Scarvelis and Wells Clinical Assessment tool for Risk of Deep Vein Thrombosis

31/10/2009

Scarvelis and Wells Clinical Assessment tool for Risk of Deep Vein Thrombosis

  1. Active cancer (treatment within last 6 months or palliative) – 1 point
  2. Calf swelling >3 cm compared to other calf (measured 10 cm below tibial tuberosity) – 1 point
  3. Collateral superficial veins (non-varicose) – 1 point
  4. Pitting edema (confined to symptomatic leg) – 1 point
  5. Swelling of entire leg – 1 point
  6. Localized pain along distribution of deep venous system – 1 point
  7. Paralysis, paresis, or recent cast immobilization of lower extremities – 1 point
  8. Recently bedridden > 3 days, or major surgery requiring regional or general anesthetic in past 4 weeks – 1 point
  9. Alternative diagnosis at least as likely – Subtract 2 points

Assessment scoring guide:

  1. Score of 2 or higher – deep vein thrombosis is likely. Follow up with diagnostic tests – imaging the leg veins.

2. Score of less than 2 – deep vein thrombosis is unlikely.

Scarvelis, D and Wells, P, S. 2006. Diagnosis and Treatment of Deep Vein Thrombosis.Journal of the American Medical Association. 175 (9) 1087-1092.

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Gestational Diabetes Mellitus (GDM)

30/10/2009

Gestational Diabetes Mellitus (GDM) is a condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy.

Signs and Symptoms:

  • Gestational diabetes generally has few symptoms
  •  is most commonly diagnosed by  blood glucose tolerance test during pregnancy.
  • Diagnostic tests detect inappropriately high levels of   glucose in the blood.
  • Gestational diabetes affects 3-10% of pregnancies, depending on the population studied.

Etiology:

  • No specific cause has been identified
  • It is believed that the hormones produced during pregnancy increase the body’s resistance to insulin, resulting in impaired glucose tolerance.

Risk factors:

  • a previous diagnosis of gestational diabetes or prediabetes
  • impaired glucose tolerance
  • Family history of a first degree relative with type 2 diabetes
  • maternal age – a woman’s risk factor increases as she gets older (especially for women over 35 years of age)
  • ethnic background (those with higher risk factors include African-Americans, Afro-Caribbeans, Native Peoples, Hispanics
  • severe obesity
  • a previous pregnancy which resulted in a child with a high birth weight (8 lbs 12.8 oz and over)

Treatment:

  • regular excercise
  • diet (containing a variety of foods, distributing calories and carbohydrates evenly throughout the day, three small-to-moderate-sized meals with two to four snacks every day is recommended)
  • blood glucose monitoring and insulin injections if needed

Gestational Diabetes usually resolves within hours of the placenta being delivered or within 1-2 days postpartum

Martin, Glenn and Porth, Carol, Mattson. 2009. Pathophysiology Concepts of Altered Health States. 8th ed. Lippincott Williams and Wilkins. Philadelphia


Helicobacter pylori and stomach ulcers

29/10/2009

Stomach ulcers are caused by the gastric mucosa being infected with the bacterium Helicobacter pylori. Helicobacter pylori infects various areas of the stomach and duodenum causing inflammation and ulcers in the stomach.

There are two tests used to assay for the presence of H. pylori infection:

  1. Endoscopy where a tube with a camera is inserted down the esophagus into the duodenum to view the mucosal lining and obtain a tissue sample for assay.

2. The Ulcer Breath Test:

  • Carbon dioxide is exhale when we breath out
  • A breath sample is taken
  • Pranactin is then taken orally
  • A second breath sample is obtained once the Pranactin has been metabolised in the GI tract
  • The breath test is based on H. pylori’s ability to break down urea, the active ingredient in Pranactin.
  • H. pylori breaks down urea in a process that produces carbon dioxide.
  • The urea in Pranactin, however, is composed of a form of carbon called carbon 13, which is not found in high levels in breath.
  • When H. pylori breaks down the urea, carbon dioxide containing the carbon 13 is formed.
  • This carbon dioxide, containing carbon 13, enters the blood and travels to the lungs, where it is exhaled.
  • The test then compares first breath sample to the second sample and determines if a higher proportion of carbon dioxide (containing carbon 13) is present.
  • a higher level of carbon 13 in the second sample results in a positive H. pylori ulcer test.
  • Antibacterial medications to treat H. pylori infection can then be given

Martin, Glenn and Porth, Carol, Mattson. 2009. Pathophysiology Concepts of Altered Health States. 8th ed. Lippincott Williams and Wilkins. Philadelphia


Coagulation Disorders and Treatment

28/10/2009

The clotting factor cascade

Diseases of Hemostatsis

 Thromboembolic disorders

  • occur when undesirable clots are formed
  • Thrombus = stationary clot
  • Embolus = a travelling clot
  • Deep vein thrombosis = thrombi in veins, usually form in leg veins

  • thrombi can form in the atria during atrial fibrillation
  • R atrium thrombi can dislodge and travel to lungs = pulmonary embolism
  • L atrial thrombus can dislodge can cause CVA or arterial infarct elsewhere in the body

  • arterial thrombi and emboli can result from procedures involving arterial punctures such as angiography

 Thrombocytopenia

  • abnormal clot formation
  • deficiency of platelets
  • a result of bone marrow function is suppression
  • Etiology: chemotherapeutic agents and immunosuppressant

 Hemophilias

  • genetic clotting factor deficiency
  • classified by prolonged coagulation times that result in persistent bleeding that can be acute
  1. Hemophilia A
  • lack of clotting factor VIII
  • 80% of all cases

 2. Hemophilia B (Christmas Disease)

  • deficiency of factor IX
  • 20% of cases

Tx:

  • administration of the absent clotting factor

 3. von Willebrand’s disease (vWD)

  • decrease in the quantity or quality of von Willebrand factor, role in platelet aggregation
  • Tx: factor VIII concentrate
  • desmopressin, which promotes release of stored vWF
  • infusion of plasma products containing vWF

Four Mechanisms of hemostasis modification

Drug Classification Mechanism Type of Modification
Anticoagulants Inhibition of specific cloting factors Clot formation prevention
Anticoagulant/antiplatelets Inhibition of platelet actions Clot formation prevention
Thrombolytic Dissolution of clot thrombolytics
Antifibrinolytic Inhibition of the destruction of fibrin Antifibrinolytics – Promotion of thrombosis by inhibiting the normal removal of fibrin, keeping the clot in place for a longer period of time

Anticoagulants

  • prolong bleeding time in order to prevent clot formation
  • Tx of thromboembolic disease
  • Heparin
  • Warfarin

Mechanism of action:

  • exert a negative charge on the surface of the platelets
  • cell aggregation is inhibited

Heparin:

  • acts by enhancing the inhibitory actions of antithrombin III

Warfarin:

  • acts by inhibiting the hepatic synthesis of coagulation factors II, VII, IX and X

Low Molecular weight heparins (LMWHs)

  • inhibit active X factor
  • possess same anticoagulant activity as heparin
  • yet are less likely to thrombocytopenia
  • last 2-4 times longer than heparin

Thrombin Inhibitors

  • bind both clot-bound and circulating thrombin preventing the formation of fibrin clots

 Adams, Micheal, Patrick, Bostwick, Paula, Manuel, Holland, Leland, Norman jr, and King, Shirley, Linda. 2009. Pharmacology for Nurses: A pathological approach. Pearson Canada, Toronto.


Karnofsky Performance Scale and Child Play Performance Scale

27/10/2009


Intramuscular (IM) Injections

26/10/2009

IM injection sites

  1. faster absorption that sub Q due to greater vascularity of muscle

  2. weight and amount of adipose tissue can influence needle site selection

  3. obese clients may require a 7.5cm long needle

  4. thin clients may require a 1.3-2.5cm needle

  5. 90 degree angle for IM

  6. healthy average sized pt can tolerate a 3mL dose into a large muscle

  7. Children and seniors can tolerate 2mL

  8. Small children and large infants 1mL

 

Site selection factors:

  1. free or infection or necrosis

  2. free of local bruising or abrasions

  3. location of underlying bones, nerves and major blood vessels

 

Common Muscle Groups for IM injection Sites

 

  1. Gluteus medius

  1. Vastus Lateralis

 3. Dorsogluteal

 4. Deltoid

 

 

Perry, A, G, Potter, P, A, Ross-Kerr, J, C and Wood, M, J. 2006. Canadian fundamentals of nursing. 3rded. Toronto: Elselvier


Burkitt lymphoma (Malignant lymphoma, Burkitt’s type)

24/10/2009

A type of non-Hodgkin’s lymphoma. a cancer of the lymphatic system. a type of cancer found in the T and B cells of the immune system. most frequently occurs in the abdomen, the ovaries, and the bones of the face.

Etiology:

It is associated with malaria

It accounts for about 30% of HIV-associated lymphomas.

Chromosomal translocations have been associated with this type of cancer. In most (approximately 90%) of the cases of Burkitt’s lymphoma, a reciprocal translocation has moved the proto-oncogene c-myc from its normal position on chromosome 8 to a location close to the enhancers of the antibody heavy chain genes on chromosome 14.