cause of death worldwide heart, brain and other vital organs secondary more and worsens angina or causes a heart attack. and a major cause of disability. It has actually to the inflammatory process. The extensive Risk factors for coronary artery disease been the leading cause of death since 1900 in the inflammation further exacerbates the ability The major risk factors for CAD, and many other United States. of oxygenated blood to flow freely in the heart diseases, are: bloodstream, leading to a further buildup of In 2003, the WHO reported that cardiovascular  Unhealthy blood cholesterol levels. This plaque and an accumulation of blood clots. Blood disease made up 16.7 million, or 29.2 percent includes high LDL cholesterol (sometimes clots accumulate when a blood vessel is stenosed of all global deaths. Of these deaths, 7.6 million called bad cholesterol) and low HDL secondary to the limited blood flow; therefore, it were due to heart attacks and 5.7 million were cholesterol (sometimes called good backs up into the previous chamber behind the due to a subset of the problem, cerebrovascular cholesterol). valve. The pressure in the previous chamber will disease and cerebrovascular accident (CVA), or  High blood pressure. Blood pressure is increase because of the resistance in the stenosed stroke, which will be addressed in Part II of this considered high if it stays at or above 140/90 blood vessel. Consequently, the heart is forced course. If current trends are allowed to continue, mm/Hg over a period of time. to work harder, which results in hypertrophy

Elite Page 23  Smoking. This can damage and tighten blood  Alcohol. Heavy drinking can damage the  Other signs include nausea (feeling sick to vessels, raise cholesterol levels and raise heart muscle and worsen other risk factors the stomach), vomiting, lightheadedness or blood pressure. Smoking also doesn’t allow for heart disease. Men should have no more fainting, or breaking out in a cold sweat. enough oxygen to reach the body’s tissues. than two drinks containing alcohol a day. What causes heart attacks?  Insulin resistance. This condition occurs Women should have no more than one drink Most heart attacks occur as a result of coronary when the body can’t use its own insulin containing alcohol a day. artery disease. CAD is the buildup over time of properly. Insulin is a hormone that helps Acute myocardial infarction (AMI) a material called plaque on the inner walls of the move blood sugar into cells where it’s used. Commonly known as a heart attack, acute coronary arteries. Eventually, a section of plaque  Diabetes. This is a disease in which the myocardial infarction is caused by reduced can break open, causing a blood clot to form at body’s blood sugar level is high because the blood flow through one or more of the coronary the site. A heart attack occurs if the clot becomes body doesn’t make enough insulin or doesn’t arteries, secondary to coronary heart disease or large enough to cut off most or all of the blood use its insulin properly. cardiomyopathy (disease of the heart muscle flow through the artery. The blocked blood flow  Being overweight or obese. Being fibers). prevents oxygen-rich blood from reaching the overweight is having extra body weight from part of the heart muscle fed by the artery. The muscle, bone, fat or water. Obesity is having Myocardial infarction includes ST-segment lack of oxygen damages the heart muscle. If the a high amount of extra body fat. elevation MI (STEMI), non-ST-segment elevation blockage isn’t treated quickly, the damaged heart  Metabolic syndrome. Metabolic syndrome MI (NSTEMI), and unstable angina as a group of muscle begins to die. is the name for a group of risk factors linked clinical diseases called acute coronary syndrome to being overweight or obese that raises the (ACS). Rupture or erosion of the plaque initiates Heart attacks also can occur due to problems chance for heart disease and other health all ACS conditions. Three stages occur when with the very small, microscopic blood vessels of problems, such as diabetes and stroke. there is occlusion of a vessel: ischemia, injury the heart. This condition is called microvascular  Lack of physical activity. Lack of activity and infarct. disease. It’s believed to be more common in can worsen other risk factors for CAD.  Ischemia is the first stage, and it indicates women than in men.  Age. As people get older, the risk for CAD that blood flow and oxygen demands are out Another less common cause of heart attack is a increases. Genetic or lifestyle factors cause of balance. The electrocardiogram (ECG) severe spasm (tightening) of a coronary artery plaque to build in the arteries as people age. will reveal ST-segment depression or T-wave that cuts off blood flow through the artery. These By the time people are middle-aged or older, changes. spasms can occur in coronary arteries that don’t enough plaque has built up to cause signs or  Injury is the second stage, and it indicates have CAD. It’s not always clear what causes a symptoms. the ischemia is prolonged enough to damage coronary artery spasm, but sometimes it can be ŠŠ In men, the risk for CAD increases after that area of the heart. The ECG will reveal related to: age 45. ST-segment elevation in at least two different  Taking certain drugs, such as cocaine. ŠŠ In women, the risk for CAD increases leads.  Emotional stress or pain. after age 55.  Infarct is the third stage, and it indicates  Exposure to extreme cold.  Family history of early heart disease. The actual death of the myocardial cells and is  Cigarette smoking. risk increases if a person’s father or a brother irreversible. In the early stages of an MI, the was diagnosed with CAD before 55 years of ECG will reveal hyperacute (very tall) or Risk factors for acute myocardial age, or if a mother or a sister was diagnosed narrow T-waves. Within hours, the T-waves infarction with CAD before 65 years of age. become inverted and ST-segment elevation  Coronary artery disease. occurs in the leads facing the area of the  Scientists continue to study other possible risk  Smoking. damage. The last stage is the development of  factors for CAD.  High blood pressure. a pathologic Q-wave. Q-waves are permanent   High levels of a protein called C-reactive  High blood cholesterol. evidence of myocardial necrosis.  protein (CRP) in the blood may raise the  Being overweight and obese.  risk for CAD and heart attack. High levels of During a heart attack, if the blockage in the  Physical inactivity.  CRP are proof of inflammation in the body. coronary artery isn’t treated quickly, the heart  Diabetes (high blood sugar).  Inflammation is the body’s response to injury muscle will begin to die and be replaced by scar  Age. Risk increases for men older than 45 or infection. Damage to the arteries’ inner tissue. This heart damage may not be obvious, or years and for women older than 55 years (or walls seems to trigger inflammation and it may cause severe or long-lasting problems. after menopause).  help plaque grow. Research is under way to  Family history of early CAD. The risk Severe problems linked to heart attack can find out whether reducing inflammation and increases if a person’s father or a brother was include heart failure and life-threatening lowering CRP levels also can reduce the risk diagnosed with CAD before 55 years of age, arrhythmias (irregular heartbeats). Ventricular of developing CAD and having a heart attack. or mother or a sister was diagnosed before 65 fibrillation is a serious arrhythmia that can cause  High levels of fats called triglycerides in years of age. death if not treated quickly. Acting fast at the the blood also may raise the risk of CAD, first sign of heart attack symptoms can save a life Certain CAD risk factors tend to occur together. particularly in women. and limit damage to the heart. Treatment is most When they do, it’s called metabolic syndrome. Other factors effective when started within one hour of the In general, a person with metabolic syndrome is Other factors also may contribute to CAD. These beginning of symptoms. twice as likely to develop heart disease and five include: times as likely to develop diabetes as someone  The most common heart attack signs and without metabolic syndrome.  Sleep apnea. Sleep apnea is a disorder in symptoms are: which breathing stops or gets very shallow  Chest discomfort or pain – uncomfortable Angina while a person sleeps. Untreated sleep apnea pressure, squeezing, fullness, or pain in the Angina chest pain or discomfort occurs when can raise the chances of having high blood center of the chest that can be mild or strong. an area of the heart muscle doesn’t get enough pressure, diabetes and even a heart attack or This discomfort or pain lasts more than a few oxygen-rich blood. Angina may feel like pressure stroke.  minutes or goes away and comes back. or squeezing in the chest and also may occur in  Stress. Research shows that the most  Upper body discomfort in one or both arms, the shoulders, arms, neck, jaw or back. Angina commonly reported “trigger” for a heart the back, neck, jaw or stomach. pain may even feel like indigestion. attack is an emotionally upsetting event –  Shortness of breath may occur with or before particularly one involving anger. chest discomfort. Page 24 Elite Angina isn’t a disease; it’s a symptom of an for oxygen is low, such as when a Right-side heart failure occurs if the heart can’t underlying heart problem, usually coronary artery person is sitting. However, with physical pump enough blood to the lungs to pick up disease. It occurs when plaque buildup interrupts exertion – like walking up a hill or oxygen. Left-side heart failure occurs if the heart blood flow to the heart muscle, causing the chest climbing stairs – the heart works harder can’t pump enough oxygen-rich blood to the pain. and needs more oxygen. rest of the body. Right-side heart failure may ŠŠ Other triggers of stable angina include: cause fluid to build up in the feet, ankles, legs, Angina also can be a symptom of coronary  Emotional stress. liver, abdomen and the veins in the neck. Right- microvascular disease (MVD). This is heart  Exposure to very hot or cold side and left-side heart failure also may cause disease that affects the heart’s smallest coronary temperatures. shortness of breath and fatigue (tiredness). arteries. Unlike traditional CAD, coronary MVD  Heavy meals. doesn’t always create blockages in the arteries. Left-sided heart failure is broken down into two  Smoking. Studies have shown that coronary MVD is more subcategories, systolic and diastolic heart failure.  Unstable angina likely to affect women than men. ŠŠ Blood clots that partly or totally block an Systolic heart failure results from the heart’s Coronary MVD also is called cardiac syndrome artery cause unstable angina. If plaque in inability to contract forcefully during systole X and nonobstructive CHD. an artery ruptures, blood clots may form. to eject an adequate amount of blood into This creates a larger blockage. A clot may circulation. In systolic heart failure, the following Types of angina grow large enough to completely block things occur [30]: The types of angina are stable, unstable, variant the artery and cause a heart attack.  Preload increases (degree of myocardial (Prinzmetal’s) and microvascular. Knowing how ŠŠ Blood clots may form, partly dissolve and stretch at the end of diastole and just before the types differ is important. This is because they later form again. Angina can occur each contraction). have different symptoms and require different time a clot blocks an artery.  Decreased contractility of the heart muscle treatments.  Variant angina  that affects the stroke volume (SV) and  Stable angina ŠŠ A spasm in a coronary artery causes cardiac output (CO). SV is the amount of ŠŠ Stable angina is the most common type variant angina. The spasm causes the blood ejected by the left ventricle during each of angina. It occurs if the heart is working walls of the artery to tighten and narrow. systole. CO is the volume of blood in liters harder than usual. Stable angina has a Blood flow to the heart slows or stops. ejected by the heart each minute. The normal regular pattern. Variant angina may occur in people who CO in adults varies from four to seven liters/ ŠŠ A person who knows he has stable angina have CAD and in those who don’t. per minute. can learn to recognize the pattern and ŠŠ Other factors that can cause the coronary  Afterload increases (pressure/resistance that predict when the pain will occur. The arteries to spasm are: the ventricles must overcome to eject blood pain usually goes away a few minutes  Exposure to cold. through the semilunar valves). after the person rests or takes angina  Emotional stress.  All of these inadequate functions lead medicine.  Medicines that tighten or narrow to an increased peripheral resistance ŠŠ Stable angina isn’t a heart attack, but it blood vessels. (hypertension). The ejection fraction (EF) is suggests that a heart attack is more likely  Smoking. the percentage of blood ejected from the heart in the future.  Cocaine use.  during systole; normal is 50 to 70 percent.  Unstable angina  Microvascular angina ŠŠ Unstable angina doesn’t follow a pattern. ŠŠ This type of angina may be a symptom Diastolic heart failure results when the left It can occur with or without physical of coronary microvascular disease ventricle is unable to relax adequately during exertion, and it may not be relieved by (MVD). Coronary MVD is heart disease diastole (rest). Over time, the ventricle will rest or medicine. that affects the heart’s smallest coronary stiffen due to the inability to relax completely, ŠŠ Unstable angina is very dangerous and arteries. leading to insufficient blood filling, resulting in requires emergency treatment. This type ŠŠ Reduced blood flow in the small coronary a decreased cardiac output (CO). The ejection of angina is a sign that a heart attack may arteries may cause microvascular angina. fraction may be within the normal range. happen soon. Reduced blood flow may be the result Diastolic heart failure occurs in 20 to 40 percent   Variant (Prinzmetal’s) angina of plaque in the arteries, spasms in the of all heart failure cases, especially in older adults ŠŠ Variant angina is rare. It usually occurs and women after an MI. arteries, or damaged or diseased artery  while a person is at rest, and the pain can walls.  Right-sided heart failure occurs over time due be severe. Variant angina usually happens to left ventricular failure, with myocardial between midnight and early morning. Congestive heart failure infarction in the right ventricle or pulmonary Medicine can relieve this type of angina. Also known as “heart” or “pump failure,” hypertension occurring. In right-sided heart  Microvascular angina congestive heart failure is a syndrome that occurs failure, the right ventricle is unable to empty ŠŠ Microvascular angina can be more severe when the heart is unable to adequately pump to completely, leading to increased volume and and last longer than other types of angina; meet the body’s metabolic needs. Heart failure pressure in the systemic veins. medicine may not relieve it. This type of develops over time as the heart’s pumping action Common causes of heart failure angina may be a symptom of coronary grows weaker. The condition can affect the right The most common causes of heart failure are MVD. side of the heart only, or it can affect both sides coronary artery disease, high blood pressure and of the heart. Most cases involve both sides of the diabetes. Treating these problems can prevent or What causes angina? heart. The underlying cause of angina is usually improve heart failure.  coronary heart disease. However, a number of The leading causes of heart failure are diseases  Coronary heart disease things can trigger angina pain, depending on the that damage the heart. Over time, the heart ŠŠ Plaque caused by CAD narrows the type of angina the patient has: weakens. It isn’t able to fill with and/or pump arteries and reduces blood flow to the  Stable angina blood as well as it should. As the heart weakens, heart muscle. It also makes it more likely ŠŠ Physical exertion is the most common certain proteins and other substances may be that blood clots will form in the arteries. trigger of stable angina. Severely released into the blood. These substances have a Blood clots can partially or completely narrowed arteries may allow enough toxic effect on the heart and blood flow, and they block blood flow. blood to reach the heart when the demand worsen heart failure.

Elite Page 25 ŠŠ CAD can lead to chest pain or discomfort stroke, kidney failure and other health problems.  Certain medical problems, such as chronic called angina, a heart attack, heart About one in three adults in the United States kidney disease, thyroid disease and sleep damage or even death. has high blood pressure, although the condition apnea, may cause blood pressure to rise.  High blood pressure itself usually has no symptoms. A person can Certain medicines, such as asthma medicines ŠŠ Blood pressure is the force of blood have hypertension for years without knowing (for example, corticosteroids) and cold-relief pushing against the walls of the arteries. it. During this time, though, it can damage the products, also may raise blood pressure. If this pressure rises and stays high over heart, blood vessels, kidneys and other parts of  In some women, blood pressure can go up if time, it can weaken the heart and lead to the body. they use birth control pills, become pregnant plaque buildup. or take hormone replacement therapy. When HBP has no ŠŠ Blood pressure is considered high if it ŠŠ Women taking birth control pills usually known cause, it stays at or above 140/90 mm/Hg over have a small rise in both systolic and may be called time. (The mm/Hg is millimeters of diastolic blood pressures. Women who essential mercury – the units used to measure have high blood pressure and want to use hypertension, blood pressure.) If you have diabetes birth control pills should discuss it with primary or chronic kidney disease, high blood their doctor. hypertension or pressure is defined as 130/80 mm/Hg or ŠŠ Taking hormones to reduce the symptoms idiopathic higher. of menopause can cause a small rise in hypertension.  Diabetes systolic blood pressure. Women who When another ŠŠ Diabetes is a disease in which the body’s already have HBP and want to start using condition causes blood glucose, or blood sugar, level is hormones should discuss the risks and HBP, it’s too high. Normally, the body breaks benefits with their doctor. sometimes called down food into glucose and then carries  Children younger than 10 years who have secondary high it to cells throughout the body. The cells HBP often have another condition that’s blood pressure or use a hormone called insulin to turn the causing it (such as kidney disease). Treating secondary hypertension. In some cases of HBP, glucose into energy. the underlying condition may resolve the only the systolic blood pressure number is high. ŠŠ In diabetes, the body doesn’t make HBP. This condition is called isolated systolic enough insulin or doesn’t use its insulin  The older a child is when HBP is diagnosed, hypertension (ISH). Many older adults have this properly. Over time, high blood sugar the more likely he or she is to have essential condition. ISH can cause as much harm as HBP levels can damage and weaken the heart hypertension. This means that doctors don’t in which both numbers are too high. muscle and the blood vessels around the know what’s causing the HBP. heart, leading to heart failure. Over time, uncontrolled or prolonged elevation Risk factors for hypertension  Other causes of the blood pressure (BP) can lead to a variety  Older age ŠŠ Cardiomyopathy, or heart muscle of changes in the myocardium (middle layer ŠŠ Blood pressure tends to rise with age. disease. Cardiomyopathy may be present composed of striated muscle fibers), coronary Males older than 45 and females older at birth or due to injury or infection. vasculature and conduction system of the heart. than 55 have a higher risk for HBP. Over ŠŠ Heart valve disease. Problems with the The most significant changes can lead to the half of all Americans aged 60 and older heart valves may be present at birth or development of left ventricular hypertrophy have HBP. due to infection, heart attack or damage (LVH), coronary artery disease, various ŠŠ Isolated systolic hypertension (ISH) is from heart disease. conduction system diseases and systolic and the most common form of HBP in older ŠŠ Arrhythmias, or irregular heartbeats. diastolic dysfunction of the myocardium, which adults. ISH occurs when only systolic These heart problems may be present manifest clinically as angina or myocardial blood pressure (the top number) is high. at birth or due to heart disease or heart infarction, cardiac arrhythmias (especially atrial About two of three people over age 60 defects. fibrillation, premature ventricular contractions who have HBP have ISH. ŠŠ Congenital heart defects. These heart and ventricular tachycardia), and congestive heart  Race/ethnicity problems are present at birth. failure. ŠŠ HBP occurs more often in African  Other factors: Hypertension is an established risk factor for the American adults than in Caucasian or ŠŠ Treatments for cancer, such as radiation development of coronary artery disease, almost Hispanic American adults. In relation to and chemotherapy. doubling the risk. It also increases the risk of these groups, African Americans: ŠŠ Thyroid disorders (having either too sudden cardiac death.  Tend to get HBP earlier in life. much or too little thyroid hormone in the  Fifteen to 20 percent of people will develop  Often have more severe HBP. body). left ventricular hypertrophy, especially if the  Are more likely to be aware that they ŠŠ Alcohol abuse or cocaine and other individual is obese. have HBP and to get treatment. illegal drug use.  Left ventricular hypertrophy plays a  Are less likely than Caucasians ŠŠ HIV/AIDS. significant role in cardiovascular disease. and about as likely as Hispanic ŠŠ Too much vitamin E. It occurs secondary to increased pressure Americans to achieve target control Heart damage from obstructive sleep apnea may demands on the left ventricle to become levels with HBP treatment. cause heart failure to worsen. Sleep apnea is enlarged and thickened. As the left ventricle  Have higher rates than Caucasians of a common disorder in which a person has one enlarges and becomes thick, it is unable to premature death from HBP-related or more pauses in breathing or shallow breaths effectively pump out an adequate amount of complications, such as coronary heart while sleeping. This can deprive the heart of oxygenated blood into the body. Therefore, disease, stroke and kidney failure. oxygen and increase its workload. Treating this blood backs up into the left atrium and then ŠŠ HBP risks vary among different groups of sleep problem may improve heart failure. into the lungs, causing pulmonary congestion, Hispanic American adults. For instance, dyspnea and activity intolerance. Hypertension Puerto Rican American adults have higher rates of HBP-related death than all Often called high blood pressure (HBP), What causes high blood pressure? other Hispanic groups and Caucasians. hypertension is a serious condition that can  Blood pressure tends to rise with age, unless But Cuban Americans have lower rates lead to coronary heart disease, heart failure, steps are taken to prevent or control it. than Caucasians.

Page 26 Elite  Being overweight or obese Each electrical signal begins in a group of cells tachycardia (PSVT) and Wolff- ŠŠ People who are overweight or obese are called the sinus node or sinoatrial (SA) node. Parkinson-White (WPW) syndrome. more likely to develop prehypertension The SA node is located in the right atrium. In a  Atrial fibrillation or HBP. Overweight is having extra body healthy adult heart at rest, the SA node fires off ŠŠ AF is the most common type of weight from muscle, bone, fat and/or an electrical signal to begin a new heartbeat 60 serious arrhythmia. It’s a very water. Obesity is having a high amount of to 100 times a minute. From the SA node, the fast and irregular contraction of extra body fat. electrical signal travels through special pathways the atria. There are three types:  Gender in the right and left atria. This causes the atria  Paroxysmal atrial fibrillation, ŠŠ Fewer adult women than men have HBP. to contract and pump blood into the heart’s two in which the abnormal But younger women (aged 18–59) are lower chambers, the ventricles. electrical signals and rapid more likely than men to be aware of and heart rate begin suddenly The electrical signal then moves down to a group get treatment for HBP. and then stop on their own. of cells called the atrioventricular (AV) node, ŠŠ Women aged 60 and older are as likely as Symptoms can be mild or located between the atria and the ventricles. Here, men to be aware of and treated for HBP. severe and last for seconds, the signal slows down just a little, allowing the However, among treated women aged 60 minutes, hours or days. ventricles time to finish filling with blood. The and older, blood pressure control is lower  Persistent atrial fibrillation, electrical signal then leaves the AV node and than it is in men in the same age group. a condition in which the travels along a pathway called the bundle of His.  Unhealthy lifestyle habits abnormal heart rhythm This pathway divides into a right bundle branch ŠŠ Eating too much sodium (salt). continues until it’s stopped and a left bundle branch. The signal goes down ŠŠ Drinking too much alcohol. with treatment. these branches to the ventricles, causing them to ŠŠ Not getting enough potassium in the diet.  Permanent atrial fibrillation, contract and pump blood out to the lungs and the ŠŠ Not doing enough physical activity. a condition in which a normal rest of the body. ŠŠ Smoking. heart rhythm can’t be restored The ventricles then relax, and the heartbeat with the usual treatments. Other factors process starts all over again in the SA node. Both paroxysmal and  A family history of HBP raises the risk for persistent AF may become the condition. Long-lasting stress also can put A problem with any part of this process can cause more frequent and over time, a person at risk for HBP. an arrhythmia. For example, in atrial fibrillation, result in permanent AF.  Prehypertension increases the likelihood a common type of arrhythmia, electrical signals ŠŠ In AF, the heart’s electrical of developing high blood pressure. travel through the atria in a fast and disorganized signal doesn’t begin in the SA Prehypertension is a normal blood pressure in way. This causes the atria to quiver instead of node. Instead, the signal begins the 120–139/80–89 mm/Hg range. contract. in another part of the atria or in  Risk factors for children and teens: Types of arrhythmia the nearby pulmonary veins and ŠŠ Being overweight, which is on the rise The four main types of arrhythmia are premature is conducted abnormally. When in youth younger than 18 years. As a (extra) beats, supraventricular arrhythmias, this happens, the electrical signal result, prehypertension and HBP also ventricular arrhythmias and bradyarrhythmia. doesn’t travel through the normal are becoming more common in this age  Premature (extra) beats pathways in the atria. Instead, it group. ŠŠ Premature beats are the most common spreads throughout the atria in ŠŠ African American and Mexican American type of arrhythmia. They’re harmless a fast and disorganized manner. youth are more likely to have HBP and most of the time and often don’t cause This causes the walls of the atria prehypertension than Caucasian youth. any symptoms. When symptoms do to quiver very fast (fibrillate) Boys are at higher risk for HBP than occur, they usually feel like fluttering instead of beating normally. As girls. in the chest or a feeling of a skipped a result, the atria aren’t able to Arrhythmias beat. Most of the time, premature beats pump blood into the ventricles An arrhythmia is a problem with the rate or need no treatment, especially in healthy the way they should. rhythm of the heartbeat. During an arrhythmia, people. ŠŠ In AF, electrical signals can travel the heart can beat too fast, too slow, or with an ŠŠ Premature beats that occur in the atria through the atria at a rate of more irregular rhythm. are called premature atrial contractions, than 300 per minute. Some of or PACs. Premature beats that occur these abnormal electrical signals A heartbeat that is too fast is called tachycardia. A in the ventricles are called premature can travel to the ventricles, heartbeat that is too slow is called bradycardia. ventricular contractions, or PVCs. causing them to beat too fast Most arrhythmias are harmless, but some can be ŠŠ In most cases, premature beats occur and with an irregular rhythm. serious or even life threatening. When the heart naturally, not due to any heart disease. AF usually isn’t life-threatening, rate is too fast, too slow or irregular, the heart But certain heart diseases can cause but it can be dangerous when it may not be able to pump enough blood to the premature beats. They also can happen causes the ventricles to beat very body. Lack of blood flow can damage the brain, because of stress, too much exercise, or fast. heart and other organs. too much caffeine or nicotine. ŠŠ The two most serious  Supraventricular arrhythmias complications of chronic (long- The heart’s electrical system ŠŠ Supraventricular arrhythmias are term) AF are stroke and heart To understand arrhythmias, it helps to understand tachycardias (fast heart rates) that failure. Stroke can happen if a the heart’s internal electrical system. The heart’s start in the atria or the atrioventricular blood clot travels to an artery electrical system controls the rate and rhythm of (AV) node. The AV node is a group of in the brain, blocking off blood the heartbeat. With each heartbeat, an electrical cells located between the atria and the flow. signal spreads from the top of the heart to the ventricles. ŠŠ In AF, blood clots can form bottom. As the signal travels, it causes the heart ŠŠ Types of supraventricular arrhythmias because some of the blood to contract and pump blood. The process repeats include atrial fibrillation (AF), atrial “pools” in the fibrillating atria with each new heartbeat. flutter, paroxysmal supraventricular instead of flowing into the

Elite Page 27 ventricles. If a piece of a blood  This extra pathway disrupts normal. If the heart rate is too slow, clot in the left atrium breaks off, the timing of the heart’s not enough blood reaches the brain, it can travel to the brain, causing electrical signals and can which can cause loss of consciousness. a stroke. People who have AF cause the ventricles to In adults, a heart rate slower than often are treated with blood- beat very fast. This type of 60 beats per minute is considered a thinning medicines to lower their arrhythmia can be life- bradyarrhythmia. Some people normally risk for blood clots. threatening. have slow heart rates, especially people ŠŠ Heart failure is when the heart  Ventricular arrhythmias who are very physically fit. For them, can’t pump enough blood to meet ŠŠ These arrhythmias start in the ventricles. a heartbeat slower than 60 beats per the body’s needs. AF can cause They can be very dangerous and minute isn’t dangerous and doesn’t heart failure if the ventricles beat usually need medical attention right cause symptoms. But in other people, too fast and don’t have enough away. Ventricular arrhythmias include bradyarrhythmia can be due to a serious time to fill with blood to pump ventricular tachycardia and ventricular disease or other condition. out to the body. Heart failure fibrillation (v-fib). Coronary heart ŠŠ Bradyarrhythmias can be caused by: causes fatigue (tiredness), leg disease, heart attack, weakened heart  Heart attack. swelling and shortness of breath. muscle and other problems can cause  Conditions that harm or change the ŠŠ AF and other supraventricular ventricular arrhythmias. heart’s electrical activity, such as an arrhythmias can occur for no  Ventricular tachycardia underactive thyroid gland or aging. apparent reason. But most of the ŠŠ Ventricular tachycardia is a fast,  An imbalance of chemicals or other time, an underlying condition that regular beating of the ventricles substances, such as potassium, in the damages the heart muscle and that may last for only a few blood. its ability to conduct electrical seconds or for much longer.  Some medicines, such as beta impulses causes AF. These A few beats of ventricular blockers. conditions include high blood tachycardia often don’t cause ŠŠ Bradyarrhythmias also can happen as pressure, coronary artery disease, problems. However, episodes that a result of severe bundle branch block. heart failure and rheumatic heart last for more than a few seconds Bundle branch block is a condition in disease. can be dangerous. Ventricular which an electrical signal traveling down ŠŠ Other conditions also can lead tachycardia can turn into other, either or both of the bundle branches is to AF, including an overactive more dangerous arrhythmias, delayed or blocked. When this happens, thyroid gland (too much thyroid such as v-fib. the ventricles don’t contract at exactly the hormone produced) and heavy  Ventricular fibrillation same time, as they should. As a result, the alcohol use. AF also becomes ŠŠ V-fib occurs when disorganized heart has to work harder to pump blood more common as people get electrical signals make the to the body. The cause of bundle branch older. ventricles quiver instead of pump block often is an existing heart condition.  Atrial flutter normally. Without the ventricles  Arrhythmias in children ŠŠ Atrial flutter is similar to AF, but pumping blood out to the body, ŠŠ A child’s heart rate normally decreases instead of the electrical signals a person will lose consciousness as he or she gets older. A newborn’s heart spreading through the atria in within seconds and die within beats between 95 to 160 times a minute. a fast and irregular rhythm, minutes if not treated. To prevent A 1-year-old’s heart beats between 90 to they travel in a fast and regular death, the condition must be 150 times a minute, and a 6- to 8-year- rhythm. treated right away with an old’s heart beats between 60 to 110 times ŠŠ Atrial flutter is much less electric shock to the heart called a minute. common than AF, but it defibrillation. V-fib may happen ŠŠ A baby or child’s heart can beat faster has similar symptoms and during or after a heart attack or slower than normal for many reasons. complications. or in someone whose heart is Like adults, when children are active,  Paroxysmal supraventricular already weak because of another their hearts will beat faster. When they’re tachycardia condition. Health experts think sleeping, their hearts will beat slower. ŠŠ PSVT is a very fast heart rate that that most of the sudden cardiac Their heart rates can speed up and slow begins and ends suddenly. PSVT deaths that occur every year down as they breathe in and out. All of occurs due to problems with the (about 335,000) are due to v-fib. these changes are normal. electrical connection between the ŠŠ Torsades de pointes (torsades) ŠŠ Some children are born with heart atria and the ventricles. is a type of v-fib that causes defects that cause arrhythmias. In other ŠŠ In PSVT, electrical signals that a unique pattern on an EKG. children, arrhythmias can develop later begin in the atria and travel to the Certain medicines or imbalanced in childhood. Doctors use the same tests ventricles can reenter the atria, amounts of potassium, calcium to diagnose arrhythmias in children and causing extra heartbeats. This or magnesium in the bloodstream adults. type of arrhythmia usually isn’t can cause this condition. ŠŠ Treatments for children who have dangerous and tends to occur ŠŠ People who have long QT arrhythmias include medicines, in young people. It can happen syndrome are at higher risk for defibrillation (electric shock), surgically during vigorous exercise. torsades. People who have this implanted devices that control the ŠŠ A special type of PSVT is condition need to be careful heartbeat and other procedures that fix called Wolff-Parkinson-White about taking certain antibiotics, abnormal electrical signals in the heart. syndrome. WPW syndrome is heart medicines and over-the- What causes an arrhythmia? a condition in which the heart’s counter medicines. An arrhythmia can occur if the electrical signals electrical signals travel along an  Bradyarrhythmias that control the heartbeat are delayed or blocked. extra pathway from the atria to ŠŠ Bradyarrhythmias are arrhythmias in This can happen if the special nerve cells that the ventricles. which the heart rate is slower than

Page 28 Elite produce electrical signals don’t work properly, or ŠŠ Diabetes, which increases the risk of  Smoking. if electrical signals don’t travel normally through high blood pressure and coronary heart  High amounts of certain fats and cholesterol the heart. An arrhythmia also can occur if another disease. in the blood. part of the heart starts to produce electrical ŠŠ Sleep apnea (when breathing becomes  High blood pressure. signals. This adds to the signals from the special shallow or stops during sleep), which can  High amounts of sugar in the blood caused by nerve cells and disrupts the normal heartbeat. stress the heart because the heart doesn’t insulin resistance or diabetes. get enough oxygen. Smoking, heavy alcohol consumption, use of When damage occurs, the body starts a healing ŠŠ An overactive or underactive thyroid certain drugs (such as cocaine or amphetamines), process. The healing may cause plaque to build gland (too much or too little thyroid use of certain prescription or over-the-counter up where the arteries are damaged. Over time, the hormone in the body). medicines, or too much caffeine or nicotine plaque may crack. Blood cell fragments called ŠŠ Heart surgery, certain drugs (such can lead to arrhythmias in some people. Strong platelets stick to the injured lining of the artery as cocaine or amphetamines), or emotional stress or anger can make the heart and may clump together to form blood clots. The an imbalance of chemicals or other work harder, raise blood pressure and release buildup of plaque or blood clots can severely substances (such as potassium) in the stress hormones. In some people, these reactions narrow or block the arteries and limit the flow of bloodstream. can lead to arrhythmias. oxygen-rich blood to the body. Peripheral arterial disease A heart attack or an underlying condition that Who is at risk for peripheral arterial Peripheral arterial disease (PAD) occurs when damages the heart’s electrical system also can disease? plaque builds up in the arteries that carry blood cause arrhythmias. Examples of such conditions Peripheral arterial disease (PAD) affects 8 to to the head, organs and limbs, a condition known include high blood pressure, coronary heart 12 million people in the United States. African as atherosclerosis. Over time, plaque can harden disease, heart failure, overactive or underactive Americans are more than twice as likely as and narrow the arteries, which limits the flow of thyroid gland, pericarditis and rheumatic heart Caucasians to have PAD. The major risk factors oxygen-rich blood to the organs and other parts disease. for PAD are smoking, age and having certain of the body. PAD usually affects the legs, but also diseases or conditions: In some arrhythmias, such as Wolff-Parkinson- can affect the arteries that carry blood from the  Smoking White syndrome, the underlying heart defect that heart to the head, arms, kidneys and stomach. causes the arrhythmia is congenital. Sometimes ŠŠ Smoking is more closely related to the cause of an arrhythmia can’t be found. Overview getting PAD than any other risk factor. Blocked blood flow to the legs can cause pain On average, smokers who develop PAD Who is at risk for an arrhythmia? and numbness. It also can raise the risk of getting have symptoms 10 years earlier than Millions of Americans have arrhythmias. They’re an infection in the affected limbs. It may be hard nonsmokers who develop PAD. very common in older adults. About 2.2 million for the body to fight the infection. ŠŠ Quitting smoking slows the progress of Americans have atrial fibrillation. Most serious PAD. Smoking even one or two cigarettes If severe enough, blocked blood flow can cause arrhythmias affect people older than 60. This a day can interfere with PAD treatments. tissue death (gangrene). In very serious cases, is because older adults are more likely to have Smokers and people who have diabetes this can lead to leg amputation. heart disease and other health problems that can are at highest risk for PAD complications, lead to arrhythmias. Older adults also tend to be A person who has leg pain when walking or including gangrene (tissue death) in the more sensitive to the side effects of medicines, climbing stairs should talk to a doctor. Sometimes leg from decreased blood flow. some of which can cause arrhythmias. Some older people think that leg pain is just a symptom  Age medicines used to treat arrhythmias can even of aging. However, the cause for the pain could ŠŠ The risk for PAD increases with age cause arrhythmias as a side effect. be PAD, and the doctor may wish to test for it. because genetic or lifestyle factors can Some types of arrhythmia happen more often Smoking is the main risk factor for PAD. The cause plaque to build in the arteries as in children and young adults. Paroxysmal risk for PAD increases four times for a person a person ages. About 5 percent of U.S. supraventricular tachycardias (PSVTs), including who smokes or has a history of smoking. Other adults who are older than 50 have PAD. Wolff-Parkinson-White syndrome, are more factors, such as age and having certain diseases Among adults aged 65 and older, 12 to common in young people. PSVT is a fast heart or conditions, also increase the risk. 20 percent may have PAD. Older age rate that begins and ends suddenly. combined with other risk factors, such as The risk for coronary artery disease, heart attack, smoking or diabetes, also puts a person at   Major risk factors: Arrhythmias are more stroke and transient ischemic attack (“mini- higher risk. common in people who have diseases or stroke”) is six to seven times greater than the risk  Diseases and conditions. A number of conditions that weaken the heart, such as: for people who don’t have PAD. A person with diseases and conditions can raise the risk for ŠŠ Heart attack. heart disease has a one-in-three chance of having PAD. These include: ŠŠ Heart failure or cardiomyopathy, which blocked leg arteries. ŠŠ Diabetes. One in three people who has weakens the heart and changes the way Although PAD is serious, the underlying diabetes and is older than 50 is likely to electrical signals move around the heart. atherosclerosis can be treated. PAD treatment have PAD. ŠŠ Heart tissue that’s too thick or stiff or that may slow or stop disease progress and reduce ŠŠ High blood pressure or a family history hasn’t formed normally. the risk of complications. Treatments include of it. ŠŠ Leaking or narrowed heart valves, which lifestyle changes, medicines, and surgery or ŠŠ High blood cholesterol or a family make the heart work too hard and can procedures. Researchers continue to explore new history of it. lead to heart failure. therapies for PAD. ŠŠ Heart disease or a family history of it. ŠŠ Congenital heart defects (problems that ŠŠ Stroke or a family history of it. are present at birth) that affect the heart’s What causes peripheral arterial disease? structure or function. The most common cause of peripheral arterial Assessing overall risk factors for the  Other conditions also can increase the risk disease is atherosclerosis. The exact cause of cardiac patient for arrhythmias, such as: atherosclerosis isn’t known. The disease may It is imperative that nurses obtain a thorough ŠŠ High blood pressure. start when certain factors damage the inner layers history of their patients to assess risk factors and ŠŠ Infections that damage the heart muscle of the arteries. These factors include: symptoms suggesting cardiovascular disease. or the sac around the heart. Because most cardiovascular disease is caused

Elite Page 29 by atherosclerosis, by the time it is discovered, for misreporting of American Indian children is overweight or obese. Obesity it may be too late. Therefore, nurses need to and Alaska native races on state death and overweight conditions are assessed by understand the potential risk factors when certificates. American Indians and Alaska using body mass index (BMI), defined as the assessing a patient for cardiovascular disease: natives die from heart diseases at younger weight in kilograms divided by the square of Non-modifiable risks are risks that an individual ages than other racial and ethnic groups the height in meters (kg/m2). does not control or have the ability to change: in the U.S. Thirty-six percent of those ŠŠ A BMI over 25 kg/m2 is defined as  Age. As people age, the risk of developing who die of heart disease die before age overweight, and a BMI of over 30 kg/m2 cardiovascular disease, especially coronary 65. Diabetes is an extremely important as obese. These markers provide common artery disease and , increases. risk factor for cardiovascular disease benchmarks for assessment, but the risks More than 83 percent of people who die of among American Indians. of disease in all populations can increase coronary heart disease are 65 or older. In  Genetics. Any family history for coronary progressively from lower BMI levels. 2005, nearly 151,000 Americans under the artery disease in a first-degree relative ŠŠ Being overweight or obese leads to age of 65 died because of cardiovascular (parent, sibling or child) is the major risk adverse metabolic effects in numerous disease. However, all individuals over the factor for developing cardiovascular disease. ways, but especially on a person’s age of 40 are at a higher risk of developing It is a higher risk than hypertension, obesity, cardiovascular system, resulting in coronary artery disease. diabetes or sudden cardiac death. In addition, hypertension, hyperlipidemia and insulin  Gender. Although heart disease is sometimes the younger the age of onset in a first-degree resistance. thought of as a “man’s disease,” it is the relative, the greater the risk for developing  Psychological factors such as stress leading cause of death for both women and coronary artery disease. may contribute to the risk of developing men in the U.S., and women account for cardiovascular disease. Research has Modifiable risks are personal habits and choices 51 percent of the total heart disease deaths. demonstrated that people who are highly that an individual has the ability to modify or Heart disease is often perceived as an “older competitive, concerned about meeting change. (see chart on following page) woman’s disease,” linked to the loss of deadlines and often angry are at a higher  Cigarette smoking is a major risk factor for estrogen after menopause and because it is risk of developing cardiovascular disease. In cardiovascular disease, especially coronary the leading cause of death among women addition, researchers have noted a significant artery disease and peripheral arterial aged 65 and older. However, heart disease correlation between coronary heart disease disease (PAD). Individuals who choose to is the third leading cause of death among risk and stress in a person’s life, their health smoke increase their risk of developing women aged 25-44 years and the second behaviors and socioeconomic status. These cardiovascular disease two to four times leading cause of death among women aged factors may affect established risk factors. higher than that of a nonsmoker. Cigarette 45-64. Unfortunately, women who suffer an For example, people under stress may smoking is also a powerful independent risk acute myocardial infarction (MI) typically overeat, start smoking or smoke more than factor for sudden cardiac death in patients tend to die more frequently than men. they otherwise would. with coronary heart disease; smokers have  Ethnicity. According to the CDC in 2009, ŠŠ Nurses can assess this risk by asking the about twice the risk of nonsmokers. Cigarette cardiovascular disease death rates per patient, “Have you ever experienced road smoking also acts with other risk factors to 100,000 population for the five largest U.S. rage?” or “How do you respond when greatly increase the risk for coronary heart racial/ethnic groups are as follows: blacks, you have to wait for an appointment?” disease. 300; whites, 228; Hispanics, 173; American  Alcohol use can raise the blood pressure, ŠŠ Other forms of smoking, such as cigars, Indian/Alaskan natives, 160; and Asian and leading to heart failure and stroke. It may pipes and secondhand smoke, also Pacific Islanders, 128. also affect the cardiovascular system by add to the risk of developing coronary ŠŠ Blacks suffer from hypertension more contributing to high triglycerides, obesity and artery disease and CVA (cerebrovascular than Caucasians and have a higher risk irregular heartbeats. accident), although the risk is not as high of developing cardiovascular disease, ŠŠ The risk of heart disease in people who as with cigarette smoking. especially coronary artery disease. drink moderate amounts of alcohol (an ŠŠ Nurses should inquire about patients’ ŠŠ In 2002, age-adjusted death rates for average of one drink for women or two smoking history in terms of the pack per heart disease were higher among black drinks for men per day) is lower than in years, which is the number of packs per women (169.7 per 100,000) than among nondrinkers. One drink is defined as 1 day multiplied by the number of years white women (131.2 per 100,000). 1/2 ounces of 80-proof spirits (such as smoked. ŠŠ White women with abdominal obesity bourbon, Scotch, vodka and gin), 1 ounce  Physical inactivity. A sedentary, inactive (greater waist circumference than hip of 100-proof spirits, 4 ounces of wine or lifestyle is a significant risk factor for the circumference) are more likely to develop 12 ounces of beer. development of cardiovascular disease. cardiovascular disease than white women Regular, moderate-to-vigorous physical with distributed fat in the buttocks, hips activity helps prevent heart and blood vessel and thighs (greater hip circumference disease by controlling the blood pressure, than waist circumference). blood lipids and clotting factors. ŠŠ Heart disease risk is also higher among  Being obese or overweight. Obesity leads to Mexican Americans, American Indians, diabetes, hypertension and high cholesterol native Hawaiians and some Asian (hypercholesteremia/hyperlipidemia). Americans, all linked to higher rates of According to the WHO in 2009, there are coinciding obesity and diabetes. more than 1 billion overweight adults; at least ŠŠ According to the CDC (2008), heart 300 million of them are considered obese. In disease is the leading cause of death addition, the WHO has estimated there are and stroke is the sixth among American 155 million overweight or obese children Indians and Alaska natives. The heart worldwide, and 22 million are overweight disease death rate was 20 percent greater under the age of 5. In 2000, 22 percent of and the stroke death rate 14 percent American preschool-age children were greater among American Indians and overweight, and 10 percent were considered Alaska natives (1996–1998) than among obese. In essence, one in four preschool age all U.S. races (1997) after adjusting Page 30 Elite Modifiable risk factors Risk factor How much it affects stroke risk Why it affects stroke risk What you can do Hypertension Hypertension causes a two- to Hypertension promotes Blood pressure medications, four-fold increase in the risk of atherosclerosis and causes such as thiazide diuretics and stroke before age 80. After age mechanical damage to the walls of angiotensin-converting enzyme 80, the impact of hypertension blood vessels. (ACE) inhibitors, can reduce the declines and other risk factors risk of stroke by 30 to 40 percent. become more important. Early treatment is essential. Among older people with normal blood pressure, prior mid-life hypertension increases stroke risk up to 92 percent. Guidelines from the Centers for Disease Control and Prevention recommend a target blood pressure of less than 140/90 mm/Hg. Cigarette smoking Smoking causes about a two-fold Smoking promotes atherosclerosis Stroke risk decreases significantly increase in the risk of ischemic and aneurysm formation, and two years after quitting smoking stroke and up to a four-fold stimulates blood clotting factors. and is at the level of nonsmokers increase in the risk of hemorrhagic by five years. stroke. Diabetes In terms of stroke and In diabetes, glucose is not Blood pressure medications, cardiovascular disease risk, having efficiently taken up by the body’s dietary changes and weight loss diabetes is the equivalent of aging cells and accumulates in the blood can lower stroke risk. Controlling 15 years. instead, where it can damage the blood sugar appears to reduce the vascular system. Hypertension risk of recurrent stroke. is common among diabetics and accounts for much of their increased stroke risk. Physical inactivity and obesity Waist-to-hip ratio equal to or Obesity is associated with While no clinical studies have above the median (mid-value for hypertension, diabetes and heart tested the effects of exercise or the population) increases the risk disease. weight loss on stroke risk, both of ischemic stroke three-fold. tend to reduce hypertension and boost cardiovascular health.

Atrial fibrillation (AF) AF affects fewer than one percent AF refers to irregular contraction Warfarin, a blood-thinning of people under age 60, but is of the atrium – the chamber where medication, can reduce the risk more prevalent in older people. blood enters the heart. AF can lead of stroke in people with AF. It is responsible for one in four to blood stagnation and increased People under age 60 with AF and strokes after age 80, and is clotting. no other stroke risk factors may associated with high mortality and benefit from aspirin. Importantly, disability. pacemakers have no effect on the risk of stroke associated with AF. Cholesterol imbalance High-density lipoprotein (HDL) LDL and HDL are needed to carry Clinical trials have shown that cholesterol is generally considered cholesterol (a fatty substance) cholesterol-lowering drugs known protective against ischemic stroke. through the blood (made up mostly as statins reduce the risk of stroke. Low-density lipoprotein (LDL) of water), and deliver it to cells. However, some studies point to cholesterol, when present in Because LDL delivers cholesterol only a weak association between excess, is considered harmful. to cells throughout the body, stroke and cholesterol, and there excess LDL can cause cholesterol is speculation that statins reduce to build up in blood vessels, stroke risk by acting through some leading to atherosclerosis. HDL unknown mechanism. sends cholesterol to the liver to be eliminated.

Elite Page 31 Other potential risk factors: It is important  Metabolic syndrome (also known as insulin cardiovascular problems, pulmonary, to assess the patient for other chronic health resistance) is a syndrome that occurs prior to gastrointestinal (GI), musculoskeletal, problems that may exacerbate the cardiac the development of diabetes. The majority of neurologic, psychogenic or idiopathic causes symptoms and increase the risk of cardiovascular individuals living with metabolic syndrome [24]. Therefore, each of the most common disease. The nurse should inquire about other co- are unaware of it because they are usually cardiovascular natures of chest pain will be morbidities by obtaining information regarding asymptomatic. However, people with a severe explored and elaborated upon in detail to help the onset, duration, frequency, location and form of insulin resistance (metabolic X) may differentiate the nature of the pain [43]: associating symptoms. have a condition called acanthosis nigricans, ŠŠ Angina pectoris chest pain or discomfort  Cerebrovascular accident (CVA or stroke) in which they will notice dark patches occurs when the heart muscle is not is a rapid onset of neurological deficits due of skin, usually on the back of the neck, getting enough blood [4]. The most to a decreased flow of oxygenated blood to elbows, knees, knuckles and the armpits, an common symptom of coronary artery the brain. CVA coincides with cardiovascular early sign of pre-diabetes. According to the disease is angina, although in some disease because most of the modifiable risk American Heart Association and the National individuals the first sign of CAD is a factors for CVA include hypertension, cardiac Heart, Lung and Blood Institute, metabolic myocardial infarction. The angina pain disease, hyperlipidemia and smoking. Strokes syndrome is diagnosed when a minimum of is paroxysmal pain in the substernal will be discussed in detail in Part II of this three of the following criteria are met: area that may radiate to the precordium, course. ŠŠ Elevated waist circumference upper extremities, neck or jaw. Angina  Diabetes mellitus seriously increases an (abdominal obesity). Increased pain typically lasts 30 seconds to a few individual’s risk of developing cardiovascular abdominal adiposity (waist greater than minutes, and patients describe it as dull, disease. Even if the overall glucose (blood 40 inches in men and greater than 35 pressing, squeezing or aching pain. sugar) levels are under control, diabetes inches for woman). The excess fat in the Angina pain is precipitated by exertion, increases the risk of heart disease and stroke, intra-abdominal area is a huge component emotional stress, sexual activity, exposure but the risks are even greater if blood sugar of the metabolic syndrome. The majority to cold and occasionally by eating. is not well controlled. According to the of experts concur that the combination However, unstable angina may occur American Diabetes Association (ADA), of obesity, obesity-related cytokines while at rest. Angina pain is alleviated most of the cardiovascular complications called adipokines, excess nutrients and by rest within 10 minutes and/or related to diabetes have to do with the way inflammatory cytokines are the main administration of a nitroglycerin (NTG) the heart pumps blood through the body. contributors to beta cell death and insulin sublingual (S/L) tablet within two to four Diabetes can change the chemical makeup of resistance in type 2 diabetes. Regardless minutes. Typically, angina symptoms last some of the substances found in the blood, of which event occurred, the mechanisms less than 20 minutes (versus greater than and this can cause blood vessels to narrow that are responsible for insulin receptor 20 minutes with an MI) [13]. or to clog up completely, which is known as binding or post receptor can be reversed ŠŠ Myocardial infarction chest pain may be atherosclerosis. Because of the compounding by weight loss. sudden and intense, similar to the “movie effects of diabetes and cardiovascular disease, ŠŠ Elevated triglycerides (TG) greater than heart attack,” where no one doubts what it is estimated that about 65 percent of people 150 mg/dl. is happening. However, the majority of living with diabetes will die from some form ŠŠ Reduced HDL cholesterol (less than 40 myocardial infarctions start slowly, with of heart or blood vessel disease. mg/dl in men and less than 50 mg/dl for mild pain or discomfort. Often people  Hyperlipidemia/dyslipidemia is an women). affected are not significantly sure what is elevation of lipids (fats) in the bloodstream ŠŠ Fasting blood glucose (hyperglycemia) going on. Although they may be aware measured by assessing the cholesterol, greater than 100 mg/dl). of the symptoms of an MI, they typically triglycerides, LDL, HDL cholesterol ŠŠ Increased blood pressures (130/85 mm/ will assume other irrational things are esters (compounds), phospholipids and Hg or greater). causing their symptoms. Other common triglycerides. A high lipid profile is typically symptoms associated with MI chest pain Signs and symptoms of cardiovascular known as a modifiable risk factor because include any of the following: it can be the result of choosing a lifestyle disease  Chest discomfort. Most heart attacks that consists of a high fatty diet and possibly Over time, many experienced health care involve discomfort in the center of drinking alcohol. However, hyperlipidemia professionals can speculate a potential diagnosis the chest that lasts more than a few may be due to genetic factors beyond an based upon their gut feeling and the symptoms minutes, or that goes away and comes individual’s choice. of the patient. However, the best way to truly back. It can feel like uncomfortable ŠŠ Over the past few decades, numerous assess and diagnose the nature of the symptoms is pressure, squeezing, fullness or pain. research studies have demonstrated by collecting a thorough history and performing  Discomfort in other areas of the that elevated plasma cholesterol levels, an explicit assessment, because the severity of upper body. Symptoms can include especially low-density lipoprotein these symptoms varies. The symptoms may get pain or discomfort in one or both cholesterol (LDL-C), has an enormous more severe as the buildup of plaque continues to arms, the back, neck, jaw or stomach. impact on developing cardiovascular narrow the coronary arteries. In other instances,  Shortness of breath with or without disease. some people do not demonstrate any signs and chest discomfort.  Hypertension (HTN) increases the heart’s symptoms of an inevitable myocardial infarction,  Other signs may include breaking workload, causing the heart to thicken congestive heart failure or an arrhythmia, which out in a cold sweat, nausea or light- is called silent coronary artery disease. and become stiffer. It increases the risk of  headedness. coronary artery disease, cerebrovascular  Chest pain is one of the most common It is important to understand that women accident, heart attack/myocardial infarction, complaints in adults and may indicate enduring an MI may present with kidney failure and congestive heart failure. a cardiovascular disease [43]. Although subtle or other symptoms. As with men, The risk of cardiovascular disease is cardiovascular disease is not always the women’s most common heart attack exacerbated if hypertension coincides with primary cause of the chest pain, nurses symptom is chest pain or discomfort. obesity, smoking, high blood cholesterol and doctors need to be able to assess the However, women are somewhat more levels or diabetes. symptomology and nature of the chest likely than men to experience some of the pain. Chest pain may be associated with other common symptoms, particularly

Page 32 Elite shortness of breath, nausea/vomiting and claudication. During physical activity, Detection, Evaluation and Treatment of High back or jaw pain. muscles need increased blood flow. If Blood Pressure. The JNC VII recommends ŠŠ Mitral valve prolapse (MVP) chest blood vessels are narrowed or blocked, accurately assessing the baseline blood pain typically occurs during rest and they won’t get enough blood. When pressure (BP) by making sure that the patient may last for a few minutes to several resting, the muscles need less blood flow, is sitting for a minimum of five minutes in hours. Patients typically describe MVP as so the pain goes away. a chair (rather than on an exam table), with “sticking,” and it may be associated with ŠŠ About 10 percent of people who have feet on the floor and arms supported at heart tachyarrhythmia and light-headedness. PAD have claudication. This symptom level, and to be sure to use an appropriate  Dyspnea (shortness of breath) is another is more likely in people who also have sized cuff. At least two measurements should common symptom of coronary artery disease atherosclerosis in other arteries. be made on two different occasions before and congestive heart failure. Shortness ŠŠ Weak or absent pulses in the legs or feet. confirming a hypertensive diagnosis. of breath occurs if coronary heart failure ŠŠ Sores or wounds on the toes, feet or legs ŠŠ Normal blood pressure is less than is caused by the heart’s inability to pump that heal slowly, poorly or not at all. 120/80. enough blood throughout the body. Since the ŠŠ A pale or bluish color to the skin.  Prehypertension is 120-139 (systolic) heart has two ventricles, right and left, it is ŠŠ A lower temperature in one leg compared or 80-89 (diastolic). possible for one side (typically the left) to to the other leg.  Stage 1 hypertension is 140-159 fail by itself for a short period. Initially, the ŠŠ Poor nail growth on the toes and (systolic) or 90-99 (diastolic). left ventricle will fail because of its inability decreased hair growth on the legs.  Stage 2 hypertension is greater to pump an adequate amount of blood to the ŠŠ Erectile dysfunction, especially among than160 (systolic) or 100 (diastolic). rest of the body, causing fluid to back up into men who have diabetes. ŠŠ For persons older than 50, systolic blood the lungs. The most common symptoms of pressure greater than 140 mm/Hg is a Health authorities recommend patients discuss left-sided congestive heart failure include, but much more important cardiovascular the need for screening with their doctor if they are not limited to: disease risk factor than diastolic blood are: ŠŠ Shortness of breath and fatigue. As pressure.  Aged 70 or older. the left ventricle enlarges because of its  The risk of cardiovascular disease  Aged 50 or older and have a history of inability to pump efficiently and blood beginning at 115/75 mm/Hg smoking or diabetes. backs up into the left atrium, other doubles with each increment of  Younger than 50 and have diabetes and one symptoms will be noted caused by right- 20/10 mm/Hg; individuals who are or more risk factors for atherosclerosis. sided heart failure, including exacerbated normotensive at age 55 have a 90 fatigue, swelling in the ankles, feet, legs, No symptoms? percent lifetime risk for developing abdomen and neck. The nurse should never assume the heart of a hypertension. Individuals with a  Palpitations are typically reported by patient without symptoms is functioning at the systolic blood pressure of 120–139 patients who are at risk of developing optimal level because some may be asymptomatic mm/Hg or a diastolic blood cardiovascular disease. Palpitations are initially. The majority of patients with coronary pressure of 80–89 mm/Hg should defined by the patient reporting the heart artery disease may be unaware of the existence be considered as prehypertensive beating or skipping beats at times. It is for years due to the lack of symptoms, especially and require health-promoting important to distinguish the timing of the elderly because the body compensates for lifestyle modifications to prevent the palpitations. For instance, if it occurs the atherosclerosis by developing collateral cardiovascular disease. after exercise, it is probably a normal circulation. Research has demonstrated that some  Cholesterol and lipid profile: The United physiological response due to the increased patients with coronary artery disease may not States Preventive Services Task Force release of catecholamines. However, develop any symptoms until 75 percent of the (USPSTF) (2001) and the American more serious pathological causes may be coronary artery is narrowed (stenosed). Academy of Family Physicians (AAFP) contemplated if the patient verbalizes one of (2006) recommends routine screening of Once the coronary artery has developed enough the following comments: a fasting lipoprotein panel for men aged stenosis, the primary initial symptom is angina, ŠŠ Heart “stopped momentarily” may imply 20 to 35 and females age 20 to 45 if the which should lead the health care professional an atrial or ventricular ectopic beat. patient is at risk for coronary artery disease to immediately speculate coronary artery disease ŠŠ Significant skipping may imply a (hypertension, smoking, DM, family history and/or myocardial infarction. Always inquire potential arrhythmia, such as atrial of coronary artery disease before age 50 in about other symptoms, such as radiation of chest fibrillation. male relatives and age 60 in female relatives pain, especially the left and jaw; nausea; ŠŠ The nurse should also inquire about other and/or family history suggestive of familial dyspnea; and light-headedness. Early screening potential symptoms that coincide with the hyperlipidemia). The USPSTF and AAFP and prevention measures are imperative for early palpitations, such as anxiety, weakness, strongly recommend routine screening for detection. dizziness and light-headedness; fainting all men at age 35 and women at 45. The or nearly fainting; sweating; dyspnea; and Screening for and diagnosing National Cholesterol Education Program chest pain. cardiovascular disease (NCEP III) (2004) recommends that all   Peripheral arterial disease causes signs or Ideally, nurses and physicians should screen men and women aged 20 and over should symptoms of it in half of those who have it, patients at risk for cardiovascular disease to have a fasting lipoprotein panel completed, although others may have a number of them. try to prevent the development and damage to then repeat every five years if the results ŠŠ People who have PAD may have the patient’s heart muscle and left ventricle. are normal. Desirable or optimal levels for symptoms when walking or climbing Because of the prevalence of cardiovascular persons with or without existing heart disease stairs. These may include pain, disease globally in all cultures, ages, races and are as follows: numbness, aching or heaviness in socioeconomic statuses, there are stringent ŠŠ Total cholesterol: Less than 200 the leg muscles. Symptoms also may guidelines set aside by professional organizations milligrams (mg) per deciliter (dL). include cramping in affected legs and to screen for cardiovascular disease as follows: ŠŠ Low density lipoprotein (LDL) in the buttocks, thighs, calves and  Blood pressure recommendations are cholesterol (“bad” cholesterol): Less than feet. Symptoms may ease after resting. guided by the Seventh Report of the 100 mg/dL. These symptoms are called intermittent Joint National Committee on Prevention,

Elite Page 33 ŠŠ High density lipoprotein (HDL) is greater than 25. According to the ADA, ŠŠ CK-MB is found in the myocardial cholesterol (“good” cholesterol): 40 diabetes is diagnosed if: muscle and is most specific for mg/dL or higher. However, the AHA ŠŠ A fasting blood glucose greater than demonstrating an MI. has recommended that men maintain 126 mg/dl (no caloric intake for over ŠŠ CK-BB is found in the brain. a level above 50 mg/dl and women 60 eight hours) on two or more occasions (a  Echocardiogram (ECHO) is a noninvasive mg/dl to reduce their individual risk of normal fasting blood glucose is less than test that allows cardiologists to assess the cardiovascular disease. Higher levels 100 mg/dl). function of the valves and structure of the of HDL (“good” cholesterol) provide ŠŠ A random plasma glucose concentration heart by visually observing and taking extra protection against heart disease. greater than 200mg/dl taken at any time, measurements via an ultrasound device. Smoking, being overweight and living regardless of the last meal.  Electrocardiogram (ECG or EKG) a sedentary lifestyle can all result in a ŠŠ A two-hour plasma oral glucose tolerance measures the electrical function, rate and lower HDL cholesterol level. To raise test (OGTT) greater than 200 mg/dl (two regularity of the patient’s heart rhythm. The their HDL levels, individuals should hours after ingesting 75 g of a glucose ECG is a useful tool to distinguish between avoid tobacco smoke, maintain a healthy load). A normal fasting blood glucose different types of arrhythmias and myocardial weight and exercise for at least 30-60 level for non-diabetics is 70-110 mg/dl. infarction, and demonstrates left ventricular minutes more days than not. hypertrophy and coronary artery disease. When cardiovascular disease is speculated, the  Triglycerides: Less than 150 mg/dL. ŠŠ Any patient who presents with chest pain, physician or nurse practitioner will order specific Triglycerides are a form of fat. Many is over 40 or has a history of the major tests to confirm a potential cardiac diagnosis. If people have high triglyceride levels because heart ailments should have an ECG to the patient presents with potential life-threatening of being overweight or obese, physical assess and differentiate cardiac ischemia, emergency cardiac symptoms, the patient will inactivity, cigarette smoking, excess injury, infarct, myocardial infarction or be immediately transferred via ambulance to the alcohol consumption or a diet very high left ventricular hypertrophy: closest emergency room (ER). Other specific tests in carbohydrates (60 percent or more of  Myocardial ischemia will result in the that may be ordered are: calories). High triglycerides are a lifestyle- inversion of the T-wave.  B-type natriuretic peptide (BNP), which related risk factor; however, underlying  Injury to the myocardial cells is is a hormone produced and released by the diseases or genetic disorders can be the more severe than ischemia and is ventricles secondary to volume and pressure cause. manifested by ST segment depression overload, thus decreasing preload [16, 46].  Coronary artery disease: The AAFP, or ST elevation. BNP increases sodium and water excretion AHA and USPSTF all recommend against  MI (infarction) implies necrosis and signifies congestive heart failure. routine screening for heart disease with or death of the myocardial cells Therefore, it is a useful test to distinguish routine electrocardiograms (ECG), exercise secondary to atherosclerosis. In the between congestive heart failure and other tolerance test (ETT) or electrobeam majority of cases, the left ventricle causes of shortness of breath. A normal computed tomography (CT) for coronary (LV) is the major site for infarction; level of BNP is less than 100 picograms per calcium because they aren’t cost-effective. however, it may occur in the right milliliter (pg/ml). According to an editorial submitted by the ventricle (RV).  C-reactive protein (CRP), which is a marker AAFP, cardiac CT is expensive ($400 to $500  Q-wave MI is defined as an initial of inflammatory process and may aide in the per scan) and thus far has not been proven to downward deflection of a duration of prediction of coronary events and signifies affect patient-oriented outcomes. At this time, 40 msec or more in any lead except atherosclerosis. CRP is a protein produced research has not demonstrated that the cost is III and a VR. by the liver and the smooth muscle cells beneficial for asymptomatic patients.  Non-Q-wave MI may be diagnosed within the atherosclerotic coronary arteries ŠŠ However, the AHA does recommend in the presence of ST depression and [24]. Although the CRP is a good predictor, screening for patients with an T-wave abnormalities. it should not be relied on solely because it intermediate risk based upon the ŠŠ Regardless, the doctor will order is only one piece to the puzzle of predicting Framingham score. The Framingham cardiac enzymes to assess for coronary artery disease, myocardial infarction risk score assesses an individual’s risk of MI. In the absence of enzyme and cerebrovascular accident. developing cardiovascular disease over a elevation, ST and T-wave  Cardiac catheterization is the most 10-year time frame based upon their age, abnormalities are interpreted as definitive, invasive diagnostic test to aide diabetes, smoking, JNC-7 blood pressure due to injury or ischemia rather in the diagnosis of cardiovascular disease. category, NCEP cholesterol levels and than infarction. During the procedure, a thin, flexible tube is total LDL. Each category correlates to a  Left ventricular hypertrophy passed through an artery in the groin or arm percentage range that is added up at the is complex to assess and more to reach the coronary arteries to assess for end of the seven categories to determine applicable for the cardiologists to any blockage, coronary artery disease and an individual’s risk level. definitively speculate a diagnosis myocardial and valvular function.  Diabetes screening: Since 2003, the based upon the height of the R and  Chest radiograph (CXR) provides a picture USPSTF has recommended that adults with S waves. It is definitely diagnosed of the organs and structures inside the chest high blood pressure or high cholesterol be based upon the thickness of the wall to determine the size, silhouette and position screened for type 2 diabetes (insulin-resistant measured during an echocardiogram of the heart. diabetes) as part of an integrated approach to (ECHO).  Creatine kinase (CK) is an enzyme specific reduce their risk of cardiovascular disease,  Homocysteine is an amino acid that is to cells of the brain, myocardium and skeletal but concluded that further research is needed produced when proteins are broken down. muscle. If a patient tests positive for CK, it to determine whether widespread screening An elevated level may be a risk factor indicates tissue necrosis or injury somewhere of the general population would improve for cardiovascular disease. However, the in the body. However, in order to definitely health outcomes. The ADA guidelines correlation is still controversial. assess for cardiac necrosis or injury, the nurse are partially congruent with the previous  Myoglobin is another early marker of an needs to be familiar with the three types of recommendations that screening should begin MI; however, it is not specific to the heart. isoenzymes: with a FBG or OGTT every three years, Myoglobin is a low-molecular protein found ŠŠ CK-MM is the predominant isoenzyme of beginning at the age of 45, especially if BMI in the cardiac and skeletal muscle. skeletal muscle.

Page 34 Elite  Stress test is useful in assessing for ischemia symptoms are and what level of exercise initiated by the American Heart Association and caused by fixed coronary lesions, but it may brings them on. For this test, the patient updated in 2006. The AHA, CDC and WHO provide inaccurate readings in patients at high walks on a treadmill to show whether have elaborated upon their diet recommendations risk or with coronary artery disease. Research there are any problems during normal by encouraging individuals to adhere to the studies have demonstrated that patients with walking. following: coronary artery disease may have a false-  An ABI test may be done before and  Consume a diet high in fruits, vegetables, positive, and patients in a high-risk category after the treadmill test to compare fiber, nuts and whole grains, and low in for developing it may have false-negatives. blood flow in the arms and legs refined grains. Fruits and vegetables have At that time, the patient’s cardiologists would before and after exercise. folate, vitamin B6 and B12 to reduce the total need to evaluate the risk and history of the  Magnetic resonance angiogram homocysteine level, especially if the patient individual to decide whether further testing is ŠŠ A magnetic resonance angiogram (MRA) is at risk for developing cardiovascular warranted. uses magnetic and radio wave energy to disease. take pictures of blood vessels inside the  Choose lean meats and poultry without skin Peripheral arterial disease diagnosis is based on body. It can find the location of a blocked and prepare them without added saturated medical and family histories, a physical exam and blood vessel and show how severe the and trans fat. Limit energy intake from total results from tests. Medical and family histories blockage is. fats and shift fat consumption away from may include questions about: ŠŠ Patients who have a pacemaker, saturated fats to unsaturated fats and towards  Whether the patient has any risk factors for man-made joint, stent, surgical clips, the elimination of trans-fatty acids. PAD. mechanical heart valve or other metallic  Select fat-free, 1 percent fat and low-fat dairy  Symptoms, including any that occur when devices in the body might not be able to products. walking, exercising, sitting, standing or have an MRA.  Increase consumption of omega-3 fatty acids climbing.  Arteriogram from fish oil or plant sources to at least twice  Diet. ŠŠ An arteriogram provides a “road map” of a week. Recent research has demonstrated  Medications the person takes, including the arteries to find the exact location of a that eating oily fish containing omega-3 fatty prescription and over-the-counter medicines. blocked artery. acids (for example, salmon, trout and herring)  Whether there is a family history of ŠŠ For this test, dye is injected through a may help limit an individual’s risk of death cardiovascular disease. needle or catheter into an artery. The from coronary artery disease. During the physical exam, the doctor will look patient may feel mildly flushed. After the  Limit foods containing partially hydrogenated for signs and symptoms of PAD. He or she may dye is injected, an x-ray is taken, which vegetable oils to reduce trans fat in the diet. check the blood flow in the patient’s legs or feet can show the location, type and extent of  Limit the total dietary cholesterol in a diet, to see whether there are weak or absent pulses. the blockage in the artery. with the goal to eat less than 300 mg of The doctor also may check the pulses in leg  Some hospitals use a newer method cholesterol every day. arteries for an abnormal whooshing sound called of arteriogram that uses tiny  Limit the consumption of beverages and a bruit, which can be heard with a stethoscope. ultrasound cameras that take pictures foods with added sugars. A bruit may be a warning sign of a narrowed or of the insides of the blood vessels.  Limit the amount of alcohol consumed to no blocked section of artery. The physician also may This method is called intravascular more than one drink per day for women and compare blood pressure between the limbs to see ultrasound. two drinks per day for men. whether the pressure is lower in the affected limb  Blood tests  Choose and prepare foods with little or no or check for poor wound healing or any changes ŠŠ These may be done to check for PAD salt. Americans should aim to eat less than in hair, skin or nails that may be signs of PAD. risk factors, for example, blood glucose 2,300 mg of sodium per day (or less than Diagnostic tests may include: levels to check for diabetes or lipid tests 1,500 mg if there is a higher risk of being  Ankle-brachial index to check cholesterol levels. affected by hypertension for those already diagnosed). ŠŠ The ankle-brachial index (ABI) compares Overall strategies for prevention of ŠŠ The DASH diet reiterates the CDC and blood pressure in the ankle to blood cardiovascular disease pressure in the arm, which shows how WHO recommendations by further Because of the significant prevalence of elaborating that 2,300 mg is the highest well blood is flowing in the limbs. cardiovascular disease globally, it is imperative While the ABI can show whether PAD is level considered acceptable by the to consider primary prevention before National High Blood Pressure Education affecting a person’s limbs, it won’t show cardiovascular diseases begin. In order to reduce which blood vessels are narrowed or Program. It is also the highest amount the risk of developing cardiovascular disease, it recommended for healthy Americans blocked. is imperative to initiate healthy lifestyle choices.  A normal ABI result is 1.0 or greater by the 2005 U.S. Dietary Guidelines The Centers for Disease Control (CDC) and for Americans. A 1,500 mg level can (with a range of 0.90 to 1.30). The World Health Organization (WHO) recommend test takes about 10 to 15 minutes to lower blood pressure further, and more the best way to fight heart disease is a healthy recently is the amount recommended by measure both arms and both ankles. diet and lifestyle. Healthy lifestyle choices for This test may be done yearly to see the Institute of Medicine (IOM) as an all people include exercising, not smoking and adequate intake level and one that most whether PAD is getting worse. eating nutritious foods. Although it may appear  people should try to achieve. In 2009,  Doppler ultrasound difficult, it is all about making healthy choices to ŠŠ A Doppler ultrasound is a test that the CDC reiterated that patients at higher protect the heart and to be able to live life to the risk of developing cardiovascular disease uses sound waves to show whether a fullest. blood vessel is blocked. This test uses a and/or hypertension (including people blood pressure cuff and special device There are a few dietary recommendations that 40 or older, African Americans or those to measure blood flow in the veins overlap, yet all have one goal in mind: protecting currently hypertensive) should limit their and arteries of the limbs. A Doppler the heart. Since 1998, then revised in 2006, the total sodium intake to less than 1,500 mg/ ultrasound can help find out how severe U.S. Department of Health and Human Services day. In 2009, a CDC report said two out PAD is. has encouraged Americans to adhere to a dietary of three (69 percent) adults in the U.S.  Treadmill test approach to stop hypertension, called DASH. fall into these three groups who are at ŠŠ A treadmill test can show how severe the Another common diet that nurses may be familiar especially high risk for health problems with in the hospital setting is the cardiac diet from consuming too much sodium. Elite Page 35 ŠŠ Eating less sodium can help prevent, improve the function of the heart. It should coronary intervention (PCI), especially lower or even control blood pressure. be important for the health care provider if the patient has ST-segment elevation Most of the sodium consumed comes to find a level of activity that a patient can myocardial infarction (STEMI). from packaged, processed, store-bought accomplish over the long term. The American Fibrinolysis should be provided within 30 and restaurant foods. Only about 5 Academy of Family Physicians (AAFP) minutes of first medical system contact, percent comes from salt added during recommends a combination of resistance and primary PCI should be provided cooking, and about 6 percent comes from and aerobic exercise, but any activity is within 90 minutes for patients presenting being added at the table. All nutritional better than none, and patients who have been with STEMI. information facts are available on food sedentary need to start with walking and  Contraindications include previous products and available at any restaurant. gradually increase duration and intensity. hemorrhagic cerebrovascular accident ŠŠ Additional research has demonstrated or other strokes, cerebrovascular Ideally, the AHA recommends regular aerobic that most Americans eat a lot more than events within the past year, known physical activity to increase an individual’s the recommended sodium intake; men intracranial neoplasm, active internal overall fitness level and capacity for exercise. It currently eat about 4,200 mg a day, and bleeding (excluding menstruation) or also plays a role in both primary and secondary women consume 3,300 mg [45]. suspected aortic disease. prevention of cardiovascular disease. Physical  Since 1993, thrombolytic agents The recommended daily nutrient goals in inactivity is a major risk factor for heart disease have been available and work by the Third Report of the National Cholesterol and stroke and is linked to cardiovascular converting plasminogen to the natural Education Program (NCEP) and DASH to reduce mortality. Regular physical activity can help fibrinolytic agent plasmin. Plasmin the overall weight, blood pressure, lipid profile control blood lipid abnormalities, diabetes and lyses clots by breaking down the and to promote a healthy heart are very similar in obesity. Aerobic physical activity can also help fibrinogen and fibrin contained in the specific recommendations: reduce blood pressure. Therefore, in order to the clot. Fibrinolytics, sometimes  Total fat, 27 percent of calories (DASH); 25- achieve health benefits to the heart, lungs and referred to as plasminogen activators, 35 percent (NCEP). circulation, an individual must perform any are divided into two categories.  Saturated fat, 6 percent of calories (DASH); moderate-to-vigorous-intensity aerobic activity  Fibrin-specific agents, including less than 7 percent of calories (NCEP). for at least 30 minutes on most days of the week alteplase, reteplase and tenecteplase,  Polyunsaturated fat, up to 10 percent of at 50-85 percent of his or her maximum heart produce limited plasminogen calories (NCEP). rate. One can accumulate 30 minutes in 10- or conversion in the absence of fibrin,  Monounsaturated fat, up to 20 percent of 15-minute sessions. It is important to include whereas nonfibrin-specific agents calories (NCEP). physical activity as part of a regular routine. such as streptokinase catalyze  Sodium, 2,300 mg; however 1,500 mg is  Ideal examples of aerobic activities that systemic fibrinolysis. Streptokinase is ideal, especially to maintain a healthy blood increase endurance include brisk walking, indicated for the treatment of an acute pressure. jumping rope, jogging, bicycling, rowing, myocardial infarction. Streptokinase  Potassium, 4,700 mg. swimming, cross-country skiing and dancing. is not widely used in the U.S.  Protein, 18 percent of calories (DASH); 15 Ideally, nurses and physicians should elaborate because it not as effective in opening percent of calories (NCEP). upon recommended food choices, smoking occluded arteries and less effective  Calcium, 1, 250 mg. cessation and choosing an active lifestyle to all in reducing mortality. However, it  Carbohydrates, 55 percent of calories their patients, regardless of their current risk is used in other countries because (DASH); 50-60 percent of calories (NCEP). of developing cardiovascular disease, because of its cheaper cost. Alteplase is the  Magnesium, 500 mg. ultimately everyone is at risk at some point. only current lytic agent the U.S. Food  Cholesterol, 150 mg (DASH); less than 200 Although we cannot change our risks due to and Drug Administration (FDA) mg/day (NCEP). our age, gender and genetics, we can choose a has approved for acute myocardial  Fiber, 30 grams (g)/day (DASH); 20-30 g/day healthier life. infarction. (NCEP).  Treatment of cardiovascular diseases  Tissue plasminogen activator NCEP is supported by the Detection, Evaluation (tPA) is a naturally occurring Since 2001, the Joint Commission (JCAHO) and Treatment of High Blood Cholesterol fibrinolytic agent found in vascular has initiated core measures to be implemented in Adults; Adult Treatment Plan (ATP III) endothelial cells and is involved in by all hospitals in the U.S. to measure and designated by the therapeutic lifestyle changes. the balance between thrombolysis improve patient care with certain diagnoses. and thrombogenesis. At the site Although the majority of patients with JCAHO has specified guidelines for nurses and of the thrombus, the binding of cardiovascular disease may be considered doctors to implement for patients with acute tPA and plasminogen to the fibrin overweight or obese based upon their BMI, it myocardial infarction and congestive heart failure surface induces a conformational may occur in the thin patient as well. Therefore, upon admission to the hospital and discharge. change, facilitating the conversion nurses should never assume by the body size In 2009, JCAHO aligned with the Centers for of plasminogen to plasmin and alone that an individual is “healthy.” The JNC Medicare and Medicaid Services (CMS) to write dissolving the clot. VII recommends patients should maintain a a specific manual to treat both of these serious  During the hospitalization, the nurse needs to normal body weight with a BMI of 18.5 to 24.9 cardiovascular diseases. The mandatory 2009 make sure of the following: kg/m2 to help maintain a normal blood pressure. guidelines and treatment modalities for patients ŠŠ The function of the left ventricle has been In addition to eating healthy, all individuals presenting with an acute myocardial infarction documented in the medical record. should be encouraged to exercise for at least 30 are: ŠŠ Initiate and administer an angiotensin minutes every day. The NCEP and the AHA have  If an acute myocardial infarction is converting enzyme (ACE) or angiotensin elaborated upon their recommendations based speculated upon arrival at the hospital: receptor blocker (ARB) for left-ventricle upon the following research: ŠŠ Administer the patient aspirin (ASA) to dysfunction that is less than 40 percent. Regular physical activity reduces very low prevent and dissolve any potential clots  ACE/ARBs have demonstrated density lipoprotein (VLDL) levels, raises circulating in the bloodstream. short and long-term improvements HDL cholesterol and in some people, lowers ŠŠ Administer some form of reperfusion in surviving an MI, especially the LDL levels. It also can lower blood therapy to the patient, either with if a patient has a low EF. ACE pressure, reduce insulin resistance and fibrinolytic therapy or percutaneous

Page 36 Elite inhibitors block the conversion of of the biggest side effects of the It is important to recognize and treat angiotensin I to the vasoconstrictor combination of an ACE and diuretic patients appropriately for hypertension to angiotensin II. Therefore, it lowers is hypotension, so patients normally reduce further complications. Numerous the blood pressure and prevents are always started with a lower dose research projects have demonstrated vasoconstriction, thus increasing and slowly worked up to assess for that medications should be initiated in blood flow, especially to the kidneys. this risk. patients based upon their blood pressure ŠŠ Educate and provide counseling on adult  Beta blockers may also be initiated and overall cardiovascular risk: smoking cessation to prevent further because of a significant rise in the EF  Thiazide-type diuretics are the initial damage to the heart muscle and to (averaging 10 percent) and reduction drug of choice in lowering the overall possibly prevent another MI. in the left ventricle size and mass. blood pressure by decreasing the  Upon discharge, the nurse needs to check  Other potential treatments include: plasma volume (by suppressing the that the patient is provided education and ŠŠ Coronary artery disease. It is tubular reabsorption of sodium, thus a prescription for ASA, ACE or ARB and imperative to reduce further progression increasing the excretion of sodium a beta-blocker (BB). A lipid-lowering of atherosclerosis, and in some patients, and water) and CO. Diuretics lower agent may be prescribed, depending on the if properly treated, it may even regress. the blood pressure in 50 percent physician’s recommendations and the lipid Therefore, if the patient clinically of patients with mild to moderate profile results. demonstrates an abnormal lipid profile hypertension. If dual therapy is ŠŠ ASA is beneficial because of its anti- implying atherosclerosis and risk of required, diuretics should be used platelet, blood thinner effect. coronary artery disease, the following in combination with a potassium- ŠŠ ACE/ARBs, as noted above, offer short- medications should be initiated [34]: sparing agent or an ACE/ARB. and long-term improvements.  Hydroxymethylglutaryl coenzyme ACE inhibitors are ideal in mild ŠŠ Beta-blockers block the stimulation A (HMG-CoA), reductase inhibitors to moderate elevations of blood of beta 1(myocardial) and beta 2 (statins) to prevent death, coronary pressure in white individuals. (pulmonary, vascular and uterine) events and CVA in patients with Research has demonstrated limited receptor sites, thus lowering the overall high cholesterol and/or high LDL benefits in blacks and older patients blood pressure, suppressing arrhythmias and coinciding diabetes. Other with SBP. However, ACE inhibitors and reducing the risk of a future MI cholesterol-lowering medications are beneficial in patients with type 1 because the overall contractility is include bile acid sequestrants (but diabetes with any renal dysfunction reduced. contraindicated if a patient has high because they prevent further  The mandatory 2009 guidelines and treatment triglycerides), fibrates to lower progression from the vasodilation modalities for the patient presenting in heart triglycerides and ezetimibe. effect. failure are:  Niacin is beneficial for patients with  The nurse should assess for the ŠŠ During the hospitalization, assess the abnormally low HDL or elevated following: function of the left ventricle and inform lipoproteins. ŠŠ Diuretics also increase the risk of the patient, then initiate an ACE inhibitor  Folic acid 1 milligram (mg)/day uric acid, thus predisposing the or ARB for left ventricular dysfunction is beneficial in the treatment of patient to gout. Other potential because the vasodilation effect reduces elevated homocysteine levels to side effects include but are not the risk of mortality by 20 percent reduce the risk of vascular events. limited to hyperglycemia and (especially if the EF is less than 40 However, adding Vitamins B6 and elevated triglycerides, LDL and percent). B12 supplements demonstrate limited cholesterol. ŠŠ Provide smoking cessation education. or no value in preventing vascular ŠŠ ACE inhibitors may cause a ŠŠ Upon discharge, the nurse needs to ensure events. new-onset diabetes, cough, patients are provided explicit details on  Aspirin (ASA) 325 mg every other hypotension, renal dysfunction, managing their heart failure, such as day, anti-platelet therapy in patients hyperkalemia, taste alteration and activity, diet, medications, follow-up over the age of 50 is beneficial in rash. ARBs are initiated if the appointments, weight checks and options reducing the risk of an MI. It is patient develops a cough caused if their symptoms worsen. It is imperative imperative to recommend a dose of by the ACE inhibitor; no coughs that nurses stress the importance of 325 mg if the patient has no other or rashes are associated with the treatment and prevention of further risk and/or contraindicating co- ARBs. attacks because the prognosis of morbidities because research has ŠŠ Beta blockers also reduce the congestive heart failure is poor. The five- demonstrated that 100 mg every other blood pressure in 50 percent of year survival rate is less than 50 percent day did not prevent MI in women 45 patients. overall. Other treatment modalities not years and older. ŠŠ The nurse should assess for listed by JCAHO include:  Clopidogrel (Plavix) has been hypoglycemia because the  Diuretic therapy. Research has effective in preventing vascular symptoms are masked in type 1 demonstrated that diuretics are the episodes for nine to 12 months after diabetics. most effective means of providing acute coronary syndrome, yet it has ŠŠ Arrhythmias: Common arrhythmia symptomatic relief in patients with not prevented vascular events. treatments include medicines, medical congestive heart failure. Ideally, ŠŠ Hypertension. According to the JNC procedures and surgery. Treatment is diuretics and ACE inhibitors block VII, it is imperative to treat systolic needed when an arrhythmia causes sodium reabsorption in the loop of (SBP) and diastolic blood pressure (DBP) serious symptoms, such as dizziness, Henle and in the proximal portion to targets that are less than 140/90 mm/ chest pain or fainting. Treatment also is of the tubule. Initially, most patients Hg, which is associated with a decrease needed if an arrhythmia increases the risk are started on a thiazide diuretic and in cardiovascular disease complications. for complications, such as heart failure, an ACE inhibitor. As the condition However, in patients with hypertension stroke or sudden cardiac arrest. worsens, the diuretic will be changed and diabetes or renal disease, the BP  Medications: Anti-arrhythmics can to a loop diuretic due to the rapid goal is lower than 130/80 mm/Hg [39]. be used to speed up a heart that’s onset and shorter duration. One Elite Page 37 beating too slow or slow down a  A procedure called catheter ablation and for hypertension, blood thinners and heart that’s beating too fast. They also is sometimes used to treat certain pain medications to ease leg pain when can be used to convert an abnormal types of arrhythmia when medicines walking or climbing steps. heart rhythm to a normal, steady don’t work. During this procedure, ŠŠ Surgical procedures may include: rhythm. These include: a long, thin, flexible tube is put into  Bypass grafting if the blood flow is ŠŠ Beta blockers (such as metoprolol a blood vessel in the arm, groin blocked or nearly blocked. A blood and atenolol), calcium channel (upper thigh), or neck and guided to vessel from another part of the blockers (such as diltiazem the heart through the blood vessel. patient’s body or man-made tubes and verapamil), and digoxin A special machine sends energy may be used. The graft bypasses the (digitalis). These medicines through the tube to the heart. This blocked part of the artery. It doesn’t often are used to slow the heart energy finds and destroys small cure PAD but can increase blood flow rate in people who have atrial areas of heart tissue where abnormal and functioning to the affected limb. fibrillation. heartbeats may cause an arrhythmia  Angioplasty may be utilized, in ŠŠ Medicines used to restore to start. Catheter ablation usually which a catheter with a balloon or an abnormal heartbeat to a is done in a hospital as part of an other device is inserted into the normal rhythm are amiodarone, electrophysiology study. artery. The balloon is inflated to sotalol, flecainide, propafenone, ŠŠ Surgery: push the plaque outward against dofetilide, ibutilide, quinidine,  Sometimes, an arrhythmia is treated the wall of the artery, which widens procainamide and disopyramide. with surgery. This often occurs when it and restores blood flow. A stent These medicines often have surgery is already being done for may be placed into the artery during side effects, some of which can another reason, such as repair of a angioplasty. make an arrhythmia worse or heart valve. Conclusion even cause a different kind of ŠŠ One type of surgery for atrial Because of the lifestyle of Americans and access arrhythmia. fibrillation is called “maze” to fast foods on every corner, heart disease ŠŠ People who have atrial fibrillation surgery. In this operation, the will continue to rise unless people make better and some other arrhythmias often surgeon makes small cuts or choices. Although we may have the ability to are treated with anticoagulants, or burns in the atria that prevent the consume a high fat diet, smoke and remain blood thinners, to reduce the risk spread of disorganized electrical inactive, heart disease will continue to compound of blood clots forming. Aspirin, signals. and cause many deaths unless we take control warfarin (Coumadin®) and ŠŠ If coronary heart disease is of our lives. In addition to educating the public heparin are commonly used blood causing arrhythmias, coronary and the patients we care for as nurses, we need thinners. artery bypass grafting may be to also practice what we preach. Nurses are also ŠŠ Medicines also can control an recommended. This surgery potentially at risk while working long, stressful underlying medical condition, improves blood supply to the shifts and grabbing food quickly on the job. such as heart disease or a thyroid heart muscle. However, it is important to realize the potential condition, that might be causing ŠŠ Other treatments: Vagal maneuvers consequences and complications of choosing to an arrhythmia. are another arrhythmia treatment. make unhealthy decisions in our personal lives ŠŠ Medical procedures: These simple exercises sometimes can and while working. Every one of us holds the key  Some arrhythmias are treated with stop or slow down certain types of to make the appropriate changes to reduce our a pacemaker, a small device that’s supraventricular arrhythmias. They do overall risk of being affected by cardiovascular placed under the skin of the chest or this by affecting the vagus nerve, which disease. abdomen to help control abnormal helps control the heart rate. Some vagal heart rhythms. This device uses maneuvers include: PART II: STROKES AND CEREBROVASCULAR electrical pulses to prompt the  Gagging.  DISEASES heart to beat at a normal rate. Most  Holding your breath and bearing Introduction pacemakers contain a sensor that down (Valsalva maneuver). More than 2,400 years ago, the father of activates the device only when the  Immersing the in ice-cold water. medicine, Hippocrates, recognized and described heartbeat is abnormal.  Coughing. stroke – the sudden onset of paralysis. Until  Some arrhythmias are treated with  Putting fingers on the eyelids and recently, modern medicine has had very little a jolt of electricity delivered to pressing down gently. power over this disease, but the world of stroke the heart. This type of treatment is Vagal maneuvers aren’t an appropriate medicine is changing, and new and better called cardioversion or defibrillation, treatment for everyone. Before therapies are being developed every day. Today, depending on which type of recommending, consult with the patient’s some people who have a stroke can walk away arrhythmia is being treated. doctor. from the attack with no or few disabilities if they  Some people who are at risk for  Peripheral arterial disease are treated promptly. Doctors can finally offer ventricular fibrillation are treated ŠŠ Although PAD is serious, the underlying stroke patients and their families the one thing with a device called an implantable atherosclerosis can be treated. PAD that until now has been so hard to give: hope. cardioverter defibrillator (ICD). treatment may slow or stop disease Like a pacemaker, an ICD is a small progress and reduce the risk of In ancient times stroke was called “apoplexy,” a device that’s placed under the skin in complications. Lifestyle changes, as general term that physicians applied to anyone the chest. This device uses electrical noted above, can include to quit smoking, suddenly struck down with paralysis. Because pulses or shocks to help control eat a healthy diet and exercise, and lower many conditions can lead to sudden paralysis, life-threatening arrhythmias. An ICD risk factors including blood pressure, the term apoplexy did not indicate a specific continuously monitors the heartbeat. cholesterol levels and blood glucose diagnosis or cause. Physicians knew very If it senses a dangerous ventricular levels. little about the cause of stroke, and the only arrhythmia, it sends an electric ŠŠ Medications may include those listed established therapy was to feed and care for the shock to the heart to restore a normal above to lower blood cholesterol levels patient until the attack ran its course. heartbeat. Page 38 Elite The first person to investigate the pathological up the ischemic penumbra and can linger in a along the inner walls of large and medium-sized signs of apoplexy was Johann Jacob Wepfer. compromised state for several hours. With timely arteries, causing thickening, hardening and loss Born in Schaffhausen, Switzerland, in 1620, treatment, these cells can be saved. of elasticity of artery walls and decreased blood Wepfer studied medicine and was the first to flow. Even though a stroke occurs in the unseen identify postmortem signs of bleeding in the reaches of the brain, the symptoms of a stroke Hemorrhagic stroke brains of patients who died of apoplexy. From are easy to spot. They include sudden numbness In a healthy, functioning brain, neurons do autopsy studies, he gained knowledge of the or weakness, especially on one side of the not come into direct contact with blood. The carotid and vertebral arteries that supply the body; sudden confusion or trouble speaking or vital oxygen and nutrients the neurons need brain with blood. He also was the first person to understanding speech; sudden trouble seeing from the blood come to the neurons across the suggest that apoplexy, in addition to being caused in one or both eyes; sudden trouble walking, thin walls of the cerebral capillaries. The glia by bleeding in the brain, could be caused by a dizziness, or loss of balance or coordination; or (nervous system cells that support and protect blockage of one of the main arteries supplying sudden severe headache with no known cause. neurons) form a blood-brain barrier, an elaborate blood to the brain; thus stroke became known as All of the symptoms of stroke appear suddenly, meshwork that surrounds blood vessels and a cerebrovascular disease (“cerebro” refers to a and often there is more than one symptom at capillaries and regulates which elements of the part of the brain; “vascular” refers to the blood the same time. Therefore, stroke can usually be blood can pass through to the neurons. vessels and arteries). distinguished from other causes of dizziness or When an artery in the brain bursts, blood spews Medical science would eventually confirm headache. These symptoms may indicate that a out into the surrounding tissue and upsets not Wepfer’s hypotheses, but until very recently, stroke has occurred and that medical attention is only the blood supply but also the delicate doctors could offer little in the area of therapy. needed immediately. chemical balance neurons require to function. Over the last two decades, basic and clinical There are two forms of stroke: This is called a hemorrhagic stroke. Such strokes investigators, including many sponsored and  Ischemic – blockage of a blood vessel account for approximately 20 percent of all funded in part by the National Institute of supplying the brain. strokes. Neurological Disorders and Stroke (NINDS),  Hemorrhagic – bleeding into or around the have learned a great deal about stroke. They Hemorrhage can occur in several ways. One brain. have identified major risk factors for the disease common cause is a bleeding aneurysm, a weak or and have developed surgical techniques and Ischemic stroke thin spot on an artery wall. Over time, these weak drug treatments for the prevention of stroke. But An ischemic stroke occurs when an artery spots stretch or balloon out under high arterial perhaps the most exciting new development in supplying the brain with blood becomes blocked, pressure. The thin walls of these ballooning the field of stroke research is the approval of suddenly decreasing or stopping blood flow and aneurysms can rupture and spill blood into the a drug treatment that can reverse the course of ultimately causing a brain infarction. This type space surrounding brain cells. stroke if given during the first few hours after the of stroke accounts for approximately 80 percent Hemorrhage also occurs when arterial walls break onset of symptoms. of all strokes. Blood clots are the most common open. Plaque-encrusted artery walls eventually cause of artery blockage and brain infarction. The Studies with animals have shown that brain injury lose their elasticity and become brittle and thin, process of clotting is necessary and beneficial occurs within minutes of a stroke and can become prone to cracking. Hypertension increases the risk throughout the body because it stops bleeding irreversible within as little as an hour. In humans, that a brittle artery wall will give way and release and allows repair of damaged areas of arteries brain damage begins from the moment the stroke blood into the surrounding brain tissue. or veins. However, when blood clots develop in starts and often continues for days afterward. the wrong place within an artery they can cause A person with an arteriovenous malformation Scientists now know that there is a very short devastating injury by interfering with the normal (AVM) also has an increased risk of hemorrhagic window of opportunity for treatment of the most flow of blood. Problems with clotting become stroke. AVMs are a tangle of defective blood common form of stroke. Because of these and more frequent as people age. vessels and capillaries within the brain that have other advances in the field of cerebrovascular thin walls and can therefore rupture. disease, stroke patients now have a chance for Blood clots can cause ischemia and infarction in Bleeding from ruptured brain arteries can survival and recovery. two ways. A clot that forms in a part of the body either go into the substance of the brain or other than the brain can travel through blood What is stroke? into the various spaces surrounding the brain. vessels and become wedged in a brain artery. A stroke occurs when the blood supply to part of Intracerebral hemorrhage occurs when a vessel This free-roaming clot is called an embolus and the brain is suddenly interrupted or when a blood within the brain leaks blood into the brain itself. often forms in the heart. A stroke caused by an vessel in the brain bursts, spilling blood into the Subarachnoid hemorrhage is bleeding under the embolus is called an embolic stroke. The second spaces surrounding brain cells. In the same way meninges, or outer membranes, of the brain into kind of ischemic stroke, called a thrombotic that a person suffering a loss of blood flow to the the thin fluid-filled space that surrounds the brain. stroke, is caused by thrombosis, the formation heart is said to be having a heart attack, a person of a blood clot in one of the cerebral arteries that The subarachnoid space separates the arachnoid with a loss of blood flow to the brain or sudden stays attached to the artery wall until it grows membrane from the underlying pia mater bleeding in the brain can be said to be having a large enough to block blood flow. membrane. It contains a clear fluid (cerebrospinal “brain attack.” fluid or CSF) as well as the small blood vessels Ischemic strokes can also be caused by stenosis, Brain cells die when they no longer receive that supply the outer surface of the brain. In a narrowing of the artery due to the buildup of oxygen and nutrients from the blood or when a subarachnoid hemorrhage, one of the small plaque and blood clots along the artery wall. they are damaged by sudden bleeding into or arteries within the subarachnoid space bursts, Stenosis can occur in large arteries and small around the brain. Ischemia is the term used to flooding the area with blood and contaminating arteries and is therefore called large vessel describe the loss of oxygen and nutrients for the cerebrospinal fluid. Since the CSF flows disease or small vessel disease, respectively. brain cells when there is inadequate blood flow. throughout the cranium, within the spaces of When a stroke occurs because of small Ischemia ultimately leads to infarction, the death the brain, subarachnoid hemorrhage can lead to vessel disease, a very small infarction results, of brain cells that are eventually replaced by a extensive damage throughout the brain. In fact, sometimes called a lacunar infarction, from the fluid-filled cavity (orinfarct ) in the injured brain. subarachnoid hemorrhage is the most deadly of French word “lacune” meaning “gap” or “cavity.” all strokes. When blood flow to the brain is interrupted, some The most common blood vessel disease brain cells die immediately, while others remain that causes stenosis is atherosclerosis. In at risk for death. These damaged cells make atherosclerosis, deposits of plaque buildup

Elite Page 39 Transient ischemic attacks Health care professionals also use a variety of whether an individual would benefit from a A transient ischemic attack (TIA), sometimes imaging devices to evaluate stroke patients. surgical procedure called carotid endarterectomy. called a mini-stroke, starts just like a stroke but The most widely used imaging procedure is the This surgery is used to remove fatty deposits then resolves, leaving no noticeable symptoms computed tomography (CT) scan. Also known from the carotid arteries and can help prevent or deficits. The occurrence of a TIA is a warning as a CAT scan or computed axial tomography, CT stroke. creates a series of cross-sectional images of the that the person is at risk for a more serious and Doppler ultrasound is a painless, noninvasive test head and brain. Because it is readily available at debilitating stroke. Of the approximately 50,000 in which sound waves above the range of human all hours at most major hospitals and produces Americans who have a TIA each year, about hearing are sent into the neck. Echoes bounce images quickly, CT is the most commonly used one-third will have an acute stroke sometime off the moving blood and the tissue in the artery diagnostic technique for acute stroke. CT also has in the future. The addition of other risk factors and can be formed into an image. Ultrasound is unique diagnostic benefits. It will quickly rule compounds a person’s risk for a recurrent stroke. fast, painless, risk-free and relatively inexpensive out a hemorrhage, can occasionally show a tumor The average duration of a TIA is a few minutes. compared to MRA and arteriography, but it is that might mimic a stroke, and may even show For almost all TIAs, the symptoms go away not considered to be as accurate as arteriography. evidence of early infarction. Infarctions generally within an hour. There is no way to tell whether Arteriography is an X-ray of the carotid artery show up on a CT scan about six to eight hours symptoms will be just a TIA or persist and lead taken when a special dye is injected into the after the start of stroke symptoms. to death or disability. The patient should assume artery. The procedure carries its own small risk that all stroke symptoms signal an emergency and If a stroke is caused by hemorrhage, a CT can of causing a stroke and is costly to perform. The should not wait to see if they go away. show evidence of bleeding into the brain almost benefits of arteriography over MR techniques Recurrent stroke immediately after stroke symptoms appear. and ultrasound are that it is extremely reliable Recurrent stroke is frequent; about 25 percent Hemorrhage is the primary reason for avoiding and still the best way to measure stenosis of the of people who recover from their first stroke certain drug treatments for stroke, such as carotid arteries. Even so, significant advances will have another stroke within five years. thrombolytic therapy, the only proven acute are being made every day involving noninvasive Recurrent stroke is a major contributor to stroke stroke therapy for ischemic stroke. Thrombolytic imaging techniques such as MRI. therapy cannot be used until the doctor can disability and death, with the risk of severe Who is at risk for stroke? confidently diagnose the patient as suffering from disability or death from stroke increasing with Some people are at a higher risk for stroke than an ischemic stroke because this treatment might each stroke recurrence. The risk of a recurrent others. Unmodifiable risk factors include age, increase bleeding and could make a hemorrhagic stroke is greatest right after a stroke, with the risk gender, race/ethnicity and stroke family history. stroke worse. decreasing with time. About 3 percent of stroke In contrast, other risk factors for stroke, like patients will have another stroke within 30 days Another imaging device used for stroke patients high blood pressure or cigarette smoking, can be of their first stroke, and one-third of recurrent is the magnetic resonance imaging (MRI) scan. changed or controlled by the person at risk. strokes take place within two years of the first MRI uses magnetic fields to detect subtle changes stroke. in brain tissue content. One effect of stroke is the Unmodifiable risk factors slowing of water movement, called diffusion, It is a myth that stroke occurs only in elderly Classic stroke symptoms adults. In actuality, stroke strikes all age groups, Symptoms of stroke appear suddenly. Watch for through the damaged brain tissue. MRI can show this type of damage within the first hour from fetuses still in the womb to centenarians. these symptoms and be prepared to act quickly: It is true, however, that older people have a  Sudden numbness or weakness of the face, after the stroke symptoms start. The benefit of MRI over a CT scan is more accurate and earlier higher risk for stroke than the general population arm or leg, especially on one side of the body. and that the risk for stroke increases with age.  Sudden confusion, trouble talking or diagnosis of infarction, especially for smaller strokes, while showing equivalent accuracy in For every decade after the age of 55, the risk understanding speech. of stroke doubles, and two-thirds of all strokes  Sudden trouble seeing in one or both eyes. determining when hemorrhage is present. MRI is  more sensitive than CT for other types of brain occur in people over 65 years old. People over  Sudden trouble walking, dizziness or loss of 65 also have a seven-fold greater risk of dying balance or coordination. diseases, such as a brain tumor, that might mimic  a stroke. MRI cannot be performed in patients from stroke than the general population. And the  Sudden severe headache with no known incidence of stroke is increasing proportionately cause. with certain types of metallic or electronic implants, such as pacemakers for the heart. with the increase in the elderly population. As How is the cause of stroke determined? baby boomers move into the over-65 age group, Physicians have several diagnostic techniques and Although increasingly used in the emergency stroke and other diseases will take on even imaging tools to help diagnose the cause of stroke diagnosis of stroke, MRI is not immediately greater significance in the health care field. available at all hours in most hospitals, where quickly and accurately. The first step in diagnosis Gender also plays a role in risk for stroke. Men is a short neurological examination. When a CT is used for acute stroke diagnosis. Also, MRI takes longer to perform than CT, and may have a higher risk for stroke, but more women die possible stroke patient arrives at a hospital, a from stroke. The stroke risk for men is 1.25 times health care professional, usually a doctor or not be performed if it would significantly delay treatment. that for women. But men do not live as long as nurse, will ask the patient or a companion what women, so men are usually younger when they happened and when the symptoms began. Blood Other types of MRI scans, often used for the have their strokes and therefore have a higher tests, an electrocardiogram and a brain scan, such diagnosis of cerebrovascular disease and to rate of survival than women. In other words, even CT or MRI, will often be done. One test that predict the risk of stroke, are magnetic resonance though women have fewer strokes than men, helps doctors judge the severity of a stroke is the angiography (MRA) and functional magnetic women are generally older when they have their standardized NIH Stroke Scale, developed by the resonance imaging (fMRI). Neurosurgeons use strokes and are more likely to die from them. NINDS. Health care professionals use the NIH MRA to detect stenosis (blockage) of the brain Stroke Scale to measure a patient’s neurological arteries inside the skull by mapping flowing Stroke seems to run in some families. Several deficits by asking the patient to answer questions blood. Functional MRI uses a magnet to pick factors might contribute to familial stroke risk. and to perform several physical and mental tests. up signals from oxygenated blood and can show Members of a family might have a genetic Other scales include the Glasgow Coma Scale, brain activity through increases in local blood tendency for stroke risk factors, such as an the Hunt and Hess Scale, the Modified Rankin flow. inherited predisposition for hypertension or Scale, and the Barthel Index. A copy of the NIH diabetes. The influence of a common lifestyle Duplex Doppler ultrasound and arteriography are Stroke Scale can be found at the end of this among family members could also contribute to two diagnostic imaging techniques used to decide chapter. familial stroke.

Page 40 Elite The risk for stroke varies among different ethnic particularly vascular abnormalities. People with prevalent in the upper age groups, which means and racial groups. The incidence of stroke among more than one risk factor have what is called that the prevalence of atrial fibrillation in the African Americans is almost double that of white “amplification of risk.” This means that the United States will increase proportionately with Americans, and twice as many African Americans multiple risk factors compound their destructive the growth of the elderly population. Unlike who have a stroke die from the event compared effects and create an overall risk greater than the hypertension and other risk factors that have a to white Americans. African Americans between simple cumulative effect of the individual risk lesser impact on the ever-rising absolute risk the ages of 45 and 55 have four to five times factors. of stroke that comes with advancing age, the the stroke death rate of whites. After age 55, the influence of atrial fibrillation on total risk for Hypertension stroke mortality rate for whites increases and is stroke increases powerfully with age. In people Of all the risk factors that contribute to stroke, equal to that of African Americans. over 80 years old, atrial fibrillation is the direct the most powerful is hypertension, or high blood cause of one in four strokes. Compared to white Americans, African pressure. People with hypertension have a risk for Americans have a higher incidence of stroke stroke that is four to six times higher than the risk Other forms of heart disease that increase stroke risk factors, including high blood pressure and for those without hypertension. One-third of the risk include malformations of the heart valves or cigarette smoking. African Americans also have a adult U.S. population, about 50 million people the heart muscle. Some valve diseases, like mitral higher incidence and prevalence of some genetic (including 40-70 percent of those over age 65) valve stenosis or mitral annular calcification, can diseases, such as diabetes and sickle cell anemia, have high blood pressure. Forty to 90 percent of double the risk for stroke, independent of other that predispose them to stroke. stroke patients have high blood pressure before risk factors. Hispanics and Native Americans have stroke their stroke event. Heart muscle malformations can also increase the incidence and mortality rates more similar to A systolic pressure of 120 mm/Hg over a risk for stroke. Patent foramen ovale (PFO) is a those of white Americans. In Asian Americans, diastolic pressure of 80 mm/Hg is generally passage or a hole (sometimes called a “shunt”) in stroke incidence and mortality rates are also considered normal. Persistently high blood the heart wall separating the two atria, or upper similar to those in white Americans, even though pressure greater than 140 over 90 leads to the chambers, of the heart. Clots in the blood are Asians in Japan, China and other countries of diagnosis of the disease called hypertension. The usually filtered out by the lungs, but PFO could the Far East have significantly higher stroke impact of hypertension on the total risk for stroke allow emboli or blood clots to bypass the lungs incidence and mortality rates than white decreases with increasing age, suggesting that and go directly through the arteries to the brain, Americans. This suggests that environment and factors other than hypertension play a greater role potentially causing a stroke. Research is currently lifestyle factors play a large role in stroke risk. in the overall stroke risk in elderly adults. For under way to determine how important PFO is as a cause for stroke. Atrial septal aneurysm (ASA), The “Stroke Belt” people without hypertension, the absolute risk of stroke increases over time until around the age of a congenital (present from birth) malformation Several decades ago, scientists and statisticians 90, when the absolute risk becomes the same as of the heart tissue, is a bulging of the septum noticed that people in the southeastern United that for people with hypertension. or heart wall into one of the atria of the heart. States had the highest stroke mortality rate in the Researchers do not know why this malformation country. They named this region the stroke belt. Like stroke, there is a gender difference in the increases the risk for stroke. PFO and ASA For many years, researchers believed that the prevalence of hypertension. In younger people, frequently occur together and therefore amplify increased risk was due to the higher percentage hypertension is more common among men than the risk for stroke. Two other heart malformations of African Americans and an overall lower among women. With increasing age, however, that seem to increase the risk for stroke for socioeconomic status (SES) in the Southern more women than men have hypertension. This unknown reasons are left atrial enlargement and states. A low SES is associated with an overall hypertension gender-age difference probably has left ventricular hypertrophy. People with left lower standard of living, leading to a lower an impact on the incidence and prevalence of atrial enlargement have a larger than normal left standard of health care and therefore an increased stroke in these populations. atrium of the heart; those with left ventricular risk of stroke. But researchers now know that the Anti-hypertensive medication can decrease hypertrophy have a thickening of the wall of the higher percentage of African Americans and the a person’s risk for stroke. Recent studies left ventricle. overall lower SES in the Southern states does not suggest that treatment can decrease the stroke adequately account for the higher incidence of, Another risk factor for stroke is cardiac surgery incidence rate by 38 percent and decrease the and mortality from, stroke in those states. This to correct heart malformations or reverse the stroke fatality rate by 40 percent. Common means that other factors must be contributing to effects of heart disease. Strokes occurring in hypertensive agents include adrenergic agents, the higher incidence of and mortality from stroke this situation are usually the result of surgically beta-blockers, angiotensin converting enzyme in this region. dislodged plaques from the aorta that travel inhibitors, calcium channel blockers, diuretics through the bloodstream to the arteries in the Recent studies have also shown that there and vasodilators. neck and head, causing stroke. Cardiac surgery is a stroke buckle in the stroke belt. Three increases a person’s risk of stroke by about 1 southeastern states, North Carolina, South Heart disease percent. Other types of surgery can also increase Carolina and Georgia, have an extremely high After hypertension, the second most powerful the risk of stroke. stroke mortality rate, higher than the rate in other risk factor for stroke is heart disease, especially stroke belt states and up to two times the stroke a condition known as atrial fibrillation. Atrial Blood cholesterol levels mortality rate of the United States overall. The fibrillation is irregular beating of the left atrium, Most people know that high cholesterol increased risk could be due to geographic or or left upper chamber, of the heart. In people with levels contribute to heart disease. But many environmental factors or to regional differences atrial fibrillation, the left atrium beats up to four don’t realize that a high cholesterol level also in lifestyle, including higher rates of cigarette times faster than the rest of the heart. This leads contributes to stroke risk. Cholesterol, a waxy smoking and a regional preference for salty, high- to an irregular flow of blood and the occasional substance produced by the liver, is a vital fat foods. formation of blood clots that can leave the heart body product. It contributes to the production and travel to the brain, causing a stroke. of hormones and vitamin D and is an integral Other risk factors Atrial fibrillation, which affects as many as 2.2 component of cell membranes. The liver makes The most important risk factors for stroke million Americans, increases an individual’s risk enough cholesterol to fuel the body’s needs, and are hypertension, heart disease, diabetes and of stroke by 4 to 6 percent, and about 15 percent this natural production of cholesterol alone is cigarette smoking. Others include heavy alcohol of stroke patients have atrial fibrillation before not a large contributing factor to atherosclerosis, consumption, high blood cholesterol levels, illicit they experience a stroke. The condition is more heart disease and stroke. Research has shown drug use, and genetic or congenital conditions,

Elite Page 41 that the danger from cholesterol comes from a A person may lower his risk for atherosclerosis Smoking increases the risk of stroke by dietary intake of foods that contain high levels and stroke by improving his cholesterol levels. promoting atherosclerosis and increasing of cholesterol. Foods high in saturated fat and A healthy diet and regular exercise are the best the levels of blood-clotting factors, such as cholesterol, like meats, eggs and dairy products, ways to lower total cholesterol levels. In some fibrinogen. In addition to promoting conditions can increase the amount of total cholesterol in the cases, physicians may prescribe cholesterol- linked to stroke, smoking also increases the body to alarming levels, contributing to the risk lowering medication, and recent studies have damage that results from stroke by weakening the of atherosclerosis and thickening of the arteries. shown that the newest types of these drugs, called endothelial wall of the cerebrovascular system. reductase inhibitors or statin drugs, significantly This leads to greater damage to the brain from Cholesterol is classified as a lipid, meaning that reduce the risk for stroke in most patients with events that occur in the secondary stage of stroke. it is fat-soluble rather than water-soluble. Other high cholesterol. Scientists believe that statins lipids include fatty acids, glycerides, alcohol, High alcohol consumption is another modifiable may work by reducing the amount of bad waxes, steroids, and fat-soluble vitamins A, D, risk factor for stroke. Generally, an increase cholesterol the body produces and by reducing and E. Lipids and water, like oil and water, do not in alcohol consumption leads to an increase the body’s inflammatory immune reaction to mix. Blood is a water-based liquid, so cholesterol in blood pressure. While scientists agree that cholesterol plaque associated with atherosclerosis does not mix with blood. In order to travel heavy drinking is a risk for both hemorrhagic and stroke. through the blood without clumping together, and ischemic stroke, in several research studies cholesterol needs to be covered by a layer of Millimeters of mercury – or mm/ Hg – is the daily consumption of smaller amounts of alcohol protein. The cholesterol and protein together are standard means of expressing blood pressure, has been found to provide a protective influence called a lipoprotein. which is measured using a sphygmomanometer. against ischemic stroke, perhaps because alcohol Using a stethoscope and a cuff that is wrapped decreases the clotting ability of platelets in the There are two kinds of cholesterol, commonly around the patient’s upper arm, a health blood. Moderate alcohol consumption may act in called the “good” and the “bad.” Good professional listens to the sounds of blood the same way as aspirin to decrease blood clotting cholesterol is high-density lipoprotein, or HDL; rushing through an artery. The first sound and prevent ischemic stroke. Heavy alcohol bad cholesterol is low-density lipoprotein, or registered on the instrument gauge (which consumption, though, may seriously deplete LDL. Together, these two forms of cholesterol measures the pressure of the blood in millimeters platelet numbers and compromise blood clotting make up a person’s total serum cholesterol level. on a column of mercury) is called the systolic and blood viscosity, leading to hemorrhage. Most cholesterol tests measure the level of total pressure. This is the maximum pressure produced In addition, heavy drinking or binge drinking cholesterol in the blood and don’t distinguish as the left ventricle of the heart contracts and can lead to a rebound effect after the alcohol is between good and bad cholesterol. For these total the blood begins to flow through the artery. The purged from the body. The consequences of this serum cholesterol tests, a level of less than 200 second sound is the diastolic pressure and is rebound effect are that blood viscosity (thickness) mg/dL is considered safe, while a level of more the lowest pressure in the artery when the left and platelet levels skyrocket after heavy drinking, than 240 is considered dangerous and places a ventricle is relaxing. increasing the risk for ischemic stroke. person at risk for heart disease and stroke. The use of illicit drugs, such as cocaine and Most cholesterol in the body is in the form of Diabetes crack cocaine, can cause stroke. Cocaine may act LDL. LDLs circulate through the bloodstream, Diabetes is another disease that increases a on other risk factors, such as hypertension, heart picking up excess cholesterol and depositing person’s risk for stroke. People with diabetes disease and vascular disease, to trigger a stroke. It cholesterol where it is needed (for example, have three times the risk of stroke compared decreases relative cerebrovascular blood flow by for the production and maintenance of cell to people without diabetes. The relative risk of up to 30 percent, causes vascular constriction and membranes). But when too much cholesterol stroke from diabetes is highest in the fifth and inhibits vascular relaxation, leading to narrowing starts circulating in the blood, the body cannot sixth decades of life and decreases after that. of the arteries. Cocaine also affects the heart, handle the excessive LDLs, which build up along Like hypertension, the relative risk of stroke causing arrhythmias and rapid heart rate that can the inside of the arterial walls. The buildup of from diabetes is highest for men at an earlier age lead to the formation of blood clots. LDL coating on the inside of the artery walls and highest for women at an older age. People hardens and turns into arterial plaque, leading to with diabetes may also have other contributing Marijuana smoking may also be a risk factor stenosis and atherosclerosis. This plaque blocks risk factors that can amplify the overall risk for stroke. Marijuana decreases blood pressure blood vessels and contributes to the formation of for stroke. For example, the prevalence of and may interact with other risk factors, such blood clots. A person’s LDL level should be less hypertension is 40 percent higher in the diabetic as hypertension and cigarette smoking, to than 130 mg/dL to be safe. LDL levels between population compared to the general population. cause rapidly fluctuating blood pressure levels, 130 and 159 put a person at a slightly higher risk Modifiable lifestyle risk factors damaging blood vessels. for atherosclerosis, heart disease and stroke. A Cigarette smoking is the most powerful Other drugs of abuse, such as amphetamines, score over 160 puts a person at great risk for a modifiable stroke risk factor. Smoking almost heroin, and anabolic steroids (and even some heart attack or stroke. doubles a person’s risk for ischemic stroke, common, legal drugs, such as caffeine and The other form of cholesterol, HDL, is beneficial independent of other risk factors, and it increases L-asparaginase and pseudoephedrine found in and contributes to stroke prevention. HDL carries a person’s risk for subarachnoid hemorrhage by over-the-counter decongestants), have been a small percentage of the cholesterol in the blood, up to 3.5 percent. Smoking is directly responsible suspected of increasing stroke risk. Many of but instead of depositing its cholesterol on the for a greater percentage of the total number of these drugs are vasoconstrictors, meaning that inside of artery walls, HDL returns to the liver to strokes in young adults than in older adults. Risk they cause blood vessels to constrict and blood unload its cholesterol. The liver then eliminates factors other than smoking – like hypertension, pressure to rise. the excess cholesterol by passing it along to the heart disease and diabetes – account for more of Head and neck injuries kidneys. Currently, any HDL score higher than the total number of strokes in older adults. Injuries to the head or neck may damage the 35 is considered desirable. Recent studies have Heavy smokers are at greater risk for stroke cerebrovascular system and cause a small number shown that high levels of HDL are associated than light smokers. The relative risk of stroke of strokes. Head injury or traumatic brain injury with a reduced risk for heart disease and stroke decreases immediately after quitting smoking, may cause bleeding within the brain leading to and that low levels (less than 35 mg/dL), even with a major reduction of risk seen after two to damage akin to that caused by a hemorrhagic in people with normal levels of LDL, lead to an four years. Unfortunately, it may take several stroke. Neck injury, when associated with increased risk for heart disease and stroke. decades for a former smoker’s risk to drop to the spontaneous tearing of the vertebral or carotid level of someone who never smoked. arteries caused by sudden and severe extension of

Page 42 Elite the neck, neck rotation or pressure on the artery, vary widely, for some people in the mid-30s Thrombolytic drugs is a contributing cause of stroke, especially in while others may not show signs of the disease In treating acute ischemic stroke (acute meaning young adults. This type of stroke is often called until later in life. CADASIL – formerly known by that the stroke has occurred within the past few “beauty-parlor syndrome,” which refers to several names, including hereditary multi-infarct hours), the immediate goal is to break apart the the practice of extending the neck backwards dementia – is one cause of multi-infarct dementia offending clot, a process known as thrombolysis. over a sink for hair-washing in beauty parlors. (dementia caused by lack of blood to several The body produces its own thrombolytic proteins, Neck calisthenics, “bottoms-up” drinking, and areas of the brain). It is an autosomal dominant and some of these have been engineered into improperly performed chiropractic manipulation inheritance disorder, meaning that one parent drugs. One, called tissue plasminogen activator of the neck can also put strain on the vertebral carries and passes on the defective gene. Most (tPA), has a proven track record for treating and carotid arteries, possibly leading to ischemic individuals with CADASIL have a family history heart attacks. In the late 1980s, NINDS-funded stroke. of the disorder. investigators laid the plans for the first placebo- controlled trial of tPA to treat acute ischemic Infections There is no treatment to halt this genetic disorder. stroke. They knew from animal studies that Recent viral and bacterial infections may act Individuals are given supportive care. Migraine irreversible brain injury is likely to occur if blood with other risk factors to add a small risk for headaches may be treated by different drugs flow is not restored within the first few hours stroke. The immune system responds to infection and a daily aspirin may reduce stroke and heart after ischemic stroke. Therefore, the NINDS tPA by increasing inflammation and increasing attack risk. Drug therapy for depression may be Study Group tested the drug within a three-hour the infection-fighting properties of the blood. given. Affected individuals who smoke should time window. Compared to individuals given a Unfortunately, this immune response increases quit because that can increase the risk of stroke in placebo, those given intravenous tPA were more the number of clotting factors in the blood, CADASIL. likely to have minimal or no disability three leading to an increased risk of embolic-ischemic Symptoms usually progress slowly. By age 65, months after treatment – a finding that persuaded stroke. the majority of persons with CADASIL have the U.S. Food and Drug Administration to Genetic risk factors severe cognitive problems and dementia. Some approve tPA for use against acute stroke. Trials Although there may not be a single genetic people lose the ability to walk, and most become in Europe and the U.S. subsequently confirmed factor associated with stroke, genes do play a completely dependent because of multiple those results. Recent studies attempt to identify large role in the expression of stroke risk factors strokes. individuals who may benefit even after three such as hypertension, heart disease, diabetes and The National Institute of Neurological Disorders hours of stroke onset. In any case, more brain vascular malformations. It is also possible that and Stroke (NINDS) conducts stroke research tissue will be saved the earlier the treatment is an increased risk for stroke within a family is and clinical trials at its laboratories and clinics delivered. due to environmental factors, such as a common at the National Institutes of Health (NIH) and A 1998 follow-up analysis of the NINDS trial sedentary lifestyle or poor eating habits, rather through grants to major medical institutions found that, after their initial hospitalization, than hereditary factors. across the country. Scientists are currently people who received tPA were less likely to Vascular malformations that cause stroke may studying different drugs to reduce cognitive require inpatient rehabilitation or nursing home have the strongest genetic link of all stroke problems seen in patients with CADASIL. care. The authors estimated that this lower risk factors. A vascular malformation is an Researchers are also looking at ways to overcome dependency on long-term care would translate abnormally formed blood vessel or group of an over-reaction to hormones that lead to high into a savings to the health care system of more blood vessels. One genetic vascular disease is blood pressure and poor blood supply in patients than $4 million for every 1,000 individuals called CADASIL, which stands for cerebral with CADASIL. treated with tPA. autosomal dominant arteriopathy with subcortical Treating stroke Because treatment with tPA interferes with blood infarcts and leukoencephalopathy. CADASIL Timing is everything in treatment of stroke, clotting and has also been shown to increase is a rare, genetically inherited, congenital particularly acute ischemic stroke, which leaking along the blood-brain barrier, it carries vascular disease of the brain that causes strokes, comprises about 80 percent of cerebrovascular a risk of intracerebral hemorrhage. Therefore, subcortical dementia, migraine-like headaches accidents. Health organizations have tried to it is not recommended for some people, such and psychiatric disturbances. CADASIL is very get the word out to the public: When symptoms as those with a history of brain hemorrhage or debilitating, and symptoms usually surface about appear, don’t delay; call 911. These organizations significantly elevated blood pressure (greater the age of 45. Although CADASIL can be treated have encouraged emergency responders to than 185/110 mm/Hg). The risk of tPA-induced with surgery to repair the defective blood vessels, also take action, and to “load and go” once a hemorrhage increases over time from stroke patients often die by the age of 65. The exact patient is stable enough for transport. Nurses onset, which has limited its use to the first three incidence of CADASIL in the United States is and physicians staffing emergency departments hours after stroke (where benefit was most clearly unknown. must be informed about stroke symptoms and established in the U.S. trials). What is CADASIL? interventions and also “ready to roll” when a CADASIL is an inherited form of cerebrovascular patient arrives. disease that occurs when the thickening of blood Medications vessel walls blocks the flow of blood to the brain. Medicines that lower blood pressure and The disease primarily affects small blood vessels cholesterol can protect against atherosclerosis in the white matter of the brain. A mutation in and reduce a person’s risk of stroke. Aspirin the Notch3 gene alters the muscular walls in and other blood-thinning medications have been these small arteries. CADASIL is characterized used for years to reduce the risk of ischemic by migraine headaches and multiple strokes stroke in individuals with AF or prior stroke. progressing to dementia. Other symptoms Recent studies have helped refine the use of Platelets (magnified here thousands of times) include white matter lesions throughout the these drugs to maximize safety and efficacy. brain, cognitive deterioration, seizures, vision go to damaged areas of blood vessels and This section, however, begins with a discussion contribute to the formation of clots. Anti- problems and psychiatric problems such as of what happens when prevention fails and a severe depression and changes in behavior and platelet drugs can help reduce the risk of person requires emergency treatment for an acute ischemic stroke. personality. Individuals may also be at higher ischemic stroke. risk of heart attack. Symptoms and disease onset

Elite Page 43 Anti-platelet drugs and anticoagulants Comparing therapies Blood-thinning medications fall into two NINDS-supported research has compared the benefits of standard medical therapy alone (treatment classes: anti-platelet drugs and anticoagulants. with aspirin, blood pressure-lowering drugs, and cholesterol-lowering drugs) with standard Anti-platelet drugs inhibit the activity of cells medical therapy plus endarterectomy for both types of carotid stenosis. The Asymptomatic called platelets, which stick to damaged areas Carotid Atherosclerosis Study (ACAS) found that endarterectomy cut the risk of stroke in half inside blood vessels and lay the foundation for among individuals with asymptomatic carotid stenosis of 60 percent or greater. The NINDS blood clots. The most common anti-platelet North American Symptomatic Carotid Endarterectomy Trial (NASCET) found major benefits for drug is aspirin. Anticoagulants, such as heparin individuals with symptomatic carotid stenosis of 70 percent or greater. Their risk of stroke over a (produced by inflammatory cells in the body) and two-year period was cut to less than 10 percent. warfarin (found in plants and also known by the trade name Coumadin©), inhibit proteins in the Endarterectomy itself is associated with a small risk of stroke because the disruption of plaque blood that stimulate clotting. during the procedure can send emboli into the bloodstream, or cause a clot at the site of surgery. NINDS supports the investigation of an alternative procedure known as carotid artery stenting, Anti-platelet drugs and anticoagulants can help which involves inserting a stent (a tube-like device that is made of mesh-like material) into the prevent a variety of potentially life-threatening carotid artery. The stent is compressed until the radiologist threads it into position, and is then conditions for which individuals with stroke are expanded to mechanically widen the artery. It is also equipped with a downstream “umbrella” to at risk, such as myocardial infarction, pulmonary catch dislodged plaque. The Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) embolism and deep vein thrombosis, which are is designed to compare these two procedures in individuals with symptomatic carotid stenosis. caused by clots in the heart, lungs and deep veins of the legs, respectively. In recent years, the value Recurrent Stroke Study (WARSS) showed that A surgery called carotid endarterectomy involves of these drugs in treating and preventing stroke aspirin was as effective as warfarin in preventing removing plaque to widen the carotids, a pair of itself has been more closely scrutinized. recurrent stroke in people with no history of arteries that ascend each side of the neck and are One focus of this research has been to determine AF or other cardioembolic causes of stroke. the main suppliers of blood to the brain. Stenosis whether there is any benefit in giving anti- The Warfarin-Aspirin Symptomatic Intracranial that narrows a carotid artery by more than 50 platelet drugs or anticoagulants during an acute Disease (WASID) trial focused more narrowly on percent is considered clinically significant. In ischemic stroke as an adjunct to tPA or as an individuals with stenosis of arteries in the brain some cases, carotid stenosis is first detected after alternative for people ineligible to receive and was terminated early because of a high rate a person experiences a stroke or other symptoms, tPA. In an international trial coordinated by of adverse events in participants treated with such as a TIA. It is also sometimes detected in researchers in the United Kingdom in the late warfarin. Both trials concluded that aspirin is the absence of symptoms, as when a physician 1990s, individuals received aspirin, subcutaneous equivalent to warfarin for reducing the risk of presses a stethoscope to the neck and hears a heparin injections, or neither treatment within 48 stroke in people without AF. bruit, a sound made by blood flowing past an obstruction. The presence of carotid stenosis hours of an ischemic stroke. Aspirin significantly Medication for subarachnoid hemorrhage can be confirmed by angiography or Doppler reduced the risk of a recurrent ischemic stroke The drug nimodipine is used to treat cerebral ultrasound. at two weeks. A similar benefit from heparin vasospasm, a complication that sometimes was offset by an increased risk of hemorrhagic follows subarachnoid hemorrhage. This refers stroke. Around the same time, NINDS-funded to a constriction of blood vessels in the brain researchers tested whether acute stroke could be that can significantly reduce blood flow, leading treated with intravenous Org 10172, a form of to ischemia and infarction. Although its precise heparin considered less likely to cause bleeding. origins are unclear, cerebral vasospasm is thought This study, Trial of Org 10172 in Acute Stroke to be triggered in part by an influx of calcium Treatment (TOAST), found that Org 10172 into the smooth muscles that control blood vessel produced no significant benefit. The study authors diameter. Nimodipine is a calcium antagonist, also developed the TOAST criteria, a set of meaning that it works by blocking the entry of guidelines for classifying different subtypes of calcium into cells. Nimodipine has been shown ischemic stroke that are now widely used in other to reduce infarction and improve outcome in studies. individuals with subarachnoid hemorrhage. The carotid and vertebral arteries Two other NINDS-sponsored trials compared Surgeries and other procedures ascend through the neck and divide into the effectiveness of daily warfarin and aspirin Surgery is sometimes used to clear the congested branches that supply blood to different for individuals who did not have AF but who blood vessels that cause ischemic stroke or to parts of the brain. had experienced a prior stroke, and thus were repair the vascular abnormalities that contribute at risk for another. The Warfarin vs. Aspirin to hemorrhagic stroke. Data from NINDS-funded research show that Surgical options the risk of ischemic stroke from clinically Several techniques are used to eliminate the vascular abnormalities linked to hemorrhagic stroke, significant asymptomatic carotid stenosis is about or at least to reduce the risk that they will rupture. Arteriovenous malformations (AVMs) can be 2 to 3 percent per year (meaning that out of 100 surgically removed through a procedure known as surgical resection. They can also be treated non- individuals with this condition, two or three will invasively (without the need to cut into the skull) using radiosurgery or embolization. Radiosurgery have a stroke each year). The risk of ischemic involves directing a beam of radiation at the AVM, while embolization involves injecting artificial stroke from clinically significant symptomatic emboli (usually made of foam) into the AVM to block it off from its parent vessel. carotid stenosis is much higher – about 25 percent during the first two years following the Clipping and coiling are procedures used to treat intracerebral aneurysms. Clipping involves appearance of symptoms. opening the skull and placing a clip near the aneurysm to separate it from its parent blood vessel. In Nurses’ role in stroke treatment and care endovascular coiling, a wire topped with a detachable coil is inserted into a leg artery and threaded Nurses play a key role in stroke treatment from into the aneurysm. Once in place, the coil is released into the aneurysm, where it stimulates blood the time a patient arrives at an ED until discharge. clotting and strengthens the blood vessel wall. Stents are also used in some cases to divert blood All emergency nurses and staff should be aware flow away from an aneurysm. The carotid and vertebral arteries ascend through the neck and divide that NINDS recommends that treatment of a into branches that supply blood to different parts of the brain.

Page 44 Elite patient with acute ischemic stroke should begin report noted that some patients have  Early mobilization, anti-thrombotic within 60 minutes of the person’s arrival, and that neurological worsening with movement, agents and the use of external time could be even shorter to meet the treatment and nurses must observe the transition compression devices (such as window requirement of three hours after onset of from bed to chair carefully. Early stockings or alternating pressure symptoms. mobilization is encouraged, however, devices) may lower the risk of the  They must be able to quickly assess the because it lessens the likelihood of condition. patient’s symptoms for triage purposes and complications such as pneumonia, deep ŠŠ Ischemic brain swelling, caused by a may help with a neurological assessment vein thrombosis, pulmonary embolism cytotoxic reaction mediated by multiple (such as the NIH Stroke Scale) and gather and pressure sores. factors, including free radicals. It history from the patient or his/her family  Pressure mattresses and close typically occurs about four days after to ascertain the time of symptom onset, a surveillance of the skin are onset, but some early swelling, called key determinant of whether the person is a recommended to help prevent “malignant” swelling, that occurs within candidate for thrombolytic therapy. pressure sores. 24 hours has been seen. Very few clinical  They must be ready to quickly implement ŠŠ Monitor patients to avoid dehydration or signs predict clinical deterioration from orders for brain imaging and other tests a malnutrition, which may slow recovery swelling. But researchers have found the doctor will order to ascertain the origin of or cause additional problems, such as following often are present in such cases: the stroke. This may mean alerting the proper deep vein thrombosis, after a stroke.  A history of hypertension and heart departments that a patient will arrive soon Problems swallowing are associated with failure. and tests must be conducted stat. a high risk of pneumonia and death.  Elevated white blood cell count.  When intravenous thrombolytic therapy  An abnormal gag reflex, impaired  Presence of more than 50 percent is ordered, a nurse will likely administer voluntary cough, dysphonia, MCA hypodensity. it. (Physicians generally administer intra- incomplete oral-labial closure, a high  Involvement of additional vascular arterial thrombolysis, which is sometimes stroke scale score or cranial nerve territory. used on patients with AIS secondary to pulses are critical signs. Nurses ŠŠ Hemorrhagic transformation from occlusion of the MCA.) The nurse also will should perform a water swallow test the ischemic stroke. Hematomas may be part of the critically important team that at bedside before a patient is given be associated with neurological decline; monitors the patient during the therapy and food or drink. small asymptomatic petechiae are usually afterward. The American Heart Association  Patients with infarctions of the less problematic. in its Comprehensive Overview of Nursing brainstem, multiple strokes, major  The use of all anti-thrombotics, and Interdisciplinary Care of the Acute hemispheric lesions or mental but especially anticoagulants and Ischemic Stroke Patient report (http://stroke. impairments are at the greatest risk of thrombolytic agents, increases the ahajournals.org/cgi/content/full/8/2911) aspiration. likelihood of serious hemorrhagic recommends: ŠŠ Because pneumonia is a frequent problem transformation. ŠŠ TPA be infused 0.9 mgk/kg (with a in seriously affected immobile patients ŠŠ Seizures usually occur within 24 hours maximum dose of 90 mg) over 60 and an important cause of death after of stroke and are usually partial. The risk minutes with 10 percent of the dose given stroke, nurses must check for signs of of late seizures is higher in patients with as a bolus over one minute. fever and infection. Some measures to pre-existing dementia. ŠŠ Blood pressure monitoring is critical prevent aspiration and infection are:  After a patient is stabilized, nurses during initial treatment and afterward; an  Protection of the airway and may be involved in rehabilitation elevated BP that cannot be safely lowered suctioning. measures, including patient and to 185/110 mm/Hg will disqualify a  Measures to treat nausea and family education and support. patient for thrombolytic therapy; and vomiting. Post-stroke rehabilitation fact sheet patients who have received the therapy  Exercise and encouragement to take also must be continuously monitored deep breaths. National Institute of Neurological to ensure a rise does not cause bleeding ŠŠ Urinary tract infections are also common Disorders and Stroke complications. During administration of among patients with stroke. Bacteremia In the United States, more than 700,000 people tPA, BP should be taken every 15 minutes or sepsis can appear. suffer a stroke each year, and approximately for the first two hours, then every 30  Screening of urine should occur two-thirds of these individuals survive and minutes for the next six hours, and then whenever a patient develops a fever. require rehabilitation. The goals of rehabilitation hourly until 24 hours after treatment. A  Indwelling catheters may be ordered are to help survivors become as independent as nurse should increase the frequency of to prevent incontinence and urinary possible and to attain the best possible quality of blood pressure measurements if a systolic retention, but their use comes with life. Even though rehabilitation does not “cure” BP is at or greater than 180 mm/Hg or if the risk of urinary infections. stroke in that it does not reverse brain damage, diastolic BP is at or greater than 105 mm/  Acidification of urine may reduce the rehabilitation can substantially help people Hg. risk of infection. achieve the best possible long-term outcome. ŠŠ Neurological assessments should be  Anti-cholinergic agents may help What is post-stroke rehabilitation? performed every 15 minutes during the recover bladder function. Rehabilitation helps stroke survivors relearn infusion and every 30 minutes after for  Nurses must watch for serious complications skills that are lost when part of the brain is the next six hours, then hourly until 24 that arise after a stroke, including: damaged. For example, these skills can include hours after treatment. ŠŠ Deep vein thrombosis and pulmonary coordinating leg movements in order to walk or  After the administration of tPA, patient embolism, which account for about carrying out the steps involved in any complex monitoring continues. AHA says that in 10 percent of deaths after stroke and activity. Rehabilitation also teaches survivors addition to blood pressure and neurological generally arise from venous thrombi new ways of performing tasks to circumvent assessments, nurses caring for all stroke that developed in paralyzed lower limbs or compensate for any residual disabilities. patients should: or pelvis. In addition to the potential Patients may need to learn how to bathe and dress ŠŠ Oversee the patient’s transition from to cause life-threatening events, deep using only one hand, or how to communicate bed rest to mobilization, usually as soon vein thrombosis slows recovery and effectively when their ability to use language has the patient is considered stable. The rehabilitation after stroke. Elite Page 45 been compromised. There is a strong consensus a disability called ataxia, leading to problems area, results in receptive aphasia. People with this among rehabilitation experts that the most with body posture, walking and balance. condition have difficulty understanding spoken important element in any rehabilitation program or written language and often have incoherent Sensory disturbances including pain is carefully directed, well-focused, repetitive speech. Although they can form grammatically Stroke patients may lose the ability to feel touch, practice – the same kind of practice used by correct sentences, their utterances are often pain, temperature or position. Sensory deficits all people when they learn a new skill, such as devoid of meaning. may also hinder the ability to recognize objects playing the piano or pitching a baseball. that patients are holding and can even be severe The most severe form of aphasia, global aphasia, Rehabilitative therapy begins in the acute-care enough to cause loss of recognition of one’s is caused by extensive damage to several areas hospital after the patient’s medical condition own limb. Some stroke patients experience involved in language function. People with global has been stabilized, often within 24 to 48 hours pain, numbness or odd sensations of tingling aphasia lose nearly all their linguistic abilities; after the stroke. The first steps involve promoting or prickling in paralyzed or weakened limbs, a they can neither understand language nor use it to independent movement because many patients condition known as paresthesia. convey thought. are paralyzed or seriously weakened. Patients Stroke survivors frequently have a variety A less severe form of aphasia, called anomic or are prompted to change positions frequently of chronic pain syndromes resulting from amnesic aphasia, occurs when there is only a while lying in bed and to engage in passive or stroke-induced damage to the nervous system minimal amount of brain damage; its effects are active range-of-motion exercises to strengthen (neuropathic pain). Patients who have a often quite subtle. People with anomic aphasia their stroke-impaired limbs. (“Passive” range-of- seriously weakened or paralyzed arm commonly may simply selectively forget interrelated motion exercises are those in which the therapist experience moderate to severe pain that radiates groups of words, such as the names of people or actively helps the patient move a limb repeatedly, outward from the shoulder. Most often, the particular kinds of objects. whereas “active” exercises are performed by pain results when a joint becomes immobilized the patient with no physical assistance from Problems with thinking and memory because of lack of movement and the tendons the therapist.) Patients progress from sitting up Stroke can cause damage to parts of the brain and ligaments around the joint become fixed in and transferring between the bed and a chair to responsible for memory, learning and awareness. one position. This is commonly called a “frozen” standing, bearing their own weight and walking, Stroke survivors may have dramatically joint; “passive” movement at the joint in a with or without assistance. Rehabilitation nurses shortened attention spans or may experience paralyzed limb is essential to prevent painful and therapists help patients perform progressively deficits in short-term memory. Individuals also freezing and to allow easy movement if and more complex and demanding tasks, such as may lose their ability to make plans, comprehend when voluntary motor strength returns. In some bathing, dressing and using a toilet, and they meaning, learn new tasks or engage in other stroke patients, pathways for sensation in the encourage patients to begin using their stroke- complex mental activities. Two fairly common brain are damaged, causing the transmission impaired limbs while engaging in those tasks. deficits resulting from stroke are anosognosia, of false signals that result in the sensation of Beginning to reacquire the ability to carry out an inability to acknowledge the reality of the pain in a limb or side of the body that has the these basic activities of daily living represents physical impairments resulting from stroke, sensory deficit. The most common of these pain the first stage in a stroke survivor’s return to and neglect, the loss of the ability to respond to syndromes is called thalamic pain syndrome, functional independence. objects or sensory stimuli located on one side which can be difficult to treat even with of the body, usually the stroke-impaired side. For some stroke survivors, rehabilitation will be medications. an ongoing process to maintain and refine skills Stroke survivors who develop apraxia lose their The loss of urinary continence is fairly common and could involve working with specialists for ability to plan the steps involved in a complex immediately after a stroke and often results from months or years after the stroke. task and to carry the steps out in the proper a combination of sensory and motor deficits. sequence. Stroke survivors with apraxia may also What disabilities can result from a Stroke survivors may lose the ability to sense the have problems following a set of instructions. stroke? need to urinate or the ability to control muscles Apraxia appears to be caused by a disruption of The types and degrees of disability that follow of the bladder. Some may lack enough mobility the subtle connections that exist between thought a stroke depend upon which area of the brain is to reach a toilet in time. Loss of bowel control and action. damaged. Generally, stroke can cause five types or constipation may also occur. Permanent Emotional disturbances of disabilities: paralysis or problems controlling incontinence after a stroke is uncommon. But Many people who survive a stroke feel fear, movement; sensory disturbances, including even a temporary loss of bowel or bladder control anxiety, frustration, anger, sadness and a sense pain; problems using or understanding language; can be emotionally difficult for stroke survivors. of grief for their physical and mental losses. problems with thinking and memory; and Problems using or understanding These feelings are a natural response to the emotional disturbances. language (aphasia) psychological trauma of stroke. Some emotional Paralysis or problems controlling At least one-fourth of all stroke survivors disturbances and personality changes are caused movement (motor control) experience language impairments, involving the by the physical effects of brain damage. Clinical Paralysis is one of the most common disabilities ability to speak, write and understand spoken depression, which is a sense of hopelessness resulting from stroke. The paralysis is usually and written language. A stroke-induced injury to that disrupts an individual’s ability to function, on the side of the body opposite the side of the any of the brain’s language-control centers can appears to be the emotional disorder most brain damaged by stroke, and may affect the severely impair verbal communication. Damage commonly experienced by stroke survivors. Signs face, an arm, a leg or the entire side of the body. to a language center located on the dominant of clinical depression include sleep disturbances, This one-sided paralysis is called hemiplegia side of the brain, known as Broca’s area, causes a radical change in eating patterns that may lead (one-sided weakness is called hemiparesis). expressive aphasia. People with this type of to sudden weight loss or gain, lethargy, social Stroke patients with hemiparesis or hemiplegia aphasia have difficulty conveying their thoughts withdrawal, irritability, fatigue, self-loathing and may have difficulty with everyday activities such through words or writing. They lose the ability suicidal thoughts. Post-stroke depression can as walking or grasping objects. Some stroke to speak the words they are thinking and to put be treated with antidepressant medications and patients have problems with swallowing, called words together in coherent, grammatically correct psychological counseling. sentences. dysphagia, due to damage to the part of the brain What medical professionals specialize in that controls the muscles for swallowing. Damage In contrast, damage to a language center located post-stroke rehabilitation? to a lower part of the brain, the cerebellum, can in a rear portion of the brain, called Wernicke’s Post-stroke rehabilitation involves physicians; affect the body’s ability to coordinate movement, rehabilitation nurses; physical, occupational,

Page 46 Elite recreational, speech-language and vocational Disabled people tend to avoid using impaired Speech-language pathologists therapists; and mental health professionals. limbs, a behavior called learned non-use. Speech-language pathologists help stroke However, the repetitive use of impaired limbs survivors with aphasia relearn how to use Physicians encourages brain plasticity and helps reduce language or develop alternative means of Physicians have the primary responsibility for disabilities. communication. They also help people improve managing and coordinating the long-term care their ability to swallow, and they work with of stroke survivors, including recommending Strategies used by physical therapists to patients to develop problem-solving and social which rehabilitation programs will best address encourage the use of impaired limbs include skills needed to cope with the aftereffects of a individual needs. Physicians are also responsible selective sensory stimulation such as tapping stroke. for caring for the stroke survivor’s general health or stroking, active and passive range-of-motion and providing guidance aimed at preventing a exercises, and temporary restraint of healthy Many specialized therapeutic techniques have second stroke, such as controlling high blood limbs while practicing motor tasks. Some been developed to assist people with aphasia. pressure or diabetes and eliminating risk physical therapists may use a new technology, Some forms of short-term therapy can improve factors such as cigarette smoking, excessive transcutaneous electrical nerve stimulation comprehension rapidly. Intensive exercises such weight, a high-cholesterol diet and high alcohol (TENS), that encourages brain reorganization as repeating the therapist’s words, practicing consumption. and recovery of function. TENS involves using a following directions and doing reading or writing small probe that generates an electrical current to exercises form the cornerstone of language Neurologists usually lead acute-care stroke teams stimulate nerve activity in stroke-impaired limbs. rehabilitation. Conversational coaching and and direct patient care during hospitalization. rehearsal as well as the development of prompts They sometimes remain in charge of long-term In general, physical therapy emphasizes or cues to help people remember specific rehabilitation. However, physicians trained in practicing isolated movements, repeatedly words are sometimes beneficial. Speech- other specialties often assume responsibility after changing from one kind of movement to another, language pathologists also help stroke survivors the acute stage has passed, including physiatrists, and rehearsing complex movements that require develop strategies for circumventing language who specialize in physical medicine and a great deal of coordination and balance, such disabilities. These strategies can include the rehabilitation. as walking up or down stairs or moving safely between obstacles. People too weak to bear use of symbol boards or sign language. Recent Rehabilitation nurses their own weight can still practice repetitive advances in computer technology have spurred Nurses specializing in rehabilitation help movements during hydrotherapy (in which water the development of new types of equipment to survivors relearn how to carry out the basic provides sensory stimulation as well as weight enhance communication. activities of daily living. They also educate support) or while being partially supported by Speech-language pathologists use noninvasive survivors about routine health care, such as how a harness. A recent trend in physical therapy imaging techniques to study swallowing patterns to follow a medication schedule, how to care for emphasizes the effectiveness of engaging in of stroke survivors and identify the exact source the skin, how to manage transfers between a bed goal-directed activities, such as playing games, of their impairment. Difficulties with swallowing and a wheelchair, and special needs for people to promote coordination. Physical therapists have many possible causes, including a delayed with diabetes. Rehabilitation nurses also work frequently employ selective sensory stimulation swallowing reflex, an inability to manipulate with survivors to reduce risk factors that may to encourage use of impaired limbs and to help food with the tongue or an inability to detect food lead to a second stroke, and provide training for survivors with neglect regain awareness of remaining lodged in the after swallowing. caregivers. stimuli on the neglected side of the body. When the cause has been pinpointed, speech- language pathologists work with the individual Nurses are closely involved in helping stroke Occupational and recreational therapists survivors manage personal care issues, such to devise strategies to overcome or minimize Like physical therapists, occupational therapists as bathing and controlling incontinence. Most the deficit. Sometimes, simply changing body are concerned with improving motor and sensory stroke survivors regain their ability to maintain position and improving posture during eating can abilities. They help survivors relearn skills continence, often with the help of strategies bring about improvement. The texture of foods needed for performing self-directed activities- learned during rehabilitation. These strategies can be modified to make swallowing easier; for occupations, such as personal grooming, include strengthening pelvic muscles through example, thin liquids, which often cause choking, preparing meals and housecleaning. Therapists special exercises and following a timed voiding can be thickened. Changing eating habits by can teach some survivors how to adapt to driving schedule. If problems with incontinence continue, taking small bites and chewing slowly can also and provide on-road training. They often teach nurses can help caregivers learn to insert and help alleviate dysphagia. people to divide a complex activity into its manage catheters and to take special hygienic component parts, practice each part and then Vocational therapists measures to prevent other incontinence-related perform the whole sequence of actions. This Approximately one-fourth of all strokes occur in health problems from developing. strategy can improve coordination and may help people between the ages of 45 and 65. For most Physical therapists people with apraxia relearn how to carry out people in this age group, returning to work is a Physical therapists specialize in treating planned actions. major concern. Vocational therapists perform disabilities related to motor and sensory Occupational therapists also teach people how many of the same functions that ordinary career impairments. They are trained in all aspects to develop compensatory strategies and how counselors do. They can help people with residual of anatomy and physiology related to normal to change elements of their environment that disabilities identify vocational strengths and function, with an emphasis on movement. They limit activities of daily living. For example, develop resumés that highlight those strengths. assess the stroke survivor’s strength, endurance, people with the use of only one hand can They also can help identify potential employers, range of motion, gait abnormalities and sensory substitute Velcro closures for buttons on clothing. assist in specific job searches and provide deficits to design individualized rehabilitation Occupational therapists also help people make referrals to stroke vocational rehabilitation programs aimed at regaining control over motor changes in their homes to increase safety, remove agencies. functions. barriers and facilitate physical functioning, such Most important, vocational therapists educate Physical therapists help survivors regain the use as installing grab bars in bathrooms. disabled individuals about their rights and of stroke-impaired limbs, teach compensatory Recreational therapists help people with a variety protections as defined by the Americans with strategies to reduce the effect of remaining of disabilities to develop and use their leisure Disabilities Act of 1990. This law requires deficits and establish ongoing exercise programs time to enhance their health, independence and employers to make “reasonable accommodations” to help people retain their newly learned skills. quality of life. for disabled employees. Vocational therapists

Elite Page 47 frequently act as mediators between employers However, undergoing treatment at home gives National Aphasia Association and employees to negotiate the provision of people the advantage of practicing skills and 350 Seventh Avenue reasonable accommodations in the workplace. developing compensatory strategies in the context Suite 902 of their own living environment. New York, NY 10001 Where can a stroke patient get [email protected] rehabilitation? What research is being done? http://www.aphasia.org Rehabilitation should begin as soon as a stroke The National Institute of Neurological Disorders Tel: 212-267-2814 800-922-4NAA (4622) patient is stable, often within 24 to 48 hours and Stroke (NINDS), a component of the federal Fax: 212-267-2812 after a stroke. This first stage of rehabilitation government’s National Institutes of Health (NIH), usually occurs within an acute-care hospital. At has primary responsibility for sponsoring research American Speech-Language-Hearing the time of discharge from the hospital, the stroke on disorders of the brain and nervous system, Association (ASHA) patient and family coordinate with hospital social including the acute phase of stroke and the 2200 Research Boulevard workers to locate a suitable living arrangement. restoration of function after stroke. The NINDS Rockville, MD 20850 Many stroke survivors return home, but some also supports research on ways to enhance repair [email protected] move into some type of medical facility. and regeneration of the central nervous system. https://asha.org Scientists funded by the NINDS are studying Tel: 800-638-8255 Inpatient rehabilitation units how the brain responds to experience or adapts Fax: 301-571-0457 Inpatient facilities may be freestanding or part to injury by reorganizing its functions (plasticity) of larger hospital complexes. Patients stay in National Rehabilitation Information Center by using noninvasive imaging technologies to (NARIC) the facility, usually for two to three weeks, and map patterns of biological activity inside the engage in a coordinated, intensive program of 8201 Corporate Drive brain. Other NINDS-sponsored scientists are Suite 600 rehabilitation. Such programs often involve at looking at brain reorganization after stroke and least three hours of active therapy a day, five Landover, MD 20785 determining whether specific rehabilitative [email protected] or six days a week. Inpatient facilities offer techniques, such as constraint-induced movement a comprehensive range of medical services, http://www.naric.com therapy and transcranial magnetic stimulation, Tel: 301-459-5900/301-459-5984 (TTY) 800- including full-time physician supervision and can stimulate brain plasticity, thereby improving access to the full range of therapists specializing 346-2742 motor function and decreasing disability. Other Fax: 301-562-2401 in post-stroke rehabilitation. scientists are experimenting with implantation of Outpatient units neural stem cells, to see whether these cells may National initiatives Outpatient facilities are often part of a larger be able to replace the cells that died as a result of Health care agencies and authorities have hospital complex and provide access to a stroke. made public education about stroke a priority with national ad campaigns urging people to physicians and the full range of therapists Where can I get more information? specializing in stroke rehabilitation. Patients understand the urgent need to call 911 at the For more information on neurological disorders first signs of a stroke in themselves or others. typically spend several hours, often three or research programs funded by the National days each week, at the facility taking part in They want people to understand that there is Institute of Neurological Disorders and Stroke, something that can be done to contain or even coordinated therapy sessions and return home contact the Institute’s Brain Resources and at night. Comprehensive outpatient facilities reverse damage from the dreaded event if they act Information Network (BRAIN) at: quickly. Many research studies are under way to frequently offer treatment programs as intense BRAIN as those of inpatient facilities, but they also can try new treatment strategies, including some to P.O. Box 5801 determine whether the window for thrombolytic offer less demanding regimens, depending on the Bethesda, MD 20824 patient’s physical capacity. treatment may be longer than three hours. New (800) 352-9424 procedures and medication therapies are being Nursing facilities http://www.ninds.nih.gov tested. Rehabilitative services available at nursing Organizations: Emergency responders are being trained in facilities are more variable than are those at American Stroke Association: A Division of the procedures for handling suspected stroke inpatient and outpatient units. Skilled nursing American Heart Association patients, and physicians, nurses and other health facilities usually place a greater emphasis on 7272 Greenville Avenue care professionals are sharpening their skills to rehabilitation, whereas traditional nursing Dallas, TX 75231-4596 provide faster and better treatment for patients homes emphasize residential care. In addition, [email protected] presenting with stroke symptoms. fewer hours of therapy are offered compared to http://www.strokeassociation.org outpatient and inpatient rehabilitation units. Tel: 1-888-4STROKE (478-7653) The Paul Coverdale Stroke Registry Home-based rehabilitation programs Fax: 214-706-5231 In 2001, Congress charged the Centers for Disease Control (CDC) with implementing Home rehabilitation allows for great flexibility National Stroke Association state-based registries that measure and track acute so that patients can tailor their program of 9707 East Easter Lane stroke care and to use data from the registries rehabilitation and follow individual schedules. Suite B in efforts to improve the quality of that care. Stroke survivors may participate in an intensive Centennial, CO 80112-3747 Congress further directed that this project be level of therapy several hours per week or [email protected] named the Paul Coverdell National Acute Stroke follow a less demanding regimen. These http://www.stroke.org Registry to memorialize the late U.S. Sen. Paul arrangements are often best suited for people Tel: 303-649-9299 800-STROKES (787-6537) Coverdell of Georgia, who suffered a fatal stroke who lack transportation or require treatment Fax: 303-649-1328 in 2000 while serving in Congress. by only one type of rehabilitation therapist. Patients dependent on Medicare coverage Easter Seals CDC, in consultation with stroke experts and for their rehabilitation must meet Medicare’s 233 South Wacker Drive organizations, piloted eight prototype registry “homebound” requirements to qualify for such Suite 2400 projects led by academic and medical institutions services; at this time, lack of transportation is Chicago, IL 60606 across the country to test models for measuring not a valid reason for home therapy. The major [email protected] the quality of care delivered to stroke patients. disadvantage of home-based rehabilitation http://www.easterseals.com “Wave I” projects, funded in 2001, were located programs is the lack of specialized equipment. Tel: 312-726-6200 800-221-6827 Fax: 312-726-1494 Page 48 Elite in Georgia, Massachusetts, Michigan and increase collaboration and encourage hospitals to center accreditation can be accessed at the Joint Ohio. “Wave II” projects, funded in 2002, were participate in one or more of the programs. The Commission’s website (http://www.qualitycheck. located in California, Illinois, North Carolina National Quality Forum endorsed eight of these org/consumer/searchQCR.aspx). Use the and Oregon. These prototype projects gathered performance measures in 2008. “advanced” button to check by city or Zip Code data concerning each step of emergency and for health care facilities with specialty programs Consensus Stroke Performance Measures hospital care for stroke patients, from emergency and designations. Hospital performance measures for acute stroke response to the patients’ eventual discharge from care have been developed based on evidence Conclusion a hospital. At the end of the three-year pilot from multiple clinical trials and in the peer- Strokes have long devastated lives, and they period, the results showed that large gaps existed reviewed stroke literature. The Coverdale registry still do. But finally, there is some hope for those between generally recommended guidelines endorses these measures as a foundation of its who suffer its effects. An effective treatment is for treating stroke patients and actual hospital work to improve quality of care: now available for some people, and heightened practices. Intensive quality improvement efforts awareness of that and the need to quickly seek are needed to close those gaps. For hemorrhagic and ischemic stroke patients aid when a stroke occurs should mean more  Deep vein thrombosis prophylaxis by end of In June 2004, CDC provided funds to the people will not only survive a stroke, but also the second hospital day. state health departments of Georgia, Illinois, see many of its effects curtailed or reversed. The  Dysphagia screening. Massachusetts and North Carolina to establish work will continue as researchers seek more and  Assessment for rehabilitation. statewide Coverdell stroke registries for acute better treatments for stroke. Health care officials  Smoking cessation counseling (TIA patients care hospitals in their states. The purpose of will continue to push the message that healthier also). these registries was to develop and implement choices make for a healthier person. And perhaps  Stroke education (TIA patients also). systems for collecting data on acute stroke care fewer and fewer people will hear the dreaded provided to patients, analyze the collected data, For ischemic stroke and TIA patients news that a loved one has suffered a stroke – or at and use the results of those analyses to guide  Anti-thrombotic therapy by end of day two least the news won’t seem quite so hopeless. quality improvement interventions at the hospital and prescribed at discharge. GLOSSARY level through partnerships with hospital doctors,  Lipid-lowering therapy for patients with Acute stroke – a stage of stroke starting at the stroke-care teams and administrators. All acute strokes of atherosclerotic origin with LDL onset of symptoms and lasting for a few hours care hospitals serving the general population in 100. thereafter. participating states were eligible for the program.  Anticoagulation for atrial fibrillation.  In the first year of program activities, states  Use of tPA intravenous thrombolytic therapy Agnosia – a cognitive disability characterized by established partnerships with leading medical – a clot-busting medicine (ischemic stroke ignorance of or inability to acknowledge one side experts, various hospital associations, local patients only). of the body or one side of the visual field.  Staten medication prescribed on discharge. affiliates of the American Hospital Association Aneurysm – a weak or thin spot on an artery and other groups interested in improving health The near-term goals of the Paul Coverdell wall that has stretched or ballooned out from the care for stroke patients; developed strategies National Acute Stroke Registry program are to: wall and filled with blood, or damage to an artery for identifying and recruiting eligible hospitals;  Increase the number of states with Coverdell leading to pooling of blood between the layers of selected and implemented customized Web-based stroke registries. the blood vessel walls. data-collection systems for hospital use; and  Develop and disseminate best practices Anoxia – a state of almost no oxygen delivery recruited hospitals to participate in the registry. in hospital recruitment and training, data to a cell, resulting in low energy production and In the second and third years, states reviewed collection and quality improvement based on possible death of the cell; see hypoxia. collected data to identify specific areas of need lessons learned. for quality improvement, worked with hospitals  Encourage the development of statewide Anticoagulants – a drug therapy used to prevent to implement quality improvement interventions systems of care for stroke patients through the formation of blood clots that can become to improve care, and evaluated progress toward coordination with emergency medical lodged in cerebral arteries and cause strokes. improving statewide acute stroke care and services and collaboration among statewide Anti-platelet agents – a type of anticoagulant promoting long-term systemic changes in how partners. drug therapy that prevents the formation of blood that care is provided. By the end of the 2004-   Communicate with major stakeholders in clots by preventing the accumulation of platelets 2007 project period, more than 180 hospitals stroke care to ensure ongoing improvement in that form the basis of blood clots; some common were participating in a stroke registry, and the the quality of that care. anti-platelets include aspirin and ticlopidine; see percentages of total statewide stroke admissions anticoagulants. treated by participating hospitals ranged from 40 The long-term goal of this program is to ensure percent to 79 percent among the four states. that all Americans receive the highest quality Anti-thrombotics – a type of anticoagulant drug of acute stroke care currently available and to therapy that prevents the formation of blood clots In June 2007, CDC expanded funding to six state reduce the number of untimely deaths attributable by inhibiting the coagulating actions of the blood health departments in Georgia, Massachusetts, to stroke, prevent stroke-related disability and protein thrombin; some common anti-thrombotics Michigan, Minnesota, Ohio and North Carolina prevent stroke patients from suffering recurrent include warfarin and heparin; see anticoagulants. for the Coverdell Registry for a new five- strokes. year funding period. Illinois will continue Aphasia – the inability to understand or create to participate in stroke quality improvement In addition, the Joint Commission on speech, writing or language in general due to activities and provide information to CDC on Accreditation of Healthcare Organization, a damage to the speech centers of the brain. its progress. In 2007, CDC also came to an nonprofit, independent organization whose Apoplexy – a historical, but obsolete term agreement with The Joint Commission’s Primary primary purpose is to provide voluntary for a cerebral stroke, most often intracerebral Stroke Center Certification program and with accreditation for health care facilities, in 2003 hemorrhage, that was applied to any condition the American Heart Association/American began a program to provide primary stroke that involved disorientation and/or paralysis. Stroke Association’s Get With The Guidelines care certification to hospitals. The program – Stroke program to jointly release a set of was based upon recommendations for primary Apoptosis – a form of cell death involving standardized stroke performance measures and stroke centers and the American Stroke Center’s shrinking of the cell and eventual disposal of clinical practice guidelines for use by all three statements/guidelines for stroke care. A list of the internal elements of the cell by the body’s programs. This effort will reduce duplication, facilities that have earned the primary stroke immune system. Apoptosis is an active, non-

Elite Page 49 toxic form of cell suicide that does not induce Coumadin® – a commonly used anticoagulant, Heparin – a type of anticoagulant. an inflammatory response. It is often called also known as warfarin. High-density lipoprotein (HDL) – also known programmed cell death because it is triggered Cytokines – small, hormone-like proteins as the good cholesterol; a compound consisting by a genetic signal, involves specific cell released by leukocytes, endothelial cells and of a lipid and a protein that carries a small mechanisms and is irreversible once initiated. other cells to promote an inflammatory immune percentage of the total cholesterol in the blood Apraxia – a movement disorder characterized response to an injury. and deposits it in the liver. by the inability to perform skilled or purposeful Cytotoxic edema – a state of cell compromise Homeostasis – a state of equilibrium or balance voluntary movements, generally caused by involving influx of fluids and toxic chemicals into among various fluids and chemicals in a cell, in damage to the areas of the brain responsible for a cell, causing subsequent swelling of the cell. tissues, or in the body as a whole. voluntary movement. Detachable coil – a platinum coil that is inserted Hypertension (high blood pressure) – Arteriography – an X-ray of the carotid artery into an artery in the thigh and strung through the characterized by persistently high arterial blood taken when a special dye is injected into the arteries to the site of an aneurysm. The coil is pressure defined as a measurement greater than artery. released into the aneurysm creating an immune or equal to 140 mm/Hg systolic pressure over 90 Arteriovenous malformation (AVM) – a response from the body. The body produces a mm/Hg diastolic pressure. congenital disorder characterized by a complex blood clot inside the aneurysm, strengthening the Hypoxia – a state of decreased oxygen delivery tangled web of arteries and veins. artery walls and reducing the risk of rupture. to a cell so that the oxygen falls below normal Atherosclerosis – a blood vessel disease Duplex Doppler ultrasound – a diagnostic levels; see anoxia. characterized by deposits of lipid material on imaging technique in which an image of an artery Incidence – the extent or frequency of an the inside of the walls of large to medium-sized can be formed by bouncing sound waves off the occurrence; the number of specific new events in arteries that make the artery walls thick, hard, moving blood in the artery and measuring the a given period of time. brittle, and prone to breaking. frequency changes of the echoes. Infarct – an area of tissue that is dead or dying Atrial fibrillation – irregular beating of the left Dysarthria – a disorder characterized by slurred because of a loss of blood supply. atrium, or left upper chamber, of the heart. speech due to weakness or incoordination of the Infarction – a sudden loss of blood supply to Blood-brain barrier – an elaborate network of muscles involved in speaking. tissue, causing the formation of an infarct. supportive brain cells, called glia, that surrounds Dysphagia – trouble swallowing. blood vessels and protects neurons from the toxic Interleukins – a group of cytokine-related Edema – the swelling of a cell that results from effects of direct exposure to blood. proteins secreted by leukocytes and involved the influx of large amounts of water or fluid into in the inflammatory immune response of the Carotid artery – an artery located on either side the cell. ischemic cascade. of the neck that supplies the brain with blood. Embolic stroke – a stroke caused by an embolus. Intracerebral hemorrhage – occurs when a Carotid endarterectomy – surgery used to Embolus – a free-roaming clot that usually forms vessel within the brain leaks blood into the brain. remove fatty deposits from the carotid arteries. in the heart. Ischemia – a loss of blood flow to tissue, caused Central stroke pain (central pain syndrome) – Endothelial wall – a flat layer of cells that make by an obstruction of the blood vessel, usually in pain caused by damage to an area in the thalamus. up the innermost lining of a blood vessel. the form of plaque stenosis or a blood clot. The pain is a mixture of sensations, including heat and cold, burning, tingling, numbness, and Excitatory amino acids – a subset of Ischemic cascade – a series of events lasting for sharp stabbing and underlying aching pain. neurotransmitters; proteins released by one several hours to several days following initial neuron into the space between two neurons to ischemia that results in extensive cell death and Cerebral blood flow (CBF) – the flow of blood promote an excitatory state in the other neuron. tissue damage beyond the area of tissue originally through the arteries that lead to the brain, called affected by the initial lack of blood flow. the cerebrovascular system. Extracranial/intracranial (EC/IC) bypass – a type of surgery that restores blood flow to a Ischemic penumbra – areas of damaged, but still Cerebrospinal fluid (CSF) – clear fluid that blood-deprived area of brain tissue by rerouting living, brain cells arranged in a patchwork pattern bathes the brain and spinal cord. a healthy artery in the scalp to the area of brain around areas of dead brain cells. Cerebrovascular disease – a reduction in the tissue affected by a blocked artery. Ischemic stroke – ischemia in the tissues of the supply of blood to the brain either by narrowing Functional magnetic resonance imaging brain. of the arteries through the buildup of plaque on (FMRI) – a type of imaging that measures the inside walls of the arteries, called stenosis, or Lacunar infarction – occlusion of a small artery increases in blood flow within the brain. through blockage of an artery due to a blood clot. in the brain resulting in a small area of dead brain Glia – also called neuroglia; supportive cells of tissue, called a lacunar infarct; often caused by Cholesterol – a waxy substance, produced the nervous system that make up the blood-brain stenosis of the small arteries, called small vessel naturally by the liver and also found in foods, that barrier, provide nutrients and oxygen to the vital disease. circulates in the blood and helps maintain tissues neurons, and protect the neurons from infection, and cell membranes. Excess cholesterol in the Large vessel disease – stenosis in large arteries toxicity and trauma. Some examples of glia are body can contribute to atherosclerosis and high of the cerebrovascular system. oligodendroglia, astrocytes and microglia. blood pressure. Leukocytes – blood proteins involved in the Glutamate – also known as glutamic acid, “Clipping” – surgical procedure for treatment inflammatory immune response of the ischemic an amino acid that acts as an excitatory of brain aneurysms, involving clamping an cascade. neurotransmitter in the brain. aneurysm from a blood vessel, surgically Lipoprotein – small globules of cholesterol removing this ballooned part of the blood vessel, Hemiparesis – weakness on one side of the body. covered by a layer of protein; produced by the and closing the opening in the artery wall. Hemiplegia – complete paralysis on one side of liver. Computed tomography (CT) scan – a series of the body. Low-density lipoprotein (LDL) – also known cross-sectional X-rays of the brain and head; also Hemorrhagic stroke – sudden bleeding into or as the bad cholesterol; a compound consisting of called computerized axial tomography or CAT around the brain. a lipid and a protein that carries the majority of scan.

Page 50 Elite the total cholesterol in the blood and deposits the Stroke buckle – three Southeastern states, North Stroke is the sudden onset of paralysis caused excess along the inside of arterial walls. Carolina, South Carolina and Georgia, that have by injury to brain cells from disruption in blood an extremely high stroke mortality rate. flow. The injury caused by a blocked blood vessel Magnetic resonance angiography (MRA) – can occur within several minutes and progress an imaging technique involving injection of Subarachnoid hemorrhage – bleeding within for hours as the result of a chain of chemical a contrast dye into a blood vessel and using the meninges, or outer membranes, of the brain reactions that is set off after the start of stroke magnetic resonance techniques to create an image into the clear fluid that surrounds the brain. symptoms. Physicians and researchers often call of the flowing blood through the vessel; often Thrombolytics – drugs used to treat an ongoing, this chain of chemical reactions that lead to the used to detect stenosis of the brain arteries inside acute ischemic stroke by dissolving the blood clot permanent brain injury of stroke the ischemic the skull. causing the stroke and thereby restoring blood cascade. Magnetic resonance imaging (MRI) scan – a flow through the artery. type of imaging involving the use of magnetic Thrombosis – the formation of a blood clot in Primary cell death fields to detect subtle changes in the water one of the cerebral arteries of the head or neck In the first stage of the ischemic cascade, content of tissues. that stays attached to the artery wall until it grows blood flow is cut off from a part of the brain Mitochondria – the energy producing organelles large enough to block blood flow. (ischemia). This leads to a lack of oxygen of the cell. (anoxia) and lack of nutrients in the cells of this Thrombotic stroke – a stroke caused by core area. When the lack of oxygen becomes Mitral annular calcification – a disease of the thrombosis. extreme, the mitochondria, the energy-producing mitral valve of the heart. Tissue necrosis factors – chemicals released by structures within the cell, can no longer produce Mitral valve stenosis – a disease of the mitral leukocytes and other cells that cause secondary enough energy to keep the cell functioning. heart valve involving the buildup of plaque-like cell death during the inflammatory immune The mitochondria break down, releasing toxic material on and around the valve. response associated with the ischemic cascade. chemicals called oxygen-free radicals into the cytoplasm of the cell. These toxins poison the Necrosis – a form of cell death resulting from Total serum cholesterol – a combined cell from the inside-out, causing destruction of anoxia, trauma or any other form of irreversible measurement of a person’s high-density other cell structures, including the gated channels damage to the cell; involves the release of toxic lipoprotein (HDL) and low-density lipoprotein of the cell membrane that normally maintain cellular material into the intercellular space, (LDL). homeostasis to open and allow toxic amounts of poisoning surrounding cells. tPA – see recombinant tissue plasminogen calcium, sodium and potassium ions to flow into Neuron – the main functional cell of the brain activator. the cell. At the same time, the injured ischemic and nervous system, consisting of a cell body, an cell releases excitatory amino acids, such as Transcranial magnetic stimulation (TMS) – a axon and dendrites. glutamate, into the space between neurons, small magnetic current delivered to an area of the leading to overexcitation and injury to nearby Neuroprotective agents – medications that brain to promote plasticity and healing. cells. With the loss of homeostasis, water rushes protect the brain from secondary injury caused Transient ischemic attack (TIA) – a short-lived into the cell making it swell (called cytotoxic by stroke. stroke that lasts from a few minutes up to 24 edema) until the cell membrane bursts under Oxygen-free radicals – toxic chemicals released hours; often called a mini-stroke. the internal pressure. At this point the nerve cell during the process of cellular respiration and is essentially permanently injured and for all Vasodilators – medications that increase blood released in excessive amounts during necrosis of purposes dead (necrosis and infarction). After a flow to the brain by expanding or dilating blood a cell; involved in secondary cell death associated stroke starts, the first cells that are going to die vessels. with the ischemic cascade. may die within four to five minutes. The response Vasospasm – a dangerous side effect of to the treatment that restores blood flow as late Plaque – fatty cholesterol deposits found subarachnoid hemorrhage in which the blood as 2 hours after stroke onset would suggest that, along the inside of artery walls that lead to vessels in the subarachnoid space constrict in most cases, the process is not over for at least atherosclerosis and stenosis of the arteries. erratically, cutting off blood flow. 2 to 3 hours. After that, with rare exceptions, Plasticity – the ability to be formed or molded; most of the injury that has occurred is essentially Vertebral artery – an artery on either side of the in reference to the brain, the ability to adapt to permanent. neck; see carotid artery. deficits and injury. Warfarin – a commonly used anticoagulant, also Secondary cell death Platelets – structures found in blood that known as Coumadin®. Because of exposure to excessive amounts are known primarily for their role in blood of glutamate, nitric oxide, free radicals and coagulation. APPENDIX excitatory amino acids released into the Prevalence – the number of cases of a disease in The ischemic cascade intercellular space by necrotic cells, nearby cells a population at any given point in time. The brain is the most complex organ in the have a more difficult time surviving. They are human body. It contains hundreds of billions receiving just enough oxygen from cerebral blood Recombinant tissue plasminogen activator of cells that interconnect to form a complex flow (CBF) to stay alive. A compromised cell can (rtPA) – a genetically engineered form of tPA, network of communication. The brain has several survive for several hours in a low-energy state. If a thrombolytic, anti-clotting substance made different types of cells, the most important of blood flow is restored within this narrow window naturally by the body. which are neurons. The organization of neurons of opportunity, at present thought to be about two Small vessel disease – a cerebrovascular disease in the brain and the communication that occurs hours, then some of these cells can be salvaged defined by stenosis in small arteries of the brain. among them lead to thought, memory, cognition and become functional again. Researchers have and awareness. Other types of brain cells are learned that restoring blood flow to these cells Stenosis – narrowing of an artery due to the generally called glia (from the Greek word can be achieved by administrating the clot- buildup of plaque on the inside wall of the artery. meaning “glue”). These supportive cells of the dissolving thrombolytic agent tPA within three Stroke Belt – an area of the Southeastern United nervous system provide scaffolding and support hours of the start of the stroke. States with the highest stroke mortality rate in the for the vital neurons, protecting them from Inflammation and the immune response infection, toxins and trauma. Glia make up the country. While anoxic and necrotic brain cells are doing blood-brain barrier between blood vessels and the damage to still viable brain tissue, the immune substance of the brain. system of the body is injuring the brain through

Elite Page 51 an inflammatory reaction mediated by the vascular system. Damage to the blood vessel at the site of a blood clot or hemorrhage attracts inflammatory blood elements to that site. Among the first blood elements to arrive are leukocytes, white blood cells that are covered with immune system proteins that attach to the blood vessel wall at the site of the injury. After they attach, the leukocytes penetrate the endothelial wall, move through the blood-brain barrier and invade the substance of the brain, causing further injury and brain cell death. Leukocytes called monocytes and macrophages release inflammatory chemicals (cytokines, interleukins, and tissue necrosis factors) at the site of the injury. These chemicals make it harder for the body to naturally dissolve a clot that has caused a stroke by inactivating anti-clotting factors and inhibiting the release of natural tissue plasminogen activator. NINDS researchers are currently working to create interventional therapies that will inhibit the effects of cytokines and other chemicals in the inflammatory process during stroke. These brain cells survive the loss of blood flow (ischemia) but are not able to function. These areas of still-viable brain cells exist in a patchwork pattern within and around the area of dead brain tissue (also called an infarct). NIH stroke scale (on the following pages)

Page 52 Elite NIH Patient Identification __ __ - ______- __ __ Pt. Date of Birth __ __ / __ __ / __ __ STROKE Hospital ______( __ __ - __ __ ) SCALE Date of Exam __ __ / __ __ / __ __ Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms +20 minutes [ ] 7 - 10 days [ ] 3 months [ ] Other ______( __ __ )

Time: __ __ : __ __ [ ] am [ ] pm

Person Administering Scale ______

Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient does, not what the clinician thinks the patient can do. The clinician should record answers while administering the exam and work quickly. Except where indicated, the patient should not be coached (i.e., repeated requests to patient to make a special effort).

Instructions Scale Definition Score 1a. Level of Consciousness: The investigator must choose a 0 = Alert; keenly responsive. response if a full evaluation is prevented by such obstacles as an 1 = Not alert; but arousable by minor stimulation to obey, endotracheal tube, language barrier, orotracheal trauma/bandages. answer, or respond. A 3 is scored only if the patient makes no movement (other than 2 = Not alert; requires repeated stimulation to attend, or is ______reflexive posturing) in response to noxious stimulation. obtunded and requires strong or painful stimulation to make movements (not stereotyped). 3 = Responds only with reflex motor or autonomic effects or totally unresponsive, flaccid, and areflexic. 1b. LOC Questions: The patient is asked the month and his/ 0 = Answers both questions correctly. her age. The answer must be correct - there is no partial credit for being close. Aphasic and stuporous patients who do not 1 = Answers one question correctly. ______comprehend the questions will score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe 2 = Answers neither question correctly. dysarthria from any cause, language barrier, or any other problem not secondary to aphasia are given a 1. It is important that only the initial answer be graded and that the examiner not “help” the patient with verbal or non-verbal cues. 1c. LOC Commands: The patient is asked to open and close the 0 = Performs both tasks correctly. eyes and then to grip and release the non-paretic hand. Substitute another one step command if the hands cannot be used. Credit is 1 = Performs one task correctly. ______given if an unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, the task 2 = Performs neither task correctly. should be demonstrated to him or her (pantomime), and the result scored (i.e., follows none, one or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored. 2. Best Gaze: Only horizontal eye movements will be tested. 0 = Normal. Voluntary or reflexive (oculocephalic) eye movements will be scored, but caloric testing is not done. If the patient has a conjugate 1 = Partial gaze palsy; gaze is abnormal in one or both eyes, deviation of the eyes that can be overcome by voluntary or but forced deviation or total gaze paresis is not present. ______reflexive activity, the score will be 1. If a patient has an isolated peripheral nerve paresis (CN III, IV or VI), score a 1. Gaze is 2 = Forced deviation, or total gaze paresis not overcome by testable in all aphasic patients. Patients with ocular trauma, the oculocephalic maneuver. bandages, pre-existing blindness, or other disorder of visual acuity or fields should be tested with reflexive movements, and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a partial gaze palsy.

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Elite Page 53 NIH Patient Identification __ __ - ______- __ __ Pt. Date of Birth __ __ / __ __ / __ __ STROKE Hospital ______( __ __ - __ __ ) SCALE Date of Exam __ __ / __ __ / __ __ Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms +20 minutes [ ] 7 - 10 days [ ] 3 months [ ] Other ______( __ __ )

3. Visual: Visual fields (upper and lower quadrants) are tested by 0 = No visual loss. confrontation, using finger counting or visual threat, as appropriate. Patients may be encouraged, but if they look at the side of the 1 = Partial hemianopia. moving fingers appropriately, this can be scored as normal. If there ______is unilateral blindness or enucleation, visual fields in the remaining 2 = Complete hemianopia. eye are scored. Score 1 only if a clear-cut asymmetry, including quadrantanopia, is found. If patient is blind from any cause, score 3 = Bilateral hemianopia (blind including cortical 3. Double simultaneous stimulation is performed at this point. If blindness). there is extinction, patient receives a 1, and the results are used to respond to item 11. 4. Facial Palsy: Ask – or use pantomime to encourage – the patient 0 = Normal symmetrical movements. to show teeth or raise eyebrows and close eyes. Score symmetry of 1 = Minor paralysis (flattened nasolabial fold, asymmetry grimace in response to noxious stimuli in the poorly responsive or on smiling). non-comprehending patient. If facial trauma/bandages, orotracheal 2 = Partial paralysis (total or near-total paralysis of lower ______tube, tape or other physical barriers obscure the face, these should face). be removed to the extent possible. 3 = Complete paralysis of one or both sides (absence of facial movement in the upper and lower face). 5. Motor Arm: The limb is placed in the appropriate position: 0 = No drift; limb holds 90 (or 45) degrees for full 10 extend the arms (palms down) 90 degrees (if sitting) or 45 seconds. degrees (if supine). Drift is scored if the arm falls before 10 1 = Drift; limb holds 90 (or 45) degrees, but drifts down seconds. The aphasic patient is encouraged using urgency in the before full 10 seconds; does not hit bed or other support. voice and pantomime, but not noxious stimulation. Each limb is 2 = Some effort against gravity; limb cannot get to or tested in turn, beginning with the non-paretic arm. Only in the maintain (if cued) 90 (or 45) degrees, drifts down to bed, case of amputation or joint fusion at the shoulder, the examiner but has some effort against gravity. should record the score as untestable (UN), and clearly write the 3 = No effort against gravity; limb falls. explanation for this choice. 4 = No movement. UN = Amputation or joint fusion, explain: ______

5a. Left Arm ______

5b. Right Arm ______

6. Motor Leg: The limb is placed in the appropriate position: hold 0 = No drift; leg holds 30-degree position for full 5 seconds. the leg at 30 degrees (always tested supine). Drift is scored if the 1 = Drift; leg falls by the end of the 5-second period but does leg falls before 5 seconds. The aphasic patient is encouraged using not hit bed. urgency in the voice and pantomime, but not noxious stimulation. 2 = Some effort against gravity; leg falls to bed by 5 Each limb is tested in turn, beginning with the non-paretic leg. seconds, but has some effort against gravity. Only in the case of amputation or joint fusion at the hip, the 3 = No effort against gravity; leg falls to bed immediately. examiner should record the score as untestable (UN), and clearly 4 = No movement. write the explanation for this choice. UN = Amputation or joint fusion, explain: ______

6a. Left Leg ______

6b. Right Leg ______

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Page 54 Elite NIH Patient Identification __ __ - ______- __ __ Pt. Date of Birth __ __ / __ __ / __ __ STROKE Hospital ______( __ __ - __ __ ) SCALE Date of Exam __ __ / __ __ / __ __ Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms +20 minutes [ ] 7 - 10 days [ ] 3 months [ ] Other ______( __ __ )

7. Limb Ataxia: This item is aimed at finding evidence of a 0 = Absent. unilateral cerebellar lesion. Test with eyes open. In case of visual defect, ensure testing is done in intact visual field. The finger-nose- 1 = Present in one limb. ______finger and heel-shin tests are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is 2 = Present in two limbs. absent in the patient who cannot understand or is paralyzed. Only in the case of amputation or joint fusion, the examiner should record UN = Amputation or joint fusion, explain: ______the score as untestable (UN), and clearly write the explanation for this choice. In case of blindness, test by having the patient touch nose from extended arm position. 8. Sensory: Sensation or grimace to pinprick when tested, or 0 = Normal; no sensory loss. withdrawal from noxious stimulus in the obtunded or aphasic patient. Only sensory loss attributed to stroke is scored as abnormal 1 = Mild-to-moderate sensory loss; patient feels pinprick is and the examiner should test as many body areas (arms [not hands], less sharp or is dull on the affected side; or there is a loss legs, trunk, face) as needed to accurately check for hemisensory of superficial pain with pinprick, but patient is aware of loss. A score of 2, “severe or total sensory loss,” should only being touched. ______be given when a severe or total loss of sensation can be clearly demonstrated. Stuporous and aphasic patients will, therefore, 2 = Severe to total sensory loss; patient is not aware of being probably score 1 or 0. The patient with brainstem stroke who has touched in the face, arm, and leg. bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically given a 2 on this item. 9. Best Language: A great deal of information about 0 = No aphasia; normal. comprehension will be obtained during the preceding sections of the examination. For this scale item, the patient is asked to describe 1 = Mild-to-moderate aphasia; some obvious loss of fluency what is happening in the attached picture, to name the items on or facility of comprehension, without significant limitation the attached naming sheet and to read from the attached list of on ideas expressed or form of expression. Reduction of sentences. Comprehension is judged from responses here, as well speech and/or comprehension, however, makes conversation as to all of the commands in the preceding general neurological about provided materials difficult or impossible. For exam. If visual loss interferes with the tests, ask the patient to example, in conversation about provided materials, examiner identify objects placed in the hand, repeat, and produce speech. can identify picture or naming card content from patient’s ______The intubated patient should be asked to write. The patient in a response. coma (item 1a=3) will automatically score 3 on this item. The examiner must choose a score for the patient with stupor or limited 2 = Severe aphasia; all communication is through fragmentary cooperation, but a score of 3 should be used only if the patient is expression; great need for inference, questioning, and mute and follows no one-step commands. guessing by the listener. Range of information that can be exchanged is limited; listener carries burden of communication. Examiner cannot identify materials provided from patient response.

3 = Mute, global aphasia; no usable speech or auditory comprehension. 10. Dysarthria: If patient is thought to be normal, an adequate 0 = Normal. sample of speech must be obtained by asking patient to read 1 = Mild-to-moderate dysarthria; patient slurs at least some or repeat words from the attached list. If the patient has severe words and, at worst, can be understood with some difficulty. aphasia, the clarity of articulation of spontaneous speech can be 2 = Severe dysarthria; patient’s speech is so slurred as to be ______rated. Only if the patient is intubated or has other physical barriers unintelligible in the absence of or out of proportion to any to producing speech, the examiner should record the score as dysphasia, or is mute/anarthric. untestable (UN), and clearly write an explanation for this choice. UN = Intubated or other physical barrier, Do not tell the patient why he or she is being tested. explain:______

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Elite Page 55 NIH Patient Identification __ __ - ______- __ __ Pt. Date of Birth __ __ / __ __ / __ __ STROKE Hospital ______( __ __ - __ __ ) SCALE Date of Exam __ __ / __ __ / __ __ Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms +20 minutes [ ] 7 - 10 days [ ] 3 months [ ] Other ______( __ __ )

11. Extinction and Inattention (formerly Neglect): Sufficient 0 = No abnormality. information to identify neglect may be obtained during the prior testing. If the patient has a severe visual loss preventing visual 1 = Visual, tactile, auditory, spatial, or personal double simultaneous stimulation, and the cutaneous stimuli are inattention or extinction to bilateral simultaneous ______normal, the score is normal. If the patient has aphasia but does stimulation in one of the sensory modalities. appear to attend to both sides, the score is normal. The presence of visual spatial neglect or anosagnosia may also be taken as evidence 2 = Profound hemi-inattention or extinction to more than of abnormality. Since the abnormality is scored only if present, the one modality; does not recognize own hand or orients to item is never untestable. only one side of space.

Rev 10/1/2003

REFERENCES 16. Joint Commission. (2009). Specifications Manual for National Hospital Quality NOTES ŠŠAmerican Academy of Pediatrics. Active Healthy Living: Prevention of Childhood Measures’, version 2.6b’ . Retrieved online August 20, 2009 at http://www. obesity through increased Physical Activity. Pediatrics, 117 (5): May 2006, 1834- jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/ 1839. Retrieved online 8/21/09 at http://aappolicy.aappublications.org/cgi/reprint/ Current+NHQM+Manual.htm pediatrics;117/5/1834.pdf 17. Lippincott, Williams & Wilkins. (2007). Professional Guide to Pathophysiology. ŠŠAmerican Academy of Pediatrics. Children, Adolescents, and Television. Pediatrics 7 (2nd ed). Wolters Kluwer: Philadelphia. ( 2) February 2001, pp. 423-426. Retrieved online August 21, 2009 at http://aappolicy. 18. Loscalzo, J., Bonow, R., & Jacobs, A. (2007). Calcium Screening and the American aappublications.org/cgi/content/full/pediatrics;107/2/423 Heart Association News Embargo. Circulation. 2004;110:3504-3505. Retrieved online ŠŠAmerican Diabetes Association (2008).All About Diabetes. Retrieved online 8/21/09 at August 21, 2009 at http://circ.ahajournals.org/cgi/content/full/110/23/3504 http://www.diabetes.org/about-diabetes.jsp 19. McPhee, S., Papadakis, M. & Tierney, L. (2008). Current Medical Diagnosis and ŠŠAmerican Diabetes Association. (2009). Diabetes and Cardiovascular Disease. Treatment (47th ed). McGraw:Lange Retrieved online August 19, 2009 at http://www.diabetes.org/diabetes-statistics/heart- 20. National Heart and Lung Blood Institute (2009). Arrhythmia. Retrieved online Aug disease.jsp 7, 2009 at http://www.nhlbi.nih.gov/health/dci/Diseases/arr/arr_signsandsymptoms. ŠŠAmerican Heart Association (2009). Cardiovascular disease. Retrieved online August 7, html 2009 at http://www.americanheart.org/presenter.jhtml?identifier=4478 21. National Heart and Lung Blood Institute (2009). Coronary Artery Disease. Retrieved ŠŠAmerican Heart Association (2009). Diet and Lifestyle Recommendations. Retrieved online August 7 2009 at http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_ online Aug 7, 2009 at http://www.americanheart.org/presenter.jhtml?identifier=851 SignsandSymptoms.Html ŠŠAmerican Heart Association. (2009). Heart Attack, Stroke and Cardiac Arrest Warning 22. National Heart and Lung Blood Institute. (2009). Coronary Artery Disease. Signs. Retrieved online August 7, 2009 at http://www.americanheart.org/presenter. Retrieved online August 16, 2009 at http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/ jhtml?identifier=3053 CAD_WhatIs.html ŠŠAmerican Heart Association. (2008). Myocardial Ischemia, Injury and Infarction. 23. National Heart and Lung Blood Institute (2009). Heart Failure. Retrieved Retrieved online August 22, 2009 at http://www.americanheart.org/presenter. online August 7, 2009 at http://www.nhlbi.nih.gov/health/dci/Diseases/Hf/HF_ jhtml?identifier=251 SignsAndSymptoms.html ŠŠAmerican Heart Association (2009).Physical Activity. Retrieved online 8/7/09 at http:// 24. National High Blood Pressure Educational Program. (2003). JNC 7 Express. www.americanheart.org/presenter.jhtml?identifier=4563 Retrieved online August 21, 2009 at http://www.nhlbi.nih.gov/guidelines/hypertension/ ŠŠAmerican Heart Association. (2009). Risk Factors and Coronary Heart Disease. express.pdf Retrieved online August 9, 2009 at http://www.americanheart.org/presenter. 25. Research Triangle Institute (2009). Task Force Issues Recommendations on Diabetes jhtml?identifier=4726 Screening for Adults and Pregnant Women. Retrieved online August 21, 2009 at http:// ŠŠAmerican Heart Association. (2006). Summary of American Heart Association Diet and www.rti.org/page.cfm?objectid=9947467A-759B-41B5-AA1BB05ACFA72C18 Lifestyle Recommendations Revision 2006. Arteriosclerosis, Thrombosis, and Vascular 26. Riaz,K., Forker, A. (2007). Hypertensive Heart Disease. Retrieved online August 22, Biology. 2006;26: 2186. Retrieved online August 20, 2009 at http://atvb.ahajournals. 2009 at http://emedicine.medscape.com/article/162449-overview org/cgi/content/full/26/10/2186#TBL1 27. Rvera-Bou, W. & Cabanas, J. (2008). Thrombolytic Therapy. Retrieved online ŠŠAmerican Heart Association. (2009). What Your cholesterol levels mean. August 20, 2009 at http://emedicine.medscape.com/article/811234-overview Retrieved online August 29, 2009 at http://www.americanheart.org/presenter. 28. Seller, R. (2000). Differential Diagnosis of Common Complaints. (4th ed). W.B jhtml?identifier=183#total Saunders: Philadelphia. ŠŠCenter for Disease Control and Prevention (2009). About Heart Disease. Retrieved 29. United States Department of Health and Human Services. (May 2001). National online August 7, 2009 at http://www.cdc.gov/heartdisease/about.htm heart, lung and blood institute. Retrieved online August 19, 2009 at http://www.nhlbi. ŠŠCenters for Disease Control and Prevention. (2008). American Indian and Alaska nih.gov/guidelines/cholesterol/atp3xsum.pdf Native Heart Disease and Stroke Fact Sheet. Retrieved online August 18, 2009 at http:// 30. United States Department of Health and Human Services, National Institute of www.cdc.gov/DHDSP/library/fs_aian.htm Health, National Heart, Lung and Blood Institute. (2006). Your Guide to Lowering ŠŠCenters for Disease Control and Prevention. (2005). Diabetes Projects. Retrieved online your Blood Pressure with DASH. Retrieved online August 20, 2009 at http://www. August 21, 2009 at http://www.cdc.gov/diabetes/projects/cda2.htm nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf 1. Centers for Disease Control and Prevention (2009). Division for Heart Disease and 31. World Health Organization. (2009). Cardiovascular disease. Retrieved online August Stroke Prevention. Retrieved online Aug 7, 2009 at http://www.cdc.gov/dhdsp/library/ 16, 2009 at http://www.who.int/cardiovascular_diseases/en/ fs_state_hbp.htm 32. World Health Organization. (2009). Cardiovascular Disease : Prevention and 2. Centers for Disease Control and Prevention. (2006). Division for Heart Disease and Control. Retrieved online August 18, 2009 at http://www.who.int/dietphysicalactivity/ Stroke Prevention. Cholesterol Fact Sheets. Retrieved online August 18, 2009 at http:// publications/facts/cvd/en/ www.cdc.gov/DHDSP/library/fs_cholesterol.htm 33. World Health Organization. (2009). Obesity and Overweight. Retrieved online 3. Centers for Disease Control and Prevention. (2009).Division for Heart Disease and August 18, 2009 at http://www.who.int/dietphysicalactivity/publications/facts/obesity/ Stroke Prevention. Sodium. Retrieved online August 18, 2009 at http://www.cdc.gov/ en/ dhdsp/library/sodium.htm 34. National Heart Lung and Blood Institute What is high blood pressure? Retrieved 4. Centers for Disease Control and Prevention. (2009). Heart Disease Fact Sheet. online April 22, 2010 at http://www.nhlbi.nih.gov/health/dci/Diseases/Hbp/HBP_ Retrieved online August 18, 2009 at http://www.cdc.gov/DHDSP/library/fs_heart_ WhatIs.html. disease.htm 35. National Heart Lung and Blood Institute What is heart failure? Retrieved online 5. Centers for Disease Control and Prevention (2009). Heart Disease is the Number One April 22, 2010 at http://www.nhlbi.nih.gov/health/dci/Diseases/Hbp/HBP_WhatIs.html. Cause of Death. Retrieved online August 9, 2009 at http://www.cdc.gov/features/ 36. National Heart Lung and Blood Institute What is angina? Retrieved online April 22, heartmonth/ 2010 at http://www.nhlbi.nih.gov/health/dci/Diseases/Angina/Angina_WhatIs. 6. Centers for Disease Control and Prevention. (2006). Women and Heart Disease Fact 37. National Heart Lung and Blood Institute What is a heart attack? Retrieved online Sheet. Retrieved online August 18, 2009 at http://www.cdc.gov/DHDSP/library/ April 22, 2010 at http://www.nhlbi.nih.gov/health/dci/Diseases/HeartAttack/ fs_women_heart.htm HeartAttack_WhatIs.html 7. Chilton, R. (2004). Pathophysiology of Coronary Artery Disease: A Brief Review. 38. National Heart Lung and Blood Institute What is cholesterol? Retrieved online April Journal of the American Osteopathic Association 104: 55-58. Retrieved online August 22, 2010 at http://www.nhlbi.nih.gov/health/dci/Diseases/Hbc/HBC_WhatIs.html 22, 2009 at http://www.jaoa.org/cgi/reprint/104/9_suppl/5S 39. National Institute of Neurological Disorders and Stroke. NINDS Stroke Information. 8. Deglin, J. & Vallerand, A. (2009). Davis’s Drug Guide for Nurses. (11th ed). FA Davis: Retrieved online April 23, 2010 at http://www.ninds.nih.gov/disorders/stroke/stroke. Philadelphia. htm? 9. Dunphy,L.,Winland-Brown,J.,Porter,B.&Thomas,D.(2007).Primary Care: Art&Science 40. National Institute of Neurological Disorders and Stroke. NINDS Stroke Information. of Advanced Practice.(2nd ed)FA. Davis Retrieved online April 23, 2010 at http://www.ninds.nih.gov/disorders/cerebral_ 10. Frederick et al. (2008). /AHA 2008 Statement on Performance Measurement arteriosclerosis/cerebral_arteriosclerosis.htm and Reperfusion Therapy: Work Group to Address the Challenges of Performance 41. Centers for Disease Control. Paul Coverdell National Acute Stroke Registry http:// Measurement and Therapy: A Report of the ACC/AHA Task Force on www.cdc.gov/DHDSP/stroke_registry.htm Performance Measures. Circulation/Journal of the American Heart Association. 42. National Institute of Neurological Disorders and Stroke (NINDS). CADASIL Retrieved online August 5, 2009 at http://circ.ahajournals.org/cgi/reprint/ Information Page http://www.ninds.nih.gov/disorders/cadasil/CADASIL.htm CIRCULATIONAHA.108.191100 43. National Institute of Neurological Disorders and Stroke. Post-Stroke Rehabilitation 11. Gomella, L. (2004). Clinician’s Pocket Reference. (10th ed). McGraw-Hill: New Fact Sheet http://www.ninds.nih.gov/disorders/stroke/poststrokerehab.htm?css=print York. 44. National Inst. of Neurological Disorders & Stroke/Hope Through Research http:// 12. Gonzales, J., & Kutner, J. (2008). Current Practice Guidelines in Primary Care. www.ninds.nih.gov/disorders/stroke/detail_stroke.htm McGraw-Hill: New York. 45. National Institutes of Health. Acute Stroke Scale http://stroke.nih.gov/documents/ 13. Guirguis-Blake, J., Lin, K., & Barton, M. (2007). Editorials Is there Benefit to NIH_Stroke_Scale.pdf Coronary Calcium Screening. American Family [14]Physician. Retrieved online 46. American Heart Association: Comprehensive Overview of Nursing and August 21, 2009 at http://www.aafp.org/afp/20070415/editorials.html Interdisciplinary Care of the Acute Ischemic Stroke Patient http://stroke.ahajournals. 14. Huether, S. & McCance, K. (2008). Understanding Pathophysiology. (4th ed). org/cgi/reprint/STROKEAHA.109.192362 Mosby: St Louis 47. National Institutes of Health, National Institute of Neurological Disorders and Stroke 15. Ignatavicus, D. & Workman, M. (2006). Medical-surgical nursing: Critical thinking report. Stroke: Challenges, Progress, and Promise. February 2009 for collaborative care (5th ed). Elsevier Saunders: St. Louis. Page 56 Elite NOTES FAMILIAR CHRONIC CASES: CARDIOVASCULAR DISEASES AND STROKE Self-Evaluation Exercises Choose True or False for questions 1 through 10 and check your answers at the bottom of the page.

You do not need to submit this self-evaluation exercise with your participant sheet

1. Cardiovascular disease is the leading cause of death worldwide and has been the leading cause of death since 1900 in the United States. True False

2. Cardiovascular diseases are mainly caused by a buildup of plaque (atherosclerosis) inside the coronary arteries. True False

3. Premature (extra) heart beats are dangerous and require immediate treatment. True False

4. For persons older than 50, a high systolic blood pressure is much less of an important cardiovascular disease factor than diastolic blood pressure. True False

5. The best way to prevent cardiovascular disease is to exercise, don’t smoke and eat a healthy diet. True False

6. Computed tomography (CT or CAT scan) is of little use in diagnosing strokes. True False

7. The thrombolytic drug tPA can be used for all strokes if administered quickly enough. True False

8. Of all the risk factors that contribute to stroke, the most powerful is hypertension. True False

9. Acute ischemic stroke comprises about 80 percent of cerebrovascular accidents. True False

10. Early mobilization of a patient after a

stroke is discouraged.

True False 10.F 9.T 8.T Answers: 7.F 6.F 5.T 4.F 3.F 2.T 1.T

Elite Page 57 CHAPTER 3 and diabetes mellitus. In fact, nearly 80 percent you are speaking clearly and distinctly and in GERIATRIC ASSESSMENT of older adults have one or more chronic health a normal tone of voice? Does the patient wear problems.5 Although older adults make up the hearing aids? (10 CONTACT HOURS) majority of those who use health care services, Is the patient alone or is he accompanied by a Learning objectives most are able to live independently in the !! Discuss demographics related to the geriatric family member or friend? Observe the interaction community. This means, however, that nurses between the patient and whoever accompanies population. must be quite knowledgeable in the delivery of ! him. Does the patient seem comfortable with ! Perform a “first glance” assessment. geriatric services in both inpatient and outpatient !! Review the importance of providing this companion? Do they interact appropriately? settings, including such services as preventive Does the patient give any indication that he is culturally appropriate care. care, risk identification, patient education and ! intimidated by his companion? ! Assess the nutritional status of the geriatric promotion of maximum health and wellness. patient. What, briefly, is the patient’s health history? For !! Offer the geriatric patient practical The health care demands of a dramatically example, is there a history of heart attack, stroke, suggestions for maintaining a healthy diet. aging population require a workforce of nurses diabetes, other conditions? What medications is !! Describe the physiological responses of the skilled in geriatrics. As a result, there has been a the patient taking? elderly adult’s body to medications. significant increase in the amount and depth of !! Explain how to facilitate safe management of gerontological nursing content in baccalaureate What is the patient’s cultural and ethnic 3 medication regimens in the older adult. schools of nursing during the past 15 years. background? Is English his first language? If !! Initiate sexual assessment of the geriatric There is a corresponding need for continuing not, how well is the patient able to communicate patient. education on gerontological nursing for licensed in English? Will an interpreter need to be !! Assess the sleep patterns of the older adult. professionals and nursing assistants. Nurses present during the assessment to facilitate !! Identify strategies for pain assessment in the play a critical role in helping older adults to communication? older adult. effectively manage health problems, create and Remember that you need to adapt your !! Identify pain reduction measures for the older maintain safe and healthy living environments, communication to the specific needs of the 6 adult. and live lives of dignity and quality. One of the geriatric patient. Never assume that because !! Assess mental health in the elderly adult. most important ways nurses can do this is to a patient is elderly that he will be unable or !! Recognize signs and symptoms of elder perform a thorough assessment of their geriatric unwilling to participate actively in his health care abuse. patients. Such assessments require that nurses be regimen. Communicate directly with the patient !! Describe changes in vision, hearing and astute observers and excellent communicators. whenever possible. Don’t bypass him or belittle sensation that affect the aging adult. A good assessment begins with the nurse’s first him by talking to family or friends instead. Make !! Describe normal age-related changes in the glimpse of the patient. sure that, if needed, he has his glasses on and integumentary system. Assessment at first glance hearing aids in place. And always let him know ! 1 ! Identify common health problems related to Assessment begins with your first glimpse of exactly what you are doing during assessment. the integumentary system in the older adult. the patient. So many things can be observed in Ask patients how they would like to be !! Assess the aging adult for potential problems these first few moments. Start with the patient’s addressed. Ask if you may call them by their first related to cardiovascular functioning. appearance. How is the patient dressed? Is the names or if they would prefer to be addressed !! Identify lung disorders commonly found in clothing appropriate for the time of year and the as Mr., Mrs., Ms. Never, ever “talk down” to an older patients. weather? Are clothes neat and clean? Do they fit elderly patient by calling him or her “sweetie,” !! Identify important aspects of assessment of properly? Is the patient clean? Do you smell any “dear,” or other such names. They are not infants the endocrine system. unusual odors such as urine, which may indicate or children and should be treated with respect. !! Explain the ways age influences hematologic incontinence problems, or sweat, which may Introduce yourself by giving your full name and function. indicate lack of hygiene? Are the patient’s hands your title/role. For example, “My name is Andrea !! Recognize common health problems of the and fingernails clean? Is there any evidence of Burns. I am a registered nurse, and I will be nervous system in the older adult. unusual bruising or injury such as lacerations, ! taking care of you today.” ! Review age-related issues of the scars or burn marks? genitourinary system. The “first glance” of the patient can provide !! Assess the musculoskeletal system of the At first glance, what is the patient’s mobility a great deal of information about the patient’s geriatric patient. status? Is he ambulating independently or does physical, mental and emotional state. Use this !! Recognize age-related immune system he require assistance? Does the patient use any first glance as a foundation for the detailed deficiencies related to the aging process. assistive devices such as a cane or a walker? assessment of the geriatric patient. Observe the quality of his gait. Is balance Introduction maintained without difficulty? Are movements of Cultural considerations The needs of persons over the age of 65 will all extremities without tremors? Cultural considerations must be incorporated into continue to place significant demands on the geriatric physical assessment. Failure to provide health care system for the foreseeable future. How does the patient respond to the nurse’s culturally appropriate and competent care can In 2009, it was estimated that nearly 13 percent initial greeting? Is the response appropriate? lead to lack of patient compliance, frustration and of the population of the United States was over Does the patient speak clearly and distinctly? even hostility. Patients need and expect that their the age of 65.10 The number of adults living into Are his facial features symmetrical? If not, cultural perspectives will be respected. late adulthood is increasing dramatically. It is what abnormalities are present? (For example, The shift in minority demographics in the United predicted that by 2050, the number of people is one side of the face drooping or is one eyelid States has changed significantly in the past 10 over the age of 60 in developed countries will drooping?) Is the patient oriented to person, years. According to the United States Census reach 416 million. According to the World Health place and time? Does he maintain eye contact (if Bureau, the 2000 census indicated that the white, Organization, the fastest-growing segment of this culturally appropriate)? Is he able to respond to non-Hispanic majority was 69.1 percent.9 In population is persons 80 years of age and older.6 simple questions such as “How are you feeling today?” 2008, this percentage had decreased to 65.6 Older adults often have one or more chronic percent.10 illnesses or conditions, such as urinary Does the patient wear glasses? Does he seem able incontinence, dementia, cardiovascular disease to see his surroundings without difficulty? Can In May 2007, Census Bureau data suggested that the patient hear what you are saying, assuming one in three U. S. residents is a minority. In fact,

Page 58 Elite it is predicted that by 2020, people of color will health care plans because they often view health Inspection be the majority population.9 care providers as authority figures.13 Inspect the patient’s lips, teeth, tongue, gums, soft Cultural sensitivity encompasses many issues. It is important to encourage questions and and hard palate, buccal mucosa and the back of Culture is complex and is made up of thoughts, facilitate active communication between older the throat. Look for any signs of cracks, bleeding, values, beliefs and traditions of racial, ethnic, adults and health care professionals. When lesions, ulcers, swelling, induration or broken religious or social groups.9 Culture influences possible, a reliable family member or friend or decayed teeth. If the patient wears dentures, moral beliefs, traditions, communication, gender should accompany the older adult to facilitate observe how they fit, whether they are clean, and familial roles, expressions of emotion, communication when needed. and whether there is any evidence of breakage. family interactions, diet, dress and beliefs Look for signs of leukoplakia, which is a white Nutritional assessment about health and wellness. The large number of or gray patch that may develop on the tongue, on Nutritional assessment is much more than an different cultures that exist in the U.S. make it the floor of the mouth or on the buccal mucosa. evaluation of the intake of nutrients and the impossible for all health care providers to have Leukoplakia is most commonly found in elderly body’s ability to effectively use nutrients. It starts an intimate knowledge of all of them. Here patients and is due to irritation from teeth or with the mouth and oral cavity and includes are some suggestions to encompass cultural dentures that rub against the inside of the cheeks the patient’s ability to taste and smell, the body appropriateness into the assessment process: or gums or chronic irritation from use of tobacco composition of the older adult, alcohol use,  Identify the various cultural populations for products. Leukoplakia is usually painless and is access to food and socioeconomic factors that 12 which you are most likely to provide health generally biopsied to rule out oral cancers. influence nutritional status. care services. When inspecting the mouth and oral cavity,  Familiarize yourself with appropriate Assessment of the mouth and oral cavity remain alert to signs and symptoms of oral cultural responses for these populations. Important questions to ask cancer. These include:9  For example, in Middle Eastern cultures, The ability to eat depends, in part, on a person’s  A lump or thickening of the lip or in the sexual segregation is often very important, teeth. Observe your patient’s teeth. Are they his patient’s mouth.  and same-sex caregivers should be assigned own or does he wear dentures? Are dentures,  A sore in the mouth or on the lip that does whenever possible. including partial dentures, clean, and do they fit not heal.    Investigate the availability of interpreters to well? Are his teeth clean? Is there any evidence  White or red patches on the gums, tongue or facilitate communication if the patient has of chipped, broken or missing teeth and/or buccal mucosa.  difficulty communicating in English. dentures? Additional important information that  Patient complains that there is always a   Develop written patient education materials should be obtained about a patient’s dental habits feeling of something “stuck” in the throat.  in the most common languages (in addition includes:  Swelling of the jaw or mouth that changes the to English) that are spoken by your patient  How does he take care of his teeth/ way dentures fit.  populations. dentures? Is he physically and mentally  Pain in the ear or when chewing or   Remember to be sensitive to dietary practices capable of taking care of his teeth and swallowing.  that are important to cultural and religious mouth? Teeth should be brushed and flossed  Changes in the patient’s voice. viewpoints. at least twice a day. A soft-bristled toothbrush Assessment Tip: When inspecting the mouth and  Remember that expression of emotions may should be used to properly clean teeth and to oral cavity, make sure that extra light is available vary from culture. Some cultures are vocal 9 avoid damaging gums. to allow good visualization of the tongue, buccal and overt about expressing fear or pain, while   How often does he visit a dentist? The mucosa, lips, teeth and gums. others are stoic. All expressions should be geriatric patient should see a dentist at least respected. annually, with the ideal time frame of every It is important to be aware of risk factors for the   Identify cultural and religious viewpoints six months. These visits should also include development of oral problems. Diseases or other concerning death and dying, life-prolonging a screening for oral cancers such as cancer of factors that cause oral problems will affect the interventions (such as feeding tubes), the tongue at each visit. patient’s ability to consume food and maintain a treatment of the body after death and funeral  Does the patient use alcohol and/or state of proper nutrition. Issues and factors that 9 4,9 practices. tobacco products? Explain to the patient that increase the risk for oral problems include:    Consult appropriate resources to gather avoiding these products decreases the risk for  Diseases such as cancer, HIV and AIDS, information about cultural perspectives. One oral or lung cancers.9 diabetes mellitus, stroke, dementia, renal such resource is www.ggalanti.com. This site  Does the patient have bad breath? What failure and viruses such as herpes simplex.  offers respectful cultural profiles of various does it smell like? Bad breath (halitosis) may  Deficiencies of vitamins including B6, B12, populations, resources, articles and related indicate poor oral hygiene or certain disease folic acid, C, K, A, and niacin.  links. When using Web sites, make sure that processes. For example, a fruity smelling  Changes that accompany aging, such as they treat all cultures with respect. Be wary breath suggests hyperglycemia. thinning teeth enamel, lines and cracks in of and avoid sources that criticize or make  Does the patient report any problems teeth, thinner and smoother mucosa that loses jokes about cultures or religious practices. with the oral cavity, such as painful teeth or elasticity, and a decrease production of saliva. The age of a person or the generation he was born gums, bleeding gums, dry mouth, changes Assessment Tip: After inspecting the mouth and into also influences the way health care services in the sense of taste, or problems chewing or oral cavity, palpate the lymph nodes in the neck. are perceived. For example, the “traditional” swallowing? Lymph nodes should be small, smooth, round  generation, also known as the “veterans,” are  Does the patient complain of having a and painless. Tenderness may indicate infection. those adults born between 1922 and 1946 and dry mouth? This is the most common oral Enlarged, fixed, hard lymph nodes require represent the oldest members who access health problem in the elderly adult and can be due further evaluation as these signs may indicate a care in this country. As a rule, these people are to mouth breathing, dehydration, oxygen serious problem, such as malignancy. At the same more formal in their approach to life and often therapy, various diseases, side effects of time, observe the neck for any lesions, moles or preferred to be addressed as Mr., Mrs. or other medication, and head and neck radiation bulging areas. formal titles. They generally have a strong work treatments. Another important risk factor for oral problems ethic and a rigid view of hierarchy and respect Assessment Tip: A frequent complication of dry (and corresponding nutritional problems) is lack for authority. This may make it difficult for them mouth is the fungal infection oral candidiasis, of money. Elderly adults living on a fixed and/ to ask questions or participate actively in their more commonly known as thrush. or inadequate income may not have the money

Elite Page 59 to schedule regular dental visits, or purchase hyposmia can reduce appetite to the point that the of fluid and fiber intake, lack of exercise or dentures and oral hygiene products. Persons with older adult becomes malnourished.9 chronic illnesses, constipation can, and often financial problems should be referred to local does, occur.4,9 There are a number of factors that contribute to dental practices that offer services at reduced  Aging diminishes the thirst drive. Because hyposmia. These include age-related changes, rates. They should also be helped to identify of this, the fluid intake of older adults is such as reduction in the number of sensory cells, stores where dental supplies may be purchased at often inadequate. Compounded by the aging injury to the olfactory mucosa and alterations to minimal costs (such as dollar stores). kidney’s inability to efficiently concentrate the structure of the upper airway hypothalamus urine, this lack of fluid intake often leads Transportation may also be an issue. Find and olfactory tract.9 Other factors include nasal to dehydration in geriatric patients. If older out whether patients have access to public congestion, smoking and drug use.4 patients experience vomiting and/or diarrhea, transportation or whether they have family Sometimes nurses and physicians simply assume excessive sweating, or excessive urination members or friends who are able to help them that a decreased sense of smell is due to a due to diuretic therapy, they must be carefully get to dental visits and purchase oral hygiene person’s age. But it could also be the result of monitored for signs and symptoms of supplies. Remember that assessment of the oral damage to the olfactory nerve (cranial nerve I). dehydration. Such symptoms include dry cavity and mouth involves much more than It is important to assess the function of this nerve skin, poor skin turgor, dark-colored urine, physical assessment techniques. Finances, mental by first checking to be sure that both nostrils are headache, dizziness, dry mucous membranes, acuity, transportation and family/friend assistance patent and unobstructed. Then ask the patient increased heart rate and respirations, and play important parts in good dental hygiene. to close his eyes. Occlude one nostril and place confusion.9 Taste assessment a familiar, strong-smelling substance (such as  Older adults often experience vision After about the age of 70, adults begin to coffee, peppermint or orange peel) under his nose changes that compromise the sense of sight. experience a reduced sense of taste, which is and ask him to identify it. Do the same thing with These include cataracts, macular degeneration called hypogeusia. The ability to perceive the the other nostril. The patient should be able to and generalized deterioration of vision. Such tastes of salt and sweet are most affected. Taste identify each smell correctly. If olfactory nerve changes can make it difficult, and unpleasant, buds are located on the tongue, epiglottis, larynx damage is suggested, the patient will need further for them to shop, prepare food and, at times, and the first third of the esophagus.9 evaluation.4 eat. Reduced vision may make it necessary for someone to transport elderly people to In addition to the normal changes of aging, many Assessment tip: Be sure that you use scents with the grocery store, help them to purchase food factors contribute to a diminished sense of taste. which the patient is familiar. He can’t identify a and even prepare it. The nurse may need to These include poor dental hygiene, broken teeth scent if he has never smelled it before. put the older adult in touch with services such or dentures, and dry mouth. There are also quite a Body composition changes in the older as Meals on Wheels and community groups few medications that adversely affect taste. These adult that assist elders in these activities. Many include:9,14 There are a number of changes in body public transportation companies offer elder  Antibiotics. composition in the older adult that can have services at reduced rates. Older patients need  Antidepressants. an impact on nutrition and overall health. One assistance to access community services that  Antihypertensives. such change is the loss of lean muscle mass that will help them with transportation, shopping  Anti-cancer drugs. occurs with aging. The loss is due to a reduction and meal preparation/delivery.  Antihistamines. in physical activity, hormone production and  Decongestants. Assessment tip: Older adults are often afraid of alterations in nutrition. If caloric intake continues  Muscle relaxants. being incontinent of urine. Because of this fear, at the rate consumed at a younger adult, the older  Cholesterol-lowering drugs. they may limit their fluid intake, which further adult will gain weight in the form of fat, not  Drugs used to treat Parkinson’s disease. increases the risk for dehydration. muscle.9 Assessment Tip: Not every drug in the preceding Socioeconomic impact on nutrition Loss of muscle mass is associated with a classifications necessarily alters taste. Be sure to It is important that socioeconomic factors be reduction in strength and endurance and an determine which medications patients are taking included as part of the nutritional assessment of increased risk for falls. Research indicates that and check to see whether these drugs have an the geriatric patient. These have been mentioned even a 10 percent loss of muscle mass is linked to impact on the sense of taste. briefly in the preceding sections, but deserve increased mortality in older adults.9 Sometimes the sense of taste can be affected by additional emphasis. the environment in which a patient eats. Elderly Other body changes that directly or indirectly Nutritional intake is closely linked to influence body composition include:4,9 adults who live alone may not be as interested in  socialization. Where we eat, how we eat, and preparing meals or in eating them compared to  Loss of bone mineral density, which with whom we eat can have as much of an impact the days when they prepared meals for a family increases the risk for osteoporosis in both as what we eat. When assessing the social aspects and ate food with others. Encourage adults to eat men and women. Loss of bone density of nutrition, consider the following issues: in a comfortable, relaxed surrounding as much increases the risk of fractures as well as the  With whom does the older adult eat? If risk of falls. as possible and to take the time to enjoy a meal.  he eats with others, is it in a home setting or Help patients to select foods that are easy to  Decrease in both the size and number of long-term care setting such as assisted living? prepare, nutritious, and that they like. gastric glands and mucous membranes, If he eats with others, is the atmosphere and reduction in gastric acid production, can Assessing the sense of smell congenial? For example, if the older adult is lead to (irritation of the living with an adult child, is he made to feel Problems with the sense of smell (olfactory) stomach due to atrophy). The decrease in welcome and a part of the family’s social are quite common (even more common than gastric acid production results in a decrease interactions? If he eats in a long-term setting, problems with taste) in older adults. In fact, in the acidity of the stomach. Since Iron in what type of an environment are meals about half of adults over the age of 60 experience and vitamin B12 need an acid environment served? Is the environment conducive to alterations in their sense of smell.9 The medical for proper absorption, this lack of acidity enjoying a meal? term for reduced sense of smell is hyposmia.9 can inhibit the absorption of both of these  If the older adult lives at home, does A lack of sense of smell can be dangerous. The 9 substances. he have easy access to a grocery store? inability to smell smoke, gas or spoiled food can   Peristalsis in the intestines slows as the Does he drive or does he depend on others actually lead to illness or death. If severe enough, adult ages. If this is compounded by a lack to transport him? Is he aware of public

Page 60 Elite transportation options for transportation and hydration, reduce salt intake, and use fish, nuts Alcohol ingestion can have an impact on how to access them? If needed, is he aware of and liquid oils instead of saturated fats. Practical nutrition, especially for deficiencies of thiamin, options such as Meals on Wheels and other suggestions to remain active include going for riboflavin, foliate and vitamin B6 because similar community services? walks, working in a garden, taking an exercise alcohol can inhibit nutrient absorption, irritate  If the older adult does have access to a class at a community center or gym, and playing the stomach and affect metabolism.9 In cases of grocery store, is he physically capable of with pets.15 These suggestions may be helpful significant alcohol use, alcohol may actually be shopping and carrying bags of groceries when working with older patients and teaching ingested in place of or in preference to food, thus or does he need help? If he needs help, who them about nutritional requirements. Additional further compounding its negative effects. is available to help him? Does he have the examples (based on an 1,800-calorie diet) of In summary, nutritional assessment is critical to visual acuity to read and understand food good dietary habits include the following.15 Note identifying problems and correcting them in the product labels and prices? Does he have that these suggestions should be adapted to the older adult. The nurse must evaluate nutritional the mental acuity to make appropriate food unique needs and health status of each patient. status carefully, taking into consideration not only choices?  Eat 6 ounces of grains per day, such as the types and quantities of food being ingested, whole-grain cereals, whole grain breads, Another important aspect of nutritional but the social and economic factors that influence rice or pasta. Choose cereals fortified with assessment is the financial impact of food nutrition as well. vitamin B12. purchase:  Eat 2½ cups of vegetables, especially dark- Pharmacology assessment and the  Does the older adult have enough money green and orange vegetables, and dried beans to purchase healthy foods? If not, he may geriatric patient and peas. purchase whatever “fits” within his budget, Mrs. Burns is 80 years old. Her physician  Eat 1½ cups of fruit per day. even if such foods are not recommended prescribed Benicar, 20 mg daily, for  Drink 3 cups of milk or other calcium-rich for his state of health. For example, does he hypertension. During a routine checkup, her foods daily, such as low fat milk or yogurt or purchase microwave dinners that are high blood pressure was still significantly elevated. low fat cheeses. in salt because they are cheap and easy to When questioned, Mrs. Burns admitted  Eat 5 ounces of lean meat, beans and other prepare, even though he is on a limited salt that she only takes the Benicar four times a sources of protein, such as low-fat meats and diet? week instead of daily. She says she does this poultry, and include fish, eggs, beans and nuts  Does the elderly adult need help managing to save money and to “make the pills last as protein sources. Bake, broil or grill foods his money? He may have adequate financial longer.” rather than fry them. resources but is unable to live within his Mr. Lord is 70 years old, and has had budget due to uncertainty over prices or There are some vitamin requirements specific to epilepsy for many years and takes Dilantin decreasing mental acuity. Does he have the needs of older adults. These include: to control his condition. He recently had anyone to help him manage his money? What  Vitamin D is important to maintain bone a seizure, the first he has had in many family or community resources are available mineralization and to facilitate proper use of years. During a thorough evaluation, it was to assist him with money management? calcium in the body. Inadequate amounts of discovered that Mr. Lord recently began vitamin D have been linked to increased risk If there is not enough money to purchase food, to take ginseng, an herbal supplement, to for falls in the elderly. If adults have limited the older adult needs to be referred to agencies “increase my energy. My daughter takes it exposure to the sun (e.g. those who reside in that may be able to help or to make referrals. and says it really helps her. I know it can’t long-term care facilities without much time Possible sources are veterans associations, hurt me because it’s ‘natural’ and not really outside), they may be at increased risk for area agencies on aging, church groups and medicine,” he said. What neither Mr. Lord vitamin D deficiency. Good food sources government assistance agencies. nor his daughter realized is that ginseng and of vitamin D include liver, milk fortified Dilantin interact, and that ginseng reduces Assessment tip: Always include socioeconomic with vitamin D, fish such as salmon, and the effectiveness of Dilantin.14,16 evaluation as part of physical assessment. These milk and juices fortified with vitamin D. If areas influence every aspect of health. Also note vitamin D deficiency is not corrected by diet, The preceding scenarios illustrate two common that women are twice as likely as men to live in older adults may be prescribed vitamin D problems with medication adherence among poverty.9 supplements by a physician. the elderly. Financial concerns may cause an  older adult to take less of his medication than Nutritional requirements  Calcium intake is important to help maintain or slow loss of bone mineral density. Older prescribed in an attempt to, as Mrs. Burns Nutritional requirements for older adults correlate adults should have three servings of calcium- says, “make the pills last longer.” Sometimes it with the physical changes that accompany aging. rich foods every day.9,15 may be difficult to make trips to the pharmacy, There are generally decreased caloric needs due  Intake of the B vitamins is very important. especially if the elder’s physical or mental health to decreased physical activity. However, the need Vitamin B6 is necessary to the metabolism of makes driving impossible. Seeking and obtaining for vitamins and minerals does not decrease. In protein and fat, and vitamin B12 is required transportation may be a problem. fact, based on food intake, there may actually be for the process of cell division and central Another issue that is impacting medication a need for vitamin supplements. nervous system functioning. Older adults compliance with increasing frequency is that of The U.S. Department of Agriculture (USDA) should be monitored if taking vitamin B adding herbs or other supplements to medication Food Pyramid is a tool often used by health supplements. Excess of vitamin B6 can regimens without the knowledge or consent of care professionals and others to plan balanced result in toxic side effects leading to sensory health care providers. Many people believe that diets. Nutrition faculty in the Department of neuropathy. 9 non-prescription agents such as aspirin, herbal Family, Youth, and Community Sciences, IFAS, Assessment tip: Older adults should not simply supplements, vitamins and minerals are harmless University of Florida in Gainesville, Florida, add vitamins to their diet. Any additions of and can be taken without medical supervision. have adapted the USDA’s MyPyramid in a vitamins, minerals or other supplements They do not realize that these agents can interact handout titled “MyPyramid for Older Adults.”15 should be under the supervision of health care with prescription drugs and cause adverse effects. This tool is based on an 1,800-calorie diet professionals. Fat-soluble vitamins, such as D, E, They also fail to realize that these agents may be and should be adapted to the individual needs K and A are stored in the body and not excreted harmful by themselves as well. of each elderly patient. It encourages older the way water-soluble vitamins are. Taking large When conducting a pharmacologic assessment adults to choose foods high in fiber to avoid amounts of fat-soluble vitamins could lead to of the older adult, start by determining what constipation, to drink plenty of fluids to maintain toxic levels and adverse effects.9 prescription medications they are taking. Elite Page 61 Reconcile the list of medications, making sure taking drugs that are metabolized by the liver Glandular tissue in the breasts decreases, and you have the most current information. Find or if taking drugs that have the potential to there is an increase in the amount of time it out how much the patient and, if appropriate, damage the liver. takes for arousal to occur.9 The vagina shortens, a family member knows about the patient’s  Renal functioning: Renal function also labia atrophy and the cervix may descend into medication regimen. Important questions to ask decreases with age, but this decrease varies the vagina, which causes discomfort. Orgasms include: considerably among older adults. Since the may become less intense and less gratifying.  What are the names of the medications you kidneys excrete most drugs, it is important to Additionally, post-menopausal women generally are taking? be aware of kidney functioning and remain return to pre-arousal state more quickly than  When do you take your medications? alert to possible build-up of potentially toxic younger women.11 Do you take your medications with food or levels of drugs.  In addition to normal age-related changes, something to drink? What kinds of food and  Gastric functioning: Aging causes cardiovascular disease, depression and diabetes drinks do you take with your medication? a decrease in gastric motility and  have been associated with sexual dysfunction  What kinds of side effects may occur when gastrointestinal absorption surface. These and/or a decrease in libido.11 Persons with these you take your medicine? If side effects take factors may cause a decrease in or delayed conditions should receive sexual counseling as place, what do you do about them? absorption of acidic drugs. necessary.  Do you have insurance that covers some  Vision changes: Age-related reduction in of the cost of your medicine? Do you visual acuity may make it difficult for older Nurses must also be aware of medications that ever have trouble affording the cost of your adults to read drug labels, thereby increasing may cause sexual dysfunction. These include medicine? the risk for taking the wrong medication. certain types of antihypertensives, selective serotonin reuptake inhibitors (SSRIs) used to You also need to find out about other medicines Assessment tip: Be sure to include socioeconomic treat depression, and beta blockers.11 When your patient is taking. You need to ask if he takes factors when assessing pharmacology factors in performing a pharmacologic as well as a sexual any medicine that the doctor has not prescribed, elderly adults. assessment, be sure to explain the potential for such as aspirin, allergy tablets, cold medication Sexual Assessment these types of side effects. and so on. Explain that non-prescription drugs Mr. Grimes, a 78-year-old retired and prescription drugs can interact and cause Sexual assessment requires that a nurse ask construction supervisor, arrives at his harmful side effects. Emphasize that he should patients questions that are highly personal and physician’s office for a routine checkup. His not take other medicines without his physician’s intimate in nature. If a nurse is uncomfortable blood pressure is unusually high, despite the approval. with such an assessment, she/he will most likely fact that he was prescribed anti-hypertensives transmit this discomfort to the patient. The more It is very important to ask if the patient is taking several months ago. When questioned, confident and comfortable the nurse is with any herbal preparations, vitamins, minerals Mr. Grimes says he “only takes my blood sexual assessment, the more at ease will be the or dietary supplements (including weight-loss pressure pills a couple times a week.” When patient.11 The nurse must maintain an objective, products or nutritional supplements). These asked why, he explains, “Since I’ve been non-judgmental attitude and conduct the agents can cause harmful interactions with each taking those things, I can’t satisfy my wife. assessment in a quiet, private area. other, alone, and with prescription and non- When I don’t take them too often, things are One framework that may be used when prescription drugs. better.” Medication side effects can include conducting a sexual assessment is the PLISSIT sexual dysfunction. Such side effects must Assessment tip: Provide simply written model.11 (To view an online video of a nurse be discussed with patients at the time of instructions about what medications the patient is demonstrating the use of the PLISSIT model visit prescription. taking, their actions, when and how to take them, http://links.lww.com/A277). common side effects and what to do if side effects Sexuality and sexual functioning are life-long The first step in the model is P: To seek occur. If necessary, a family member or friend issues for all persons. Health care professionals permission to begin the sexual assessment. should be involved to help the patient adhere to sometimes forget or disbelieve that these issues Asking for permission helps to preserve the his medication regimen. are important to geriatric patients. Research patient’s dignity and to allow him some control shows that interest in sex and sexuality continues After determining what medications (including over the assessment process. You might begin by throughout the life span.11 Therefore, it is non-prescription, vitamins, herbs, minerals and so asking the patient, “Mr. Grimes, would it be all important that sexual assessment be part of the on) the patient takes, if he knows how and why right if I asked you some questions about your physical assessment of older adults. to take them and the possibility of side effects, sexual health?”11 After permission is obtained, consider the physiological alterations in the body First, be aware of changes in the reproductive you could proceed by asking, ”What kinds of of the older adult that impact on medication tract that occur with aging. In men, sperm changes have you noticed in your sexual health effectiveness. production and testosterone levels decrease. The since you began taking your heart medication?” time needed to become aroused and to ejaculate The body’s ability to metabolize drugs and use Make the questions pertinent to your patient’s increases, and the refractory period lengthens. them most effectively decreases with age. Here situation. If appropriate, you might ask the patient The firmness and force of ejaculation decreases.9 are some aging body changes that influence if he would like his sexual partner to take part in Oral medications for erectile dysfunction, such the effectiveness of medication in the geriatric the discussion. Respect his response, whether it is as sildenafil (Viagra) and tadalafil (Cialis) are patient.9,14 “yes” or “no.” often able to compensate for normal age-related  Body water content: As the body ages, there The next step is to provide limited information changes in the sexual functioning in men.11 is as much as a 15 percent decrease in water (LI).11 For example, if specific medications content and an increase in body fat. The extra In women, as estrogen levels decrease, the are linked to the patient’s sexual difficulties, fat means that the effects of fat-soluble drugs thickness, elasticity and lubrication of vaginal information about medication side effects could may be increased, and the reduction in water tissues decreases.9 These changes may cause be provided. Other types of limited information content means that water-soluble drugs exist intercourse to become painful. Women may avoid might include discussing normal age-related in more concentrated amounts. sexual intercourse due to such pain. The use of changes in the reproductive system or the effects  Liver functioning: Hepatic (liver) blood vaginal lubricants can help alleviate dryness and of certain diseases on sexual functioning. flow, liver mass and liver metabolic activity reduce discomfort.11 Next, offer specific suggestions (SS).11 This may decrease with age. It is important that means that you will offer specific suggestions liver functioning be assessed if the patient is

Page 62 Elite tailored to your patient’s situation. For example, heart rate and body temperature decrease. problems. For example, a patient may tell if sexual dysfunction is related to painful The body prepares to enter deep sleep. you that some nights he wakes up gasping intercourse due to vaginal dryness, you could  Stages 3 and 4: These stages are known as for air or coughing, indicating a possible recommend the use of vaginal lubricants. If slow-wave or delta sleep. Sleep is deep, with cardiovascular or nervous system problem. problems are related to medication, referral to Stage 4 being more intense than Stage 3.  “How many naps do you take during the the patient’s physician or nurse practitioner for day?” “How long do you nap?” Frequent Stages one through four comprise the period of possible medication alterations may be indicated. naps or lengthy naps can disrupt a person’s non-REM sleep and last from 90 to 120 minutes. nighttime sleep patterns. The final step in the model is intensive therapy Each stage lasts from five to 15 minutes.9,17 (IT).11 Intensive therapy is indicated when The preceding questions are a good baseline REM sleep is characterized by rapid respiration, sexual dysfunction requires more than nursing for questioning older patients about their sleep. increased heart rate and blood pressure, interventions. For example, if the patient is Become familiar with some of the more common increased brain activity, rapid eye movements exhibiting inappropriate sexual behaviors, (e.g. sleep problems and how they impact the elderly and temporary paralysis of limbs. REM sleep is exposing oneself in public) or has suffered from patient’s ability to obtain a good night’s sleep. It also referred to as dream sleep because dreaming sexual abuse, intensive therapy is indicated. is estimated that about 5 million older adults in takes place during this stage. It is believed the United States have a serious sleep disorder.9 In summary, sexual assessment is important that REM sleep is necessary for psychological Some of the more common problems include the for persons of all ages. Sexuality and sexual restoration, learning, memory and concentration following issues: functioning are important throughout the life during the day. This stage occurs in cycles about  Anxiety and depression. These issues can span. These are highly sensitive subjects and every 90 to 120 minutes following the first interfere with a person’s ability to fall asleep must be handled objectively, with tact and four stages.9,17 The percentage of time spent in and/or stay asleep. discretion. A barrier to sexual assessment may REM sleep is greatest during infancy and early  Substance abuse. Abuse of alcohol, be the discomfort of the nurse as well as the childhood and decreases during adolescence and prescription drugs and/or illegal drugs can patient. Use of an assessment model, such as the young adulthood with greater increases occurring profoundly disrupt a person’s sleep patterns. PLISSIT model, may help to initiate and direct in old age. 17  Excessive intake of caffeine. Excessive the assessment and increase the comfort of nurse, Sleep assessment in the older adult intake of caffeine, especially in the evening, patient and patient’s partner. A common mistaken belief is that the need for can prevent a person from falling asleep or Resources specific to the geriatric population sleep decreases with age. In fact, the elderly staying asleep. that may be helpful to nurses working with adult needs about the same amount of sleep as  Pain. Older adults may deal with chronic older adults include the following Web sites. he did as a young person and in middle age.9 The pain issues. Pain may be due to arthritis, Information is offered pertaining to sexuality as majority of older adults need between six and 10 cancer, nervous system disorders, and so well as many other issues that impact geriatric hours of sleep each night. Research shows that on. Elderly patients who are in physical nursing practice. less than four or more than eight hours of sleep discomfort take longer to fall asleep, stay  The website for the Hartford Institute for is associated with mortality rates that are higher asleep or find a comfortable sleeping Geriatric Nursing provides information about than those of persons sleeping eight hours.9 position. best practices and geriatric assessment tools  Cardiovascular disease and respiratory When asking the older adult about his sleep and models. The site may be accessed at: disease. These types of diseases may cause patterns, try to avoid “yes” and “no” questions, www.ConsultGeriRN.org. orthopnea and shortness of breath. Asking because these usually do not elicit enough helpful  Lippincott’s Nursing Center’s older adults the patient “How many pillows do you sleep information. For example, if you ask, “Do you section provides articles, tools and links to on at night” gives you an indication that he have trouble sleeping?” many older adults will sites that specialize in information about needs to sit up or be propped up to sleep simply say “no.” Here are some suggestions for geriatric care. This site may be accessed at without having difficulty breathing. phrasing questions when assessing sleep patterns. www.nursingcenter.com/AJNolderadults.  Dementia. Older persons with dementia  “What time do you usually go to bed?”  The American Nephrology Nurses’ experience more sleep problems than other “What time do you usually get up?” The Association (ANNA) has created a new older persons. Sleep is often fragmented, and answers to these questions will give you an resource, Spotlight on Older Adults, which nighttime wandering may occur.9 idea whether the patient goes to bed and gets contains links, articles, tools and information  Urinary issues. Frequency, nocturia and up at about the same time each day. A regular about continuing education events for nurses urgency commonly occur in older adults and bedtime and awakening time is associated specializing in geriatric nursing care. The site increase with age. Older men may experience with better sleep patterns. is accessed at www.annanurse.org/aging. benign prostatic hypertrophy, which prevents  “How many times do you wake up during the bladder from emptying completely and Assessing sleep patterns the night?” “What causes you to wake often causes the sensation of constantly up?” This is better than asking the patient Sleep stages feeling the urge to void. These issues are whether he sleeps through the night. It A good night’s sleep is important for health compounded by the decreased bladder requires the older adult to think about his and well-being. There are five recurring stages capacity of the elderly.9 answer. He may assume it’s normal to wake of sleep: four non-REM (rapid eye movement)  Sleep apnea. Sleep apnea is an intermittent, up frequently during the night. If he does, this stages and the REM (rapid eye movement) temporary pause in breathing during sleep. .9,17 may indicate a health problem. stage This can occur many times throughout the  “How many times do you wake up to go The stages of sleep can be described as night and lasts about 10 seconds each time to the bathroom during the night?” The follows:9,17 it occurs. These interruptions in breathing answer to this question can indicate various  Stage 1: Characterized as light sleep or can lead to hypoxia. Research shows that problems, such as incontinence, enlarged drowsiness, this stage lasts for about five to older adults who suffer from these kinds prostate in men or anxiety. 10 minutes. If awakened, the person may feel of hypoxic episodes are more likely to  “What kinds of things help you to sleep as if he has not been asleep at all. experience sudden death, stroke, angina and at night?” What kinds of things prevent  Stage 2: This stage is a period of light sleep exacerbating hypertension.9 Patients and their you from sleeping at night?” The answers from which the person is easily aroused. sleeping partners should be questioned about to these questions may provide you with Brain waves slow, eye movements stop, and the occurrence of the signs and symptoms clues to specific physical or mental health

Elite Page 63 of sleep apnea, which include heavy, loud example, a back injury may initially cause acute cultures value stoicism when confronting snoring; choking, coughing or struggling to pain, but damage may be severe enough to cause pain while others are quite emotionally vocal breathe while sleeping; extreme sleepiness lingering effects. about expressing pain. Remember to remain during the day, headaches in the morning and objective and respectful of a patient’s cultural Chronic pain is “ongoing” pain that is treated trouble concentrating.9 and religious beliefs about pain and how it is but not self-limiting. It may be related to disease  Medications. A number of medications can dealt with. processes such as cancer, neurological disorders, interfere with sleep patterns. When providing degenerative diseases, arthritis, osteoporosis and Many patients may be able to participate in pharmacology patient education as well as vascular disease. Older adults (or any adult for completing pain assessment scales. A numeric assessing sleep and rest, be sure to familiarize that matter) who suffer from chronic pain need pain rating scale generally consists of a scale yourself with medications that may disturb a thorough pain treatment plan that not only of 0-10 with 0 indicating no pain and 10 a patient’s sleep. Some drugs commonly addresses pain relief but the social and emotional indicating the worst possible pain. The degree associated with sleep interference include consequences of living with such pain as well. of pain worsens as the numbers increase.9 This decongestants, antihistamines, beta-blockers type of scale requires that the patient be able and beta-agonists.9,14 Assessment tip: Persons living with chronic pain to understand your explanation of the scale, should also be assessed for depression. Chronic Assessment tip: Some antidepressants, such correlate his pain to a numeric value, and pain can limit mobility, social interaction, as Elavil and Sinequan, can have sedating communicate this correlation to you. interfere with performance of activities of daily effects and should be taken in the evening. But living and interfere with sleep and rest.9 A verbal descriptor scale is one that requires the antidepressants such as Zoloft and Paxil have patient to describe his pain from “no pain,” to stimulating effects and should be taken in the There are a number of pain assessment “mild,” “moderate,” “severe,” or “as bad as the morning.9 techniques in use. Some require the use of pain could be.”9 This requires that the patient be numeric pain rating scales while others rely Pain assessment able to understand the descriptive terms used and on pictures that illustrate various degrees of Pain assessment should be part of the assessment be able to correlate the terms with his pain, and pain. Important issues for the nurse to address of all geriatric patients. Older adults often describe his pain using the given terms without when conducting a pain assessment include the live with chronic illnesses and disorders that the benefit of visual cues. following. cause varying degrees of pain. They may also  Ask the patient to describe the pain, aching, A pictorial scale such as the Pain Scale experience more acute types of pain that follow or soreness he is experiencing. For example requires that the patient select a visual depiction trauma or surgery. is the pain sharp or dull? Is it constant or of pain. For example, the patient is asked to look Research shows that about 25 percent-50 percent intermittent? Is it burning or “squeezing?” at a number of different faces that range from a of older adults who live in the community Does it cause any lack of sensation? Does face with an expression of calm or contentment to suffer from some type of pain. That percentage it cause tingling, numbness, or “pins and faces that look increasingly uncomfortable. The increases to 45 percent-80 percent for older needles” feelings? Does the pain stay in one patient chooses the face with the expression that adults who live in long-term care facilities. spot or does it radiate? best “fits” his current pain experience.9 This scale Research also indicates that older adults are often  When does the pain occur? Is it worse at does not require the patient to express himself undertreated for both acute and chronic pain, and specific times during the day or at night? using specific descriptive terms or to understand some live with untreated pain every day of their If so, what is the patient doing or what is specific descriptive terms. lives.9 happening in his environment when the pain Assessment tip: A family member, friend or becomes worse? Why is pain undertreated? Some reasons reliable caretaker should be involved in the pain 2,9  What makes the pain better or less include: assessment if patients are unable or reluctant to  Some health care professionals may be uncomfortable?  communicate their pain experience. unaware of the prevalence of pain in the older  What makes the pain feel worse?  population or may think that some degree of  Are there any other symptoms that occur with But what about patients who are unable to pain is “normal” in the geriatric population. the pain, such as nausea or vomiting? understand verbal or visual communications,   Failure of older adults to report pain. They  Does the patient take any medications for such as the patient suffering from dementia? may believe that pain is a “normal” part of his pain? What are they and how often Researchers are working to develop valid and the aging process and that nothing can be does he take them? How well do these reliable pain assessment tools for use with done to alleviate it. Some older adults may medications work to control your pain? patients suffering from dementia. One such tool believe that taking pain medication is a Be sure to ask about ALL medications is the Pain Assessment in Advanced Dementia sign of weakness or are afraid of becoming including prescription, over-the-counter, (PAINAD) scale, which relies on direct 2 dependant on pain relief medications. herbal preparations, minerals, vitamins and observation of five behavioral indicators of pain.  It is difficult to assess pain in patients who other supplements. Remember that some An overview of the five behaviors used to assess have difficulty communicating, such as those patients don’t consider items such as herbal pain includes.2 persons suffering from various forms of preparations, minerals, vitamins and over-  Breathing (does not include mechanical dementia or following a disorder that affects the-counter drugs as “medicine.” Are the ventilation): Ranges from a score of 0 for communication, such as stroke. medications causing any side effects?  normal breathing, a score of 1 for occasional  Does the patient do anything specific to labored breathing or short periods of Assessment tip: Some older adults may not alleviate his pain (in addition to medication)? believe that they have pain, but may admit to hyperventilation, to a maximum score of 2 Some patients may drink alcohol or take for noisy, labored breathing and prolonged discomfort or other unpleasant sensations. When other drugs (including illegal drugs) to assessing for pain, do not only ask a patient, “Do periods of hyperventilation. relieve pain. Others may use remedies such  Negative vocalization: Ranges from a score you have any pain?” Also ask whether they have as warm milk to induce sleep, relaxation any discomfort, aching or soreness. of 0 for none, a score of 1 for occasional tapes, meditation or prayer. How successful moaning or groaning, to a maximum score Pain may be either chronic or acute. Acute pain are these interventions?  of 2 for loud moaning or groaning, crying, or is due to surgery, medical procedures, injury or  What does pain mean to the patient from calling out. 9 trauma. It is often self-limiting with appropriate a cultural and/or religious viewpoint? For  Facial expressions: Ranges from a score treatment of the underlying cause. However, example, some patients may believe that of 0 for no expression or an expression of some acute pain may become chronic. For pain is punishment for misdeeds. Some calm or smiling, a score of 1 for frowning or

Page 64 Elite expressions of sadness, to a maximum score dementia are at significant risk for having their and review some mental health and cognition of 2 for facial grimacing, frowning, scowling, pain undertreated. problems and how they can be identified in the etc. older adult. Involve family, friends and caretakers as part  Body language: Ranges from a score of of the pain assessment process as well as its 0 for a relaxed body posture, a score of 1 Normal age-related changes in mental treatment. Many of these individuals (including for tenseness, fidgeting, or, if ambulatory, health and cognition the patients themselves as well as some health distressed pacing, to a maximum score of 2 An older adult’s mental health and cognition stay care professionals) may hold the mistaken belief for rigid body posture, clenched fists, pushing comparatively stable. The alterations that do take that pain is simply part of the aging process or striking out, and/or pulling knees up place are usually not dramatic enough to cause and must, to some degree, be tolerated. Help towards chest. major problems with activities of daily living. to educate all of these individuals, including  Consolability: Ranges from a score of 0 Serious changes and abrupt loss of cognition colleagues, about the need for adequate for needing no consolation, a score of 1 to usually indicate a physical or mental disorder assessment and treatment of pain. 9 the need for reassurance by touch or tone of such as Alzheimer’s disease or stroke. Some voice, to a maximum score of 2 for being Remain alert to the complications of under- normal age-related changes in mental health and 9 inconsolable. treating pain, including depression and social cognition include the following. isolation. Also be sure to monitor and to teach the  The speed with which information is Scores for each category are totaled with scores patient about the side effects of medications used processed decreases with age. This means ranging from a minimum total of 0 to a maximum to alleviate pain and how to reduce or eliminate that older adults take a longer time to learn total of 10. The higher the total number, the such adverse occurrences. new information and require that information more severe the pain. The Harford Institute for be repeated. Geriatric Nursing Web site offers a detailed Use a variety of pain assessment techniques  The ability to deal with multiple tasks slows. explanation of the scale and may be accessed at including verbal discussion and the use of valid  The capability with which the older adult can www.ConsultGeriRn.org. Specific information and reliable pain assessment tools. Remain maintain attention and ignore unimportant about the use of the scale may also be found sensitive to the issue of culture and religion and information decreases with age. in the publications of the American Medical how they influence the expression of pain and  The use of language is maintained, but word 18 Directors Association. compliance with treatment options. finding and naming ability decreases with A comprehensive pain management treatment Finally, remember to involve the patient, age. plan is important for anyone dealing with pain. family and caregivers in pain assessment and  The ability to use abstract thought and A number of complementary and alternative management. Often the key to success in demonstrate mental flexibility are associated therapies are being used with increasing managing pain is the cooperation of the patient with some decline as a person ages. frequency. These include acupuncture, herbal and of those with whom he is most involved.  The ability to acquire practical experience and wisdom continues until the end of life. supplements, massage therapy, chiropractic Assessing mental health care, Yoga, meditation, relaxation therapy, Mental health and well-being is as important to Grief and bereavement biofeedback, and, in some cases where not the older adult as it is to any other population. Geriatric patients generally must deal with the prohibited, exercise. Any and all complementary Unfortunately, some mental health issues, such loss of loved ones, including spouses, siblings, and alternative therapies should be initiated and as depression and anxiety, may be overlooked parents and others. Grief is considered to be a maintained only under the supervision of the in elderly adults. The signs and symptoms of normal response to such losses within a two- patient’s primary health care provider. these and other mental health problems may be year period. Grief that lasts longer than two Most patients dealing with pain participate in mistakenly attributed to the aging process or years is considered to be pathological. However, some type of medication regimen. Be aware dementia, and as a result, a thorough assessment the length of grief varies with cultural norms. of and help the patient and family prepare for is not done. In fact, only about half of older The American Psychological Association’s and deal with some common side effects of adults with mental health problems actually standard of care concerning grief in the older analgesics. receive appropriate mental health services.19 adult encourages the health care professional  Some analgesics, particularly opioid not to focus on time, but on the way grief is Assessment tip: When assessing mental health, analgesics, slow the intestinal tract and can presented. Profound depression, extensive guilt, be sure to evaluate the patient for mental lead to constipation. Stool softeners, adequate overwhelming senses of loss, preoccupation disturbances related to medication side effects. fluid intake, and fruit and vegetable intake with death, difficulty performing activities Sometimes adverse occurrences are related to should help to alleviate the problem of of daily living and social incapacitation alterations in mental status. constipation.9,14 indicate pathological grief and require medical  Nausea and vomiting are also fairly Some health care professionals may hold the intervention.9 common side effects, and an antiemetic mistaken belief that older adults suffer from Depression may be prescribed for these types of mental health problems more than younger While the prevalence of major depression adverse occurrences. Some analgesics cause adults. Actually, older adults demonstrate fewer declines with age, symptoms of depression drowsiness and sedation, and patients should diagnosable psychiatric disorders than younger increase. Eight to 20 percent of older adults living be cautioned against activities that require persons with the exception of cognitive problems in the community and up to 37 percent in primary alertness. In severe pain, morphine may be such as Alzheimer’s disease, which show age- care settings experience depressive symptoms.19 administered, and pruritis is often associated related increases.9 Some experts bemoan the fact Depressive symptoms are often associated with with its administration. Antihistamines are that many health care professionals are more chronic illness and pain.9 effective in combating pruritis, but may also concerned about a broken bone than a “broken cause sedation as a side effect.9,14 spirit.”7 Older adults suffering from depression often report numerous somatic complaints, including In summary, a thorough pain assessment must The geriatric population can experience a number chronic pain. They may not consider themselves be conducted as part of a thorough geriatric of mental health problems, just as younger depressed and focus on physical rather than assessment. Remember that pain is often persons do. Although some problems may mental symptoms.9 undertreated in this population, particularly develop in old age, others may have begun earlier in those elderly adults who cannot or will not in life (e.g. depression, obsessive-compulsive Assessment tip: Older people may feel that it is a communicate about their pain. Patients with disorder). Let’s look at the normal aging changes sign of weakness to report feelings of depression. that influence mental health and cognition They may believe it is more “acceptable” to have

Elite Page 65 a physical illness, thus the focus on physical According to the Diagnostic and Statistical grandchildren stops in to ask for a ride to a complaints. Your first clue to depression in Manual of Psychiatric Disorders – Text Revision sports event. The grandchild does not interact older adults may be the reporting of somatic (4th edition20, the diagnostic criteria must include with Mrs. Dash, but rolls her eyes and complaints. both a decline in memory and at least one of the mutters something about “that old woman is following: more trouble than it’s worth.” Mrs. Dash’s A number of tools for the assessment of geriatric  depression are available. One such tool is the  The ability to understand spoken or written daughter prepares to leave and casually Geriatric Depression Scale, which consists of 30 language and to generate understandable says, “So long, Mom,” and leaves without speech. looking back. Mrs. Dash looks at the visiting questions (a shortened 15-question version may  also be used) that can be answered with “yes” or  The ability to recognize or identify objects nurse and says sadly, “They take care of me, “no.” 9 Examples of questions include:9 (assuming such ability is not impaired by but no one really cares about me. There is  other disease processes). no love. They don’t like me.” Mrs. Dash is  Are you basically satisfied with your life?   Do you feel full of energy?  The ability to perform motor activities suffering from emotional neglect, sometimes  Do you feel happy most of the time? (assuming such activities are not impaired by characterized as a form of elder abuse. other disease processes).  Do you think that most people are better off When nurses hear the term “elder abuse,” they  The ability to think abstractly, make than you are? often picture an older adult who is bruised, in appropriate judgments, and plan and execute poor physical condition and may be dressed in Criteria for major depression as noted in the complex tasks. dirty clothing. But there are many forms of abuse, Diagnostic and Statistical Manual of Mental  The decline in cognitive ability must be of a 20 not all of them readily apparent. Elder abuse can Disorders-IV-TR include: severity to interfere with normal activities of  take place in any setting: the patient’s home, an  Depressed mood or loss of interest or feelings daily living. of loss of pleasure. acute-care hospital or long-term care facility.  Symptoms must last for at least two There are a number of types of dementia, with It occurs among all socioeconomic groups. As consecutive weeks and indicate a change the most common being Alzheimer’s disease nurses, we must be aware of the various types of from previous mood and functioning. (AD). It is responsible for about 50 percent to abuse and how to protect the elderly adult from  At least five of the following: depressed 70 percent of cases and has a subtle onset. The the effects of abuse. exact etiology of AD is unknown, but researchers mood, changes in sleep patterns, reduced Physical abuse believe that genetic and environmental feelings of interest or pleasure, feelings of Physical abuse is defined as the use of physical components may play a role in its development.9 guilt or worthlessness, loss of energy or force to intentionally inflict physical injury or fatigue, inability to concentrate, changes in There are three stages of dementia: mild, pain. Actions such as hitting, pushing or shaking weight or appetite, psychomotor agitation or moderate, and severe. Six aspects of cognition are forms of physical abuse.9 retardation, and suicidal thoughts. are evaluated to determine staging. These six Signs of physical abuse include bruising, aspects are memory, orientation, judgment and The incidence of depression is twice as high fractures, abrasions, lacerations and cuts. But it problem solving, community affairs, home and in older women than in older men. Some of can be difficult to distinguish accidental injury hobbies, and personal care. Diagnosis is based on the possible reasons for this difference is that from physical abuse. The elderly adult’s skin assessment of these aspects because there is not older women are more likely to experience contains only small amounts of subcutaneous a definitive diagnostic study or studies that can loneliness, financial problems and a reduction in 22 9 fat, and blood vessels are thin and fragile. This 9 confirm diagnosis. independence cause by functional disabilities. makes the older person susceptible to accidental Assessment tip: Depression is a major risk factor Treatment is aimed at slowing the progression of bruising, which can be difficult to distinguish for suicide. Adults age 65 and older have the the dementia and improving cognitive function. from physical abuse. However, research shows highest suicide rates of all age groups. Suicide is Medications such as Namenda and Exelon are that 90 percent of accidental bruising occurs on highest among caucasians, followed by Asians, currently used to treat cognitive impairment. the extremities. Accidental bruises rarely, if ever, Hispanics and non-Hispanic blacks. Older adults Alternative therapies, such as ingestion of ginkgo occur on the neck, ears, genitals, buttocks or 22 suffering from alcoholism have a greater risk for biloba and various vitamins and minerals, are soles of the feet. under investigation.9 suicide as well. Nurses must not only assess for Low bone density and the existence of depression but for suicidal ideation!9 Assessing for elder abuse osteoporosis place the elderly at high risk for When evaluating elderly patients for depression, Mrs. Dash is an 80-year-old female who fractures. To date, no particular pattern of abuse 22 be sure to check on the potential for depressive lives with her daughter, son-in-law and three fractures has been identified. The location, side effects of certain medications. Medications grandchildren. She was recently hospitalized frequency and health history of the older adult that can cause depression include:21 for a total hip replacement and infection with fractures must be evaluated to identify  Antihypertensives, such as reserpine. of the surgical wound. After discharge, she suspected abuse.  returned to her daughter’s home. A visiting  Hormonal replacement therapy, including When evaluating abrasions, lacerations and nurse arrives this morning to assess Mrs. estrogen and progesterone. cuts, it is important to describe them accurately.  Dash’s wound and perform a dressing  Cardiac agents, such as digitalis. Many nurses refer to any wound as a laceration.  change. Mrs. Dash lives in a self-contained  Analgesics, such as codeine. When documenting these kinds of trauma, it is  apartment attached to the main house via a  Anti-anxiety agents, including diazepam. important to be accurate.22 short hallway. Her daughter provides Mrs.  Abrasion: A scraping injury that can occur if Dementia Dash with housecleaning services and brings the elder is pulled or dragged across a surface Dementia is a syndrome that leads to a decline her meals three times a day. Mrs. Dash’s (e.g. a carpet) that abrades the skin.22 in multiple cognitive abilities. The presenting apartment is spotlessly clean. Mrs. Dash is  Laceration: Full-thickness splitting open of signs and symptoms range from mild cognitive dressed in a clean housedress, and is wearing the skin with ragged edges that occurs when impairment to complete incapacitation. make-up and jewelry. She does not make the individual is traumatized by blunt force.22 eye contact with the visiting nurse and has Dementia is both chronic and terminal, because  Cut: An incision made by a sharp object that a sad expression on her face. Her daughter the syndrome progresses to causing the patient has smooth, clean edges.22 to become completely dependent in all aspects of is present and interacts with the visiting activities of daily living. There is no consistent nurse, asking if her mother is “healing.” She Sexual abuse course, and the rapidity with which the disease does not interact with Mrs. Dash. One of the Sexual abuse is defined as any type of 9 will progress cannot be predicted.9 nonconsensual sexual intimacy. Examples Page 66 Elite include rape, molestation, sexual harassment, unexplained disappearance of personal items, There are a number of elder assessment screening unwanted touching, sodomy, coerced nudity and unusual withdrawals of money from savings tools available for use. The Hartford Institute nonconsensual explicit sexual photography. Signs or checking accounts, or changes in property for Geriatric Nursing recommends the Elder and symptoms of sexual abuse include:9,22 ownership. As a result of financial losses, elders Assessment Instrument (EAI) as a screening tool  Bruises around the genital area and/or may not be able to pay bills or buy food and in the clinical setting.9 This is a 40-item tool used breasts. medicine. to determine whether the elderly patient needs to  Unexplained vaginal or anal bleeding. be referred for suspected elder abuse.9 Risk factors for elder abuse  Unexplained occurrence of venereal disease Elder abuse can occur within all socioeconomic, Elders are often reluctant to report abuse. They or genital infections. cultural and intellectual groups. However, may be afraid of retaliation by the abuser. They  Torn, stained or bloody undergarments. research shows that certain characteristics surface may believe that they have done something to  Elder’s verbal report of sexual abuse. most commonly among abuse victims. These deserve the abuse or feel guilty about being an Emotional or psychological abuse include:9,23 abuser themselves at some point in their lives. Emotional or psychological abuse is defined  Sex: Women are more likely to be victims of Abused elders may also be reluctant to report as infliction of distress, anguish or sadness via elder abuse than men. abuse if they are dependent on the abuser for verbal and/or non-verbal acts.9 Examples of  Age: Victims of elder abuse are likely to be care, shelter or financial help. elder emotional or psychological abuse include more than 75 years of age.  Assessment tip: The elder and the suspected yelling, threatening, swearing, name calling,  History of violence: Victims of elder abuse abuser should be interviewed separately. This insults, intimidation and humiliation. Other are more likely to be prior victims of abuse, may reveal inconsistencies in reported histories forms of emotional abuse include isolating the such as child abuse or spousal or intimate or explanations of signs and symptoms of abuse. older adult from family and friends, preventing partner abuse. If the elder abuse victim was If the suspected abuser refuses to allow separate him from pursuing his regular social activities himself an abuser (e.g. abused his children), interviews, the suspicion of abuse increases.8,9 (e.g. attending church, visiting a senior citizen’s he is more likely to be a victim of elder abuse center), isolating him from others in the committed by those he abused in the past. Nurses must be aware of local elder abuse/ home, and/or giving the older adult the “silent  Functional status: Elders whose physical mistreatment reporting laws. Many states have treatment” and not providing any affection.23 and/or mental status is impaired are more mandatory reporting laws, and health care likely to be abused. professionals must report suspected cases of elder Signs and symptoms of emotional or 9  Poor social network: Elders who have fewer abuse. Know your organization’s policies and psychological abuse include sadness, emotional than three significant others are more likely procedures regarding the reporting of elder abuse, upset or agitation, withdrawal and verbal to suffer abuse. and familiarize yourself with contact information reporting of emotional abusive behaviors.9,22,23  Economic status: Elders who are poor are for local departments on aging and adult Neglect more likely to be abused. protective services. For state reporting numbers, Neglect is defined as the failure to fulfill or  Education: Older adults who have less than visit the National Center on Elder Abuse Web refusal to fulfill obligations to an elder such as an eighth-grade education are more likely to site at www.ncea.aoa.gov or call the Eldercare safety, shelter, affection, food, water, clothing, be abused. Locator at 1-800-677-1116. 9,22,23  hygiene, medicine or comfort. Neglect may  Minorities: Members of minority groups Assessment tip: You don’t need to prove that be on the part of a spouse, family member, friend have statistically higher rates of elder abuse. abuse is occurring. You do need to report your or caregiver. Additionally, the elderly adult may Characteristics of abusers suspicions. The experts in abuse will follow up to also initiate self-neglect, which occurs when the Some common characteristics of abusers include investigate your suspicions. elder himself disregards such needs as hygiene, the following.9,23 food, safety and so on, because of mental or Overview of assessment of body systems  Sex: Abusers are more likely to be men. physical impairments or because he chooses not Basic physical assessment techniques, such  Substance abuse: Abusers are more likely to to take care of himself.9,22,23 as inspection, palpation and percussion, are have a history of substance abuse, including similar for all age groups. This overview of Signs and symptoms of neglect include alcohol abuse. the assessment of body systems focuses on  malnutrition, dehydration, poor personal hygiene,  Mental health: Abusers are more likely to those issues that are particular to the geriatric untreated health problems, unsanitary or unsafe suffer from mental illness. population. living conditions, history of being left alone  Family status: Elders are more likely to be or choosing to be alone, and reports of being abused by members of their own families. Vision, hearing and touch neglected.22,23  Social network: Abusers have a poor social Vision The first step in assessing the vision of an older Abandonment network and are more likely to be dependent on the elder for financial or shelter or other adult is observation. Elderly persons who have Abandonment is the desertion of an elderly needs. stained clothing, poorly combed hair or excessive person by someone who is responsible for  Caregiver stress: Caregivers who are or poorly applied makeup may have vision providing care to the elder or who has physical 9 overwhelmed by the burden of caring for the impairment. A Snellen chart may be used to custody of the elder.9,23 In such cases, the elder is older adult may end up abusing the person for assess visual acuity, or you may ask the patient to simply deserted or abandoned at a hospital (e.g. whom they are caring. read from a newspaper or other printed material emergency department), long-term care facility,  Cycle of family violence: Caregivers may with various size prints. shopping center or other public location.9 In have been abused by the elder they are now addition to being abandoned, the elderly adult Assessment tip: Be sure that the patient is abusing. may also exhibit signs and symptoms of other wearing his glasses or contact lens when types of abuse. Screening for elder abuse assessing vision. Assess vision with and without corrective lenses. It is estimated that 92 percent Financial or material abuse Evaluate signs and symptoms that may indicate abuse. Monitor those who provide care for of persons over 70 wear glasses, 18 percent also Financial or material abuse is defined as illegal or elderly adults. Do they show signs and symptoms use a magnifying glass for close work, and 14 improper use of an older adult’s money, property of stress and difficulty coping? Is there a history percent of persons 70-74 have difficulty seeing or other assets. The person committing this of abuse in the elder or caregiver’s family? even with corrective lenses. Thirty-two percent abuse does so for personal or monetary gain or of persons over 85 have trouble seeing even with 9 benefit. Examples of this type of abuse include corrective lenses.9

Elite Page 67 There are a number of normal age-related disease; personal history of hypertension, as part of the treatment as well as relaxation changes pertaining to the appearance of the eye diabetes, myopia, or migraines; and African- techniques, biofeedback and counseling to deal and vision. These include the following issues.4,9 American ancestry.4,9,24 with the discomfort.9  The eyebrows gray and thin, as do the  Age-related macular degeneration Touch eyelashes. Skin around the eye wrinkles (ARMD): ARMD is the leading cause of The sense of touch or physical sensation as subcutaneous tissue atrophies. Orbital blindness in persons over the age of 65. decreases with age. This is because nerve fat decreases, giving the eyes a sunken It is the atrophy of the macular region impulses are conducted at a slower rate in the appearance, and eyelids sag. of the retina. The dry form of ARMD is elderly. There is also a reduction in the function  The eye becomes less sensitive to feelings characterized by retinal pigment degeneration of peripheral nerves. Medications used to calm of pain and discomfort. This can cause the and is slow and progressive and associated or sedate may also contribute to a decrease in the patient to be unaware of infections or injuries with a mild vision loss. The wet form sense of touch.9 to the eye. involves the leakage of blood or serum  The lenses thicken and harden, which reduces from blood vessels beneath the retina. It These physiological changes lead to a decreased accommodation and brings a decrease in is not as common as the dry form but is ability to perceive pain and temperature, which, near-vision (presbyopia). The lens begins to responsible for the majority of severe vision in turn, can increase the risk for injury. For appear “yellowish” and rather opaque. Visual loss associated with ARMD. The primary example, the older adult may not perceive the acuity starts to decrease starting about the symptom is a change in central vision, such temperature of water in the bathtub or shower to age of 50. This decrease becomes more rapid as distortion of straight lines or bland areas be too hot, increasing the risk for burns. If the after the age of 70. that appear in the center of printed pages. sense of pain is diminished, the elderly patient  The eye begins to lose its ability to adapt to There is no treatment for the dry form, may not be aware that he has injured himself after changing degrees of light. Thus, as the adult but the wet form may be treated with laser falling or other types of blunt trauma. ages, he needs more light to see objects in treatments or injections.4,9,24 The sense of touch is also important in conveying shadow or in dim light.  Diabetic retinopathy: This is a affection, and in some cultures, to communication  The eye’s ability to adapt to a darkened room microvascular disease of the eye associated in general. A loss of physical sensation may be decreases with age. It takes more time for the with diabetes. The ocular microvascular detrimental emotionally as well as physically. eye to accommodate to darkness. system is damaged, and transport of oxygen  The elder’s pupils become sluggish as the and nutrients to the eye is inhibited. Patients Assessment tip: Some diseases, such as diabetes pupils decrease in size and become less experience a gradual vision loss. Treatment mellitus, can cause peripheral neuropathies that responsive with age. consists of laser therapy.9 add to the loss of the sensation of touch.9 Assessment tip: As always, include medication Hearing One of the simplest ways to assess touch is to use evaluation as part of your assessment. Some Hearing loss is quite common in the elder patient. a wisp of cotton. Patients close their eyes and are drugs, such as Tamoxifen and thiazide diuretics, It is estimated that more than 30 percent of older asked to indicate when they feel the sensation can interfere with vision.9,14 persons between 65 and 74 have some degree of touch. The nurse touches parts of the body, such as the face, the arms, the legs and the back. There are several visual problems that are of hearing loss. This percentage increases to 66 Additional techniques are to touch various areas commonly seen in the older adult. Nurses must percent in persons over 75. In addition to age, of the body with a pin alternating with a wisp of be aware of these problems and their signs and risk factors for hearing loss include smoking, cotton. The patient is asked to say whether he symptoms so that appropriate referrals may be history of middle ear infections, tumors, the feels a sharp sensation (when touched with a pin) made. buildup of ear wax and long-term exposure to 9 or dull (with the cotton wisp).9,24  Cataracts: Cataracts are the most common loud noises. causes of correctable vision loss.24 A cataract Normal aging changes that influence hearing Some nurses find it helpful to use objects of is an opacity of the lens that develops include:9 various sensations, such as sand paper, a piece of gradually without pain. It decreases the  The skin of the external ear wrinkles and silk or fur and ask the patient if he feels a rough amount of light able to reach the retina, thus sags. or a soft sensation. Tubes of hot and cold water inhibiting vision. The patient experiences  Cerumen is drier and harder and tends to may be placed against the patient’s skin as he painless, gradual blurring and loss of accumulate in the ear more than in younger is asked to state whether he feels a cold or a hot vision; may see halos around objects; and adults. object.9,24 have difficulty distinguishing colors. The   Loss of nerves and sensory organs associated Assessment tip: Teach older adults to examine pupil of the eye appears hazy. Cataracts with hearing. their skin, especially over bony prominences, the are the leading cause of blindness in the Assessment tip: When assessing hearing, be sure soles of their feet and between fingers and toes world. Surgery is the treatment of choice, to assess for the presence of excessive ear wax, for open or broken areas of skin. Because of the and prognosis is usually good. Risk factors which may hinder hearing. decrease in the sensation of touch, open areas include increased age, diabetes, eye trauma, may not be noticed until they are severe and/or long-term use of medications, Hearing is assessed in the same ways as with infected. smoking and alcohol use, and Caucasian other adult age groups. The use of a tuning fork race.4,9,24 and covering one ear and whispering two-syllable The integumentary system  Glaucoma: This is a group of disorders words toward the uncovered ear are two of the The integument, or the skin, is the body’s largest characterized by an increase in intraocular ways to assess hearing. organ and consists of three layers: the epidermis, pressure (IOP) that can damage the optic the dermis and subcutaneous layers. The Assessment tip: As with all assessment nerve. Untreated glaucoma can lead to epidermis is the outermost layer of the skin and evaluations, be sure to review the patient’s peripheral vision loss and blindness. Its onset has up to five layers (depending on the specific medications to determine whether any of them can be slow and insidious (chronic open- part of the body). The dermis is the second layer may affect hearing. angle glaucoma) or abrupt (angle-closure of the skin, is made up of connective tissue, glaucoma), which is a medical emergency. Tinnitus is a common problem in older adults. has an abundant blood supply, and lymph and Treatment includes medications and/or laser It is a ringing sound in the ear and can happen neurosensory receptors. It supports and nourishes therapy. Risk factors include IOP; being older with or without accompanying hearing loss. the dermis. The subcutaneous layer lies below than 60 years of age; a family history of the The problem may be self-limiting or chronic. the dermis, attaches to muscles and gives shape Tricyclic antidepressants may be prescribed

Page 68 Elite to the body and provides a protective cushion  Damage from sun exposure: Persons who Squamous cell cancer is the second most for bones and internal organs. There are also a spend a lot of time in the sun, whether common type of skin cancer in Caucasians and number of accessory structures that are part of the because of their occupations or simply from the most common type of skin cancer in persons integumentary system. These are the hair, nails, their desire to acquire a deep, dark tan, are with dark skin.9 It is an invasive tumor that sebaceous glands (which produce sebum for at risk for a number of health problems, has the potential to metastasize. Clues to the skin lubrication) and eccrine glands that produce particularly skin cancer. It is estimated existence of squamous cell cancer are changes sweat. 4,9 that more than 90 percent of skin cancers in existing skin lesions (e.g. moles, warts) or are related to exposure to the sun. The the appearance of a new lesion that ulcerates The skin is very important to health and wellness. cumulative effects of years of sun exposure and fails to heal. This type of skin cancer, if It is responsible for:9 increase the amount of age-related changes, diagnosed and treated early, has a high cure  Regulation of body temperature. such as wrinkles and freckles, and often make rate. But if it spreads, it can lead to disability or  Regulation of body fluids. people appear older than they really are. death.24  Provision of a barrier to infection and Damage done by the sun is not reversible.9 promotion of the immune system. Squamous cell cancer often develops on the  Production of vitamin D synthesis. Assessment tip: Some drugs increase a person’s face, ears and dorsa of the hands and forearms.  Provision of sensory reception. sensitivity to sunlight. Some examples are Risk factors for this type of skin cancer include antibiotics, antihistamines, antidepressants and sun overexposure or overexposure to X-rays, There are a number of age-related changes that antiarrhythmics. As always, educate patients radiation therapy, chronic irritation of the skin, affect how the integumentary system functions. about the risk for sun sensitivity if they are on and ingestion of arsenic-containing substances. Nurses need to be aware of these changes not medications that increase this problem.9 It is most commonly found in fair-skinned white only for their impact on physical health, but on men older than 60 years of age.24 self-perception and self-esteem as well. Skin cancer is a common problem among older  Thickness and elasticity: Both decrease adults. It is important that nurses recognize Diagnosis is based on appearance and biopsy. with age, which leads to the appearance potentially malignant lesions and initiate Treatment includes excision, and if the tumor of wrinkles and causes the skin to sag, appropriate follow-up and treatment. Skin is extensive, radiation therapy, or possibly especially the skin of the face, neck and cancer is the most common type of cancer in the chemotherapy. upper arms. Smoking is associated with an United States. Its effects range from mild, easily Malignant is the most serious of all increase in wrinkling of the skin.9 curable lesions, to devastating, life-threatening skin cancers and is responsible for more than  The epidermis: The epidermis thins, and malignancies. 75 percent of all deaths due to skin cancers. moisture is lost. The skin begins to have a dry Basal cell carcinomas: Basal cell cancer is the Melanoma lesions may grow from an existing and rough appearance. The rate of cell growth most common type of skin cancer in Caucasians. mole or appear as a new lesion. In appearance, is decreased, which leads to an increased It is primarily due to sun exposure.9 Fortunately, melanoma lesions grow and become brown, risk for infection. This decrease combined if diagnosed early, basal cell cancer has a cure black or multicolored. They develop nodules or with a lack of moisture makes the skin more rate of 95 percent.24 When assessing the patient’s plaques with irregular black outlines. susceptible to damage. Liver or “age” spots skin, be alert to the presence of basal cell cancers. may crust or bleed and are usually larger than 6 appear and the number of moles and freckles This type of skin cancer can occur on any mm in diameter.9 may increase. The cosmetic aspects of these exposed surface of the skin, but is most common changes may have a negative impact on the Appearance and biopsy confirm diagnosis. on the face, head, neck, nose, and ears.9 older adult’s self-image and self-esteem.4,9 These lesions are treated with surgical resection  The dermis: Beginning in a person’s 30s, the There are three types of basal cell cancers. They that may include removal of the lymph nodes. dermis begins to decrease in thickness and are:24 Chemotherapy may also be part of the treatment effectiveness. The connective tissue decreases  Noduloulcerative lesions: Usually found on plan, depending on the size and extent of the in function, which causes a loss of skin turgor the face, these lesions are small, smooth, ink lesion.24 and translucent papules. As they grow, their that progresses with age. The capillaries Part of your assessment should include patient centers become depressed with firm, elevated thin, which leads to bruising. There is an education regarding the prevention of skin borders. They seldom metastasize, but if accompanying reduction in sensation that cancers. Advise patients to avoid exposure to the untreated they can become infected or lead increases the risk for injuries such as burns, sun, especially between the hours of 10 a.m. and 4,9 to hemorrhage if they move into large blood infections and pressure sores. 4 p.m. Sunscreen should be used year-round, and  vessels.  Subcutaneous layer of skin: This layer clothing should cover the arms and legs when  Superficial basal cell lesions: Commonly increases in some parts of the body and spending time in the sun. A broad-brimmed hat found on the chest and back, these cancers decreases in others, resulting in changes in fat should be worn to protect the face and scalp. are oval or irregular in shape, lightly distribution. It thins in the face, neck, hands Patients should perform regular skin checks to pigmented and have clearly defined, slightly and lower legs. With age, fat distribution monitor the appearance of new lesions or changes elevated threadlike borders. They look scaly becomes more pronounced in the abdomen in old ones. Be sure to explain the potential for and may be mistaken for psoriasis or eczema. and thighs in women, and in the abdomen in photosensitivity that some medications can cause. 9 These lesions are associated with ingestion or men. Encourage that patient to have an adequate intake  exposure to arsenic-containing substances.  Hair and nails: The color of the hair of vitamin D, because this vitamin may actually  Sclerosing basal cell lesions: These lesions becomes gray or white and becomes thin. lower the risk of certain cancers.24 There is a loss of axillary and pubic hair, and are waxy, yellow to white plaques and do not alopecia, or baldness, appears. Men generally have clearly defined borders. They are most Older adults are also susceptible to skin experience more obvious loss of hair from often found on the head and neck and appear breakdown and skin infections. Because of the head than do women. Balding may have in patches. the fragility of the elderly person’s skin and decreasing sensation, older adults are at high a significant impact on self-esteem. Women Report suspicious lesions for medical follow-up. risk for skin breakdown. A slight cut may go may also begin to experience the growth of Diagnosis is based on appearance and biopsy. unnoticed until it becomes infected. Sitting or facial hair on their faces. Nails become dull, Treatment involves careful excision and possibly sleeping for long periods of time in one position and yellow or gray. They become thick and chemotherapy and/or radiation, depending on the 4,9 may lead to redness and even breakdown of the break or split easily. extent of the lesion.24 skin over bony prominences. Persons who rely

Elite Page 69 on wheelchairs for their mobility are at particular pathology, but also to opportunities to teach arterial “stiffening,” and may make it difficult risk for skin breakdown over the sacrum and patients ways to enhance their cardiovascular to palpate some peripheral pulses. gluteal areas. health throughout the life span.  Veins thicken, allowing for increased valvular reflux (backflow of blood) and increasing the Teach patients how to prevent or reduce their Mr. Lewis is 80 years old. He is hypertensive, risk for varicosities and dependency edema risk for skin breakdown. Here are some points to has an elevated cholesterol, and suffered a after sitting or standing for long periods of include in your teaching. moderately significant myocardial infarction time.  Eat a nutritious diet. Proper nutrition one year ago. He takes his medication  Decreased cardiac ability to handle stressful helps all body systems to maintain a healthy on schedule but does not follow his activities, such as shoveling snow. balance. recommended low-fat, low-cholesterol diet.  Encourage adequate hydration. Older Mr. Lewis arrives at his physician’s office Assessment tip: You may hear bruits (swishing adults dehydrate easily and need adequate for a routine check-up. His nurse performs or blowing sounds) over arteries such as the amounts of fluid. Discourage excessive intake the initial assessment and reviews his lab carotid arteries in elderly patients who have of caffeine and alcohol. work, which indicates his cholesterol is still atherosclerosis. Pay special attention to this  Avoid sitting or lying in one position higher than normal, even though he takes finding because there is a high incidence of stroke for extended periods. Change positions his medication as prescribed. Mr. Lewis associated with bruits.4 frequently. If using a wheelchair for mobility, explains: “I eat bacon and eggs every Although the preceding normal aging changes change your position by lifting the weight off morning. I’m not supposed to, but I’ve must be acknowledged, nurses should not expect the buttocks several times every hour. eaten bacon and eggs every morning for 60 older adults to experience a debilitated cardiac  Massage bony prominences such as the years and I’m not changing now. Those egg system because of aging alone. By remaining heels, hips and elbows. Use moisturizing substitutes are terrible!” Should the nurse re- physically active, not smoking, maintaining lotion. Use gentle motions. Vigorous massage emphasize the importance of eliminating his a normal weight, eating a healthy diet, and may bruise or tear the skin. Avoid lotions morning breakfast eggs as recommended by controlling blood pressure and cholesterol, with large amounts of perfume because these the dietician? Or is there a compromise that geriatric patients can lead healthy lives and can further dry the skin. can be reached with her geriatric patient? maintain a healthy cardiac status. However, chest  Examine the skin for reddened areas, This scenario illustrates one of the challenges of pain, abnormal fatigue and significant sleep cuts, abrasions, and lacerations. Seek geriatric nursing practice. The nurse knows the disturbances are not normal and may indicate medical attention for such areas that fail to clinical importance of adhering to his diet. But cardiac pathology. Let’s review some of the heal, bleed, swell, become red and warm sometimes a compromise must be reached. As more common cardiac problems seen in elderly to the touch, or drain pus or foul-smelling part of cardiovascular assessment (and patient persons: hypertension and myocardial infarction discharge. education), the nurse must be able to work with,  (heart attack).  Avoid having bath or shower water too not in opposition to, her patient’s pursuit of health hot. Older persons’ skin burns easily. and wellness. Mr. Lewis may not be willing to Hypertension   Examine the skin for changes in moles, eliminate eggs from his diet, but would he be About 25 percent of American adults have lesions, and freckles. Note any newly willing to reduce the number of times a week hypertension. Untreated, high blood pressure developing moles, lesions or freckles. he eats eggs? How much input has he had in his can lead to stroke, heart attack, blindness and   Avoid wearing clothing that is too tight or plan of care? What options has he been offered? renal dysfunction. It increases the workload of rubs or irritates the skin. This can lead to Remember that the patient is the most important the heart, which can lead to heart failure and 24 skin breakdown. partner in the establishment of, and adherence to, pulmonary edema.  Avoid wearing shoes that are too tight or an effective treatment plan. The National Institutes classify blood pressure too loose. Tight shoes can damage the skin. based on stages as follows.4,24 If shoes are too loose, they may rub up and Age-related changes in the cardiovascular down with walking, which can also cause system Systolic Diastolic Stage skin irritation. It can be challenging to distinguish between <120 mm Hg <80 mm Hg Normal  Avoid wearing jewelry or watches that rub disease pathology and normal aging changes in 120-139 mm Or 80 to 89 Pre- and irritate the skin. the cardiovascular system. A decrease in cardiac Hg mm Hg hypertension tolerance may be due to disease or simply an Assessment tip: Help elders to identify a family effect of the aging process. 140 to 159 Or 90 to 99 Hypertension member, close friend or caregiver to help perform mm Hg mm Hg Stage 1 skin examination and skin care as needed. It However, age does not necessarily equate with may not be possible to examine the entire body cardiac health. A middle-aged person who eats >160 mm Hg Or > 100 Hypertension without help. a diet high in saturated fat, smokes and leads a mm Hg Stage 2 sedentary lifestyle may very well have poorer The cosmetic skin changes due to aging may Assessment tip: A systolic blood pressure cardiac functioning than an elderly person who cause a negative change in body image in the greater than 140 mm Hg is a more significant has maintained an active lifestyle, exercises and older adult. Monitor older adults for signs of cardiovascular disease risk factor than diastolic eats a “heart healthy” diet. Here are some normal depression or unrelieved stress and anxiety blood pressure. cardiovascular changes that are associated with related to appearance. Never assume that because aging.4,9 If blood pressure readings indicate hypertension, a patient is “old,” he may not be concerned about  Heart valves lose elasticity and stiffen, thus make sure that the cuff size is appropriate for his physical appearance. Remember that pride decreasing cardiac conductivity. the patient’s arm circumference and that the cuff in appearance is a life-long trait and should be  Left ventricular wall thickens. is properly applied. Check blood pressure in considered when working with patients of all  Increased potential for postural hypotension. standing, sitting and supine positions. Ask the ages.  Increased risk for arrhythmias. patient whether he drank beverages containing The cardiovascular system  Arterial elasticity decreases, which increases caffeine or if he is stressed or emotionally upset, Cardiovascular disease is the No. 1 cause of death the risk for systolic hypertension and left which can cause an elevated reading. Do not in the United States. Nurses, when assessing the ventricular hypertrophy. initiate treatment based on one reading, especially  Increased risk for “silent” heart attack. if dietary or emotional factors influence geriatric patient’s cardiovascular system, should 4,24 not only be alert to normal aging changes and  Decreased blood perfusion to vital organs readings. and the periphery of the body. This is due to

Page 70 Elite Patient education for older adults should include  Unexplained feelings of weakness and Let’s look at some lung diseases that are often these items:24 extreme fatigue. found in older patients and treatment issues  Maintain a healthy weight.  Pain or discomfort between the shoulder impacted by age.  Reduce salt intake. blades. Pneumonia  Stop or do not start smoking.  Sense of impending doom. Pneumonia, an acute infection of the lungs, is  Initiate a medically approved exercise Women may also experience the typical among the leading causes of death in the United program. symptoms the same as men. But their atypical States.24 Prognosis is usually good for persons  Increase potassium, especially if taking symptoms are just as significant as those with normal lung function. However, age-related potassium-depleting diuretics. Fruits and experienced by men. It is imperative that nurses changes in the respiratory system can make it vegetables are good sources of potassium. teach their female patients about the symptoms difficult for elderly patients to recover.  Reduce stress. A consult concerning methods women are likely to experience when having a of relieving stress (counseling, relaxation Currently the vaccination for pneumonia is heart attack. If they do not recognize signs and techniques, etc.) may be necessary. recommended for all individuals aged 65 and symptoms indicating a medical emergency, they older and for all adults who are dealing with Assessment tip: Remember that the patient must may delay or refuse to seek help. In fact, findings chronic illnesses or have suppressed immune be a partner in developing treatment regimens! from recent research show that women wait an systems. The vaccine is about 80 percent His cooperation is essential if treatment and average of 22 minutes longer than men to seek effective, but effectiveness does decrease over patient education are to be effective. help when having a heart attack.9 This delay can time. 9 cause serious complications, including death. Heart attack The sooner treatment is initiated, the better are Patients who are immobile after surgery, have Most nurses are aware of the signs and symptoms the chances of reducing damage to the heart and limited mobility due to physical deterioration or of heart attack. Many patients are aware of them resulting complications. who lead sedentary lifestyles are at risk for lung as well. Most clinicians and even laypersons disease. Encourage patients to change position, think of crushing, substernal chest pain; jaw In summary, cardiac status in older adults does become and stay ambulatory, and take frequent pain; pain that radiates to the left arm, neck, jaw not necessarily deteriorate enough to adversely deep breaths. As always help patients access or shoulder; sweating; nausea; vomiting; and affect health and well-being. Leading a “heart- smoking cessation programs if they smoke! some respiratory discomfort as typical presenting healthy” life can promote cardiac wellness symptoms.24 However, these typical symptoms throughout the life span. Assessment tip: A word about influenza. Encourage elderly patients to be vaccinated may not be present. In fact, women often present The respiratory system with atypical symptoms. Let’s review the atypical against the flu annually. They may think that it is As with the cardiovascular system, it can be symptoms as part of the assessment process not a serious illness, but it can be fatal, especially difficult to distinguish normal age-related because such signs and symptoms may not be as in those of advanced age! changes from pathology in the older person’s familiar as the typical symptoms. respiratory system. The following changes in Chronic obstructive pulmonary disease Women and heart attack lung physiology and structure occur with normal Chronic obstructive pulmonary disease (COPD) After a woman experiences menopause, she is aging and can influence the effectiveness of is chronic airway obstruction that is the result at as much risk as men. Women are typically respirations.9 of emphysema, chronic bronchitis, asthma or older than men when they present with  Decrease in lung elasticity, reducing the any combination of these diseases.24 Smoking is symptoms of cardiovascular disease. This is ability of the lungs to recoil. probably responsible for more than 90 percent of because, prior to menopause, estrogen seems  Decreased airway clearance, cough reflex and diagnosed cases of COPD.9 Other contributing to offer some protection against cardiovascular laryngeal reflex. factors include chronic respiratory infections, air disease. Therefore, the earliest presenting age of  Chest muscles are decreased in strength; pollution and inflamed lung tissues.24 symptoms is generally older, but this depends chest wall stiffens.  COPD also compromises cardiac function, on the age of the woman when she experienced  Ciliary action decreases, which increases placing strain on the right ventricle, which is menopause. the risk of respiratory infection as well as responsible for pumping blood into the lungs.9 aspiration. One in four women die of heart disease in the Older patients are particularly vulnerable to  Decreased ability of the lungs to respond to United States. (One in 30 die of breast cancer). compromised cardiac function as a result of elevated levels of carbon dioxide. Twenty-three percent of women die within COPD.  Immune system antibody production one year after having their first heart attack, decreases, thus increasing susceptibility to The earliest clue to the presence of COPD is an and within six years of having a heart attack, lung infections. early morning cough that produces clear sputum. approximately 46 percent of women become Periods of wheezing may occur if the patient has disabled with heart failure. About 66 percent of Assessment tip: Smoking contributes to all forms a “cold.” As the disease progresses, shortness women who have heart attacks fail to make full of lung disease. Help patients to quit smoking. of breath develops and becomes progressively 9 recoveries. Be aware of smoking cessation programs that worse.9,24 The usual progression of COPD looks patients can access. These statistics illustrate how important it is for like this:9  older women to be assessed for heart disease. Part Here are some patient education items to  There are usually no symptoms within the of this assessment is to identify those atypical help patients avoid or reduce the risk for lung first 10 years after the patient starts to smoke. 9,24  symptoms of heart attack in women, who are disease.  At about 10 years after starting to smoke, more likely to experience:9,24,25  Stop smoking! the patient develops a chronic cough that  Indigestion or “gas-like” pain.  Avoid contact with family and friends if they produces a clear sputum.   Feelings of “tightness” in chest. are ill.  At the age of 40 or 50, the patient begins to  Fullness or pressure in the chest.  Wash hands frequently. Carry antibacterial exhibit dyspnea.   Discomfort in the back, neck, stomach or jaw. hand wash and use it when in public.  At about the age of 50, patients begin to be  Dizziness.  Receive the pneumonia vaccine if not vulnerable to respiratory infections with  Shortness of breath. contraindicated. progressively longer recovery times.   Nausea.  Drink plenty of fluids to maintain hydration  As COPD progresses, shortness of breath  Cold sweat. and keep lung secretions moist. occurs with the most minor activities, such as  Take 10 deep breaths every hour to expand making a bed. lungs. Elite Page 71 Assessment tip: Elderly patients who suffer from  Teach patients to change position and move The endocrine system COPD often have calluses on their elbows. This lower extremities frequently The endocrine system is responsible for is the result of leaning over tables to stretch out managing the body’s metabolic functioning. Smoking cessation their upper body so that more air can enter and The endocrine glands manufacture and release Since smoking cessation is so critical to the leave the lungs during respiration.9,24 Be alert hormones that trigger cellular responses and prevention of and reducing the effects of lung for this sign. Watch for signs that your patient actions.9 is attempting to stretch out his torso to facilitate disease, it is worthwhile to spend some time Normal age-related changes in the endocrine breathing. discussing ways to facilitate the process. system include:9,24 Some older adults (and some health care Lung cancer  Decreased pancreatic secretion of insulin. professionals as well) may believe that if they Lung cancer is the most common cause of cancer  Decreased body sensitivity to insulin, which have smoked most of their lives, it will do no deaths in men and women. The most current causes changes in blood glucose levels. good to stop now. This is not true! The effects available statistics show that in 2004, lung  The peripheral tissues of the body become of smoking can actually begin to reverse cancer was responsible for more deaths than resistant to insulin. This resistance is themselves. If older adults stop smoking, their breast cancer, prostate cancer and colon cancer especially evident in persons who are obese. risk of heart attack, stroke and cancer goes down. combined.9,24 Once more predominant in men,  Changes in thyroid function that can cause Circulation improves and so does lung function. lung cancer rates in women are rapidly increasing systemic problems. Eliminating tobacco products can also help to as the incidence of female smokers increases. keep diseases such as COPD and bronchitis from The normal age-related changes in the endocrine Lung cancer is largely preventable.24 Smoking getting worse.9 system most predominantly affect the body’s is the biggest risk factor for developing the use of insulin and the ability of the thyroid to Some older adults may think that they are more disease. The pollutants in tobacco smoke cause function. Therefore, let’s look at the effects of likely to return to smoking after they have quit. In progressive lung cell degeneration. Lung cancer diabetes mellitus and thyroid malfunction. fact, research shows that older smokers are much is about 10 times more common in smokers than more likely than younger smokers to stay away Diabetes mellitus non-smokers, and 80 percent of patients with from tobacco products. Older smokers also seem Diabetes mellitus (DM) is quite prevalent, and lung cancer are smokers.24 to know more about the health benefits of quitting its incidence is increasing in people who are over Symptoms of lung cancer mimic symptoms of smoking.9 the age of 65. This increase is especially evident other lung diseases. Chronic cough, shortness in persons who belong to racial and ethnic How can you help older patients to stop of breath, coughing up blood, fatigue, weight minorities.9 smoking? Here are some suggestions. loss and frequent lung infections are common  Involve the patient’s family, friends and/ Type 1 DM is usually an autoimmune disease symptoms.9,24 Older patients may undergo or caregivers. It is not easy to quit smoking, and most often affects children and young surgical removal of the tumor, part of the lung, and the support of significant others in the adults. Type 2 DM most often begins as insulin or the entire lung depending on the extent of patients’ lives can be a big help. resistance because of changes in the endocrine the tumor and the patient’s general condition.  Find out if the patient lives with or has system and is linked to old age, family history Radiation and chemotherapy may also be frequent contact with people who smoke. It and obesity. The incidence of type 2 DM is necessary.9,24 is very difficult to stay away from tobacco increasing in the geriatric population.9,24 products if constantly in the company of Pulmonary embolism Risk factors for DM 2 include the following others who are smoking. If possible, the Pulmonary embolism is not a disease but a factors:9,24 patient may be able to avoid the company of complication of primarily hospitalized patients.  Over 45 years of age: risk increases with age. others who smoke. It occurs when part of the pulmonary arterial bed  Obesity.  Consult with the patient’s physician or nurse is obstructed by a dislodged thrombus, an air  Inactive lifestyle. 9,24 practitioner about prescription and non- bubble, or tissue fragment of lipids. Pulmonary  Hypertension. prescription aids for smoking cessation. embolism results in about 100,000 deaths every  Family history of DM.  Keep an objective, non-judgmental attitude. year and is the third leading cause of death in  Elevated cholesterol. 9 Stopping smoking is difficult, and feeling that the United States. Symptoms of pulmonary  Persons of African American, Hispanic, nurses and other health care professionals embolism include rapid respirations, dyspnea, Pacific Islander, Asian American, and Native disapprove of them or their behaviors only chest pain, hypoxia, decreased cardiac output and American origin. 9,24 makes the process more difficult. Patients possibly shock.  Impaired glucose tolerance. need encouragement and support to stop Risk factors for pulmonary embolism include smoking. Signs and symptoms include fatigue, polyuria immobility, surgery, obesity, clotting disorders,  Find out about reputable smoking cessation dehydration, thirst, poor skin turgor, dry mucous dehydration, atherosclerotic changes in the 24 programs in the community and on the membranes and unexplained weight loss. Older elderly person’s circulatory system and atrial patients with DM may most often exhibit the 9 Internet. Support groups can be very helpful. fibrillation. Many of these risk factors are found 9,24 Many older adults often explore the Internet following. in the elderly population as part of normal aging and seek out health information online.  Excessive thirst: This is a cardinal symptom. changes. Teach your patients how to avoid this There are many excellent health resources However, older adults may not report complication, especially if you know they are on the Web. However, there are also many excessive thirst because the thirst mechanism facing upcoming surgery. fraudulent, inaccurate sources of information. functions less effectively in older adults than  Teach and facilitate the patient’s ability to Familiarize yourself with websites that are in younger adults. perform active range of motion exercises. good sources of information and support for  Excessive hunger.  If the patient is unable to perform active those trying to quit smoking. Older adults  Blurred vision. range of motion, teach caregivers how to who have limited access to transportation or  Vaginal infections. perform passive range of motion exercises. who have limited mobility may rely on the  Frequent urinary tract infections in women.  Facilitate the administration of low-dose Internet for information and communication  Skin infections. anticoagulant therapy. with others. Be able to guide them towards  Difficulty healing.  Implement compression stockings as reliable online sources of smoking cessation appropriate. programs.  Encourage early postoperative ambulation.

Page 72 Elite Assessment tip: To help prevent urinary tract him from performing foot care or administering  The symptoms of hypothyroidism most infections, encourage older patients to drink insulin, if needed. Nurses need to make sure that often noted in older people include mental cranberry juice, which is believed to stop the patient has adequate resources and support deterioration, new patterns of incontinence, bacteria from sticking to the lining of the systems to help him manage his care. reduction in mobility and difficulty coping. bladder.9  Untreated hypothyroidism may lead to Thyroid problems hypertension and hyperlipidemia, both of The treatment regimen for DM in older adults The incidence of thyroid disorders increases with which are common in the elderly population. is similar to that of younger adults. There are a age. As a person ages, the thyroid slowly loses A life-threatening complication of untreated few issues that deserve special emphasis in the its ability to function and begins to atrophy. It hypothyroidism is myxedema coma, a life- older population, however. These include the becomes more nodular, and the occurrence of threatening medical emergency. In myxedema following:9,24 thyroid nodules and hypothyroidism increases coma, mental confusion deteriorates to  Meticulous foot care: The older person significantly with age. The thyroid antibody stupor and coma and significant electrolyte must be taught (or his caregiver taught) to levels rise with age, which makes it difficult to imbalances. Emergency intensive care examine his feet for any open areas, cracks or determine whether such elevation is pathological hospitalization is required if this potentially evidence of compromised skin integrity. Feet or part of the aging process. Hyperthyroidism lethal complication develops. should be washed and carefully dried every rates are similar for younger persons and older day. Special attention should be given to the adults, but the disease may produce less obvious The goal of treatment of hypothyroidism in the areas between the toes, which are harder to symptoms in the elderly, making diagnosis older adult is to alleviate symptoms and return keep dry. Socks should be changed daily and problematic. The incidence of hypothyroidism is the thyroid-stimulating hormone (TSH) to normal be kept clean and dry. Referral to a podiatrist quite a bit higher in women compared to men in levels. However, TSH replacement must be done is appropriate. Older persons with DM should all age groups, and is higher in the elderly who with caution because an increase in levels may not cut their own toenails because of the risk live in long-term care facilities than older persons trigger significant cardiac problems.9 of cutting the skin of the feet, thus increasing 9 who live in the community. In summary, thyroid problems in the older patient the risk of infection and should visit a are often difficult to diagnose. Presenting signs podiatrist regularly to have their toenails cut Some important points about hyperthyroidism in 9,24 and symptoms may be subtle and mimic a variety and feet evaluated. Shoes should be fit by the older adult are:  of diseases and disorders commonly found in this someone who is familiar with the problems  Hyperthyroidism is harder to diagnosis in population. It is important to rule out conditions of DM. If cost is an issue, refer patients for the elderly compared to younger people such as heart disease and to determine whether financial counseling. Nurses should be aware because older adults present fewer signs and two or more problems co-exist simultaneously. of podiatrists in the community who make symptoms. Additionally, their symptoms may be different than those of younger persons. special arrangements for older persons in  Unfortunately, because of the vagueness of financial difficulty. Teach the patient never to  The predominant symptoms of clinical presentation, thyroid disorders are often walk barefoot. hyperthyroidism in older people are rapid overlooked in the elderly patient. Nurses have  Checking blood glucose: Evaluate the older heart rate, weight loss, fatigues, apathy, excellent opportunities to serve as advocates for adult’s ability to perform blood glucose changes in sleep patterns, mood changes, patients and to remain aware of the possibility monitoring and evaluate the results. As changes in bowel movements, visual of thyroid disease when they perform geriatric necessary, teach other family members or disturbances and weakness. The thyroid is assessment. If thyroid disease is suspected, nurses caregivers to perform this task. usually not enlarged nor is it easy to palpate. should advocate for laboratory assessment of  Medications: Teach patients, families and/or By contrast, the predominant symptoms in thyroid hormone levels. caregivers about the medications the patient younger persons are nervousness, anxiety, heat intolerance, sweating and an enlarged Some of the nurse’s responsibilities include the is taking and the potential for side effects. provision of careful patient education. Patients  Diet: The dietician should be involved thyroid.  About 27 percent of older persons who have will most likely be on some type of medication in helping the patient understand dietary for the remainder of their lives. They need implications. If the patient is unable to adhere hyperthyroidism present with some type of cardiac symptoms such as atrial fibrillation, to understand the importance of taking their to dietary restrictions, programs such as medication as prescribed. They also need to be Meals on Wheels may be initiated. chest pain, angina and even heart failure.  These symptoms may be mistaken for aware of the signs and symptoms of hyper- and  Signs and symptoms: Teach patients, hypothyroidism. Patient education efforts should family members and caregivers the signs of active cardiac disease, and the actual cause, hyperthyroidism, may be overlooked or not focus on disease management and adherence to hyperglycemia and hypoglycemia and what treatment regiments. to do in the event of occurrences. even considered.  Blood pressure: Help the patient to adhere Nurses need to be aware of conditions, such as The hematologic system to blood pressure management regimen. If he hyperthyroidism, that mimic other conditions The main function of the hematologic system is is not hypertensive, teach him ways to avoid common in the elderly population. Treatment of the ability of the circulating blood to transport developing high blood pressure. hyperthyroidism in older adults generally consists oxygen and nutrients to the body’s internal organs  Exercise: In conjunction with the patient’s of ingesting radioactive sodium iodide instead of and peripheral tissues and to remove carbon physician, physical therapy and others, nurses surgery. If treatment results in hypothyroidism, dioxide and waste products.9 must help the patient to design an exercise 9,24 thyroid replacement therapy is intitiated. There are a number of age-related changes that program appropriate for his state of health Hypothyroidism is rather common. Here are occur in the hematologic system. These include and wellness. some points about hypothyroidism in the elderly the following:4,9,24 Management of DM is a lifelong endeavor. population.9,24  As the body ages, the bone marrow’s ability The nurse must help the patient, family and  The older person who is diagnosed with to manufacture red blood cells (RBC) swiftly caregivers to adapt to the lifestyle modifications hypothyroidism is typically a female over the in the event of blood loss or disease slows. necessary for the maintenance (or achievement) age of 50. This does not usually have a major impact on of a maximum state of health and well-being.  Older persons who have hypothyroidism health and wellness unless the blood loss or The elderly patient may have difficulty adjusting present with fewer symptoms than do disease process is extensive. to some aspects of the ongoing nature of DM younger people. Generally, their symptoms  Hemoglobin and hematocrit values are management. Physical limitations may prevent are rather non-specific and can be attributed slightly decreased, but should remain within to a variety of other health problems. normal ranges.

Elite Page 73  There is a reduction in the number of stem Folic acid deficiency anemia Onset in children is quite dramatic. In older cells. Folic acid deficiency anemia is a common, slowly adults, the onset is more gradual, with  There is a decreased production of intrinsic progressive anemia seen in not only the elderly presenting symptoms of weakness, pallor and factor, which can trigger pernicious anemia. but in infants, adolescents, pregnant and lactating acute confusion. The liver, spleen and lymph  Cellular immunity decreases. women, alcoholics, and people with cancer or nodes are found to be enlarged upon palpation.  The functional ability of the lymphocytes intestinal diseases. Folic acid deficiency may Persons of advanced age have a poor prognosis. decreases. be due to poor diet, impaired absorption, and Treatment involves the administration of various combinations of drugs to inhibit WBC The most common hematologic disorder is prolonged use of certain medications such as 24 production. Bone marrow transplant is rarely anemia. Although common in older adults, anticonvulsants and estrogens. initiated in persons over the age of 65. Infections anemia is not a normal age-related change, Assessment tip: Older adults living alone or who are a leading cause of death in older patients, contrary to what some health care professionals are impaired physically and mentally may lack who, even with treatment, relapse within one may believe. Anemia is a sign of disease, and if it essential nutrients in their diets. Remember that year.9 occurs, it cannot be successfully treated until the part of nutritional assessment should include underlying cause is addressed.9,24 screening for anemia. Chronic lymphocytic leukemia Anemia exists when there is an inadequate Typical symptoms of folic acid deficiency anemia Chronic lymphocytic leukemia (CLL) is a amount of hemoglobin to meet the body’s needs. include fatigue, shortness of breath, fainting, progressive disease that is common in the It is defined as a reduction in the number of irritability, nausea, anorexia and headache. elderly. It is characterized by uncontrollable circulating RBCs. This reduction can be due Treatment consists of the administration of folic spread of abnormal lymphocytes in blood, bone to loss of blood, an abnormally high rate of acid supplements and correction of underlying marrow and lymphoid tissue. Almost all patients 24 RBC destruction, or an inadequate or impaired causes. Supplements may be given orally or diagnosed with CLL are over the age of 50. 9,24 production of RBCs.9 parenterally. Typical symptoms include fever, fatigue, malaise There are several types of anemia. Some of those Assessment tip: Teach elderly patients about and lymph node enlargement. As the disease most commonly found in elderly patients are as foods that are high in folic acid to help prevent reaches advanced stages, fatigue, weight loss, follows: folic acid deficiency anemia. Such foods include bone pain and liver or spleen enlargement Pernicious anemia liver, orange juice, whole grains, beans, nuts and become apparent. Treatment consists of 9 chemotherapy and radiation. Curiously enough, Pernicious anemia is characterized by a decreased dark green leafy vegetables. early treatment is not associated with increased gastric production of hydrochloric acid and Hemolytic anemia survival. Thus, treatment is not initiated in older a deficiency of intrinsic factor.24 Factors that Hemolytic anemia is due to the premature persons until they manifest weight loss, night contribute to this problem are small bowel destruction of RBCs (hemolysis). The body sweats, fever or enlarged lymph nodes.9 disease, infection, excessive use of antacids, attempts to compensate for this destruction by overgrowth of intestinal bacteria and a strict increasing production of immature RBCs in the Lymphomas vegetarian diet.9 The incidence of pernicious bone marrow. Hemolytic anemia becomes more Hodgkin’s disease is a malignancy of the anemia increases with age. As people age, the common with aging. Infections, malignancies, lymphoid tissue characterized by painless, body’s ability to absorb vitamin B12 diminishes. trauma burns and exposure to toxic substances progressive enlargement of lymph nodes, spleen This vitamin is necessary for RBC growth.24 can cause this type of anemia. Drugs associated and other lymphoid tissue. This disease is most Signs and symptoms of pernicious anemia with its development include ibuprofen, aspirin, common in young adults, but its incidence peaks include:24 acetaminophen, insulin, some antibiotics and in two age groups: persons who are between 15 9,14 24  Cardinal signs of weakness, sore tongue, and sulfonamides. and 35 and people over 50. numbness and tingling of the extremities. The focus of treatment is folic acid supplements, It is believed that there is a viral connection   Lips, gums and tongue seem to be bloodless. because folic acid is depleted with increased associated with the development of Hodgkin’s   Patients are quite vulnerable to infections. bone marrow production of RBCs. Correction of disease, with the Epstein-Barr virus as the focus   The sclera and skin may be jaundiced. underlying causes must also be accomplished. of attention. Risk factors include a family history   GI symptoms may include nausea, In addition to supplement administration, the of infectious mononucleosis and an immune vomiting, weight loss, diarrhea, patient’s diet should be rich in foods high in folic system that is compromised.24 and constipation. The tongue may become acid such as beans, nuts, whole grains and green Symptoms include painlessly enlarged lymph inflamed, and the gums may bleed. leafy vegetables.9  Neurologic symptoms: Weakness, poor nodes, persistent fever, night sweats, fatigue, coordination, ataxia, dizziness and loss of Malignancies of the hematologic system weight loss, pruritis and anemia. The disease is bowel and bladder control. Malignancies of the hematologic system are treated with radiation, chemotherapy, or both and  Cardiovascular symptoms: Reduced associated with overproduction of lymphoid and depends on the stage of the disease. Older adults hemoglobin levels, decreased cardiac output, myeloid cells linked with bone marrow failure. usually receive chemotherapy for six to eight 9,24 rapid heart rate and arrhythmias. They are characterized by the accrual of large months.  Musculoskeletal symptoms: Scissors gait numbers of white blood cells (WBC) in the bone Non-Hodgkin’s lymphoma is a malignancy may develop as a late sign if pernicious marrow, liver, spleen, lymph nodes and central of lymphoid tissue but is not diagnosed as 9 anemia goes untreated. nervous system. Hodgkin’s disease. It is more systemic in nature Pernicious anemia is treated with a high dose Acute leukemia than Hodgkin’s disease, and prognosis is usually of parenteral vitamin B12 replacement therapy. Acute leukemia is a proliferation of the poorer. Normal lymphoid tissue is replaced by This triggers rapid regeneration of RBCs. After precursors of WBCs in bone marrow or lymph cancerous cells. This compromises the immune 9,24 hemoglobin levels return to normal and the tissue. They accumulate in bone marrow, body system and leads to infections. patient’s condition stabilizes, vitamin B12 can be tissues and peripheral blood. With treatment, The first symptoms of the disease are usually administered monthly at maintenance level doses. children between the ages of 2 and 8 have the swelling of the lymph glands, enlarged tonsils Since the patient must continue to receive vitamin best chance of survival (about 50 percent). and adenoids, and painless, rubbery nodes in the B12 injections for the rest of his life, he, a family Adults, however, generally survive about cervical supraclavicular areas. Fatigue, malaise, member, or caregiver should learn to administer only about one year after diagnosis, even with weight loss, fever and night sweats may also be 24 the injections. treatment.24 present.24

Page 74 Elite The cause of non-Hodgkin’s lymphoma is vertebrae. The spinal cord is the major pathway There are no definitive diagnostic tests. Diagnosis unknown, but a viral link is suspected. Persons for messages that travel back and forth between depends on age, history and presenting signs and with impaired immune system abnormalities or the brain and the body’s peripheral areas.4 symptoms.4,9 Nursing assessment may be critical those taking phenytoin seem to be at increased to the diagnosis of this and other diseases that The peripheral nervous system is composed of risk to develop the disease.9 Treatment includes occur in the elderly adult. the cranial nerves, spinal nerves, the somatic and chemotherapy and, in localized cases, radiation. autonomic nervous system, and the reflex arc. There is no cure for Parkinson’s disease. Another option is the administration of There are 12 pairs of cranial nerves that transmit Treatment focuses on symptom relief and monoclonal antibodies, specifically rituximab.24 motor and/or sensory communications between maximizing function for as long as possible. Both types of lymphoma may be curable, the brain or brain stem and the head and neck.4 Drug therapy generally includes levodopa, a depending on the stage of the malignancy, with There are 31 pairs of spinal nerves that transmit dopamine replacement; physical therapy; and radiation and aggressive chemotherapy. However, messages to and from various regions of the in very severe cases, stereotactic neurosurgery older adults may not be able to tolerate such body.4,9 The somatic nervous system functions as or the controversial treatment of fetal cell intense treatment. The geriatric patient may need the link between the brain via the spinal cord to transplantation.24 assistance with activities of daily living as he muscles and sensory receptors. The autonomic Assessment tip: Dosages of anti-Parkinson drugs undergoes treatment for the disease, which may nervous system is responsible for maintaining may need to be decreased in elderly patients take six months or longer.9 homeostasis.9 because of inability to tolerate higher doses Patients should also take every precaution to It can be a challenge to differentiate between of such medications. Patients must be taught avoid infection. They should avoid crowds, and normal aging changes of the central nervous to recognize medication side effects, such as family members and friends who are ill, even system and pathology. The impact of aging on the orthostatic hypotension, irregular heartbeats, with minor infections such as colds, should not nervous system varies quite a bit among elderly anxiety or confusion.24 come into contact with the patient. adults. Experts recommend that health care Transient ischemic attack (TIA) or “mini- professionals “not treat normal aging changes as The nervous system disease. A common myth is that cognitive decline stroke” The nervous system consists of two systems: is inevitable.”9 There are some age-related Mrs. Stephens is 80 years old, She lives with the central nervous system and the peripheral changes in memory and attention, but older adults her husband, who is 81 and dealing with nervous system. The central nervous system retain the ability to learn new things and live prostate cancer. During an appointment with consists of the brain and the spinal cord. It is independently as long as neurological disease and his oncologist, Mr. Stephens tells the nurse responsible for the integration of all nervous pathologies do not occur.9 practitioner that he is worried about his wife. system activities.9 He says, “I think there might be something Here are some normal age-related changes of the Parts of the brain include the cerebrum, the wrong with my wife. Sometimes she acts like nervous system.4,9 brain stem, the cerebellum, the limbic system she doesn’t know what’s going on. Her speech  Decrease in size and weight of the brain. and the reticular activating system (RAS).4 The gets really funny, and she can hardly walk. It  Decrease in number of neurons. cerebrum contains the nerve center that controls only lasts for a few minutes, and then she is  Decrease in short-term memory. intelligence and motor and sensory function. OK. But I don’t think this is good.”  Decrease in blood flow to the brain. The brain stem serves as the relay center for  Decrease in coordination. Mr. Stephens is right to be concerned about his messages between the various parts of the  Decrease or absence of deep tendon reflexes. wife. Transient ischemic attack (TIA), often nervous system. The cerebellum is responsible  Decrease in responses and movements. referred to as a “mini-stroke,” is a neurologic for maintaining muscle control, balance and  Increase in pain threshold. deficit caused by microemboli that temporarily coordination. The limbic system initiates the  Increase in incidence of physiologic tremor. interrupt blood flow in the cerebral circulation. basic human drives such as hunger, emotional  Decreased reaction time. This interruption causes symptoms that correlate and sexual arousal and aggression. The RAS  Sleep disturbances become more common, with the area of the brain affected and may assesses all incoming sensory information and including insomnia and loss of REM sleep. include double vision, slurring speech, trouble sends it to the appropriate areas of the brain  Incidence of mood disorders and depression walking, falling and dizziness. The effects last for interpretation. It is also imperative for increase. from seconds to hours and resolve spontaneously. maintaining consciousness.4,9 There is not permanent damage from TIAs, but Normal age-related changes may mimic The brain is divided into the right and left their occurrence is considered to be a warning pathological changes. Here are some common hemispheres, which are further divided into four sign of impending stroke. Incidence increases diseases of the nervous system seen in elderly lobes: frontal, temporal, parietal and occipital.9 It significantly after the age of 50 and is greatest persons. 9,24 is important to know the functions of the various among men and African-Americans. lobes because damage to one or more locations Parkinson’s disease The occurrence of TIAs indicates a need for affect various body system functions. Parkinson’s disease is a chronic, progressive meticulous assessment and actions to prevent the  The frontal lobe is responsible for disease characterized by progressive muscle occurrence of stroke. personality, judgment, abstract reasoning, rigidity, involuntary tremor, akinesia and some aspects of language (Broca’s area), dementia. Complications include aspiration Cerebrovascular accident (stroke) motor function, problem solving, reasoning pneumonia, infection, injury from falls, urinary Stroke is an abrupt impairment of cerebral and memory.4,9 tract infections and compromised skin integrity. circulation. This impairment interrupts the  The temporal lobe is responsible for language Parkinson’s disease in found in two out of every flow of oxygen to the brain, which can cause comprehension (Wernicke’s area), some 1,000 people. It usually develops after the age of serious damage to brain tissue. Depending on the memory recall and hearing.4,9 50, but can occur in children and young adults.24 location and extent of damage, the patient can be  The parietal lobe integrates sensory left with serious disabilities that may affect all The cause of Parkinson’s disease is not 24 information such as temperature and taste. aspects of daily living. known, but research suggests that exposure to It also interprets, size, shape, texture and 9,24 environmental toxins or genetic predisposition There are three major types of stroke. distance.4,9  may play significant parts in its development.  Thrombosis: The most common cause in  The occipital lobe interprets visual stimuli.4,9 Studies of the pathophysiology of the disease middle-aged and elderly adults, thrombosis The spinal cord reaches from the first cervical show that a dopamine deficiency inhibits the causes ischemia in brain tissue affected by vertebrae to the lower border of the first lumbar affected brain cells from functioning normally.23 diminished circulation.

Elite Page 75  Embolism: The second most common cause of adherence to treatment regimens and how  Avoid extensive conversation. Allow patient of stroke, embolism is due to the occlusion of to avoid injury in the event of seizures. Family to concentrate on eating and swallowing. a blood vessel by a fragmented clot, tumor, members and caregivers must be involved in  Plan meals with patient’s food preferences in fat, or air. patient education as well. mind.  Hemorrhage: The third most common cause The gastrointestinal system Constipation of stroke, hemorrhage is due to a sudden The gastrointestinal system undergoes quite Constipation affects up to 20 percent of older rupture of a cerebral artery. a few changes with aging. These changes can adults in the community and between 50 percent Signs and symptoms depend on the location of have significant impact on a person’s nutritional and 75 percent of those living in long-term care the stroke and may include speech impediments, status and general health and well-being. The facilities.9 Factors that contribute to constipation paralysis or weakness of the extremities, gastrointestinal (GI) system is responsible for in the elderly include lack of adequate fluid disorientation, vision disturbances, headaches, digestion, absorption, secretion and motility.9 intake, lack of adequate fiber in the diet, and side vomiting and coma.24 effects of medications. Normal age-related changes in the GI system The sooner the patient receives emergency include:9 Here are some tips to reduce constipation:4,9 medical intervention, the better the chances  Decrease in salivary secretion and the  If constipation is due to medications, consult for survival. Emergency administration of number of taste buds. with physician or nurse practitioner about medications includes:24  Decreased esophageal mobility. possible changes in medication regimen.  Tissue plasminogen activator to dissolve  Decreased size and weight of the liver.  Increase fluid intake unless contraindicated. clots in non-hemorrhagic stroke. It must be  Decreased rate of fat, mineral and vitamin  Increase fiber intake. administered within three hours of symptom absorption.  Increase whole grain, fruits and vegetables onset.  Tooth enamel and dentin erode. intake.  The antiplatelet drug ticlopidine may be  Increased incidence of gastroesophageal  Participate in exercise as tolerated. effective in preventing stroke and in reducing reflux.  Add stool softeners or laxatives under the risk for future strokes in patients who  Increased incidence of constipation. medical supervision. have already suffered one.  Delay in gastric mobility and emptying. Assessment tip: Patients need to be evaluated  Corticosteroids may be administered to Assessment tip: Many medications can add for possible serious cause of constipation, such reduce cerebral edema and anticonvulsants to the age-related changes in the GI system. as impaction or bowel obstruction. Be alert to given to prevent seizures. These include antidepressants, antihistamines, additional symptoms, such as severe abdominal Patients will need long-term follow-up and antihypertensives, calcium channel blockers, pain, nausea and vomiting, which may indicate rehabilitation. diuretics and laxatives.9,14 bowel obstruction, or a lump or thickening in the lower abdomen, indicating a growth or tumor. Measures to reduce the risk for stroke include:24 These changes contribute to a number of common  Participate in a regular exercise program. age-related disorders in the geriatric patient. Fecal incontinence and diarrhea  Stop smoking. Dysphagia When evaluating diarrhea, determine the quality  Monitor blood pressure and take anti- of diarrhea. For example, are the stools loose but Dysphagia is the most common esophageal hypertensives as ordered. formed, or watery? Is the diarrhea accompanied problem in older adults.9 It is characterized  Reduce salt intake. by cramps, frequency and/or urgency? How many by trouble with any part of the mechanism of  Reduce the intake of saturated fats. times a day does diarrhea occur?  Eat at least two servings of fish per week. swallowing foods or liquids. This problem  Eat five or more servings of fruit and inhibits adequate nutritional intake and can Diarrhea may be due to viral, bacterial or vegetables every day. adversely affect the older adult’s health and well- parasitic infection; medications; tumors; or stress.  Eat six or more servings of grain products being. Treatment measures include identifying and correcting underlying causes and medications to every day. When assessing swallowing, the nurse should relieve symptoms. be aware of factors than increase the risk of Seizures disorders dysphagia.4,9 Fecal incontinence may accompany diarrhea or Seizures occur when there is an acute, abnormal  Reports of dysphagia from patients, families, exist with normal quality bowel movements. release of electrical activity in the brain. Seizures or caregivers. It may be due to cognitive impairment, tumors may be partial or focal or generalized. Focal  Observation of drooling or dribbling. or muscle weakness. Correction of underlying seizures include a brief change in level of  Observation that patient has trouble causes is necessary, and a bowel-training program consciousness characterized by a blank stare, controlling food or liquids in the mouth. is often indicated. rolling of the eyes and/or a brief change in level  Facial drooping or facial paralysis. of consciousness. Generalized seizures can Assessment tip: Bloody stools or passage of  Changes in mental acuity that affect eating. include muscular jerks of the extremities or entire blood is a medical emergency and requires  Slurred speech. body, incontinence, difficulty breathing, apnea immediate evaluation and intervention!  Coughing. and loss of consciousness.9,24  Pocketing food in mouth. Gastroesophageal reflux disease The nurse should assess when and how often  Changes in voice quality (e.g. weak voice, Gastroesophageal reflux disease (GERD) is the seizures occur and what occurs during seizures. hoarse voice) when eating. backflow of gastric and/or duodenal contents Some adults may have had seizures for many  Existence of neurologic problems and/or into the esophagus. GERD is due to problems years due to problems such as epilepsy. They may muscle disorders. with deficient pressure of the lower esophagus, also develop epilepsy in old age. Adults over 75 Symptoms range from none at all to heartburn of Underlying causes, such as tumors, dementia, are twice as likely to develop new-onset epilepsy varying degrees of severity, and pain that radiates neurologic diseases and so on, should be than all adult age groups less than 65 years of to the neck, jaws and arms. The patient may identified and corrected or treated. Here are some age.24 awaken during the night with coughing and a tips to help reduce dysphagia.9,24 mouthful of saliva.24 Nurses should find out what, if anything, triggers  Be sure that the patient is seated comfortably seizures and what treatment measures are in in an upright position. Many patients, and even health care place to control the occurrence of seizures.  Encourage a calm, pleasant atmosphere professionals, may believe that these symptoms Patient education should stress the importance during meals.

Page 76 Elite are trivial and unlikely to indicate a serious health Peptic ulcers are defined as circumscribed lesions Age-related changes associated with kidneys, problem. In reality, GERD may be responsible in the mucus membrane and can be located in the ureters, bladder and urethra include the for 1,700 deaths annually in the United States.9 lower esophagus, stomach, pylorus, duodenum, following:4,9 Complications include esophageal ulcer, or jejunum. Most peptic ulcers (about 80 percent)  Nighttime production of urine increases and hemorrhage, , hoarseness, are located in the duodenum. Gastric ulcers are ability to concentrate urine decreases. esophagitis and inflammation of the esophagus most common in middle-aged and elderly men.  Blood flow to the kidneys decreases. that can predispose the patient to the development Risk factors for peptic ulcer development include  Glomerular filtration rate decreases. of adenocarcinoma.9 chronic use of nonsteroidal anti-inflammatory  Bladder capacity is decreased. drugs, alcohol and tobacco products.24  Bladder contractility increases. Certain medications and substances can increase  Risk of overflow incontinence and urinary the risk of GERD. These include antichoinergics, Ulcer development is caused by infection retention increases in men. caffeine and alcohol, nicotine, beta blockers, with Helicobacter pylori and pathologic  Detrusor becomes unstable in women, potassium supplements, and non-steroidal anti- hypersecretory disorders. Gastric acid is believed causing an increased potential for inflammatory agents.9,14 to contribute to the development of infection.24 incontinence. Treatment of GERD focuses on relief and control Assessment tip: Blood type seems to influence  Prostate increases in size in men. of symptoms and promotion of esophageal peptic ulcer development. Gastric ulcers are  Half-life of drugs is prolonged due to a healing.9 Lifestyle changes are the first line of more common in people with type A blood, and reduction in renal function. treatment and include the following:9,24 duodenal ulcers are more common in people with Assessment tip: Assess for signs of drug toxicity  Diet: Avoid caffeine, chocolate, spicy type O blood.24 due to changes in excretion ability of the foods, carbonated beverages, orange juice, Signs and symptoms include heartburn and kidneys.9 tomato juice, alcohol and other beverages indigestion, bloating, abdominal distention, that stimulate the production of gastric acid. Common age-related problems of the kidneys and and nausea. Specific symptoms are as follows. Reduce fat content in diet. related structures include the following:9,24 Duodenal ulcers cause heartburn, localized mid-  Positioning: Avoid lying down for at least epigastric pain that is relieved with eating, weight Urinary incontinence two hours after eating. Sleep with the head gain because patients eat to relieve pain, and an Urinary incontinence affects over 13 million of the bed elevated six to eight inches. Avoid unusual sensation of hot water bubbling at the adults.9 It is of considerable concern to older lying on right side, which encourages reflux. back of the throat. Gastric ulcers cause heartburn adults, who are often ashamed and embarrassed  Weight: Achieve or maintain normal weight. and indigestion, pain with eating since food by the problem. They may not seek help for this  Tobacco products: Avoid use of tobacco causes the gastric wall to stretch, thus causing problem because they assume it is a normal part products. pain, and feelings of fullness and bloating.24 of the aging process. Be sure to assess the older  Stress: Participate in stress reduction efforts. patient for urinary incontinence, because this  Alcohol: Reduce or avoid the intake of Treatment includes antibiotic therapy, analgesics 24 is a problem that can be treated, reduced, and alcohol. and drugs to reduce gastric acid production.  sometimes eliminated.  Medications: Ask about possible alterations Colorectal cancer in medical regimen. There are several types of urinary incontinence.9 Colorectal cancer is the most common cancer  Clothing: Avoid clothing that fits tightly.  Stress incontinence occurs when urine is that develops after the age of 65.9 Early diagnosis  Exercise: Do not exercise within one hour involuntary expelled when a person laughs and treatment is associated with improvement after meals. or coughs. The muscles of the pelvic floor or in survival. Routine colonoscopies are the best  Hydration: Drink six to eight ounces of urethral sphincter are not strong enough to diagnostic tool for early diagnosis. water with medications. control the loss of urine. Signs and symptoms may not appear until the  Overflow incontinence occurs when the If lifestyle changes do not control GERD, disease is advanced. They include overt or covert bladder muscles stretch beyond their ability medications may be necessary. These include:14,24 bleeding; change in quality and/or quantity of to contract or when the urethra is blocked.  Promotility agents that improve lower bowel movements; black, tarry stools; cramps;  Urge incontinence occurs when there are esophageal sphincter tone and stimulate urgent need to defecate when first getting up in strong, unexpected contractions of the upper GI motility. the morning; feelings of fullness or incomplete bladder muscles and the internal sphincter  Proton pump inhibitors and histamine evacuation of stool; and blood or mucus in the cannot hold the urine in the bladder. receptor antagonists to reduce gastric acidity. stool. 9,24  Functional incontinence is due to a cause  Over-the-counter antacids, which may not associated with the urinary system. reduce symptoms but may cause side effects Treatment depends on the extent of the tumor For example, the older adult may not be such as diarrhea, constipation and acid-base and the stage of the disease. It can include able to get to a bathroom in time to avoid disturbances. simple removal of the tumor, removal of part of the intestine, radiation and/or chemotherapy. incontinence or he may be physically unable In severe cases, surgery may be necessary to A colostomy may be needed. This could be to reach a bathroom by himself. Another control symptoms, prevent complications and temporary or permanent.24 example is that of the adult whose cognition stop hemorrhage. is impaired and who does not recognize the Assessment tip: Elderly adults may assume Assessment tip: Stress the importance of lifestyle need to void. that symptoms of colorectal cancer are due to changes as the first line of treatment for GERD. aging changes and not report them. Educate Treatment interventions include bladder training. Such changes are also helpful to promote overall patients, families and caregivers about the signs Bladder training involves training the bladder health and, if effective, can reduce or eliminate and symptoms of this type of cancer and the to hold gradually increasing amounts of urine the need for medications and/or surgery. importance of appropriate preventive screening. by extending the time between trips to the Peptic ulcers bathroom. Pelvic floor exercises, also referred to The genitourinary system as Kegel exercises, may also be helpful. These It is estimated that 10 percent of adults in The genitourinary system is composed of the exercises involve tightening the bladder muscles the United States have peptic ulcer disease. kidneys, ureters, bladder, and urethra, and the and releasing them in patterns of 15. A general Hospitalization, morbidity and mortality rates for reproductive organs. Since this system is so broad exercise program may also help to strengthen peptic ulcer disease are higher in older adults as in scope, this section concentrates on those issues appropriate muscles. Bladder irritants such as compared to younger persons.9 most closely associated with the aging process. spicy foods, carbonated beverages, caffeine,

Elite Page 77 and alcohol, may be avoided.9 There are also a  Diminished ejaculation in men and the Recent controversy over screening number of protective undergarments that can be need for more time and stimulation to reach recommendations from various health care worn to protect clothing, stop odor and decrease arousal. groups has led to some confusion about the embarrassment.  Increased incidence of erectile dysfunction value of screening. In general, recommendations in men. include yearly mammograms for women over Urinary tract infections  Drastically decreased estrogen levels in the age of 40, monthly self-breast examination, Older adults are especially vulnerable to urinary women, which leads to vaginal dryness and and yearly breast examination by a health care tract infections (UTI). UTIs in older adults are possibly painful sexual intercourse. professional.9 There is some question about the often asymptomatic. Antibiotic therapy may be  Increase in facial hair in women. value of mammography for the very old woman. prescribed, although, in some asymptomatic  Increased length of time for arousal in Screening techniques and their value should be cases, no treatment may be initiated.9 women. discussed with the woman’s health care provider. Assessment tip: In elderly adults, the most These changes do not prevent older adults from Treatment of breast cancer includes a variety of common symptoms of UTI are often lethargy and having a satisfying sex life. It is important to options based on the stage of the disease. For changes in mental status.24 assess sexuality as part of physical assessment. localized tumors without metastasis, lumpectomy Tips to prevent UTIs include:24 For more detailed information about sexual and radiation are often the treatments of choice.24  Maintain adequate hydration. Cranberry assessment and interventions see the section However, a growing number of women are juice may have some properties that fight on Sexual assessment presented earlier in this choosing to have mastectomies to avoid the need infections. education program. for adjunct therapy and to decrease the chances  Void promptly when the urge to urinate of recurrence. Some women with unilateral breast Common gynecological malignancies in occurs. Don’t wait a long time between cancer and some with a strong family history voiding. older women or the presence of genetic markers are choosing  Wipe from front to back after going to the Uterine, breast and ovarian malignancies are to have bilateral mastectomies to reduce their bathroom. more common in older women than in younger risk for developing the disease in the unaffected  Avoid using products such as douches and women. Uterine cancer is the most common breast or to prevent the occurrence of the disease 9 perfumes and scented powders over the gynecological cancer in older women. The most at all. Radiation and/or chemotherapy may also genital areas as these can irritate the urethra. common symptom is bleeding from the vagina be part of the treatment regimen. Treatment after menopause. Other signs and symptoms options should be discussed at length with the Benign prostatic hyperplasia include weight loss and pain, but these do not woman’s health care team. Ultimately, she must 24 Benign prostatic hyperplasia (BPH) affects appear until the disease is advanced. make the choice (e.g. lumpectomy, mastectomy about half of men between 51 and 60 years of Treatment includes surgery, which is generally a or even refusal to have surgery) herself. It is age and 90 percent of men over 80.9 Signs and total abdominal hysterectomy. Hormonal therapy, important that health care providers maintain an symptoms include decreased urinary stream and radiation therapy and chemotherapy in various objective attitude. Breast cancer triggers not only force, feeling of incomplete bladder emptying, combinations are generally part of the treatment fear of death but also the fear of disfigurement. frequency and urgency, dribbling, incontinence, regimen. 24 Women are usually quite concerned with the difficulty initiating voiding, and, at times, 24 cosmetic effects of breast cancer treatment. hematuria. Seventy-five percent of ovarian cancer cases Reconstruction options should be presented to occur in women over 55. Unfortunately, The only effective treatment is surgical removal women undergoing mastectomy. prognosis is often poor, especially in older of the prostate tissue. Such tissue is always women. There is no screening test at this time. Assessment tip: Lymphedema is a potential biopsied to rule out malignancy. However, the CA-125 blood test for tumor complication of lymph node removal. The patient Malignancies markers does exist. It is not recommended as must be taught to exercise her arm(s) and hand(s) Bladder cancer is fairly common in older adults, a screening tool because there are no data to to avoid the development of this potentially with men nearly four times as likely as women to support the hope that such screening would debilitating complication. 9 develop this malignancy. Symptoms are similar decrease mortality. The musculoskeletal system to UTI. The first symptom is often painless Ovarian cancer is the leading cause of The musculoskeletal system includes the bones, hematuria.24 As with other cancers, treatment gynecological deaths in the United States.24 muscles, ligaments, bursae and joints. The bones depends on the stage of the disease and its exact Symptoms are generally vague and include or skeleton provides the forma and support of location. Chemotherapy, surgery and radiation abdominal discomfort, dyspepsia, feeling of the body. Muscles move the various body parts. may be part of treatment plan. being bloated, urinary frequency, abdominal Joints, the areas where two bones are attached, The incidence of prostate cancer in men is even distention and weight loss.9,24 provide stability and facilitate mobility.9 higher than that of bladder cancer.9 Symptoms are Treatment includes removal of the uterus, Changes in the musculoskeletal system may have usually not evident until the disease is advanced. ovaries, fallopian tubes and omentum. adverse effects on mobility and decrease the That is why it is so important to have a prostate Aggressive therapy is usually indicated, including independence of older adults. Normal age-related examination as part of the annual physical exam. chemotherapy and sometimes radiation.24 changes include:4,9 Symptoms include lower back pain, difficulty  Decreased range of motion of some joints. According to the American Cancer Society, initiating urination, dribbling, retention of urine,  Loss of bone mass. 24 breast cancer affects approximately one in and hematuria. Radiation is used to treat locally  Loss of height. every 14 women over 60 years old. Risk factors invasive lesions. Surgery and hormone therapy  Joint degeneration. include: age, family history of breast cancer, also may be used in conjunction with radiation  Arthritic changes of the joints. 24 early menarche and late menopause, ingestion therapy.  Problems maintaining balance. of hormonal contraceptives, use of hormonal  Problems with the feet, such as corns, Issues related to reproductive organs replacement therapy for more than five years, bunions and calluses. Age-related changes in the reproductive system never having been pregnant, had first pregnancy 9  Muscles atrophy. include: after the age of 30, personal history of breast   Bones become stiffer and brittle.  Decreased libido. cancer, regular use of alcohol, history of ovarian   Breast tissue atrophies. cancer and exposure to low-level ionizing These changes increase the risk of the following radiation.9,24 problems.

Page 78 Elite Osteoporosis and development of new bone at the joints. future infections of the virus that causes mumps. Osteoporosis is a metabolic bone disorder and is Symptoms often begin after the age of 40 and Vaccines also cause the body to develop acquired the most common metabolic disease, affecting progress with age.24 active immunity. Booster vaccines may be necessary to maintain immunity.4,9 half of all women during their lifetimes. Although Signs and symptoms include a deep, aching joint its occurrence is higher in women, men are also 9,24 pain, morning stiffness, weather-related aching Acquired passive immunity is acquired when a affected by the disease. pain, joint instability and poor posture.24 serum that contains specific antibodies is given to a person who is vulnerable to a particular Osteoporosis occurs when the rate of bone Treatment is aimed at symptom relief and disease. For example, gamma globulin may resorption increases while the rate of bone minimizing disability. Joint replacement surgery be administered to prevent the development of formation decreases, leading to a loss of bone may be necessary. Assistive mobility devices and hepatitis A.9 mass. The exact cause is unknown, but prolonged anti-inflammatory medications are also used.24 negative calcium imbalance is probably a The components of the immune system include Falls contributing factor. The most common presenting organs and tissues rich in lymphocytes. The two Falls are certainly not a disease condition. But symptom is back pain. A loss of height is primary lymphocytes are B cells and T cells. they are a significant health problem of older common, and the risk of fractures and falls is These cells are found throughout the body, but 24 adults. In fact, falls are the leading cause of death high. are predominant in the lymph nodes and spleen. in persons over the age of 65.24 As age increases, There is no cure for osteoporosis. The goals They possess receptors that respond to specific so does the risk of falls and the death rate from of treatment are to slow or prevent loss of antigens.26 Antigens are substances (usually falls. bone, avoid fractures and reduce pain. Calcium proteins) that are recognized by the body as and vitamin D supplements may also be Fall prevention is a key goal of gerontological foreign and can produce an immune response. recommended.9,24 nursing. Some tips to prevent falls include: This response involves producing antibodies  Make sure patients wear glasses as needed. to attack the foreign substance. Antibodies are Assistive devices such as walkers or canes Assess the home environment for adequate specific to the antigens that trigger them.26 may be used to provide stability when walking. lighting. Patients should be taught safety precautions and The older person’s immune system is not as  Assess the home for safety. Remove small measures to avoid falls. effective as that of a younger person. However, area and “scatter” rugs, which may cause the exercise, diet and emotional well-being all There are steps that can be taken to reduce the older adult to trip. contribute to boosting the immune system and risk of osteoporosis. These steps may also be part  Are there stairs in the older person’s home? If enhancing health and wellness. Specific age- of the treatment regimen for the disease. These so, are there safety rails to support the older related immune system changes include:4,9 steps include:24 adult as he ascends and descends the stairs?  Reduction in the rate and strength of the  Ingest adequate amounts of calcium and  Does the patient use assistive devices for immune response. vitamin D. Postmenopausal women and all mobility? If so, are they appropriate to the  The number of available B cells decreases. women and men over the age of 65 should older adult’s needs? If he does not use such  The manufacture of antibodies that fail ingest 1,500 mg of calcium and at least devices, does he need them? to differentiate between the person’s own 800 international units of vitamin D on a  Is the older adult alert and oriented? If not, is body and foreign substances increases. This daily basis. Vitamin D is necessary for the there someone in the home to help him with makes the older adult more vulnerable to absorption of calcium and enhances muscle safety issues? autoimmune disease development. strength. Some older adults may understand  Does the adult get adequate amounts of  There is an overall decrease in cellular the need for calcium supplements but fail sleep? Does he seem to be tired or fatigued? immunity. to realize the need for vitamin D. Patient Lack of rest and/or fatigue or weakness education should include an explanation of increase the risk of falls. As part of the assessment of the immune system, the need for adequate amounts of calcium as the nurse must recognize those factors that can Assessment tip: More than 95 percent of hip well as vitamin D on a daily basis. have an impact on the immune system. fractures are the result of falls. Hip fractures  Alcohol intake should be limited. Having  First, as with most body systems, a person’s are associated with complications such as more than two alcoholic drinks per day may general state of health and wellness impacts permanently decreased mobility and death.9 decrease the formation of bone. Alcohol may the effectiveness of the immune system. A also adversely affect the body’s ability to The immune system nutritious diet, adequate rest and relaxation, absorb calcium. The immune system is responsible for defending and social interaction with family and friends  Limit the intake of caffeine. No more than the body against infection. The immune system all contribute to good health. Patients should two to three cups of beverages containing must recognize the normal components of the also be encouraged to have preventive caffeine should be consumed per day. body and differentiate between these components screenings as recommended by their health Some patients may assume that caffeinated and foreign substances that are potentially care providers. beverages means “coffee.” They should be harmful. There are three types of immunity.  Research suggests that the regular exercise taught that chocolate, colas and teas also Natural immunity is “natural” to the body and may slow the rate or even prevent age- contain caffeine. not produced by an immune response (e.g., an associated decline in the immune system.  Participate in an appropriate exercise immune response triggered by a vaccine). A Benefits of regular exercise include program. Exercise helps to slow the rate of human is born with natural immunity. Examples reduced risk for infection, enhanced bone loss and increase bone strength. Weight- of natural immunity include immunity to diseases vaccine efficiency, increased rate of healing bearing exercises are important to help that affect animals but not humans. Natural after infection and improvement in the increase bone strength. Exercise programs passive immunity is natural immunity that comes performance of activities of daily living. should be designed and implemented under as a mother’s antibodies cross the placental Older adults may find that the practice of the supervision of the geriatric patient’s barrier to the fetus. This type of immunity is only moderate, slow-movements, such as those health care provider. temporary and generally lasts for the first three to performed in tai chi, a Chinese exercise six months of the infant’s life.4,9 of ancient origin, have a positive impact Osteoarthritis on cardiovascular and respiratory function Osteoarthritis is the most common form of Acquired active immunity occurs as a result as well as mental acuity, balance, muscle arthritis. It is a chronic disease that causes of the body’s response to a foreign substance. strength, flexibility and immune system deterioration of the cartilage of the joints For example, if a person has the mumps, his response.24 body responds by developing protection against Elite Page 79  Stress reduction is important to most, if 30 minutes after the person is exposed to an many older adults have unprotected sex, not all, aspects of health. Stress related antigen (or allergen). These disorders are believing that since the risk of pregnancy is no to living alone, the death of loved ones, referred to as anaphylactic, immediate, atopic longer an issue among older couples, there is no financial concerns and/or concerns about or IgE-mediated reactions. Sometimes, as in need for protection. dealing with chronic illness all may have an the case of anaphylactic reactions, the type The rates of sexually transmitted disease are impact on health. Additionally, many older 1 hypersensitivity reaction may be life- increasing among persons who live in retirement adults are providing caregiver services to a threatening. Other examples include reactions communities. This also includes an increase in spouse or other elderly significant others. to insect stings, food and drug reactions, and the incidence of HIV infection in this population.9 This, too, is a stressful situation. Stress can some cases of urticaria (hives).9,26 elevate heart and respiratory rates, blood Assessment tip: Asthma is a common type 1 When HIV was first recognized as a serious pressure, and adversely affect emotional hypersensitivity reaction that is often both health problem, the primary means of stability and ability to concentrate. It may under-diagnosed and under-treated in older transmission of the virus in older adults was via also have a negative effect on the immune adults.9 blood transfusion. But today, the risk of infection system. The relationship between stress and  Type II hypersensitivity disorders seems to be primarily due to intravenous drug use the effectiveness of the immune system is are referred to as cytotoxic, cytolytic and sexual activities. As a result of the increasing currently the focus of a number of research or complement-dependent cytotoxicity incidence of HIV infection, the Centers for endeavors.24 reactions.26 They also occur within 15 to Disease Control (CDC) recommends that routine  The effects of long-term and chronic illness 30 minutes of exposure and include such HIV testing should be initiated in all health care can have an adverse effect on the ability of problems as transfusion reactions, drug settings for persons between the ages of 13 to 64.9 the immune system to function. Both physical reactions and autoimmune hemolytic Assessment tip: When assessing the health and mental health problems can have a anemia.9  status of an older adult, the nurse should provide negative impact on the immune system. Since  Type III hypersensitivity disorders are patient education regarding sexually transmitted the immune system is interrelated with many referred to as immune complex disease 26 diseases, including HIV. Such education is often other body systems, problems in one system reactions. They are characterized by the automatic when working with younger patients. can affect one or more other systems. body’s failure to remove antigen-antibody Age should not preclude the nurse from offering complexes from the circulation and tissues.9 There are a number of diseases related to this type of education to her geriatric patients. Examples of type III disorders include defective immune system responses. Here are reactions that are associated with infections Vulnerability to infections in the older some that are common in the elderly population. such as hepatitis B and bacterial endocarditis, adult Hypersensitivity problems cancers, and autoimmune disorders such As the immune system undergoes age-related Mrs. Slater is 68 years old. She recently as systemic lupus erythematosus (SLE).9,26 changes that reduce its effectiveness, nurses need retired from her job and is looking forward Rheumatoid arthritis also is thought to be a to be aware that older patients are at increased to spending more time with her family type III disorder that affects older adults.9 risk of infection. This risk includes viral and friends. Mrs. Slater lives in Florida,  Type IV hypersensitivity disorders are infections such as influenza; bacterial infections, where the climate allows her to spend time referred to as delayed or cell-mediated such as pneumonia; and infections following gardening year round. Mrs. Slater has a hypersensitivity reactions.26 Tissue damage surgery or other open wounds. Even a slight lengthy history of coughing and becoming occurs due to a delayed T-cell reaction to an laceration may result in a serious infection. slightly short of breath when working in her antigen. Reactions after exposure take place Because of its prevalence, it is appropriate to garden, especially in the spring, when her within one day to two weeks, but may be discuss pneumonia as a problem of particular garden is in full bloom. She also sneezes and even slower in older adults.9 Examples of concern among the elderly. The prognosis her eyes water. These symptoms, especially type IV hypersensitivity disorders include is generally good for persons with normal the cough and shortness of breath, have dermatitis from a latex allergy, sarcoidosis, respiratory function and intact immune systems. slowly, insidiously become worse with age. tuberculin reactions and transplant However, among the elderly, who may have a She has always attributed such symptoms to rejections.9,26 compromised immune system or are dealing “allergies,” but at her husband’s insistence, Immunodeficiency disorders with chronic disease or disorders, pneumonia is she visits their family doctor for evaluation. Mr. St. John is a 75-year-old retired a leading cause of death in people over the age Mrs. Slater is indeed allergic to some construction worker who is infected with of 65. Not only is it the most common hospital- environmental substances, such as pollen, the human immunodeficiency virus (HIV). acquired infection (nosocomial infection), but but she also has asthma, a frequently under- His infection has been traced to a blood it also has the highest mortality rate of such diagnosed problem in older adults. transfusion Mr. St. John received many infections.9 Mrs. Slater’s situation illustrates what is referred years ago. He has difficulty dealing with the To add to the problem of pneumonia among older to as a hypersensitivity problem. Hypersensitivity disorder and says he is “ashamed.” He is adults, the signs and symptoms of the disease in problems are excessive immune responses that doing well on his treatment regimen, and his this population are often atypical. The cardinal occur when the immune system has an excessive wife of 50 years is supportive. But Mr. St. signs of fever, chest pain, chills and shortness of response to various triggers.9 John needs help dealing not only with the breath may be subtle and not obviously apparent. physical components of HIV infection but Hypersensitivity disorders or responses are Persons over the age of 65 are urged to receive with its emotional consequences as well. classified as type 1 through type IV. Classification pneumococcal vaccine.9,24 depends on which immune system activity causes Infection with HIV is often underreported and Assessment tip: Older adults who live alone tissue damage.26 A hypersensitivity response does under-diagnosed in the elderly population. in the community seem to be at particular risk not usually occur with the first exposure to the Although the average age of patients who are for not being diagnosed until pneumonia has antigen that eventually causes a symptomatic first identified as HIV positive is progressively reached an advanced stage.9 This could be response. As the body encounters the antigens on increasing, both older adults and some health that the symptoms are so subtle that the patient a recurring basis, the excessive immune response care workers seem to lack knowledge about may assume he has a cold or simple viral results in hypersensitivity reactions.9,26 the potential for HIV infection in the elderly infection. Teach older patients to be aware of  Type 1 hypersensitivity disorders are population. Older persons who have had multiple the prevalence of pneumonia and to recognize immediate, usually occurring within 15 to sexual partners in their youth continue to have the signs and symptoms as they appear in the multiple partners as they age. Unfortunately, Page 80 Elite older population. When possible, teach family 25. MedicineNet.com. (2010). Heart attack symptoms: Different in women! Retrieved August 30, 2010 from www.medicinenet.com/script/main/art.asp?articlekey=19561. 8. A normal finding when assessing the members, friends and caregivers about the signs 26. Comerford, K. (Ed.). (2009). Anatomy & physiology made incredibly easy (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. skin of an older adult is the presence of and symptoms that indicate pneumonia. The a multicolored lesion with nodules and earlier the disease is recognized, the more prompt irregular black outline. and effective the treatment. GERIATRIC ASSESSMENT True False Summary Self Evaluation Exercises Nurses working with geriatric patients have Choose True or False for questions 9. Research has demonstrated that on average, unique opportunities to promote health and 1 through 10 and check atypical symptoms of heart attack in women wellness throughout a long and hopefully your answers at the bottom of the page. include complaints of indigestion and productive life span. Although basic assessment discomfort in the back, neck, stomach or techniques of interview, observation, You do not need to submit this self- jaw. auscultation, percussion, and palpation are evaluation exercise with your participant similar for all age groups, the unique aspects of True False sheet. geriatric assessment require that the nurse have an in-depth understanding of how the body ages 1. According to the World Health 10. To cure osteoporosis, patients should be and a respect for older patients and their wealth Organization, the fastest-growing segment advised to take vitamin E supplement as of life experiences. of people over 65 are those 80 years of age well as calcium supplements. and older. Nurses also have unique opportunities to teach True False their colleagues about the older population and True False to dispel myths about this age group. All health care professionals should understand that “old” does not equate with “sick.” Most older adults 2. Members of the traditional generation live independently and enjoy their lives. Too prefer a more informal environment and many people believe that older adults are inactive prefer that young health care providers physically, mentally and sexually. Nothing could automatically address them by their first be further from the truth. names. The people in this age group deserves the respect True False and support of the health care profession. They also deserve the opportunity to access health 3. A frequent complication of dry mouth in care services provided by professionals who the older adult is the fungal infection oral understand how the body ages and want to serve candidiasis, more commonly known as as advocates for older adults. Work with your thrush. older patients to not only promote their health True False and well-being, but to also promote community awareness of the contributions older adults have made, and can continue to make, to their families, 4. As the body ages, there is as much as a 15 friends and communities. percent decrease in water content and an References increase in body fat. The extra fat means 1. EMS Responder. (2008). The geriatric patient. How to tailor your assessment and care. that the effects of fat-soluble drugs may be . Retrieved July 13, 2010 from www.emsresonder.com. Posted July 8th, 2008. 2. Horgas, A., & Miller, L. (2008). Pain assessment in people with dementia. American increased. Journal of Nursing, 108(7), 62-70. 3. Miller, L. L., et al. (2010). Enhancing the capacity to teach gerontological nursing: A faculty development project. The Journal of Continuing Education in Nursing, 41(5), True False 211-216. 4. Munden, J. (Ed.). (2006). Professional guide to assessment. Philadelphia: Lippincott Williams & Wilkins. 5. Page, J. B., Kowlowitz, V., & Alden, K. R. (2010). Development of a scripted 5. When assessing the sleep patterns of unfolding case study focusing on delirium in older adults. The Journal of Continuing Education in Nursing,41(5), 225-230. older adults it is important to know what 6. Palmer, M. H., & Paterson, J. (2010). Educating nurses to meet the needs of an aging population. The Journal of Continuing Education in Nursing, 41(5), 201-202. medications they are taking. Advise them 7. Sifton, C. B. (2007). Alzheimer’s care today: A new name, a new look, the same to take antidepressants such as Zoloft that evidence-based practical focus. Alzheimer’s Care Today, 8(3), 169-172. 8. Starr, L. A. (2010). Preparing those caring for older adults to report elder abuse. The have a sedating effect in the evening. Journal of Continuing Education in Nursing, 41(5), 231-235. 9. Tabloski, P. A. (2010). Gerontological nursing (2nd ed.). Upper Saddle River, NJ: Pearson Education. True False 10. United States Census Bureau. (2009). USA quick facts from the US census bureau. Retrieved July 26 from http://quickfacts.census.gov/qfd/states/00000.html. 11. Wallace, M. A. (2008). Assessment of sexual health in older adults. American Journal of Nursing, 108(7), 52-60. 6. Your first clue to depression in older adults 12. WebMD. (2009). Dental health and leukoplakia. Retrieved August 14, 2010 from www.webmd.com/oral-health/guide/dental-health-leukoplakia. may be the reporting of somatic complaints. 13. Zemke, R., Raines, C., & Fillpczak, B. (1999). Generation gaps in the classroom. Training, 36(11), 48-54. True False 14. Mosby. (2010). Mosby’s nursing drug reference (23rd ed.). St. Louis: Mosby Elsevier. 15. University of Florida IFAS Extension. (2007). MyPyramid for Older Adults. Gainesville, FL: Author. 16. Skidmore-Roth, L. (2006). Mosby’s Handbook of Herbs & Natural Supplements (3rd 7. Persons who commit sex abuse are more ed.). St. Louis: Mosby. likely to be women. 17. Healthcommunities.com. (2010). Overview, waking, non-REM,REM, sleep cycle, factors, age. Retrieved August 25, 2010 from www.sleepdisorderchannel.com/stages/ index.shtml. True False 18. Warden, V., Hurley, A. C., & Volicer, L. (2003). Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. Journal of the American Medical directors Association, 4(1), 9-15. 19. American Association of Geropsychiatry. (2008). Geriatrics and mental health: The facts. Retrieved August 27, 2010 from www.aagpgpa.org/prof/facts_mh.asp. 20. American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, D C: Author. 21. Twedell, D. (2007). Depression in the elderly. The Journal of Continuing Education in Nursing, (38(1), 14-15.

22. Stokowski, L. A. (2008). Forensic issues for nurses: Elder abuse. Retrieved August 20, 2008 from www.medscape.com/viewprogram/17048. 9.T.10.F

23. National Center on Elder Abuse. (2010). Elder abuse. Retrieved August 28, 2010 Answers: 8.F 7.F 6.T 5.F 4.T 3.T 2.F 1.T from www.ncea.aoa.gov. 24. Harold, C. (2009). Professional guide to diseases (9th ed.). Philadelphia: Lippincott Williams & Wilkins. Elite Page 81 NOTES

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