CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) It is a preventable and treatable disease with some significant extrapulmonary effects that

may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases. EMPHYSEMA is a chronic (long-term) lung disease, usually caused by smoking. Emphysema is the main form of chronic obstructive pulmonary disease (COPD). Emphysema Management 1. Rest to reduce oxygen demands of tissues. 2. Increase fluid intake to liquefy mucus secretion. 3. Good oral care to remove sputum and prevent infection. 4. Diet high calorie, high protein, low carbohydrates. High caloric diet provide adequate source of energy. High protein diet helps maintain integrity of alveolar walls. Low carbohydrate diet limits carbon dioxide production (natural end product of carbohydrate metabolism). Pharmacologic Management 1. Inhaled bronchodilators relax and open the airways. They may be short-acting (albuterol, ipratropium) or long-acting (formoterol, salmeterol, tiotropium). These medicines are available in metered-dose inhalers ("puffers") or as a solution. 2. Inhaled corticosteroids reduce inflammation in the airways. Although inflammation is not generally felt to be a large contributor to emphysema, these medicines often still help. Numerous corticosteroids are available, such as fluticasone or beclomethasone. Corticosteroids are also available with bronchodilators in combined preparations, like Advair. 3. Oral or intravenous corticosteroids are used for exacerbations (sudden worsening) of emphysema. These medicines (prednisone, methylprednisolone) are effective, but can have serious side effects if used regularly. Besides medications, other treatments include: 1. Oxygen therapy: People with severe emphysema and low oxygen in the blood can benefit from longterm oxygen therapy. Oxygen therapy reduces strain on the heart and helps some people with severe emphysema live longer. Oxygen therapy is typically inhaled through the nose by a tube called a nasal cannula. Some may need oxygen therapy continuously, others may not. 2. Lung volume reduction surgery: Surgical removal of large areas of damaged lung can improve function of the healthy part of the lung. This can improve breathing and quality of life. 3. Pulmonary rehabilitation: An intensive program that combines exercise, nutrition, counseling, and medication management. People with severe emphysema often breathe better through this diverse and aggressive treatment approach. 4. Lung transplantation: This is the most drastic of emphysema treatments. Although it could be called an

emphysema cure, lung transplant can create medical problems that can be worse than severe emphysema. CHRONIC BRONCHITIS is a disease of the airways. It is the presence of cough and sputum production for at least 3 months in each of consecutive years. TREATING CHRONIC BRONCHITIS: 1. The most effective treatment for chronic bronchitis is to avoid air pollutants and, if the patient is a smoker advise the patient to STOP SMOKING! 2. Antibiotics to treat recurring infections. 3. Bronchodilators to relieve bronchospasm and facilitate mucus clearance. 4. Adequate hydration. 5. Chest Physiotherapy to mobilize the secretions. 6. Nebulizer treatments to loosen and mobilize secretions. 7. Corticosteroids to combat inflammation. 8. Diuretics for edema. 9. Oxygen for hypoxia. MEDICAL MANAGEMENT: The main goals are to improve oxygenation and decrease CO2 retention. These are accomplished by: 1. Relieving the portion of the airway obstruction that is irreversible (asthma). 2. Facilitating the elimination of bronchial secretions. 3. Preventing and treating the respiratory infections. 4. Increase exercise tolerance. 5. Controlling complications. 6. Avoiding airway irritants / allergens. 7. Relieving anxiety and treating depression that often accompany COPD. AVOIDING IRRITANTS: 1. Known allergens should be avoided. 2. Smoking should cease. PSYCHOLOGICAL SUPPORT: 1. As much as possible, the client should be encouraged to live an active life with daily exercise. POST HOSPITAL CARE: 1. Home oxygen therapy may be required by the client with COPD. 2. Clients and their families should be instructed in the proper use of this therapy, including potential hazards and complications. DISCHARGE TEACHINGS: 1. In order to facilitate self-care and adherence, the client and significant others need thorough info about the disease process and prescribed medications and treatments. 2. Discussion of the hazards of infection and ways to decrease personal risk like avoiding crowds during flu and cold season, obtain immunization against influenza and pneumococcal organisms and cleanse respiratory equipment well. 3. Avoidance of exposure to respiratory irritants such as smoke, dust, mold, and severe air pollutions which can increase mucus production and cause bronchospasm. NURSING CARE OF THE ELDELY 1. PROMOTING HYGIENE AND SKIN CARE

 Good oral care to remove sputum and prevent infection. Daily bath is not necessary for the elderly client. The skin is dry and there is poor temperature regulation. He/ she feel cold most of the time. Sponge bath may be done alternately with full bath. Use mild soap to promote moisture of the skin. Dry skin can easily be impaired. Use bath oils or body lotion to protect the skin. Avoid use of alcohol because it dries the skin. Use protective devices like pads/mattress to prevent pressure sores. Change position frequently. Loss of subcutaneous supporting tissues makes the skin sensitive to pressure. Massage bony prominences and weight-bearing areas every two (2) hours. To promote circulation and prevent pressure sores. Assist ambulation as much as possible. 2. EXERCISE Progressively increased walking is the most common form of exercise unless contraindicated. To enhance cardiovascular fitness and train skeletal muscles to function more effectively Breathing exercise for lung expansion. Client should be discouraged from rapid, shallow panic breathing. 3. PROMOTION OF REST AND SLEEP PATTERNS Rest. To reduce oxygen demands of tissues The elderly client sleeps lightly, intermittently, with frequent waking. Provide low bed, night light, and adequate supervision when getting up to prevent falls. Limit fluid intake of the client before going to bed. This prevents sleep pattern disturbance related to frequent urination during the night. Promote comfort and relaxation. Create restful environment. Attend to bedtime rituals. Promote regular sleeping and waking hours. Provide a glass of warm milk at bedtime. Avoid caffeine and alcohol in the evening. Go to bed only when sleepy. Avoid long naps in the afternoon. 4. PROVISION OF NUTRITIONAL NEEDS High protein, low calorie, low carbohydrates. Provide skim milk. This is rich in protein and calcium and low in fats and cholesterol. High protein diet helps maintain integrity of alveolar walls. Increase protein in diet, but reduce calories. The metabolic rate of the elderly is slowed. Low carbohydrates diet limits carbon dioxide production (natural end product of carbohydrate metabolism). The client with COPD has difficulty exhaling carbon dioxide. Increase fiber (fruits, vegetables) in diet and fluids to prevent constipation. Provide vitamin and mineral supplements as prescribed. To promote health. Increase fluid intake to liquefy mucus secretions. 5. PROVISION FOR EMOTIONAL NEEDS The elderly needs someone to talk to. Plan time to visit them. The client is oftentimes comforted by touch. Touch conveys feelings of concern, intent and acceptance. Maintain family contact. Provide diversional activities. Allow the client to verbalize feelings on death. Do not avoid the topic.

DEGENERATIVE HEART DISEASE Coronary Artery Disease (CAD): It is characterized by atherosclerosis in the epicardial coronary arteries. Atherosclerotic plaques, the hallmark of atherosclerosis, progressively narrow the coronary artery lumen and impair antegrade myocardial blood flow. The reduction in coronary artery flow may be symptomatic or asymptomatic, occur with exertion or at rest, and culminate in a myocardial infarction, depending on obstruction severity and the rapidity of development.

Assessment: 1. INSPECTION a. Skin Color: Pallor and Cyanosis - are due to inadequate oxygenation. Jaundice -is due to hemolysis of RBC the bilirubin was release into systemic circulation. b. Neck Vein Distention due to venous congestion and aneurysm. c. Respiration Note sign of Dyspnea it indicates inadequate oxygenation. d. Peripheral Edema due to venous insufficiency 2. PALPATION a. Peripheral pulse. Weak or bounding and irregular pulse may indicate presence of cardiovascular disorder. 3. PERCUSSION a. Pulmonary Edema produces dullness and percussion of the chest 4. AUSCULTATION a. S1 the lubb sound. Closure of mitral and tricuspid valve. b. S2 the dubb sound. Closure of aortic and pulmonary valve. c. S3 ventricular diastolic gallop. Normal in children, young adults and athletes it indicates Chronic Heart Failure to older adults. d. S4 atrial diastolic gallop. Abnormal in all ages. e. Murmursvibrations of the heart and vessels produced by turbulent blood flow. f. Pericardial friction rub sign of inflammation, infection or infiltration. Nursing Interventions and Managements: 1. Keep medicines available for immediate use. 2. During anginal or ischemic episode, monitor blood pressure and heart rate. 3. Record duration of pain, amount of medication required to relieve ir, and accompanying symptoms. 4. Ask the patient to grade the sverity of his pain on a scale 1 to 10. 5. Monitor the patient for chest pain, hypotension and coronary artery spasm. 6. Help the patient more effectively cope with stress and identify activities that precipitate pain. 7. Stress the need to follow the prescribed drug regimen.

8. Encourage the patient to maintain the prescribed diet. 9. If a patient experience angina or ischemia they are usually placed in bed rest with commode priveleges for 24-48 hours. 10. Gradual increase in activity is encouraged after first 24-48 hours monitor signs of dysarrythmia, chest pain and changes of VS during the activity. 11. Avoid stimulants. Avoid taking very hot and very cold food, vasovagal stimulation may lead to bradycardia and cardiac arrest. 12. Avoid use of bed pan or and straining at stool. Valsalva maneuver changes heart rate and blood pressure which may trigger ischemia or cardiac arrest. Health Teaching and Health Education Stop cigarette smoking and the use of tobacco products Smoking is directly related to an increased risk of heart attack and its complications. If you smoke, ask your doctor about counselling, nicotine replacement medications and programs to help you quit. You and your family should try to avoid second hand smoke. Control high blood pressure High blood pressure can damage the lining of your coronary arteries and lead to coronary artery disease. Check your blood pressure on a regular basis. Most patients with coronary artery disease should target a systolic blood pressure of less than 130 mm Hg. A healthy diet, exercise, medications and controlling sodium in your diet can help control high blood pressure. Follow a regular exercise plan A regular exercise program helps to regain or maintain your energy level, lower cholesterol, manage weight, control diabetes and relieve stress. Check with your doctor first before beginning an exercise program. if safe, 30 minutes per day of sustained aerobic exercise is recommended. Achieve and maintain your ideal body weight Obesity is defined as being very overweight with a body mass index (BMI) of greater than 30. When you are very overweight, your heart has to do more work, and you are at increased risk of high blood pressure, high cholesterol levels and diabetes. A healthy diet and exercise program aimed at weight loss can help improve your health. Control Stress and Anger Uncontrolled stress or anger is linked to increased coronary artery disease risk. You may need to learn skills such as time management, relaxation, or yoga to help lower your stress levels. Diet and Elimination Low calorie, Low cholesterol and Low Sodium diet. Avoid stimulants. Avoid taking very hot and very cold food, vasovagal stimulation may lead to bradycardia and cardiac arrest. geriatric oncology Introduction While anyone can develop cancer, the risk of getting the disease increases with age. Certain cancers, in particular, are linked to aging, such as breast, colorectal, prostate, pancreatic, lung, and bladder and stomach cancers. For many reasons, older adults (generally age 70 and higher) with cancer have different needs than younger adults with the disease. Treatment for older adults needs to consider many issues. For example, older adults: May be less able to tolerate certain cancer treatments. Have a decreased reserve (the capacity to respond to disease and treatment).May have other medical problems in addition to cancer. May have functional problems, such as the ability to do basic activities (dressing, bathing, eating) or more advanced activities (such as using transportation, going shopping or handling finances).May not always have access to transportation, social support or financial resources.

Cancer and other tumors are common among elderly. Elderly have many peculiarities as regard dosing, complications and tolerance of treatment options of cancer. Clinical trials that guidelines for treatment of cancer were based on were mainly applied for young age and rarely in elders, so a lot of research in this area is needed. Just as a child would see a pediatrician for medical care, an older patient should go to a geriatrician. And an older patient with cancer will benefit from the combined expertise of the Geriatric Oncology Programs physician experts. Older patients have unique needs because of their often complex medical histories, numerous drugs they are taking, their social situations, possible problems with cognitive dysfunction related to age, and general diminution of organ function that occurs naturally in the older population. An expert in geriatrics, working in conjunction with a medical oncologist sensitive to these problems, can decide on the appropriate treatment for any elderly cancer patient. Biology of Aging Aging is associated with both systemic and organ-related changes. Of the systemic changes, an increased concentration of inflammatory substances, such as interleukin 6 , tumor necrosis factor [TNF], and Creactive protein [CRP], has received special attention in recent years. This accumulation, which may result from a succession of inflammatory processes that fail to heal completely and may cause low-grade disseminated intravascular coagulation [DIC], appears to be responsible for many of the manifestations of aging. Inflammatory cytokines may induce a general catabolic status characterized by sarcopenia and hypoproteinemia; they may cause osteoporosis and cognitive decline ; and they also may compromise hemopoiesis and the immune response . In addition, endocrine senescence may be responsible for reduced protein synthesis, whereas immune senescence may accommodate the development of infection, leading to further accumulation of cytokines in the circulation. Of special interest in the management of pain in older patients are changes that take place in the central and peripheral nervous systems and in drug pharmacokinetics. Though nerve conduction appears to be well maintained with age, the number of nociceptive receptors in the skin and the amount of afferent fibers decrease with age, which may alter the perception of pain . Between ages 20 and 80, the brain may lose as many as 20% of its original neurons, a loss leading to a reduced number of opioid receptors and increased sensitivity to opioids . It also has been suggested that this reduction in brain volume may result in altered ratios of and receptors and increased susceptibility to the complications of opioids. Of the pharmacokinetic changes, two of the most important are the decline in glomerular filtration rate, which is progressive with age in the majority of persons over 65 , and the reduction in activity of the cytochrome system, which is responsible for the activation and the metabolism of a number of opioids Clinical Evaluation of Older Patients Age-related changes occur at different rates in different persons, and the extent of their presence is poorly reflected in chronologic age . The clinical assessment of the older person must address questions of life expectancy, risk of functional decline and need of assistance, tolerance to stress, rehabilitation, and management of reversible conditions, such as depression, malnutrition, and polypharmacy, that may compromise survival, function, and quality of life if left untreated. Since aging involves different living domains that are interwoven in generating the clinical picture of aging, the most reliable evaluation of aging in any given person is a multidimensional comprehensive geriatric assessment (CGA), accounting for function, comorbidity, social support, nutrition, presence of geriatric syndromes, and polypharmacy (Table 1).

Signs and Symptoms Symptoms and signs of cancer depend on the type of cancer, where it is located, and/or where the cancer

cells have spread. For example, breast cancer may present as a lump in the breast or as nipple discharge while metastatic breast cancer may present with symptoms of pain (if spread to bones), extreme fatigue (lungs), or seizures (brain). A few patients show no signs or symptoms until the cancer is far advanced. However, there are some signs and symptoms, although not specific, which usually occur in most cancer patients that are fairly easy for the person to detect. They are as follows: -Fever (no clear infectious source, recurrent or constant) -Fatigue (not relived by rest) -Weight loss (without trying to lose weight) -Pain (usually persistent) -Skin changes (coloration, sores that do not heal, white spots in mouth or on tongue, wart changes) -Change in bowel or bladder functions (including trouble swallowing orconstipation) -Unusual bleeding (mouth, vaginal, and bladder) or dischargePersistent cough or change in voiceLumps or tissue masses Anyone with these signs and symptoms should consult their doctor. Many cancers will present with some of the above general symptoms but often have one or more symptoms that are more specific for the cancer type. For example, lung cancer may present with common symptoms of pain, but usually the pain is located in the chest. The patient may have unusual bleeding, but the bleeding usually occurs when the patient coughs. Lung cancer patients often become short of breath, and then become very fatigued. MANIFESTATIONS OF PAIN IN YOUNGER AND OLDER INDIVIDUALS Atypical manifestations of pain are more common in older individuals than in younger ones and may include delirium, confusion, fatigue, withdrawal, and depression . Although these manifestations may be more common in cognitively impaired persons,previously depressed patients, and patients with multiple comorbidities, they may occur also in individuals who appear functionally, cognitively, and emotionally intact. The pathogenesis of these atypical manifestations is poorly understood but certainly reflects the multidimensional nature of aging and the involvement of different domains in the response to stress. IMPACT OF PAIN ON FUNCTION AND QUALITY OF LIFE In older individuals, pain is not just an unpleasant sensation that momentarily lowers a persons quality of life. Given the limited functional reserve of older individuals, pain may have long-lasting and irreversible consequences that compromise the effects of antineoplastic treatment, the function, and even the survival of the patient . It behooves the practitioner to be highly alert to the possibility of these problems and to intervene promptly to break the vicious circle of pain, dysfunction, disease, and more pain. Of special concerns are movement limitations and depression. Immobility causes sarcopenia, deep-vein thrombosis and deconditioning and may result in permanent functional dependence in persons who were formerly fully functional Given the serious implications of immobility in older individuals, the American Geriatrics Society (AGS) and other authorities around the world recommend that even nonmalignant pain be managed with opioids when other interventions fail, because the long-term risks of pain are seen as more dangerous than the long-term drug complications. Depression is a common complication of both pain and immobility and is associated with increased risk of death in older individuals . In the cancer patient, depression may undermine the willingness to live and to take needed treatment . In some situations, the concomitant management of pain and depression may be synergistic in improving both the mood and the pain

Age and Pain Assessment While cognitive decline may be an impediment to proper pain assessment, it is important to underlinethat reliable pain measurements still may be obtained from individuals who are mildly or moderately cognitively impaired . It is a common misconception that any degree of dementia may prevent a person from making responsible decisions about his or her life or from being able to verbalize ongoing feelings. It would be a serious disservice to the older person if the inexperienced provider would consult a family member or another caregiver, rather than the patient, about the patients symptoms under the wrong assumption that patient communication of pain or other symptoms is unreliable just because the patients memory is failing. PAIN SCALES The most common pain scales, with their respective advantages and disadvantages, have been summarized by Herr and Garand (Table 2). As a general principle, scales that require a high level of abstract thinking, such as the visual analog scale or MPQ are unsuitable for older individuals, especially for those who are cognitively impaired or have a low educational level, because the abstractive capacity declines with age. The completion rate of these scales by older patients has generally been very low. Of the Numerical Rating Scales, the verticals appear easier to complete by older individuals. Of the visual scales, the thermometer is preferred and has the highest completion rate, even among cognitively impaired individuals. The facial expression scales are unreliable in cognitively impaired or emotionally disturbed patients, who may identify the facial expressions with their feelings rather than with their pain. The verbal descriptor scale probably has the highest completion rate and may be the best to utilize outside of a research setting. The absence of reference numbers makes this scale unsuitable for research aimed at demonstrating changes in pain and also is inconvenient in following the course of pain in patients undergoing treatment.

Diagnostics Samples collected for cancer blood tests or other tests of urine, fluid or tissue are analyzed in a lab for signs of cancer. The samples may show cancer cells, proteins or other substances made by the cancer. Blood and urine tests can also give your doctor an idea of how well your organs are functioning and if they've been affected by cancer. Complete blood count (CBC) This common blood test measures the amount of various types of blood cells in a sample of your blood. Blood cancers may be detected using this test if too many or too few of a type of blood cell or abnormal cells are found. A bone marrow biopsy may help confirm a diagnosis of a blood cancer. Urine cytology Examining a urine sample under a microscope may reveal cancer cells that could come from the bladder, ureters or kidneys. Blood protein testing A test to examine various proteins in your blood (electrophoresis) can aid in detecting certain abnormal immune system proteins (immunoglobulins) that are sometimes elevated in people with multiple myeloma. Other tests, such as a bone marrow biopsy, are used to confirm a suspected diagnosis. Tumor marker tests Tumor markers are chemicals made by tumor cells that can be detected in your blood. But tumor markers are also produced by some normal cells in your body and levels may be significantly elevated in noncancerous conditions. This limits the potential for tumor marker tests to help in diagnosing cancer.

The best way to use tumor markers in diagnosing cancer hasn't been determined. And the use of some tumor marker tests is controversial. Examples of tumor markers include prostate-specific antigen (PSA) for prostate cancer, cancer antigen 125 (CA 125) for ovarian cancer, calcitonin for medullary thyroid cancer, alpha-fetoprotein (AFP) for liver cancer and human chorionic gonadotropin (HCG) for germ cell tumors, such as testicular cancer and ovarian cancer. Biopsy A biopsy is a procedure to remove a piece of tissue or a sample of cells from your body so that it can be analyzed in a laboratory. If you're experiencing certain signs and symptoms or if your doctor has identified an area of concern, you may undergo a biopsy to determine whether you have cancer or some other condition. Single-photon Emission Computerized Tomography A single-photon emission computerized tomography (SPECT) scan lets your doctor analyze the function of some of your internal organs. A SPECT scan is a type of nuclear imaging test, which means it uses a radioactive substance and a special camera to create 3-D pictures. Positron Emission Tomography A positron emission tomography (PET) scan is an imaging test that can help reveal how your tissues and organs are functioning. A small amount of radioactive material is necessary to show this activity. The precise type of radioactive material and its delivery method depend on which organ or tissue is being studied by the PET scan. The radioactive material may be injected into a vein, inhaled or swallowed. More radioactive material accumulates in areas that have higher levels of chemical activity. This often corresponds to areas of disease and shows up as brighter spots on the PET scan. A PET scan is useful in evaluating a variety of conditions including neurological problems, heart disease and cancer. Ultrasound Ultrasound examination, also called sonography or diagnostic medical sonography, is an imaging method that uses high-frequency sound waves to produce precise images of structures within your body. The images produced during an ultrasound examination often provide information that's valuable in diagnosing and treating a variety of diseases and conditions. Most ultrasound examinations are done using a sonar device outside of your body, though some ultrasound examinations involve placing a device inside your body. Despite its valuable uses, ultrasound can't provide images of all areas of your body. But there are several other imaging alternatives Computerized Tomography A CT scan also called computerized tomography or just CT combines a series of X-ray views taken from many different angles to produce cross-sectional images of the bones and soft tissues inside your body. The resulting images can be compared to a loaf of sliced bread. Your doctor will be able to look at each of these slices individually or perform additional visualization to make 3-D images. CT scan images provide much more information than do plain X-rays. A CT scan is particularly well suited to quickly examine people who may have internal injuries from car accidents or other types of trauma. A CT scan can also visualize the brain and with the help of injected contrast material check for blockages or other problems in your blood vessels. Magnetic Resonance Imaging Cancer doctors use MRI, or magnetic resonance imaging, for cancer diagnosis, staging, and treatment planning. The main component of most MRI systems is a large tube-shaped or cylindrical magnet.

Using non-ionizing radiofrequency waves, powerful magnets, and a computer, this technology produces detailed, cross-sectional pictures of the inside of the body. With MRI, we can distinguish between normal and diseased tissue to precisely pinpoint cancerous cells within the body. It is also useful in revealing metastases. Additionally, the MRI system provides greater contrast between the different soft tissues of the body than a CT scan. Thus, it is especially useful for imaging the brain, spine, muscle, connective tissue, and the inside of bones. Prostate-specific antigen Prostate-specific antigen (PSA) is a protein produced by cells of the prostate gland. The PSA test measures the level of PSA in the blood. The doctor takes a blood sample, and the amount of PSA is measured in a laboratory. Because PSA is produced by the body and can be used to detect disease, it is sometimes called a biological marker or a tumor marker. It is normal for men to have a low level of PSA in their blood; however, prostate cancer or benign (not cancerous) conditions can increase a mans PSA level. As men age, both benign prostate conditions and prostate cancer become more common. The most frequent benign prostate conditions are prostatitis(inflammation of the prostate) and benign prostatic hyperplasia (BPH) (enlargement of the prostate). There is no evidence that prostatitis or BPH causes cancer, but it is possible for a man to have one or both of these conditions and to develop prostate cancer as well. A mans PSA level alone does not give doctors enough information to distinguish between benign prostate conditions and cancer. However, the doctor will take the result of the PSA test into account when deciding whether to check further for signs of prostate cancer. Management Pain Management The general principles of pain management are the same for both younger and older individuals, including the application of the three-step ladder proposed by the World Health Organization. It is important to state once more that cognitive impairment does not in any way preclude the use of opioids . In many cases, the effectiveness of treatment may be monitored based on the patients responses to specific questions. When the patient is unable to verbalize, the observation of changes in a patients behavior is generally a reliable sign of treatment effectiveness. NONPHARMACOLOGICAL PAIN TREATMENT STRATEGIES Despite lack of conclusive evidence, older individuals often like to adopt alternative strategies for pain management . They include traditional home remedies, such as massages and heating pads, or informal cognitive strategies, such as visiting friends, social gathering, prayer, and humor . Whereas the reports related to transcutaneous electrical nerve stimulation (TENS) are mainly anecdotal , a recent randomized controlled trial demonstrated the effectiveness of percutaneous electrical nerve stimulation (PENS) in the management of low-back pain. Other methods often quoted include hypnosis, meditation, relaxation, guided imagery, biofeedback, prayer, and music therapy. The practitioner should be aware of these approaches and support their application in individual cases where they seem to be effective. TREATMENT OF UNDERLYING CONDITIONS It is stating the obvious to say that the most definitive treatment of cancer-related pain is the treatment of cancer. In addition to that, however, a number of low-toxicity options are now available, from bisphosphonates and radioisotopes, in the case of bone metastases, to low-dose chemotherapy. Low-dose chemotherapy can include capecitabine (Xeloda), weekly taxane therapy, vinorelbine (Navelbine), gemcitabine (Gemzar), and liposomal doxorubicin (Doxil), and appears to be well tolerated, even by frail patients .As previously stated, depression may portend and aggravate the complaints of pain.

SYMPTOM MANAGEMENT The management of symptoms in older individuals follows the same principles as in younger patients. However, the approach may require modification because of comorbidities or physiologic changes associated with aging. Differences in symptom management in elderly versus younger patients have been best studied for chronic somatic and neuropathic pain. Somatic pain Estimates of the prevalence of pain in older adults range from 25 to 50 percent of community-dwelling older adults. Among those in nursing homes, 45 to 80 percent of patients have significant pain that is undertreated. Unrecognized or undertreated pain in the geriatric population can lead to complications such as depression, decreased socialization, insomnia, gait instability, or loss of functional capacity. The use of analgesic medications is the most common strategy in the management of pain in older adults. Physiologic changes (eg, decreased renal or hepatic function and altered body fat distribution) may result in higher serum drug levels in elderly patients given the same dose of a medication as younger individuals. Furthermore, older patients may be more susceptible to adverse events. Choice of the proper analgesic medication should be carefully considered based upon the source and intensity of the pain and the patient's previous responses and reactions to analgesic medications. Opioid therapy is the first-line approach for moderate or severe chronic pain that is related to cancer. While opioids have been endorsed for persistent nonmalignant pain by major professional pain organizations (eg, American Academy of Pain Management, American Pain Society), their use in older adults can be limited by patients' fears of addiction and side effects. Clinicians can help to allay patients' concerns by explaining that while physical dependence is unavoidable with opioid analgesics, addiction is extremely rare in older patients and that side effects can be appropriately controlled . All patients are at risk of developing the common side effects of opioids (eg, nausea, constipation, pruritus, sedation, mental cloudiness). In older patients, fecal impaction and urinary retention are more common and a particular concern . Therefore, close attention to the regularity of bowel movements and bladder emptying is recommended, especially in patients who are nonverbal. Delirium is a common complication in the elderly. Although opioids are often cited as culprits in the development of delirium in older adults, carefully controlled studies have demonstrated that proper pain management actually decreased the incidence of delirium in cognitively intact patients This finding can be explained by the fact that uncontrolled pain itself is a risk factor for the development of delirium. While there are no specific studies on dosing adjustments for opioids in the geriatric population, a prudent approach is to start with a low dose, monitor closely, and titrate the dose upward as required. A reasonable approach is to begin with 30 to 50 percent of the recommended starting dose for younger adults. Neuropathic pain Neuropathic pain syndromes are common in older adults. Etiologies can include a spectrum of disorders (eg, diabetic neuropathy, post-herpetic neuralgia, spinal stenosis). General aspects of the management of neuropathic pain in cancer patients are discussed separately. In addition to opioids, a number of pharmacologic agents termed adjuvant analgesics, or coanalgesics may be useful in the treatment of neuropathic pain and have special considerations in the geriatric population. Gabapentin is widely used in the treatment of neuropathic pain, but common side effects include somnolence and ataxia, which can be particularly problematic in the geriatric population. If gabapentin is used in older adults, treatment should be initiated with a dose of 100 mg at night. Patients should be questioned specifically about these side effects before any increases in the dose . Likewise,pregabalin is also becoming used more commonly for the treatment of neuropathic pain. There are no specific dosing adjustments recommended for the geriatric population. With both gabapentin and pregabalin, care should be taken when discontinuing therapy as a withdrawal syndrome can occur. Pregabalin should be tapered off over a week. Gabapentin should be tapered gradually. The length of the gabapentin taper will depend on the maximum dose of gabapentin that a patient is on at the time of the

initiation of the taper. While both tricyclic antidepressants (TCAs) and carbamazepine have been shown to be effective in neuropathic pain, their side effects and potential for drug-drug interactions limit their utility in older adults. Other medications that have been evaluated for the treatment of neuropathic pain include the selective serotonin reuptake inhibitors (SSRIs) and mixed reuptake inhibitors (eg, paroxetine, citalopram,duloxetine, venlafaxine). These agents may be particularly useful in elderly patients because of their favorable side-effect profiles. Transdermal lidocaine can be useful in the elderly to treat both neuropathic and localized, nociceptive pain because of its low incidence of side effects. Proper usage of transdermal lidocaine is critical, and careful instructions should be provided. Transdermal lidocaine should be applied for 12 hours and removed for 12 hours each day, and patients can cut the patches in half in order to utilize them on different parts of the body (eg, the right and the left knee). Patients who are also using other transdermal preparations (eg, fentanyl, clonidine, nitroglycerin) should be carefully instructed regarding the differences between these medications and their appropriate use. While transdermal lidocaine patches can be cut with scissors, the others cannot. Confusion is a particular concern when a patient is using transdermal preparations of both lidocaine and fentanyl for pain management. Depression Major depression is a treatable condition, even in terminally ill patients. The more favorable side effect profile of newer antidepressants has facilitated their use in the elderly and medically ill. Because treatment with these agents is relatively benign and well tolerated, clinicians should have a low threshold for initiating therapy. The treatment of depression in palliative care is discussed separately. Other symptoms While other symptoms including delirium, dyspnea, fatigue, nausea, constipation, and anorexia are all common in older adults, there is a paucity of evidence focusing specifically on their evaluation and management in older adults. Palliative care and Cancer Disease Palliative care is care that does not alter the course of a disease, but improves the quality of life. An unfortunate aspect of cancer is that chronic pain is a part of life for more than 75 percent of those with advanced stages of the disease. These figures remain unchanged for decades despite numerous medical breakthroughs and are significantly skewed towards the elderly. Due to the aging of the population, cancer in older people and the management of its pain are frequent problems and present unique challenges. Clinicians treating elders need to recognize atypical manifestations of pain; utilize of individualized forms of pain assessment; and select treatment tailored to the individual case. Recognizing these unique challenges, the American Geriatric Society (AGS) annually convenes a panel of experts to discuss the management of pain in the elderly and publishes its recommendations in a yearly supplement to the Societys journal. The principles stated by Dr Balducci are in substancial agreement with those in the latest AGS supplement. They include the following: Pain in elders is common and undertreated due to a number of barriers, including atypical manifestations of pain in the elderly and the inability and unwillingness of older persons to verbalize pain complaints. It behooves the practitioner in charge of the older person to elicit an appropriate pain history, to recognize atypical pain, and to provide adequate pain relief. Effective treatment of pain in the older person is compelling, because pain may compromise general health, the management of existing conditions and even shorten the life span. Pain assessment in older patients may have to be more comprehensive than in younger ones and to include conditions that may affect the perception of pain, such as depression, disability, and comorbidities. Simultaneous management of these conditions may enhance the effectiveness of pain management. Other conditions, such as functional dependence, may be followed to monitor the effectiveness of pain treatment. Self-report of pain by older individuals is reliable, even in the presence of moderate dementia. Vertical visual scales, such as pain thermometers, and numerical or verbal descriptor scales are the most suitable for older individuals with cognitive impairment and/or a low educational level. Observation of pain

behavior is useful and reliable in assessing pain in individuals unable to verbalize their complaints. Nonpharmacological treatment may be helpful in selected individuals. In cases of pain associated with specific movements, the administration of analgesics should occur at those movements. In the absence of risk of gastrointestinal bleeding, COX-1 inhibitors are more cost-effective than COX-2 inhibitors, as long as indomethacin, piroxicam, mefenamic acid, and ketorolac are avoided. Of the COX-2 inhibitors, rofecoxib has a lesser risk of drug interactions. Older individuals may have an increased sensitivity to opioids, due to decreased hepatic and renal function, as well as a reduced number of opioid receptors because of brain atrophy. . In general, initiation of opioids should be at lower doses and longer dose intervals than used in younger patients. As with younger patients, dose escalations should be linked to individual pain relief. Important considerations when medicating elderly patients: Elders have decreased total body water, so use baby doses of watersoluble drugs to prevent excessive drug concentrations. Elders typically have more body fat and thus an increased risk of toxicity when using fat-soluble or lipophilic drugs (psychotropics, vitamins A and E, some statins), which are slow to activate and accumulate. Elders have decreased serum protein levels and consequently a higher rate of free drug, so treat to efficacy and not to levels. Almost 50% of elders are slow metabolizers, associated with an increased risk of adverse effects and toxicity; dont just assume the drug is not working and then increase the dose. Watch for drugdrug interactions and toxicities in patients treated with 1 or more drugs metabolized along the CYP3A4 pathway. Elders, especially those aged >85 years, frequently have impaired kidney and renal function, so evaluate total drug burden. Try to elicit from the patient information about changes in behavior or mood by asking questions like Are you sleeping? or Are you still doing [a favorite activity]?; responses might indicate an adverse drug reaction. Rheumatic Heart Disease Rheumatic heart disease was formerly one of the most serious forms of heart disease of childhood and adolescence. Rheumatic heart disease involves damage to the entire heart and its membranes. Rheumatic heart disease is a complication of rheumatic fever and usually occurs after attacks of rheumatic fever. The incidence of rheumatic heart disease has been greatly reduced by widespread use of antibiotics effective against the streptococcal bacterium that causes rheumatic fever. Signs/Symptoms Painful joints and involuntary spasms Fever Heart murmur Fatigue Lack of stamina Chest pain Irregular pulse Shortness of breath Dry cough Assessment 1. Assess if patient recently had a strep infection like sore throat and pharyngitis .

2. Perform physical examination and check for signs of rheumatic fever, including joint pain and inflammation. 3. Auscultate to check for abnormal rhythms or murmurs that may signify that the heart has been strained. 4. Ready the patient for throat culture, a blood test, or both to check for the presence of strep antibodies. 5. Chest X-ray to check the size of the heart and to see if there is excess fluid in the heart or lungs. 6. Echocardiogram, a non-invasive test that uses sound waves to create a moving image of the heart and to measure its size and shape Nursing Intervention Monitor vital signs Monitor cardiac rhythm and frequency Sleeping position high fowler Instruct the client to do stress management techniques Maintain sleep and rest until the results of laboratory and clinical status improved Collaboration and providing oxygen therapy Create a schedule of activity and rest Monitor the gradual increase in the level of activity Monitor closely the prescribed medication of the client (antibiotics)