Bones and Joints, lecture presentation

Joints and Muscles

Joints (articulations)

• Where parts of skeleton meet
• Allows varying amounts of mobility
• Classified by structure or function
• Arthrology: study of joints

Classification of Joints

• Function:
• Synarthroses = no/little movement
• Amphiarthroses = slight movement
• Diarthroses = great movement

Joints by Functional Classification

Type	Movement	Example
Synarthrosis	None (minimal)	Sutures, Teeth, Epiphyseal plates, 1 st rib and costal cart.
Amphiarthrosis	Slight	Distal Tibia/fibula Intervertebral discs Pubic symphysis
Diarthrosis	Great	Glenohumeral joint Knee joint TMJ

Joint Classification

• Structure
• Cartilagenous
• Synchondrosis: connected by hyaline cartilage
• Symphysis: connected by fibrocartilage
• Fibrous
• Sutures: connected by short strands of dense CT
• Syndesmoses: connected by ligaments
• Gomphosis: peg in socket w/short ligament
• Synovial
• Page 20 & 23

Joints by Structural Classification

Structure	Type	Example
Cartilagenous	Synchondrosis Symphysis	Epiphyseal plates Intervertebral discs
Fibrous	Sutures Syndesmoses Gomphosis	Skull Distal Tibia/fibula Teeth in sockets
Synovial	6 Shapes	Glenohumeral joint Knee joint TMJ

Components of SYNOVIAL JOINTS:
(Structural Joint Classification continued)

• Articular cartilage: hyaline; covers ends of both bones articulating
• Synovial (joint) cavity: space holding synovial fluid
• Articular capsule: Made of 2 layers
• Fibrous: external, dense CT for strength
• Synovial membrane: internal, produces synovial fluid
• Synovial fluid: viscous; lubricates and nourishes; contained in capsule and articular cartilages
• Reinforcing ligaments: extracapsular/intracapsular
• Nerves + vessels: Highly innervated, Highly vascular
• Meniscus (some): fibrocartilage; improves the fit of 2 bones to increase stability

pg 21

Bursae & Tendon Sheaths

• Bursae: flat, fibrous sac w/synovial membrane lining
• Tendon Sheaths: elongated bursae that wraps around tendons
• 3 Factors in Joint Stability:
• Muscle Tone
• Ligaments
• Fit of Articular Surface

Shapes of Synovial Joints

• Hinge: cylindrical end of 1 bone fits into trough shape of other
• Uniaxial movement
• (eg) elbow, ankle, interphalangeal
• Plane: articular surface in flat plane
• Short gliding movement
• (eg) intertarsal, articular processes of vertebrae

Joint Shapes

• Condyloid: egg-shape articular surface + oval concavity
• Multiaxial movement
• (eg) metacarpophalangeal (knuckle)
• Pivot: round end fits into ring of bone + ligament
• Uniaxial movement
• rotation on long axis
• (eg) prox. radius/ulna, atlas/dens

Joint Shapes

• Saddle: articular surface both concave + convex
• side-to-side, back-forth movement
• Multiaxial movement
• (eg) carpometacarpal jt of thumb
• 
  
• Joint Shapes Ball + Socket: spherical head + round socket
• multiaxial movement
• (eg) shoulder, femur

!Muscles!

Function: 

1) movement
2) maintain posture
3) joint stability
4) generate heat

!Muscles!

• 3 Types: Skeletal, Cardiac, Smooth
• Origin vs. Insertion
• Direct vs. Indirect Attachments
• direct = right onto bone
• indirect = via tendon/aponeurosis
• more common
• leave bony markings = tubercle, crest, ridge, etc.
• Sometimes attach to skin

Special Features of Muscle

• Contractibility = cells generate pulling force
• Excitibility = nervous impulses travel through muscle plasma membrane to stimulate contraction
• Extensibility = after contraction, muscle can be stretched back to original length by opposing muscle action
• Elasticity = after being stretched, muscle passively recoils to resume its resting length

Muscle System: uses levers to move objects

• How it works: A rigid bar moves on fixed point when a force is applied to it, to move object
• Lever = rigid bar = bone
• Fulcrum = fixed point = joint
• Effort = force applied = muscle contraction
• Load = object being moved = bone

Movements of Muscles

• Extension: increasing angle between body parts
• Flexion: decreasing angle between body parts
• Dorsiflexion vs. Plantarflexion
• Inversion vs. Eversion
• Abduction: moving away from the median plane
• Adduction: moving towards the median plane
• Rotation: moving around the long axis
• Circumduction: moving around in circles

Movements of Muscles

• Elevation: lifting body part superiorly
• Depression: moving body part inferiorly
• Protraction: Anterior movement
• Retraction: Posterior movement
• Supination: rotating forearm laterally
• Pronation: rotating forearm medially
• Opposition: movement of thumb against other fingers

Functional Muscle Groups

• Agonist = primary mover of a muscle, major response produces particular movement
• (eg) biceps brachii is main flexor of forearm
• Antagonists = oppose/reverse particular movement, prevent overshooting agonistic motion
• (eg) triceps brachii is antagonist to biceps brachii

Functional Muscle Groups

• Synergists = muscles work together, adds extra force to agonistic movement, reduce undesirable extra movement
• (eg) muscles crossing 2 joints
• Fixators = a synergist that holds bone in place to provide stable base for movement
• (eg) joint stablilizers

Naming Muscles

• Location: (eg) brachialis = arm
• Shape: (eg) deltoid = triangle
• Relative Size: (eg) minimus, maximus, longus
• Direction of Fascicles: (eg) oblique, rectus
• Location of Attachment: (eg) brachioradialis
• Number of Origins: (eg) biceps, quadriceps
• Action: (eg) flexor, adductor, extensor

  download lecture presentation Bones and Joints
source by  faculty.ccri.edu

Cells and Tissue lecture presentation

Introduction and Tissues

Human Anatomy

 BIOL 1010
 Liston Campus     
                                                                        

What is Anatomy?

• Anatomy (= morphology): study of body’s structure
• Physiology: study of body’s function
• Structure reflects Function!!!
• Branches of Anatomy
• Gross: Large structures
• Surface: Landmarks
• Histology: Cells and Tissues
• Developmental: Structures change through life
• Embryology: Structures form and develop before birth

Hierarchy of Structural Organization
Each of these build upon one another to make up the next level:

• Chemical level
• Cellular
• Tissue
• Organ
• Organ system
• Organism

Hierarchy of Structural Organization

• Chemical level
• Atoms combine to make molecules
• 4 macromolecules in the body
• Carbohydrates
• Lipids
• Proteins
• Nucleic acids

Hierarchy of Structural Organization

• Cellular
• Made up of cells and cellular organelles (molecules)
• Cells can be eukaryotic or prokaryotic
• Organelles are structures within cells that perform dedicated functions (“small organs”)

Hierarchy of Structural Organization

• Tissue
• Collection of cells that work together to perform a specialized function
• 4 basic types of tissue in the human body:
• Epithelium
• Connective tissue
• Muscle tissue
• Nervous tissue

Hierarchy of Structural Organization

• Organ
• Made up of tissue
• Heart
• Brain
• Liver
• Pancreas, etc……

Hierarchy of Structural Organization

• Organ system (11)
• Made up of a group of related organs that work together
• Integumentary
• Skeletal
• Muscular
• Nervous
• Endocrine
• Cardiovascular
• Lymphatic
• Respiratory
• Digestive
• Urinary
• Reproductive

Hierarchy of Structural Organization

• Organism
• An individual human, animal, plant, etc……
• Made up all of the organ systems
• Work together to sustain life

 













Anatomical Directions

• Anatomical position
• Regions
• Axial vs. Appendicular
• Anatomical Directions-It’s all Relative!
• Anterior (ventral) vs. Posterior (dorsal)
• Medial vs. Lateral
• Superior (cranial) vs. Inferior (caudal)
• Superficial vs. Deep
• Proximal vs. Distal
• Anatomical Planes
• Frontal = Coronal
• Transverse = Horizontal = Cross Section
• Sagittal

Anterior – (ventral) Closer to the front surface of the body	Posterior – (dorsal) Closer to the rear surface of the body	Frontal Plane
Medial – Lying closer to the midline	Lateral – Lying further away from the midline	Sagittal Plane
Superior – (cranial) Closer to the head in relation to the entire body (More General)	Inferior – (caudal) Away from the head or towards the lower part of the body	Horizontal Plane
Superficial – Towards the surface	Deep – Away from the surface	Surface of body or organ
Proximal – Closer to the origin of a body part (More Specific)

Tissues: groups of cells closely associated that have a similar structure and perform a related function

• Four types of tissue
• Epithelial = covering/lining
• Connective = support
• Muscle = movement
• Nervous = control
• Most organs contain all 4 types
• Tissue has non-living extracellular material between its cells

EPITHELIAL TISSUE: sheets of cells cover a surface or line a cavity

• Functions
• Protection
• Secretion
• Absorption
• Ion Transport

Characteristics of Epithelium

• Cellularity
• Composed of cells
• Specialized contacts
• Joined by cell junctions
• Polarity
• Apical vs. Basal surfaces differ
• Supported by connective tissue
• Avascular
• Innervated
• Highly regenerative

Classification of Epithelium-based on number of layers and cell shape

• Layers
• Simple
• Stratified
• Stratified layers characterized by shape of apical layer
• Psuedostratified
• Shapes
• Squamous
• Cuboidal
• Columnar
• Transitional

 

 Types of Epithelium

• Simple squamous (1 layer)
• Lungs, blood vessels, ventral body cavity
• Simple cuboidal
• Kidney tubules, glands
• Simple columnar
• Stomach, intestines
• Pseudostratified columnar
• Respiratory passages (ciliated version)
• Stratified squamous (>1 layer)
• Epidermis, mouth, esophagus, vagina
• Named so according to apical cell shape
• Regenerate from below
• Deep layers cuboidal and columnar
• Transitional (not shown)
• Thins when stretches
• Hollow urinary organs

Special Epithelium

• Endothelium
• Simple squamous epithelium that lines vessels
• e.g. lymphatic & blood vessel
• Mesothelium
• Simple squamous epithelium that forms the lining of body cavities
• e.g. pleura, pericardium, peritoneum

Features of Apical Surface of Epithelium

• Microvilli: (ex) in small intestine
• Finger-like extensions of the plasma membrane of apical epithelial cell
• Increase surface area for absorption
• Cilia: (ex) respiratory tubes
• Whip-like, motile extension of plasma membrane
• Moves mucus, etc. over epithelial surface 1-way

Features of Lateral Surface of Epithelium

• Cells are connected to neighboring cells via:
• Contour of cells-wavy contour fits together
• Cell Junctions (3 common)
• Desmosomes
• Proteins hold cells together to maintain integrity of tissue
• Tight Junctions
• Plasma membrane of adjacent cells fuse, nothing passes
• Gap junction
• Proteins allow small molecules to pass through

Features of the Basal Surface of Epithelium

• Basement membrane
• Sheet between the epithelial and connective tissue layers
• Attaches epithelium to connective tissue below
• Made up of:
• Basal lamina: thin, non-cellular, supportive sheet made of proteins
• Superficial layer
• Acts as a selective filter
• Assists epithelial cell regeneration by moving new cells
• Reticular fiber layer
• Deeper layer
• Support

Glands

• Epithelial cells that make and secrete a product
• Products are water-based and usually contain proteins
• Classified as:
• Unicellular vs. multicellular
• Exocrine vs. Endocrine

Glands: epithelial cells that make and secrete a water-based substance w/proteins

• Exocrine Glands
• Secrete substance onto body surface or into body cavity
• Activity is local
• Have ducts
• Unicellular or Multicellular
• (ex) goblet cells, salivary, mammary, pancreas, liver

Glands: epithelial cells that make and secrete a water-based substance w/proteins

• Endocrine Glands
• Secrete product into blood stream
• Either stored in secretory cells or in follicle surrounded by secretory cells
• Hormones travel to target organ to increase response (excitatory)
• No ducts
• (ex) pancreas, adrenal, pituitary, thyroid

  

  Connective Tissue (CT):
most abundant and diverse tissue

• Four Classes
• Functions include connecting, storing & carrying nutrients, protection, fight infection
• CT contains large amounts of non-living extracellular matrix
• Contains a variety of cells and fibers
• Some types vascularized
• All CT originates from mesenchyme
• Embryonic connective tissue

Fibers in Connective Tissue

• Fibers For Support
• Reticular:
• form networks for structure & support
• (ex) cover capillaries
• Collagen:
• strongest, most numerous, provide tensile strength
• (ex) dominant fiber in ligaments
• Elastic:
• long + thin, stretch and retain shape
• (ex) dominant fiber in elastic cartilage

Components of Connective Tissue

• Fibroblasts:
• cells that produce all fibers in CT
• produce + secrete protein subunits to make them
• produce ground matrix
• Interstitial (Tissue) Fluid
• derived from blood in CT proper
• medium for nutrients, waste + oxygen to travel to cells
• found in ground matrix
• Ground Matrix (substance): 

• part of extra-cellular material that holds and absorbs interstitial fluid
• Made and secreted by fibroblasts
• jelly-like with sugar & protein molecules
• Connective Tissue Proper

 

Two kinds: Loose CT & Dense CT

• Functions
• Support and bind to other tissue
• Hold body fluids
• Defends against infection
• Stores nutrients as fat
• Each function performed by different kind of fibers and cells in specific tissue

 












 Defense from Infection

• Areolar tissue below epithelium is body’s first defense
• Cells travel to CT in blood
• Macrophages-eat foreign particles
• Plasma cells-secrete antibodies, mark molecules for destruction
• Mast cells-contain chemical mediators for inflammation response
• White Blood Cells = neutrophils, lymphocytes, eosinophils-fight infection
• Ground substance + cell fibers-slow invading microorganisms

Loose CT Proper

• Areolar CT
• All types of fibers present
• All typical cell types present
• Surrounds blood vessels and nerves

Specialized Loose CT Proper

• Adipose tissue
• Loaded with adipocytes, highly vascularized, high metabolic activity
• Insulates, produces energy, supports
• Found in hypodermis under skin
• Reticular CT
• Contains only reticular fibers
• Forms caverns to hold free cells, forms internal “skeleton” of some organs
• Found in bone marrow, holds blood cells, lymph nodes, spleen

Dense/Fibrous Connective Tissue

• Contains more collagen
• Can resist extremely strong pulling forces
• Regular vs. Irregular
• Regular-fibers run same direction, parallel to pull
• (eg) fascia, tendons, ligaments
• Irregular-fibers thicker, run in different directions
• (eg) dermis, fibrous capsules at ends of bones

Components of CT Proper Summarized

• Chondroblasts produce cartilage 
• Cartilage
• Chondrocytes mature cartilage cells
• Reside in lacunae
• More abundant in embryo than adult
• Firm, Flexible
• Resists compression
• (eg) trachea, meniscus
• Avascular (chondrocytes can function w/ low oxygen)
• NOT Innervated
• Perichondrium
• dense, irregular connective tissue around cartilage
• growth/repair of cartilage
• resists expansion during compression of cartilage

Cartilage in the Body

• Three types:
• Hyaline
• most abundant
• fibers in matrix
• support via flexibility/resilience
• (eg) at limb joints, ribs, nose
• Elastic
• many elastic fibers in matrix too
• great flexibility
• (eg) external ear, epiglottis
• Fibrocartilage
• resists both compression and tension
• (eg) meniscus, annulus fibrosus

Components of Cartilage Summarized

• Well-vascularized
• Function:
• support (eg) pelvic bowl, legs
• protect (eg) skull, vertebrae
• mineral storage (eg) calcium, phosphate (inorganic component)
• movement (eg) walk, grasp objects
• blood-cell formation (eg) red bone marrow

Bone Tissue

• Osteoblasts
• Secrete organic part of bone matrix
• Osteocytes
• Mature bone cells
• Sit in lacunae
• Maintain bone matrix
• Osteoclasts
• Degrade and reabsorb bone
• Periosteum

Image

• Bone Tissue: (a bone is an organ)

• External layer of CT that surrounds bone
• Outer: Dense irregular CT
• Inner: Osteoblasts, osteoclasts
• Endosteum
• Internal layer of CT that lines cavities and covers trabeculae
• Contains osteoblasts and osteoclasts

Compact Bone

• External layer
• Osteon (Haversian system)
• Parallel to the long axis of the bone
• Groups of concentric tubules (lamella)
• Lamella = layer of bone matrix where all fibers run in the same direction
• Adjacent lamella fibers run in opposite directions
• Haversian Canal runs through center of osteon
• Contains blood vessels and nerves
• Connected to each other by perforating (Volkman) canals
• Interstitial lamellae fills spaces and forms periphery

Bone Anatomy: Spongy bone

• Spongy bone (cancellous bone): internal layer
• Trabeculae: small, needle-like pieces of bone form honeycomb
• each made of several layers of lamellae + osteocytes
• no canal for vessels
• space filled with bone marrow
• not as dense, no direct stress at bone’s center

Shapes of Bones
Image
Anatomy of a Long Bone

• Diaphysis
• Medullary Cavity
• Nutrient Artery & Vein
• 2 Epiphyses
• Epiphyseal Plates
• Epiphyseal Artery & Vein
• Periosteum
• Does not cover epiphyses
• Endosteum
• Covers trabeculae of spongy bone
• Lines medullary cavity of long bones

2 Types of Bone Formation

• Intramembranous Ossification
• Membrane bones: most skull bones and clavicle
• Osteoblasts in membrane secrete osteoid that mineralizes
• Endochondral Ossification: All other bones
• Begins with a cartilaginous model
• Cartilage calcifies
• Medullary cavity is formed by action of osteoclasts
• Epiphyses grow and eventually calcify
• Epiphyseal plates remain cartilage for up to 20 years

Bone Growth & Remodeling

• Appositional Growth = widening of bone
• Bone tissue added on surface by osteoblasts of periosteum
• Medullary cavity maintained by osteoclasts
• Lengthening of Bone
• Epiphyseal plates enlarge by chondroblasts
• Matrix calcifies (chondrocytes die and disintegrate)
• Bone tissue replaces cartilage on diaphysis side
• REMODELING
• Due to mechanical stresses on bones, their tissue needs to be replaced
• Osteoclasts-take up bone ( = breakdown) release Ca 2++ , PO 4 to body fluids from bone
• Osteoblasts-form new bone by secreting osteoid
• Ideally osteoclasts & osteoblasts work at the sam
• GROWTH
• e rate!
• Components of Bone Tissue Summarized

 













 

• Blood: Atypical Connective Tissue
• Function:
• Transports waste, gases, nutrients, hormones through cardiovascular system
• Helps regulate body temperature
• Protects body by fighting infection
• Derived from mesenchyme
• Hematopoiesis: production of blood cells
• Occurs in red bone marrow
• In adults, axial skeleton, girdles, proximal epiphyses of humerus and femur

Blood Cells

• Erythrocytes: (RBC) small, oxygen-transporting
• most abundant in blood
• no organelles, filled w/hemoglobin
• pick up O 2 at lungs, transport to rest of body
• Leukocytes: (WBC) complete cells , 5 types
• fight against infectious microorganisms
• stored in bone marrow for emergencies
• *Platelets = Thrombocytes:
• fragments of cytoplasm
• plug small tears in vessel walls, initiates clotting
• Components of Blood Summarized

 
 
 















Muscle Tissue

• Muscle cells/fibers
• Elongated
• Contain many myofilaments: Actin & Myosin

• FUNCTION
• Movement
• Maintenance of posture
• Joint Stabilization
• Heat Generation
• Three types: Skeletal, Cardiac, Smooth

Skeletal Muscle Tissue
(each skeletal muscle is an organ)

• Cells
• Long and cylindrical, in bundles
• Multinucleate
• Obvious Striations
• Skeletal Muscles-Voluntary
• Connective Tissue Components:
• Endomysium-surrounds fibers
• Perimysium-surrounds bundles
• Epimysium-surrounds the muscle
• Attached to bones, fascia, skin
• Origin & Insertion

Cardiac Muscle

• Cells
• Branching, chains of cells
• Single or Binucleated
• Striations
• Connected by Intercalated discs
• Cardiac Muscle-Involuntary
• Myocardium-heart muscle
• Pumps blood through vessels
• Connective Tissue Component
• Endomysium: surrounding cells

Smooth Muscle Tissue

• Cells
• Single cells, uninucleate
• No striations
• Smooth Muscle-Involuntary
• 2 layers-opposite orientation (peristalsis)
• Found in hollow organs, blood vessels
• Connective Tissue Component
• Endomysium: surrounds cells

 

Nervous Tissue

• Neurons: specialized nerve cells conduct impulses
• Cell body, dendrite, axon
• Characterized by:
• No mitosis (cell replication)
• Longevity
• High metabolic rate

Nervous Tissue: control

• Support cells (= Neuroglial): nourishment, insulation, protection
• Satellite cells-surround cell bodies within ganglia
• Schwann cells-surround axons (PNS)
• Microglia-phagocytes
• Oligodendrocytes-produce myelin sheaths around axons
• Ependymal cells-line brain/spinal cord, ciliated, help circulate CSF
• Brain, spinal cord, nerves

Integumentary System

• Functions
• Protection
• Mechanical, thermal, chemical, UV
• Cushions & insulates deeper organs
• Prevention of water loss
• Thermoregulation
• Excretion
• Salts, urea, wa
• Sensory reception

Microanatomy - Layers of the Skin

• Epidermis
• Epithelium
• Dermis
• Connective tissue
• Hypodermis / subcutis
• Loose connective tissue
• Anchors skin to bone or muscle
• Skin Appendages = outgrowths of epidermis
• Hair follicles
• Sweat and Sebaceous glands
• Nails

Cell Layers of the Epidermis

• Stratum corneum
• Dead keratinocytes
• Stratum lucidum
• Only in “thick” skin
• Dead keratinocytes
• Stratum granulosum
• Water proofing
• Stratum spinosum
• Resists tears and tension
• Stratum basale
• Sensory receptors
• Melanocytes
• Keratinocytes (in all layers)

Layers of the Dermis

• Highly innervated
• Highly vascularized
• Collagen & Elastic fibers

• 2 layers:
• Papillary layer (20%)
• Areolar CT
• Collagen & Elastic fibers
• Innervation
• Hair follicles
• Reticular layer (80%)
• Dense irregular CT
• Glands
• sebum
• 2.5 million sweat glands!!
• Smooth muscle fibers
• Innervation

Hypodermis

• Also called superficial fascia
• Areolar & Adipose Connective Tissue
• Functions
• Store fat
• Anchor skin to muscle, etc.
• Insulation

Structure of Tubular Organs

LUMEN

• Serosa – suspends organ in the peritoneal
• Tunica Mucosa
• Lamina epithelialis
• Lamina propria
• Lamina muscularis mucosa
• Tunica Submucosa
• Tunica Muscularis
• Inner circular
• Outer longitudinal
• Tunica Adventitia / Serosa
• Adventitia – covers organ
• cavity

 

 

Care of the Client with Breast Dysfunction

Lecture Eighteen: Care of the Client with Breast Dysfunction
NURS 2208

Fall 2002

T. Dennis RNC, MSN

Physiology

The breast has regular cyclic changes in response to hormonal stimulation.

Mastodynia: premenstrual swelling and tenderness of the breast.

Menopuase results in a loss of elasticity and adipose tissue turns into connective tissue.

Breast Self Examination (pg. 54)

Recommended monthly procedure by which women may detect changes or abnormalities in their breasts (pg. 55).

Breast examination should be taught as early as possible and taught correctly.

Should be performed one week after the menstrual cycle.

Most effective when inspection and palpation are used (after menopause on the same day each month).

Mammography (pg. 56)

A soft tissue radiograph of the breast without injection of a contrast medium.

Detects lesions in the breast before they can be felt.

An accepted screening tool for breast cancer.

Recommended every 1 to 2 years for women age 40 to 49 and annually for all women 50 and older (age is a primary factor).

30% of women age 40 to 49 are likely to have a false-positive result requiring biopsy.

25% miss in breast cancers in women 40 to 49.

Many women avoid mammograms due to the discomfort associated with procedure.

Discomfort can be reduced by avoiding caffeine in the diet and scheduling the procedure 2 weeks after menses.

Benign Breast Disease (pg. 63)

Fibrocystic Breast disease

Fibroadenoma

Intraductal papilloma

Duct ectasia

Fibrocystic Breast Disease (pg. 62)

Commonly occurs between age 30-50.

Associate with breast tenderness

Associated with a risk for cancer when the disorder is proliferative and with atypical hyperplasia.

Nipple discharge may vary from none to clear, milky, straw colored or green.

Location usually the upper outer quadrant.

Multiple lumps may occur bilaterally, are influenced bymenstrual cycles and be nodular.

Needle aspiration, smear of nipple discharge, observation , sonography and biopsy may be used for diagnosis and treatment.

Normal Breast

Fibroadenoma (pg. 62)



















Fibroadenoma (pg. 62)

Commonly occurs between ages 15-25 (median age is 20).

No pain associated with the disorder.

No cancer risk associated with the disorder.

No discharge associated with the disorder (a milky discharge may occur with pregnancy).

Location may be nipple or upper outer quadrant along the lateral side of the breast.

Appears solid, well defined, sharply delineated, rubbery, and mobile.

Diagnosis and treatment by mammography, observation and possible surgical excision.

Intraductal Papilloma (pg. 62)

Found in women 50-60.

Pain noted on palpation.

Cancer risk occurs with multiple papillomas.

Drainage is typically serous, bloody, or brownish green.

Occurs in no specific location.

May be non-palpable or small, ball-like, poorly delineated.

Diagnosis and treatment may consist of smear of nipple discharge, mammography, ductogram, or surgical excision.

Duct Ectasia (pg. 63)

Commonly occurs between ages 45-55.

Pain occurs and may include burning and itching around the nipple.

In perimenopausal women, discharge may be thick, sticky, green, greenish brown, or bloodstained.

Mass is located behind or around the nipple.

Poorly circumscribed, inflammation, nipple retraction, axillary lymph adenopathy.

Diagnosis and treatment include: smear of breast discharge, mammography, drug therapy for symptoms, observation and surgical excision.

Malignant Breast Disease (pg. 62)

Affects one in eight women in the United States.

Predisposing factor include:

Age-incidence increases steadily with age (especially after 50)

History of previous breast cancer

Family history of mother or sister with bilateral pre-menopausal breast cancer

High fat diet

Alcohol consumption

No history of pregnancy

Longer reproductive phase

Geographic location (North America, northern Europe; in the US urban North; Low risk areas: Asia, Africa; in the US, rural south.

Malignant Breast Disease (pg. 62)

50% of breast cancers originate in the upper outer quadrant and spread or metastasize to axillary lymph nodes.

Common sites of metastasis: lymph nodes, lungs, liver, brain, and bone.

Discovery may be by BSE, clinician, mammography, fine needle biopsy, ultrasonography, thermography, and MRI.

Diagnosis is determined by biopsy.

Treatment plan is based on lymph node involvement and clinical staging of the disease.

Malignant Breast Disease (pg. 62)
Surgical treatment may include: mastectomy followed by reconstructive surgery, lumpectomy with adjunct treatment including chemotherapy, radiation, and hormone therapy.

Preoperative care: teaching, emotional support, pain management, introduction to support groups.

Postoperative care: Minimize edema, BP cuff is never placed on the affected arm. Affected arm elevated, early arm movement encouraged, early ambulation encouraged. Physical therapy is usually prescribed.

Convalescent care: may include plans for reconstructive surgery and participation in support groups.

Nursing Care (pg. 63)

Assessment and Diagnosis:

Therapeutic communication

Knowledge Deficit related to a lack of information about the diagnostic procedures.

Anxiety related to threat to body image or her life.

Plan and Implementation:

Clarify misconceptions

Provide education on self breast care

Provide psychological support.

Allow client to discuss her fear.

Refer to professional support groups.

Questions?
 
  DOWNLOAD PPT NOTES : Lecture 18

Source and copyright:

Tamara Dennis

RNC, MSN 

The Client Experiencing Infertility

Lecture Seventeen: The Client Experiencing Infertility
NURS 2208
Fall 2002
T. Dennis RNC
Objectives

1. Identify common terms associated with infertility
2. Discuss methods of evaluation for infertility
3. Discuss therapeutic management of infertility.
4. Describe drugs commonly used to treat infertility.
5. Describe common assisted reproductive techniques.
6. Identify data to be included in the assessment of a client with infertility.
7. Formulate nursing diagnosis.
8. Select appropriate interventions.

Definitions

1. Infertility: lack of conception despite unprotected sexual intercourse for at least 12 months; diminished ability to conceive.
2. Sterility: Inability to conceive or produce offspring.
3. Subfertility: a couple having difficulty conceiving because both partners have reduced ability to reproduce.
4. Spinnbarkheit: the elasticity of the cervical mucous that is present at ovulation.
5. Huhner test: postcoital examination to evaluate sperm and cervical mucous.
6. Artificial insemination: introduction of viable semen into the vagina by artificial means for the purpose of impregnation.

Definitions

1. In Vitro Fertilization (IVF): procedure during which oocytes are removed from the ovary, mixed with spermatozoa, fertilized, and incubated in a glass petri dish; then up to four viable embryos are placed in the woman’s uterus.

1. Gamete intrafallopian transfer (GIFT): retrieval of oocytes by laparoscopy; immediately combining oocytes with washed motile sperm in a catheter; and placement of the gametes into the fimbriated end of the fallopian tube.
2. Zygote intrafallopian transfer (ZIFT): retrieval of oocytes under ultrasound guidance followed by in vitro fertilization and laparoscopic replacement of fertilized eggs into fimbriated end of the fallopian tube.

Infertility (pg. 178)

1. Infertility affects couples emotionally, psychologically, and economically.
2. Approximately 8% of couples in their reproductive years are infertile.
3. Subfertility occurs when both partners have a reduced ability to reproduce.
4. Primary infertility: women who have never conceived.
5. Secondary fertility: women who have been pregnant in the past but have not conceived during one or more years of unprotected intercourse or cannot sustain a pregnancy.
6. Professional intervention can assist 65% of infertile couples achieve pregnancy.

Essential Components of Fertility
Female:

1. Cervical mucous must be favorable for transport of sperm
2. Fallopian tubes must be patent
3. Ovaries must produce and release
4. No obstruction between ovaries and uterus
5. Endometrium in adequate physiologic state.
6. Adequate reproductive hormones.

Male:

1. Testes must produce sperm of normal quantity, quality, and motility.
2. Genital tract not obstructed.
3. Genital tract secretions normal.
4. Ejaculated sperm are deposited in vagina so that they reach the cervix (viable for 48 – 72 hours).

Preliminary Investigation

1. Refer for infertility evaluation if lack of conception despite unprotected sex for at least one year – if client is > 35 years old or if history predisposes her to infertility refer after six months. (↑ age = ↑ infertility).
2. Time, financial, and emotional strain on the relationship occurs when the evaluation begins (self-esteem, cultural).
3. Approximately 3 to 4 months are required for a thorough evaluation.
4. Treatment averages months to years.

1. Determine if timing of intercourse and length of coital exposure have been adequate.
2. Comprehensive history and physical exam.
3. Hx of ovarian function, cervical mucus, receptivity to sperm, sperm adequacy, tubal patency, and condition of pelvic organs. (pg. 180)
4. Semen analysis
5. A costly, time consuming, emotional investment is begun with initial evaluation. (pg. 181)

Testing (pg. 179)

1. The easiest and least intrusive infertility testing approach is used first.
2. A thorough history is taken on both partners.
3. Basal body temperature (BBT): aids in identifying follicular and luteal phase abnormalities. Special thermometer, temp taken every morning before getting out of bed and graphing the temperature (pg 183).
4. Endometrial biopsy: tissue from the endometrium is used to determine effects of progesterone and endometrial receptivity.
5. Transvaginal ultrasound: method of choice for follicular monitoring of women undergoing ovulation induction cycles and for timing ovulation for insemination.
6. Ferning capacity: method of determining crystallization of cervical mucus to determine if ovulation has occurred (pg. 184).
7. Laparoscopy: Exam of the pelvic structure by inserting a small endoscope through an incision in the abdomen.

Client Assessment (pg.180)
Female:

1. BBT
2. Hormonal assessments
3. Endometrial biopsy
4. Transvaginal ultrasound
5. Cervical factors
6. Evaluation of uterine structures and tubal patency

Male:
Semen analysis

Basal Body Temperature (BBT) (pg. 180)

1. Only use BBT thermometer (measures 96 -100 F, is calibrated to a tenth of a degree to denote very slight temperature changes).
2. Take every morning before rising (after 6-8 hrs uninterrupted sleep).
3. Record on a temperature graph.
4. Should see a biphasic pattern during the ovulatory cycle (pg.183).
5. Detect ovulation to plan intercourse.
6. Pre-ovulatory temp < 98 F.
7. Release of egg occurs 24 to 36 hrs prior to first temp elevation.
8. Intercourse every other day beginning 3 – 4 days prior to and continuing for 2-3 days after expected ovulation.

Hormonal Assessments of Ovulatory Function (pg.182 )

1. FSH: assess ovarian reserve and function
2. LH: day of maximum LH surge is time of maximum fertility.
3. Progesterone: levels rise with LH surge and peak about 8 days later.
4. Prolactin: increased prolactin levels are frequently the cause of ovulatory dysfunction.
5. Thyroid stimulating hormone (TSH): stimulates prolactin secretion (Hypothyroidism has a dramatic effect on ovulatory function).
6. Androgen levels: androgen excess may lead to oligomenorrhea, anovulation, and amenorrhea.

Endometrial Biopsy (pg.182 )

1. Provides information about the effects of progesterone produced by the corpus luteum after ovulation and endometrial receptivity.
2. Performed not earlier than 10 to 12 days after ovulation (pelvic discomfort, cramping, vaginal spotting during and following the procedure).
3. Onset of menses following biopsy noted for accurate interpretation of biopsy report.
4. Dysfunction is diagnoses if endometrial lining does not show that the expected amount of secretory tissue for that day of the cycle.
5. A repeat biopsy may be need to confirm luteal phase dysfunction.

Transvaginal Ultrasound (pg. 183)

1. Method of choice for follicular monitoring of women undergoing ovulation induction cycles, for timing ovulation for insemination, intercourse, for retrieving oocytes for in vitro fertilization, and monitoring of early pregnancies.

Cervical Factors (pg. 183)

1. To be receptive to sperm, cervical mucus must be, profuse, alkaline and acelluar.
2. As ovulation approaches, mucus increases and water content rises significantly.
3. Mucus elasticity or Spinnbarkheit increases and viscosity decreases (excellent when mucus is stretched 8 to 10 cms or longer).
4. Ferning capacity (crystallization) occurs due to decreased levels of salt and water.
5. 24 to 48 hours after ovulation, there is a marked decrease in these factors.
6. Causes of an inhospitable cervical mucus: ↓estrogen secretion, cervical infection, GYN procedures, medications, secretory immunologic reactions.
7. Treatment: estrogen therapy and intrauterine insemination.
8. Huhner test: postcoital test performed 1-2 days after expected date of ovulation. Evaluates cervical mucus, sperm motility.

Uterine Structures and Tubal Patency (pg.186 )
Hysterosalpingography (HSG):

1. Instill radiopague substances into the uterine cavity
2. Fill uterus, tubes, and spills into peritoneal cavity viewed on x-ray.
3. Tube patency and uterine abnormalities.
4. Water based dye: brushes away debris, breaks peritoneal adhesions, stimulates cilia, and improves cervical mucus.
5. Performed during follicular phase (days 1 to 14) so as not to interrupt pregnancy.
6. Moderate discomfort, referred shoulder pain (increased with sitting position and cramping (may cause recurrence of PID).
7. Correct with knee-cheat position, OTC prostaglandin inhibitors, disappears in 12 hours (prophylactic antibiotics).

Uterine Structures and Tubal Patency (pg.186 )
Hysteroscopy:

1.  Done with laparoscopy to look into the uterus to determine if any structural abnormalities are present.

Laparoscopy:

1. Direct visualization of the pelvic organs done 6 to 8 months after the HSG (HSG may be therapeutic).
2. Done as outpatient procedure with general anesthesia.
3. Three puncture sites, carbon dioxide to distend the abdomen (biopsy or remove adhesions).
4. Post surgery: Discomfort related to gas in abdomen, pain meds, supine position, and resume activities in 24 hrs.

Male Assessment (pg.187)
Semen Analysis:

1. Specimen obtained 2-3 days after abstinence by masturbation or special condom (without lubricant).
2. Taken to lab within two hours of ejaculation (avoid heat or cold).
3. May do repeat semen analysis (minimum of 2, if testicular insult wait 2.5 months).
4. Determines: motility, morphology, number
5. Anatomic or endocrine problems: ↑scrotal heat (hot tubs, occupation sitting), heavy use of marijuana, alcohol, cocaine within 2 years of testing can ↓sperm count & testosterone levels, cigarette smoking decreases motility, medications may cause neurological ejaculatory dysfunction, lead and pesticide exposure ↓ sperm count, and autoimmunity to sperm development.

Pharmacologic Management (pg. 188)
Clomid (clomiphene citrate) :

1.  if normal ovaries, normal prolactin levels, and an intact pituitary gland.
2. Increases secretion of FSH, LH, and stimulates follicular growth.
3. Induces ovulation in 80%, pregnancy in 40%, and multiple gestation in 5%.
4. Usual dosage is 50 to 250 mg/ day for 5 days, starting from 3 to 5 days after last menses.
5. Estrogen may be needed if there is a decreased amount of cervical mucous.

1. Ovulation occurs 5 to 10 days after last dose. May be assessed by LH kit, BBT, US, progesterone assays, and endo-biopsy.
2. Assess for hyperstimulation: ovarian enlargement, bloating, hotflashes, breast discomfort, abdominal distention, N&V, blurred vision, and mood swings.
3. Sex every other day for 1 week beginning five days after the last day of meds.
4. If no period, do a pregnancy test before Clomid can be re-prescribed.

Artificial Insemination (pg.191 )
Artificial insemination: depositing partner’s or donor’s sperm at the cervical os or in the uterus by mechanical means.

1. Indications: Low sperm count, decreased motility, low percentage, abnormal morphology, unexplained infertility, hypospadius.
2. Donor insemination is considered in cases of an absence of sperm, inherited male sex linked disorders.
3. Donor sperm: screening process, sperm frozen for 6 months and quarantined, then donor retested for any disease process, genetic disorders.
4. Takes 6 to 8 cycles of well times insemination to initiate pregnancy.

In Vitro Fertilization (pg.192)

1. Infertility has resulted from tubal factors, cervical mucus abnormalities, male infertility, unexplained infertility, immunologic infertility, and cervical factors.
2. Fertility drugs used to induce ovulation and egg retrieved transvaginally.
3. Woman’s eggs are collected and fertilized in the lab then placed in the uterus after normal embryonic development has begun.
4. 3-4 embryos are placed as opposed to one.
5. Client is restricted to minimal activity for 12 to 24 hours and progesterone supplements are begun.
6. An average of three cycles are required for success and the rate of multiples is 30% to 50%.

Nursing Care (pg. 195)

1. Financial, physical, and emotional resources are affected.
2. Emotional needs, quality of the relationship.
3. Spontaneity in relationship is stressed.
4. Clients may experience guilt, shame, loss, and depression.
5. Promote appropriate resources and accurate information
6. Adoption may be a possibility for this couple.

Questions
Medical Blooper
Our emergency department was trying different types of exam lights in the OB/GYN room.  One afternoon, a patient was on the table prepared for a pelvic exam. As the doctor began the procedure, the nurse positioned one of the new lights, and said, “What do you think, Doctor?”
The doctor replied, “Well, I’ve seen better.”
The doctor had some fast explaining to do when the patient raised her head, and said, “Well, my husband’s never complained.”
A chuckle a day…® from the medical community.