FEMALE PELVIS

                                FEMALE PELVIS

What is female pelvis?

A female pelvis is a bony canal that assists the fetal passage for being born.

Composition of bony pelvis:

4 bones:

• 2 innominate bones
• 1 Sacrum
• 1 coccyx

1] Innominate bone:

Each innominate bone consists of 3 parts.

Ilium: 

• It is the large flared out part.
• Crest is the upper edge of ilium.
• Bony prominence of ilium at front is called anterior superior & inferior iliac spine each of which are 2 in number.
• 2 similar points at the back is called posterior superior & inferior iliac spine.
• Iliac fossa is the concave anterior surface of ilium.

Ischium:

• It is the thick lowest part.
• Ischial tuberosity is the prominence on which the body rests while sitting.
• Ischial spines are posterior prominence of ischium which is responsible for estimation of fetal station at the time of labor.

Pubis:

• It is the anterior bone.
• Superior & inferior rami are the body of pubis.
• Inferior ramus of each side merges to form the pubic arch.
• Fusion of pubic arch occurs at Ramus of ischium.
• 2 pubic bones meet at symphysis pubis.
• Greater & lesser sciatic notch are the curves on the lower border of innominate bones.

2] The sacrum:

• Wedge shaped bone formed by the fusion of 5 fused vertebrae.
• Anterior concave surface of sacrum is called as hollow of sacrum.
• Upper border of first sacral vertebra is called sacral promontory.
• Ala are the wings of sacrum.
• Posterior rough surface receives the muscle attachments.
• Nerve supply from cauda equina emerge to supply pelvic organs.

3] Coccyx:

• It is triangular bone consist of 4 fused vertebrae.

Pelvic Joints:

• The symphysis pubis-1
• The sacroiliac joints-2
• The sacroccygeal joint-1

Pelvic ligaments:

Each pelvis joint is held together by following ligaments:

• Interpubic ligament
• Sacroiliac ligaments
• Sacrococcygeal ligament
• Sacrotuberous ligament
• Sacrospinous ligament

Caldwell- Moloy classification of pelvis:

Gynecoid pelvis: 

It is the typical female pelvis & is most suitable for labor & delivery.

Features:

• Inlet is round
• Sacrum is concave & sacral promontory is not prominent.
• Sacrosiatic notch admits 2 fingers.
• Pelvic side walls are straight & parallel.
• Ischial spines are not prominent.
• Subpubic angle >90 degrees
• Interischial diameter admits knuckles.

Android Pelvis:

It is a typical male pelvis.

Features:

• Inlet is heart shaped.
• Sacrum is flat & sacral promontory is prominent.
• Sacrosiatic notch does not admit 2 fingers & is narrow.
• Pelvic side walls converge downwards
• Ischial spines are prominent
• Subpubic angle < 80 degrees.

Anthropoid pelvis:

Features:

• Oval shaped.
• Sacrum is curved & sacral promintory not prominent
• Sacrosiatic notch is wide & deep.
• Pelvic side walls are straight.
• Ischial spines are not prominent.
• Subpubic angle = 80 degrees

Platypelloid Pelvis:

• Flat pelvis & is transversely oval.
• Sacrum is flat & sacral promontory is prominent.
• Sacrosiatic notch is wide & shallow.
• Pelvic side walls are straight.
• Ischial spines are not prominent.
• Subpubic angle > 90 degrees.

Anatomical position of pelvis:

• Both Anterior superior iliac spine & upper end of Symphysis pubis lie in same coronal plane.
• Pubis is directed upward & forward.
• Sacral canal facing upward.
• Tip of coccyx should correspond lower border of symphysis pubis.
• Angle of pelvic inlet is 50-60 degrees with horizontal.
• Angle of pelvic outlet- 10 degrees with horizontal.

Landmarks of Pelvis:

• Upper border of symphysis pubis
• Pubic crest
• Pubic tubercle
• Pectineal line
• Iliopectineal eminence
• Iliopectineal line
• Sacroiliac joint
• Ala of sacrum
• Sacral promontory

Parts of pelvis:

False Pelvis:

• Lies above pelvic brim
• Bounded by :

Posteriorly: Lumbar vertebrae

Laterally: Iliac fossae

Anteriorly: Abdominal walls.

True pelvis:

• Bonded by:

Posteriorly: Sacrum

Laterally: Ischium & Sacrosiatic notch

Anteriorly: Pubic bone, obturator foramen & ischiopubic rami.

• Divided into 3 planes:

Pelvic inlet

Pelvic cavity

Pelvic outlet.

Pelvic inlet:

• Boundaries:

Lateral: Pectineal lines.

Anterior : Pubic ramus & Symphysis pubis.

• Shape: Round
• Diameters:

Anterio-Posterior diameters:

• True conjugate:Distance between Sacral promomtory & upper border of symphysis pubis-11 cm
• Obstetric Conjugate:Distance between sacral promontory & the most prominent part of symphysis pubis- 10 cm.
• Diagonal conjugate: Distance between sacral promontory to inferior border of symphysis pubis- 12cm.

Transverse diameter: Distance between 2 farthest points of ileopectineal lines-13 cm.

Oblique diamter: Distance between sacroiliac joint of one side to ileopectineal eminence of other-12 cm.

Pelvic cavity:

• No diameters beacuse of absence of bony projection & joining of various ligaments.
• Shape: Truncated cylinder.
• Plane of greatest pelvic dimensions:

At the level of second & third vertebrae of savrum.

• Plane of least pelvic dimensions:

At the level of ischial spine & fourth & fifth vertebrae of sacrum.

• Interischial diameter:At the level of ischial spine : 10 cm.

Pelvic outlet:

• Boundaries:

Anterior: Subpubic arch, ischiopubic rami

Lateral: Sacrosiatic ligaments, ischial tuberosities

Posterior: Tip of sacrum

• Shape: Diamomd
• Diameters:

Anterioposterior:Distance between tip of coccyx to inner border of sympohysis pubis- 12-13 cm

Transverse diameter: Distance between 2 ischial tuberosities- 10 cm

Waste space of Morris:

• When the head is being delivered, it passes through the pelvic outlet between ischiopubic rami behind subpubic angle. The space between subpubic angle & head circumference of fetus < 1 cm.
• In case of android pelvis the subpubic angle is narrow & the space > 1 cm. This is called Waste Space of Morris.

Clinical implications of pelvis:

• The head engages at transverse diameter of inlet which is greater.
• The fetal head rotates to accommodate under anterio-posterior diameter of outlet which is largest.
• Malrotation or arrest usually occurs at interspinous diameter.
• The direction of fetus is along the plevic axis.
• Relaxation of pelvic joints increases the diameters of pelvis which helps in descend & delivery.
• Backache is common due to relaxation of sacroiliac joints.
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MEAL PLANNING FOR DIABETICS

                     MEAL PLANNING FOR DIABETICS

Introduction:

• Diabetes is a lifestyle disorder along with lifelong disorder.
• Controlling blood sugar level is the major task for the patients.
• Medicines or insulin are however controlling it yet dietary management is very essential to control the blood sugar levels along with healthy life.
• Meal planning needs to done as per food preferences, lifestyle, usual eating times, & ethnic & cultural background.
• An assessment regarding weight loss, weight gain or maintenance of weight of patient is taken into consideration.
• Sometimes it is difficult for a patient to accept the diagnosis of diabetes resulting in no restrictions in eating.

Caloric Requirements:

• It is planned as per energy needs, caloric requirements as per age, sex, height & weight of patient.
• The planned caloric requirements should maintain he healthy weight of the patient.
• A reduction in 500-1000 calories from regular meal pattern is made for effective weight management of patient.
• These caloric requirements are distributed in macronutrients.
• In some cases patients may be underweight, in such a situation meal planning should be done with a aim of gaining weight followed by weight maintenance.
• The meal planning needs to be done to promote healthy growth & development.

Carbohydrates:

• The caloric requirements should be more from carbohydrates than fats.
• ADA recommends 50-60% calorie source needs to be carbohydrates.
• Once digested 100% carbohydrates are converted into glucose.
• Hence the servings of CHO must be done considering the other macronutrients.
• Carbohydrate counting & counting grams of carbohydrates are common for type 1 & type 2 diabetes.
• In each serving 15g carbohydrate is served along with other macronutrients.
• Sugars & starches need not be eliminated  rather should be taken moderately.
• Breads, pasta, rice, potato, etc are included in meal planning of diabetics.
• ADA nutritional guidelines recommend to eat all carbohydrates in moderate amount to avoid high PPBS values.
• Reduction of foods high in carbohydrates should be done upto 10% of totaly calories.

Fats:

• 20-30% caloric requirements can be obtained from fats.
• Saturated fats should be limited to 10% of toatl calories.
• Dietary cholesterol can be reduced upto 300mg/day to avoid high cholesterol levels in blood.

Proteins:

• 10-20% caloric requirements need to be get from proteins.
• Animal & nonanimal meals can be included.
• Cultural value & preference along with fat content in food needs to be considered.
• In the patients developing renal complications due to diabetes, the protein intake needs to be reduced further.
• Whole grains & legumes are some of the protein sources that reduces saturated fats & cholesterol in the body.

Fibres:

• High fibre diet can reduce the need of insulin & maintain blood glucose levels.
• Soluble fibres obtain legumes oats & fruits are having tendency to reduce the blood glucose level.
• However there digestion leads to a gel which slows down the GI motility & causes regurgitation.
• Insoluble fibres obtain from whole grains, vegetables & breads are associated with providing bulk to the stool & preventing constipation.
• Both the types of fibres are having weight loss potential.
• The only risk of high fibre diet is hypoglcemia.
• Hence dose of oral drugs & insulin needs to be adjusted to manage hypoglycemia.
• Fluid intake needs to be very adequate along with fibre rich diet to prevent flatullence, nausea, abdominal fullness & other symptoms.

 

Food guide pyramide:

Guidelines for dietary recommendations:

• Combining starchy food along with fat & protein containing food tends to lower glycemic response due to slow absorption.
• Raw & whole foods have more hypoglycemic values than chopped or cooked.
• Whole fruits should be taken instead of its juices to allow fibre content in the body.
• Foods high in sugar should be taken with high fibre or protein rich diet to increase the hypoglycemic value as the later foods have slow absorption rate.

Alcohol consumptions:

• Patients with diabetes do not need to give up on alcohol.
• But alcohol needs to be taken into moderate amounts to prevent hypoglycemia.
• Alcohol is avoided or restricted in diabetes patients especially patients taking insulin as it produces major hypoglycemia.
• In addition excessive alcohol can impair the ability of patient to recognize & treat hypoglycemia.
• Alcohol consumption may lead to excessive weight gain & hyperlipidemia.
• Patients treated with Diabinese can have disulfiram like reactions after ingesting alcohol.

Sweetners:

• Moderation in amount of sweetner used is encouraged .
• Nutritive sweetners contains calories.
• It contains fructose, sorbitol & xylitol which are not calorie free.
• These are often called "sugar free" foods as they cause less blood glucose elevation than sucrose.
• Non nutritive sweetners have no or minimal calories.
• They are used in food products & are available for table uses.
• Saccharin, aspartame, sunette, sucralose are non nutritive sweetners having sweetness more than sugar.
• These are used in baked foods, nonalcoholic beverages, chewing gums, coffee, frostings & frozen dairy products.

Food Labels:

• Food labels with "no sugar" or "sugar free" label will provide calories equivalent to sugar if they are made with nutritive sweetners.
• Patients must look at ingredients to assess the health value as some food may contain animal fats which are contraindicated in diabetics with hyperlipidemia.
• Due considerations in dietary & food habits help to manage the lifestyle with diabetes.

BENIGN PROSTATE HYPERTROPHY

What is BPH?

It is enlargement of prostate gland.

Definition:

BPH os characterized by proliferation of both stromal & epithelial elements with resultant enlargement of gland resulting in urinary obstruction.

Etiology & Risk factors:

• Age over 40 years & older
• Family history of BPH
• Obesity
• Cardiovascular disease
• Type 2 diabetes 
• Sedentary lifestyle
• Erectile dysfunction
• Decrease levels of testosterone in blood

Pathophysiology:

Development of multiple fibroadenomatous nodules in the periurethral region of prostate leads to narrowing of lumen of prostatic urethra leading obstruction in urinary flow causing diverticula& hypertrophy of bladder causing increase pressure with micturition leading to incomplete emptying of bladder causing infection & hydronephrosis.

Sign & Symptoms:

• Urinary hesitancy- difficulty initiating stream of urine due to pressure ob urethra & bladder neck
• Urinary frequency- Need to urinate frequently owing to pressure on bladder
• Urinary urgency
• Nocturia
• Decrease force of urine stream
• Dribbling of urine
• Hematuria
• UTI
• Bladder stones
• Pelvic discomfort
• Azotemia
• Abdominal straining

Medical & Nursing Management:

• Alpha 1 adrenergic blockers - doxazosin, tamsulosin
• 5 Alpha recductase inhibitors to reduce the size of prostate-finasteride, dutasteride
• Antimuscarinics such as  tolterodine 
• Phosphodiesterase-5 inhibitors such as tadalafil 
• Combination therapy of alpha blockers & 5 aplha reductase inhibitors.
• Monitor blood pressure as hypotension may be the side effect of alpha 1 blockers
• Monitor renal function
• Administer anti spasmodoics for patient experiencing bladder symptoms.
• Explain patient to avoid caffeine, alcohol, decongestants which may increase symptoms of BPH.
• Surgical treatment may be a choice to alliviate symptoms.
• Monitor postoperative patient's bladder irrigation:

1. 3 way port catheter
2. Monitor amount of fluid instilled & returned.
3. Subtract the amount of fluid instilled from amount of fluid returned to determine actual urine output.
4. Monitor bladder spasm as it may indicate blocked catheter drainage postoperatively
5. Document the color of urinary output post operatively.
6. Maintain record of cardinal signs.
7. Continuous bladder irrigation post operatively.

Distinctive facts:

• Ix: Prostate specific antigen [PSA], BUN & creatinine levels - elevated, Digital rectal examination 
• Sx: Transurethral Resection of Prostate [TURP], Transurethral Incision of prostate [TUIP].
• Main factor of cause: Dihydrotestosterone [DHT]
• More common in white & black men than in Asian men.
• Also called as benign prostate hyperplasia, adenofibromyomatous hyperplasia, benign prostatic hypertrophy,benign prostatic obstruction
• Complications include: Vesicourethral reflux, Cystolithiasis.
• May be caused by taking drugs such as beta blockers.

Prognosis:

Prognosis is often associated with surgical management. The prevalence rate is 2.7% for men aged 45–49, it increases to 24% by the age of 80 years. Medical management can reduce the course of disease. 

CIRRHOSIS OF LIVER

                                 CIRRHOSIS OF LIVER

What is liver cirrhosis?

It is repeated destruction of hepatic cells causing formation of scar tissues.

Definition:

A chronic progressive disease of liver characterized by diffused damage to cells with fibrosis & nodular regeneration.

Etiology & Risk factors:

• Alcohol consumption
• Hepatits C
• Exposure to drugs or toxins
• Steatohepatitis
• Autoimmune hepatitis
• Cystic fibrosis
• Metabolic disorders 
• Genetic causes
• Biliary disease
• Primary hemochromatosid
• Cryptogenic cirrhosis
• Vascular abnormalities
• Primary sclerosing cholangitis

Types:

Alcoholic Cirrhosis: Scar tissue characteristically surrounds the portal area.

Post necrotic Cirrhosis: There are broad scar tissue bands due to late results of acute viral hepatitis, postinfection with industrial chemicals.

Biliary Cirrhosis: Scaring occurs around bile duct in liver, results from Chronic biliary obstruction & infection.

Cardiac Cirrhosis: Associated with long term right sided heart failure.

Classification:

Micronodular Cirrhosis: Small nodules generally uniform & less than 3 mm & is associated with:

• Alcoholic hepatitis
• Haemochromatosis
• Drugs
• Chronic biliary disease

Macronodular Cirrhosis: Nodules are larger than 3 mm. these are associated with:

• Chronic viral hepatitis
• Autoimmune
• Long duration of any of etiological factors

Mixed: Nodularity with variably sized nodules.

Pathophysiology:

Hepatocytes are injured due to etiological factors secret paracrine factors & activate stellatate cells & loose vitamin A & proliferate resulting in collagen production causing fubrosis & scar tissue & compress the central vein.

Sign & Symptoms:

• Initially asymptomatic
• Weakness
• Muscle cramps
• Weight loss
• Anorexia
• Nausea & vomiting
• Ascites
• Pale, clay colored stool
• Abdominal pain
• Portal hypertension
• Pruritis
• Ecchymosis
• Coagulation defects
• Nosebleeds, bleeding gums
• Amenorrhea
• Impotence
• Jaundice
• Hepatomegaly
• Dilated venous pattern over abdomen
• Palmar erythema
• Dyspnea
• Encephalopathy

Medical & Nursing Management:

• Low sodium diet with adequate calorie intake
• Restrict fluid intake in case of hyponatremia or fluid overload
• Administer multivitamins
• Diurestics: furosemide, spironolactone
• Paracentesis to remove ascitic fluid
• Administer lactulose to promote ammonia removal from gut
• Antibiotics: neomycin sulfate, metronidazole
• Shunt placement: Peritoneovenous shunt, portocaval shunt, transjugular intrahepatic shunt
• Gastric lavage
• Balloon temponade to control oesophageal varices bleeding
• Administer blood products if needed
• Sclerotherapy
• Vaccine for influenza & hepatitis B
• Elevate head 30 degrees to ease breathing
• Weight patient daily
• Elevatye feet to decrease peripheral edema
• Monotor level of consciousness, orientation, recent & remote memory, behaviour, mood.

Distinctive facts:

• Ix: AST, LDH, ALt levels- elevated, Liver biopsy, USG, CT scan, Serum protein, albumin, WBC- low
• Special signs: Muehrcke's nails & terry's nails spider angioma caput medusae
• Liver transplant is a surgical option
• NSAIDs & Aspirin to be avoided
• 3000 cal/day
• Hepatotoxins are to be removed
• Hepatocellular carcinoma & encephalopathy are most common complications

Prognosis:

As cirrhosis progresses, the patient may develop encephalopathy & coma. Survival from liver transplantation is now around 80%. Alcoholic cirrhosis has a worse prognosis. Mortality of 34–66%

ASYSTOLE

What is Asystole?
Absence of all electrical activity within ventricles. Asystole is a criteria of certifying that the patient is dead.

Definition:

Asystole is defined as no cardiac electrical activity causing ventricles to stop contractions, leading to no cardiac output & no blood flow.

Causes of Asystole:

• MI
• Underlying heart disease
• Severe uncorrected acid base imbalance
• Electrical shock
• Electrolyte imbalance such as hyperkalemia
• Massive pulmonary embolism
• Prolonged hypoxia
• Drug intoxication

Characteristic of Asystole

• Rate & Regularity : Total absence of electrical activity
• P waves : Absent
• QRS complexes : Absent
• PR & QT intervals: Absent

Sign & symptoms:

• Cyanosis
• No pulse
• Apnea

Medical & Nursing management:

• CPR & BLS to be started
• Epinephrine, Atropine, Vassopressin, Sodium Bicaronate
• Oxygenation
• IV fluids
• ET Intubation 
• Transcutaneous pacing

Distinctive Facts:

• Ix: ECG - No atrial or ventricular rhythm on ECG
• Life saving procedures such as percardiocentesis can be perfomed.
• Defibrillator might not be used as the problme lies in response of myocardial tissue to electrical impulses.
• Asystole is also called as cardiac flat line.

Prognosis:

Prognosis is usually poor.Even in the rare case that a rhythm reappears, if asystole has persisted for fifteen minutes or more, the brain will have been deprived of oxygen long enough to cause brain death.

TUBERCULOSIS

What is tuberculosis?
TB is a respiratory tract infection spread by airborne route. It is one of the oldest disease known to affect humans & is a major cause of death world wide.

Definition :
It is a chronic bacterial infection caused by Mycobacterium tuberculosis, that is characterized by formation of granulomas in infected tissue & by cell mediated hypersensitivity.

Types:
Primary TB: It occurs when patient is initially infected with Mycobacterium.
Secondary TB: The disease is reactivated in later stage.

Pathophysiology:
Inhaled bacteria lodge into alveoli activating macrophages transforming into epithelial cells & Langhan cells which aggrevate lymphocytes to form tuberculous granuloma which will form ghon's focus followed by limiting the spread of bacilli causing latent TB. Healing then occurs with late calcification of granulomas & the combination of calcified peripheral lung leision & calcified hilar lymph nodes forms Ghon's complex.

Etiology & risk factors:

• Contact with infected person
• HIV
• Smoking
• Alcoholism
• Poverty
• Overcrowding
• Diseases such as diabetes mallitus, cancer & other immunocompromised conditions
• Certain dugs such as corticosteroids
• Silicosis & other lung diseases

Mode of Transmission:

By ingestion of unboiled milk or uncooked meat of diseased cattle.

From droplet infection by affected person.

Incubation period:

4-12 weeks from infection to primary lesion. But the disease may be seen in years. The chances of getting the disease is more during first 6-24 months of life.

Sign & Symptoms:
Primary TB: Patients may develop symptoms like influenza, consolidation, conjuctivitis etc.
Miliary TB: Night swats, anorexia, weight loss, dry cough, hepatosplenomegaly, headache etc
Secondary TB: Chronic cough, hemoptysis, unresolved pneumonia, pneumothorax, cavitation & consolidation of lungs.
Extrapulmonary TB:
Lymphadenitis: Most commonly cervical & mediastinal glands are involved leading to abscess formation & discharge from lymph nodes.
GI TB:  fever, night sweats, anorexia weight loss are common symptoms. Tuberculous peritonitis is characterized by abdominal distention, pain & other symptoms & sometimes patients may become icteric 
Bone & joint involvement: Mostly spine is involved characterized by backache,abscess formation, subsequent kyphosis, pain & swelling if hip or knee joints are involved.
Other regions: Pericardium, CNS system, Genito-urinary system.

Medical & Nursing Management:
EARLY DETECTION : The presumptive clinical symptoms & chest examination by doctor are sufficient to confirm diagnosis. Confirmation should be made by sputum examination & radiology.
CHEMOPROPHYLAXIS : There are now 12-13 drugs active against M. tuberculosis. Out of which , 6 are considered essential.
Bactericidal drugs:
•rifampicin
•izoniazide
•streptomycin
•pyrazinamide
Bacteriostatic drugs:
•ethambutol
•thioacetazone
•fluoroquinolones
•Ethionamide
•Capromycin
•Kenamycin, Amikacin, Cycloserine
PROTECTION & DISINFECT :
•Use of PPE by medical personnel
•Use of cheap disposable tissues to receive sputum or nasal discharge
•Disinfection of utensils used by patients
ISOLATION :
•Isolation of the patient is necessary & special care to be taken of the patient
HEALTH EDUCATION :

The public in general should be told about the spread of infection & importance of BCG vaccination to children. Health education regarding hygienic & safety precautions to be given.

Distinctive facts:

• Ix: Montaux test, AFB culture, CXR, Sputum analysis
• Granuloma & calcification can be assessed by CXR in primary TB
• Purified Protein Derivative 0.1 ml is injected Intradermally for 48-72 hours & results are measured using tuberculin skin scale.
• CT Scan may be used to detect Pott's spine.
• MRI is useful in case of intracranial TB.
• Management of TB needs to be done by RNTCP criteria.
• Bovine TB is caused by ingesting unboiled milk of cattles or poorly cooked meat.
• Drug resistant TB must be diagnosed & the drugs needs to be changed. mostly people develop resistance from rifampicin.

Prognosis:

If appropriate treatment is not taken the patients will develop multi drug resistant TB. The risk of reactivation increases with immunosuppression, such as that caused by infection with HIV. In people coinfected with M. tuberculosis and HIV, the risk of reactivation increases to 10% per year.The chance of death from a case of tuberculosis is about 4%