Education

1. MEDICAL AND SURGICAL NURSING I

2. LEARNING OUT COMES
1. Death & Dying
Death and dying frameworks
five stages of grieving
Nursing Implications
2. Introduction to pathophysiology
Definition
Cell injury and Cellular Adaptive Changes
Types of cellular Adaptive-changes
2

3. LEARNING OUT COMES
3. Neoplasm
3.1. Definition of terms
3.2. Benign and Malignant Neoplasia
3.3 Classification of neoplasms
3.4 Mechanisms of carcinogenesis
3.5 Metastatic Mechanisms
3

4. 1.1 Death and Dying
Coping with death, one’s own or a loved one’s, is
considered the ultimate challenge.
The idea of death is threatening and anxiety
provoking to many people.
Kubler-Ross (1975, p. 1) stated, “The key to the
question of death unlocks the door of life. . . . For
those who seek to understand it, death is a highly
creative force.” Common fears of dying people
are fear of the unknown, pain, suffering,
loneliness, loss of the body, and loss of personal
control.

5. 1.2 Death and Dying (Continued)
Preparation for an impending death can
precipitate the experience of anticipatory
grieving.
Although anticipatory grief can have
positive effects on later grief, this does not
hold true for all people.
For some family members, anticipatory
grief is seen as a risk factor for poor early
bereavement adjustment (Levy, 1991).

6. 1.2 Death and Dying (Continued)
Bereavement is the period following the death of
a loved one during which grief is experienced
and mourning occurs.
The nurse must be aware of the uniqueness and
individuality inherent in the grieving process and
work to meet the needs of those involved in the
best way possible.

7. 1.3 DEATH AND DYING FRAMEWORKS
Various frameworks for understanding the
concept of grief and the stages of death and
dying may be useful to the nurse.
The stages of bereavement described by
Bowlby (1961) are:
 protest,
 disorganization, and
 reorganization.

8. 1.3 Stages of Grieving
Kubler-Ross (1975) conceptualized five stages of
grieving:
 denial,
 anger,
 bargaining,
 depression, and
 acceptance.
Often, the dying person and the survivors do not
experience these responses in an orderly or linear
fashion;
rather, there is random movement between all the
stages for differing periods of time.

9. Five Stages of Grief
• The stages of grief have been a topic of debate in
grief counseling since their introduction in 1969
by Elisabeth Kubler-Ross, in her book “On Death
and Dying”.
1. Denial – The first stage of grief is Denial.
(No, not me, It cannot be true).
It is really the first of our reactions to any form of
sudden loss.
initially deny the event in order to subconsciously
avoid sadness, or the thought of pending mental
struggles.

10. Five Stages of Grief(Continued)
2. Anger – The second stage of grief is Anger.
 (Why me?)
upset with the person or situation which put
them in their grief state.
May be angry at the person who inflicted the
hurt (even after death) or at the world for letting
it happen.
May be angry with self for letting an event (e.g.,
car accident) take place, even if nothing could
have stopped it.

11. Five Stages of Grief(Continued)
3. Bargaining – The third stage of grief is Bargaining.
(Yes me, but… )
May make bargains with God, asking “If I do this,
will you take away the loss?”
People will often try to make a deal, or promise to
do anything, if the pain will be taken away.

12. Five Stages of Grief(Continued)
4. Depression – The fourth stage of grief is
 (Yes me, and I am sad)
Feels numb, although anger and sadness may
remain underneath.

13. Five Stages of Grief(Continued)
5. Acceptance – The fifth stage of grief is
Acceptance.
(Yes me, but it is okay)
Anger, sadness, and mourning have tapered off.
Accepts the reality of the loss.
At this point, they are beginning to understand
that there is a new beginning on the horizon.

14. 5. Acceptance (Continued)
Acceptance should not be confused with healing
or recovering from the loss,
Acceptance is really the beginning of the real
healing process. It is the point where recovery
becomes about the person left behind,

15. 1.4 NURSING IMPLICATIONS
Nursing care involves:
 providing comfort,
 maintaining safety,
 addressing physical and emotional needs,
 teaching coping strategies to terminally ill
patients and their families.
 Hospice care,
 attention to family and individual psychosocial
issues,
 symptom and pain management are all part of
the nurse’s responsibilities.

16. 1.4 NURSING IMPLICATIONS(Continued)
 the nurse explores choices and end-of-life
decisions with the patient and family.
 The nurse is also an advocate for the dying
person and works to uphold that person’s
rights.
 The use of living wills and advance
directives allows the patient to exercise the
right to have a “good” death or to die with
dignity.

17. 1.4.1.What is HOSPICE CARE
Hospice is not a place, but a concept of care in which
the end of life is viewed as a developmental stage.
The root of the word hospice is hospes, meaning
“host.”
Historically, hospice has referred to a shelter or way
station for weary travelers on a pilgrimage
(Bennahum, 1996).
The goal of hospice care is to enable the patient to
remain at home, surrounded by the people and
objects that have been important to him or her
throughout life.
Hospice is not a place but a concept of care that
provides compassion, concern, and support for the
dying

18. 1.4.1 Hospice care (Continued)
Hospice care does not seek to hasten death, nor
does it encourage the prolongation of life through
artificial means.
There is no limit to the length of time that an eligible
patient may continue to receive hospice care.
Patients who live longer than 6 months under hospice
care are not discharged if:
 their physician and the hospice medical director
continue to certify the patient,
is terminally ill with a life expectancy of 6 months or
less, assuming that the disease continues its
expected course.

19. 1.4.2. Eligibility Criteria for Hospice Care
General
Serious, progressive illness
Limited life expectancy
 Informed choice of palliative care over cure-
focused treatment
Hospice-Specific
Presence of a family member or other caregiver
continuously in the home when the patient is no
longer able to safely care for him/herself
some hospices have created special services
within their programs for patients who live alone

20. 1.4.2 Eligibility Criteria (Continued)
Medicare and Medicaid Hospice Benefits
Medicare Part A; Medical Assistance eligibility
Waiver of traditional Medicare/Medicaid benefits
for the terminal illness
Life expectancy of 6 months or less
Physician certification of terminal illness
Care must be provided by a Medicare-certified
hospice program

21. 1.4.3 Palliative care
Palliative care is any form of care or
treatment that focuses on reducing the
severity of disease symptoms, rather than
trying to delay or reverse the progression of
the disease itself or provide a cure.
The overall goals of palliative care are to
(1) prevent and relieve suffering and
(2) improve quality of life for patients with
serious, life-limiting illnesses

22. Relationship of palliative care, end-of-
life care, and hospice care.

23. 1.4.4. END-OF-LIFE CARE
End of life generally refers to the final phase of a
patient’s illness when death is imminent.
End-of-life care (EOL care) is the term used for
issues and services related to death and dying.
EOL care focuses on physical and psychosocial
needs for the patient and the patient’s family.

24. 1.4.4.END-OF-LIFE CARE (Continued)
The goals for EOL care are to
1. provide comfort and supportive care
during the dying process,
2. improve the quality of the patient’s
remaining life,
3. help ensure a dignified death, and
4. provide emotional support to the family.

25. 1.5. Spirituality and Spiritual Distress
 Spirituality is defined as connectedness with self,
others, a life force, or God that allows people to
experience self-transcendence and find meaning
in life.
Spirituality helps people discover:
 a purpose in life,
 understand the vicissitudes of life,
 and develop their relationship with God or a
Higher Power.

26. 1.5. Spirituality (Continued)
A strong sense of spirituality or religious faith can
have a positive impact on health (Dunn & Horgas,
2000;
Spirituality is also a component of hope, and,
especially during chronic, serious, or terminal
illness,
patients and their families often find comfort and
emotional strength in their religious traditions or
spiritual beliefs.

27. 1.5. Spirituality (Continued)
At other times, illness and loss can cause a loss of
faith or meaning in life and a spiritual crisis.
The nursing diagnosis of spiritual distress is
applicable to those who have a disturbance in the
belief or value system that provides strength,
hope, and meaning in life.

28. 1.5. Spirituality (Continued)
Spiritually distressed patients (or family
members) may show:
 despair,
discouragement,
ambivalence, (continual fluctuation)
detachment,
anger,
ressentiment, or fear.
They may question the meaning of suffering, life,
and death, and express a sense of emptiness.

29. 1.5.1 SPIRITUAL ASSESSMENT
1. Who or what provides you strength and hope?
2. Do you use prayer in your life?
3. How do you express spirituality?
4. How would you describe your philosophy of life?
5. What type of spiritual or religious support do
you desire?
6. What is the name of your clergy, minister,
chaplain, pastor, rabbi?
7. What does suffering mean to you?
8. What does dying mean to you?

30. 1.5.1 SPIRITUAL ASSESSMENT(Continued)
9. What are your spiritual goals?
10. Is there a role of church/synagogue in your life?
11. Has belief in God been important in your life?
12. How does your faith help you cope with illness?
13. How do you keep going day after day?
14. What helps you get through this health care
experience?
15. How has illness affected you and your family?

31. 1.5.2 Interventions that
foster spiritual growth
Interventions that foster spiritual growth or
reconciliation include:
 being fully present
listening actively
conveying a sense of caring
respect, and acceptance
using therapeutic communication techniques to
encourage expression;
suggesting the use of prayer,
meditation, or imagery;
and facilitating contact with spiritual leaders or
performance of spiritual rituals (Sumner, 1998;
Sussman, 2000).

32. 1.6. Legal and ethical issues affecting
end-of-life care
Many people decide that the outcomes related to
their care should be based on their own wishes and
values.
It is important to provide information to assist
patients with these decisions.
The decisions may involve the choice for:
1. organ and tissue donations,
2. advance directives (e.g., medical power of attorney,
living wills),
3. resuscitation,
4. mechanical ventilation, and
5. feeding tube placement.

33. Exercise
The family of a man who is dying from lung
cancer tells the hospice nurse that they are
overwhelmed by the hopelessness of their
father’s situation. What can the nurse do to
provide guidance and find hope within
terminal illness?
How does the nurse assist this family to meet
their emotional, social, and spiritual needs?

35. 2.1 Definition
Pathophysiology – The study of the biologic &
physiological manifestation of disease as they correlate
with the under lying abnormalities & physiologic
disturbances.
It does not directly deal with treatment.
Rather, it explains the process of disease.
Pathology – the study of the characteristics, cause &
effects of disease.

36. 2.2 Cell injury and Cellular Adaptive Changes
Adaptation is a normal life cycle adjustment like
in growth during puberty;
changes during pregnancy or aging and stressful
life style produce physiologic changes that may
lead to adaptation or disease.
The cell constantly makes adjustments to a
changing, hostile environment to keep the
organism functioning in normal steady state

37. 2.2 Cell injury and Cellular (Continued)
Prevention of disease by the body depends on
the capacity of the affected cells to undergo self-
repair and regeneration i.e. adaptive-changes.
When cells are confronted to one of the following
stimulus, they may undergo adaptive changes.
The common stimuli are:-
a) Physical agents
 Trauma, Burn, pressure, irradiation, etc

38. adaptive changes (Continued).
b) Chemical agents
 Poisons, drugs, simple compounds, etc.
c) Micro organisms
 Bacteria
 Virus
 Fungus
 Parasites

39. adaptive changes (Continued).
d) Hypoxia
 Is the most common stimuli (cause)
 Is because of inadequate oxygen in the blood or
decreased tissue Perfusion.
e) Genetic defects

40. adaptive changes (Continued).
 Can affect cellular metabolism through inborn
errors of metabolism or gross malformation
f) Nutritional imbalances
 Under nutrition or over nutrition causes cellular
injury or changes.
g) Immunologic reaction
E.g. - Hypersensitivity reaction.

41. 2. 2.1 Types of cellular Adaptive-
changes
When cells are exposed to one of the above noxious
stimulus they will undergo one or more of the
following types of adaptive changes:-
i. Increased concentrations of normal cellular
constituents.
ii. Accumulate abnormal substances
iii. Change the cellular size or number or
iv. Undergo a lethal change.

42. Abnormal and normal accumulation of
intracellular substances
Intracellular accumulations often result from
environmental changes or an inability of the cell to
process materials (substances) that cannot be
metabolized by the cells.
These substances may accumulate in the cytoplasm.
As a result common changes include:-
 Cellular swelling

43. Abnormal and normal accumulation….
 Lipid accumulation (Fatty change process in the
cytoplasm of cells).
 Glycogen depositions (Excess deposition of glycogen
in organs).
 Calcification (precipitation of calcium in dead or
Chronic inflammation area)
 Hyaline infiltration( characteristic alteration within
cells or in the Extra-cellular spaces that appear as
inclusion on stained histology).

44. Changes to cellular size or numbers
Changes in size and numbers of the cells are usually
as a result of response to adapt to harmful agents.
The changes include:-
• I) Atrophy
Atrophy refers to a decrease in cell size.
 Causes: - Decreased work load (Disuse atrophy)
 Loss of nerve supply

45. I) Atrophy…
 Decreased blood supply
 Inadequate nutrition
 Loss of hormonal stimulation
Eg. - Uterine atrophy after menopause.
 Physiologic Atrophy
Eg. - Loss of muscle bulk with ageing.

46. II) Dysplasia
Dysplasia refers to the appearance of cells that
have undergone some atypical changes in
response to chronic irritation.
It is not a true adaptive process in that it serves
no specific functions.
It is complete loss of normal architectural
orientation of one cell with the next both in shape
and size.

47. II) Dysplasia …
Epithelial cells are common sites for dysplastic
changes.
Eg: Bronchial epithelium,
 Cervical epithelium, etc.

48. III) Hyperplasia
It is defined as increase of tissue mass due to an
increase in the number of cells.
It occurs in cells that are under increased
physiologic workload or stimulations. I.e. the
cells are capable of dividing thus increasing their
numbers.

49. Types of Hyperplasia
a) Physiologic Hyperplasia: occurs when there
hormonal stimulation
Occurs in puberty and pregnancy
b) Compensatory-Hyperplasia
Occurs in organs that are capable of regenerating
lost tissues.
Eg. When part of liver is destroyed.

50. Types of Hyperplasia…
c) Pathologic Hyperplasia
Is seen in abnormal stimulation of organs with
cells that are capable of regeneration.
E.g. Enlargement of Thyroid gland due to TSH from
pituitary gland.

51. IV) Hypertrophy
Is an increase in the size of individual cells,
resulting in increased tissue mass with out an
increase in the number of cells.
It is usually response of a specific organ to an
increased demand for work.
Example: - Enlargement of muscles in Athletes

52. V) Metaplasia
Metaplasia is a reversible change in which one
type of adult cell is replaced by another type.
It is an adaptive substitution of one cell type
more suitable to the hostile environment for
another.
Eg. - Replacement of the normal columnar, ciliated
goblet cells of the bronchial mucosa by Stratified
squamous epithelial cells in chronic smokers.

53. Types of cellular adaptive changes

54. 2.2.2. Cell Death
Cell injury can be sub lethal or lethal.
Sub lethal injury alters functions with out causing
cell death.
Causes of cell injury:
Causes of cell injury are the same causes of
cellular adaptive changes as mentioned above.

55. Classification of cell injury:-
Cellular injury can be reversible or it may
progress to irreversible change (Lethal change).
1. Reversible cell injury
• Ex. Ischemia: refers to a critical lack of blood
supply to a localized area.
The classic conditions resulting from ischemia is
Angina pectoris.

56. 2. Irreversible Cell injury
Ex. A. Infarction: Is localized area of tissue death
due to lack of blood supply.
It is also called Ischemic Necrosis.
It is due to occlusion of blood vessels by
thrombus or embolus.
Septic Infarction is added when there is evidence
of infection in the area.
Ex. Acute myocardial infarction (AMI)

57. B. Necrosis
 The term necrosis refers to cell or tissue death
characterized by structural evidence of this death.
Based on the structural changes, Necrosis is classified in to
two main classes.
1. Coagulative-Necrosis
 Usually results from lack of blood supply to an area.
 The cell structure and its architectural outline is
preserved, but the nucleus is lost (structureless necrosis)

58. 1. Coagulative-Necrosis
Caseouse Necrosis: - is a good example of
structure less necrosis.
 It is common in tuberculosis and i s characterized
by central area of necrosis which is soft, friable
and surrounded by an area with a cheesy
appearance.

59. 2. Colliquative- Necrosis (liquefactive-
Necrosis)
It frequently occurs in brain tissues,
results from break down of neurons by released
lysosomal enzymes,
resulting in formation of pockets of liquid, debris
and cyst like structures in the brain tissue.

61. 3.1 Neoplasm
3.1. Definition of terms
Neoplasm: - New abnormal growth because of
abnormal cellular- reproduction. It is synonymously
used with tumor.
Aberrant cellular growth:- An alteration in normal
cell growth
Tumor: - A growth of Neoplastic cells clustered
together to form a mass.
It can be benign or malignant.

62. 3.1 Definition (Continued)
Benign tumor: - Is characterized by abnormal cell
division but no metastasis or invasion of the
surrounding tissues.
Malignant tumor: - Abnormal cell division
characterized by ability to invade locally,
metastasize and reoccur. It is cancer cells.
Carcinogenesis: - production or origination of
cancer cells.

63. 3.1 Definition (Continued)
Sarcoma: - Malignant growth from mesodermal
tissues I.e. connective tissues, blood-vessels,
organs, etc.
Metastasis: - Ability to establish secondary
tumor growth at a new location away from the
primary tumor.
Carcinoma: - Malignant growth originating in
epithelial tissues

64. 3.2 Benign and Malignant Neoplasia
The capacity of undergoing mitosis is inherent in
all cells.
Mitosis is repressed or controlled until specific
stimulation for growth occurs.
Every time a normal cell passes through a cycle
of division, the opportunity exists for it to
become Neoplastic.

65. 3.2 Benign and Malignant (Continued)
N.B. Cancer cells lack repression or lode control of
Mitosis I.e. cancer cells are crazy cells.

66. 3.3 Classifications of Neoplasms
 Neoplasms are classified according to their cells
of origin and their behavior of growth as benign
or malignant.

67. A comparison of benign and malignant
Neoplasms
Benign
 Similar to cell of origin
 Edges move out word
smoothly
 Compress locally
 Slow growth rate
• Seldom Recur after
• removal by surgery
• Necrosis and ulceration is
uncommon
• Systemi c ef fec t i s
uncommon
Malignant
• Dissimilar from cell of origin
• Edges move out ward
irregularly.
• Invade locally
• Rapid to very rapid growth
rate.
• Frequently recur after
removal
• Necrosis and ulceration
common.
• Systemic effect common.

68. 3.4 Mechanisms of carcinogenesis
There are large numbers of research done in the
world to know the etiology of cancer but none of
the theories that attempt to explain the
peculiarities of the cancer cells have been
completely successful.
 The following are some of the theories on
carcinogenesis:

69. A. Genetic Instability
The theory of somatic cell mutation supports the
concept that mutational carcinogenic agents and
heredity susceptibility can induce genetic
abnormalities.
B. Carcinogens
Carcinogens are those substances that are capable
of inducing neoplastic growth.
They are also called oncogenes.

70. B. Carcinogens (Continued)
Some substances induce neoplastic growth at
higher doses and exposure rates while others can
be carcinogenic at lower doses and exposure
rate.
The three commonly encountered carcinogens
are:
1. Chemical carcinogens
Many chemical agents are capable of causing
Neoplasms in either humans or animals.

71. 1. Chemical carcinogens (Continued)
Chemical carcinogens are grouped as:-
A. Polycyclic aromatic hydrocarbons:-
They are common carcinogens; present in
tobacco smoke or automobile exhaust, .Usually
cause cancer of lips, oral-cavity, lungs, neck,
pancreases,

72. B. Aromatic amines
Commonly found in insecticides, certain foods and
Naphthalene.
Usually related with cancer of the bladder.
C. Alkylating agents
They can cause cancer when given in large dose. Are
usually used as therapeutic agents. example:-
• Nitrogen mustard, Mustard gas
D. Others: Like aflatoxines, nitrosamides, drugs, etc.

73. 2. Physical carcinogenic agents
Physical factors associated with carcinogenesis include:
 exposure to sunlight or radiation,
 chronic irritation or inflammation, and tobacco use.
Ionizing radiation is a recognized cause of cellular
mutations.
Damage to DNA may be direct or indirect.
A long latent period often exists between exposure
and development of clinical disease.

74. 2. Physical carcinogenic (Continued)
Example:-leukemia and skin cancers became very
common long years later in Hiroshima and
Nagasaki, Japan; after atomic bomb detonation.

75. 3. Viral carcinogens (oncogenic viruses)
Viruses are thought to cause some human and
Animals malignant neoplasms.
Current evidence shows that viruses alter the
genome of the infected cells, which then alter
the offspring of the host cells.

76. 3. Viral …
Some of the oncognic viruses are:
 EBV (Epstein-Barr virus) associated with
Burkett’s lymphoma.
HPV (Human-papilloma-virus types 16, 18, 31,
and 33 ) associated with cervical cancer and skin-
papilloma.
Herpes simplex virus type II, cytomegalovirus,

77. 3. Viral …
The hepatitis B virus is implicated in cancer of the
liver.
The bacterium Helicobacter pylori has been
associated with an increased incidence of gastric
malignancy, perhaps secondary to inflammation
and injury of gastric cells.

78. 4. Other Factors in carcinogenesis
Epidemiologic studies have revealed other
factors in the occurrence of neoplasms besides
chemical, physical and viral-carcinogens.
Some of these factors are dietary habits,
sexuality, and other personal habits like
smoking, alcohol consumption etc.

79. 4. Other Factors (Continued)
About 75% of all cancers are thought to be related
to the environment.
Tobacco smoke, thought to be the single most lethal
chemical carcinogen, accounts for at least 30% of
cancer deaths (Heath & Fontham, 2001).
Smoking is strongly associated with cancers of the
lung, head and neck, esophagus, pancreas, cervix,
and bladder.

80. 4. Other Factors (Continued)
Exposure to radioactive materials at nuclear weapon
manufacturing sites or nuclear power plants is
associated with a higher incidence of:
 leukemias,
multiple myeloma,
cancers of the lung,
bone,
breast,
thyroid, and other tissues.

81. 3.5 Metastatic Mechanisms
Lymph and blood are key mechanisms by which
cancer cells spread.
 Lymphatic spread
 Hematogenous spread
Angiogenesis Malignant cells also have the ability
to induce the growth of new capillaries from the
host tissue to meet their needs for nutrients and
oxygen.

82. Review exercise
1) List the types of cellular adaptive changes.
2) Discuss the common stimuli for cellular
changes?
3) Which of the following adaptive change have
higher chance of malignant transformation?
a) Hyperplasia b) Hypertrophy
c) Dysplasia d) None of the above
4) List the types of carcinogens.
5) Explain the most important features of
malignant cells.