N-Trivia

Pyloromyotomy for Pyloric Stenosis
Sickle Cell Anemia – Case Study
Johari Window
Sequential Pattern in Female Reproductive Cycle

Posted: 16 Oct 2010 12:22 AM PDT

Definition

The incision and suturing of the muscles of the pylorus to treat congenital hypertrophy of the pyloric sphincter (pyloric stenosis) that can cause pyloric and/ or gastric obstruction.

Discussion

The Ramsted-Fredet pyloromyotomy is the procedure of choice to correct this defect surgically.
Signs and symptoms of high gastrointestinal obstruction usually appear at around 2 to 6 weeks of age, with first symptom being projectile vomiting that is free of bile.
As a precautionary measure, the stomach is emptied via a nasogastric tube prior to induction of anesthesia, and the nasogastric tube is then removed to prevent gastric contents from accumulating around the tube during the procedure.

Positioning

Supine, with arms restrained at the side.

Packs/ Drapes

Pediatric transverse Lap sheet or basic pack and sheet with small fenestration.

Instrumentation

Pediatric laparotomy tray
Pyloric spreaders

Supplies/ Equipment

Thermal blanket with control unit
Thermal sheets, head covering
Basin set
Handheld cautery
Blades
Needle counter
Dissector sponges
Solutions
Sutures

Procedure Overview

The abdomen is opened through a right subcostal transverse incision, splitting the rectus muscle vertically and excising the peritoneum.
The pylorus is delivered into the wound and rotated to expose the anterior superior border of the mass.
Using a pyloric spreader, all remaining circular muscle fibers are separated to the level of the submucosa.
Any lacerations of the gastric or duodenal mucosa are immediately repaired.
After hemostasis is achieved, the peritoneum and posterior rectus sheath are closed with a continuous absorbable suture.
The anterior rectus sheath is closed with absorbable suture and the skin is closed using a subcuticular technique.
Steri-strips are applied with an abdominal dressing.

Perioperative Nursing Considerations

Maintain aseptic technique during the procedure.
If tape is being used during positioning, do not allow tape directly contact the skin.
Do not begin skin preparation without specific instruction from the surgeon.

Sickle Cell Anemia – Case Study

Posted: 15 Oct 2010 06:09 PM PDT

Definition

Sickle cell anemia is an inherited disorder on the beta chain of the hemoglobin resulting to abnormally shaped red blood cells. RBC's assume a crescent or C-shape that decreases the cell's life span and ability to function thereby, producing various complications. In some cases, these sickled cells may block the flow causing pain and organ damage.

Incidence

Equal male-female ratio
Increase incidence in African Americans

Etiology

Autosomal recessive disorder

Review of Related Anatomy and Physiology

Red blood cells or erythrocytes carry oxygen to the different parts of the body. Different from other cells, RBC's do not contain a nucleus (anucleated). These small cells are circular and flattened with depressed centers on both sides resembling to that of a doughnut when viewed under a microscope. Their size and shape provides a large surface area for carrying oxygen in relation to their volume. The normal RBC count is 4-6 million/mm3. RBC's has the life span of 120 days.

Hemoglobin is a form of protein that contains iron which is responsible for transporting oxygen that is carried in blood. Adult hemoglobin contains a beta chain (HBB) while a fetus' hemoglobin has a gamma chain. Hemoglobin is comprised of four protein (amino acid) components. It has two beta-globin and two alpha-globin. The subunit beta-globin is located inside the RBCs. These amino acids carry an iron-bearing molecule called heme. Heme molecules, which are only found in mature RBC's, enables the erythrocytes to pick oxygen from the lungs and transport it throughout the body. Once oxygen attaches to hemoglobin it gives the blood its bright red pigment.

The more hemoglobin molecules the RBC contain, a higher amount of oxygen will they be able to carry. If the hemoglobin is defective, the erythrocyte will also malfunction. A red blood cell is just a vessel; the one that performs the oxygen transportation is the hemoglobin. Normal hemoglobin is 13-18 grams/100 ml of blood in males and 12-16 grams in females.

Pathophysiology

Erythrocytes in sickle cell anemia contain abnormal hemoglobin that affects the beta-chain producing hemoglobin S or HbS. In this disorder, the beta-chains (beta-globins) are replaced by Hemoglobin S. Valine (an amino acid) takes the place of the normally appearing glutamic acid in beta-chains. Replacement of glutamic acid with valine causes the polymerization of HbS components to cohere forming long and insoluble particles. These distort the red blood cells, which assumes an inflexible crescent or sickle shape.

The abnormally shaped cells become sharp and spiky when the RBCs are discharging oxygen molecules and in cases where the oxygen content in blood is low such as performing vigorous exercise and being in high altitude areas. Typically, a sickled cell's lifespan is only 20 days. The deformed erythrocytes also rupture easily and they tend to be trapped in the microcirculation, obstructing blood flow and oxygen transport that might lead to painful episodes of ischemic injury.

Sickle cell crisis refers to episodes of acute and severe sickling that blocks the circulation posing a threat of extensive organ damage. Severe pain is noted during these incidents caused by occluded vessels in the bone possibly resulting to bone necrosis. The crisis is triggered by hypoxemia, acidosis, or other conditions such as dehydration, infection, vigorous exercise, pregnancy or cold weather.

A condition called a sickle cell trait is identified by the presence of a single defective gene, instead of two. Individuals with this trait are essentially normal however, they are carriers. Meaning two sickle cell trait carrier parents can contribute a defective gene to a child that will carry the sickle cell disorder.

Diagnosis

Prenatal:

Chorionic Villi sampling
Amniocentesis (blood from the cord)

At birth:

Newborn Screening
Hemoglobin electrophoresis

Signs and Symptoms

The following manifestations are observed in children with a sickle cell disorder, at about 6 months of age (because fetal hemoglobin contains gamma, not a beta chain):

Fever
Anemia
Swelling of the hands and feet (hand-foot syndrome) – caused by blood stasis and infarction
Protruding abdomen – due to enlarged spleen and liver secondary to trapping of sickled cells in microcirculation and obstruction of blood flow
Icteric sclera – caused by bilirubin release during hemolysis (sickle cell destruction)
Priaprism (males) – due to pooling of abnormally shaped erythrocytes in the blood vessels of the penis.
Chest syndrome – symptoms same with pneumonia that is the major cause of death in sickle-cell patients

Management

Conservative Management

Pain relief with Acetaminophen (Tylenol) or IV of morphine to reduce metabolic demand of oxygen thereby, terminating cell sickling.
Adequate hydration – IV fluids and electrolyte replacement
Oxygenation
Antibiotics – if the cause of sickling is infection.
Blood transfusion with packed RBC's
Hydroxyurea – antineoplastic agent that increases production of fetal hemoglobin in children.
Exchange transfusion – replacing sickled with normal cells

If the patient does not respond to the usual therapies STEM CELL TRANSPLANTATION is done.

Nursing Management

Monitor vital signs. Assess for pain.
Obtain blood and urine culture, chest x-ray and CBC results if infection is the cause of sickling.
Monitor child's nutritional intake with hydroxyurea. If taken orally, this drug can cause anorexia.
Assess for kidney function by noting if the child has urinated or not. (Kidney infarction may occur)
Do not administer potassium if the kidney function is not verified. Potassium if not excreted by the kidney may cause arrhythmia.

Possible nursing diagnosis

Ineffective tissue perfusion R/T decreased hemoglobin concentration in blood
Acute pain R/T impaired blood flow due to obstruction of sickled cells

image from elev8.com, daviddarling.info

Johari Window

Posted: 15 Oct 2010 06:03 PM PDT

As a nurse, dealing with physically and/or mentally ill patients requires a great deal of patience and understanding. However, before a person can understand and empathize with others, he or she must first know himself or herself. The process of knowing ones own principle, beliefs, feelings, personality, strengths, weaknesses, preconceptions, attitudes and responses in different situations is called self awareness. Discerning ones own capabilities and limitations allow a nurse to consider, observe and pay attention to the bizarre or subtle reactions of clients.

Self-awareness gives the nurse a skill in establishing relationships with clients of different values, beliefs, attitudes and principles. This is achieved by the nurse's utilization of aspects in his or her personality, values, feelings and coping skills commonly known as the therapeutic use of self.

Johari window is a psychological tool used to develop self-awareness and promote better relationships among people. It was created by two American Psychologists Joseph Luft and Harry Ingham in 1955. The word "JOHARI" comes from the first names of its developers Joseph and Harry (Joharry). It is also known as "disclosure or feedback model of self awareness."

Utilizing this tool creates a portrait of someone; this is done by giving the person a psychosocial exercise. A list of 56 adjectives is given to the subject and he or she is instructed to choose five or six words that best describe him or her. The same list is given to the subject's peers, friends and colleagues. These people will also choose 5 or 6 adjectives that best describe the subject. After the test, the answers are mapped, compared and categorized in four areas. The four areas are as follows:

Quadrant 1: Open Arena or Public self

These pertain to the qualities known to others and the subject himself.
If quadrant 1 is the longest, it means that the subject is open to others and has gained self-awareness.
If this area is the shortest, the subject shares little about him or her.

Area or Quadrant 2: Blind spot or Blind Area

These refer to the subject's attributes that are unknown to him but are known by his or her peers.

Area or Quadrant 3: Hidden or Private self

The things that the subject knows about himself.

Area or Quadrant 4: Unknown

An empty quadrant which symbolizes the qualities undiscovered by the neither the subject nor others.

The success of the test depends on the honesty of the opinions given. A person is represented with little insight if quadrants 1 and 3 have the smallest adjective listed. The main goal the subject is to work towards moving the qualities from quadrants 2, 3, and 4 to the first area.

Image from ninguem5.operahost.uni.cc

Sequential Pattern in Female Reproductive Cycle

Posted: 15 Oct 2010 05:35 PM PDT

Menstruation is the actual blood flow from the sloughing off of the uterine endothelium. The actual blood loss is due to progesterone withdrawal that occurs in the latter part of menstruation. The female reproductive cycle involves a sequential pattern of changes in the tropic hormones (hormones that stimulates an organ) which will cause a cyclic change in the female gonads (ovaries). Average cycle varies from woman to woman but it usually is 28, ranging from 20-45 days. The female reproductive cycle is further divided into two cycles that considers the changes in the uterus and ovaries.

In obstetric nursing it is important to fully understand and if possible, memorize the menstrual cycle as it is the backbone of OB learning. However, before proceeding to the cycle stages, it is important to note that all the phases in a reproductive cycle is influenced by the functioning of four organs, namely:

Hypothalamus
Anterior pituitary gland
Ovaries
Uterus

It is very essential to chronologically memorize these body organs to easily remember the sequence of changes that occurs recurrently in a woman's body each month. Again, remembering these body parts in order would help one to fully understand the processes involve in a menstrual cycle. Now let's start.

Approximately three days after menstruation (actual blood flow), a dramatic decrease estrogen level would be noted. Extreme reduction of its level will stimulate the hypothalamus to produce Follicle Stimulating Hormone Releasing Factor (FSHRF), a tropic hormone indirectly related in estrogen production.
FSHRF then triggers the Anterior Pituitary Gland to produce Follicle Stimulating Hormone (FSH).
In response FSH goes to the ovaries and would cause release of the first ovarian hormone, estrogen.
With the influence of estrogen, primordial follicles (immature cells incapable of fertilization located at the cortex of the ovaries) are now called Graafian follicles.
Estrogen in higher amount would cause rapid growth of the uterine lining (proliferation). Therefore, this phase is called a Proliferative phase because of the rapid growth of uterine lining. It is also termed as Estrogenic phase due to increase estrogen production and Follicular phase because of the presence of graafian follicle. Because this event occurs after the actual menstruation it is also called a Postmenstrual Phase and since ovulation has not occurred yet it can also be termed as Preovulatory phase (before ovulation).
Estrogen increases fat deposition causing a woman to feel bloated.
A significant decline of progesterone will stimulate the hypothalamus to stimulate to release of Luteinizing Hormone Releasing Factor.
LHRF sets off the production of luteinizing hormone (LH) in the anterior pituitary gland.
LH makes it way to the ovaries which in turn produces the second ovarian hormone, progesterone.
High levels of estrogen and progesterone would then cause the release of the mature ovum. This phenomenon known as ovulation exactly occurs 14 days before the next menstrual period. Meaning to say, in a 30 day cycle, ovulation occurs on the 16^th day. In a 28 day cycle it is on the 14^th day. The technique here is just to subtract 14 from the number of cycle the woman has. (E.g. 30 days – 14 = 16^th day)
During ovulation the woman may feel pain in either right or left lower abdominal quadrant due to the pressure in the release of the ovum. This is called mittelschmerz.
Right after ovulation, Graafian follicle (a body containing high amounts of estrogen) with the influence of the escalating progesterone level will change its color to yellow and is now called corpus luteum.
Corpus luteum has a life span of about 8-10. Because follicles develop to corpus luteum (a body containing high amounts of progesterone), this stage is termed Luteal Phase and as the changes occurred after ovulation it is also called Postovulatory phase. Menses is expected in a fixed date (if no fertilization will occur) therefore it is also a premenstrual phase.
Progesterone causes increase blood supply, thickening and vascularity of the uterus. Capillaries are pooling down the uterine portions in preparation for possible implantation of zygote (the result of the fusion of DNA from sperm and egg). This is the reason why progesterone is called the hormone of pregnancy. However, if no fertilization would occur on the 8^th to the 10^th of corpus luteum's lifespan, progesterone level starts to drop.
Progesterone diminution will cause alteration in corpus luteum's color. Thus, it will turn white for the succeeding 3-4 days and is called corpus albicans.
Withdrawal of the progesterone hormone (on the 4^th day of corpus albicans) would cause the sloughing off and rupture of capillaries in the uterus. Thus, actual blood flow then takes place.