Nursing care in patients with AIDS

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A I D S

UNDERSTANDING

• HIV (human immunodeficiency virus): The virus that causes one's immune system weaknesses.
• AIDS (Acquired immunodeficiency syndrome): an infection that can cause severe damage to the immune system and can not be cured, so people are very open or vulnerable to infection or certain cancers.
• Patients with HIV: is someone who is infected with human immunodeficiency virus, which infects mainly T lymphocyte cells and disrupt cell immunity.
• Patients with HIV-AIDS is someone who has been infected with HIV and are at the last stage of infection with signs of the emergence of various bacterial infectious diseases, fungi, parasites and viruses that are opportunistic or malignancy.

CAUSE
AIDS is caused by human immunodeficiency virus. This type of retrovirus that is easy to die outside the body. The period between infected with HIV until the onset of symptoms (incubation period) is 6 months in children and 60 months in adults.

SYMPTOMS AND SIGNS
Clinical stage I:

• Without symptoms (asymptomatic)
• Generalized lymphadenopathy which persistent

Clinical Stage II:

• Weight loss <10% - Preview minor mucocutaneous - herpes zoster - Upper respiratory tract infections recurring Clinical Stage III: - weight loss> 10%
• Prolonged fever that can not be explained (intermittent or constant), more than a month
• Oral candidiasis
• Pulmonary Tuberculosis
• Severe bacterial infection

Clinical Stage IV:

• HIV wasting syndrome
• Pneumonia carini
• Toxoplasmosis of brain
• CMW in organs other than liver, spleen, or lymph nodes
• Infection with Herpes simplex virus (HSV) mucocutaneous more than 1 month
• Candidiasis esophagus, trachea, bronchus, or lung
• Micobakteriosis
• Septicemia
• Extra pulmonary tuberculosis
• Lymphoma
• Kaposi's sarcoma
• HIV encephalopathy

LABORATORY EXAMINATION
1. Tests to determine the presence of antibodies and HIV antigen:

• Detection of HIV antigen by ELISA (enzyme linked immunosorbent assay).
• Immunoblot western blot (WB)

2. The tests showed a decrease in body immunity
Decrease the body's immunity:
Simple laboratory tests: Hb, Smear of peripheral blood, leucocytes, lymphocytes and platelets, the AIDS found existence of anemia ,leukopenia ,and thrombocytopenia limfopenia .

3. Testing for the presence of malignancy or opportunistic infection

• Serology or culture against herpes simplex, CMV, Epstein Barr
• Staining culture or histopathology of pneumonia carinii, cryptosporidium, toxoplasmosis, candidiasis, or aspergilus.
• Histopathologic of Kaposi's sarcoma or lymphoma.

NURSING ASSESSMENT IN AIDS PATIENTS
A. Diagnose
History of free sex, homosexuality, history of drug abuse via intravenous blood transfusion recipient, a parent suffering from HIV - AIDS, chronic diarrhea, decreased appetite, weight loss, fever.
B. Psychological
knowledge and acceptance of disease, function and role in family, community, and employment.
acceptance of the patient's family.
C. Social
Support systems are available and affordable with the ability financially.
The Group of HIV-AIDS sufferers.
D. Clinical manifestations
clinical manifestations that spread throughout the body that can of whole organs, infections, malignancies.
E. Neurologic (malignancy)
HIV encephalopathy, Cryptococcus neofarmans, progressive multifocal lauciensefalopaty (PML).

NURSING DIAGNOSIS

1. PK: Opportunistic Infections
2. PK: Sepsis
3. PK: malignancies
4. Ineffective airway clearance
5. Diarrhea
6. Changes in family process
7. Risk of infection
8. The risk of transmission of infection
9. Fatigue
10. Social isolation
11. The risk of ineffective management of therapeutic regimen
12. Powerlessness
13. Anxiety

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Nursing care in patients with Lung Cancer

LUNG TUMOR (CARCINOMABRONCHOGENIC)

DEFINITION
Bronchogenic carcinoma is a malignant tumor originating from primary lung airways.
Most of the primary lung tumor is a carcinoma bronchi (John E. Stark, 1990).

PHYSICAL SYMTOMS
Hemopthisis, Cough, Chest pain, Shortness of breath, this is due to enlargement of the tumor and due to collapse of the lung, Wheezing / stridor, this sounds arising from the trachea or bronchus obstruction, Hoarse, this happens due to his stricken recurents left laryngeal nerve, Pneumonia Recurents, Dysfagia, this may occur due to the spread of tumors via lymphatic vessels to the area mediatinum or to the esophagus, Obstruction of superior vena cava, Systemic symptoms: such as weight loss, no appetite, which is the initial symptom in 50% of patients with lung cancer, Symptoms of metastasis, the most common of the organs of the brain, liver, bone and adrenal gland, Non-metastatic effects: such as peripheral neuropathy, dermatomiositis or syndrome whose symptoms such as secretion of hormones (eg ADH, ACTH, PTH).

ETIOPATOGENSIS
Such as cancer in general, the exact etiology of carcinoma bronkogenik still unknown, but it is expected that the long-term inhalation of carcinogenic materials is a major factor, without prejudice to possible predisposing role of family relations or ethnic / racial and immunologis status. Inhalation of carcinogenic materials is highlighted that many cigarettes.

HIGH RISK GROUPS:
- Smokers.
- Workers at asbestos factories.
- History fibrosis suffer from chronic lung diffus.

EFFECT OF CIGARETTE:
The materials are carcinogens in tobacco smoke include: polomium 210 and 3.4 benzypyrene. The use of a filter is said to reduce her risk of carcinoma broncogenik, but still remained higher than non-smokers.
In the long term ie, 10-20 years, smoking:
1-10 cigarettes / day increases the risk 15 times
20-30 cigarettes / day increases the risk 40-50 times
40-50 cigarettes / day increases the risk 70-80 times.

Industry Influence
The most widely associated with the carcinogen is asbestos, which otherwise increases the risk of cancer is 60-10 times. Following the industrial radioactive materials, miners uramium 4 times the population at risk in general. Exposure to this industry only visible effect after the 15-20 years.

Effect of Other Diseases
Pulmonary tuberculosis is associated as much bronchogenik carcinoma predisposing factors, through mechanisms hyperplasi - metaplasi - carcinoma in situ-carcinoma - bronkogenik as a result of scar tissue tuberculosis.

Effect of Genetic and immunological status
In 1954, Tokuhotu can prove that despite the influence of heredity rather than factors of environmental exposure, this provides an opinion that can be derived bronkogenik carcinoma. Research recently skewed that the factors involved with Aryl Hydrocarbon hydroxylase enzymes (AHH). Status immonologis patients are monitored from cellular mediated showed a correlation between the degree of cell differentiation, stage of disease, response to treatment and prognosis.

Classification by histopathology using ordinary light microscope (WHO, 1977).
1. Epidermois carcinoma (squamous cell carcinoma).
2. Adeno carcinoma
3. Undiferentiated small cell carcinoma (oat cell)
4. Large cell carcinoma undeferentiated.

INVESTIGATIONS
Radiological
Radiopaque mass in the lung, Airway obstruction with resultant atelectasis, Pneumonia, Enlarged hilar glands, Cavitation.

Sputum cytology:
In sputum cytologic examination to help establish the case up to 70%. Sputum for cytologic sample should be received by the laboratory within 2 hours after ekspectorasi / expenditure. Sample dawn is not required.

Bronchoscopy:
In the biopsy is used to determine the type of tumor cells. Bronkografi
The picture is considered bronkografi patognomonik irregular stenosis is obstruction, stenosis rats and indented thumb.

Pleural aspiration and biopsy:
Aspiration is an action that must be done if patients with lung tumors have effusi pleura. Effusi not always result from the spread of tumors to the pleura, but may result from pneumonia reaction to the tumor or lymphatic obstruction.

Biopsy needle percutan:
This examination is useful for diagnosing tumors that are difficult peripheral transbronchial biopsied denag techniques.

Mediatinoscopy:
This technique is used to take samples of lymph gland enlargement mediatinum experiencing, this is done if no visible pulmonary tumor.

Endoscopy
Includes examining laryngoscopy and bronchoscopy and bronchial washings, scrapings / sweep and biopsy. The objective examination of Bronchoscopy (fiber optics) are:
a. Knowing the changes in the bronchus of lung cancer.
b. Retrieving material for cytological examination.
c. Noting the changes on the surface of tumor / mucosa to predict the type of malignancy.
d. Assessing the success of therapy.
e. Determining overbilitas lung cancer.

Immunology
The existence of a negative correlation between cancer and immunological reactions have been generally known. Immunological disorders mainly seen in cell mediated immunity that can be given through a delayed hypersensitivity reaction is clearly, tolerance to skin graft, total circulatory low T cell, and lymphocyte transformation in vitro is low. At this time more immunological examination serve as prognostic factors than diagnostic factor. Conclusion Correlation of skin test and response to cytostatic:
a. Less than 1.0 cm. : Prognosis is poor, widespread disease.
b. Less than 2.5 m. ; Better prognosis, limited disease, good response to chemotherapy.

PHASING CLASSIFICATION CLINIC (Clinical Staging)
Based on TNM
T = Tumor: N. : Nodules, namely the lymph nodes of M. : Metastases
1. T: T-0: No visible primary tumor

• T-1: tumor diameter of less than 3 cm. Without the invasion of bronchus
• T-2: tumor diameter more than 3 cm. Can be accompanied by atelectasis or pneumonitis, but is more than 2 cm. From Karina, and there is no pleural effusion.
• T-3: Tumor size with an invasion into the surrounding (thoracic wall, diaphragm or mediastinum) or have been near Karina accompanied by pleural effusion.

2. N: N-0: There was no propagation to regional lymph nodes.

• N-1: There is a propagation to the ip silateral hilar lymph nodes.
• N-2: There is a spreading to the lymph limfemediastinum or contralateral
• N-3: There extratoracal spreading to lymph nodes.

3. M. M-0: There is no distant metastases.
M-1: Already there are distant metastasis to other organs.
Based on TNM. Compiled phasing following clinics.
a. Carcinoma in situ: T-0, N-0, M-0, but positive sputum cytology for malignant cells.
b. Phase I. T-1, N-0, M-0, or T-2, N-0, M-0
c. Phase II. T-2, N-1, M-0.
d. Stage III: when there are already T-3, N-2, or M-1.


MANAGEMENT
Treatment of lung tumors depend on tumor cell types.
1. Surgical resection.
2. Palliative therapy.

ASSASSMENT:
Activity / rest : Weakness, inability, to maintain regular habits, dyspnea because the activity, lethargy usually advanced stage.

Cardiovaskuler and circulation :
Pallor, cyanosis, diaphoresis, hypotension, bradycardi, tachycardi, arrytmia in atrial or ventricular, decreased cardiac output, shock. Increased jugular vein, heart sound: friction pericardial (addressing effusion) Dysrhythmias, finger percussion.

Ego Integrity : Anxiety, fear of death, resist harsh conditions, anxiety, insomnia, the question is repeated. lack of rest.

Elimination :
Diarrhea that intermittent (hormonal imbalance) Increased frequency / amount of urine (Hormonal Imbalance).

Food / liquids :
Weight loss, poor appetite, decreased food input, difficulty swallowing, thirst / increase fluid intake, Thin, wiry, less weight or appearance (stage 0, edema face, periorbital (hormonal imbalance), Glucose in the urine.

Discomfort / pain :
Chest pain, which does not / can be affected by the change of position. Painful shoulder / hand, bone pain / joint, cartilage erosion secondary to the increase of growth hormone. Abdominal pain is gone / arise.

Respiratory :
Cough mild cough or a change from the usual pattern, increased sputum production, shortness of breath, workers exposed to carcinogenic substances, hoarse, vocal cord paralysis, and smoking history. dyspnea, increased employment, increased tactile fremitus, wheezing on inspiration or expiration (air flow interruption). persistent wheezing tracheal deviation (the area that suffered lesions) hemoptysis.
Blood gas analysis (obtained hypoksemia, acidosis, an increase or decrease in CO2). Respiratory function (VC reduction, increased tidal volume). ECG (may show a arrytmia).

Security : Fever, maybe there is / are not, reddish, pale skin.

Sexuality :
Gynecomastia, amenorrhea, or impotence.
family risk factors: a history of lung cancer, tuberculosis.

NURSING DIAGNOSIS

• Ineffective breathing pattern related to decreased lung expansion.
• Ineffective airway clearance related to airway obstruction.
• Damage to gas exchange associated with chronic hypoxia in lung tissue.
• Anxiety associated with an inability to breathe.
• Acute pain b / d of cancer invasion into the pleura, chest wall.
• Nutrition less than body requirements b / Inadequate nutrition, increased metabolism, the process of malignancy.
• Impaired body image b / d of changes in body structure.

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Nursing care in patients with Congestive Heart Failure

Inception Report

NURSING IN PATIENTS WITH CONGESTIVE HEART FAILURE

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UNDERSTANDING
Congestive heart failure is a condition where the heart can no longer pump enough blood to meet body needs circulation for tissue metabolism in certain circumstances, whereas in cardiac filling pressure is still high.

CAUSES OF HEART FAILURE

1. Causes of heart failure are classified as follows:
2. Myocardial dysfunction (myocardial failure).
3. Expenses excessive pressure - systolic loading (systolic overload).
4. Excessive volume load - loading diastolic (diastolic overload).
5. Impaired filling (input resistance).
6. Increased metabolic needs - increasing need for excess

LEFT HEART FAILURE SYMPTOMS:
Complaints of body feeling weak, tired, palpitations, shortness of breath, cough, anorexia, and sweating cold, cough and / or coughing up blood, decreased kidney function.

RIGHT HEART FAILURE SYMPTOMS:
Edema, anorexia, nausea, ascites, abdominal pain.

FUSE
Hypertension, myocardial, pulmonary embolism, infection, arrhythmia, anemia, febrile, emotional stress, pregnancy / delivery, infusion / transfusion.

PATHOPHYSIOLOGY
Each obstacle in the flow direction (forward flow) in the circulation will cause the dam to flow in reverse direction (backward congestion). Barriers flux (forward failure) will cause the symptoms of failure in the system backward flow of blood circulation. Cardiac compensatory mechanisms in heart failure is the way the body to maintain blood circulation to meet tissue metabolic needs. Compensatory mechanisms that occur in heart failure are: ventricular dilation, ventricular hypertrophy, increased sympathetic stimulation in the form of tachycardia and peripheral vasoconstriction, elevation of plasma catecholamine levels, retention of salt and fluid loss and increase oxygen ekstraksi by the network.
When the heart of the right and the left together in a state of failure due to interruption of blood flow and the presence of dams, it would appear the signs and symptoms of heart failure on systemic circulation and pulmonary circulation. This is called Congestive Heart Failure (CHF).

LABORATORY EXAMINATION:
There is no specific test that can diagnose heart failure (T. Santoso, heart failure 1989). Laboratory tests are needed to determine the extent to which heart failure has been disturbing the functions of other organs such as liver, kidney and others.

EXAMINATION OF OTHER SUPPORT:
A. Radiology:

• The image of the lung hili thick and wide, getting to the edge density decreases.
• Field lung spots because of pulmonary edema.
• Pulmonary venous distension.
• Hidrothorak.
• Enlargement of the heart, Cardio-thoragic ratio increased.

B. ECG:
Can be found in the primary abnormality of the heart (ischemia, ventricular hypertrophy, rhythm disturbances) and signs of acute trigger factors (myocardial infarction, pulmonary embolism).

C. Echocardiography:
For detection of functional and anatomical disorders that cause heart failure.

D. Cardiac Catheterization:
In left heart failure is obtained (VEDP) 10 mmHg or pulmonary arterial wedge pressure> 12 mmHg in the resting state. Cardiac output is lower than 2.7 lt/mnt/m2 body surface area.

MANAGEMENT
According to the priority is divided into 4 categories:

1. Improving myocardial contraction / perfusion systemic.
2. Lowering the volume of excess fluid.
3. Post Op prevent complications.
4. Surgical treatment (Komisurotomi).
5. Health education regarding disease, prognosis, medications and prevention of recurrence.

ad. 1 Improving myocardial contraction / perfusion systemic:

• Bed rest / bed rest in semi-Fowler position
• Provide oxygen therapy as needed
• Provide medical therapy: digitalis to strengthen heart muscle contraction

ad.2 Lose excess fluid volume

• Provide medical therapy: diuretics to reduce fluid in the tissues
• Record intake and output
• Considering weight
• Restriction of salt / low salt diet

ad.3 Preventing complications

• Schedule a gradual mobilization according to client circumstances
• Prevent the occurrence of immobilization due to bed rest
• Changing sleeping positions
• Noting the adverse effects of Medica mentosa; digitalis poisoning
• Checking or monitoring ECG

ad.4 Surgical Treatment Komisurotomi
Only in the aorta due to infection of aortic regurgitation, aortic valve repair can be considered. While in aortic regurgitation due to other diseases should generally be replaced with artificial valves. Indications on the complaint shortness of breath that can not be overcome by treatment symptomatik. When ekhokardiografi showed left ventricular systole 55 mm, or 25% fractional shortning considered for surgery before heart failure arise.

ad.5 health education, in terms of disease, prognosis, drug use and preventing relapse

• Explaining the course of the disease and prognosis.
• Explaining the use of medications that are used, as well as providing drug administration schedule.
• Changing lifestyles / habits that one: smoking, stress, heavy work, drinking alcohol, foods high in fat and cholesterol.
• Explain about the signs and symptoms that contribute to heart failure, particularly those associated with fatigue, soon tired, palpitations, shortness of breath, anorexia, cold sweat.
• Advise to all controls on a regular basis even if no symptoms.
• Providing mental support; client to accept his situation is real / reality will itself well.

ASSESSMENT OF DATA

1. Activity and rest

• The existence of fatigue / exhaustion, insomnia, lethargy, lack of rest.
• chest pain, dyspnea at rest or during activity.

2. Circulation

• History of hypertension, valve disorders, cardiac surgery, endocarditis, anemia, septic shock, swelling in the legs, ascites, tachycardia.
• Dysrhythmias, atrial fibrillation, premature ventricular contraction.
• Sound S3 Gallop, the sound of CA, the presence of systolic or diastolic, murmur, increased JVP.
• Presence of chest pain, cyanosis, pale, ronchi, hepatomegaly.

3. Mental Status

• Anxiety, fear, anxiety, anger, iritabel / sensitive.
• Stress related to illness, financial social

4. Elimination

• Decrease in urine volume, urine is concentrated
• Nocturia, diarrhea and constipation

5. Food and fluid

• Loss of appetite, nausea, and vomiting
• In the lower limb edema, ascites

6. Neurology

• Dizziness, fainting, pain
• Lethargi, confusion, disorientation, iritabel

7. Comfort
Chest pain, chronic / acute angina

8. Respiration

• Dispnoe at the time of activity, takipnoe
• Sleeping and sitting, history of lung disease

9. Sense of security

• Changes in mental status
• Disorders of the skin / dermatitis

10. Social interaction
Reduced social activity

PRIORITY TREATMENT

• Increase myocardial contractility / systemic tissue perfusion.
• Lose excess fluid volume.
• Preventing Post op complications.
• Provides information about the tailor, prognosis, therapy and prevention of recurrence of disease.

TREATMENT DIAGNOSIS FREQUENTLY ARISING:

1. Decrease in cardiac output in relation to the decrease in myocardial contractility, characterized by:Increased heart rate, changes in blood pressure, decreased urine output, the S3 and S4, chest pain.
2. Limitations of activity in relation to the imbalance between supply and demand of oxygen, characterized by: weakness, fatigue, changes in vital signs, dysrhythmias, dispnoe, diaporesis
3. Disorders of fluid balance, more of the needs in relation to the decline in GFR, marked by: heart sounds 3, orthopnoe, oliguria, edema, weight change, hypertension, respiratory distress, abnormal breath sounds.
4. High risk of failure of gas exchange in relation to changes in alveolar capillary membrane by accumulation of fluid in the lung cavity.
5. Risk of damage to skin integrity about its continuity due to edema, decreased perfusion to the skin.
6. Lack of knowledge about diseases, conditions and treatment in relation to the lack of information is marked with: the patient asked the patient the wrong statement.

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Dysphagia

Disfagi
 

Definition
Realize the difficulties in solid or liquid food flowing from the mouth through the esophagus.

Pathogenesis
1. Lumen of the esophagus or oropharynx obstruction due to intrinsic lesions on the wall, extrinsic compression or foreign objects of nature lumen.
Causes include :

• Malignancy (primary or secondary)
• Peptic stricture
• Chemical injury (eg corrosive)
• "oesophageal web"
• Esophageal diverticulum
• Infection of the esophagus (candidiasis)
• Foreign body (corpus alenum)
• Vascular (large left atrium)

2. Neuromuscular disorders that interfere with the coordination of the flow of normal food and fluid from the esophagus to the stomach.
causes include:

• Cerebro vascular accident
• Motor neuron disease
• Multiple sclerosis
• Myasthenia gravis
• Polimiositis, dermatomiositis, scleroderma
• Tiro toxic myopathy
• Akalasia

Clinical picture1. difficulty in cleaning the posterior pharynx, often accompanied by nasal regurgitation and pulmonary aspiration, almost always associated with neuro muscular disorders oropharynx. in such cases, solid and liquid foods can trigger symptoms.

2. Dysphagia for solid and liquid meal in patients who can cleanse the posterior pharynx leading to esophageal disorders such as diffuse esophageal spasm, or sklero akalasia charity. typical dysphagia are intermittent and not progressive.

3. Dysphagia a progressive slow, initially limited to solid foods, in patients with a history of gastro-esophageal reflux before, leading to peptic stricture.

4. Dysphagia rapid progressive, especially in elderly patients, typical for malignant lesions obstruction.

5. Chest pain accompanied by dysphagia have limited diagnostic value and occurs in both the esophageal spasm or obstructive lesions in each.

Diagnosis
Observation of patients swallowing is an important diagnostic maneuvers and should be performed for all patients. When the oropharynx disorder is suspected, formal neurologic examination should be performed with direct visualization of the neuromuscular function of the pharynx and larynx.

Radiology
"Barium swallow" with contrast medium flow visualization carefully is the most important examination for verification for each obstructive lesions. This examination must show proof akalasia and maybe get other neuromuscular disorders, especially spasm of the esophagus.

Endoscopy
Fiber-optic endoscope may be needed to see firsthand and to biopsy lesions that are not entirely typical of the "barium swallow", especially to distinguish between benign and malignant strictures. If endoscopy performed before the "barium swallow" takes meticulous care to avoid trauma and possible perforation of the esophagus with high-lesion location. If the tests above failed to get the diagnosis or lead to motility disorders, esophageal manometri be done.

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