CONSTRICTIVE PERICARDITIS

PERICARDITIS
• Pericarditis is the inflammation of the pericardium
• The pericardium envelops, supports and protect the
heart
• There are both Acute and Chronic Forms
• The Acute form is characterized by serous, purulent or
haemorrhagic exudates

Constrictive Pericarditis
• The chronic form results in thickening of the
pericardial membranes.
• Constrictive pericarditis develops when the
parietal and visceral pericardium form a rigid
envelope of fibrous or calcified tissue which adheres
to and sometimes infiltrate the myocardium.
• The heart is compressed and its diastolic filling is
restricted
• Diastolic filling of the ventricles is limited, thereby
decreasing stroke volume and cardiac output.
• Venous hypertension due to the obstruction is the
cause of the engorged veins, enlarged liver, ascites
and peripheral oedema.
CAUSES
1. Idiopathic or nonspecific causes
2. Infection: usually viral (e.g, Coxsackie, influenza),
sometimes the infectious agent could be bacterial
(eg, streptococci, staphylococci, meningococci,
gonococci); and mycotic (fungal)
3. Disorders of connective tissue: systemic lupus
erythematosus, rheumatic fever, rheumatoid
arthritis.
4. Hypersensitivity states: immune reactions, drug
reactions, serum sickness
5. Disorders of adjacent structures: myocardial
infarction, dissecting aneurysm, pleural and
pulmonary disease (pneumonia)
6. Neoplastic disease: caused by metastasis from lung
cancer or breast cancer, leukaemia
7. Radiation therapy
8. Trauma: chest injury, cardiac surgery, cardiac
catheterization, pacemaker implantation
9. Renal failure and uraemia
10.Tuberculosis
• INCIDENCE
• It affects males more than females
• CLINICAL PRESENTATION
• Chest pain usually remains fairly constant, but it may
worsen with deep inspiration and when lying down or
turning.
• It may be relieved with a forward leaning or sitting
position.
• Pericardial friction rub
• Diminished apical pulse
• Ascites, Hepatomegaly that resembles right sided heart
failure
• Tachycardia
• Dyspnoea
Diagnostic Investigations
• FBC
• Erythrocyte Sedimentation Rate (ESR)
• BUE/Cr
• ECG shows elevated ST segment
• Pericardial Fluid Culture
• Echocardiogram
• CT scan
• MRI
Management
• Surgery
• The only effective treatment of constrictive pericarditis
is pericardiectomy.
• The heart is exposed through a median sternotomy and
the fibrous calcified pericardium is peeled off the
surface of the heart.
• In most cases of idiopathic constriction without
calcification the heart bulges out after an incision is
made in the parietal pericardium, which is then peeled
off a little at a time.
Nursing Management
• Complete Bed Rest
• Nurse in cardiac bed
• Give supplementary oxygen
• Prescribed drugs ( TB drugs, Corticosteroids,
Antibiotics)
• Analgesics
• Ensure mediastinal drainage tube is below the bed or
connected to the suction with appropriate pressure
• Monitor the mediastinal drainage
• Monitor vital signs
• Fluid intake and urine output
• Spo2
• ECG

PERICARDIAL EFFUSION AND CARDIAC TAMPONADE

PERICARDIAL EFFUSION
• Pericardial effusion refers to the accumulation of fluid
in the pericardial sac.
• This occurrence may accompany;
a. Pericarditis
b. Metastatic carcinoma,
c. Cardiac surgery,
d. Trauma or non traumatic haemorrhage.
Cardiac Tamponade
• Cardiac tamponade is the accumulation of fluid within
the pericardial space resulting in
1. Reduced ventricular infilling
2. Reduced cardiac output
3. Haemodynamic changes
4. Pulmonary oedema

PERICARDIAL EFFUSION
• Normally, the pericardial sac contains less than 50 mL
of fluid, which is needed to decrease friction for the
beating heart.
• An increase in pericardial fluid raises the pressure
within the pericardial sac and compresses the heart.
CARDIAC TAMPONADE
• Acute Compression of the heart as a result of
accumulation of fluid within the pericardial space.
• Rapidly increase intra-pericardial pressure caused by
fluid accumulation in the pericardial sac or
• A rapidly developed pericardial effusion which
stretches the pericardium to its maximum size results
in increased pericardial pressure.
• Progressive accumulation of fluid in the pericardium,
causes compression of the heart chambers
• Inability of the ventricles to distend adequately and to
fill
• This obstructs/reduces blood flow to the ventricles
(venous returns)
• Reduce venous returns also lead to reduce cardiac
output
• CAUSES
1. Metastatic carcinoma of Lungs, Breast, or
Oesophagus
2. Chest infections (TB and Bacterial Infections)
3. Mediastinal Trauma
4. Viral infection
5. Post radiation Pericarditis
6. Myocardial Infarction
7. Chronic renal Failure
8. Cardiac catheterization
9. Cardiac Surgery
10.Leukaemia
11.Idiopathic
CLINICAL MANIFESTATION
• It presents with the signs and symptoms of shock
• However the following are the specific presentations
a. Distended jugular vein
b. Elevated Central Venous Pressure
c. Muffled or Distant heart sounds
d. Pulsus paradoxus: Pulse which tends to disappear
during inspiration
e. Low Cardiac Output
f. Feeling of fullness in the chest
f. Diaphoresis
g. Hypotension
h. Weak rapid pulse
i. Anxiety
j. Restlessness
k. Shortness of breath

TREATMENT
• PERICARDIOCENTESIS
• Pericardiocentesis (puncture of the pericardial sac to
aspirate pericardial fluid) is performed to remove fluid
from the pericardial sac.
• Head of the bed is elevated to 60 Degrees
• Oxygen administration
• Connect patient to a monitor with ECG
• Obtain IV access in case the need arise for emergency
drugs/blood products
• Set up a sterile trolley for the procedure
• The pericardial aspiration needle is attached to a 50-
mL syringe by a three-way stopcock.
• Possible Entry sites:
1. The needle may be inserted in the angle between
the left costal margin and the xiphoid, near the
cardiac apex
2. The fifth or sixth intercostal space at the left sternal
margin; or
3. On the right sternal margin of the fourth intercostal
space.
• A resulting fall in central venous pressure and an
associated rise in blood pressure after withdrawal of
pericardial fluid indicate that the cardiac tamponade
has been relieved.
• The patient almost always feels immediate relief.
• If there is a substantial amount of pericardial fluid, a
small catheter may be left in place to drain recurrent
accumulation of blood or fluid.
• When the drainage is completed pressure dressing is
done
• Trolley discarded
• Procedure documented
• Pericardial fluid is sent to the laboratory for
examination for tumour cells, bacterial culture,
chemical and serologic analysis, and differential blood
cell count.
PERICARDIOTOMY
• This is done when there is recurrent pericardial
effusions, usually associated with neoplastic disease.
• The patient receives a general anaesthesia
• A portion of the pericardium is excised and catheter
inserted to permit the pericardial fluid to drain into
the peritoneum.

THORACOTOMY
• an incision into the chest wall to allow access and
surgical treatment
of the lungs, heart, oesophagus, aorta and diaphragm.
• Transfusion of Blood and Blood Products
• Inotropic Drugs
• Nursing Management
• Ensure complete bed rest
• Nurse in upright position/60 degrees
• Administer prescribed Oxygen
• Give prescribed inotropes and analgesics
• Ensure the chest tube drainage is below the level of the
chest and is
not kink
• Assist in pericardiocentesis
• Arrange for Chest X-ray if requested
• Monitoring
• Spo2
• Intake and output
• Chest tube drainage
• ECG
• Vital signs
• Level of pain
• Comfort
• Elevate the of the bed to 60 degrees
• Straighten the bed
• Give the prescribe analgesic
• Aeration
• Calm environment
LUNG ABSCESS
DESCRIPTION
• A lung abscess is a localized necrotic lesion of the lung
parenchyma (the portion of the lung involved in gas
transfer - the alveoli, alveolar ducts, and respiratory
bronchioles) containing purulent material that
collapses and forms a cavity.
• A lung abscess is a localized collection of pus in a
cavity formed by the disintegration of the lung
parenchyma.
• The right lung is involved more frequently than the
left because of the dependent position of the right
bronchus, the less acute angle that the right main
bronchus forms within the trachea, and its larger size

PATHOPHYSIOLOGY
• A lung abscess forms after lung tissue becomes
consolidated (i.e. after alveoli become filled with
fluid, pus, and microorganisms).
• In up to 89% of patients, anaerobic organisms are
identified.
• Consolidated tissue becomes necrotic.
• This necrotic process can spread to involve the entire
bronchopulmonary segment and progress proximally
until it ruptures into a bronchus or pleurae.
CAUSES
1. Aspiration of gastric content or oral secretions
(major cause)
2. Pneumonia
3. Mechanical obstructions from pulmonary embolism,
tumours
4. Chest trauma
5. TB
• The organisms frequently associated with lung
abscesses are S. aureus, Klebsiella,
RISK FACTORS
a. CNS disorders (seizure, stroke) i.e. diseases that
affect swallowing
b. Drug addiction,
c. Alcoholism,
d. Oesophageal disease,
e. Compromised immune function,
f. Patients receiving nasogastric tube feedings
CLINICAL PRESENTATION
i. Fever
ii. Chills
iii. Productive cough with moderate to copious
amounts of foul smelling, often bloody, sputum.
iv. Leucocytosis may be present.
v. Haemoptysis
vi. Pleurisy (chest pain that worsens with breathing or dull
chest pain,
vii. Dyspnoea
viii. Weakness
ix. Anorexia and
x. Weight loss
xi. Dull percussion
xii. Reduced breath sounds on auscultation
xiii. Intermittent pleural friction rub (grating or rubbing
sound) on
auscultation.
xiv. Crackles may be present
DIAGNOSTIC INVESTIGATIONS
a. Chest X-ray
b. Chest CT Scan
c. Sputum for culture and sensitivity tests
d. Bronchoscopy
• In addition
i. FBC
ii. C reactive protein
TREATMENT
1. A prolonged course of antibiotics (6–8 weeks)
dependent on
repeated bacterial cultures
2. drainage of the abscess: internal drainage can be
achieved by chest
physiotherapy
3. Percutaneous Drainage under ultrasound guidance
4. Diet therapy: A diet high in protein and calories
5. Surgery
SURGERY
• Indication for Surgery
1. There are persistent symptoms and signs despite
medical therapy
2. There is a suspicion of an underlying lung carcinoma
3. A large abscess (>6cm) persists radiologically despite
a full course of
treatment
4. Complications develop such as a bronchopleural fistula
or an
empyema.
• Surgical treatment entails thoracotomy under general
anaesthesia
• There is segmental resection, often with the affected
lobe of the
lung.
• Lobectomy may be done

POST OPERATIVE NURSING CARE

• Receive to bed and elevate head of bed
• Give Oxygen or assist with care of patients on
mechanical ventilation
• Monitor vital signs, level of consciousness, chest tube
drainage
• When patient becomes stable
i. Carry out coughing, deep breathing exercises and
incentive
spirometry.
ii. Measure and record the volume of sputum to follow
patient’s
clinical course
iii. Give adequate fluids to enhance liquefying of
secretions
iv. Administer Mucolytics
• Use nursing measures to combat generalized
discomfort; oral
hygiene, positions of comfort, relaxing massage.
• Encourage rest and limitation of physical activity during
febrile
periods.
• Monitor chest tube functioning.
• Evaluate patient for signs of hypoxia thoroughly,
including SpO2,
when anxiety, restlessness, and agitation of new onset
are noted,
before administering as-needed sedatives.
• Consider physician evaluation when these signs are
present,
especially if accompanied by cyanotic nailbeds, pallor,
increased
respiratory rate
• Administer analgesics as directed.
• Use caution with opioids that might depress respirations
• Provide a high-protein, high-calorie diet.
• Offer liquid supplements for additional nutritional
support when
anorexia limits the patient’s intake.
• Monitor weight weekly

LUNG CANCER
BRONCHOGENIC CARCINOMA
DESCRIPTION
• Lung cancer is a malignant tumour of the lung
tissue characterized by uncontrollable cell
growth and multiplication
• Most primary lung cancers arise as a result of
failure of cellular regulation in the bronchial
epithelium.
• These cancers are collectively called
bronchogenic carcinomas
Incidence
• Lung cancer is a leading cause of cancer-related
deaths worldwide.
• It affects more men than women
• Approximately 70% of patients with lung cancer,
have metastasis by the time of diagnosis
Incidence
• The overall 5-year survival for all patients with
lung cancer is only 16%.
• This poor long-term survival is because most
lung cancers are diagnosed at a late stage,
when metastasis is present
Pathophysiology
• Lung cancers arise from mutation of epithelial
cell in the tracheobronchial airways, in which
the carcinogen binds to and damages the cell’s
DNA.
• This damage results in cellular changes,
abnormal cell growth, and eventually a
malignant cell.
• As the damaged DNA is passed on to daughter
cells, the DNA undergoes further changes and
becomes unstable.
• The genetically changed pulmonary epithelium
undergoes malignant transformation from normal
epithelium eventually to invasive carcinoma.
• Carcinoma tends to arise at sites of previous
scarring (TB, fibrosis) in the lung
Classification
• Lung cancers are classified into two major
categories:
1. Small cell carcinoma
2. Non–small cell carcinoma.
• Small cell carcinoma represents 15% to 20% of
lung cancers
• Non–small cell lung carcinoma (NSCLC)
represents approximately 80% of tumors
• Small cell lung carcinomas are aggressive
lung cancer that are oval in shape and look
small under the microscope
• They spreads early via lymphatics and
bloodstream; frequent metastasis to brain
• Non-small cell lung carcinoma: these
types are also malignant but appears
comparatively larger
• They produce early symptoms of
nonproductive cough and hemoptysis.
• Does not have a strong tendency to
metastasize
Risk Factors
1. Cigarette smoking (both firsthand and
secondhand smoke)
2. Radiation exposure
3. Chronic exposure to inhaled environmental
irritants (air pollution, asbestos, other talc
dusts)
4. Older adult clients have decreased pulmonary
reserves due to normal lung changes
Risk Factors
5. Family History of lung cancer.
6. underlying respiratory diseases, such as COPD
and TB

Clinical Presentation
a. Persistent/chronic cough, with or without
hemoptysis (rust-colored or blood-tinged
sputum)
b. Hoarseness of voice
c. Chest wall masses
d. Muffled heart sounds
e. Pleural friction rub
f. Clubbing of fingers
g. Increased work of breathing (retractions, use of
accessory muscle, stridor, nasal flaring)
h. Malaise, fever, weight loss, fatigue, anorexia
i. Hemoptysis
j. Altered breath sounds (wheezing), diminished,
or absent breath sounds (obstruction)
Diagnostic investigation
i. Chest X-ray
ii. CT Scan
iii. Bronchoscopy
iv. Sputum cytology
v. Fine-needle aspiration
vi. Full blood count,
vii. BUE/Cr
viii. Liver function test
Surgical Intervention
• Surgical resection is the preferred method of
treating patients with localized non–small cell
tumors, no evidence of metastatic spread, and
adequate cardiopulmonary function.
• Surgery is primarily used for NSCLCs
• Because small cell cancer of the lung grows
rapidly and metastasizes early and extensively
many patients with this cancer are inoperable at
the time of diagnosis
Types of Surgical Intervention
1. Lobectomy: a single lobe of the lung is removed
2. Bilobectomy: two lobes of the lung are removed
3. Sleeve resection: cancerous lobe(s) is removed
and a segment of the main bronchus is resected
4. Pneumonectomy: removal of entire lung
5. Chest wall resection with removal of cancerous
lung tissue: for cancers that have invaded the
chest wall

Radiation Therapy
• Radiation therapy may offer cure in a small
percentage of patients.
• It is useful in controlling neoplasms that cannot
be surgically resected but are responsive to
radiation.
• Radiation also may be used to reduce the size
of a tumor, to make an inoperable tumor
operable, or to relieve the pressure of the
tumor on vital structures.
Nursing Management
• Nurse the patient with the head of the bed
elevated
• Give oxygen
• Manage the chest tube and drainage system.
• Monitor vital signs and pulse oximetry
• Deep Breathing Exercise
• Administer Bronchodilators, Cough Expectorants and
Analgesics

DEEP VEIN THROMBOSIS

Description
• Deep Vein Thrombosis is the formation of blood clot
in the deep veins of the leg (especially the calf)
characterised by pain, redness, swelling and warmth.
• The formation of venous thrombi is believed to be
triggered by 3 pathological factors called the
Virchow's Triad
Virchow's Triad
1. Venous Stasis
2. Vessel wall injury, and
3. Altered blood coagulation
Venous Stasis:
• Venous stasis occurs when blood flow is reduced, as in
a. Heart failure
b. Shock
c. When veins are dilated, as with some medication
therapies
d. When skeletal muscle contraction is reduced, as in
immobility, paralysis of the extremities, or anaesthesia.
e. Moreover, bed rest reduces blood flow in the legs by at
least 50%.
f. Age
Endothelial Damage:
• Damage to the intimal lining of blood vessels creates a
site for clot formation.
• Direct trauma to the vessels, as with fractures or
dislocation,
• Surgery
• Venous Catheterisation
• Chemical irritation of the vein from intravenous
medications or solutions, can damage veins
Increased blood Coagulability:
• Occurs most commonly in patients who have
a. been abruptly withdrawn from anticoagulant
medications.
b. Oral contraceptive use
c. Pregnancy
d. Polycythaemia
e. Septicaemia
f. Cancer
Incidence
1. 1 in 1000 adult population
2. Higher in men than women
CLINICAL MANIFESTATION
1. Calf pain, which may be described as tightness or a
dull, aching pain in the affected extremity,
particularly upon walking, is the most common
symptom.
2. Tenderness,
3. Swelling
4. Warmth
5. Erythema may be noted along the course of involved
veins

Diagnostic Investigations
• Duplex ultrasound (involves using high frequency
sound waves to look at the speed of blood flow, and
structure of the leg veins)
• MRI
• Contrast venography has a high sensitivity and
specificity for occluded vein segments and is the most
accurate method of assessing post- thrombotic
changes.
• D-Dimers
TREATMENT
1. Anticoagulant Therapy: these work by reducing
further formation of clots while giving the body time
to dissolve what was formed
a. Heparin
b. Low Molecular Weight Heparin (Clexane =
Enoxaparin) or Fragmin
c. Oral Warfarin
• Warfarin doses are adjusted to maintain the
international normalized ratio (INR) between 2.0 to
3.0
Thrombolytic Therapy.
• Unlike the anticoagulants, thrombolytic (fibrinolytic)
therapy causes the thrombus to lyse and dissolve in
50% of patients.
• Thrombolytic drugs are given within the first 3 days
after acute thrombosis.
• Therapy initiated beyond 5 days after the onset of
symptoms is significantly less effective
• The advantages of thrombolytic therapy include less
long-term damage to the venous valves and chronic
venous insufficiency.
• However, thrombolytic therapy results in
approximately a threefold greater incidence of
bleeding than Heparin.
• If bleeding occurs and cannot be stopped, the
thrombolytic agent is discontinued.
• Examples of Thrombolytic drugs
• Alteplase
• Streptokinase
• Urokinase
Surgery
• Venous thrombosis usually is effectively treated with
conservative measures and anticoagulation.
• In some cases, however, surgery is required to remove
the thrombus, prevent its extension into deep veins,
or prevent the effects of embolization.
Venous Thrombectomy:
• This is done when thrombi lodge in the vein and their
removal is necessary to prevent pulmonary embolism
or gangrene.
• An incision is made to the area of blood clot and into
the vessel to remove the clot

Embolectomy:
• This is done by inserting a small catheter with a small
inflatable balloon attached.
• The balloon is inflated and the catheter is pulled out
removing the clot
• Successful thrombus removal rapidly improves venous
circulation.
• When venous thrombosis is recurrent and
anticoagulant therapy is contraindicated, a filter may
be inserted into the vena cava to capture emboli from
the pelvis and lower extremities, preventing
pulmonary embolism

NURSING CARE
• Bed Rest
• Elevation of the affected limb
• Give prescribed anticoagulants
• Give prescribed analgesics
• Thromboembolic Deterrent Stockings (TED Stockings)
• Monitor signs of Bleeding: bruises, nosebleeds, and
bleeding gums are also early signs.
• Drug interaction especially with Warfarin
• Warm moist compress

VARICOSE VEINS
Varicose veins are irregular, tortuous veins with
incompetent valves.

-Varicosities may develop in any veins, and may be

called by other names, such as haemorrhoids in
the rectum and varices in the oesophagus.
-The condition is most common in women and in
people whose occupations require prolonged
standing, such as salespeople, hair stylists,
teachers, nurses, ancillary medical personnel, and
construction workers
Types
1.Primary
2.secondary
-Primary Varicose Veins
These originate in the superficial veins of the leg
(saphenous veins)
Valve and vein wall failure.

-Secondary varicose veins

Follows valve destruction by Deep Vein thrombosis
and/or valve ring dilatation secondary to proximal
obstruction.
-PATHOPHYSIOLOGY
A weakened valve allows backflow of blood to the
distal valve
If that valve cannot hold the pooling of blood it
becomes incompetent allowing even more blood to
flow backward
As the volume of venous blood build up, pressure
in the vein increases and the vein becomes
distended
As the vein stretches, it loses elasticity, enlarges
and become torturous.
-CAUSES
faulty Valves
-Risk factors
Pregnancy
Tight clothing
Occupations that necessitate prolong standing
Deep Vein Thrombosis
CLINICAL PRESENTATION
1-Feeling of heaviness in the legs that worsens in
the evening and in warm weather
2-Leg cramps at night
3-Diffuse leg pain after prolong standing
4-Dilated purplish rope-like vein in the calf
5-Orthostatic oedema of the calves and ankles
6-Venous stasis ulcers may be present
DIAGNOSTIC INVESTIGATIONS
Duplex ultrasonography
Phlebography
TREATMENT
SCLEROTHERAPY
In sclerotherapy, a chemical is injected into the
vein

The chemical irritates the venous endothelium and

producing localized phlebitis and fibrosis

This leads destruction the lumen of the vein.

SURGERY
Surgery for varicose veins requires that the deep
veins be patent and functional.
The vein is ligated high in the groin, where the
saphenous vein meets the femoral vein.
The vein is removed (stripped).
After the vein is ligated, an incision is made above
the ankle, and a metal or plastic wire is passed the
full length of the vein to the point of ligation.
The wire is then withdrawn, pulling (removing,
“stripping”) the vein as it is removed
NURSING CARE
Bed rest for at least 24hrs
Vital signs
Affected leg is elevated

Prescribed analgesics

Check for circulation in the toes by observing

colour and warmth
Monitor bleeding

Assist patient to mobilize out of bed after 24hrs

Patient begins walking every 2 hours for 5 to 10

minutes

Ensure TED Stockings are worn for at least 1 week

HIRSCHSPRUNG’S DISEASE
Hirschsprung’s disease may be defined as a
functional intestinal obstruction resulting from the
congenital absence of parasympathetic ganglion
cells in the intermuscular and submucosal plexus
of the distal bowel
PATHOPHYSIOLOGY
Hirschsprung’s disease results in a functional
obstruction of the bowel with dilatation of the
proximal colon and hypertrophy of the muscles
(i.e. megacolon).
Macroscopically, Hirschsprung’s disease features a
narrow aganglionic segment and a transitional
zone, and then the dilated proximal portion with a
thickened bowel wall as a result of hypertrophy of
the muscular wall of the intestine
Parasympathetic nerve cells regulate peristalsis in
the intestine.

The name aganglionic megacolon actually

describes the condition because there is an
absence of parasympathetic ganglion cells within
the muscular wall of the distal colon and the
rectum.

As a result, the affected portion of the lower bowel

has no peristaltic action.
Thus, it narrows, and the portion directly proximal
to (above) the affected area becomes greatly
dilated and filled with feces and gas
Hirschsprung’s disease classically affects the
rectum and sigmoid.

The aganglionosis always starts at the internal

anal sphincter and then extends proximally to the
recto-sigmoid area in about 75 % of cases

The remaining 25% affects the whole colon.

CLINICAL PRESENTATION
1.A delay in passage of meconium in neonate in the
first 24 hrs
2.Obstinate Constipation
3.Gross abdominal distension
4.Late onset of bilious vomiting
5.Digital rectal examination reveals a narrow, tight
and empty anal canal. A small amount of meconium
or an explosive mixture of flatus and faeces is
passed on withdrawing the finger
6.The child does not develop normally and is often
thin and malnourished.
7.Chronic anaemia
DIAGNOSTIC INVESTIGATIONS
1.Abdominal X-rays
2.Contrast Enema (The narrow aganglionic
segment is shown with a dilated proximal bowel
segment, and a transitional zone is observed
3.Rectal Biopsy for histologic confirmation of
absence ganglion cells
4.Rectal manometry
INCIDENCE
Occurs in 1 in 5000 live births
It 7 times more common in males than females
More prevalent in whites
Females with Hirschsprung's Disease are at higher
risk of giving birth to affected children
TREATMENT
Preoperative
Colonic lavage or irrigation to empty the bowel
until the time of surgery
When bowel sound returns after the lavage, feed
with Breast milk or formula
Give resuscitation IV Fluids
Give Antibiotics
Parenteral nutrition may be indicated to correct
profound malnutrition
SURGERY
Laparotomy with colostomy is done to relieve the
obstruction

The diversion of the faecal stream, allows the

chronically distended bowel to return to a normal
calibre lumen before definitive surgical correction.

3 – 9 mths later, the ganglionated colon is brought

through and anastomosed to the rectum.
POST OPERATIVE NURSING MANAGEMENT
Receive patient into a warm incubator or cot
Give oxygen
Maintain a patent airway
Give prescribed IV Fluids with dorciflow or
volumetric pump
Elevate the head of the cot/incubator slightly to
enhance respiration
Monitor vital signs
Intake and output
Prescribed analgesics
Prescribed antibiotics
Change of dressing any other day
Teach colostomy care

DISEASES OF THE HEART VALVES

Mitral valve stenosis is Narrowing of the valve
orifice usually the result of rheumatic heart
disease.

Inflammation of the mitral valve as the result of

rheumatic fever is followed by healing and fibrosis
which affect the valve leaflets the chordae
tendinae and the papillary muscles.
The valve leaflets become scarred and fibrotic.
This results in narrowing of the mitral valve orifice
leading to sluggish flow of blood from the left
atrium to the left ventricle

Deposition of platelets and other blood elements

results in calcification worsening the fibrosis
The left atrial volume and pressure increases and
the atrial chamber dilates
Increase resistance to blood flow results in
pulmonary hypertension, right ventricular
hypertrophy and eventually right sided heart
failure

CAUSES
Rheumatic Fever
Endocarditis
Congenital defects
INCIDENCE
Occur predominantly in females (two-thirds are
females)
40% of the patients with rheumatic fever

CLINICAL PRESENTATION
Nocturnal cough
Haemoptysis
Dyspnoea on exertion
Gradual intolerance to exercise
Orthopnoea
Peripheral cyanosis including the lips and cheeks
Hepatomegaly
Ascites
Peripheral oedema
Jugular vein engorgement
Palpitation
Crepitation over the lung bases
Shortness of breath

DIAGNOSTIC INVESTIGATIONS
Chest X-ray
Echocardiography
Cardiac Catheterization

TREATMENT
Drugs
Anticoagulants
Diuretics
Digoxin
Oxygen
Calcium Channel Blockers
Antibiotics

Synchronized Cardioversion if there is atrial

fibrillation
Percutaneous Balloon mitral valvuloplasty
A guide wire (light source and balloon tip)
introduced through the femoral/internal jugular
vein into the right atrium.
A puncture is made in the intra-atrial septum.
A dilation catheter placed through an atrial
transseptal puncture and across the mitral valve
Mitral Valve Replacement
Indications for replacement rather than repair of
the stenotic valve include the presence of a heavily
calcified valve, shortened and extensively fused or
obliterated chordae tendinea.

The valve is excised near the annulus and the

chordae are divided at their origin from the
papillary muscles.
An appropriate size prosthetic valve is implanted
Commissurotomy
The most common valvuloplasty procedure is
commissurotomy.
Each valve has leaflets; the site where the leaflets
meet is called the commissure.
The leaflets may adhere to one another and close
the commissure (ie, stenosis).
Less commonly, the leaflets fuse in such a way
that, in addition to stenosis, the leaflets are also
prevented from closing completely, resulting in a
backward flow of blood (ie, regurgitation).

A commissurotomy is the procedure performed to

separate the fused leaflets.
CLOSED COMMISSUROTOMY
Closed commissurotomies do not require
cardiopulmonary bypass.
The valve is not directly visualized.
The patient receives a general anaesthetic, a
midsternal incision is made, a small hole is cut into
the heart, and the surgeon’s finger or a dilator is
used to break open the commissure.

This type of commissurotomy has been performed

for mitral, aortic, tricuspid, and pulmonary valve
diseases.
NURSING MANAGEMENT
Patients who have had valvuloplasty or valve
replacements are admitted to the intensive care
unit
Care focuses on recovery from anaesthesia and
hemodynamic stability.

Vital signs are assessed every 5 to 15 minutes and

as needed until the patient recovers from
anaesthesia or sedation and then assessed every 2
to 4 hours and as needed.
Intravenous medications to increase or decrease
blood pressure and to treat dysrhythmias or
altered heart rates are administered and their
effects monitored.
The intravenous medications are gradually
decreased until they are no longer required or the
patient takes needed medication by another route
(eg, oral, topical).
Patient assessments are conducted every 1 to 4
hours and as needed, with particular attention to
neurologic, respiratory, and cardiovascular
systems
Nurse in the upright position
Give oxygen
Prescribed drugs including anticoagulants
Ensure complete bed rest
Monitor vital signs
Intake and output
Monitor thrombosis and embolism

COLORECTAL CANCERS
DESCRIPTION
• Malignant tumours of the colon or rectum.
• Found mostly at the rectosigmoid area
• The tumour typically grows slowly and remain
asymptomatic for a long time.
DESCRIPTION
• By the time manifestations occur, the disease
may have spread into deeper layers of the bowel
tissue and adjacent organs.
• Colorectal cancer spreads by direct extension to
involve the entire bowel circumference, the
submucosa, and outer bowel wall layers.
• Neighbouring structures such as the liver,
greater curvature of the stomach may be involved
by direct infiltration.
• Other structures that might be affected by
direct infiltration are duodenum, small intestine,
pancreas, spleen, genitourinary tract, and
abdominal wall.
• Metastasis to regional lymph nodes is the most
common form of tumour spread.
• This is not always an orderly process; distal
nodes may contain cancer cells while regional
nodes remain normal.
RISK FACTORS
• CAUSE: Unknown
• RISK FACTORS
1. Excessive intake of saturated animal fat
2. History of Ulcerative Colitis
3. Age over 40yrs
4. Family history of colorectal cancer
5. Excessive consumption of high protein low fibre
diet
RISK FACTORS
6. History of colon or rectal polyps
7. Smoking
8. Alcoholism
9. Obesity
10. Exposure to radiation
INCIDENCE
• Affects men and women equally
• Higher in areas of higher economic
development
CLINICAL MANIFESTATION
a. Black Tarry Stool
b. Abdominal pains (dull cramps)
c. Weakness
d. Diarrhoea
e. Anorexia
CLINICAL MANIFESTATION
f. Weight loss
g. Vomiting
h. Rectal bleeding
i. Intermittent abdominal fullness
j. Urgent need to defecate on arising
CLINICAL MANIFESTATION
f. Abdominal distention
g. Enlarged abdominal veins
h. Enlarged inguinal and supraclavicular lymph
nodes
i. Generalized abdominal tenderness
DIAGNOSTIC INVESTIGATIONS
i. Digital rectal examination (to feel for the mass)
ii. Stool for occult blood test
iii. Barium Enema iv. CT Scan
v. Colonoscopy
TREATMENT
•If the patient develops intestinal obstruction, he
is treated with intravenous fluids.
•Nasogastric tube is inserted to drain decompress
the stomach.
•If there has been significant bleeding, blood
component therapy may be required.
TREATMENT
•Radiation or Chemotherapy is used before and
after surgery to shrink the tumour, to achieve
better results from surgery, and to reduce the risk
of recurrence.
•For inoperative or unresectable tumours,
irradiation is used to provide significant relief from
symptoms.
•Intracavity and implantable devices are used to
deliver radiation to the site.
SURGERY
•Surgery is the primary treatment for most colon
and rectal cancers.
•It may be curative or palliative.
•The type of surgery recommended depends on the
location and size of the tumour
SURGERY
•Types of Surgery
1. Segmental resection with anastomosis: This
involves the removal of the tumour and portions of
the bowel on either side of the growth, as well as
the blood vessels and lymphatic nodes
2. Abdominoperineal resection with permanent
sigmoid colostomy: The removal of the tumour
and a portion of the sigmoid and all of the rectum
and anal sphincter.
SURGERY
3. Temporary colostomy followed by segmental
resection and anastomosis and subsequent
reanastomosis of the colostomy, allowing initial
bowel decompression and bowel preparation
before resection
4. Permanent colostomy or ileostomy for palliation
of unresectable obstructing lesions
SURGERY
•A colostomy is the surgical creation of an opening
ie, stoma into the colon.
•It can be created as a temporary or permanent
faecal diversion.
•It allows the drainage or evacuation of colon
contents to the outside of the body.
Nursing Management
•PREOPERATIVE CARE
•Physical preparation for surgery involves building
the patient’s strength before surgery and
cleansing the bowel the day prior to surgery.
•If the patient’s condition permits, the nurse
recommends a diet high in calories, protein, and
carbohydrates and low in residue for several days
before surgery
Nursing Management
•A full-liquid diet may be prescribed 24 to 48 hours
before surgery to decrease bulk.
•The bowel is cleansed with laxatives, enemas, or
colonic irrigations the evening before and the
morning of surgery.
•The nurse measures and records intake and
output, including vomitus, to provide an accurate
record of fluid balance.
•The patient’s intake of oral food and fluids may be
restricted to prevent vomiting.
•The nurse administers antiemetics as prescribed.
•Full or clear liquids may be tolerated, or the
patient may be allowed nothing by mouth.
•A nasogastric tube may be inserted to drain
accumulated fluids and prevent abdominal
distention.
POSTOPERATIVE CARE
•The nurse also monitors the patient for
complications such as
•leakage from the site of the anastomosis,
•prolapse of the stoma,
•perforation,
•stoma retraction,
•faecal impaction,
•skin irritation, and
•pulmonary complications associated with
abdominal surgery.
•The nurse assesses the abdomen for returning
peristalsis and assesses the initial stool
characteristics.
• Nutrition
• A complete nutritional assessment is important
for patients with a colostomy.
• The patient avoids foods that cause excessive
odour and gas, including foods in the cabbage
family, eggs, fish, beans, and highcellulose
products such as peanut
• The nurse can help the patient identify any
foods or fluids that may be causing diarrhoea, such
as fruits, high-fibre foods, soda, coffee, tea, or
carbonated beverages.
• Wound Care
• It is important to help the patient splint the
abdominal incision during coughing and deep
breathing to lessen tension on the edges of the
incision.
• The nurse monitors temperature, pulse, and
respiratory rate for elevations, which may indicate
an infectious process.
• If the patient has a colostomy, the stoma is
examined for swelling
• colour (a healthy stoma is pink or red) and
discharge
• Stoma Care
• The colostomy begins to function 3 to 6 days
after surgery.
• The nurse manages the colostomy and teaches
the patient about its care until the patient can take
over.
• Teaches patient skin care and how to apply and
remove the colostomy bag.
• Care of the peristomal skin is an ongoing
concern because excoriation or ulceration can
develop quickly.
• The presence of such irritation makes adhering
the ostomy appliance difficult, and adhering the
ostomy appliance to irritated skin can worsen the
skin condition.
• To remove the appliance, the patient assumes a
comfortable sitting or standing position and gently
pushes the skin down from the faceplate while
pulling the pouch up and away from the stoma.
• Gentle pressure prevents the skin from being
traumatized and any liquid faecal contents from
spilling out.
• The nurse advises the patient to protect the
peristomal skin by washing the area gently with a
moist, soft cloth and a mild soap.
• Soap acts as a mild abrasive agent to remove
enzyme residue from faecal spillage.
• The patient should remove any excess skin
barrier. While the skin is being cleansed, a gauze
dressing can cover the stoma to absorb excess
drainage.
• After cleansing, the patient pats the skin
completely dry with a gauze pad, taking care not
to rub the area.
• A new colostomy bag is then put in place

BENIGN PROSTATIC HYPERPLASIA

BENIGN PROSTATIC HYPERPLASIA
Benign prostatic hyperplasia (BPH) is
nonmalignant, nodular growth of prostatic tissue
The enlargement eventually compresses the
urethra, causing lower urinary tract symptoms
Description
There 2 ways enlargement occur
1. There is excessive proliferation of normal cells
in normal organs
2. Hypertrophy (an increase in the size of an
organ)
BPH is one of the most common disorders of older
men and is a nonmalignant enlargement of the
prostate gland.
BENIGN PROSTATIC HYPERPLASIA

INCIDENCE
BPH typically occurs in men older than 40 years of
age.
By the time they reach 60 years of age, 50% of
men have BPH.
PATHOPHYSIOLOGY
BPH develops over a prolonged period; changes in
the urinary tract are slow and insidious
Typically, BPH develops in the inner part of the
prostate.
As the prostate gland enlarges, it extends upward
into the bladder and inward, causing bladder
outlet obstruction
PATHOPHYSIOLOGY
As the urinary urethra constricts, it causes
increased pressure to urinate, thereby causing
bladder distention, eventual hypertrophy
The hypertrophied lobes of the prostate may
obstruct the bladder neck or urethra, causing
incomplete emptying of the bladder and urinary
retention.
PATHOPHYSIOLOGY
The problems that ensue include;
1. bladder diverticula,
2. urinary stasis, 3. infection, and
4. bladder stone formation.
PATHOPHYSIOLOGY
If the obstruction is prolonged, hydronephrosis
(backflow of urine into the renal pelvis) will occur
and cause damage to the kidneys
BLADDER DIVERTICULUM

USG OF BLADDER DIVERTICULUM

PREDISPOSING FACTORS
The cause of BPH is not known but some school of
thought associate it with proportional increase in
estrogen
Predisposing factors include;
1. aging,
2. obesity
3. lack of physical activity,
PREDISPOSING FACTORS
4. Alcohol consumption,
5. erectile dysfunction,
6. smoking,
7. Diabetes mellitus
8. positive family history of BPH CLINICAL
PRESENTATIONS
Symptoms can be divided into two groups: a.
irritative and
b. obstructive.
Irritative symptoms include
1. nocturia
2. urinary frequency,
3. urgency,
4. dysuria,
5. incontinence
CLINICAL PRESENTATIONS
Obstructive symptoms include;
1. hesitancy in starting urination,
2. decreased force of stream
3. incomplete bladder emptying,
4. straining with urination,
5. Dribbling after urination DIAGNOSTIC
INVESTIGATIONS
1. Urinalysis and urine culture are typically
obtained to diagnose urinary tract infection and
microscopic hematuria
2. Full blood count to evaluate any evidence of
systemic infection or anemia
3. Blood urea nitrogen (BUN) and serum creatinine
levels to evaluate renal function (both are usually
elevated with kidney disease)
DIAGNOSTIC INVESTIGATIONS
4. prostate-specific antigen (PSA) to rule out
prostate cancer
5. Transabdominal ultrasound or transrectal
ultrasound to measure the residual urine volume
6. Digital Rectal Examination
PHARMACOLOGICAL MANAGEMENT
Pharmacologic treatment for BPH includes use of
Alpha-adrenergic receptor antagonists which cause
relaxation of the bladder outlet and prostate
gland.
Tamsulosin, Terazosin and Doxazosin
These agents decrease pressure on the urethra,
thereby re-establishing a stronger urine flow.
Teach the client that postural hypotension may
occur, and that changes in position must be made
slowly
THERAPEUTIC INTERVENTIONS
I. Transurethral needle ablation (TUNA)
Low-level radiation is used to shrink the prostate.
II. Transurethral microwave therapy (TUMT)
Heat is applied to the prostate to decease its size.
III. Prostatic stent: Can be placed to keep the
urethra patent, especially if client is a poor
candidate for surgery.
Transurethral needle ablation

Transurethral microwave therapy

PROSTATIC STENT:

SURGERY
Surgical resection is an option for clients who do
not receive adequate relief from conservative
measures.
Typically, epidural and spinal anesthesia are used
SURGERY
Transurethral Incision of the Prostate
(TUIP) involves incisions into the prostate to
relieve constriction of the urethra.
Tissue is not removed with this procedure.
It is minimally invasive and typically performed in
an outpatient setting.
SURGERY
Transurethral Resection of the Prostate (TURP) is
the most common surgical procedure for BPH.
TURP is performed using a resectoscope (similar
to a cystoscope) that is inserted through the
urethra
It trims away excess prostatic tissue, enlarging
the passageway of the urethra through the
prostate gland.
TURP SURGERY

Urethra after TURP

POST OPERATIVE NURSING CARE

Postoperative treatment usually includes
placement of an indwelling three-way catheter.
The urinary catheter drains urine and allows for
instillation of a continuous bladder irrigation (CBI)
of normal saline (isotonic) or another prescribed
irrigating solution to keep the catheter free of
obstruction.
Continuous Bladder Irrigation

POST OPERATIVE NURSING CARE

The rate of the CBI is adjusted to keep the
irrigation return pink or lighter.
For example, if bright-red or ketchup-appearing
(arterial) bleeding with clots is observed, the nurse
should increase the CBI rate.
If the catheter becomes obstructed (bladder
spasms, reduced irrigation outflow), turn off the
CBI and irrigate with 50 mL of irrigation solution.
POST OPERATIVE NURSING CARE
Contact the surgeon if unable to dislodge the clot.
Record the amount of irrigating solution instilled
(generally very large volumes) and the amount of
return.
The difference equals urine output
POST OPERATIVE NURSING CARE
Monitor the client’s vital signs and urinary output.
Administer IV fluids as prescribed.
Monitor the client for bleeding (persistent bright-
red bleeding unresponsive to increase in CBI or
reduced Hgb levels) and report to the surgeon.
POST OPERATIVE NURSING CARE
Assist the client to ambulate as soon as possible
to reduce the risk of deep-vein thrombosis and
other complications that occur due to immobility.
Administer prescribed medications.
1. Analgesics (surgical manipulation or incisional
discomfort)
2. Antispasmodics (bladder spasms) e.g. Ditropan
3. Antibiotics (prophylaxis)
4. Stool softeners (avoid straining) e.g. Lactulose
POST OPERATIVE NURSING CARE
When the catheter is removed, monitor the
client’s urinary output.
The initial voiding following removal may be
uncomfortable, red in color, and contain clots.
The color of the urine should progress toward
amber in 2 to 3 days.
Instruct the client that expected output is 150 to
200 mL every 3 to 4 hr.
The client should report if unable to void.
CLIENT EDUCATION
Tell the client to avoid heavy lifting, strenuous
exercise, straining, and sexual intercourse for 2
to 6 weeks.
Tell the client to drink 3 to 4L of water each day.
Tell the client that nonsteroidal NSAIDs promote
bleeding and should be avoided.
CLIENT EDUCATION
Tell the client to avoid bladder stimulants, such as
caffeine and alcohol.
Tell the client that if urine becomes bloody, stop
activity, rest, and increase fluid intake.
Tell the client to report to the hospital if
persistent bleeding or obstruction (distention)
occur.

PROSTATE CANCER
DESCRIPTION
Prostate cancer is a malignant tumor of the
prostate gland
One of every six men will develop prostate cancer
at some point during his life.
Prostate cancer is the most common cancer
among men, excluding skin cancer.
DESCRIPTION
It is the second leading cause of cancer death in
men (exceeded only by lung cancer).
The majority (more than 60%) of cases occur in
men over age 65.
PATHOPHYSIOLOGY
The prostate has three zones:
1. central zone, 2. peripheral zone, and
3. transitional zone.
These zones are surrounded by a fibromuscular
casing.
The peripheral zone, where prostate cancer
usually originates, occupies about 70% of the
gland.
PATHOPHYSIOLOGY
Most are adenocarcinomas and arise from
epithelial cells located in the posterior lobe or
outer portion of the gland.
Of all malignancies, prostate cancer is one of the
slowest growing
It metastasizes (spreads) in a predictable pattern.
PATHOPHYSIOLOGY
Common sites of metastasis are
I. the pelvic bones,
II. nearby lymph nodes,
III. lungs, and
IV. liver
It can spread by three routes:
1. direct extension,
2. through the lymphatic system, or
3. through the bloodstream.
RISK FACTORS
The cause of prostate cancer is unknown
However, there are a number of risk factors
1. History of vasectomy
2. Age greater than 65 years (risk increases with
age)
3. Family history
RISK FACTORS
4. African-American heritage
5. High-fat diet
6. BRCA2 mutation may be associated with an
increased risk
7. Rapid growth of the prostate
CLINICAL PRESENTATIONS
i. Urinary hesitancy and weak stream ii. Recurrent
bladder infections iii. Urinary retention iv. Blood in
urine
v. Blood in semen (late manifestation) vi. Painful
ejaculation
CLINICAL PRESENTATIONS
Symptoms of metastases include a. backache,
b. hip pain,
c. Perineal and rectal discomfort,
d. anemia,
CLINICAL PRESENTATIONS
e. weight loss,
f. weakness,
g. nausea,
h. oliguria (decreased urine output), and
i. spontaneous pathologic fractures.
INVESTIGATIONS
1. Digital Rectal Examination (DRE)
Early cancer may be detected as a nodule within
the gland or as an extensive hardening in the
posterior lobe.
The more advanced lesion is “stony hard” and
fixed.
INVESTIGATIONS
2. Serum PSA (Prostate Specific Antigen)
Elevated levels of PSA level may indicate
malignancy(normal level, 0 to 4 ng/mL (0 to 4
mcg/L),
PSA is a glycoprotein produced by the prostate.
Elevation does not necessarily indicate prostate
cancer.
INVESTIGATIONS
Mild elevations in PSA may occur with aging, BPH,
recent ejaculation, or acute or chronic prostatitis
or after long bike rides
3. Tranrectal USG (TRUS)
4. Biopsy: A biopsy of the prostate tissue may be
obtained through TRUS.
Biopsy of prostate tissue is necessary to confirm
the diagnosis of prostate cancer.
TREATMENT
Chemotherapy may be used on clients whose
cancer has spread or who have had minimal
improvement with other therapies.
Client must know that routine blood tests will be
done to monitor for neutropenia, leukopenia,
thrombocytopenia, and anemia.
Radiation therapy: brachytherapy
SURGERY
Radical Prostatectomy
This is the treatment of choice.
it involves the removal of the prostate gland,
along with the seminal vesicles, the cuff at the
bladder neck, and the regional lymph nodes.
SURGERY
Open or laparoscopic surgery may be done using
a suprapubic approach.
Perineal nerves are seldom disrupted, so the
client should not experience sexual dysfunction.
SURGERY
This is similar to that of BPH
COMPLICATIONS
1. Urinary incontinence
2. Erectile dysfunction
3. Radiation cystitis or proctitis
Renal Calculi
OBSTRUCTIVE UROPATHIES
Urinary obstruction refers to any anatomic or
functional condition that blocks or impedes the
flow of urine
It may be congenital or acquired.
Damaging effects from urinary tract obstruction
affect the system above the level of the
obstruction.
Renal Calculi
Renal calculi is an obstructive uropathy where
stones in the urinary tract blocks the flow of urine
Urolithiasis and nephrolithiasis refer to stones
(calculi) in the urinary tract and kidney,
respectively
Urolithiasis

Nephrolithiasis

Pathophysiology
Renal and ureteral calculi are formed when
substances in the urine come out of solution and
form a precipitate that accumulates and grows in
size.
Stones are formed in the urinary tract when
urinary concentrations of substances such as
a. calcium oxalate,
b. calcium phosphate, and
c. uric acid increase.
Pathophysiology
Although many theories have been proposed, no
single theory can account for stone formation in all
cases.
One theory is that there is a deficiency of
substances that normally prevent crystallization in
the urine, such as citrate, magnesium,
nephrocalcin, and uropontin (Porth & Matfin,
2009).
Pathophysiology
Another theory relates to fluid volume status of
the patient i.e. supersaturation and crystallization
occur in dehydrated patients
Location of Stones
Stones may be found anywhere from the kidney to
the bladder but are usually found in the
i. Renal pelvis or calyces ii. Ureters iii. Bladder
Types of Urinary Calculi
The five major categories of stones are
1. Calcium phosphate,
2. Calcium oxalate,
3. Uric acid,
4. Cystine and
5. Struvite (magnesium ammonium phosphate;
more common in women)
Calcium Stones forms 80% of all renal calculi
Incidence
stone disorders are more common in men than in
women.
The majority of patients are between 20 to 55
years.
About half of patients with a single renal stone
have another episode within 5 years
RISK FACTORS
The cause of urolithiasis is unknown
However, predisposing factors include;
1. Metabolic (Increased intestinal absorption or
decreased renal excretion of calcium. Increased
oxalate production)
2. Dietary (Excessive intake of vitamin D, and
milk). Vitamin D enhances the absorption of
Calcium
RISK FACTORS
3. Family history of stone formation
4. Dehydration
5. Sedentary occupation, immobility
6. High alkalinity or acidity of the urine caused by
urease-splitting bacteria such as Proteus,
Pseudomonas, Klebsiella, Staphylococcus, or
Mycoplasma species.
RISK FACTORS
These are known to cause hypercalcemia
7. Hyperparathyroidism
8. Renal tubular acidosis
9. Cancers
10. Granulomatous diseases (increase Vit D
absorption
Clinical Presentation
1. Severe pain (renal colic)
a. Pain intensifies as the stone moves through the
ureter.
b. Flank pain suggests stones are located in the
kidney or ureter.
c. Flank pain that radiates to the abdomen,
scrotum, testes, or vulva is suggestive of stones in
the ureter or bladder.
2. Urinary frequency or dysuria (stones in the
bladder)
3. Fever
Clinical Presentation
4. Diaphoresis
5. Pallor
6. Nausea/vomiting
7. Tachycardia, tachypnea, increased or decreased
blood pressure with pain
8. Oliguria/anuria (occurs with stones that
obstruct urinary flow); urinary tract obstruction is
a medical emergency and needs to be treated to
preserve kidney function.
9. Hematuria (smoky-looking urine)
Diagnostic Investigations
CT Scan of kidneys, ureters, bladder
Pelvic USG
Urinalysis
An intravenous pyelogram (IVP) of KUB: is an xray
examination of the kidneys, ureters and urinary
bladder that uses iodinated contrast material
injected into veins
Diagnostic Investigations
FBC
BUE + Cr
Urine chemistry
Blood chemistry
Management
Lithotripsy is a procedure used to eliminate
calculi from the urinary tract.
Lithotripsy techniques include
1. Laser lithotripsy,
2. Extracorporeal shock-wave lithotripsy (ESWL),
3. Percutaneous ultrasonic lithotripsy
Laser lithotripsy
Laser lithotripsy is used to fragment ureteral and
large bladder stones (bladder stones are described
above).
To access ureteral stones, a ureteroscope is used
to get close to the stone.
A small fiber is inserted up the endoscope so that
the tip (which emits the laser energy) can come in
contact with the stone.
Laser lithotripsy
A holmium laser in direct contact with the stone is
commonly used.
The intense energy breaks the stone into small
pieces, which can be extracted or flushed out.
Because of the type of laser energy, no other
tissue is affected.
Video

Extracorporeal Shock-wave Lithotripsy

In extracorporeal shock-wave lithotripsy (ESWL),
a noninvasive procedure, the patient is
anesthetized (spinal or general) to ensure that he
or she maintains the same position during the
procedure.
Fluoroscopy or ultrasound is used to focus the
lithotripter on the affected kidney, and a
highvoltage spark generator produces high-energy
acoustic shock waves that shatter the stone
without damaging the surrounding tissues.
Extracorporeal Shock-wave Lithotripsy
The stone is broken into fine sand
(steinstrasse) and excreted in the urine.
Video

Open surgery
Open surgery uses a surgical incision to remove
the stone.
This surgery is used for large or impacted stones
(staghorn calculi) or for stones not removed by
other approaches
Nursing Care
Assess Pain status.
Give prescribed analgesics Give prescribed
antibiotics Monitor Intake and output.
Monitor vital signs
Nursing Care
Strain all urine to check for passage of the stone
and save the stone for laboratory analysis.
Encourage increased oral intake to 3 L/day unless
contraindicated.
Administer IV fluids as prescribed.
Encourage ambulation to promote passage of the
stone