Causes Bronchiectasis

The primary etiology in the development of ordinary acquired Bronchiectasis is inflammatory destruction of the elastic tissue, smooth muscle, and cartilage of bronchial walls usually due to severe preceding infection(s). Fewer cases are caused by genetic or immune deficiencies or result from inhalation injury.

Bronchiectasis results from conditions associated with repeated damage to bronchial walls and with abnormal mucociliary clearance, which causes a breakdown of supporting tissue adjacent to the airways. Such conditions include:

Predisposing factors:

• Bronchopulmonary infection— Mycobacterium species, bacterial (e.g., Staphylococcus aureus, Bordetella pertussis, Klebsiella pneumoniae, H. influenza ), viral (e.g., measles, HIV, adenovirus, influenza), fungal (histoplasmosis, coccidiomycosis), recurrent aspiration pneumonia.
• Bronchial obstruction—foreign body aspiration, lung or bronchogenic neoplasm, airway nodules, hilar adenopathy (e.g., sarcoidosis), mucus impaction (e.g., allergic bronchopulmonary aspergllosis), broncholith, external compression by vascular aneurysm.
• Immunodefi ciency states—hypogammaglobulinemia, IgG subclass deficiency, selective IgA deficiency.
• Other congenital syndromes—cystic fibrosis, alpha1-antitrypsin deficiency, primary ciliary dyskinesia (e.g., Kartagener’s syndrome), Young’s syndrome (azoospermia and chronic sinopulmonary infections).
• Inhalation injury—smoke, ammonia, sulfur or nitrogen dioxide.
• Rheumatologic disease—rheumatoid arthritis, Sjogren’s syndrome
• Anatomic defects—bronchomalacia, Swyer-James syndrome, bronchial cartilage deficiency (Williams-Campbell syndrome), tracheobronchomegaly (Mounier-Kuhn syndrome)

Complications Bronchiectasis

1. Hemoptysis occurs in nearly 50% of patients with bronchiectasis (Mysliwiec & Pina, 1999); major pulmonary hemorrhage and death from exsanguination are rare (Swartz, 1998).
2. Empyema, lung abscess, and pneumothorax are serious but rare complications of acute infections in bronchiectasis (Luce, 1994).
3. Progressive respiratory insuffi ciency and cor pulmonale complicate severe bronchiectasis associated with deteriorating pulmonary function and hypoxemia.

TREATMENT FOR BRONCHIECTASIS

a. Medical interventions

1. Inhaled bronchodilators may be helpful in diffuse small airway disease; beta adrenergic agents dilate airways and improve ciliary activity (Swartz, 1998).
2. Antimicrobial therapy for treatment of acute infectious exacerbations is based on results of sputum gram stain and culture.
3. Corticosteroids reduce the airway infl ammatory response in bronchiectasis.
4. Oxygen therapy is prescribed as indicated for patients with hypoxemia at rest, during sleep, and/or with activity.
5. Gamma globulin replacement for immunoglobulin defi ciency may be effective in reducing the frequency and severity of sinopulmonary infections (George et al., 1995).
6. Effective reduction and removal of bronchial secretions by a variety of available methods is critical in patients with bronchiectasis. The approach selected should be based upon an individual’s self-care abilities, motivation, breath control, neuromuscular status, preferences, needs, and financial resources (Langenderfer, 1998).

• Effective cough
• Percussion and postural drainage
• Autogenic drainage
• Positive expiratory pressure (PEP) therapy
• Flutter valve
• Vest therapy
• Humidifi cation (by cold water, jet nebulizers) as an adjunct to chest physiotherapy enhanced sputum production (Conway, Fleming, Perring, & Holgate, 1992).

1. Aerosolized recombinant human DNase may lyse the DNA that causes the sputum to be highly viscous. Initial studies for cystic fibrosis are promising, but this therapy is not FDA approved in non-CF bronchiectasis (O’Donnell, Barker, Ilowite, & Fick, 1998; Wills et al., 1996).
2. Non-invasive intermittent positive pressure ventilation (NIPPV) is an alternative to tracheostomy for respiratory failure due to advanced bronchiectasis.

b. Surgical intervention

1. Surgical resection
2. Lung or heart-lung transplantation

Nursing Assessment

The patient typically reports gross, painless, intermittent hematuria and often with clots. Patients may complain of suprapubic pain after voiding, and also complain of bladder irritability, urinary frequency, nocturia, and dribbling. If he reports flank pain, he may have an obstructed ureter.

Patient’s history

Gross, painless, intermittent hematuria is the most frequently reported symptom. Occult blood may be discovered during a routine urinalysis. Dysuria and urinary frequency are also reported. Burning and pain with urination are present only if there is infection. The patient may not seek medical attention until urinary hesitance, decrease in caliber of the stream, and flank pain occurs. Other symptoms may include suprapubic pain after voiding, bladder irritability, dribbling, and nocturia.

Physical assessment

The physical examination is usually normal. A bladder tumor becomes palpable only after extensive invasion into surrounding structures.

Psychosocial assessment

Diagnosis of cancer and treatment of cancer with radical cystectomy and creation of a urinary diversion system can threaten sexual functioning of both men and women. The procedure can cause impotence in men and psychological problems similar to those that accompany a hysterectomy and oophorectomy in women. In addition, a portion of the vagina may be removed, thus affecting intercourse. The psychological impact of a stoma and external urinary drainage system can cause changes in body image and libido.

Diagnostic tests for bladder cancer

To confirm a bladder cancer diagnosis, the patient typically undergoes

• Cystoscopy should be performed when hematuria first appears.
• Biopsy (If the test results show cancer cells, further studies will determine the cancer stage and treatment).
• Excretory urography can identify a large, early-stage tumor or an infiltrating tumor; delineate functional problems in the upper urinary tract; assess hydronephrosis; and detect rigid deformity of the bladder wall.
• Urinalysis can detect blood and malignant cells in the urine.
• Retrograde cystography evaluates bladder structure and integrity. Test results also help confirm a bladder cancer diagnosis. A bone scan can detect metastases. A computed tomography scan can define the thickness of the involved bladder wall and disclose enlarged retroperitoneal lymph nodes. Ultrasonography can find metastases in tissues beyond the bladder and can distinguish a bladder cyst from a bladder tumor.
• Laboratory tests, such as a complete blood count and chemistry profile, may be ordered to evaluate conditions such as anemia that are associated with bladder cancer.

Nursing diagnosis bladder cancer

Common nursing diagnosis found in nursing care plans for bladder cancer

• Acute pain
• Anxiety
• Disturbed body image
• Fear
• Impaired skin integrity
• Impaired urinary elimination
• Ineffective coping
• Ineffective therapeutic regimen management
• Risk for infection
• Sexual dysfunction

Most bladder tumors are transitional cell carcinomas, arising from the transitional epithelium of mucous membranes. Less common are adenocarcinomas, epidermoid carcinomas, squamous cell carcinomas, sarcomas, tumors in bladder diverticula, and carcinoma in situ. Bladder tumors are most prevalent in men older than age 50 and are more common in densely populated industrial areas, but women are diagnosed at more advanced stages.

The most common presenting symptom of bladder cancer is hematuria. Gross hematuria obviously warrants a thorough evaluation of the genitourinary system. When gross hematuria is painless and total (present during the entirety of the urinary stream), it especially causes concern for bleeding from the bladder or upper tracts. Irritative urinary symptoms are relatively common at presentation, including frequency, urgency, and dysuria. The combination of these symptoms with hematuria is very suggestive and warrants full urologic evaluation. Depending on the location of their tumors, patients may have symptoms of bladder-outlet obstruction or ureteral obstruction. A small subset, 5% to 10% of patients, have symptoms related to metastatic disease.

Causes for Bladder cancer

Environmental carcinogens are known to predispose a person to transitional cell tumors such as 2-naphthylamine, benzidine, tobacco, coffee, and nitrates.Thus, workers in certain industries (rubber workers, weavers, leather finishers, aniline dye workers, hairdressers, petroleum workers, and spray painters) are at high risk for such tumors. The period between exposure to the carcinogen and development of symptoms is about 18 years.

Squamous cell carcinoma of the bladder is common in geographic areas where schistosomiasis is endemic, such as Egypt. What is more, it’s also associated with chronic bladder irritation and infection in people with renal calculi, indwelling urinary catheters, chemical cystitis caused by cyclophosphamide, and pelvic irradiation.

Complications of bladder cancer

If bladder cancer progresses, complications include bone metastases and problems resulting from tumor invasion of contiguous viscera.

• Instruct patients about the need to maintain a high fluid intake, to ensure adequate urine output.
• Teach the patient to monitor urinary output for 4 to 6 weeks after surgery to ensure adequacy in volume of elimination combined with a decrease in volume of retention. Teach the patient to recognize the signs of Urinary Tract Infection (UTIs). Urge him to immediately report these signs to the physician because infection can worsen the obstruction.

• After the catheter is removed, the patient may experience urinary frequency, dribbling and, occasionally, hematuria. Reassure him and family members that he’ll gradually regain urinary control
• Instruct the patient to follow the prescribed oral antibiotic regimen, and tell him the indications for using gentle laxatives.

Postoperative Patient teaching

• Provide information about sexual anatomy and function as it relates to prostatic enlargement helps client understand the implications of proposed treatments because they might affect sexual performance.
• Encourage the patient to discuss any sexual concerns he or his partner may have after surgery with the appropriate counselors.
• Reassure the patient that a session can be set up by the nurse or physician whenever one is indicated. Usually, the physician recommends that the patient have no sexual intercourse or masturbation for several weeks after invasive procedures.
• Reinforce prescribed limits on activity. Warn the patient against lifting, performing strenuous exercises, and taking long automobile rides for at least 1 month after surgery because these activities increase bleeding tendency. Also caution him not to have sexual intercourse for at least several weeks after discharge

Prevention

Instruct the patient to report any difficulties with urination to the physician immediately. Explain that BPH can recur and that he should notify the physician if symptoms of urgency, frequency, difficulty initiating stream, retention, nocturia, or bladder distension.

• Urge the patient to seek medical care immediately if he can’t void at all, if he passes bloody urine, or if develops a fever.
• Reinforce importance of medical follow-up for at least 6 months to 1 year, including rectal examination and urinalysis.

Nursing Priorities Nursing care plans for Benign Prostatic Hyperplasia (BPH)

• Relieve acute urinary retention.
• Promote comfort.
• Provide information about disease process, prognosis, and treatment needs.
• Prevent complications.
• Help client deal with psychosocial concerns.

Sample Nursing care plans for Benign Prostatic Hyperplasia (BPH) with nursing diagnosis Urinary retention (acute or chronic)

Nursing Assessment nursing care plans for Benign Prostatic Hyperplasia (BPH)

BPH Clinical features depend on the extent of prostatic enlargement and on the lobes affected. Patient history, generally, men with suspected BPH have a history of frequent urination, nocturia, straining to urinate, weak stream, and an incomplete emptying of the bladder. Patient usually complains of a group of symptoms known as prostatism: decreased urine stream caliber and force, an interrupted stream, urinary hesitancy, and difficulty starting urination, which results in straining and a feeling of incomplete voiding. As the obstruction increases, the patient may report frequent urination with nocturia, dribbling, urine retention, incontinence and, possibly, hematuria.

Physical examination. Inspect and palpate the bladder for distension. Physical examination reveals a visible midline mass above the symphysis pubis, which represents an incompletely emptied bladder. Palpation discloses a distended bladder, A digital rectal exam (DRE) reveals a rubbery enlargement of the prostate, but the degree of enlargement does not consistently correlate with the degree of urinary obstruction. Some men have enlarged prostates that extend out into soft tissue without compressing the urethra. Determine the amount of pain and discomfort that is associated with the DRE.

Diagnostic tests Benign Prostatic Hyperplasia (BPH)

Several tests help to confirm Benign Prostatic Hyperplasia (BPH) diagnosis:

• Excretory urography may indicate urinary tract obstruction, hydronephrosis, calculi or tumors, and filling and emptying defects in the bladder.
• Elevated blood urea nitrogen
• Serum creatinine levels suggest impaired renal function.
• Urinalysis and urine culture
• Cystourethroscopy
• Intravenous pyelography (IVP)
• Transrectal prostatic ultrasound (TRUS)
• A prostate-specific antigen test may be performed to rule out prostatic cancer.

Nursing diagnosis nursing care plans for  Benign Prostatic Hyperplasia (BPH)

Primary nursing diagnosis:

Urinary retention (acute or chronic) related to bladder obstruction

Common nursing diagnosis found in patient with Benign Prostatic Hyperplasia (BPH)

• Acute pain
• Fear/Anxiety [specify level]
• Impaired urinary elimination
• deficient Knowledge regarding condition,prognosis, treatment, self-care, and discharge needs
• Risk for infection
• Risk for injury
• Sexual dysfunction
• Urinary retention

Causes for Benign prostatic hyperplasia (BPH)

A link between Benign prostatic hyperplasia (BPH) and hormonal activity suggests.  As males age, production of androgenic hormones decreases, causing an imbalance in androgen and estrogen levels and high levels of dihydrotestosterone, the main prostatic intracellular androgen.

Other causes of Benign prostatic hyperplasia (BPH) include:

• Neoplasm
• Arteriosclerosis
• Inflammation
• Metabolic Imbalance
• Nutritional disturbances.

Complications for Benign prostatic hyperplasia (BPH)

• Urinary stasis
• Urinary tract infection (UTI)
• Renal calculi
• Bladder wall trabeculation
• Detrusor muscle hypertrophy
• Bladder diverticula and saccules
• Urethral stenosis
• Hydronephrosis
• Paradoxical (overflow) incontinence
• Acute renal failure or chronic renal failure
• Acute postobstructive diuresis.

Nursing care plans for Benign Prostatic Hyperplasia (BPH)

Nursing diagnosis for Benign Prostatic Hyperplasia (BPH)

• Help the patient set realistic goals for recovery.
• Show the patient how to use his crutches properly.
• Tell the patient with a cast to report immediately signs of impaired circulation (skin coldness, numbness, tingling, or discoloration).
• Warn the patient against getting the cast wet, and instruct him not to insert foreign objects under the cast.
• Teach the patient to exercise joints above and below the cast as ordered.
• Tell the patient not to walk on a leg cast or foot cast without the physician’s permission.
• Emphasize the importance of returning for follow-up care.

Nursing Goals Nursing Care Plans for Bone Fractures

• Pain controlled.
• Prevented or minimized Complications
• Fracture stabilized.
• Condition, prognosis, and therapeutic regimen understood.
• Plan in place to meet needs after discharge.

Nursing Care Plans for Bone Fractures with nursing diagnosis Acute pain

Patient Teaching Discharge and Home Healthcare Guidelines for asthma

• Teach the patient and his family to avoid known allergens and irritants.
• Teach the patient about his medications, drug interactions, including proper dosages, administration instructions, and adverse effects.
• Teach the patient how to use a metered dose inhaler.
• Explain how to use a peak flow meter to measure the degree of airway obstruction, If the patient has moderate to severe asthma. Tell him to keep a record and Explain the importance of calling the physician at once if the peak flow drops suddenly
• If the patient develops a fever above 100° F (37.8° C), chest pain, shortness of breath without coughing or exercising, or uncontrollable coughing. Tell the patient to notify the physician
• Teach the patient and his family an uncontrollable asthma attack requires immediate attention.
• Teach the patient diaphragmatic and effective coughing techniques.
• Urge him to Increase fluid intake to help loosen secretions and maintain hydration.
• Teach the patient and his family important of Regular medical follow-up care, when to notify healthcare professional of changes in condition, and periodic spirometry testing, chest x-rays, and sputum cultures.