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Arthroscopy

Arthroscopy is an endoscopic procedure that allows direct visualization of a joint. This procedure is minimally invasive in which the examination for diagnosis and/or treatment of the internal joint structure is performed using an arthroscope or a tube-like viewing instrument. An arthroscope is a type of endoscope that is inserted into the joint through a small incision.If procedures are performed in addition to examining the joint with arthroscope the procedure is now called arthroscopic surgery. A procedure done arthroscopically instead of by traditional surgical techniques, usually causes less tissue trauma, results in less pain, and may promote a quicker recovery.
Indications of Arthroscopy

• Arthritis – helpful in diagnosis and treatment of inflammatory, non-inflammatory and infectious types of arthritis and non-inflammatory degenerative arthritis or osteoarthritis.
• Various joint injury such as cartilage tears or meniscus tears, ligament strains and tears, cartilage deterioration underneath the patella or kneecap
• Evaluation of knees and shoulders
• Examine and treat conditions of the wrist, ankles and elbows
• Removing loose tissues, chips of bone or cartilage or foreign objects (plant thorns)that are lodged in the joint

Before the Procedure

• Patients who are on anticoagulants (blood thinners) should have these medications carefully adjusted prior to surgery.
• Physical examination
• Blood tests
• Urinalysis
• ECG and Chest X-ray for patients who have a history of heart or lung problems and generally anyone over the age of 50
• Signs of ongoing infection in the body usually postpone arthroscopy, unless it is being done for possible infection of the joint in question.

Technique in Arthroscopy

• The procedure is carried out in the operating room under sterile conditions. In some cases, it is performed by orthopedic surgeons in an outpatient setting. When performed in the outpatient setting, patients can usually return home after the procedure.
• An injection of a local anesthetic into the joint or general anesthesia is used.
• A large bore needle is then inserted and the joint is distended with saline.
• The arthroscope, a small tube that contains optical fibers and lenses, is introduced through the tiny incision in the skin into the joint to be examined.
• Joint structures, synovium and articular surfaces are visualized because the arthroscope is connected to a video camera and the interior of the joint is seen on a television monitor.
• The size of the arthroscope varies with the size of the joint being examined.

After the Procedure

• Wrap the joints with a compression dressing to control swelling
• Apply ice over the area to control edema and discomfort
• Keep the joint extended and elevated to reduce swelling
• Advise the patient to limit activity following procedure
• Monitor neurovascular function
• Administer analgesics per doctor’s prescription to control discomfort

Complications

• Infection
• Hemarthrosis
• Thrombophlebitis
• Stiffness
• Delayed wound healing

      

Types of Phobias

A phobia is an anxiety disorder characterized by obsessive, irrational, and intense fear of a specific object an activity, or a physical situation. The fear, which is out of proportion to reality, usually results from early painful or unpleasant experiences involving a particular object or situation. A phobia may arise from displacing an unconscious conflict on an object that is symbolically related. Types of Phobias Agoraphobia Fear of being in places or situations from which escape may be difficult or help may not be readily available. Social Phobia Also called Social Anxiety Disorder Characterized by persistent fear of appearing shameful, stupid or inept in the presence of others. Specific Phobia Also called Simple Phobia A persistent fear of a specific object or situation, other than of two phobias mentioned above. Sub-categories: Injury-blood-injection Situational Natural environment Animals Other (fear of costumed character, space, etc) Risk Factors Learning theory The belief that phobias are learned and become conditioned responses when the client needs to escape an uncomfortable situation. Cognitive theory Phobias are produced by anxiety-inducing self-instructions of faulty cognitions. Life experiences Certain life experiences, such as traumatic events, may set the sage for phobias later in life. Signs and Symptoms Withdrawal High levels of anxiety Inability to function and meet self-care needs Inappropriate behavior used to avoid the feared situation, object or activity Dysfunctional social interactions and relationships Nursing Diagnoses Anxiety Powerless Ineffective individual coping Impaired verbal communication Altered thought processes Self-esteem disturbance Impaired social interaction Risk for injury Therapeutic Nursing Management Systematic desensitization This process of gradual exposure to phobic object or situation aimed at decreasing the fear and increasing the ability to function in the presence of phobic stimulus.

Suicidal Ideation

• Self imposed death stemming from depression.

Risk Factors

1. Theories of Suicide
   • Anger turned inward: anger that was previously directed at someone else is turned inward.
   • Hopelessness, depression, and guilt: desperate feelings of the client.
   • A history of aggression and violence: rage and violent behavior is correlated with suicides.
   • Shame and humiliation: suicide viewed as a “saying face” or saving the family name following a suicidal defeat.
   • Developmental stressors: certain stressors at developmental stages have been identified as precipitating factors to suicide.
2. Biological theories
   • Generic tendency: Twin studies have indicated a predisposition toward suicidal behavior.
   • Neurochemical factors: Postmortem studies have revealed a decreased serotonin level in the brainstem and spinal fluid.

Signs and Symptoms

1. Self mutilation
2. Unexplained decrease in daily functioning
3. Isolation and withdrawal, decreased social interaction
4. Channeling of anger and hostility towards self
5. Inability to discuss the future
6. Destructive coping mechanisms
7. Express anger toward self
8. Previous suicide attempts
9. Low self-esteem
10. Anxious and apprehensive
11. Non-verbal cues such as giving away possessions

Assessment

1. Suicidal Assessment: Question to ask the client to assess how realistic the client’s plan is.
   • Do you have thoughts of harming or killing yourself?
   • Do you have a plan to harm or kill yourself?
   • What is the plan?
   • Is it possible to implement the plan?
   • When do you plan to do it?
2. A person is considered at a high-risk for suicide if the plan could be carried out within 24-48 hours. Other issues in determining risk include the lethality of the method and the plan of discovery after death.

Nursing Diagnoses

• High risk for violence, self-directed or directed at others
• Risk for self mutilation
• Ineffective individual coping
• Ineffective family coping
• Spiritual distress

Therapeutic Nursing Management

1. Establish a therapeutic relationship
2. Talk directly with the client about suicide and plans
3. Communicate the potential for suicide to team members and family
4. Stay with the client
5. Accept the person. Listen to the person.
6. Secure a “no suicide/harm” contract
7. Give the person a message of hope based on reality
8. When client is able, encourage gradual increase in activities
9. Maintain suicide precautions, be particularly concerned with personal items the client may used to harm self, remove all dangerous and potentially dangerous items (belts, glass, sharps).

Captopril Nursing Responsibilities

 Brand Name: Capoten
Classification: Angiotensin Converting Enzyme (ACE) Inhibitor, Antihypertensive
Indications

• Hypertension
• Management of congestive heart failure (CHF)
• Reduces the risk of death or development of CHF after myocardial infarction (MI)
• Slows the progression of left ventricular dysfunction  into overt heart failure
• Used to decreased the progression of diabetic neuropathy

Mechanism of Action

• Captopril (Capoten) is an angiotension converting enzyme inhibitor. An Angiotensin-Converting Enzyme converts angiotensin I to angiotensin II. Angiotensin II is a potent endogenous vasoconstrictor substance.
• ACE inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II. It also inactivates the vasodilator bradykinin and other vasodilatory prostaglandins.
• ACE inhibitors also increase plasma rennin levels and reduce aldosterine levels. This is due to the suppression of the rennin-angiotensin-aldosterone system resulting in decreased serum concentrations of angiotensin I and aldosterone. The reduction of angiotensin I leads to decreased aldosterone secretion and as a result small increases in serum potassium may occur along with sodium and fluid loss.

Contraindications

1. Hypersensitivity
2. Cross sensitivity among Ace inhibitors
3. Pregnancy
4. Angioedema (hereditary or idiopathic)

Use cautiously in

1. Renal impairment
2. Hepatic impairment
3. Hypovolemia
4. Hyponatremia
5. Elderly patients
6. Concurrent diuretic therapy
7. Surgery or anesthesia
8. Lactation
9. Children

Side Effects

1. Dizziness or lightheadedness
2. Fatigue
3. Headache
4. Insomnia
5. Weakness or excessive tiredness
6. Cough
7. Hypotension
8. Tachycardia or fast heartbeat
9. Taste disturbances: salty or metallic taste or decreased ability to taste
10. Diarrhea
11. Nausea
12. Proteinuria
13. Hyperkalemia
14. Sore throat
15. Fever
16. Mouth sores
17. Unusual bruising

Nursing Management

1. Monitor blood pressure and pulse frequently during initial dose adjustment and periodically during therapy. (for patients treated with hypertension)
2. For patients treated with CHF, monitor weight and assess patient routinely for resolution of fluid overload. Signs of fluid overload are: peripheral edema, rales or crackles, dyspnea, weight gain and jugular vein distention.
3. The nurse should keep in mind that Captopril may cause false-positive result for urine acetone.
4. The drug should be administered 1 hour before or 2 hours after meals. It may be crushed if the patient has difficulty swallowing.
5. Keep this medication in the container it came in, tightly closed, and out of reach of children.
6. Store it at room temperature and away from excess heat and moisture (not in the bathroom).
7. Throw away any medication that is outdated or no longer needed.
8. Inform the patient that Captopril tablets may have a slight sulfur odor (like rotten eggs).
9. Instruct the patient to notify the physician immediately when the following manifestations are experienced:

• chest pain
• swelling of the face, eyes, lips, tongue, arms, or legs
• difficulty breathing or swallowing
• fainting
• rash

Group Therapy

Group therapy is a form of psychotherapy which as small, carefully selected group of individuals meets regularly with a therapist. The client participates in sessions with a group of people. These individuals share a common purpose and are expected to contribute to the group to benefit from others in return.
In group therapy approximately 6-10 individuals meet face-to-face with a trained group therapist. During the group meeting time, members decide what they want to talk about. Members are encouraged to give feedback to others. Feedback includes expressing your own feelings about what someone says or does. Group rules are established that all members must observe. These set of rules vary according to the type of group.
Purpose of a Group Therapy

1. It helps an individual gain new information or learning
2. It helps an individual gain inspiration or hope.
3. The group also allows a person to develop new ways of relating to people.
4. During group therapy, people begin to see that they are not alone and that there is hope and help. It is comforting to hear that other people have a similar difficulty, or have already worked through a problem that deeply disturbs another group member.
5. In a group, a person feels accepted.
6. Group therapy sessions allow an individual to interact freely with other members that shares the same past or present difficulties and problems. The individual then, becomes aware that he is not alone and that others share the same problem.
7. A person gains insight into one’s problem and behaviors and how they affect to others.
8. Altruistic behavior is practiced. Altruism is the giving of oneself for the benefit of others.

As the group members begin to feel more comfortable, they will be able to speak freely. The psychological safety of the group will allow the expression of those feelings which are often difficult to express outside of group. The client will begin to ask for the support he or she needs.
Types of Group Therapy

1. Psychotherapy Groups
2. Family therapy
3. Education groups
4. Support groups
5. Self-help groups

Kleihauer-Betke (KB) Test

The Kleihauer-Betke (KB) test is a blood test that measures the amount of fetal hemoglobin transferred from a fetus to the mother’s bloodstream. It is usually done for the purpose of determining the RhoGam dose. This test is used to predict certain types of pregnancy complications, particularly after a mother has suffered a traumatic injury. Kleihauer-Betke Test is usually performed on Rhesus-negative mothers to determine the required dose of Rho (D) Immnuglobulin (RhIg) to inhibit the formation of Rh antibodies in the mother and prevent Rh disease in future Rh-positive children.
Other Names of Kleihauer-Betke Test

• Fetal RBC determination
• Fetomaternal haemorrhage calculation, Kleihauer-Betke method
• Fetomaternal hemorrhage calculation, Kleihauer-Betke method
• Haemoglobin F cytochemical demonstration test
• Hemoglobin F cytochemical demonstration test

Purpose of Kleihauer Betke Test:

• Complication related to pregnancy. This test is used to predict certain types of pregnancy complications, particularly after a mother has suffered a traumatic injury.
• Measures fetal cells in maternal circulation. Staining of postpartum maternal blood for identification of percentage of fetal cells present
• Used in assessing for Rh Sensitization ( Maternal blood Rh negative, Large antepartum bleed)
• Determine possible fetal maternal hemorrhage in the newborn, aid in diagnosis of certain types of anemia in adults; assess the magnitude of fetal maternal hemorrhage; calculate dosage of Rh immune globulin to be given.

Normal Range or Value
Full-term newborns: Hb F cells are > 90%; normal adults Hb F cells are < 0.01%.
Before the Procedure

1. Assess for latex allergy.
2. Assess for bleeding disorders.
3. Note any medication or supplement taken by the patient that may cause excessive bleeding.

During the procedure

1. The nurse selects a vein that will be used in the test. In most cases, the vein in the arm is usually selected.
2. A tourniquet (large rubber strap) is secured above the selected vein.
3. The skin over the vein is cleaned, and a needle will be inserted.
4. Instruct the client to hold very still while the blood is collected.
5. After blood is collected into one or more tubes, the tourniquet is removed.
6. Expose blood smear to acid bath (this removes adult hemoglobin, which is acid-sensitive) but not fetal hemoglobin. Stain smear (fetal cells appear pink; maternal cells look like “ghosts”).
7. Count lots of cells and report percentage of cells that are fetal (specifically: you count the number of fetal blood cells per 50 low power fields. If you see 5 cells per 50 low power fields, that’s equivalent to a 0.5 mL fetomaternal hemorrhage).

After the Procedure

1. A bandage, cotton ball or gauze is placed on the area where the needle was inserted.
2. Apply pressure to the area.
3. Strenuous exercises should be avoided after the test is done.
4. Pain, redness, swelling or discharges from the puncture site should be reported to the physician immediately.

Wernicke’s Encephalopathy

Wernicke’s encephalopathy is a serious neurological condition that results primarily from a deficiency of the nutrient thiamine which is also known as Vitamin B1. This condition is an inflammatory, hemorrhagic, degenerative condition of the brain. It is characterized by lesions in several parts of the brain, including the hypothalamus, mammillary bodies, and tissues surrounding the ventricles and aqueducts, double vision, ophthalmoplegia, involuntary and rapid movements of the eyes, lack of muscular coordination, and decreased mental function, which may be mild or severe. The disease is comprised of three main symptoms: mental confusion, lack of muscle coordination, and a paralysis of the muscles which control eye movements.
Frequency

• The male-to-female ratio is 1.7:1, likely owing to alcoholism being 3-4 times more frequent in men than in women.
• Wernicke encephalopathy have placed the incidence between 0.8% and 2.8% of the general population
• The incidence can be as high as 12.5% in a population of alcoholics

Causes

• This disease is caused by a lack of thiamin (vitamin B1), which leads to problems with the normal functioning of the brain.
• Thiamine deficiency is characteristically associated with chronic alcoholism, because it affects thiamine uptake and utilization. Most cases of Wernicke’s encephalopathy are rooted in chronic alcohol abuse.  Alcohol can, over time, severely impair the body’s ability to absorb thiamine, gradually leading to a deficiency of this nutrient. When someone who is known to abuse alcohol has symptoms such as confusion and gait ataxia, meaning lack of coordination in walking, Wernicke’s encephalopathy should be considered as a possible cause.
• Wernicke encephalopathy may develop in nonalcoholic conditions such as:

1. prolonged starvation
2. hyperemesis gravidarum (continuous nausea and vomiting during pregnancy)
3. bariatric surgery and other gastric bypass surgeries
4. HIV-AIDS
5. healthy infants given the wrong formulas
6. malnutrition
7. complication of GI tract disease
8. Cancers that have spread throughout the body
9. Heart failure (when treated with long-term diuretic therapy)
10. Long periods of intravenous (IV) therapy without receiving thiamine supplements
11. Long-term dialysis
12. Very high thyroid hormone levels (thyrotoxicosis)
13. Chronic renal failure
14. Carbohydrate loading in the presence of marginal thiamine stores (feeding after starvation)
15. Absence of thiamine from the diet (in the case of infants fed formula without the addition of thiamine)
16. Congenital transketolase function abnormalities

Salicylates Toxicity

Salicylates are agents found in hundreds of over-the-counter (OTC) medications and in numerous prescription drugs. These medications possess anti-inflammatory, analgesic, and antipyretic properties. They are available for ingestion as tablets, capsules, and liquids.
Therapeutic Uses of Salicylates
Therapeutic uses of salicylates are the following:

• Analgesic
• Anti-inflammatory
• Antipyretic
• Keratolytic
• Rubifacient

Acetylsalicylic acid is colorless or white in a crystalline, powder, or granular form. The chemical used in this drug is odorless and is soluble in water. Many people are using Aspirin as an anti-inflammatory agent to treat soft tissue and inflammation in the joints. Thrombosis is also prevented with a low dose of Aspirin.
Factors Influencing Salicylate Toxicity

• Dose
• Age of victim
• Renal function
• Dehydration
• Fever

Clinical Manifestations
PHASE 1
Phase 1 of the toxicity is characterized by hyperventilation resulting from direct respiratory center stimulation, leading to respiratory alkalosis and compensatory alkaluria. Both potassium and sodium bicarbonate are excreted in the urine. This phase may last as long as 12 hours.
PHASE 2
In phase 2, paradoxic aciduria in the presence of continued respiratory alkalosis occurs when sufficient potassium has been lost from the kidneys. This phase may begin within hours and may last 12-24 hours.
PHASE 3
Phase 3 includes dehydration, hypokalemia, and progressive metabolic acidosis. This phase may begin 4-6 hours after ingestion in a young infant or 24 hours or more after ingestion in an adolescent or adult.
Earliest Sign of Salicylate Toxicity

• Nausea and vomiting
• Tinnitus
• Diaphoresis or sweating

Other Early Sypmtoms

• Tachycardia
• Vertigo
• Hyperventilation
• Hyperactivity

Symptoms occurring as the toxicity or poisoning progresses:

• Agitation
• Delirium
• Disorientation
• Respiratory acidosis
• Hallucinations
• Stupor
• Coma
• Cardiovascular system collapse

Hyperthermia is an indication of severe toxicity, especially in young children.
Management:
Home Care

• Seek immediate medical help. Do NOT make a person throw up unless told to do so by poison control or a health care professional.
• Determine the following information: Patient’s age, weight, and condition, Name of the product (ingredients and strengths, if known), Time it was swallowed, Amount swallowed
• Call the Poison Control Center.
• Bring the patient to the nearest hospital.

Emergency Room Care

1. Treat respiratory depression
2. Induce gastric emptying: emesis or lavage.
3. Give activated charcoal to absorb aspirin. A cathartic may be given with charcoal to help assure intestinal cleansing.
4. Support patient with intravenous infusions as prescribed to establish hydration and correct electrolyte imbalances.
5. Enhance elimination of salicylates as directed by forced dieresis, alkalinization of urine, peritoneal dialysis or hemodialysis according to severity of intoxication.
6. Monitor serum salicylate level for efficacy of treatment.
7. Administer specific prescribed pharmacologic agent for bleeding and other problems.