Category Archives: The world of nursing

Nursing is not a simple task of caring.

Postoperative Ileus

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When patients are recovering from anesthesia after surgery. I think that the last and most common struggle is the reestablish of the digestive system. When I first had my cesarean section, I had no problem awakening, but I had problem moving my bowels. My third CS was worst, I had severe gas pain, suppository did help but was too slow. Then an interesting case hit me. Should Ditropan be given early post operative period?

I picked on Ditropan as the culprit for the ilues and flatulence because it is an anticholinergic that decreases motility in the digestive tract as it lessens spasm in the bladder. When the guts are recovering from anesthesia, this medication should not be taken, or anything that decreases motility should be held until the digestive tract has fully recovered with no distention and abdominal pain. For those who had prior history of post op ileus, should have a cleansing enema before surgery. Early mobility is the key but what if it hits you even before you start to ambulate? Prevention is the no.1 priority to avoid repetition.

What do you think? Please write a comment.

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Seizure after Cessation of Benzodiazepines 1

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I have discussed about the how, when and what happens when taking Benzo longer than it should be and why it is addictive. Addictive in the sense that the body becomes dependent of the action of benzo. Remember the role of GABA inhibitors? How it inhibits neurotransmitters to be excited? This role is very important in managing balance in our body. When the body becomes excited and hyper, GABA reacts by balancing the situation appeasing the activity as it slowly brings back normalization. Now with the prolonged use of benzo it now takes over and replaces GABA. How? With more and more use of benzo the body thinks GABA is not needed anymore so its production is suppressed. This becomes a problem now because once the blood level of benzo is lessened/decreased, an immediate reaction takes place because GABA is so suppressed that in situation like this, it won’t be able to control hyperexcitement. How is these corrected? If it takes 4 weeks continuous use of benzo before the body becomes dependent then I can say that it will also take 4 weeks for the body to adjust once stopping benzo intake. The most critical period would be the first ten days of withdrawal since it is during this period that seizure is very inevitable and the body is unable to produce GABA inhibitors to counter react the situation. But once the critical period is surpassed, the brain now will rethink as their is cessation of the artificial GABA, it will start producing its own GABA inhibitors again. During this 4 weeks of recovery most of the time the body needs assistance in order to recover smoothly as it transitions during the cleansing period. This time it would need gradual tapering dose of benzo or any anticonvulsant like depakote to control the withdrawal symptoms at the same time provides enough time for the brain to regain control of its GABA inhibitors.

To my readers, this is pure analysis and I hope this will help anybody who are interested in giving up benzo. Do not let drugs control your life, instead control drug use and be wise. Doctors prescribe the medication with the confidence that it will help your symptoms, there is nothing wrong with that. ..But the wrong comes on the way when you pretend to be innocent and ignorant about your prescription. It is too late when you realize a damage was already done before you can even say something. But.. hope and life should be the inspiration to live again, this time be in control!!!!

Signs of Vascular Compromise in a New Stoma

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A normal budding stoma should be healthy pink/red in color which indicates adequate perfusion, but a dusky looking stoma should be questioned and surgeon should be notified. A dusky stoma could mean ischemia, their is inadequate tissue perfusion and oxygenation, if not corrected, it can lead to mucosal sloughing and necrosis/death of tissue. When patient continue to ask for pain medication for persistent abdominal pain, nausea and vomiting, a GI warning sign that something is wrong calls for a re-look. Non healing wound due to lack of circulation will be imminent. A good stool output mean a functioning bowel, presence of a slough could also mean dead tissue from surgical injury. Once the slough falls off, a pink/red stoma should be uncovered.

SVT Secondary to Low Blood Sugar

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Very interesting and unlikely, patient is a end stage renal desease on hemodialysis 3x a week, history of atrial fibrillation and a recent CVA with right upper arm paralysis and right lower extremity hemiparesis. Admitted for pneumonia secondary to aspiration. Pt was NPO since admission. Suddenly developed SVT with HR 190’s. No fever, no signs of pain, K+ level normal, Mg 1.5, BUN/Creatinine elevated but not bad considering patient is in renal failure. Glucose serum an hour ago was 64, no h/o of diabetes. stat CBG down to 53, she was then given 1/2 amp of Dextrose 50%. A dramatic gradual slow down of her HR which is now afib was a surprise but educational. Analyzing the case, pt’s energy reserve has been exhausted due to the recent CVA, has not been eating well and worst was made NPO due to swallowing difficulty and aspiration precaution. That alone had depleted her glucose. My first suspicion was another bout of stroke as patient was awake but aphasic which was baseline on admission.

It is important to note not to forget CBG in any emergency situation. A simple procedure that could save life and any unnecessary diagnostic procedure as well as medications that may worsen the situation.

Again it is proven how our body amazingly communicates when it cannot manifest itself in the normal expected course.

Colchicine in Renal Failure

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Colchicine is a wonder drug for a gout flare. Two consecutive dose is enough to abate the inflamed joint. Hospitalized patients who have history of gout are susceptible to gout flare due to physical trauma, surgery, immunosuppressant drugs Ciclosporin and Tacrolimus, use of diuretics and metabolic syndrome. Since Colchicine is excreted 10- 20 % unchanged in the kidneys it is highly probable to cause toxic accumulation in a renal failure patient. Colchicine can not be removed through dialysis nor does it have an antidote to combat any toxic effect. For this reason prescription of this medication for an acute gout flare should be limited to 2 doses then prophylactic as needed treatment. A few of its distinctive side effects include gastrointestinal upset( diarrhea, vomiting)and symptoms of peripheral neuropathy ( tingling, burning, restless upper and lower extremities) secondary to damage of the peripheral nerves from colchicine toxicity.

What Happens during Gout Flare?
Hyperuricemia is the main cause of gout. Due to an increased uric acid in the blood and slow excretion, uric acids favorite stop are the joints causing uric acid crystal formation, because it is a foreign and an abnormal process the body protects itself from invasion by sending guards to destroy and get rid of this deposits. As plasma and leukocytes which are mainly neutrophils floods the area, an acute inflammation occurs. The area becomes red and hot due to increased blood flow, swelling occurs due to fluid build up and becomes very painful and tender because of damaged nerve endings.

How does Cochicine work?
With Colchicine, it inhibits the activity of neutrophil flooding the area, with decrease in neutrophils, inflammation slows down and pain is lessened.

How to control Gout?
Once the flare is under control, Alluporinol should be taken to block uric acid formation. Uric acid is a by product of purine metabolism, a diet high in purine should be avoided ( e.g. herring, tuna, anchovies, scallops, beer,red meat, turkey.. pls. see reference).

Case study and analysis:
My patient encounter had opened my eyes to investigate Colchicine. Patient have a history of gout and takes allupurinol daily and colchicine as needed for gout flare. In this hospitalization, many things had happened although he has chronic kidney disease hemodialysis is now his last resort of cleansing the body from toxins and waste products of metabolism as well as correcting electrolyte imbalance and fluid excess. He started to have joint pains and was attributed to gout flare. Colchicine BID was started. My second night of encounter patient was restless and was unable to sleep. Trazodone barely helped as he only started to sleep at around 4 am. The following night he complained of the same but now with jumpy burning feet which is new for him. Tracking down what could have caused this symptom pointed to Colchicine. With him who have kidney failure, colchicine toxic accumulation is inevitable. He had already taken said drug for the past 3 consecutive days. My PA that night was very helpful. Patient rested well after 1 mg of IV Ativan. Colchicine was decreased to PRN only. Because it is a weekend his next dialysis is Monday. Even then, colchicine cannot be removed through dialysis. Will he continue to have this symptom of peripheral neuropathy? Highly probable for sometime. This is my last night with him and I will be off for 3 days. But at least the culprit was found.

Reference:
1. Health;Foods to avoid if you have gout
By Anne Harding
2.Colchicine
From Wikipedia, the free encyclopedia
“In August 2009, colchicine won Food and Drug Administration (FDA) approval in the United States as a stand-alone drug for the treatment of acute flares of gout and familial Mediterranean fever.[12][13] It had previously been approved as an ingredient in an FDA-approved combination product for gout. The approval was based on a study in which two doses an hour apart were effective at combating the condition.”
3.Gout
From Wikipedia, the free encyclopedia
4.Allopurinol
From Wikipedia, the free encyclopedia
5.Hyperuricemia
From Wikipedia, the free encyclopedia

Coumadin and Antibiotic

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When taking any form of antibiotic while on coumadin, it is important to closely monitor PT/INR. While antibiotics eradicates bacteria in the guts, Vitamin K2 is produced by the synthesis of vitamin K by the bacteria present in the colon. Washing off the bacteria in the colon depletes vitamin K source. Coumadin is then well absorbed and INR level will readily increase or double. Taking antibiotics due to infection can not be avoided. I would suggest more frequent lab draw for PT/INR.

Reference:
1. Vitamin K – Wikipedia, the free encyclopedia
en.wikipedia.org/wiki/Vitamin_K
2. Microbial Fermentation
biology.about.com/library/organs/bldigestlargeint4.htm

A Wake Up Call For The Non- Compliant Patient

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Patient C thinks he is doing well. It has been 3 weeks since he was admitted. He is in the road to recovery but because of some complications his stay was longer than expected. He became irritable because of not being able to do what he wants, he wants to get up but disappointed because of extreme weakness while doing so. His will power is strong but his body is weak. His mind is narrowed by his desire to shortcut the course but the body does not think that way. Our body is amazingly and intricately created to undergo processes that only those gifted with wisdom will understand. The body has its own healing power that is mandated by the immune system with the life giving power of the blood that goes around every corner of our body tissues. With the help of medicine this power is sometimes enhanced but failure may take place if the body senses it’s inappropriate and dangerous. A sound and understanding mind is also essential and plays an important role with the healing process. Educating ourselves and respecting those who studied them should guide us to a speedy recovery but averting the process with stupidity and immature control will only delay the whole picture of a smooth and healthy expectations.

Patient C realized the mistake he did, the following night his behavior changed, was more cooperative and patient. But he still needs continued education as his case is unique and extremely delicate. I thought I should have been more insistent and assertive but things happen this way so the one concerned will learn in a way.