DISSEMINATED INTRAVASCULAR COAGULATION (consumptive coagulopathy)

·         A grave blood coagulation disorder occurs as a complication of conditions that accelerate clotting wherein activation of thrombin & fibrinolytic system results in simultaneous bleeding & thrombosis.

·         Caused by infections, obstetric complications, neoplastic disease, tissue necrosis, cardiac arrest, stroke, incompatible blood transfusion, etc.

Signs & Symptoms:

ü  Petechiae

ü  Ecchymosis

ü  Dyspnea

ü  Prolonged bleeding after venipuncture

ü  Joint pain

ü  Hemorrhage

ü  Purpura

ü  Oliguria

ü  Anxiety

ü  Restlessness

Screening & Diagnosis:

·         Hematology -  ↓platelets, RBC, fibrinogen, factor assay (II,V,VII), ↑fibrin split products, thrombin, PT, PTT, (+) protamine sulfate test 

·         ABG analysis – metabolic acidosis

·         D-dimer test – result (+) ; specific test for DIC

Treatment:

·         Medications

o    Anticoagulants: heparin, antithrombin III (ATnativ^®, Thrombate^® III)

·         Blood transfusion – platelets, PRBC, FFP, whole blood, volume expanders, cryoprecipitates.

·         Bed rest

·         Oxygen therapy

·         IV therapy : hydration, electrolyte replacement, heparin lock

·         Hemodialysis

Complications:

·         Acute renal failure

·         Shock

·         CVA

·         Convulsions

·         Hemorrhage

·         Coma

Nursing Interventions:

·         Administer prescribed medications & IV fluids.

·         Monitor cardiovascular, respiratory, & fluid balance.

·         Avoid intramuscular injections, enemas, rectal temperatures & straight razors.

·         Check all IV & venipuncture sites frequently for bleeding.

·         Enforce complete bed rest during bleeding episodes.

·         Monitor for transfusion reactions.

·         Monitor results of blood studies & report any signs of complications.

·         Maintain seizure precautions.

Concepts on Growth and Development

                                                     INFANCY (0-1)
I - ron supplement begins at 4-6 months
     Immunization schedule Hepatitis B is the first to be given at birth,2months and 6 months
     OPV (2,4,15 mos) DPT ( 2,4,6 mos)
N-o choking hazards
F- ear of strangers peaks at 8 months
A-llow the use of pacifier if NPO
N- ote the weight doubles at 6 months, triples in 1 year and quadruples at 2 1/2 years
T- rust vs. mistrust
S-olitary play

                                                   TODDLER (1-3 years)
T- alk to the child in simple terms
O- ffer choices to the child to provide control
D-o not leave alone near the bathtub or swimming pool
D-oubt and shame vs. Autonomy
L-earns about death beginning at the age 3
E- limination patterns (Toilet training begins at 18 months)
R-ituals and routines

                                                   PRE-SCHOOLER (3-6 YEARS)
P-lay is associative / cooperative
R-egression is common
E-xplain procedures
S-ame age group for room assignment
C- urious
H- ighly imaginative (imaginary playmate)
O-bserve for inintiative vs. guilt
O-ff limits to the kitchen (risk for poison and burns)
L-oss of body part ( mutilation) is a common fear

                                                  SCHOOLER (6-12 YEARS)
S- ame sex stage
C-ompetitive play
H-ero worship, realistic concept of death 9-10yrs
O-bserve for industry and inferiority
O-ff limits to vehicles (risk for accidents)
L- oss of control is a common fear
E-xplain procedures
R-egression is common


         

GASTROENTERITIS

GASTROENTERITIS (gastro/gastric flu; stomach flu)

·         Inflammation of the gastrointestinal tract both the stomach & small intestines which leads to acute diarrhea.

·         Caused by infection, viruses, bacteria, parasites (protozoa, helminths) or adverse reaction to medications.

·         Most cases are seen during winter in the temperate climates & summer in the tropics.

Disease & Organism	Pathogenesis	Manifestations	Management
Selected Bacterial Infections of the Bowel
Traveler’s diarrhea: Escherichia coli Incubation: (24-72 hours)	Enterotoxin causes hypersecretion of the small intestines	Abrupt onset of diarrhea; vomiting rare	Prophylactic bismuth subsalicylate; antidiarrheals such as loperamide or diphenoxylate; 3-5 day course of norfloxacin, ciprofloxacin, or trimethoprim-sulfamethazole
Staphylococcal Food poisoning Incubation: (2-8 hours)	Enterotoxin impairs intestinal absorption & affects vomiting centers in the brain	Severe nausea, vomiting; abdominal cramping, diarrhea; headache and fever	Fluid and electrolyte replacement as needed
Botulism: Clostridium botulinum Incubation: (1.5-8 days)	Absorbed enterotoxin produces neuromuscular blockade and progressive paralysis	Diplopia, pupils fixed & dilated; dry mouth, dysphagia; progressive cephalocaudal weakness & paralysis; GI symptoms minimal	Gastric lavage to remove toxin from gut; administration botulinus antitoxin; respiratory, fluid and nutritional support
Cholera Vibrio Cholerae Incubation: (1-3 days)	Enterotoxin affects entire small intestine, causing secretion of water & electrolytes into bowel lumen	Severe diarrhea with “rice watery stool”, grey, cloudy, odorless, with no blood or pus; vomiting; thirst; oliguria, muscle cramps, weakness; dehydration	Oral or intravenous rehydration; possible antimicrobial therapy with ampicillin, tetracycline, trimethoprimsulfame-thoxazole, others
Hemorrhagic colitis:  E. coli Incubation: (1-3 days )	Enterotoxin causes direct mucosal damage in large intestine; also toxic to vascular endothelial cells	Severe abdominal cramping, watery diarrhea that becomes grossly bloody; fever	Supportive care with fluid replacement and bland diet; may require dialysis or plasmapheresis for complications
Salmonellosis: Salmonella Incubation: (8-48 hours)	Superficial infection of the GI tract without invasion or production of toxins	Diarrhea with abdominal cramping, nausea, vomiting; low-grade fever, chills, weakness	Treatment of symptoms: trimetho-primsulfamethoxazole, ampicillin, or cipro- floxacin for severe illness

Shigellosis (bacillary dysentery): Shigella Incubation: (1-4 days)	Local tissue invasion, primarily involving large intestine and distal ileum; endotoxin causes fluid and electrolyte secretion into bowel lumen	Watery diarrhea with severe abdominal cramping and tenesmus; lethargy	Fluid and electrolyte replacement; correction of acidosis; antibiotic therapy
Protozoal Infections of the  Bowel
Giadiasis: Giardia lamblia Incubation: (1-3 weeks or more)	Throphozite attaches to the mucosa in duodenum and jejunum, causing superficial invasion, inflammation, tissue destruction	Diarrhea, mild or severe, daily or intermittent; anorexia, nausea, vomiting;epigastric  pain, cramping, distention; flatulence, belching; may be asymptomatic	Metronidazole, quinacrine, furazolidone
Amebiasis: Entamoeba histolytica Incubation: (2-4 weeks)	Organisms may reside in large intestine w/o causing disease or can invade colon wall, causing ulceration; may be carried via blood à liver à abscess	Usually asymptomatic; diarrhea may be mild, with few semiformed mucus containing stools per day, or severe, with 10-20 blood streaked liquid stools/day; abdominal cramps; colic, tenesmus, vomiting, tenderness; weight loss, fatigue	Metronidazole, Diloxanide furoate or iodoquinol; chloroquine for hepatic abscess
Cryptospo-ridiosis: Crypto- sporidium Incubation: (2-10 days)	Organisms attach to epithelial surface of small bowel(jejunum), causing villous atrophy and mild inflammatory changes	Asymptomatic to profuse, watery diarrhea of sudden onset, abdominal cramping; malaise, fever; anorexia, nausea, vomiting; electrolyte imbalance; weight loss	Self-limiting in immunocompetent clients. For immuno-deficient: spiramycin, zidovudine(AZT), paromomycin (Humatin), octreotide, eflornithine; fluid & electrolyte imbalance; parenteral nutrition
Selected Helminthic  Disease
Nematode Infections (Ascaris, pinworm, hookworm, trichinosis)	Eggs are ingested in fecally contaminated food, under- cooked meats; it may enter through skin or by ingestion	Low-grade fever,cough,epigastric pain , vomiting, abdominal distention, nocturnal perianal, perineal pruritus, pruritic dermatitis, diarrhea, anorexia	Helminthic infections often treated with single oral dose or 3-day course of pyrantel pamoate (Antiminth®) or mebendazole (Vermox®); Corticosteroids to reduce inflammation & manage symptoms
Cestode infections (Intestinal fluke; tapeworms)	Organism is ingested by eating uncooked fish/meat, fecal contamination; swallowing infected hosts	Asymptomatic; diarrhea; abdominal pain; nausea, vomiting; thrombocytopenia, anorexia, weight loss, irritability

                   (

Signs & Symptoms: (Gastroenteritis)

ü  Anorexia

ü  Nausea & vomiting

ü  Orthostatic hypotension

ü  Fever

ü  Headache

ü  Loss of appetite

ü  Abdominal cramping & pain

ü  Borborygmi

ü  Increased bowel sounds

ü  Bloody stools

ü  Diarrhea

ü  Poor skin turgor

ü  Fatigue & weakness

Screening & Diagnosis:

·         Stool culture – reveals (+) organism that causes  infection, presence of WBC, blood, mucus in the stool

·         Complete blood count - ↑ hemoglobin & hematocrit related to presence of vomiting & diarrhea.

·         Kidney function test - ↑ creatinine & BUN

Treatment:

·         Hydration & electrolyte balance

·         Diet therapy– bland foods, avoid foods high in simple sugars because the osmotic load will worsen diarrhea.

·         Probiotics – to restore beneficial bacteria to the body. (e.g. yogurt, kimchee, sauerkraut, & kombucha)

·         Medications

o    Antibiotics: metronidazole,vancomycin, fluoroquinolone

o    Antidiarrheals: loperamide

o    Antihelmithic /antiparasitic: pyrantel pamoate (Antiminth®), mebendezole (Vermox®), iodoquinol (Amebaquine®), paromomycin (Humatin®)

o    Antiemetic: promethazine (Phenergan®)

Complications:

·         Dehydration

·         Malabsorption

Nursing Interventions:

·         Rest bowel (NPO) for 24 hrs. before starting diet.

·         Administer prescribed medications.

·         Stress the importance of the following:

o    Oral rehydration

o    Proper handwashing, particularly before handling food, and after each bowel movement.

o    The need to wash contaminated clothing and linens separately in hot water and detergent.

o    Safe food storage, handling, and preparation.

o    Keeping toilet areas clean and maintain good personal hygiene.

·         Monitor for signs & symptoms for possible complications.

ANTIHYPERTENSIVES

CENTRAL  ALPHA₂ AGONISTS

·         Stimulates alpha receptors in the CNS to inhibit vasoconstriction and reduce peripheral resistance

·         Indication:

o    Hypertension

·         Contraindication:

o    Liver disorders

Example:
clonidine (Catapres®)	guanabenz (Wytensin®)
methyldopa (Aldomet®)	guanfacine (Tenex®)

Side Effects:

·         Dry mouth

·         Drowsiness, dizziness

·         Constipation

·         Tiredness

·         Headache

·         Nervousness

·         Decreased sexual ability

·         Upset stomach

·         Vomiting

·         Rash

·         Fainting

·         Edema of the ankles or feet

·         (+) Coombs test with methyldopa (Aldomet^®)

Nursing Considerations:

ü  Monitor vital signs.

ü  Monitor liver function studies.

ü  Provide patient teaching:

o    Instruct patient to avoid abrupt withdrawal (can cause rebound hypertension).

o    Use of clonidine patch (applied once every 7 days):

§  Clean a hairless area of unbroken skin on upper arm or chest with mild soap and water and dry it completely.

§  Peel the clear plastic strip from the adhesive side of a patch.

§  Attach the patch skin by placing the adhesive side against it and pressing firmly. Place an overlay patch provided with prescription over the top of the patch to secure it.

§  If the patch loosens before replacement time, place adhesive tape or an overlay patch to secure it.

§  If the skin under the patch becomes irritated, remove the patch and replace it with a new one in a different area.

§  Fold the used patch in half with the sticky sides together and dispose of it carefully. The patch still contains active medication that could be harmful to children or pets. Always be sure to remove the old patch before applying another one.

ACE INHIBITORS (Angiotensin Antagonists)

·         Inhibits the formation of angiotensin II (vasoconstrictor) and blocks the release of aldosterone.

·         Indication:

o    Used primarily to treat hypertension

o    Also effective in treating heart failure

·         Contraindication:

o    Avoid using with potassium supplements and potassium sparing diuretics

o    Avoid use during the 2^nd & 3^rd trimester of pregnancy

Example:

benazepril (Lotensin®)

captopril (Capoten®)

enalapril (Vasotec®)

fosinopril (Monopril®)

lisinopril (Prinivil®, Zestril®)

quinapril (Accupril®)

ramipril (Altace®)

moexipril (Univasc®)

perindopril (Aceon®)

trandolapril (Mavik®)

Side Effects:

·         Constant or irritating cough

·         Nausea and vomiting

·         Diarrhea

·         Headache, dizziness

·         Fatigue

·         Insomnia

·         Hyperkalemia

·         Tachycardia

·         First dose hypotension

Nursing Considerations:

ü  Monitor renal function (BUN, creatinine, protein).

ü  Monitor blood glucose levels. Watch for hypoglycemic reactions in patients with DM.

ü  Report bruising, petechiae, bleeding (adverse reaction to captopril)

ü  If patient has experience angioedema with use of ACE inhibitor, do not administer.

ü  Provide patient teachings:

o    Instruct patient not to abruptly discontinue use of captopril (rebound hypertension can occur).

o    Instruct patient to rise slowly after first dose

o    Inform the patient not to take OTC drugs.

o    Teach patient how to take blood pressure.

o    Provide information about side effects.

ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARB)

·         Lower BP by blocking the vasoconstrictive effects of angiotensin II

·         Indication:

o    Used alone or in combination with other agents (ex. Diuretic) for treatment of hypertension.

·         Contraindication:

o    Pregnancy (2^nd & 3^rd trimester), breastfeeding, renal disoders, hyperkalemia, anuria, hypersensitivity to sulfa drugs

Example:

losartan (Cozaar®)

iosartan HCTZ (Hyzar®)

valsartan (Diovan®)

eprosartan (Tevetan®)

irbesartan (Avapro®)

olmesartan medoxomil (Benicar®)

telmisartan (Micardis®)

Side Effects:

·         Headache

·         Fatigue

·         Cough, tickling in the throat

·         Angioedema

·         GI reactions

·         Increased serum potassium

·         Transient increase in BUN and creatinine levels

Nursing Considerations:

ü  Obtain baseline BP, PR and rhythm. Monitor regularly.

ü  Monitor the patient for adverse effects.

ü  Monitor patient’s weight, fluid and electrolyte levels.

ü  If given once daily, administer in the morning to prevent insomnia.

ü  Prevent or minimize orthostatic hypotension by assisting the patient to get up slowly. Inform the patient not to make sudden movements.

ü  Maintain sodium restriction, calorie reduction, stress management and exercise program.

ü  Periodic eye examinations are recommended.

  

DIURETICS

Thiazide Diuretics

·         Depress the ability of the convulated tubules to reabsorb sodium and chloride.

·         Indication:

o    Hypertension, edema (CHF)

·         Contraindication:

o    Allergy to sulfa drugs, gout, hypotension, renal failure, lithium therapy, hypokalemia

o    May worsen diabetes

Example:

chlorothiazide (Diuril®)

hydrochlorothiazide (HydroDiuril®)

chlorthalidone (Hygroton®)

indapamide (Lozol®)

metolazone (Zaroxolyn®)

Side Effects:

·         Electrolyte imbalances (hypokalemia, hyponatremia, hypochloremia, hypercalcemia, hyperurecemia, hypomagnesemia)

·         Decrease in glucose tolerance

·         Increase in LDL cholesterol and triglycerides

·         Hypotension

·         Anorexia

·         Epigastric distress

·         Photosensitivity

·         Sexual dysfunction

Nursing Considerations:

ü  Monitor for side effects of electrolyte imbalance: (muscle weakness, leg cramps, dizziness, abdominal distention, cardiac dysrhythmias)

ü  Provide patient teaching:

o    Thiazides should be taken in the morning to avoid interference with sleep patterns.

o    Take with food if GI distress occurs.

o    Weigh self every morning and report weight gain of more than 2 to 3 lbs.

o    Instruct to eat foods high in potassium (oranges, bananas, broccoli, tomato juice, apricots)

o    Avoid alcohol and black licorice (may precipitate hypokalemia).

o    Thiazides increase lithium toxicity due to loss of sodium.

Loop (High Ceiling) Diuretics

·         Inhibit reabsorption of sodium and chloride in the proximal and distal tubules in the loop of Henle

·         Indication:

o    Potent diuretic for significant diuresis with edema

·         Contraindication:

o    Presence of severe electrolyte imbalances, hypovolemia, anuria, hhypersensitivity to sulfonamides, hepatic coma

Example:

bumetanide (Bumex®)

ethacrynic acid (Edecrin®)

furosemide (Lasix®)

torsemide (Demadex®)

Side Effects:

·         Fluid and electrolyte imbalances (hypokalemia, hyponatremia, hypocalcemia, hypomagnesemia, hypochloremia)

·         Orthostatic hypotension

·         Thrombocytopenia

·         Skin disturbances, photosensitivity

·         Transient deafness/ ototoxicity (especially with ethacrynic acid)

·         Thiamine deficiency with prolonged use

Nursing Considerations:

ü  Explain that this type of drug is very fast acting.

ü  Monitor for side effects of electrolyte imbalance.

ü  Provide patient teaching:

o    Take loop diuretics in the morning.

o    Take with food or milk.

o    Avoid orthostasis.

o    Use sunscreen for increased photosensitivity.

o    Take potassium supplements as ordered.

o    Weigh self daily and report weight gain of more than 2 or 3 lbs.

Osmotic Diuretics:  

·         Increase osmotic pressure of the glomerular filtrate, inhibiting reabsorption of water and electrolytes

·         Indication:

o    Prevention of renal failure, to decrease ICP, to decrease IOP in narrow-angle glaucoma, used with chemotherapy, oliguria

·         Contraindication:

o    Well established anuria due to renal disease, frank pulmonary edema, cerebral edema, severe dehydration, progressive heart failure or pulmonary congestion after institution of mannitol therapy

Example:
mannitol (Osmitrol®)
Urea (Ureaphil®)	Not used for diuretic actions.        See ophthalmic meds.
Glycerin (Osmoglyn®)
Isosorbide (Ismotic®)

Side Effects:

·         Fluid and electrolyte imbalances

·         Pulmonary edema

·         Nausea and vomiting

·         Tachycardia

·         Dehydration

Nursing Considerations:

ü  Monitor the following:

o    Patient’s vital signs

o    Weight

o    Urine output

o    Electrolyte levels

o    Lungs and heart sounds for edema

o    Neurological status

ü  Serum osmolality may be ordered prior to administer

ü  Use filter to administer

ü  Change the patient’s position slowly to prevent orthostatic hypotension.

ü  Do not administer medication if crystallization is noted in the vial.

Carbonic Anhydrase Inhibitors

·         Inhibit the action of the enzyme carbonic anhydrase; decrease availability of hydrogen ions in the kidney, blocking sodium- hydrogen exchange mechanisms, thus increasing urinary excretion of sodium, potassium, bicarbonate and water

·         Indication:

o    Promote diuresis, treat glaucoma, epilepsy and acute mountain sickness

·         Contraindication:

o    Decreased sodium and potassium levels, hepatic and renal disease, severe pulmonary obstruction, adrenocortical insufficiency, patients with drug-induced edema or heart failure (may cause metabolic acidosis), chronic noncongestive angle-closure glaucoma, hypersensitivity to sulfonamides

Example:

cetazolamide (Diamox®)

metazolomide (Neptazine®,GlaucTabs®)

dichlophenamide (Daranide®)

Side Effects:

·         Fatigue, malaise

·         Drowsiness

·         Headache

·         Orthostatic hypotension

·         Paresthesia

·         Urticaria

·         Pruritus

·         Stevens-Johnson syndrome

·         Photosensitivity

·         Hypokalemia, other electrolyte imbalances

·         Metabolic acidosis

Nursing Considerations:

ü  Administer drug with food if GI upset occurs.

ü  Provide patient teaching. Advise patient to avoid prolonged or unprotected exposure to sunlight during therapy.

Potassium-Sparing Diuretics

·         Act directly on the distal tubule of the kidney to increase excretion of sodium, water, chloride, calcium ions; decrease excretion of potassium and hydrogen ions

·         Indication:

o    Hypertension, edema, heart failure, cirrhosis, nephrotic syndrome, diuretic-induced hypokalemia

·         Contraindication:

o    Severe renal and hepatic disease, hyperkalemia

o    Use with caution in patients with DM

Example:

amiloride (Midamor®)

amiloride HCL and hydrochlorothiazide (Moduretic®)

spinorolactone (Aldactone®)

spinorolactone and hydrochlorothiazide (Aldactazide®)

triamterene (Dyrenium®)

Side Effects:

·         Abdominal pain or cramps ·         Anorexia	·         Diarrhea ·         Constipation
·         Acidosis	·         Nausea and vomiting
·         Agranulocytosis	·         Blood volume depletion
·         Sore throat, dry mouth	·         Dizziness
·         hyperkalemia ·         Orthostatic hypotension Megaloblastic anemia (with triamterene)	·         Impotence, gynecomastia and menstrual abnormalities (Spinorolactone)

Nursing Considerations:

ü  Monitor the patient for signs and symptoms of hyperkalemia (confusion, hyperexcitability, muscle weakness, paresthesia, flaccid paralysis, arrhythmias, abdominal distention, diarrhea, intestinal colic). Monitor for other electrolyte imbalances.

ü  Weigh the patient daily.

ü  Assess the patient for dehydration.

ü  Administer potassium-sparing diuretics with care if patient is also taking other medications that can increase potassium.

ü  Give potassium-sparing diuretic in the morning to avoid nocturia.

ü  Give amiloride with food.

ü  Avoid salt substitutes and foods rich in potassium.

ü  Store spironolactone in a light-resistant container.