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  1. 1. The Reproductive System Nelia B. Perez RN, MSN Academic Coordinator College of Nursing
  3. 3. Ovary = primary sex organ: paired, <ul><li>Produce eggs (ova) & secretes estrogen & progesterone </li></ul><ul><li>Posterior pelvic wall </li></ul><ul><li>Supported parietal peritoneum = broad ligament </li></ul>
  4. 4. Ovary – cont. <ul><li>Consists of four layers; </li></ul><ul><ul><li>1. Superficial (Germinal) Epithelium - single layer of cuboidal cells, thin outermost </li></ul></ul><ul><ul><li>2. Tunica Albuginea - a collagenous C.T. </li></ul></ul><ul><ul><li>3. Cortex – primary substance of the ovary </li></ul></ul><ul><ul><li>4. Medulla - innermost, vascular area </li></ul></ul>
  5. 5. Oogenesis: egg formation <ul><li>Before birth - Ovary contains about one  million oogonia (immature egg cells, 46 chromosomes). </li></ul><ul><li>At birth - SOME of the oogonia grow and begin into the 1st Meiotic division but stop in Prophase I = Primary Oocytes. </li></ul><ul><li>Primordial Follicle = The immature Primary Oocyte + flattened, randomly-arranged Follicle Cells </li></ul>
  6. 6. Oogenesis <ul><li>Puberty – (Primary Follicle formation) FSH stimulates some Primordial Follicles to grow bigger by developing numerous layers of uniformly-arranged,cuboidal Follicle Cells surrounding a Primary Oocyte   </li></ul>
  7. 7. Oogenesis <ul><li>Secondary Follicle formation -LH stimulates, the Follicle Cells to secrete a nutritive fluid which collects into several fluid-filled cavities called Vesicles which aggregate together to form an Antrum (fluid-filled cavity). Also, a protective layer develops around the Primary Oocyte = Zona Pellucida. The Primary Oocyte plus the Antrum, multiple layers of Granulosa Cells, and the Zona Pellucida = Secondary Follicle. </li></ul>
  8. 8. Oogenesis <ul><li>With continued hormonal stimulation, the Granulosa (Follicle) Cells continue to increase in number and to secrete the nutritive fluid, and the Antrum enlarges to its maximum size. At this stage, the follicle is known as a Graafian (Mature, Vesicular) Follicle.   </li></ul><ul><li>In the Graafian Follicle, under the influence of LH , the Primary Oocyte undergoes completion of the 1st meiotic division & begins into the 2nd meiotic division, but stops in Metaphase II = Secondary Oocyte   </li></ul>
  9. 9. Oogenesis -menstruation <ul><li>Once a month (at approximately day 14 of the normal 28 day cycle), under the influence of LH, the Graafian Follicle is induced to rupture = Ovulation. </li></ul><ul><li>  A Secondary Oocyte is released, surrounded by: </li></ul><ul><ul><li>1. Zona pellucida - a protective gel layer made by the granulosa cells </li></ul></ul><ul><ul><li>2. Corona radiata - two layers of granulosa cells   </li></ul></ul><ul><li>The remaining portion of the Graafian Follicle, under the influence of LH, is induced enlarge and to form a Corpus Luteum. It will produce Estrogen & Progesterone which thickens the stratum functionalis of the uterus.   </li></ul>
  10. 10. Secondary Sex Organs –Fallopian tubes <ul><li>Fallopian tubes: 4 parts; fimbriae, infundibulum, ampulla, isthmus, transport Oocyte to uterus </li></ul><ul><ul><li>1. Fimbriae - motile processes which hang over ovary. Draw secondary oocyte into Uterine Tube </li></ul></ul>
  11. 11. Secondary sex organs- Uterus <ul><li>3 Parts; Fundus, Body, & Cervix </li></ul><ul><li>Histology: </li></ul><ul><ul><li>a. Endometrium </li></ul></ul><ul><ul><ul><li>i. Stratum functionalis - shed during menses, implantation occurs here </li></ul></ul></ul><ul><ul><ul><li>ii. Stratum basale - deep, very vascular, never shed, replaces Stratum Functionalis </li></ul></ul></ul><ul><ul><li>b. Myometrium - middle, smooth m. </li></ul></ul><ul><ul><li>c. Perimetrium - outer, C.T.   </li></ul></ul>
  12. 12. Secondary sex organs - Vagina <ul><li>Vagina: copulatory organ, opening = Vaginal Orifice, in most newborns it is covered by a hymen (vascular connective tissue) </li></ul>
  13. 13. Secondary sex organs - Vulva <ul><li>External Genitalia = Vulva </li></ul><ul><ul><li>Mons pubis - hair covered fat pad </li></ul></ul><ul><ul><li>Labia majora - hair covered skin folds </li></ul></ul><ul><ul><li>Labia minora - smaller, hairless skin folds. Anteriorly, they fuse to form a prepuce (over Clitoris) </li></ul></ul><ul><ul><li>Vestibule: space between labia minora. Contains: </li></ul></ul><ul><ul><ul><li>a. Vaginal orifice </li></ul></ul></ul><ul><ul><ul><li>b. Urethral orifice </li></ul></ul></ul><ul><ul><ul><li>c. Openings for Vestibular (Bartholin's) glands </li></ul></ul></ul><ul><ul><li>Clitoris: contains 2 columns of erectile tissue = corpora cavernosa </li></ul></ul>
  14. 14. Secondary sex cells – Mammary Glands <ul><li>Mammary glands: modified sweat glands. </li></ul><ul><li>Divided into lobules which are subdivided into lobules. The lobules contain Alveolar Glands </li></ul><ul><li>  Milk flows through the Lactiferous ducts & is stored in the Lactiferous sinuses just below the areola. </li></ul><ul><li>Milk leaves the sinuses via Lactiferous Ducts to Nipple </li></ul><ul><li>  Areola - pigmented area around nipple, many oil glands   </li></ul>
  15. 17. <ul><li>Testes (singular = testis) </li></ul><ul><li>Male gonads </li></ul><ul><li>Suspended outside the abdominal cavity in the scrotum </li></ul><ul><li>Hang outside the body to ensure optimal temperatures for sperm production (a few degrees below body temperature is required) </li></ul><ul><li>Testes descend into scrotum during last 2 months of fetal development </li></ul><ul><ul><li>If testes do not descend, sperm can not develop properly </li></ul></ul><ul><ul><ul><li>Male may become sterile </li></ul></ul></ul><ul><ul><ul><li>Increased chance of testicular cancer & injuries </li></ul></ul></ul><ul><li>**Testes are able to move in and out of abdominal cavity to maintain proper temperature for spermatogenesis </li></ul><ul><li>2 Functions </li></ul><ul><ul><li>Make s perm in seminiferous tubules, maturing sperm are moved to the epididymis </li></ul></ul><ul><ul><li>Make hormones : androgens and testosterone </li></ul></ul>
  16. 19. <ul><li>Seminiferous Tubules~250m in length! </li></ul><ul><li>site of spermatogenesis (meiosis) </li></ul><ul><li>also produce inhibin (negative -feedback vehicle to regulate the production of testosterone ) </li></ul><ul><li>Interstitial Cells </li></ul><ul><li>Site of testosterone production </li></ul><ul><li>Epididymis </li></ul><ul><li>area where sperm mature and begin to gain motility and the ability to fertilize </li></ul><ul><li>storage area for sperm </li></ul><ul><li>tightly coiled tubules </li></ul>
  17. 22. <ul><li>Spermatogenesis </li></ul><ul><li>After puberty this is ongoing (unlike females) </li></ul><ul><li>Usually100-300 million sperm delivered per ejaculate </li></ul><ul><ul><li>Only 15% are viable, of this only 400 survive to fertilize egg </li></ul></ul><ul><li>Vas deferens (plural = vas deferentia) (also ductus deferens) </li></ul><ul><li>storage area for sperm </li></ul><ul><li>tube which carries the sperm to the ejaculatory duct and the urethra </li></ul><ul><li>Smooth muscle contractions propel the sperm into the vas deferens </li></ul>
  18. 23. <ul><li>Penis </li></ul><ul><li>spongy, erectile tissue containing distensible blood spaces </li></ul><ul><li>becomes erect during sexual arousal due to an increase in arterial blood flow to the penis caused by parasympathetic nerves </li></ul><ul><li>flaccid if not sexually aroused </li></ul>
  19. 24. P3: List the functions of the seminal fluid <ul><li>Semen ( seminal fluid) </li></ul><ul><li>thick, whitish fluid </li></ul><ul><li>contains sperm and fluids from the seminal vesicles, the prostate and Cowper’s gland. </li></ul><ul><li>is used for nutrition , motility , neutralization, and lubrication </li></ul><ul><li>Seminal Vesicles : </li></ul><ul><li>lie at base of bladder </li></ul><ul><li>secrete a thick, clear fluid containing fructose (energy), prostaglandins (chemical signal in female to trigger rhythmic contractions of smooth muscle in female – facilitates movement of sperm towards egg </li></ul><ul><li>Prostate gland </li></ul><ul><li>Secretes a milky alkaline buffer that protects the sperm from the acidic environment of the vagina. </li></ul><ul><li>Helps activate sperm, helps with motility </li></ul>
  20. 26. y
  21. 27. <ul><li>Cowper’s gland (bulbourethral glands) </li></ul><ul><li>secrete mucous secretes mucus rich fluids prior to ejaculation, thought to neutralize any remaining acidic urine in the urethra. Also contains some sperm before ejaculation – reason for high failure rate of withdrawl method of birth control. </li></ul><ul><li>May also help to lubricate the urethra </li></ul><ul><li>Urethra </li></ul><ul><li>Double purpose tube (semen&urine) but NEVER at same time </li></ul><ul><li>Semen is expelled out of the urethra by rhythmic smooth muscle contractions = male orgasm </li></ul>
  22. 28. <ul><li>Sperm </li></ul><ul><li>Several hundred million released per ejaculate </li></ul><ul><li>fewer than one hundred even get close to the ovule </li></ul><ul><li>Only ONE will fertilize the egg (if any!) </li></ul>
  23. 29. P4: Identify the tail, midpiece, head and acrosome of a mature sperm and state their functions. <ul><li>3 Distinct Parts </li></ul><ul><li>Head </li></ul><ul><li>contains the nucleus (23 chromosomes) </li></ul><ul><li>covered by a cap ( acrosome ) which stores enzymes needed to penetrate the egg/ovum </li></ul><ul><ul><li>also provides chemical guidance system </li></ul></ul>
  24. 31. <ul><li>Middle Piece (midpiece) </li></ul><ul><li>contain microtubules similar to cilia or flagella </li></ul><ul><li>mitochondria are wrapped around the microtubules to provide energy for movement/swimming </li></ul><ul><li>Tail </li></ul><ul><li>microtubules only which “whip” back and forth to “ swim ” to the ovule. </li></ul>
  25. 32. P6: Demonstrate a knowledge of the control of testosterone levels by the endocrine system . <ul><li>Hormonal Regulation in Males </li></ul><ul><li>hypothalamus secretes gonadotropic releasing hormone (GnRH) </li></ul><ul><li>GnRH stimulates the anterior pituitary to secrete the gonadotropic hormones: </li></ul><ul><li>Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) </li></ul><ul><li>[this is true of both males and females] </li></ul>
  26. 33. <ul><li>FSH </li></ul><ul><li>promotes spermatogenesis </li></ul><ul><li>Act directly on the sperm producing cells of the seminiferous tubules </li></ul><ul><li>LH </li></ul><ul><li>controls the production of testosterone </li></ul><ul><li>acts directly on the testosterone producing interstitial cells </li></ul><ul><li>testosterone itself is involved in the negative -feedback system exerted on the hypothalamus and the anterior pituitary gland to regulate testosterone levels in the blood . </li></ul>
  27. 34. P5: Describe the functions of testosterone. <ul><li>Testosterone </li></ul><ul><li>main male sex hormone </li></ul><ul><li>produced in the interstitial cells in the testes </li></ul><ul><li>responsible for the normal development and functioning of the male sex organs </li></ul><ul><li>necessary for the maturation of sperm </li></ul><ul><li>Secondary Sex Characteristics </li></ul><ul><li>- body and facial hair growth </li></ul><ul><li>- deepening of voice (voice box enlarges) </li></ul><ul><li>- growth spurt </li></ul><ul><li>- broad shoulders, longer legs relative to trunk length </li></ul><ul><li>- greater muscle strength </li></ul><ul><li>- oil and sweat glands will secrete more </li></ul><ul><li>- baldness </li></ul><ul><li>also responsible (they think!) for sex drive </li></ul>
  28. 37. Assessment <ul><li>Health History and Clinical Manifestation </li></ul><ul><li>- Menstrual Hx </li></ul><ul><li>- Hx of pregnancies </li></ul><ul><li>- Hx of exposure to medications </li></ul><ul><li>- dysmenorrhea, dyspareunia </li></ul><ul><li>- hx of vaginal discharge and odor in itching </li></ul><ul><li>- history of problems with urinary dysfunction </li></ul><ul><li>- hx of problems with bowel or bladder control </li></ul>
  29. 38. Assessment <ul><li>Sexual hx </li></ul><ul><li>Hx of sexual abuse or physical abuse </li></ul><ul><li>Hx of surgery </li></ul><ul><li>Hx of chronic illness or disability </li></ul><ul><li>Hx of genetic disorder </li></ul>
  30. 39. Physical Assessment <ul><li>Positioning </li></ul><ul><li>Inspection </li></ul><ul><li>Speculum Examination </li></ul><ul><li>Bimanual palpation </li></ul>
  31. 40. Diagnostic Evaluation <ul><li>Pap Smear </li></ul><ul><li>Colposcopy and Cervical Biopsy </li></ul><ul><li>Cryotherapy and laser therapy </li></ul><ul><li>Cone biopsy and leep </li></ul><ul><li>Endometrial biopsy </li></ul><ul><li>D & C </li></ul><ul><li>Endoscopic examination </li></ul>
  32. 41. <ul><li>Menstruation </li></ul><ul><li>Perimenopause </li></ul><ul><li>Menopause </li></ul><ul><li>Premenstrual Syndrome </li></ul><ul><li>Dysmenorrhea </li></ul><ul><li>Amenorrhea </li></ul><ul><li>Abnormal Uterine Bleeding </li></ul>
  33. 42. <ul><li>Dyspareunia </li></ul><ul><li>Contraception </li></ul><ul><li>Abortion </li></ul><ul><li>Infertility </li></ul><ul><li>Ectopic Pregnancy </li></ul>
  34. 44. Chapter 47 Management of Patients With Female Reproductive Disorders
  35. 45. Vulvovaginal Infections <ul><li>Candidiasis </li></ul><ul><li>Seminal Plasma Protein Allergy </li></ul><ul><li>Bacterial Vaginosis </li></ul><ul><li>Trichomoniasis </li></ul><ul><li>Human Papillomavirus </li></ul><ul><li>Herpes virus, Type 2 Infection </li></ul><ul><li>Toxic Shock Syndrome </li></ul><ul><li>Endocervicitis and Cervicitis </li></ul><ul><li>Chlamydia and Gonorrhea </li></ul><ul><li>Pelvic Infection (PID) </li></ul><ul><li>HIV </li></ul>
  36. 46. Structural Disorders <ul><li>Fistulas </li></ul><ul><li>Pelvic Organ Prolapse </li></ul><ul><ul><li>Cystocele </li></ul></ul><ul><ul><li>Rectocele </li></ul></ul><ul><ul><li>Enterocele </li></ul></ul><ul><li>Uterine Prolapse </li></ul>
  37. 49. Benign Disorders <ul><li>Vulvitis </li></ul><ul><li>Vulvar Cysts </li></ul><ul><li>Vulvar Dystrophy </li></ul><ul><li>Ovarian Cysts </li></ul><ul><li>Benign Tumors of the Uterus: Fibroids </li></ul><ul><li>Endometriosis </li></ul><ul><li>Adenomyosis </li></ul>
  38. 50. Malignant Disorders <ul><li>Cancer of the Cervix </li></ul><ul><ul><li>Precursor or preinvasive lesions </li></ul></ul><ul><ul><li>Invasive Cancer </li></ul></ul><ul><li>Pregnancy-Related Neoplasm- Hydatidiform mole </li></ul><ul><li>Cancer of the Uterus (Endometrium), Vulva, Fallopian Tubes, and Ovary </li></ul>
  39. 51. Hysterectomy <ul><li>Postoperative Nursing Interventions </li></ul><ul><ul><li>Relieving anxiety </li></ul></ul><ul><ul><li>Improving body image </li></ul></ul><ul><ul><li>Pain relief </li></ul></ul>
  40. 52. Radiation Therapy <ul><li>Side Effects </li></ul><ul><li>Methods of Radiation </li></ul><ul><ul><li>external </li></ul></ul><ul><ul><li>intraoperative </li></ul></ul><ul><ul><li>internal (intracavitary) </li></ul></ul>
  41. 54. Assessment <ul><li>Health History and Clinical Manifestations </li></ul><ul><li>Physical Assessment: Female Breast </li></ul><ul><ul><li>Inspection </li></ul></ul><ul><ul><li>Palpation </li></ul></ul><ul><li>Physical Assessment: Male Breast </li></ul><ul><ul><li>Gynecomastia </li></ul></ul>
  42. 55. Diagnostic Evaluation <ul><li>Self-Breast Examination </li></ul><ul><li>Mammography </li></ul><ul><li>Galactography </li></ul><ul><li>Ultrasonography </li></ul><ul><li>MRI </li></ul><ul><li>Procedures for Tissue Analysis </li></ul>
  43. 56. Conditions Affecting the Nipple <ul><li>Fissure </li></ul><ul><li>Breast Discharge </li></ul><ul><li>Bleeding or Bloody Nipple Discharge </li></ul>
  44. 57. Breast Infections <ul><li>Mastitis </li></ul><ul><li>Lactational Abscess </li></ul>
  45. 58. Breast Cancer <ul><li>Role of hormones </li></ul><ul><li>Genetics- BRCA-1 and BRCA-2 </li></ul><ul><li>Risk Factors </li></ul><ul><li>Protective Factors </li></ul><ul><li>Staging and Prognosis </li></ul>
  46. 60. Medical and Surgical Management of Breast Cancer <ul><li>Radiation and Chemotherapy </li></ul><ul><li>Modified Radical Mastectomy </li></ul><ul><li>Breast-conserving surgery (lumpectomy) </li></ul><ul><li>Hormonal Therapy </li></ul><ul><li>Reconstructive surgery </li></ul>
  47. 61. Medical and Surgical Management of Breast Cancer (cont’d) <ul><li>Prosthetics </li></ul><ul><li>Rehabilitation </li></ul>
  48. 63. Nursing Management <ul><li>Relieving pain and discomfort </li></ul><ul><li>Maintaining skin integrity </li></ul><ul><li>Promoting positive body image </li></ul><ul><li>Promoting positive adjustment and coping </li></ul><ul><li>Rehabilitation </li></ul>
  49. 64. Nursing Management (cont’d) <ul><li>Potential Complications </li></ul><ul><ul><li>Lymphedema </li></ul></ul><ul><ul><li>Hematoma </li></ul></ul>
  50. 65. Diseases of the Male Breast <ul><li>Gynecomastia </li></ul><ul><li>Male Breast Cancer </li></ul>
  52. 67. THE BREAST <ul><li>It has an important role in modern culture </li></ul><ul><li>Often viewed as measures of sexuality , femininity and attractiveness because it is visible for its size and shape. </li></ul><ul><li>However, it is a secondary sex characteristic </li></ul><ul><li>Its physiologic function is milk secretion to feed infants </li></ul>
  53. 68. Clinical value <ul><li>Experience has verified that 90% of breast cancers are found by women themselves </li></ul><ul><li>When women discover lumps in their breasts at ea very early stage, surgery can save 70-80% of proven cases </li></ul>
  54. 69. Recommendation <ul><li>All women age 20 years and older perform BSE on a monthly basis. Beginning in their 20’s, women should be told about the benefits and limitations of breasts self examination. The importance is prompt reporting of any new breast symptoms to a health professional should be emphasized. </li></ul><ul><li>All women ages 29 to 39 should have clinical examinations every 3 years preferably be part of a periodic health examination. </li></ul><ul><li>All women ages 40 years and older have regular (every 1 to 2 years) mammograms. </li></ul><ul><li>Asymptomatic women ages 40 and older should continue to receive clinical breast examination preferably be part of a periodic health examination annually. </li></ul><ul><li>Screening decisions for older women should be individualized by considering the potential benefits and risk of mammography in the context of the current health status and estimated expectancy. As long as woman is in good health and would be candidate for treatment, she should continue to be screened with mammography. </li></ul>
  55. 70. Advantages of BSE Women can use BSE to asses their breasts. When they perform BSE properly and regularly, they can not any changes in their breasts and seek further evaluation. Examination should be done every month and at the end of menses in all menstruating women.
  56. 71. Barrier to BSE The major barrier to BSE is the lack of CONFIDENCE
  57. 72. Physical assessment findings in a healthy adult <ul><li>By inspection </li></ul><ul><li>By palpation </li></ul>
  58. 73. By inspection the breast should be: <ul><li>Symmetrical, full, rounded, smooth in all portions, without dumpling, retractions or masses </li></ul><ul><li>Faint, even vascular pattern and striae are noted </li></ul><ul><li>Nipples everted, areola even </li></ul><ul><li>Axillae even color, without masses or rash </li></ul>
  59. 74. In palpation the breast should be: <ul><li>Firm and without masses, lumps, local areas with warmth, or tenderness </li></ul><ul><li>Nipples should have no discharges </li></ul><ul><li>Axillae should be smooth and node are nonpalpable </li></ul>
  60. 75. Assessment interview <ul><li>Sexual health history </li></ul><ul><li>Are you currently sexually active? With men, women, or both? </li></ul><ul><li>Describe the positive or negative aspects of your sexual functioning </li></ul><ul><li>Do you have difficulty with sexual desire? Arousal? Orgasm? Satisfaction? </li></ul><ul><li>Do you experience any pain with sexual interaction? </li></ul><ul><li>If there are problems, how have they influenced how you feel about yourself? Have have they affected your partner? How have they affected the relationship? </li></ul><ul><li>Do you expect your sexual functioning to be altered because of your illness? </li></ul><ul><li>What are your partner’s concern about your future sexual functioning? </li></ul><ul><li>Do you have any other sexual questions or concerns that have not been addressed? </li></ul>
  61. 76. Assessment interview <ul><li>Breast History </li></ul><ul><li>Ask the client about breast pain or tenderness and its occurrences in relation to menstrual cycle. </li></ul><ul><li>Ask whether the woman has had in the past or currently has breast lumps or masses. If a lump is present, ask the woman to describe its location, onset and size and whether it is painful </li></ul><ul><li>Determine whether the lump has changed shape, size, consistency, or degree f redness since it was first noticed </li></ul><ul><li>Ask about nipple discharge, which is abnormal in women who are not pregnant or lactating. If there is a discharge, determine the color, consistency, amount and odor. </li></ul><ul><li>Ask whether the woman perform BSE regularly </li></ul><ul><li>Note whether the woman include axillary nodes in BSE. </li></ul><ul><li>Ask for her HISTORY of breast cancer in her blood-related FEMALE relatives – mother, sisters, maternal grandmother or maternal aunts. It indicates an increased risk of breast cancer if she has any family history of breast cancer. </li></ul>
  62. 77. Identifying clients at risk <ul><li>Altered body structure or function due to trauma, pregnancy, recent childbirth, anatomic abnormalities of genitals or disease </li></ul><ul><li>Physical, psychosocial, emotional, or sexual abuse; sexual assault </li></ul><ul><li>Disfiguring conditions, such as burns, skin conditions, birthmarks, scars (e.g. mastectomy) and ostomies </li></ul><ul><li>Specific medication therapy that causes sexual problems </li></ul><ul><li>Temporary or long term impaired physical ability to perform grooming and maintain sexual attractiveness </li></ul><ul><li>Value conflicts between personal beliefs and religious doctrines </li></ul><ul><li>Loss of partner </li></ul><ul><li>Lack of knowledge or misinformation about sexual functioning and expression </li></ul>
  63. 78. SIGNS OF BREAST CANCER <ul><li>Elevation </li></ul><ul><li>Asymmetry </li></ul><ul><li>Bleeding </li></ul><ul><li>“Orange Peel” skin </li></ul><ul><li>Nipple Retraction </li></ul>
  64. 79. Women are screened for breast cancer in 3 ways: <ul><li>Mammography – roentgenography of breasts without injection of contrast meduim. It is most sensitive. </li></ul><ul><li>3 views : </li></ul><ul><li>Craniocaudal </li></ul><ul><li>Mediolateral </li></ul><ul><li>Axillary </li></ul>
  65. 80. Women are screened for breast cancer in 3 ways: <ul><li>2. Clinical Breast Examination - clinical breast exam is an examination by a doctor or nurse, who uses his or her hands to feel for lumps or other changes </li></ul><ul><li>3. Breast self-exam. A breast self-exam is when you check your own breasts for lumps, changes in size or shape of the breast, or any other changes in the breasts or underarm (armpit). </li></ul>
  66. 81. BIOPSY is a medical test involving the removal of cells or tissues for examination. <ul><li>Aspiration – a syringe and g 18 needle is used to aspirate tissue from the site which is under local anesthesia. The specimen is spread on a glass slide, fixed, stained and sent to the laboratory </li></ul><ul><li>Incisional – a piece of tissue is obtained in the operating room, sent to the laboratory fro frozen section which is the stained and examined under the microscope. </li></ul>
  67. 82. Classification of Breast Tumors and Preferred Method of Treatment <ul><li>Variable depending upon nature of metastasis, such as bone, sofe tissue, etc. </li></ul><ul><li>Radiation therapy to primary lesion or metastasis </li></ul><ul><li>Hormonal theraphy, hypophysectomy, adrenalectomy </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Oophorectomy </li></ul>Stage IV Distant Metastasis <ul><li>Variable depending on extensiveness: </li></ul><ul><li>Simple mastectomy with radiation </li></ul><ul><li>Simple mastectomy with excision of large axillary nodes </li></ul><ul><li>Radiation therapy alone if tumor is fixed to the chest wall </li></ul>Stage III Breast Mass locally extensive; axillary supraclavicular and internal mammary nodes positive Radical mastectomy preferred with or without postoperative irradiation Stage II Breast Mass Localized; axillary nodes positive Radical mastectomy preferred by surgeons. Some prefer simple mastectomy plus or without irradiation. Stage I Breast Mass Localized; all nodes negative Treatment Clinical Anatomic Observation
  68. 83. STEPS IN BREAST SELF EXAMINATION <ul><li>Inspection before a mirror </li></ul><ul><li>Palpation: Lying Position </li></ul><ul><li>Palpation: Standing or sitting </li></ul>
  69. 84. Inspection before a mirror <ul><li>Stand and face a mirror with your arms relaxed at your sides or arms resting on your hips; then turn to the right and left for a side view look. (look for any flattening in the side view </li></ul>
  70. 85. <ul><li>… continuation </li></ul><ul><li>Bend forward from the waist with arms raised overhead </li></ul><ul><li>Stand straight with arms raised over the head and move the arms slowly up and down at the sides. (look for free movement of the breasts over the chest wall) </li></ul><ul><li>Press your arm firmly together at the chin level while the elbows are raised to shoulder level. </li></ul>
  71. 86. Palpation: Lying Position <ul><li>Place a pillow under your right shoulder and place the right hand behind your head. This position distributes breast tissues more evenly on the chest. </li></ul><ul><li>Use the finger pads (tips) of the three middle fingers (held together)on your left hands to feel the lumps. </li></ul><ul><li>Press the breast tissue against the chest wall firmly enough to know hoe your breast fells. A ridge of firm tissue in the lower curve of each breast is normal. </li></ul><ul><li>Use circular motions systematically all the way around the breasts as many times as necessary until the entire breast is covered. </li></ul><ul><li>Bring your arm down to your side and feel under your armpit, where breast tissues are also located. </li></ul><ul><li>Repeat the exam on your left breast using the right finger pads of your right hand . </li></ul>
  72. 87. Palpation: Standing or Sitting <ul><li>Repeat the examination of both breasts while upright with one arm behind your head. This position makes it easier to check the upper part of the breast and toward the armpit. </li></ul><ul><li>Optional: Do the upright BSE in the shower. Soapy hands glide more easily over when wet </li></ul><ul><li>Report any changes to your health care provider </li></ul>
  73. 88. The next slide is a video about breast awareness and how to perform BSE
  74. 90. Assessment <ul><li>Health History and Clinical Manifestations </li></ul><ul><li>Physical Assessment </li></ul><ul><ul><li>Digital Rectal Examination </li></ul></ul><ul><ul><li>Testicular Examination </li></ul></ul>
  75. 91. Diagnostic Evaluation <ul><li>Prostate-Specific Antigen Test </li></ul><ul><li>Ultrasonography </li></ul><ul><li>Prostate Fluid or Tissue Analysis </li></ul><ul><li>Test of Male Sexual Function </li></ul>
  76. 92. Disorders of Male Sexual Function <ul><li>Erectile Dysfunction </li></ul><ul><ul><li>Endocrine Therapy </li></ul></ul><ul><ul><li>Sildenafil (Viagra) </li></ul></ul><ul><ul><li>Penile Implants </li></ul></ul><ul><ul><li>Negative-Pressure Devices </li></ul></ul>
  77. 93. Disorders of Male Sexual Function (cont’d) <ul><li>Ejaculation Problems </li></ul><ul><ul><li>Behavioral Therapy </li></ul></ul><ul><ul><li>Chemical, vibratory, and electrical stimulation </li></ul></ul>
  78. 94. Infections of the Male Genitourinary Tract <ul><li>Cystitis </li></ul><ul><li>Sexually Transmitted Diseases </li></ul><ul><ul><li>Urethritis </li></ul></ul><ul><ul><li>Genital Ulcers and warts </li></ul></ul><ul><ul><li>Scabies, pediculosis pubis, molluscum contagiosum </li></ul></ul>
  79. 95. Infections of the Male Genitourinary Tract (cont’d) <ul><ul><li>Hepatitis and enteric infections </li></ul></ul><ul><ul><li>Proctitis </li></ul></ul><ul><ul><li>AIDS </li></ul></ul>
  80. 96. Conditions of the Prostate <ul><li>Prostatitis </li></ul><ul><li>Benign Prostatic Hyperplasia (BPH) </li></ul><ul><li>Cancer of the Prostate </li></ul><ul><ul><li>Radical Prostatectomy </li></ul></ul><ul><ul><li>Radiation Therapy </li></ul></ul><ul><ul><li>Hormonal Therapy </li></ul></ul>
  81. 97. Conditions Affecting the Testes and Adjacent Structures <ul><li>Cryptorchidism </li></ul><ul><li>Orchitis </li></ul><ul><li>Epididymitis </li></ul><ul><li>Testicular Cancer </li></ul><ul><ul><li>Germinal Tumors </li></ul></ul><ul><li>Hydrocele </li></ul><ul><li>Varicocele </li></ul><ul><li>Vasectomy </li></ul><ul><li>Vasovasostomy </li></ul><ul><li>Banking Sperm </li></ul>
  82. 98. Conditions Affecting the Testes and Adjacent Structures (cont’d) <ul><ul><li>Nongerminal Tumors </li></ul></ul><ul><ul><li>Secondary Testicular Tumors </li></ul></ul>
  83. 99. Conditions Affecting the Penis <ul><li>Hypospadias and Epispadias </li></ul><ul><li>Phimosis </li></ul><ul><li>Cancer of the Penis </li></ul><ul><li>Priapism </li></ul><ul><li>Peyronie’s Disease </li></ul><ul><li>Urethral Stricture </li></ul><ul><li>Circumcision </li></ul>
  84. 100. Chapter 52 Management of Patients With HIV Infection and AIDS
  85. 101. HIV and AIDS
  86. 102. HIV <ul><li>Human Immunodeficiency Virus </li></ul><ul><li>The virus that causes AIDS </li></ul>
  87. 103. AIDS <ul><li>Acquired Immunodeficiency Syndrome </li></ul><ul><li>Is a deadly disease that interferes with the body’s ability to fight infection </li></ul>
  88. 104. <ul><li>Someone who is infected by HIV may not show any signs ( carriers ) of the illness for a long time. </li></ul><ul><li>On average, 10 years may pass before HIV infection leads to AIDS . </li></ul><ul><li>During this time, the virus is seriously damaging the infected person’s immune system . </li></ul>
  89. 105. <ul><li>Although there is no cure for AIDS, they are working hard to develop a vaccine . </li></ul><ul><li>A vaccine that works against one form of HIV may not work against another form. </li></ul><ul><li>If someone has HIV, they will have it for the rest of their life. </li></ul>
  90. 106. What symptoms are there? <ul><li>Symptoms include swollen lymph nodes </li></ul><ul><li>Tiredness </li></ul><ul><li>Diarrhea </li></ul><ul><li>Weight loss </li></ul><ul><li>Fever </li></ul><ul><ul><li>These symptoms become worse over time </li></ul></ul>
  91. 107. How HIV attacks the body <ul><li>1. The virus enters the body through the mucous membranes or through a break in the skin . </li></ul><ul><ul><li>HIV invades a host cell ( T-cell : a key part of the immune system) </li></ul></ul><ul><ul><li>The virus uses the cell’s resources to reproduce </li></ul></ul><ul><ul><li>Eventually the host cell is destroyed </li></ul></ul>
  92. 108. <ul><li>2. The virus multiplies within the body </li></ul><ul><li>More and More t-cells are destroyed </li></ul>
  93. 109. <ul><li>3. As the number of t-cells drops , the immune system gets weaker </li></ul><ul><ul><li>The body loses its ability to resist infections and diseases that a healthy immune system could fight off. </li></ul></ul>
  94. 110. How HIV is Spread <ul><li>Having sexual relations with an infected person </li></ul><ul><ul><ul><li>Most common way of getting AIDS </li></ul></ul></ul><ul><ul><ul><li>HIV circulates in the blood and in the body fluids </li></ul></ul></ul><ul><ul><ul><li>Avoiding sexual contact is the only sure way to protect yourself against this kind of transmission </li></ul></ul></ul>
  95. 111. How HIV is spread continued... <ul><li>Using a contaminated needle </li></ul><ul><ul><li>Any blood left on the needle can pass the virus from person to person </li></ul></ul><ul><ul><li>People who share needles for drug use (heroin) are at high risk of transmitting HIV </li></ul></ul>
  96. 112. How HIV is spread continued… <ul><li>Passing HIV from an infected mother to her fetus </li></ul>
  97. 113. How HIV is NOT spread <ul><li>Through the air by coughing or sneezing </li></ul><ul><li>By casual contract with an HIV-infected person ( shaking hands and hugging ) </li></ul><ul><li>By using the same sports equipment, clothing , towel , brush , or furniture as an infected person. </li></ul>
  98. 114. How HIV is NOT spread cont… <ul><li>By using the same telephone, shower , bathtub, or toilet as an infected person </li></ul><ul><li>By sharing eating utensils or dishes with an infected person </li></ul><ul><li>Through bites of mosquitos , ticks , or other insects </li></ul>
  99. 115. How HIV is NOT spread cont… <ul><li>By swimming in the same pool as an infected person </li></ul><ul><li>By donating blood </li></ul>
  100. 116. Stages of HIV Disease <ul><li>Primary Infection </li></ul><ul><li>HIV Asymptomatic </li></ul><ul><li>HIV Symptomatic </li></ul><ul><li>AIDS </li></ul>
  101. 118. Assessment and Diagnostic Findings <ul><li>HIV Antibody Tests </li></ul><ul><ul><li>EIA </li></ul></ul><ul><ul><li>Western Blot Assay </li></ul></ul><ul><ul><li>Rapid HIV Antibody Screening Test </li></ul></ul><ul><li>Viral Load Tests </li></ul><ul><ul><li>Polymerase Chain Reaction </li></ul></ul><ul><ul><li>HIV RNA levels </li></ul></ul><ul><ul><li>RT-PCR </li></ul></ul>
  102. 119. Treatment of HIV Infection <ul><li>Antiretroviral Agent Protocols </li></ul><ul><li>Drug Resistance </li></ul><ul><li>Structured Intermittent Therapy </li></ul><ul><li>Immunomodulator Therapy </li></ul><ul><li>Vaccines </li></ul>
  103. 121. Complementary and Alternative Modalities <ul><li>Spiritual or psychological therapies </li></ul><ul><li>Nutritional therapies </li></ul><ul><li>Drug and biological therapies </li></ul><ul><li>Treatment with physical forces and devices </li></ul>
  104. 122. Nursing Management <ul><li>Nutritional Status </li></ul><ul><li>Skin Integrity </li></ul><ul><li>Respiratory Status </li></ul><ul><li>Neurological Status </li></ul><ul><li>Fluid and Electrolyte Balance </li></ul><ul><li>Knowledge Level </li></ul>
  105. 123. Emotional and Ethical Concerns <ul><li>Stigmatized behaviors </li></ul><ul><li>Confidentiality </li></ul><ul><li>Death and Dying </li></ul>
  106. 124. Burn Injuries
  107. 125. BURN INJURIES <ul><li>Cell destruction of the layers of the skin and the resultant depletion of fluid and electrolytes. </li></ul><ul><li>Burn size </li></ul><ul><li>1. Small burns: body’s response is localized to the injured area </li></ul><ul><li>2. Large or extensive burns: </li></ul><ul><ul><ul><li>consist of 25% or more of the total body surface area (TBSA)‏ </li></ul></ul></ul><ul><ul><ul><li>body’s response to injury is systemic </li></ul></ul></ul><ul><ul><ul><li>affect all of the major systems of the body </li></ul></ul></ul>
  108. 126. Characteristics <ul><li>1. Minor Burns </li></ul><ul><ul><li>Partial thickness burns are no greater than 15% of the TBSA in the adult </li></ul></ul><ul><ul><li>Full thickness burns are < 2% of the TBSA in the adult </li></ul></ul><ul><ul><li>Burn areas do not involve the eyes, ears, hands, face, feet, or perineum </li></ul></ul><ul><ul><li>There are no electrical burns or inhalation injuries </li></ul></ul><ul><ul><li>The client is an adult younger than 60 y.o. </li></ul></ul><ul><ul><li>The client has no preexisting medical condition at the time of the burn injury </li></ul></ul><ul><ul><li>No other injury occurred with the burn </li></ul></ul>
  109. 127. Characteristics <ul><li>2. Moderate Burns </li></ul><ul><ul><li>Partial thickness burns are deep and are 15% to 25% of the TBSA in the adult </li></ul></ul><ul><ul><li>Full thickness burns are 2% to 10% of the TBSA in the adult </li></ul></ul><ul><ul><li>Burn areas do not involve the eyes, ears, hands, face, feet, or perineum </li></ul></ul><ul><ul><li>There are no electrical burns or inhalation injuries </li></ul></ul><ul><ul><li>The client is an adult younger than 60 y.o. </li></ul></ul><ul><ul><li>The client has no chronic cardiac, pulmonary, or endocrine disorder at the time of the burn injury </li></ul></ul><ul><ul><li>No other complicated injury occurred with the burn </li></ul></ul>
  110. 128. Characteristics <ul><li>3. Major Burns </li></ul><ul><ul><li>Partial thickness burns are > 25% of the TBSA in the adult </li></ul></ul><ul><ul><li>Full thickness burns are > 10% of the TBSA </li></ul></ul><ul><ul><li>Burn areas involve the eyes, ears, hands, face, feet, or perineum </li></ul></ul><ul><ul><li>The burn injury was an electrical or inhalation injury </li></ul></ul><ul><ul><li>The client is older than 60 y.o. </li></ul></ul><ul><ul><li>The client has a chronic cardiac, pulmonary, or metabolic disorder at the time of the burn injury </li></ul></ul><ul><ul><li>Burns are accompanied by other injuries </li></ul></ul>
  111. 129. Estimating the extent of injury <ul><li>Rule of nine Lund and Browder Method </li></ul><ul><li>- Modifies percentages for body segments acc. to age </li></ul><ul><li>- Provides a more accurate estimate of the burn size </li></ul><ul><li>- Uses a diagram of the body divided into sections, </li></ul><ul><li>with the representative % of the TBSA for ages </li></ul><ul><li>throughout the lifespan </li></ul><ul><li>- Should be reevaluated after initial wound </li></ul><ul><li>debridement </li></ul>9 18 9 18 9 18 1
  112. 130. Assessment of Burn Injury Takes several weeks to heal. Scarring may occur. Takes several weeks to heal. Scarring may occur. Superficial: Pink or red; blisters form (vesicles); weeping, edematous, elastic. Superficial layers of skin are destroyed; wound moist and painful. Deep dermal: Mottled white and red: edematous reddened areas blanch on pressure. May be yellowish but soft and elastic – may or may not be sensitive to touch; sensitive to cold air. Hair does not pull out easily Second degree In about 5 days, epidermis peels, heals spontaneously. Itching and pink skin persist for about a week. No scarring. Heals spont. If it does not become infected w/in 10 days - 2 weeks. Pink to red: slight edema, which subsides quickly. Pain may last up to 48 hours. Relieved by cooling. Sunburn is a typical example. First Degree Reparative Process Assessment of Extent Extent / Degree
  113. 131. Assessment of Burn Injury <ul><li>AGE AND GENERAL HEALTH </li></ul><ul><li>Mortality rates are higher for children < 4 y.o, particularly those < 1 y.o., and for clients over the age of 60 years. </li></ul><ul><li>Debilitating disorders, such as cardiac, respiratory, endocrine, and renal d/o, negatively influence the client’s response to injury and treatment. </li></ul><ul><li>Mortality rate is higher when the client has a preexisting disorder at the time of the burn injury </li></ul>Eschar must be removed. Granulation tissue forms to nearest epithelium from wound margins or support graft. For areas larger than 3-5 cm, grafting is required. Expect scarring and loss of skin function. Area requires debridement, formation of granulation tissue, and grafting. Destruction of epithelial cells – epidermis and dermis destroyed Reddened areas do not blanch with pressure. Not painful; inelastic; coloration varies from waxy white to brown; leathery devitalized tissue is called eschar. Destruction of epithelium, fat, muscles, and bone. Third degree Reparative Process Assessment of Extent Extent / Degree
  114. 132. <ul><li>TYPES OF BURNS </li></ul><ul><li>Thermal Burns: caused by exposure to flames, hot liquids, steam or hot objects </li></ul><ul><li>Chemical Burns: </li></ul><ul><ul><li>Caused by tissue contact with strong alkali, or organic compounds </li></ul></ul><ul><ul><li>Systemic toxicity from cutaneous absorption can occur </li></ul></ul><ul><li>Electrical Burns: </li></ul><ul><ul><li>Caused by heat generated by electrical energy as it passes through the body </li></ul></ul><ul><ul><li>Results in internal tissue damage </li></ul></ul><ul><ul><li>Cutaneous burns cause muscle and soft tissue damage that may be extensive, particularly in high voltage electrical injuries </li></ul></ul><ul><ul><li>Alternating current is more dangerous than direct current because it is associated with CP arrest, ventricular fibrillation, tetanic muscle contractions, and long bone or vertebral fractures </li></ul></ul><ul><li>Radiation Burns: caused by exposure to UV light, x-rays, or radioactive source </li></ul>
  115. 133. <ul><li>INHALATION INJURIES </li></ul><ul><li>A. Smoke inhalation injury </li></ul><ul><li>: results from inhalation of superheated air, steam, toxic fumes, or smoke </li></ul><ul><li>: Assessment </li></ul><ul><li>- facial burns - erythema </li></ul><ul><li>- swelling of oro / nasopharynx - singed nasal hair </li></ul><ul><li>- stridor, wheezing and dyspnea - flaring nostrils </li></ul><ul><li>- sooty sputum and cough - hoarse voice </li></ul><ul><li>- agitation and anxiety - tachycardia </li></ul><ul><li>B. Carbon Monoxide Poisoning </li></ul><ul><li>: CO is colorless, odorless and tasteless gas that has an affinity for Hgb 200 times greater than that of oxygen </li></ul><ul><li>: O2 molecules are displaced and carbon monoxide reversibly binds to Hgb to form carboxyhemoglobin </li></ul><ul><li>: can lead to coma and death </li></ul>
  116. 134. <ul><li>C. Smoke Poisoning </li></ul><ul><li>: Caused by inhalation of by-products of combustion </li></ul><ul><li>: A localized inflammatory reaction occurs, causing a decrease in bronchial ciliary action and a decrease in surfactant </li></ul><ul><li>: Assessment </li></ul><ul><li>- mucosal edema in the airways </li></ul><ul><li>- wheezing on auscultation </li></ul><ul><li>- after several hours, sloughing of the tracheobronchial epithelium may occur, and hemorrhagic bronchitis may develop </li></ul><ul><li>- ARDS can result </li></ul><ul><li>D. Direct Thermal Heat Injury </li></ul><ul><li>: Can occur to the lower airways by the inhalation of steam or explosive gases or the aspiration of scalding liquids </li></ul><ul><li>: Can occur to the upper airways, w/c appear erythematous and edematous, with mucosal blisters and ulcerations </li></ul><ul><li>: Mucosal edema can lead to upper airway obstruction, esp. during the first 24 to 48 hours </li></ul><ul><li>: Monitored for airway obstruction, ET intubation if obstruction occurs </li></ul>
  117. 135. <ul><li>PATHOPHYSIOLOGY OF BURNS </li></ul>BURN ↑ Vascular permeability ↓ Cardiac output ↑ Peripheral resistance ↑ Viscosity ↑ Hematocrit ↓ IV volume Edema
  118. 136. <ul><li>HEMODYNAMIC / SYSTEMIC CHANGES </li></ul><ul><li>Initially hyponatremia and hyperkalemia occur. Followed by hypokalemia as fluid shifts occur and K+ is not replaced. </li></ul><ul><li>The hematocrit level increases as a result of plasma loss; this initial increase falls to below normal at the 3 rd to 4 th day postburn as a result of the RBC damage and loss at the time of injury. </li></ul><ul><li>Initially, the body shunts blood from the kidneys, causing oliguria; then the body begins to reabsorb fluid, and diuresis of the excess fluid occurs over the next days to weeks. </li></ul><ul><li>Blood flow to the GIT is diminished, leading to intestinal ileus and GI dysfunction. </li></ul><ul><li>Immune system function is depressed, resulting in immunosuppression and thus increasing the risk of infection and sepsis. </li></ul><ul><li>Pulmonary hypertension can develop, resulting in a decrease in the arterial O2 tension and a decrease in lung compliance. </li></ul><ul><li>Evaporative fluid losses through the burn wound are greater than normal, and the losses continue until complete wound closure occurs </li></ul><ul><li>If the intravascular space is not replenished with IV fluids, hypovolemic shock and ultimately death will occur. </li></ul>
  119. 137. BURN INTERVENTIONS <ul><li>MAINTAIN AIRWAY </li></ul><ul><li>FLUID RESUSCITATION </li></ul><ul><li>RELIEVE PAIN </li></ul><ul><li>PREVENT INFECTION </li></ul><ul><li>PROVIDE NUTRITION </li></ul><ul><li>PREVENT STRESS ULCERATION </li></ul><ul><li>PROVIDE PSYCHOLOGIC SUPPORT </li></ul><ul><li>PREVENT CONTRACTURES </li></ul>
  120. 138. <ul><li>MANAGEMENT OF THE BURN INJURY </li></ul><ul><li>Phases of Management of the Burn Injury </li></ul>Resuscitative phase - begins w/ the initiation of fluids and ends when capillary integrity returns to near normal levels and the large fluid shifts have decreased - the amount of fluid administered is based on the client’s weight and extent of injury - most fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital - the goal is to prevent shock by maintaining adequate circulating blood volume and maintaining vital organ perfusion Emergent phase - begins at the time of injury and ends with the restoration of capillary permeability, usually at 48-72 hours after the injury - the 1 ˚ goal is to prevent hypovolemic shock and preserve vital organ functioning - includes prehospital care and emergency room care
  121. 139. Rehabilitative phase - final phase of burn care - overlaps the acute care phase and goes well beyond hospitalization - goals of this phase are designed so that the client can gain independence and achieve maximal function Acute phase - begins when the client is hemodynamically stable, capillary permeability is restored, and diuresis has begun - usually begins 48 - 72 hours after the time of injury - emphasis during this phase is placed on restorative therapy, and the phase continues until wound closure is achieved - the focus is on infection control, wound care, wound closure, nutritional support, pain management, and physical therapy
  122. 140. FLUID SHIFTING IN BURNS OLIGURIC PHASE – Intravascular to Interstitial Hct increased, renal output decreased, hyper K, hypo Na, hypo CHON, metabolic acidosis DIURETIC PHASE – Interstitial to Intravascular Hct decreased, renal output increased, hypo K, hypo Na, hypo CHON, metabolic acidosis
  123. 141. <ul><li>FLUID RESUSCITATION </li></ul><ul><li>Indications: </li></ul><ul><li>- Adults with burns involving more than 15% - 20% TBSA </li></ul><ul><li>- Children with burns involving more than 10-15% TBSA </li></ul><ul><li>- Patients with electrical injury, the elderly, or those with cardiac or pulmonary disease and compromised response to burn injury </li></ul><ul><li>The amount of fluid administered depends on how much intravenous fluid per hour is required to maintain a urinary output of 30 - 50 ml/hr </li></ul><ul><li>Successful fluid resuscitation is evidenced by: </li></ul><ul><ul><li>- Stable vital signs - Palpable peripheral pulse </li></ul></ul><ul><ul><li>- Adequate urine output - Clear sensorium </li></ul></ul><ul><li>Urinary output is the most common and most sensitive assessment parameter for cardiac output and tissue perfusion </li></ul><ul><li>If the Hgb and Hct levels decrease or if the urinary output exceeds 50ml/hr, the rate of IV fluid administration may be decreased </li></ul><ul><li>Generally, a crystalloid (Ringer’s lactate) solution is used initially. Colloid is used during the 2 nd day (5% albumin, plasmate or hetastarch)‏ </li></ul>
  124. 142. ½ in 1 st 8 hours ½ in next 16 hours crystalloid only (lactated Ringer’s)‏ PARKLAND (Baxter)‏ 4ml/kg/% BSA for 24hr period ½ in 1 st 8 hours ½ in next 16 hours ¾ crystalloid, ¼ colloid D5W maintenance BROOKE 2ml/kg/% BSA + 2000ml/24hr (maintenance)‏ Infusion Rate Solution Formula Brooke and Parkland (Baxter) Fluid Resuscitation Formulas for 1 st 24hrs after a Burn Injury
  125. 143. <ul><li>PARKLAND FORMULA </li></ul><ul><li>Example: Patient’s weight: 70 kg; % TBSA burn: 80% </li></ul><ul><li>1 st 24 hours: </li></ul><ul><li>4ml x 70kg x 80% TBSA = 22,400ml of lactated Ringer’s </li></ul><ul><li>1 st 8 hours = 11,200 ml or 1,400 ml/hour </li></ul><ul><li>2 nd 16 hours = 11,200 ml or 700 ml/hour </li></ul><ul><li>2 nd 24 hours: </li></ul><ul><li>0.5ml colloid x weight in kg x TBSA + 2000ml D5W run concurrently over the 24 hour period </li></ul><ul><li>0.5ml x 70kg x 80% = 2800 ml colloid + 2000 ml D5W </li></ul><ul><li>= 117 ml colloid/hour + 84 ml D5W/hour </li></ul>
  126. 144. <ul><li>PAIN MANAGEMENT </li></ul><ul><li>Administer morphine sulfate or meperidine (Demerol), as prescribed, by the IV route </li></ul><ul><li>Avoid IM or SC routes because absorption through the soft tissue is unreliable when hypovolemia and large fluid shifts are occurring </li></ul><ul><li>Avoid administering medication by the oral route, because of the possibility of GI dysfunction </li></ul><ul><li>Medicate the client prior to painful procedures </li></ul><ul><li>NUTRITION </li></ul><ul><li>Essential to promote wound healing and prevent infection </li></ul><ul><li>Maintain nothing by mouth (NPO) status until the bowel sounds are heard; then advance to clear liquids as prescribed </li></ul><ul><li>Nutrition may be provided via enteral tube feeding, peripheral parenteral nutrition, or total parenteral nutrition </li></ul><ul><li>Provide a diet high in protein, carbohydrates, fats and vitamins </li></ul>
  127. 145. <ul><li>ESCHAROTOMY </li></ul><ul><li>A lengthwise incision is made through the burn eschar to relieve constriction and pressure and to improve circulation </li></ul><ul><li>Performed for circulatory compromise resulting from circumferential burns </li></ul><ul><li>After escharotomy, assess pulses, color, movement, and sensation of affected extremity and control any bleeding with pressure </li></ul><ul><li>Pack incision gently with fine mesh gauze for 24 hours after escharotomy, as prescribed </li></ul><ul><li>Apply topical antimicrobial agents as prescribed </li></ul><ul><li>FASCIOTOMY </li></ul><ul><li>An incision is made, extending through the SQ tissue and fascia </li></ul><ul><li>Performed if adequate tissue perfusion does not return after an escharotomy </li></ul><ul><li>Performed in OR under GA, after procedure assess same as above </li></ul>
  128. 146. <ul><li>WOUND CARE </li></ul><ul><li>The cleansing, debridement and dressing of the burn wounds </li></ul><ul><li>Hydrotherapy </li></ul><ul><ul><li>Wounds are cleansed by immersion, showering or spraying </li></ul></ul><ul><ul><li>Occurs for 30 minutes or less, to prevent increased sodium loss through the burn wound, heat loss, pain and stress </li></ul></ul><ul><ul><li>Client should be premedicated prior to the procedure </li></ul></ul><ul><ul><li>Not used for hemodynamically unstable or those with new skin grafts </li></ul></ul><ul><li>Debridement </li></ul><ul><ul><li>Removal of eschar to prevent bacterial proliferation under the eschar and to promote wound healing </li></ul></ul><ul><ul><li>May be mechanical, enzymatic or surgical </li></ul></ul><ul><ul><li>Deep partial- or full-thickness burns: Wound is cleansed and debrided and topical antimicrobial agents are applied once or twice daily </li></ul></ul>
  129. 147. <ul><li>Mobility limitations </li></ul><ul><li>Prevents effective ROM exercises </li></ul><ul><li>Wound assessment is limited </li></ul><ul><li>Decreases evaporative fluid and heat loss </li></ul><ul><li>Aids in debridement </li></ul><ul><li>CLOSED </li></ul><ul><li>Gauze dressings are carefully wrapped from the distal to the proximal area of the extremity to ensure circulation is not compromised </li></ul><ul><li>No 2 burn surfaces should be allowed to touch; can promote webbing of digits, contractures, and poor cosmetic outcome </li></ul><ul><li>Dressings are changed every 8 – 12 hours </li></ul><ul><li>Increase chance of hypothermia from exposure </li></ul><ul><li>Visualization of the wound </li></ul><ul><li>Easier mobility and joint ROM </li></ul><ul><li>Simplicity in wound care </li></ul><ul><li>OPEN </li></ul><ul><li>Antimicrobial cream applied, and wound is left open to the air w/o a dressing </li></ul><ul><li>Antimicrobial cream is applied every 12 hrs </li></ul>Disadvantages Advantages Method Open Method Versus Closed Method of Wound Care
  130. 148. <ul><li>TOPICAL ANTIMICROBIAL AGENTS FOR BURNS </li></ul><ul><li>Silver sulfadiazine </li></ul><ul><li>Most widely used agent and least common incidence of side effects </li></ul><ul><li>May cause transient leukopenia that disappears 2-3 days of treatment </li></ul><ul><li>Use with either open treatment, light or occlusive dressings </li></ul><ul><li>Applied once or twice daily after thorough wound cleansing </li></ul><ul><li>Mafenide acetate 10% cream or 5% solution (Sulfamylon)‏ </li></ul><ul><li>Painful during and for a while after application </li></ul><ul><li>May cause metabolic acidosis, not used if >20% TBSA </li></ul><ul><li>Cream must be reapplied 12 hours to maintain therapeutic effectiveness </li></ul><ul><li>Solution concentration is maintained with bulky wet dressings, rewet every 2-4 hours </li></ul><ul><li>Silver nitrate (0.5% solution)‏ </li></ul><ul><li>Stains everything including normal skin brown or black </li></ul><ul><li>Monitor electrolyte balance carefully </li></ul><ul><li>Other topical dressings </li></ul><ul><li>Cerium nitrate </li></ul><ul><li>Povidone iodine </li></ul><ul><li>Gentamycin </li></ul><ul><li>Polymixin B – Bacitracin ointment </li></ul>
  131. 149. <ul><li>WOUND CLOSURE </li></ul><ul><li>Prevents infection and loss of fluid </li></ul><ul><li>Promotes healing </li></ul><ul><li>Prevents contractures </li></ul><ul><li>Performed on the 5 th to 21 st day, depending on the extent of the burn </li></ul><ul><li>AUTOGRAFTING </li></ul><ul><li>Permanent wound coverage </li></ul><ul><li>Surgical removal of a thin layer of the client’s own unburned skin, which is then applied to the excised burn wound </li></ul><ul><li>Monitor for bleeding following the graft because bleeding beneath an autograft can prevent adherence </li></ul><ul><li>Immobilized after the surgery for 3-7 days to allow time to adhere and attach to the wound bed </li></ul><ul><li>Care of the graft site </li></ul><ul><li>Care of the donor site </li></ul>
  132. 150. <ul><li>TEMPORARY WOUND COVERINGS </li></ul><ul><li>Biological </li></ul><ul><li>Amnion </li></ul><ul><li>Amniotic membranes from human placenta </li></ul><ul><li>Dressing is changed every 48 hours </li></ul><ul><li>Allograft (Homograft)‏ </li></ul><ul><li>Donated human cadaver skin is harvested w/in 24 hrs after death </li></ul><ul><li>Monitor for wound exudate and signs of infection </li></ul><ul><li>Rejection can occur w/in 24 hours </li></ul><ul><li>Xenograft (Heterograft)‏ </li></ul><ul><li>Porcine skin is harvested after slaughter and preserved </li></ul><ul><li>Rejection can occur w/in 24 – 72 hours </li></ul><ul><li>Replaced every 2-5 days until the wound heals naturally or until closure with autograft is complete </li></ul><ul><li>Biosynthetic and synthetic </li></ul><ul><li>Visual inspection of wound is possible, as dressings are transparent or translucent </li></ul><ul><li>Monitor for wound exudate and signs of infection </li></ul>
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