Valve Disorders

MITRAL STENOSIS

 Definition

• Mitral valve thickens and gets narrower, blocking blood flow fro. the left atrium to left ventricle

Physiology

• Function of the heart is the transport of oxygen, carbon dioxide, nutrients and waste products
• Cardiac cycle consists of:
• Systole - the phase of contraction during which the chambers eject blood
• Diastole - the phase of relaxation during which the chambers fill with blood. When heart pumps, myocardial layer contracts and relaxes.
• Blood flow:
1. Deoxygenated blood enters the right atrium through the superior and inferior vena cava
2. Enters the right ventricle via the tricuspid valve
3. Travels through the pulmonic valve to pulmonary arteries and lungs
4. Oxygenated blood returns from the lungs through the pulmonary veins into the left atrium and enters the left ventricle via the bicuspid (mitral) valve
5. From the left ventricle, through the aortic valve through the aorta to the systemic cicrculation
• The heart itself is supplied with blood by the left and right coronary arteries
• The vascular system is a continuous network of blood vessels
• the arterial system consists of arteries, arterioles and capillaries and delivers oxygenated blood to tissues
• Oxygen, nutrients and metabolic waste are exchanged at the cellular level
• The venous system, veins and venules, returns the blood to the heart

Heart Infections: Rheumatic Heart Diseases (Rheumatic Endocarditis)

 Definition and Related Terms

• Rheumatic Heart Disease - damage to the heart by one or more episodes of rheumatic fever. Pathogen is a group A streptococci.
• Rheumatic Endocarditis - damage to the heart, particularly the valves, resulting in valve leakage (regurgitation) and/or stenosis. To compensate, the heart's chambers enlarge and walls thicken.

Epidemiology

• Worldwide, 15-20 million new cases of rheumatic fever are reported each year
• Rheumatic Fever - follows a Group A streptococcal infection. We could prevent it by finding and treating streptococcal pharyngitis
• Where malnutrition and crowded living are common, rheumatic fever is most common in children between ages 5 and 15.
• Rheumatic Fever strikes most often during cool, damp weather. In the US, it is most common in the Northern States.
• It is unknown how and why group A streptococcal infections cause the lesions called Aschoff bodies
• Damage depends on site of infection: most often the mitral valve in females and the aortic valve in males
• Malfunction of these valves leads to severe pericarditis, and sometimes pericardial effusion and fatal heart failure. Of those who survive this complication, about 20% die within ten (10) years.

Heart Infections: Endocarditis

 Definition and Related Terms

• An infection of the endocardium, heart valves,  or cardiac prosthesis resulting from bacterial or fungal invasion
• Endocarditis can be classified as:

1. Native valve endocarditis
2. Endocarditis in IV drug users
3. Prosthetic valve endocarditis

Epidemiology

• With proper treatment, about 70% of clients recover
• The prognosis is worse when endocarditis damages valve severely or involves a prosthetic valve
• Infective endocarditis occurs in 50-60% of clients with previous valvular disorders
• Systemic Lupus Erythematosus (SLE) often leads to nonbacterial endocarditis
• In 12-35% of clients, with subacute endocarditis, lesions produce clots that show the findings of splenic, renal, cerebral or pulmonary infarction, or peripheral vascular occlusion

Common Lab Tests for Cardiovascular Disorders

1. Serum chemistry
2. Serum Electrolytes
3. Alanine Aminotransferases (AST) 
4. Creatine Kinase (CK)
5. CK-MB (isoenzyme)
6. Lactic Dehydrogenase
7. Complete Blood Count
8. Lipid Levels
9. Prothrombin Time
10. Alkaline Phosphatase
11. ESR
12. Arterial Blood Gases
13. Troponin

Measles

Definition:

Also known as Rubeola, an acute highly communicable infection characterized by fever, rashes and symptoms referable to upper respiratory tract; the eruption is preceded by about 2 days or coryza, during which stage grayish pecks (Koplik spots) may be found on the inner surface of the cheeks. A morbilliform rash appears on the 3rd or 4th day affecting face, body and extremities ending in branny desquamation.

Death is due to complication (e.g. secondary pneumonia, usually in children under 2 years old. Measles is severe among malnourished children with fatality of 95-100%. Infection confers life-long immunity.

Etiologic Agent: Filterable virus of Measles

Source of Infection: Secretion of nose, mouth and throat of infected persons.

Modes of Transmission:

1. Directly - by being sprayed with droplets emanating from a cough or sneeze
2. Indirectly - with articles newly contaminated with respiratory secretions from a patient.
3. Probably Airborne

• Incidence peak age is about 1-5 years old in congested urban areas and at early school age in less crowded sections.
• Immunity from the disease is long lasting while passive immunity transmitted transplacentally from mothers who have had measles may last about 5-6 months. The live attenuated vaccine confers almost lifelong immunity while the inactivated antigen gives an immunity 0f 6-18 months.
• Recent data suggests that cases is on the rise again in the United States and Canada due to the unsubstantiated claim that measles vaccine is associated with autism. In fact, various studies by government and non-government agencies disputing these claims.

Incubation Period:

• 10-12 days; one attack usually confers a lasting immunity
• 8 days shortest; 20 days longest

Period of Communicability:

• During the period of coryza or catarrhal symptoms - 9 days (from 4 days before and 5 days after rash appears)

Clinical Manifestations:

1. Pre-eruptive Stage
   • patient is highly communicable
   • fever
   • catarrhal symptoms - start in the nasal cavities; then in the conjunctivae, oropharynx, progress to the bronchi resulting successively in rhinitis, conjunctivitis and then bronchitis.
   • Respiratory symptoms - which appear first as a common cold, and sneezing nasal discharges, steadily progress into a distressing and annoying cough that persists up to convalescence.
2. Eruptive Stage/Stage of Skin Rashes
   • exanthem sign - means eruption in the skin
     • Maculopapular Rashes - appears 2-7  days after onset
     • With high fever - increases steadily
     • Anorexia and irritability - are disturbing particularly at the height of the fever
     • Diarrhea, pruritis, lethargy and occipital lymphadenopathy
3. Stage of Convalescence
   • Rashes - fade in the same manner as they appeared, from the face downwards, leaving a dirty brown pigmentation and finely granular which maybe noted for several days.
   • Fever - gradually subsides as the eruptions disappear on the hands and feet

Tests:

• Usually none (most diagnosis is based clinically)
• Measles serology
• Viral culture (rarely done)

Treatment:

No therapy is indicated for uncomplicated measles, Gamma globulin although effective in prophylaxis is no value once symptoms are evidence. Patient should be monitored for the development of bacterial infections which should be treated with appropriate antibiotics on the basis of clinical and bacteriological findings.

The patient may also take over-the-counter medications such as acetaminophen (Tylenol, others) or nonsteroidal anti-inflammatory drugs (NSAIDs) to help relieve the fever that accompanies measles. Don’t give aspirin to children because of the risk of Reye’s syndrome — a rare but potentially fatal disease.

Maintain bedrest and provide quiet activities for the child. If there is sensitivity to light, keep room darkly lit. Remove eye secretions with warm saline or water. Encourage the patient not to rub the eyes. Administer antipyretic medication and tepid sponge baths as ordered. A cool mist vaporizer can be used to relieve cough. Apply antipruritic medication to prevent itching. Isolate child until fifth day of rash.


Prognosis


Prognosis is very good specially for those who do not develop complications like bronchitis, encephalitis (1 of 1000 cases), ear infections and pneumonia.

Methods of Prevention and Control

1. Avoid exposing children to any person with fever or with acute catarrhal symptoms
2. Isolation of cases from diagnosis until about 5-7 days after onset of rash
3. Disinfection of all articles soiled with secretion of nose and throat
4. Encourage by health department and by private physician of administration of measles immune globulin to susceptible infants and children under 3 years of age in families or institutions where measles occurs.
5. Live attenuated and inactivated measles virus vaccines have been tested and are available for use in children with no history of measles, at 9 months of age or soon thereafter

Public Health Nursing Responsibilities

1. Emphasize the need for immediate isolation when early catarrhal symptoms appear .
2. If immune serum of globulin is available (gamma Globulin), explain this to the family and refer to physician or clinic giving this service.
3. Observe closely the patient for complications during and after the acute stage.
4. Teach, demonstrate, guide and supervise adequate nursing care indicated.
5. Explain proceedings in proper disposal of nose and throat discharges.
6. Teach concurrent and terminal disinfection.

Nursing Care

1. Protect eyes of patients from glare of strong light as they are apt to be inflamed.
2. Keep the patient in an adequately ventilated room but free from drafts and chilling to avoid complications of pneumonia.
3. Teach, guide and supervise correct technique of giving sponge bath for comfort of patient.
4. Check for corrections of medication and treatment prescribed by physician.

Chicken Pox vs. Small Pox

PhotoCredit: Ourmed.Org

In smallpox, lesions are commonly found on the palms and soles. In chickenpox, however, there are very few or no lesions on the palms and soles.

In smallpox, fever is present for 2 to 4 days before the rash begins, while with chickenpox, fever and rash develop at the same time.

All the pocks of the smallpox rash are in the same stage of development on any given part of the body and develop slowly. In chickenpox, the rash develops more rapidly, and vesicles, pustules, and scabs may be seen at the same time.

Small Pox

• Evolution: Centripetal distribution - eruption starts from the face and extremities towards the body
• Rashes: Pocks present on palms and soles
• Associated Symptoms: Malaise, fever, rigors, vomiting, headache and backache
• Incubation Period: 7 to 17 days after close contact with a smallpox patient
• Prodromal Period: Prolonged and severe; systematic manifestations are more pronounced
• Fever: High grade fever
• Scabs: Forms 10 to 14 days after appearance of rash and may be infectious; fall off 14 to 28 days after rashes appear
• Characteristics: Multilocular, areas of the body (areas of the pressure and tight skin), hard shotty discrete and deep lesions
• Vesicles: Do not collapse on puncture

Chicken Pox

• Evolution: Centrifugal distribution - eruption starts from the trunk and spread to exposed parts or away from the center
• Rashes: Pocks seldom present on palms and soles
• Associated Symptoms: None
• Incubation Period: 14 to 21 days after close contact with chicken pox patient
• Prodromal Period: Milder constitutional manifestations with less complications
• Fever: Low grade fever
• Scabs: Form 4 to 7 days after appearance of rash and may not be infectious; fall off within 14 days after rashes appear
• Characteristics: Unilocular, over the body (exposed parts of the body), skin superficial lesions
• Vesicles: Collapse on puncture

Nervous System In Focus

Overview

The brain performs a lot of things for a human body to function well such as controlling what a person thinks and feel, learning and remembering things, the way a person moves and talk, and some other things such as the beating of the heart, digestion of the food and etc. Thus, it is very important to have an understanding on how this amazing brain or the nervous system works.

The nervous system is essentially a biological information highway, and is responsible for controlling all the biological processes and movement in the body, and can also receive information and interpret it via electrical signals which are used in this nervous system

It consists of the Central Nervous System (CNS), essentially the processing area and the Peripheral Nervous System which detects and sends electrical impulses that are used in the nervous system


Central Nervous System

The Central Nervous System is effectively the centre of the nervous system, the part of it that processes the information received from the peripheral nervous system. The CNS consists of the brain and spinal cord. It is responsible for receiving and interpreting signals from the peripheral nervous system and also sends out signals to it, either consciously or unconsciously. This information highway called the nervous system consists of many nerve cells, also known as neurons

The Nerve Cell

PhotoCredit: websters-online-dictionary.org

Each neurone consists of a nucleus situated in the cell body, where outgrowths called processes originate from. The main one of these processes is the axon, which is responsible for carrying outgoing messages from the cell. This axon can originate from the CNS and extend all the way to the body's extremities, effectively providing a highway for messages to go to and from the CNS to these body extremities.

Dendrites are smaller secondary processes that grow from the cell body and axon. On the end of these dendrites lie the axon terminals, which 'plug' into a cell where the electrical signal from a nerve cell to the target cell can be made. This 'plug' (the axon terminal) connects into a receptor on the target cell and can transmit information between cells

Definition

The nervous system is an organ system that contains a network of specialized cells called neurons. This is the master controlling and communicating system of the body. It coordinates the action of an animal and transmits signals between the different parts of the body. Every thought, movement and emotions reflect the activity of the nervous system.

Communication

The "All-Or-None-Law" applies to nerve cell communication as they use an on / off signal (like an digital signal) so that the message can remain clear and effective from its travel from the CNS to the target cell or vice versa. This is a factor because just like electricity signals, the signal fades out and must be boosted along its journey. But if the message is either 1 or 0 (i.e.) on or off the messages are absolute.

Classification of Neurons

Interneurones - Neurones lying entirely within the CNS

Afferent Neurones - Also known as sensory neurones, these are specialised to send impulses towards the CNS away from the peripheral system

Efferent Neurones - These nerve cells carry signals from the CNS to the cells in the peripheral system

Functions of the NERVOUS SYSTEM

1. To monitor changes that takes place inside and outside the body. The nervous system utilizes the million sensory receptors to carry out this function. Any changes or stimuli occurring are noted by the nervous system and the gathered data is now called a sensory input.
2. Another important function of the nervous system is to process and interpret the sensory input or gathered data. It is the working of this system to make decision about what should be done at each moment. This is the process known as INTEGRATION.
3. As the nervous system has reached a decision of what response and appropriate action to be done in response to the stimuli, it then effects a response by activating muscles or glands through motor output.

These functions of the nervous systems works hand in hand. The process starts with the sensory input. The nervous system then processes and integrates this information. The nervous system then  sends motor output to response.

Operating Room Committee

Definition

The Operating Room Committee is an interdisciplinary committee charged to coordinate and standardize the care of patients undergoing surgical or other invasive procedures. It is a committee of the medical staff. This Committee oversees clinical practice related to Preoperative, intraoperative and Postoperative procedure care. It has the authority to establish clinical procedure and policy within the Operating Rooms and recommend policy related to those procedures outside of the Operating Room. It works collaboratively with the quality improvement quality to monitor and improve care and ensure patient safety.

Members of the Operating Room Committee

1. Chief or director of the department of surgery ( a surgeon) – The Chair of this Committee shall be a Physician from one of the surgical specialties or subspecialties.
2. Director of the anesthesia department (in teaching hospitals only)
3. Other chiefs or representatives of the specialty services
4. OR nurse manager – shares with the OR committee, hospital administration and nursing service the responsibility for clarification, implementation and day-to-day enforcement of approved policies and procedures.
5. OR coordinator or OR business manager
6. Hospital administrator and director (optional)

Responsibilities and Duties

1. Responsible for professional practice and administrative activities within their respective departments.
2. Maintain continuing evaluation of the professional performance of all members of the medical staff.
3. Serve as liaison representatives between the medical staff and hospital administration.
4. Formulate policies and procedures pertaining to utilization of facilities, schedule of surgical procedures and maintenance of a safe environment. Policies and associated directives formulated and approved by the committee serve as guides for governing the actions of surgeons, anesthesiologists and the Operating Room nursing staff while in the OR suite.
5. Utilizes evidence-based medicine to recommend changes in the clinical practice.
6. Approves policy and procedures that are specific to the Operating Room.
7. Provides Institutional oversight and direction for staff and faculty education related to operative and invasive procedures and care of the surgical patient.
8. Ensures an effective process for patient and family education related to surgical care and informed consent.
9. Works collaboratively with the quality improvement quality to monitor and improve care and ensure patient safety.
10. Monitors adherence to policies and procedures.
11. Recommends corrective measures to the hospital administration for efficient functioning within the OR suite.

Standards of Professional Performance of Registered Nurses in Operating Room

The entry into the professional operating room (OR) nursing as the clinical practice setting of choice is as a staff nurse. A staff nurse should have a degree in Nursing (Nursing) who has successfully passed the nursing licensure examination (registered nurse or RN). A registered nurse should be competent to provide nursing care for all surgical patients and to ensure a safe environment to achieve desired outcomes of surgical interventions.

Eight standards of perioperative practice has been identified that may be used to measure professional performance of registered nurses (RNs) in the operating room (OR).

1. Quality of Care. The perioperative nurses are expected to systematically evaluate the quality and appropriateness of nursing practice. It is anticipated that RN’s in the OR should participate the quality assessment and improvement programs to promote a quality care.
2. Performance Appraisal. The practice of a perioperative nurse evaluates his or her own performance in context with the professional practice standards and relevant statutes and regulations. Defining and evaluating professional practice behaviors is an ongoing process. To provide a framework for future growth and development self-assessment and feedback from the health care team members should be gathered.
3. Education. The perioperative nurse acquires and maintains current knowledge in the nursing practice.
4. Collegiality. It is expected that a perioperative nurse contribute to the professional growth of his or her peers, colleagues and others by sharing knowledge and expertise through preceptor program, role modeling and mentorships. This assists the colleagues to attain a broader base knowledge.
5. Ethics. The decisions and the actions of a perioperative nurse on behalf of the patients are determined by the governing ethical principles. Delivery of care and services should be within the practice parameter of not violating the basic rights of the clients.
6. Collaboration. It is a standard obligation of a perioperaive nurse to collaborate not only with the patient but also with the significant others and health care providers in providing care. To attain the expected outcomes patient care should be a unified effort that is supported by internal and external forces that follows the same goal.
7. Research. The perioperative nurse uses research findings in carrying out his or her practice.
8. Resource Use. In the planning and the implementation of the patient care the perioperative nurse should consider factors relating to safety, effectiveness, efficiency, environmental concerns and cost.