Module 10, 11, 12 Test 4 review

What is an intestinal obstruction?

An occlusion of either the small or large intestine that can be partial or complete in nature. When an obstruction occurs, sequestration of gas and fluid will occur proximal to the obstruction which causes abdominal distention.

Why is an unequal pupil size (from one eye to the other) important?

When one eye responds to a stimulus (such as a light) and the other eye does not, it could be a potentially important sign of a neurological disorder or such as increased ICP or intracranial hemorrhage.

How do you know what type of stroke it is or what treatment is best?

You can't tell from the patient's symptoms...you must have a CT scan (or an MRI) to be able to tell if it is a hemorrhagic or ischemic stroke.

A diabetic educator is instructing a patient to inspect the bottom of her feet every night. The nursing student understands the purpose for this education is to prevent _________________ because the patient with diabetes may have ____________. a. infection; neuropathy b. hyperglycemia; sweaty feet c. hypoglycemia; over dosed on insulin d. macroangiopathy; a fungal infection

a

A jaundiced patient has a higher than normal indirect bilirubin. The mechanism most likely responsible for this is ________, and a likely responsible disease process is ____________. a. increased hemolysis; erythroblastosis fetalis b. increased protein intake; hepatitis. c. posthepatic obstruction; cholelithiasis. d. transmural intestinal ulceration; Crohn's disease.

a

Which assessment finding is expected in a patient with multiple sclerosis (MS)? a. Cogwheel rigidity and dysarthria. b. Ascending paralysis of the lower extremities. c. Asymmetric muscle weakness and ataxia. d. Photophobia and phonophobia.

c

Which symptoms are indicative of diverticulitis? a. Melena stools and epigastric pain. b. Fever with periumbilical pain that migrates to the right lower abdomen. c. Fever, leukocytosis and hematochezia. d. Severe, colicky abdominal pain and abdominal distension.

c

Addison's disease (hypoadrenalism)

a state of hypocortisolism & hypoaldosteronism cause: most frequent one is autoimmune attack on adrenal gland cause atrophy and hypofunction; other possible causes includes pituitary problem where not enough ACTH is secreted (hypopituitarism).

What are two bizarrely abnormal motor responses to stimuli that may be present in a patient with brain stem abnormalities?

decorticate and decerebrate posturing

Patho of ischemic brain attack

diminished perfusion to brain tissue->cellular ischemia which may lead to infarction (death of cell)->inflammatory process->swelling, cerebral edema->increased ICP->further decrease in perfusion

diverticular disease

diverticulosis—state of having diverticulum (outpouchings of muscle layer of lower intestines into lumen); most of time asymptomatic diverticulitis—diverticula become inflamed, infected; LLQ pain, fever, leukocytosis -can result in abscess formation, rupture and peritonitis if not treated adequately. .tx: increase dietary fiber, avoid certain foods (seeds, nuts); sometimes antibiotics, occasionally surgery is required

to best assess how a hemispheric stroke has affected sensorimotor status what should we do?

divide body into longitudinal halves & then consider each half above the shoulders & then below the shoulders

What is diplopia?

double vision. It may be caused by a week ocular muscle, neuromuscular disease, cerebral hemispheric diseases, or thyroid disease.

diplopia

double vision; caused by a week ocular muscle, neuromuscular disease, cerebral hemisphere diseases, or thyroid disease

Small intestines

duodenum, jejunum, ileum

diagnosis of brain attack:

dx made through history of incident, presenting S&S, CAT scan, MRI 1) public is encouraged to use the "act FAST" scale— Face: Ask the person to smile. Does one side of the face droop? Arms: Ask the person to raise both arms. Does one arm drift downward? Speech: Ask the person to repeat a simple sentence. Are the words slurred? Can he or she correctly repeat the sentence? Time: If the answer to any of the above questions is yes, time is important. Immediately, call 911 or go to the nearest hospital emergency room. Brain cells are dying. 2)often in an ER, a severity scale is used for quicker diagnosis

What is gastritis?

An inflammation that affects the gastric mucosa and can cause erosions in the mucosa. S/Sx include pain or burning over the epigastric area and occasionally bleeding.

what is an essential component (ingredient) of T3 & T4

Iodide

What are the functions of the spinothalamic tracts?

They carry sensations of pain, temperature, and crude and light touch from the body to the brain (thalamus) for processing.

What are the most common causes of a lower GI bleed?

IBD, diverticulitis, neoplasms

What "rules" sensorimotor status above the shoulders?

The 12 cranial nerves.

What are the s/sx of a patient who is post-ictal?

The patient is often dazed, confused, and may be combative. The brain's circuits are still not back to normal.

S&S of unconsciousness and unilateral decerebrate posturing would indicate a. a diffuse lesion involving edema throughout the brain. b. a focal lesion involving an increase in ICP on one side of the brain. c. Alzheimer's disease. d. multiple sclerosis.

b

aphasia

inability to speak

Type 1 DM tx

insulin

What are some etiologies of hypothyroidism?

congenital defects direct removal of tissue (tumor) or direct destruction of tissue (radiation) autoimmune thyroiditis endemic iodide deficiency

SS of HYPERthyroidism

"overactive" S&S, due to the hypermetabolic processes caused by high levels of T3, T4: LAB—T4 high, TSH low due to negative feedback pysch/CNS—nervous, irritable, tremors, insomnia, emotionally labile, sometimes psychosis (hallucinations, paranoia) 2) cardiovascular—tachycardia, increased afterload, sometimes HF due to increased heart workload 3) GI—increased appetite, diarrhea 4) hair changes-hair thins out or falls out (alopecia). 5) exophthalmus (bulging eyes from deposits of excess tissue behind eyes) 6) goiter (1) the enlargement is a result of overactive cells a) fatigue & weight loss (due to hypermetabolism) b) increased body temp & overall heat intolerance c)skin is usually flushed, warm, and damp from excessive sweating

steps for assessing patient for S&S of various kinds of BA (and other types of neurologic disorders):

#1 assess patient's autonomic status (includes LOC-- level of consciousness and mental status) #2 assess sensorimotor system (2A- above shoulders, 2B-below shoulders) #3 assess reflexes

diminished hepatocyte function other

(1) Kupffer cells no longer function properly to filter out bacteria, plus leukopenia from splenomegaly = increased risk of infection (2)jaundice from inability to conjugate bilirubin HIGH unconjugated LOW conjugated

problems related to portal hypertension

(1) ascites manifested by a large distended abdomen- due to increased back pressure in the portal veins-> increased hydrostatic pressure in all the veins of the area->fluid is forced into abdominal cavity (2) splenomegaly-shunting of blood into splenic vein enlarges spleen (1) syndrome develops called hypersplenism— stasis of blood in the abnormally large spleen causes RBCs, thrombocytes, and WBCs to undergo more breakdown than usual due to their prolonged time in the spleen (2) sequelae include anemia, thrombocytopenia, leukopenia-> S&S of fatigue & SOB, easy bleeding / bruising, and/or increased susceptibility to infection (3) varices—hemorrhoidal, esophageal. -enlarged, thin-walled veins (1) , rectum (hemorrhoids), (2)worst one is esophageal varices --can easily rupture & pt can bleed to death from huge outpouring of blood into esophagus-causes hematemesis and blood loss (4) hepatic encephalopathy S&S of this range from lack of mental alertness to confusion to coma; blurred vision, tremors, szres; very early sign is flapping tremor of hands called _asterixis (AKA "liver flap")

patho of portal HTN

(1) because of fibrotic liver tissue that develops with cirrhosis, the liver essentially becomes resistant to portal system—the system of veins & venous flow between organs in the abdomen—spleen, stomach, liver, pancreas, intestines -> normal portal venous flow (2) ->venous pressure in the liver area begins to climb as venous flow tries to overcome the resistance—this is called portal hypertension.. (3)->venous back pressure increases & the veins going into the liver begin to dilate-> the liver & its surrounding area begin to be engorged with larger-than-normal amount of venous blood.

diminished hepatocyte function problems with metabolism (breakdown) of many substances, including ammonia, drugs & hormones

(1) decreased ability to break down ammonia into urea, resulting in increased blood ammonia levels - hepatic encephalopathy ( very early sign is flapping tremor of hands called _asterixis (AKA "liver flap") (2) sex hormones can't be broken down, so men may get gynecomastia (breast growth in men), & women may get hirsutism (abnormal hair growth). (3) glucocorticoids can't be broken down-> hypercortisolism-> Cushing's syndrome (4) aldosterone can't be broken down-> hyperaldosteronemia -> salt & fluid retention-> ascites and generalized edema. (5) drugs can't be broken down PLUS not enough albumin to bind to-> this would cause increased effect of drugs

diminished hepatocyte function protein depletion problems

(1) decreased levels of plasma proteins, which contributes to fluid shift problems such as ascites & peripheral edema, pulmonary edema (cough, SOB, crackles heard in lungs) (2) decreased levels of clotting factors-- fibrinogen, prothrombin, other factors (a) this is partially due to inability to create these proteins (b) result-- will tend to bleed easily & labs reflecting clotting times will be abnormal; ex--PT, PTT will be prolonged (note: contributing to bleeding problems will be thrombocytopenia from splenomegaly [hypersplenism])

meningitis

(infection /inflammation of meninges) -inflammation causes increased permeability of meningeal structure -> edema -> this irritates nerve endings of spinal meninges plus often causes cerebral edema

multiple sclerosis

- autoimmune disorder in which our own T-cells attack myelin sheaths of random axons in the brain. - this eventually causes scarring & sclerosing of the myelin sheath cells, affecting the parts of the body controlled by those areas; this is called demyelination - since myelin sheaths are important in maintaining velocity of nerve signals, damage to the myelin results in slowed or interrupted signals

intestinal obstruction

- can be partial or complete occur anywhere in intestines types: - direct blockage—tumor, hernia - slowed / absent peristalsis—paralytic ileus (sometimes happens post-surgery—prevent by early mobility) - ischemic / strangulation type situation: intussusception—telescoping of one portion of bowel into another; volvulus—twisting of intestine S&S—pain, distention, N, V, dehydration, lyte imbalance; tx—prevention by keeping pt as mobile as possible, NG tube to relieve distention, fluid & lyte replacement, surgery.

myasthenia gravis causes

- caused by autoantibodies that destroy acetylcholine receptors at the distal end of neuromuscular junction - characterized by weakness that gets worse with activity and better with rest

migraines patho/causes

- headache syndrome thought to be a disorder of blood flow to brain combined with hyperreactivity of certain neural pain-information tracts. -hyperreactivity can be triggered by, red wine, chocolate, certain cheeses OR the trigger can also be a stressful event, or a smell, a sound,

DM is characterized by:

- hyperglycemia & glucosuria, and also (most of the time) long-term problems that are system-wide - usually also polyuria & polydipsia, so DM is a DRY disease. 3rd "P" is polyphagia, excess hunger, seen in DM Type I

Cirrhosis S&S are related to the sequela of two basic factors:

- inability of diseased hepatocytes to carry out normal metabolic functions AND/OR - obstructive problems from normal cells being replaced with stiff, fibrotic tissue—this causes resistance to venous flow & results in portal hypertension

UPPER GI (UGI—esophagus, stomach, duodenum) BLEED. Example disease processes:

-PUD (peptic ulcer dz), Crohn's. 1.Hematemesis (blood in vomitus)--> ->Occult bleeding ...blood is present in vomitus, but not visible to naked eye OR ->Frank bleeding ...blood in vomitus is visible to naked eye; two possibilities in the nature of what might be seen: AND/OR Obvious bloodiness— usually occurs in very acute bleeds in which there hasn't been time for digestion by stomach -"Coffee-ground emesis"—this occurs in somewhat slower bleeds in which there has been time for digestion of blood in stomach (the partially digested blood 2. Blood in stools -->Melena (black, tarry stool) ...presence of blood is visible to naked eye as black, tarry stool... this is because any UGI blood that makes its way into stool has been partially digested (broken down) by stomach OR Occult bleeding ...blood is present in stool, but not visible to naked eye

SS of SIADH

-decreased urine output (oliguria) because your body is holding onto water inappropriately in the vascular space b) B to T -> edema. c) peripheral & pulmonary edema. (crackles can be heard) characterized by abnormally high levels of ADH: you "hold onto" water too much by abnormally decreasing urination -> results in increased vascular fluid volume -> essentially means that water has been added to the blood = diluted plasma compartment & lower serum osmolality-> small amounts highly concentrated urine

Type 1 DM SS

-polyuria (large amounts of urine) -dehydration-> poor skin turgor, dry skin from fluid being pulled from T to B and then being peed out, dry mucus membranes -polydipsia (great thirst), -glucosuria -High BS--untreated> 200-300 -fatigue because of less ATPs -polyphagia because body trying to get more food energy -fat loss, then muscle loss due to gluconeogenesis-> thin person. -ketonemia, ketonuria & acetone breath due to body trying to get rid of excess ketones from gluconeogenesis -ABGs show metabolic acidosis -patient might have acetone breath (ketones are being blown off) -might have Kussmaul respirations to blow off CO2 & bring up pH. - if not treated, side effects of gluconeogenesis can lead to DKA (diabetic ketoacidosis); (crisis state) - extreme state-> patient could become unconscious (from irritating effects of acidosis on brain tissue)—this would be a form of diabetic coma.

focal problems:

-usually associated with asymmetric, unilateral findings- - focal S&S in the body, depending on where in the brain the lesion is - if there is focal pressure (lesion, edema, etc) on motor tracts in brain there would likely be paresis (and maybe reflex changes) on contralateral side of the body below the neck (opposite to where the brain lesion is) - if there is focal pressure on CN's there would likely be abnormalities in facial movement, visual disturbances and pupillary response to light.

the differences in hypoglycemic situations & diabetic ones:

1) one has low BS, the other has high 2) one has WET S&S & the other has DRY S&S. 3) hypoglycemic crises occur much more rapidly than diabetic ones, so of the two, hypoglycemia is more dangerous.

jaundice (icterus)

deposition of excess bilirubin under skin, mucous membranes, sclera of eyes; types (based on the part of the bilirubin cycle that has been altered)—prehepatic, hepatic, posthepatic

acute pancreatitis SS and dx

1) pain in epigastric area --abrupt onset of post-prandial or post-alcohol- ingestion epigastric pain that is severe and often radiates to the back 2) jaundice may appear because of biliary obstruction/inflammation c. diagnosis 1) labs-- serum amylase & lipase will be elevated; may also have leukocytosis 2) abdominal CT (CAT scan).

Let's start all over...the nurse is assessing a patient in the ED. The patient is awake, alert and oriented X 4 (person, place, time and events). We have already identified from the presenting S&S that there is some kind of lesion/pathology in the left hemisphere. A CT or MRI is needed for a diagnosis of "what's going on in the head". •If the diagnosis was a hemorrhagic brain attack, what additional S&S might have been stated by the patient? •How does the treatment for a hemorrhagic BA differ from an ischemic BA? •Is the mortality rate the same for a hemorrhagic BA and an ischemic BA?

1 •intense headaches. Described as "the worse headache" ever experienced, neck pain, light intolerance, nausea and vomiting. 2 Medical treatment -surgical intervention may be needed. Would we given them the clot buster? NO!

A stroke patient refuses to acknowledge that there is anything wrong with him. He also has some facial drooping. (1) where is the focal lesion—right or left hemisphere? (2) which side of the face would likely be drooping? (3) what side below the shoulders would have hemiparesis? (4) what other special functions problems do you expect him to have?

1) Right hemisphere. (Special functions of the right hemisphere include spatiality, insight into their disease, facial recognition, musical/creativity ability). 2)Left side (contralateral to the right hemisphere.) 3) Left-sided weakness (contralateral to the right hemisphere). 4)Left-sided neglect, unable to recognize family members. (Special functions of the right hemisphere include spatiality, insight into their disease, facial recognition, musical/creativity ability).

Type II DM causes

1) abnormally low insulin production (but there is SOME insulin) and 2) impaired insulin utilization (insulin resistance)

most common underlying etiologies of brain attack (BA) are:

1) atherosclerosis of cerebral arteries (within the brain) and/or of incoming arteries (carotids & vertebral arteries). 2) HTN 3)"other"— brain aneurysms, heart problems -> which can lead to ↓ cardiac output ->↓ blood to brain.

You shine a penlight into a patient's eyes; both pupils remain fixed and dilated instead of constricting. The patient is comatose. (1) where is the lesion/problem? (2) which arm and leg would most likely be flaccid? (3) identify two abnormal findings, likely to be seen, related to the autonomic system? (4) identify two abnormal findings, likely to be seen, related to the reflexes?

1) brain stem (bilateral loss of pupillary light reflex, both pupils are either: fixed n dilated OR fixed n pinpoint) 2) Both. Sensation, muscle tone, movement, & strength would be weaker bilaterally & often symmetrically. May see abnormal movements such as decerebrate or decorticate posturing. 3) HR and blood pressure changes as well as abnormal/irregular breathing patterns. Breathing may stop completely (apnea). 4)Loss of protective reflexes such as the gag reflex. A positive Babinski in both feet

ascites can be caused by one or more of three factors in liver disease:

1) decreased ability of liver to metabolize aldosterone -> therefore there is increased aldosterone in the circulation -> causes increase in salt retention -> water retention -> increased plasma volume & decreased serum osmolality -> fluid shifts into the abdominal tissue / cavity. 2) decreased ability of liver to create proteins -> decreased serum albumin (& other proteins)-> decreased serum oncotic pressure -> fluid shifts into the abdominal cavity. 3) increased back pressure in the portal veins

Alzheimer's disease causes:

1) exact cause unknown, but thought to be due to genetic mutation that improperly encodes a normal protein called amyloid -> end result is accumulation of abnormal amyloid in brain -> the abnormal amyloid forms plaque-like material called senile plaques. 2) also, microtubules of neurons in the brain become distorted and twisted and form a neurofibrillary tangle. 3) the amyloid plaques and the neurofibrillary tangle combine to disrupt normal nerve impulses in the brain.

Alzheimer's disease a. types:

1) familial Alzheimer's (FAD)—inheritance-linked - can be early onset or late 2) non-hereditary (AKA sporadic)-- late onset—70% of cases

ulcerative colitis

1) found only in colon, not small intestines-- severe inflammation and ulcerations begin in the rectum & progress to involve entire colon 2) the involved segments are not separated by normal tissue—ie, areas are confluent, not patchy 3) inflammation and ulcerations are usually not transmural—do not extend beyond submucosa b. S&Ss-- many of same S&Ss as Crohn's; main differences: 1) dehydration risk more severe in ulcerative colitis because colon is usually the site of main water reabsorption by body 2) risk not as high for nutritional deficiency in ulcerative colitis compared to Crohn's

Cushing's syndrome or disease

1) hypercortisolism— a) usually called Cushing's syndrome when the high levels of cortisol are due to receiving chronic steroid treatment (remember, exogenous steroids are essentially cortisol) b) usually called Cushing's disease in two general situations: (1) there is pathologic oversecretion of adrenocorticotropic hormone (ACTH) from the pituitary gland - if pituitary malfunctions, such as when there is a pituitary tumor, the amount of ACTH is abnormally high- stimulates adrenal cortex to secrete abnormally high amounts of cortisol and/or (2) the adrenal cortex itself has a tumor or other malfunction that causes it to hypersecrete cortisol. 2) hyperaldosteronism - oversecretion of aldosterone by adrenal cortex.

A patient is alert and oriented X 4. He is able to smile to command on the left side of his face, but not on the right, which droops a bit—ie, he definitely has facial asymmetry. (1) where is the focal lesion—right or left hemisphere? (2) in which hand do you expect to have a weaker-than normal grip (hemiparesis)? (3) what "special functions" problems do you expect him to have?

1) left hemisphere (contralateral to the facial drooping) 2) right-sided weakness (contralateral to the left hemisphere). 3) Difficulty with speech - aphasia or dysphasia and difficulty doing math, organizing, reasoning etc. (Special functions of the left hemisphere are speech, math, organize, reason and analyze).

thus the risk factors for BA are same for all atherosclerotic disorders & include:

1) preexisting hx of atherosclerosis in any part of body 2) preexisting hx of HTN 3) older age (most strokes occur in pts over 65, though 28% occur in younger) 4) family history 5) diabetes (pts w/ DM are 3 times more likely to have strokes) 6) lifestyle choices such as smoking (increases risk by 50%) and high-fat diets

severe episodic headaches that occur in a typical pattern for each person but usually some elements are common:

1) prodrome (S&S before the headache, may include an aura =perception of a strange light, an unpleasant smell or confusing thoughts) 2) headache itself, which is often unilateral and accompanied by N,V, photophobia (light hurts eyes), phonophobia (sound hurts ears) 3) postdrome—washed out, tired, weak.

diminished hepatocyte function nutritional problems due to impaired...

1) production of bile salts->unable to absorb fat & fat- soluble vitamins—will have many vitamin deficiencies, weight loss (2)fat & cholesterol metabolism, will have impaired synthesis of lipoproteins & altered cholesterol levels -inappropriate distribution of lipoproteins-low HDLs, more LDLs (3) glycogenolysis & gluconeogenesis, may easily become -hypoglycemic because no back up glucose

hemoccult test

1) testing of the stool for small, hidden (""occult") amounts of blood—stool may look normal but still have blood from hidden disease process (AKA, "hemoccult positive") 2) used to screen for colon cancer & other causes of occult bleeding such as peptic ulcer disease (PUD).

causes of hemorrhagic brain attack

1) the pressure of hypertension 2) weakened arterial walls from atherosclerosis 3) aneurysms-- pts with intracranial aneurysms can remain asymptomatic for many years, but once leakage of blood and/or rupture begins, usually have intense headache and may suddenly lapse into unconsciousness 4) congenital vascular malformations—deformities in the arteries that predispose them to bleed 5) bleeding into a tumor 6) coagulation disorders (ex—hemophilia, excess coumadin, etc)

blood test results that reflect prehepatic jaundice:

1) total serum bili high (norm = 0.3 to 1.0) 2) serum indirect bilirubin (ie, unconjugated bili) —high 3)serum direct bilirubin —normal

blood test results that reflect hepatic jaundice:

1) total serum bili: high or normal 2) serum indirect bilirubin (ie, unconjugated bili): —high 3) serum direct bilirubin —low (because the diseased liver cannot conjugate)

blood test results that reflect posthepatic jaundice:

1) total serum bilirubin—high 2) indirect bilirubin—normal. 3) direct bilirubin--—high.

Tx for Migraines

1) trigger-avoidance 2) NSAIDS to help with the inflammatory component that can occur and add to the pain. 3) "abortive" drugs, such as Immitrex, that patients are instructed to use at the start of their migraine - at the first sign of the prodrome.

cerebellar BA SS

1) vertebral -basilar artery occlusion/near-occlusion 2) problems with coordination and balance are commonly seen 3) vertigo, nystagmus (rapid eye movement). 4) nausea and vomiting . 5) loss of coordination.

A patient is diagnosed with hypocalcemia. What hormone abnormalities would cause this state? Explain how the hormone works. Identify the S&S of hypocalcemia

1-OVER production (too much) calcitonin would cause hypocalcemia. UNDER production of parathyroid hormone (PTH) would also cause hypocalcemia 2-Calcitonin works by decreasing osteoclastic activity and moving calcium into bone. PTH works by, first, increasing osteoclastic activity which then allows for the movement of calcium (stored in the bone) into blood. The movement of calcium from bone into blood is known as bone resorption 3-. Tetany, muscle spasms, + Chvostek's, petechiae, purpura

A patient is diagnosed with hypercalcemia. What hormone abnormalities would cause this state? Explain how the hormone works. Identify the S&S of hypercalcemia

1-UNDER production (too little) calcitonin would cause hypercalcemia. OVER production of parathyroid hormone (PTH) would also cause hypercalcemia 2-Calcitonin works by decreasing osteoclastic activity and moving calcium into bone. PTH works by, first, increasing osteoclastic activity which then allows for the movement of calcium (stored in the bone) into blood. The movement of calcium from bone into blood is known as bone resorption. 3-Lethargy, weakness, renal calculi, osteoporosis

What are the first interventions in a hospital setting for stroke?

1. Prevention of further increase of ICP: give oxygen, manage BP, keep the head of the bed up at least 30 degrees, administer diuretics, sometimes monitor ICP more directly. 2. Determine the type of stroke (hemorrhagic or ischemic) by using a CT scan. 3. Treatment is based on the type of stroke: ischemic stoke = anticoagulant therapy of some type, hemorrhagic stroke = possibly a surgical intervention.

INCREASED HYDROSTATIC PRESSURE IN PORTAL VEINS

1. fluid is pushed from vessels in the abdomen into abdominal tissue -ascites (manifested by a large, distended abdomen) 2.fluid backs up into spleen->splenomegaly-> blood pools in the enlarged spleen & results in syndrome called hypersplenism—this is the spleen's normal functions taken to extreme-> --excess destruction of RBCs- anemia-fatigue, SOB --excess destruction of WBCs - leukopenia-infection risk increased --excess destruction of platelets- thrombocytopenia-easy bleeding 3. veins all along the GI tract enlarge from all the extra pressure->varices (enlarged veins)> hemorrhoidal, esophageal -hemorrhoids - protrude into rectal areas-- uncomfortable, not usually serious -esophageal varices- enlarged veins of esophagus can sometimes rupture & cause serious hematemesis & blood loss

What are the sequelae of Type I diabetes (having no insulin production)?

1. glucose can't get into the cells, so it accumulates in the blood. This results in hyperglycemia/ glucosuria, polydipsia, and polyuria. 2. Without glucose, cells have no energy source. This results in gluconeogenesis (high ketones in blood, acetone breath, ketonuria), polyphagia, fatigue, weight loss).

Type 1 DM ACUTE sequela of no insulin

1. hyperglycemia & its untoward effects, including dehydration 2. no cellular energy source

Problems related to diminished hepatocyte function

1. nutritional problems 2. protein depletion problems 3. problems with metabolism (breakdown) of many substances 4. other

What would be some typical s/sx of a patient with a cerebral hemispheric stroke?

1. sensorimotor deficits caused by the lesion / pressure on the CNs in / near the affected area in that hemisphere 2. sensorimotor deficits caused by the lesion / pressure on the corticospinal tracts in / near the affected area in that hemisphere 3. deficits based on what special functions are controlled by that hemisphere

hematemesis _—sudden vomiting of blood TYPES:

1. visible, or "frank" hematemesis (usually seen with acute problems): a) bright red, usually indicating very acute problem like esophageal bleeding or erosion of artery related to peptic ulcer 2. "coffee ground" hematemesis—brownish-red with flecks, indicating there is acute bleeding but it has had a little more time to be partially digested in the stomach or duodenum 3. occult bleeding-- vomitus looks normal, but actually has small amt of hidden blood from a slower, perhaps chronic bleeding situation

What are the three main assessment points for a stroke patient?

1.) assess autonomic status (includes level of consciousness and vital signs). 2.) assess sensorimotor status above and below the shoulders 3.) assess reflexes

What is hypoglycemia?

A blood glucose below 70 plus the following s/sx: weakness, fatigue, mental fogginess, apathy, confusion, shakiness, irritability, sweating "Cold and clammy? Need some candy!"

metabolic syndrome

25% of people in US have this!!! b. it is a cluster of traits that SIGNIFICANTLY increases risk for CV disease: 1) Type II DM with its hyperglycemia and insulin resistance 2) elevated triglycerides, decreased HDL 3) HTN 4) abdominal obesity

if there is focal cerebral edema around the right CN VII, that innervates a smile, you would expect to see

facial drooping on the opposite side of the mouth.

What is a normal fasting serum glucose?

70 - 99

What symptoms are specific to Chron's disease?

70% of cases involve the small intestines transmural involvement of the wall patchy pattern of inflammation malabsorption, malnutrition, weight loss, since most nutrients are absorbed in the small intestine

normal fasting serum glucose

= 70 to 99 (glucose level normally rises after meals, but should normalize as insulin "ushers" it into cells)

What are the risk factors for colorectal cancer?

50+ years, high-fat diet, obesity, sedentary lifestyle, smoking, ETOH over consumption, and family history.

What are the s/sx of diabetes type II?

fatigue, mild polydipsia and polyuria fasting blood sugar that is higher than normal sometimes the first signs are organ damage from chronically high blood sugar

What is dementia?

A chronic dysfunction of memory and / or function that develops over time.

What is a hiatal hernia?

A herniation of the stomach through the diaphragm so that it protrudes into the thoracic cavity. The patient may experience GERD, epigastric pain, dysphagia, or no s/sx at al.

What is the "Act FAST..." scale?

A method of assessing for stroke that the public is encouraged to use. Face = Ask the person to smile. Does one side of the face droop? Arms = Ask the person to raise both arms. Does one arm drift downward? Speech = Ask the person to repeat a simple sentence. Are the words slurred? Can s/he correctly repeat the sentence? Time = If the answer to any of the above three questions is yes, time is important. Immediately call 911 or go to the nearest hospital emergency room. Brain cells are dying.

What is age-related macular degeneration?

A severe and irreversible loss of central vision due to the destruction of the macula (it's like having a black spot in the center of your vision). There is no effective treatment.

What is the difference between acute gastritis and chronic gastritis?

Acute gastritis - typically results from NSAIDS or ETOH overuse and can heal with removal of offending agent. Chronic gastritis (aka atrophic gastritis) - thought to be an autoimmune etiology, occurs mainly in the elderly, an atrophy of the gastric mucosa occurs and the patient develops pernicious anemia because of the loss of intrinsic factor.

paralytic ileus

AKA just "ileus")-- loss of peristaltic motor activity in the intestine 1) not a physical obstruction, but a functional one, because all peristalsis stops, & fluids, gases, etc, build up, causing distention, constipation, pain, etc 2) associated with immobility, post-anesthesia effects, surgery (especially abdominal), peritonitis, electrolyte imbalances, spinal trauma. 3)prevention—increasing patient mobility as soon as possible

What is cystic fibrosis?

An autosomal recessive disorder in which s/sx develop by the age of 6 months. An abnormality in the chloride channel causes thickened secretions in various systems, including the lungs and pancreas.

What would be the cause of a diffuse brain / brain stem stroke?

An event would have to happen that causes the whole brain to become hypoxic and edematous with increased ICP. For example: the patient's heart stops beating and they stop breathing or there is a complete occlusion of the vertebral - basilar artery.

What is a myxedema coma or a myxedema crisis?

An extreme state of hypothyroidism that is precipitated by a stressor such as an infection, drug, exposure to cold, or trauma. Manifested by progression of hypothyroid sluggishness and drowsiness into gradual or sudden impaired consciousness and often hypotension and hypoventilation.

What is meningitis?

An infection & inflammation of the meninges. There are two types viral (aseptic) and bacterial meningitis.

What is hepatitis?

An inflammation of the liver, which may come from one of many etiologies, including: autoimmune, microbes (including viruses), and even idiopathic causes.

Type I diabetics have a _______ ________ of insulin secreted from the beta cells of the pancreas.

total lack

What places a patient at risk for peptic ulcer disease?

ASA, NSAID, and /or chronic steroid use (anything that suppresses the synthesis and activity of the protective prostaglandins) heavy alcohol use cigarette smoking chronic diseases - chronic gastritis, liver disease, CKD, diabetes, COPD severe psychological stress the presence of H. pylori, which increases your vulnerability to injury by hydrochloric acid and pepsin

What are the s/sx of an intestinal obstruction?

Abdominal distention, severe colicky abdominal cramping, nausea / vomiting, constipation (full obstruction) or diarrhea (partial obstruction)

Identify possible etiologies for Addison's Disease?

Addison's disease can occur because of a pituitary under secretion of ACTH or autoimmune disease which causes adrenal atrophy and hypofunction

What are the s/sx of a patient with hypothyroidism?

All s/sx are "hypoactive" due to the hypometabolic processes caused by the low levels of T3 and T4. Examples of some, but not all s/sx: psych: confusion, slow speech and thinking, memory loss. Cardio: bradycardia, decr. CO, anemia. GI: decr. appetite, constipation. Misc: alopecia, myxedema, goiter, cold intolerance, weight gain.

What s/sx would a patient have when they are diagnosed with Graves' disease?

All s/sx are "overactive" due to the hypermetabolic processes caused by the high levels of T3 and T4. Examples of some, but not all s/sx: psych: nervous, irritable, tremors, psychosis. Cardio: tachycardia, incr. afterload, HF. GI: incr. appetite, diarrhea. Misc: exophthalmus, goiter, fatigue, weight loss, damp skin.

What is delirium?

An acute state of confusion due to problems such as high fever, electrolyte imbalances, etc.

What is glaucoma?

An age-related disease process in which there is an elevation of intra-occular pressure that results in a loss of visual fields and can eventually lead to blindness.

What is Graves disease?

An autoimmune disorder in which autoantibodies attack / stimulate TSH receptors on the thyroid. This results in an increase in production of T3 and T4 by the thyroid.

The RN (registered nurse) is assessing a patient who has been diagnosed with a left hemispheric brain attack (BA). Which clinical manifestations would the RN document? a. Hemiparesis of the left arm and aphasia. b. Hemiparesis of the right arm and dysphasia. c. Diplopia and ataxia. d. Inability to recognize family members and emotional lability.

b

The patient at most risk for an intestinal obstruction would be one who a. smokes and consumes large amounts of caffeine. b. is on prolonged bedrest. c. is eating a high fiber diet. d. has diverticulosis.

b

posthepatic, or obstructive jaundice

conjugated bili unable able to reach the intestines (blockage due to gallbladder problems, tumor, etc) - back pressure causes the conjugated bili to "leak" into the blood-> high direct bili, normal indirect. a hallmark sign of obstructive jaundice is stool that is gray-colored (lack of pigment from bilirubin)

at any given time there is a certain, normal amount of calcium in circulation; when the serum calcium is LOWER than normal called

hypocalcemia

Addison's disease has two main components. What are they?

hypocortisolism and hypoaldosteronism

sequelae of HYPOcortisolism

hypoglycemia, which results in fatigue, weakness, apathy, confusion; also anorexia, N, V, D, weight loss

What are some causes of hepatic jaundice?

a problem exists with diseased hepatocytes due to hepatitis or cirrhosis, so the liver cannot conjugate the the unconjugated bili that arrives.

§After receiving insulin and IV fluids all day, the patient's blood sugar and serum osmolality level are returning to a near-normal level. She is awake and alert but upset because she has "soiled" herself with urine. What might be a reason for her poor bladder control?

Autonomic neuropathy ---damage to nerves of the autonomic system from hyperglycemia- can cause poor bladder control, slowing of the gut (gastroparesis—see nausea, vomiting, poor appetite) or poor pain transmission

What are some causes of post-hepatic (aka. obstructive) jaundice.

a problem with the flow of conjugated bilirubin making it's way to the intestines due to an obstruction or inflammation. Ex: cholecystitis, choledocholithiasis,tumor of the area, etc.

If there is a focal lesion related to a cranial nerve, what type of assessment findings would you expect to have?

Asymmetric findings with the defect manifesting itself unilaterally on the opposite side. Example: if there is focal cerebral edema around the right cranial nerves you would see facial drooping on the left side of the face.

What are some typical s/sx of migraines?

a prodrome (s/sx before the headache, which may also include an aura) the headache itself, which may be unilateral, and accompanied by nausea, vomiting, photophobia, or phonophobia. a postdrome, where the patient complains of feeling week, tired, or washed out.

PTH enhances movement of calcium from bone into bloodstream by

increasing osteoclastic activity (calcium goes from BONE TO BLOOD)

When Assessing pupillary response (CN II & III) and note whether

BOTH pupils EQUALLY respond to light - both pupils should constrict to the same size.

hemorrhagic brain attack SS

BUT typically cause: (a) intense headaches. Described as "the worse headache" ever experienced. (b) neck pain (c) light intolerance (d) nausea and vomiting 4) higher mortality rate with hemorrhagic strokes.

What is portal hypertension?

Because fibrotic liver tissue develops in cirrhosis, the liver essentially becomes resistant to normal portal venous flow. Venous pressure in the liver area begins to climb as venous flow tries to overcome the resistance. Venous back pressure increases, veins going into the liver begin to dilate, the liver and the surrounding area begin to be engorged with larger than normal amounts of venous blood.

Abnormalities of pupillary light reflex:

Bilateral loss of pupillary light response - both pupils either fixed and dilated or fixed and pinpoint - indicates a lesion in the brain stem.

What are the symptoms for hyperglycemia-hyperosmolar-nonketotic syndrome?

Blood glucose 400 - 900+ (often reached slowly and are overlooked) very high serum osmolality, extreme polyuria, extreme dehydration If not treated, HHNKS can progress to a diabetic coma. "Hot and dry? Sugar high!"

What are typical vital signs to assess and what do they indicate when they are normal?

Blood pressure (BP), heart rate (HR), respiratory rate (RR), temperature. When they are within a normal range, it is an indicator that the brain stem is functioning normally.

a patient stops breathing/heart stops beating OR complete occlusion of the vertebral-basilar artery-> decreased blood flow to the brain or brain stem -> diffuse brain/brain stem hypoxia ->cellular edema -> IICP

Brain/brain stem stroke example

How do diabetics monitor their blood sugar?

By pricking their finger several times daily and every few months using a glycosylated hemoglobin test (Hgb A1c). Goal for Hgb A1C: less than or equal to 7%.

abnormal CPP often results in increased ICP:

CPP can be too low in states like hypotension, hypovolemia, atherosclerosis of carotid arteries, etc—this can cause ischemia & hypoxemia of the brain -> cerebral edema -> increased ICP or CPP can be too high (ex—high BP) and cause intracerebral bleeding, etc-> edema-> increased ICP.

What are the two types of diseases listed in inflammatory bowel disease?

Chron's disease and ulcerative colitis

What are the s/sx of cholecystitis?

Colicky pain in the RUQ and epigastric area (or referred pain to the right shoulder, right scapula, and back) that is worse after a high fat meal. Also nausea and vomiting, obstructive jaundice and gray stools.

•The patient is being given insulin for DKA. During her care of the patient, the nurse should monitor for which manifestations as a sign of hypoglycemia?

Confusion, fatigue, weakness, shakiness, irritability, sweating, tachycardia are S&S of hypoglycemia.

Which type of bilirubin is water soluable?

Conjugated bilirubin is water soluable, which makes it easier to be sent to the blood and the kidneys for excretion.

How is Hepatitis A transmitted? How is Hepatitis B & C transmitted?

Hep A = enteral (tainted food) Hep B & C = parenteral (IV drug abuse, receiving blood, needlestick from an infected patient, sexual transmission.

What is gastroesophageal reflux disorder (GERD)?

a reflux of hydrochloric acid and pepsin from the stomach into the esophagus, which may be due to a relaxation of the lower esophageal sphincter and / or a delayed emptying of the stomach.

What are some typical s/sx of alzheimer's disease?

Dementia, behavioral changes, emotional upset, possible posture and motor/gait changes due to neurofibrillary tangles and amyloid plaques present in brain.

dx & tx of GB problems

Dx: often leukocytosis (from inflammation & sometimes infection) 2) high direct bilirubin levels (an obstructive process) b. other tests: ultrasound (can detect stones as small as 1-2cm), CAT scan tx:, but if the GB is inflamed enough, the tx of choice is often to remove it (cholecystectomy)

What is papilledema?

Edema and inflammation of the optic nerve where it enters the retina. This is caused by the blockage of venous return from the retina mainly because of increased ICP.

What is cirrhosis?

End stage, irreversible disease of the liver. It usually begins with some inflammatory initiation, which eventually leads to most of normal architecture of the entire liver being destroyed and replaced with fibrous tissue and abnormal nodules.

What are some tests that are used to assess the GI system?

Endoscopy - a general term for passing a scope into the GI tract for direct visualization. Esophagogastroduodenoscopy - visualization of the esophagus, stomach, and duodenum Colonoscopy - visualization of the rectum, colon, and distal small bowel. x-rays (may be done with or without barium to aid in seeing the GI tract) - an upper GI series or a lower GI series hemoccult test - used to screen for colon cancer and other causes of occult bleeding in the stool (such as PUD)

thyroid storm (AKA thyrotoxicosis)

Extreme version of HYPERthyroidism triggered by some stressor such as infection, trauma, surgery, etc 1) neuro: extreme restlessness & agitation; delirium; seizures; coma. 2) circulatory: severe tachycardia, heart failure, shock 3) other: diaphoresis, hyperthermia (103-105 F)

What is Barrett's esophagus?

a relatively uncommon disorder that is almost always caused by GERD where the esophagus tissue can become dysplastic, and if untreated can lead to esophageal cancer.

Why are fat emboli a problem in long bone fractures?

Fat emboli occur when fat is released from the marrow of broken / injured long bones to systemic circulation. The fat globules can lodge in the smaller circulation of the lungs, brain, or kidney causing inflammation and ischemia.

What are the two types of seizures?

General seizures: the patient is always unconscious and the movement is tonic-clonic (alternating ridigity and contraction of muscles of the whole body) Partial seizures: begin locally and the patient can have varied levels of consciousness.

S&S have fairly acute onset (fever, malaise, jaundice); course usually mild with full recovery b) often transmitted enterally; ex-- tainted food such as oysters c) a vaccine is now available for this, but can also get immunoglobulin shot if you haven't been vaccinated & suspect that you have been exposed

HAV

a) transmitted parenterally (from "outside" the gut) via IV drug abuse, receiving blood, needlestick of infected patient & sexually b) insidious onset with potentially devastating destruction of liver cells; can exist without S&S for many years while being passed on to others unknowingly c) vaccine & immunoglobulin available for HBV, but NOT for HCV

HBV and HCV

Type II DM extreme state

HHNK—hyperglycemic, hyperosmolar, nonketotic state high BS 800-1000 cause extremely high serum osmolality, polyuria, & extreme dehydration, ABGs normal--- patient can become unconscious (usually from brain cell dehydration)—this would be another form of diabetic coma

any situation that pathologically increases PTH/ decreases calcitonin results in

HYPERcalcemia-> increase chance for kidney stones, so weakness, lethargy; also, less calcium in bone, so osteoporosis

any situation that pathologically decreases PTH/ increases calcitonin results in

HYPOcalcemia—including tetany, muscle spasms, positive Chvostek's ( Note that calcium is used in clotting -> bleeding problems could occur with hypocalcemia.

Myxedema Coma or Crisis

HYPOthyroidism extreme state precipitated by stressor such as infection, drug, exposure to cold, trauma manifested by progression of hypothyroid sluggishness & drowsiness into gradual or sudden impaired consciousness and often hypotension and hypoventilation

What is a transient ischemic attack (TIA)?

Happens in a thrombotic or embolic situation and causes the same s/sx as a fully evolved stroke, but symptoms resolve themselves within 24 hours and the event does not damage brain tissue. TIAs are a warning that a more serious, fully-evolved stroke can occur at a later date.

§The patient, who presented to the ED with a complaint of leg pain, is diagnosed with a pathological fracture of the femur. Identify the likely cause of this pathological fracture.

Hypercortisolism will cause increased breakdown of bone (increased osteoclastic activity), increased resorption and movement of calcium from bone to blood-> causing osteoporosis à porous bones are weaker and can be fractured without trauma. In addition, hypercortisolism will cause a reduced calcium absorption in the gut.

HYPERCALCEMIA

Hyperparathyroidism excess PTH-> excess resorption of calcium-> hypercalcemia--> hypopolarization rmp Calcitonin hyposecretion decreased calcitonin-> increased resorption of calcium-> hypercalcemia--> hypopolarization rmp Menopause /aging—less bone-building, more osteoclastic activity, thus commonly causes osteoporosis, though not always hypercalcemia.) S&S and/or associated with: weakness, lethargy, renal calculi, osteoporosis

What is the etiology of the S&S of hypoglycemia?

Hypoglycemia triggers the secretion of the counter regulatory hormones -glucagon, cortisol and epinephrine. The S&S are due to these counter regulatory hormones.

What is the "extreme state" of hypoglycemia?

Hypoglycemic shock or hypoglycemic coma. S/sx include those for hypoglycemia and possible loss of consciousness, seizures, and death if not treated. Remember: glucose provides fuel for the cells of the brain. They can't work without it.

HYPOCALCEMIA

Hypoparathyroidism decreased PTH-> decreased resorption of calcium-> hypocalcemia hyperpolarization rmp Calcitonin hypersecretion increased calcitonin-> decreased resorption of calcium-> hypocalcemia hyperpolarization rmp S&S and/or associated with: muscle spasms, CKD tetany, positive Chvostek's sign, petechiae & purpura

How is hypoglycemia treated?

If awake and able to follow commands: give orange juice or a packet of sugar followed by a more complex carbohydrate. If in danger of not being able to swallow or is unconscious, give IV glucose or give glucagon intramuscularly (IM) or subcutaneously (SQ)

How portal HTN comes about

If the liver begins to "stiffen" because of cirrhosis, it becomes more difficult for venous blood to enter the liver; this causes venous blood backup pressure, AKA increased hydrostatic pressure, or "pushing" pressure. As a result, the veins of the portal system enlarge and have higher pressures

What are the s/sx of Addison's disease?

In general...they're the opposite of Cushing's disease. A few extra symptoms to consider: hypoglycemia, anorexia, nausea, vomiting, diarrhea, weight loss dehydration, decreased blood volume, hypotension

What are the symptoms of closed-angle glaucoma?

In this type of glaucoma, the angle closes suddenly and unexpectedly. The patient experiences acute eye pain, blurred vision, and haloes around objects. This is considered a medical emergency.

What are the symptoms of open angle glaucoma?

In this type of glaucoma, the angle doesn't close completely, but instead slowly diminishes and stays diminished. The patient experiences a painless, slow loss of peripheral vision.

What is diverticulitis?

Inflammation / infection of the diverticula. S/sx include: LLQ pain, fever, leukocytosis and can result in abcess formation, rupture, and peritonitis if not treated adequately.

What are the common features of both Chron's disease and ulcerative colitis?

Inflammation which causes episodes of bloody diarrhea and abdominal cramps that have patterns of exacerbation and remission, often related to stress. A possible autoimmune etiology. Sometimes the patient may have systemic autoimmune symptoms. Potential problems such as: intestinal obstruction from chronic inflammation and scarring, fistula formation, and sometimes intestinal perforation and spillage of intestinal contents into abdominal cavity.

What are some potential causes of seizures?

It can be a congenital problem (such as epilepsy) or due to an acute problem in the brain (fever, stroke, head injury).

What does "resorption" mean?

It is the movement of calcium out of the bone and into the blood.

What does level of consciousness mean?

It refers to the brain's ability to respond appropriately to the environment. Expected LOC includes: being alert or easily arousable to alertness if asleep being oriented x 4 (self, time, place, events) following commands appropriately having normal speech conversing appropriately (cognition, "mental status" ok)

How do patients with cirrhosis have difficulty fighting infection?

Kupffer cells no longer function properly to filter out bacteria, plus leukopenia from splenomegaly = increased risk of infection.

What treatment is indicated for osteoporosis?

Medications may be prescribed to decrease osteoclastic activity, such as nasal calcitonin and bisphosphonates (Fosamax).

Patho of Type 1 DM no cellular energy source

NO INSULIN ->without insulin, glucose cannot get from blood into cells for use as the main source molecule of metabolic pathway in creating ATP. -> back-up plans triggered-> glycogenolysis until glycogen used up, then gluconeogenesis->uses fat & then protein to create energy form

Patho of Type 1 DM hyperglycemia & its untoward effects, including dehydration

NO INSULIN-> high BS-> exceeds renal threshold & glucose "spills" into urine-> high urine osmolality-> H2O drawn into urine from tubular cells-> polyuria & dehydration-> polydipsia, dry skin, dry mucus membranes, etc.

What are normal, expected reflex assessment findings in a neurological assessment?

Normal peripheral reflexes included an expected degree of response, which is equal bilaterally, reflects good connections in the reflex arc of he spine and also normal interpretation in the brain. Normal central reflexes include a normal cough, gag, and swallow reflex.

What are normal, expected sensorimotor findings in a neurological assessment?

Normal sensation, muscle tone, and movement that is symmetric bilaterally.

What is the etiology of diabetes type II

Obesity. Fat cells have a decreased number of insulin receptors in their cell membranes, which causes insulin resistance and the decreased ability to transport glucose inside the cells for metabolic use. The resultant hyperglycemia keeps stimulating beta cells to secrete insulin, which causes hyperinsulinemia.

bone resorption greatly exceeds bone formation

Osteoporosis

___largely responsible for calcium movement; calcitonin from thyroid is second influence; they counterbalance each other.

PTH (parathyroid hormone)

if there is a state of HYPOcalcemia, or if calcium is needed in other parts of body, PTH ____, calcitonin _____t?

PTH= increases calcitonin= suppressed -resulting in increased osteoclastic activity and bringing up serum calcium levels.

Identify complications of osteoporosis.

Pathological bone fractures = bone break without stress/injury. Osteoporosis could cause the bone to break more easily with a fall ---in comparison to an individual, of the same age without osteoporosis, who has fallen. More common for hip/vertebra to break.

gastroesophageal reflux disorder (GERD)

a. reflux of HCL (hydrochloric acid) and pepsin from the stomach into the esophagus. b. may be due to a relaxation of the lower esophageal sphincter (LES) and/or delayed emptying of the stomach. c. may have symptoms of heartburn, epigastric pain, coughing, within 1 hour of eating d.S&S worsen when lying down, aggravated by ETOH, coffee, and smoking

PTH is secreted by parathyroid gland & stimulates

resorption somewhere else; in this case refers to movement of calcium from bone

Bilirubin is the product of _____ breakdown.

RBC breakdown.

S&S of bacterial meningitis

S&S of edema of meninges surrounding brain are due to the increased ICP: (a) photophobia (pain in eyes when exposed to light); also can have blurred vision (b) headache, irritability, restlessness, decreased LOC (c) nausea & vomiting S&S of edema of meninges surrounding spinal cord manifest as signs of meningeal irritation: (a) neck stiffness, also known as nuchal ridigity. (b)positive Brudzinski's and /or Kernig's signs— maneuvers that demonstrate any kind of meningeal irritation OTHER: (1) fever (2) leukocytosis shows up in CBC (3) sometimes petechiae and purpura in meningococcal meningitis, due to bacterial endotoxin inflaming vasculature just under the skin (meningococcal is most serious kind, so when petechiae & purpura are seen, treated as medical emergency).

A patient, diagnosed with Graves' disease, is being treated. What S&S would the nurse expect to see if the dose of antithyroid medication was too low (undertreated)?

S&S of hyperthyroidism

A patient, diagnosed with Hashimoto's disease, is being treated. What S&S would the nurse expect to see if the dose of Synthroid medication was too high (over treated)?

S&S of hyperthyroidism

A patient, diagnosed with Graves' disease, is being treated. What S&S would the nurse expect to see if the dose of antithyroid medication was too high (overtreated)?

S&S of hypothyroidism

A patient, diagnosed with Hashimoto's disease, is being treated. What S&S would the nurse expect to see if the dose of Synthroid medication was too low (undertreated)?

S&S of hypothyroidism

dx of Cushing's

S&S plus obtaining cortisol levels at different times of the day (cortisol secretion is cyclical)

What are some typical s/sx of multiple sclerosis?

S/sx are usually variable, individualistic, and usually asymmetric due to demyelination of the axons in the brain. This auto-immune disease typically has patterns of exacerbation and remission. Symptoms may include, but are not limited to: paresthesias, weakness of certain muscles, vertigo, incoordination, ataxia, dysarthria, double vision, bladder control problems, etc.

SS of viral meningitis

SS in brain: photophobia headache, irritability Nausea and vomitting SS in spinal cord: neck stiffness, + Brudzinski's and Kernig's signs fever

What does the serum lab work for a patient with hypothyroidism look like?

Serum T4 and T3 will be low, and serum TSH will be high.

What is thyroid storm or thyrotoxic crisis?

The extreme state of hyperthyroidism. It is a hyperthyroid emergency and is triggered by some stressor such as infection, trauma, surgery, etc. S/sx include: extreme restlessness and agitation, delerium, seizures, coma, severe tachycardia, HF, shock, diaphoresis, hyperthermia

What rules sensorimotor status below the shoulders?

The corticospinal and spinothalamic tracts.

A patient arrives in the emergency department in a comatose state. You shine a penlight into the patient's eyes; both pupils remain fixed and dilated. What part of the brain is affected? Report anticipated assessment findings below the shoulders. Identify abnormal findings, likely to be seen, related to the autonomic system? Identify abnormal findings, likely to be seen, related to the reflexes?

The entire brain and/or brain stem. .Sensation, muscle tone, movement, & strength would be weaker bilaterally & often symmetrically. May see abnormal movements such as decerebrate or decorticate posturing HR and blood pressure changes as well as abnormal/irregular breathing patterns. Breathing may stop completely (apnea). Diminished LOC for this patient COMA. Abnormal Vital Signs Temp, HR, RR, BP •Bilateral abnormal or absent peripheral reflexes---bilateral positive Babinski. Abnormal or absent CENTRAL reflexes. Central reflexes include cough, gag, blink reflexes. Do not have the protective reflexis- known as central reflexes.

What are some potential causes of migraines?

The exact cause is unknown, but it is thought to be a disorder of blood flow to the brain. In addition, some individuals have are thought to have a hyperreactivity to certain stressful events or chemicals.

The nurse is assessing a patient in the ED. The patient is awake, alert and oriented X 4 (person, place, time and events). Look at the picture of the patient. What do you see? The patient has right facial drooping. and from your assessment determine: Where is the focal lesion - right or left hemisphere? Relate additional expected sensorimotor findings above the shoulders- with the cranial nerves? Relate additional expected sensorimotor findings below the shoulders? What special function problems would you anticipate?

The left hemisphere is affected. If the left hemisphere is affected expect the s&S to be on the (the opposite side). Homonymous hemianopia. Half vision. There will be a visual deficit abnormality of the right visual field of each eye Right arm and leg weakness. Positive Babinski of the right foot. up going) of the toes especially the big toe and fanning (spreading apart) of the other toes during and immediately after stroking the lateral plantar surface of the foot. Cough and gag could be altered. What special functions are controlled by the left hemisphere. Difficulty with speech - aphasia or dysphasia and difficulty doing math, organizing, reasoning etc. (Special functions of the left hemisphere are speech, math, organize, reason and analyze

What are the traits that are associated with metabolic syndrome?

type II diabetes with hyperglycemia and insulin resistance elevated triglycerides and decreased HDL (<-- the cholesterol good guy) hypertension abdominal obesity

A patient presents to the ED with a severe headache and fever of 102°. To "rule out" meningitis, what physical assessment should the nurse obtain (think S&S of meningitis) ?

The nurse should ask the patient if they are experiencing photophobia, blurred vision, nausea or vomiting. The nurse should assess/examine the patient for nuchal rigidity = stiff neck. The nurse should also assess for a positive Kernig's and a positive Brudzinski sign. •Kernig's is performed by having the supine patient, with hips and knees flexed, extend the leg passively. The test is positive if the leg extension causes pain. And this indicates meningeal irritation. •The Brudzinski's sign is positive when passive forward flexion of the neck causes the patient to involuntarily raise his knees or hips in flexion.

If there is a focal lesion related to the corticospinal or spinothalamic tracts, what types of assessment findings would you expect to have??

The pathological changes will usually be unilateral, on the contralateral (opposite) side of the body because of the decussation of the nerves.

A patient, diagnosed with Cushing's disease, arrives in the ED. What physical characteristics do you notice as you perform a patient assessment? Blood is drawn. What abnormal laboratory values are expected for this patient?

The patient has a moon face (A), striae (B), truncal obesity + more striae (C), buffalo hump (D). 2-•Elevated serum cortisol levels—how Cushing's disease is diagnosed. •Serum glucose will be elevated.=Hypercortisolism will cause increased glycogenolysis and gluconeogenesis. •Hyperlipidemia---elevated levels of LDL. Hypercortisolism will cause lipolysis. •Hypercalcemia---Hypercortisolism will cause increased breakdown of bone (increased osteoclastic activity), increased resorption and movement of calcium from bone to blood. •Hypokalemia—occurs as a result of hyperaldosteronism -aldosterone will cause the retention of Na +H2O, potassium is then excreted by the kidney.

What would be some typical s/sx of a patient with a cerebellar stroke?

There are usually problems with coordination and balance. S/sx may also include vertigo, nystagmus, nausea / vomiting, loss of coordination, and falling down. This can also occur because of a vertebral-basilar artery occlusion / near occlusion.

What is an important sequelae of esophageal varicies?

They can easily rupture and the patient can bleed to death from a huge outpouring of of blood into the esophagus.

What are the functions of the corticospinal tracts?

They carry impulses that produce voluntary movements of purpose and skill from the brain via the spinal cord to various peripheral spinal nerves to the neuromuscular junctions between the nerves and muscles.

body cannot tolerate much of an increase in ICP; if ICP is increased:

• prevents oxygenated blood from being able to easily get into brain arteries (ie, decreased CPP) • causes malfunction of various parts of brain, with varied sequela

What is the object of the bilirubin cycle?

To get unconjugated bilirubin into the conjugated form so that it can form appropriate composition of bile and be more easily excreted into blood and eventually urine.

What is the job of T3 and T4?

To regulate many of the body's metabolic activities, including: the metabolic rate, caloric requirements, oxygen consumption, carbohydrate and lipid metabolism, growth and development, and brain and nervous system functions.

What type of serum lab results would reflect post hepatic jaundice?

Total serum bilirubin: high indirect bilirubin: normal direct bilirubin: high

How does the treatment for type I diabetes differ from type II diabetes?

Type I diabetics need insulin and diet / exercise counseling. Type II diabetics need diet / exercise / weight loss counseling, oral medications, and insulin is usually used only as a last resort.

A nurse is caring for a patient with gastroesophageal reflux disease (GERD). What history finding would the nurse expect to learn from this patient? a. Smokes 2 packs of cigarettes/day. b. Consumes a lot of milk and dairy products. c. Has been in close contact to someone with the "stomach flu". d. Has had a great deal of stress in the last several months.

a

A patient arrives in the ED (emergency department); a right hemispheric brain attack is suspected. Which nursing intervention would be supportive for this acute illness? a. Frequently assess their levels of consciousness (LOC). b. Keep the head of their bed/ED stretcher flat. c. Offer food and fluids immediately after their arrival. d. Approach the patient on their left side.

a

A patient has arrived in the emergency department after being successfully resuscitated by the EMS (emergency medical services). EMS personnel report that the patient has suffered from a prolonged period of pulselessness and apnea. Which assessment findings are expected in a patient who has suffered from a prolonged period of pulselessness? a. Bilateral decerebrate posturing and Cheyne-Stokes breathing pattern. b. Fixed and dilated pupils with a positive Babinski reflex of the right foot. c. Homonymous hemianopia of the right half of both eyes. d. Strong central reflexes with unilaterally absent peripheral reflexes.

a

A patient has arrived in the emergency department after being successfully resuscitated by the EMS (emergency medical services). EMS personnel report that the patient has suffered from a prolonged period of pulselessness and apnea. Which option correctly identifies the pathophysiologic rationale for the nurse's assessment findings in a patient who has suffered from a prolonged period of pulselessness? a. Diffuse brain and brain stem hypoxia have resulted in cellular edema and increased intracranial pressure (ICP). b. Diminished cardiac output have resulted in increased cerebral perfusion pressure (CPP) and decreased ICP. c. Bleeding in a brain hemisphere likely caused cellular inflammation and edema; abnormal reflex findings on the contralateral side of the arms and legs will be noted. d. Bleeding in a brain hemisphere likely caused cellular inflammation and edema; abnormal reflex findings on the ipsilateral side of the arms and legs will be noted.

a

A patient is admitted to the hospital with a diagnosis of hyperglycemic-hyperosmolar-nonketotic syndrome (HHNS/HHNKS). Which signs and symptoms (S&S) would the nurse expect to find? a. Polyuria. b. Acetone breath c. Blood pH <7.35 d. Peripheral edema

a

A patient is diagnosed with hypothyroidism. Which S&S (signs and symptoms) are expected? a. Complaints of fatigue and hair loss. b. Complaints of nervousness and exophthalmos. c. Tachycardia, increased appetite and diarrhea. d. A goiter and complaints of stiffness of the hands.

a

A patient is newly diagnosed with hepatitis C virus (HCV). Which type of precaution should his wife implement to protect from being exposed to the virus? a. Use of barrier protection during sex. b. Get the HCV vaccine. c. Do not eat or drink after each other. d. Wear a mask when in the same room together.

a

A patient states: "This headache began suddenly and is the worst headache I've ever experienced!" The patient is also complaining of light intolerance and nausea and the nurse notices that they cannot hold their arms out in front of them at shoulder height without the left arm beginning to drift downward. Based on these signs and symptoms, which statement is true. a. The patient may be having a hemorrhagic stroke and will need a CT scan. b. The patient may have Parkinson's disease and has an increased risk for falling. c. The patient may have a migraine and need education about trigger avoidance. d. The patient may be having a transient ischemic attack; symptoms should resolve in a few hours.

a

A patient with choledocholithiasis is likely to have a _______ because_____. a. high serum direct bilirubin: obstruction of bile duct results in leakage of conjugated bilirubin into the blood. b. normal level of conjugated bilirubin; prehepatic breakdown of RBCs is unaffected. c. low serum direct bilirubin: obstruction of bile duct results in leakage of unconjugated bilirubin into the blood. d.high level of indirect bilirubin: a stone in the bile duct causes bleeding and hemolysis

a

A patient with cirrhosis has ascites. In reviewing the patient's lab work, the nurse understands that one likely cause of the ascites is: normal osmolality: 280-295 a. serum osmolality of 275 due to decreased serum protein. b. serum osmolality of 300 due to increased serum protein. c. hypernatremia due to decreased levels of aldosterone. d. hypernatremia due to increased levels of aldosterone.

a

A patient, diagnosed with cirrhosis, is asking why he must receive an injection of vitamin K. Which statement, by the nurse, indicates an understanding of the pathophysiology of the disease as it relates to the supplemental need for vitamin K? a. "Your sick liver is making less bile salts; causing a vitamin K deficiency." b. "This medication will help with the fluid shift problems causing your ascites." c. "You have a lowered level of blood protein; a higher dosage can be given in an injection." d. "Your liver cells are damaged; vitamin K will reduce blood ammonia levels."

a

A person diagnosed with meningitis will be at risk for a. increased intracranial pressure. b. decreased cerebral edema. c. a negative Kernig's sign. d. motor tract decussation.

a

Lab work is done on a patient with untreated Grave's disease. The expected findings would be a ___TSH and a _____T4. a. low; high b. high; low c. normal; high d. high; normal.

a

Which assessment finding is NOT expected in a patient diagnosed with Cushing's disease? a. exophthalmos. b. hirsutism. c. truncal obesity. d. high blood pressure.

a

Which assessment finding would not be expected in the patient diagnosed with cholecystitis? a. An elevated amylase and lipase. b. An elevated direct bilirubin level. c. A normal indirect bilirubin level. d. Gray stools and icteric sclera

a

Which statement, by the patient, supports the diagnosis of multiple sclerosis (MS)? a. "I had a really bad case of the flu a few weeks ago." b. "I think one of my coworkers was also just diagnosed with MS." c. "I should have a full recovery from this illness in a few days." d. "I thought only elderly women got this disease?"

a

What is peptic ulcer disease?

a chronic inflammatory disease of the stomach and/or proximal duodenum in which disturbance of their mucosal lining allows acid to ulcerate the underlying tissue causing gastric and/or duodenal ulcers.

cortisol

a glucocorticoid -- an endogenous steroidal hormone that affects MANY metabolic activities of the body b)exogenous steroids (made in a lab & given to patients) mimic this glucocorticoid

What is the function of cortisol?

a glucocorticoid that affects many metabolic activities of the body

What would be the location of a cerebral hemispheric stroke?

a lack of blood flow or bleeding in an area of the left or right hemisphere of the cerebrum that results in swelling and edema. This could occur because of a lack of blood flow or bleeding in the left or right middle cerebral artery or one of its many branches.

What is the function of aldosterone?

a mineralcorticoid that "directs" the kidneys to hold on to sodium in the blood (and therefore hold on to water) in exchange for the secretion of potassium in the urine.

aldosterone

a mineralocorticoid that "directs" the kidneys to "hold onto" Na+ in the blood (and therefore also "hold onto" water -- H2O generally follows Na+) in exchange for secretion of K+ into the urine.

What are the most common causes of Addison's disease?

a pituitary malfunction in which there is not enough ACTH secreted an autoimmune disorder in which autoantibodies specific to the adrenal gland cause adrenal atrophy and hypofunction.

Autonomic, LOC & mental status manifestations seen as a result of brain/brain stem abnormalities:

a) abnormal VS BP, HR, RR, temp (brain stem) diminished LOC : most often with brain stem problems, patient is comatose or in near-coma state (brain stem) b) heart rate and blood pressure changes due to pressure on the medulla (brain stem). c) breathing pattern changes— ex; apnea (absence of breathing) or Cheyne-Stokes (seen in comatose patients who are not on ventilator)

Sensorimotor manifestations seen as a result of brain/brain stem abnormalities:

a) bilateral loss of pupil light response-both pupils either fixed n dilated or fixed n pinpointed (brain stem) -sensation, muscle tone, movement, & strength would be weaker bilaterally & often symmetrically. b) patients are often comatose. - decerebrate & decorticate posturing reflecting effect of cerebral edema on brain stem nuclei. c) HR problems when the vagus nerve (CN X) is affected (remember, the CN's originate in the brain stem). d)Mixed degree of cranial nerve abnormalities

tx of liver disease

a) enhance nutrition & no alcohol b) reestablish appropriate fluid balance (1) give diuretics to mobilize fluid from tissue to blood to urine (2) sometimes give IV albumin to increase protein in blood so water won't be going out from blood to tissues c)control ammonia - low protein diet & certain drugs can be given d) protection—against infection, trauma, overdose of drugs e) liver transplant yes, you want to increase protein molecules in bloodstream, but decrease dietary protein

along with inflammation that causes diarrhea & cramps, other potential problems with IBD include

a) intestinal obstruction from chronic inflammation and scarring c) fistula formation --abnormal channels or tracts that develops in the presence of inflammation and infection) d)sometimes perforation of intestinal wall & spillage of intestinal contents into abdominal cavity

abnormals of LOC include:

a) not being alert: from being lethargic to inability to awaken the patient at all (coma) b) not oriented to some or all of self, time, place, events c) doesn't follow commands d) speech might be garbled or no speech at all e) verbal responses / conversational efforts show inappropriate or dysfunctional mental status; examples: (1)confusion - spectrum of severity (2) behavioral changes such as withdrawal or aggression

Reflex manifestations seen as a result of brain/brain stem abnormalities:

a) protective reflexes such as sneezing, coughing, gagging, & swallowing are diminished or lost b) reflexes weaker, usually symmetrically, and sometimes there is bilateral positive Babinski's.

S&S of cerebral hemispheric BA are from what THREE possible sets of deficits?

a) sensorimotor deficits caused by lesion / pressure on CNs in / near the affected area in that hemisphere b) sensorimotor deficits caused by lesion / pressure on corticospinal tracts in / near the affected area in that hemisphere c) deficits based on what "special functions" are controlled by that hemisphere.

melena

a) stool is loose and appears dark and tarry b) usually indicates blood partially digested in stomach or duodenum (like "coffee ground" but blacker & pastier.) UGI Bleed

tx of Cushings

a) to decrease exogenous steroids if possible b) in other situations, remove cause of endogenous cortisol hypersecretion (tumors, enlarged adrenals, etc) via surgery, chemo, radiation. c) drugs which block the effect of aldosterone (like spironolactone).

happens in both genders as they age, but women are much more likely to have problems, due to two factors

a) women's bones are significantly less dense than men's to begin with b) menopausal loss of estrogen (1) bones have estrogen receptors; when stimulated by estrogen, bone-building & maintenance of density results (2) during and after menopause there is atrophy of ovaries & therefore less estrogen (3) less estrogen = less bone building ->balance is tipped toward osteoclastic activity ->more resorption than bone-building->less density

hepatic encephalopathy

at toxic levels the ammonia affects CNS, resulting in brain inflammation, (b) S&S of this range from lack of mental alertness to confusion to coma; blurred vision, tremors, szres; very early sign is flapping tremor of hands called _asterixis (AKA "liver flap")

LGI bleed most common causes

a. IBD b. diverticulitis c. neoplasms

UGI bleed most common causes:

a. acute hemorrhagic gastritis b. esophageal varices - large torturous veins in the esophagus caused by liver disease that can be easily irritated & caused to bleed c. peptic ulcers

A patient with cirrhosis has an RBC count of 2 million (anemia), and thrombocytopenia. These abnormal lab values are most likely caused by: a. cellular hemolysis from pancreatitis. b. splenomegaly secondary to portal hypertension. c. esophageal varices secondary to portal stricture. d. cholecystitis due to malfunctioning lithotripsy.

b

etiology of obstructions

a. adhesions—scar tissue from surgery or from a chronic inflammation such as IBD. b. hernia-- intestine protrudes through a weakness in the abdominal muscle or through the inguinal ring c. tumor in the lumen of the intestine d. intussusception-- telescoping of one portion of the bowel into the other, causing strangulation of blood supply; more common in infants. e. volvulus, AKA torsion -- twisting of the intestine with occlusion of blood supply. f.paralytic ileus_(AKA just "ileus")--loss of peristaltic motor activity in the intestine

other calcium-movement-related problems

a. electrical issues: as discussed in previous lectures, hypo or hypercalcemia can affect Na+ movement in and out of cells, thus affecting RMP & causing certain S&S b. clotting issues: low calcium = low clotting ability, so if a disorder results in hypocalcemia, a patient might have easy bleeding, manifested by S&S such as petechiae and purpura. c. urologic issues: hypercalcemia can cause kidney stones.

GI organs:

a. epigastric—area across upper part of abdomen just below sternum & ribs; some of organs in this area: pyloric area of stomach, duodenum, part of pancreas b. RUQ—right upper quadrant—liver & gall bladder; part of pancreas, part of transverse colon c. LUQ—part of stomach, spleen, part of transverse colon d. RLQ—cecum & appendix, part of ascending colon e. LLQ— part of descending colon, sigmoid colon f. umbilical region, AKA periumbilical area (area around navel)-- lower duodenum, jejunum, ileum

diverticulum

a. herniations or saclike outpouchings of mucosa from the muscle layer of the intestine that protrude from the intestine b.most commonly occur in the sigmoid colon

sequelae of HYPERcortisolism

a. pathologically increased glycogenolysis & gluconeogenesis,-> hyperglycemia, which can lead to the development of Type II diabetes mellitus b. abnormal breakdown of adipose tissue (lipolysis), -> in high levels of circulating fat products (hyperlipidemia) and their deposition in certain body areas: 1) trunk ("truncal obesity"); face ("moon face"); and back ("buffalo hump)— this combination is often known as "cushinoid appearance" 2) high levels of LDL & increased risk for atherosclerosis 3) weight gain in general. c. abnormally catabolized protein--has negative effects on skin & muscle: 1) muscle weakness & wasting (thin arms & legs) 2) in children—short stature 3) weakened collagen fibers leads to skin fragility->skin bruises & tears easily; and stretching->purple striae (stretch marks) often seen where skin has stretched from increased fat deposits d. increased break down of bone (increased osteoclastic activity) can lead to: 1) hypercalcemia and its S&S's—lethargy, fatigue, etc 2) spillage of calcium into urine (hypercalcinuria)-> increased risk of renal calculi. 3) osteoporosis & pathological fractures; risk increases even more because in Cushing's there is also reduced calcium absorption in gut. e. suppression of prostaglandin activity, resulting in: 1) anti-clotting effects --patient may bleed more easily 2) anti-immunocyte effects -- more susceptible to infection 3) decreased protection of stomach lining (due to steroidal inhibition of phospholipase in arachidonic pathway, prostaglandin no longer protects stomach)-> increased risk of peptic ulcers 4) increased peripheral vasoconstriction-> HTN

regulated by the secretion of thyroid stimulating hormone (TSH) from the pituitary -> TSH stimulates the thyroid as needed to produce, release, and/or store the 3 thyroid hormones:

a. thyroxine (T4) and triodothyronine (T3), which regulate many metabolic activities of body b. calcitonin, which increases calcium movement from blood into bone

hypoglycemia S&S & their causes:

a. weakness, fatigue, mental fogginess, apathy, confusion are due to lack of energy source in cells b. shakiness, irritability, sweating are due to effects of counterregulatory hormones: glucagon, cortisol, growth hormone, epinephrine-> these are triggered by hypoglycemia & their functions are to: 1) let you know you need to eat (irritable, sweating, tachycardia) 2) stimulate glycogenolysis & gluconeogenesis-> yields glucose.

Type II diabetics have two specific characteristics related to insulin...

abnormally low insulin production (they make some insulin) and impaired insulin utilization (aka. insulin resistance)

What are the most common causes of an upper GI bleed?

acute hemorrhagic gastritis esophageal varices peptic ulcers

HAV

acute onset—fever, malaise, sometimes jaundice; most commonly transmitted by oral/fecal route; vaccine & immunoglobulin available.

A patient, diagnosed with hypothyroidism is prescribed a synthetic thyroid hormone (levothyroxine). Which assessment data indicate the medication has been effective? a. A measured heart rate of 48 beats/minute. b. A measured temperature of 98.6°. c. A 3-pound weight gain. d. Hypotension and hypoventilation.

b

What are some possible causes of obstructions?

adhesions, hernias, tumors, intussception, volvulus, and paralytic ileus.

Colorectal cancer

almost always arises from a pre-existing benign neoplasm, usually in the form of a polyp (stalk-like growth on the wall of the colon) which becomes malignant. c. risk factors: 1) age over 50 2) high-fat diet, obesity, sedentary lifestyle 3) smoking & ETOH over-consumption 4)family hx

viral meningitis

also known as aseptic_meningitis— ie, almost never causes sepsis. 2) same basic spread & entry as bacterial meningitis but much milder S&Ss and clinical course than bacterial

What is jaundice (aka icterus)?

an alteration somewhere in the normal bilirubin cycle that allows bilirubin to accumulate in the blood in abnormal amounts and to become deposited in various pathological places in the body (manifested as a green-yellow pigment).

Appendicitis

an inflammation most often caused by fecal matter getting caught in lumen of appendix, inviting infection & inflammation; a slight genetic predisposition b. treatment is appendectomy (the most common surgical emergency of the abdomen) 2. S&S /complications: a. pain pattern: 1) epigastric or periumbilical pain that then migrates to become RLQ pain. 2) pain is exacerbated upon movement (patient wants to hold very still) 3) "rebound" tenderness sometimes present. b. N/V/D, anorexia. c. fever, leukocytosis if not acted upon quickly, inflammation can spread to peritoneum - resulting in peritonitis, a potentially life-threatening condition that can lead to sepsis and other complications.

What is appendicitis?

an inflammation most often caused by fecal matter getting caught in the lumen of the appendix, inviting infection and inflammation

sequela of hypersplenism

anemia, thrombocytopenia, leukopenia -> S&S of fatigue & SOB, easy bleeding / bruising, and/or increased susceptibility to infection.

PUD is treated by

antacids, H2-blockers (Zantac, Pepcid), PPIs (proton pump inhibitors—Nexium, Prevacid), & eradication of H. pylori with antibiotic regimen.

tx for myasthenia gravis

anti cholinesterase drugs, steroids; sometimes thymectomy helps

tx for HYPERthyroid

antithyroid meds that inhibit synthesis of thyroid hormones b. surgery-- thyroidectomy (usually ~ 90 % removed)

epigastric

area across upper part of abdomen just below sternum & ribs; some of organs in this area: pyloric area of stomach, duodenum, part of pancreas

osteoporosis cause

as a part of the aging process & genetics, resorption will slowly increase due to increased osteoclastic activity—ie, osteoclastic break down of bone & movement of calcium into the blood exceeds the bone formation that is maintained by the osteocytes c. this causes bone density to decrease, and bone becomes more porous

spinothalamic tracts

ascending (sensory) tracts. (1) carry sensations of pain, temperature, crude and light touch from body to brain (thalamus) for processing.

What three problems occur as a result of portal hypertension?

ascities splenomegaly esophageal and hemorrhoidal varicies

abnormalities of vision or facial expression: (1)if there is a focal lesion - a brain attack, tumor or bleeding - in the right hemisphere, expect to have

asymmetric findings, with the defect manifesting unilaterally on the opposite side, ie, the contralateral side, of the lesion.

if there is a focal lesion related to corticospinal or spinothalamic tracts in the brain, expect to see

asymmetric sensorimotor changes-below shoulders (1) the pathologic changes will usually be unilateral, on the contralateral side of the body because of decussation —ie, abnormal findings on the opposite side of the lesion in the brain. (2) ex: a patient with a tumor on the right side of the brain would have decreased strength & sensation of arms and legs on the contralateral, or opposite side of the body.

diverticulosis-

asymptomatic diverticular disease

What are the risk factors for a brain attack?

atherosclerosis in any part of the body, hypertension, older age, family history, diabetes, lifestyle issues (smoking and high fat diets)

What are the most common etiologies of a brain attack?

atherosclerosis of the cerebral arteries or of the incoming arteries (vertebrals and carotids), hypertension, heart problems that can lead to not enough cardiac output or blood to the brain, and brain aneurysms.

What types of events can contribute to a thrombotic or embolic ischemic stroke?

atrial fibrillation, atherosclerosis of the carotids, air emboli, clots around a mitral / aortic valve prosthesis, or the development of intracranial artery plaque.

HYPERthyroidism most common cause

autoimmune disease called Graves' disease, in which autoantibodies mimic TSH by fitting into TSH receptors on the thyroid & causing it to over-secrete T3 & T4

A nurse reviewing the drug list of a Parkinson's patient notes that he is on an anticholinergic drug. The nurse understands that the reason for the patient to be on this drug is most likely a. his increased risk of environmental allergies. b. to suppress some of the function of acetylcholine in the brain. c. to stimulate of adrenergic receptors in the eyes. d. to decrease dopamine levels of the brain.

b

A nurse suspects that a patient is having a stroke. Which of these choices reflects the first step in assessing a patient for a stroke? a. The nurse assesses the patient's muscle strength and movement by asking them to push down on her hands with their feet. b. The nurse measures the patient's vital signs and assesses the patient's level of consciousness (LOC). c. The nurse looks at the patient's face to assess for facial drooping and asks them to raise their eyebrows. d. The nurse assesses the patient for their ability to cough and swallow normally.

b

A nurse, caring for a patient who has been diagnosed with diabetes insipidus (DI), would expect to find which sign and symptom (S&S)? a. signs of cerebral edema such as decreased LOC. b. signs of cerebral cell dehydration such as headache. c. generalized edema d. crackles in the lungs upon auscultation.

b

A patient is diagnosed with Addison's disease. Which intervention, by the nurse, would be supportive for this illness? a. Restrict the fluids that the patient is allowed to drink. b. Administer their prescribed steroid medication. c. Place them on a low salt diet. d. Suggest they enroll in a weight loss program.

b

A patient is diagnosed with peptic ulcer disease (PUD). Which statement, by the patient, indicates an understanding of the contributing factors of this illness? a. "I will continue to take an NSAID when my stomach pain begins." b. "I will stop drinking alcohol products." c. "I should stop taking my antibiotic regimen as soon as I feel better." d."I plan to eliminate nuts, seeds and popcorn from my diet."

b

A patient is having melena stools. This is most likely due to: a. low level of intrinsic factor in the gut. b. digested blood from a duodenal ulcer. c. gastroparesis causing slow emptying. d. hematemesis from peptic ulcer disease (PUD).

b

A patient who just came out of general anesthesia has lab work done. The serum osmolality is 165. The nurse taking care of this patient suspects that his _____ is due to _________. Normal serum osmolality: 280 to 295 a. hyperosmolality: diabetes insipidus (DI). b. hypoosmolality: syndrome of inappropriate ADH (SIADH). c. dry mucus membranes: SIADH. d. shift of calcium into blood: a state of hypopolarization inside the cells.

b

Upon assessing his patient, a nurse notes hemiparesis of the right arm & leg and dysphasia which the patient states began 2 days ago. The nurse thinks it is most likely that the patient has had a. basal ganglion issues. b. a stroke involving the left hemisphere of the brain. c. a brain attack involving the right hemisphere of the brain. d. a TIA (transient ischemic attack) involving the left hemisphere of the brain.

b

Which laboratory finding is expected to be elevated in a patient diagnosed with pancreatitis? a. Serum creatinine and blood urea nitrogen (BUN). b. Serum amylase and lipase. c. Serum bilirubin and calcium. d. Neutrophils and thrombocytes.

b

Which statement by the patient diagnosed with cirrhosis warrants immediate intervention by the clinic nurse? a. "I will not drink any type of beer, wine or alcohol." b. "I took some acetaminophen for my headache." c. "I will ensure I get 8 hours of sleep every night." d. "I will reduce the amount of protein that I eat."

b

Which statement, by a patient, would cause a registered nurse (RN) to suspect the patient is experiencing hyperthyroidism? a. "I just don't seem to have an appetite anymore." b. "My hair is falling out and my skin is always moist." c. "My skin is really dry and course." d. "I have not had a bowel movement in 4 days."

b

upper GI (UGI) bleeding:

bleeding from esophagus, stomach, duodenum

lower GI (LGI) bleeding:

bleeding from jejunum, ileum, colon

What are the s/sx of a lower GI bleed?

bleeding in stool detected by a hemoccult test, and /or hematochezia

What are the symptoms of colorectal cancer?

blood in stool (either visible or occult) and a change in bowel habits a colonoscopy will reveal polyps growing on the wall of the colon, which will be removed and examined for the presence of cancer.

What are common sequela of osteopenia and osteoporosis?

bone fractures (especially in the hip and vertebrae)

What are some of the important functions of calcium?

building and maintenance of bone density, electrical activity in the body, clotting, and others.

A migraine abortive drug, such as Imitrex, will most likely be given in which situation? a. "I've had a migraine for hours—the pain is killing me." b. "Nurse Ratchet, this patient is post-ictal." c. "I'm having a pre-migraine aura, but it's not bad." d. "My dad's memory is getting worse and worse."

c

A patient diagnosed with type 1 diabetes has a glycosylated hemoglobin (A1C) of 9%. Which interpretation should the nurse make based on this result? This result indicates ___________________ Hgb A1C: ≤ 7% a. that there are fewer than normal blood glucose molecules. b. the patient has achieved acceptable glycemic control over the past few weeks. c. the patient has poorly managed their blood glucose levels over the past few months. d. the patient has maintained a therapeutic level of blood glucose in the last few days.

c

A patient with Type I diabetes has a pH of 7.32. This is most likely caused from the byproducts of increased: a. insulin resistance. b. hyperinsulinism. c. gluconeogenesis. d. glucagon.

c

A patient with type 1 diabetes has a pH of 7.32. Which additional S&S would the nurse expect to find? a. Shakiness and hunger pains. b. Slow shallow respirations. c. Kussmaul respirations. d. Oliguria.

c

CSF (cerebral spinal fluid) testing on a patient with fever and neck stiffness shows a high protein level. This is most likely due to a. leakage of protein into the CSF from traumatic injury. b. edema from an embolic stroke. c. the presence of bacteria in the CSF. d. the presence of amyloid in the CSF.

c

Drugs that _____________________ should be prescribed for the patient with osteoporosis. a. increase osteoclastic activity b. increase calcium resorption c. decrease osteoclastic activity d.increase osteopenia

c

Osteopenia is likely associated with all the following EXCEPT: a. low dietary calcium. b. hyperparathyroidism. c. high levels of calcitonin. d. increased osteoclastic activity.

c

While examining a patient diagnosed with the extreme state of hyperthyroidism, a nurse notes ___________, which is associated with a(n) _______________. a. hypoventilation; myxedema coma. b. tetany; Addisonian crisis. c. a temperature of 105°; thyrotoxic crisis. d. cretinism; adrenal crisis.

c

What two hormones regulate the movement of calcium?

calcitonin (moves calcium from blood to bone) parathyroid hormone (PTH) (moves calcium from bone to blood by increasing osteoclastic activity)

if there is a state of HYPERcalcemia, or if more calcium is needed in the bone (e.g., for building more bone matrix), calcitonin is ___by thyroid, PTH ____?

calcitonin= increased PTH= suppressed -resulting in decreased osteoclastic activity and bringing down serum calcium levels.

calcitonin is secreted by the thyroid gland and enhances movement of

calcium from blood into bone.

PTH secreted when there is need for

calcium to be used in other parts of body, or when there is a state of hypocalcemia, because PTH increases movement of Ca from bone to blood (resorption) by stimulating increase in osteoclastic activity

bacterial meningitis causes

can be caused by several strains of bacteria a) the most common are meningococcus & pneumococcus

TIA—transient ischemic attack

can happen in either thrombotic or embolic situation & causes the same S&S as a fully-evolved stroke, but does not damage brain tissue because it is transient, i.e., temporary— resolves itself quickly 2) by definition, S&S from this type only last <24 hours & have no lasting neurologic deficit ( last between 10 minutes to <24 hours) 3) however, they are often a warning that more serious, fully-evolved stroke can occur at later date (without tx, 80% of pts with it have full strokes later!)

ischemic brain attack (~80% of all brain attacks) causes

cause is usually the narrowing or blockage of arteries supplying brain (carotid or vertebral arteries) or intracranial arteries themselves 1) usually related to atherosclerosis and other processes that damage arterial walls, resulting in same process as plaque formation in coronary arteries

Large intestines (AKA colon):

cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum.

What is the main culprit that causes an increase in ICP?

cerebral edema

the main culprit in causing IICP & the loss of balance between ICP & CPP is

cerebral edema; ex: ischemia from a blockage (plaque or stricture) of an artery in brain or going into brain (ex—carotid) -> cells become hypoxic-> swell, increased vascular permeability-> edema-> increased ICP-> decreased CPP-> further brain ischemia

Maintenance of cerebral blood flow is dependent on keeping what two forces in balance?

cerebral perfusion pressure (CPP) and intracranial pressure (ICP)

sensorimotor assessment below the shoulders-what you are assessing:

certain parts of the sensorimotor apparatus — the corticospinal tracts & the spinothalamic tracts-- is there a lesion in one of these tracts and/or in the cerebral brain tissue around it? (2) is the left side equal to the right side in sensation, tone, movement, strength? If not, consider that there might be a focal lesion and/or edema where a corticospinal tract passes through that cerebral hemisphere.

Inflammatory bowel disease (IBD)

chronic disorder characterized by inflammation of the lining and walls of the intestines. b. it includes 2 main types—Crohn's disease & ulcerative colitis c. common features of both: 1) basic problem is inflammation which causes episodes of bloody diarrhea & abdominal cramps that have patterns of exacerbation & remission, often related to stress 2) no proven primary etiology but possible causes include: a) infectious agents (bacteria, viruses) b) links to familial occurrence c) autoimmune response: (1) formation of autoantibodies against glycoproteins in walls of the intestines->inflammation. (2) sometimes patient has manifestations of systemic autoimmune features as well—arthritis, vasculitis, iritis a) intestinal obstruction from chronic inflammation and scarring c) fistula formation --abnormal channels or tracts that develops in the presence of inflammation and infection) d) sometimes perforation of intestinal wall & spillage of intestinal contents into abdominal cavity 4) IBD treatment--generally directed at controlling inflammation by giving steroids & other meds; sometimes surgery to remove parts of bowel

Inflammatory bowel disease (IBD)

chronic disorder characterized by inflammation of the lining and walls of the intestines. b. it includes 2 main types—Crohn's disease & ulcerative colitis c. common features of both: 1)basic problem is inflammation which causes episodes of bloody diarrhea& abdominal cramps tha thave patterns of exacerbation & remission, often related to stress

PUD—peptic ulcer dz

chronic inflammation of stomach and/or duodenum resulting in breakdown of luminal lining & ulcerations causes—NSAIDs (inhibit prostaglandin), ETOH, smoking, chronic dz, genetics - most common triggering cause—Helicobacter pylori (H. pylori) - bacteria ingested via oral/fecal route burrows through mucous layers & attaches to epithelium (one of few bacteria to thrive in HCl)-> colonizes, creates favorable ulcer environment

LOWER GI (LGI—jejunum, ileum, colon) BLEED. Example disease processes:

colon cancer, ulcerative colitis Blood in stools -->Occult bleeding ...blood is present in stool, but not visible to naked eye OR -->Hematochezia (obviously bloody stool) ...presence of blood is visible to naked eye as frank blood and/or clots... this is because any LGI blood that makes its way into stool has not been digested (broken down) by stomach

What two substances does the adrenal cortex secrete?

cortisol and aldosterone

sensorimotor assessment above the shoulders (eyes, face, tongue, some shoulder function) what you are assessing:

cranial nerves (CN) function— ie, is there a lesion in a CN and/or in the cerebral brain tissue around it? (2) is the left side of the face equal to the right side in sensation, tone, movement, strength? Are the pupils equal and reactive to light? If not, consider that there might be a focal problem with a CN.

A nurse is caring for a patient with type 1 diabetes mellitus. Which assessment finding indicates the patient is developing a complication after the administration of their morning insulin? a. Unresponsiveness with warm and dry skin. b. Nausea and constipation. c. Glucosuria with polydipsia. d. Tachycardia, sweating and irritability.

d

A patient complains of severe vertigo and nausea. The RN notes the presence of nystagmus. Which of the following would be the most likely diagnosis? a. brain stem stroke. b. papilledema. c. age-related macular degeneration (AMD). d. cerebellar stroke.

d

A patient presents with S&S of a fluid volume deficit, weakness, fatigue and a blood glucose of 50. A likely diagnosis is: a. Cushing's disease. b. hyperpituitarism. c. hypothyroidism. d.Addison's disease.

d

A patient with myasthenia gravis (MG) is on a drug to block an enzyme called cholinesterase. This drug's action will help the patient by decreasing the a. amounts of acetylcholine in neuromuscular junctions. b. build-up of senile plaques. c. effect of hypertonia. d. breakdown of acetylcholine in neuromuscular junctions.

d

A patient with ulcerative colitis (UC) will have a. a paralytic ileus. b. patchy area of inflammation of the jejunum. c. intestinal polyps. d. hematochezia

d

A patient, diagnosed with myasthenia gravis (MG), is complaining of diplopia and wants to know the reason for this ocular abnormality. The nurse demonstrates understanding of the disease and associated symptoms when he explains that a. "a lack of oxygen to your brain has caused swelling in the area of your optic nerve". b. "the involuntary movements of your eye are caused by a lack of oxygen to a part of your brain". c. "there is nothing wrong; you just have temporary pupillary constriction from the bright light". d. "your disease decreases the strength of the eye muscles which can cause double vision".

d

All the following are consistent with upper GI problems EXCEPT a. GERD (gastroesophageal reflux disease). b. Helicobacter pylori (H. pylori). c. esophageal varices. d. diverticulitis.

d

An obese white female presents to her health care provider with complaints of right shoulder and scapula pain. The nurse suspects cholecystitis. What history finding would the nurse expect to learn from this patient? a. A polyp was found after a recent colonoscopy. b. Dysphagia is present during most meals. c. Symptoms are aggravated by caffeine products (coffee). d.Symptoms worsen after a high-fat meal.

d

An occupational health nurse is preparing a presentation to a group of factory workers about preventing colon cancer. Which information should be included in the presentation? a. Use of a mask when around chemicals in the factory. b. Avoid eating shellfish in certain months of the year. c. High-risk sexual behaviors and IV drug abuse can cause colorectal cancer. d. Eat several servings of fruits and vegetables (high-fiber diet) every day.

d

Complaints of polydipsia and polyuria could be linked to all the following disease processes EXCEPT: a. Diabetes mellitus (DM) b. Addison's disease. c. Diabetes insipidus (DI). d. syndrome of inappropriate ADH (SIADH).

d

Following an illness, a patient becomes hypocalcemic. Which of the following mechanisms will increase the calcium in her blood? a. The pituitary will decrease its secretion of T4. b. The thyroid will increase secretion of calcitonin. c. The pituitary will decrease its secretion of parathyroid hormone (PTH). d. The parathyroid will increase its secretion of PTH.

d

The RN (registered nurse) is taking care of a patient with Parkinson's disease (PD). Which assessment data support this diagnosis? a. Paresthesia and ataxia b. Dementia and emotional upset c. Drooping eyelid and muscle weakness d. Shuffling gait and mask-like facial expressions.

d

The nurse caring for a patient with cirrhosis notices signs and symptoms of encephalopathy such as confusion and asterixis. The cause of these is most likely: a. increased serum lipase. b. low serum liver enzymes. c. decreased conjugated bilirubin. d. increased serum ammonia.

d

Which S&S should the nurse expect to find in a patient diagnosed with Crohn's disease? a. Bloody diarrhea that worsens when alcohol is consumed. b. Epigastric pain that worsens when lying down. c. A fever with urinary stress incontinence. d. Bloody diarrhea and weight loss.

d

Which patient would the nurse identify as being most at risk for experiencing a brain attack? HDL: High-density lipoprotein LDL: Low-density lipoprotein a. a 28-year-old who smokes 1 pack of cigarettes/day. b. a 70-year-old who exercises daily and has a low LDL. c. a 60-year-old who has a BP of 110/70 and a high HDL. d. a 40-year-old with poorly controlled diabetes and a BP of 150/90.

d

Which is true? a. An eye drop that constricts the pupils belongs in a medication category that mimics the effect of the sympathetic nervous system (sympathomimetic). b. An eye drop that causes miosis belongs in a sympathomimetic medication category. c. If eye drops causes mydriasis, it has probably blocked the adrenergic effect of a cranial nerve. d. If eye drops causes mydriasis, it has probably blocked the cholinergic effect of a cranial nerve.

d the reflexive action of your pupils constricting when exposed to light (miosis) is controlled by a cranial nerve (CN) that secretes a cholinergic (ie, governed by the parasympathetic nervous system) substance—acetylcholine—which causes the constriction. So if you were given an eye drop that inhibits that process, you would end up with non-constricting pupils; ie, your pupils might dilate (mydriasis). Adrenergic effect on your pupils is what happens in a "fight or flight" situation—your body says, "prepare for flight by allowing the most light that is possible into your eyes so you can have the best vision possible for running away"...so your body is flooded with adrenergic (sympathetic nervous system) substances such as epinephrine (AKA adrenalin) and your pupils become dilated.

Hypoglycemia causes

defined as blood glucose <70 plus a. not eating or food not absorbed (food unavailable, malabsorption / starvation states); over- exercising compared to food intake b. natural hyperinsulinism (this is rare)—glucose in blood triggers over-secretion of insulin; these people usually must avoid simple sugars & deep carbohydrates to a minimum. c. taking too much insulin (usually happens when diabetics are changing their doses, make a mistake, don't eat after taking their insulin, etc)

clinical manifestations of Alzheimer's disease

dementia—a type of forgetfulness that is different from normal absentmindedness; emotional upset, behavioral changes 2) if posterior frontal lobe is involved, there are also motor changes such as rigidity, and postural & gait changes

corticospinal tracts

descending (motor) tracts ("cortico"—cortex of brain); also called the pyramidal tracts -the pyramidal tracts carry impulses that produce voluntary movements of purpose and skill from brain via spinal cord to various peripheral spinal nerves to neuromuscular junctions between nerve & muscles

What are the two problems related to the inappropriate secretion of antidiuretic hormone (ADH)?

diabetes insipidus (DI) a problem of undersecretion of ADH syndrome of inappropriate antidiuretic hormone (SIADH) a problem of oversecretion of ADH

What is the "extreme state" of Type I Diabetes?

diabetic ketoacidosis (DKA), which include all of the symptoms of type I diabetes (when no insulin is present) and metabolic acidosis (know your ABGs). The patient may have kussmaul respirations and progress to a diabetic coma if DKA is not detected and treated. "Hot and dry? Sugar high!"

tx of Type II DM

diet, weight loss, various combinations of meds, including sometimes insulin

dysarthria

difficulty speaking because the jaws don't work well

dysphasia

difficulty speaking usually due to a neurologic problem in the brain)

dysphagia

difficulty swallowing

With any type of brain lesion, some reflexes might...

diminish or become absent. Examples: 1. deep tendon reflexes may become hypoactive 2. gag, swallow, or cough reflexes may fail to protect adequately. 3. inappropriate reflexes may appear (ie. a Babinski reflex in adults)

What are the two major problems related to cirrhosis?

diminished hepatocyte function problems related to portal hypertension

patho / S&S of cirrhosis can be categorized as problems of

diminished hepatocyte function versus problems related to portal hypertension.

diagnosis / monitoring of DM

dx-FBS (fasting blood sugar) > 126 on two occasions (norm = 70 to 99) monitored by finger prick BS- Hgb A1C: the percentage of glucose-carrying Hgb molecules over the lifespan of an RBC; norm around 4%; aim for diabetics—keep it < 7%; high A1C = high average daily blood glucose

papilledema

edema and inflammation of the optic nerve where it enters the retina. - this is caused by the blockage of venous return from the retina mainly because of increased intracranial pressure c. can't be seen by naked eye—have to assess via ophthalmoscope

What are the s/sx of bacterial meningitis?

edema of meninges surrounding the brain, increased ICP, photophobia, headache, irritability, restlessness, decreased LOC, nausea and vomiting, neck stiffness (nuchal rigidity), positive Brudzinski and Kernig's signs,, fever, purpura, petechiae, leukocytosis. CSF will be positive for high WBC count, higher than normal protein count, lower than normal glucose count, and blood.

How is liver disease treated?

enhance nutrition and no alcohol re-establish appropriate fluid balance (diuretics, possibly IV albumin) control ammonia (low protein diet, certain drugs) protect against infection, trauma, overdose of drugs liver transplant

What are the s/sx of appendicitis?

epigastric or periumbilical pain that then migrates to become RLQ pain. Pain is exacerbated with movement. Rebound tenderness may be present. N/V/D, anorexia, fever, leukocytosis.

When assessing reflexes- sometimes reflexes appear that are inappropriate

ex- a "positive Babinski" reflex (AKA plantar reflex) means that stroking plantar surface of foot makes big toe flex ("upgoing toe"). b) this is normal until after 2 years old; after that, it is a sign of neurologic dysfunction of some sort. c) can be unilateral or bilateral (brain stem), depending on whether there is diffuse or focal lesion in brain.

What are some possible causes of cirrhosis?

excessive alcohol intake toxic reactions to drugs and chemicals viral hepatitis diseases of the viral ducts such as primary biliary cirrhosis or secondary biliary cirrhosis genetic disorders (hemochromatosis & Wilson's disease)

S&S, dx, tx Colorectal cancer

few obvious early S&S but most common are: 1) blood in stool, either visible or occult 2) change in bowel habits b. dx'd most often by colonoscopy c. tx 1) if confined to a polyp, a simple polypectomy during the colonoscopy will cure it 2) if more widespread, tx will include colectomy (removal of part of colon) & sometimes colostomy (opening created in abdomen for stool); chemothx. 3) best tx—prevention! --high-fiber diet, lifestyle changes.

interpretation of sensorimotor findings above the shoulders, assessment will be focused on what nerves?

first on vision (CN II) and facial expression (CN VII). When everything is normal & symmetric we know these nerves are ok and the brain tissue around them is ok (no injury/edema) pupillary response (CN II & III)

What are two common etiologies of acute pancreatitis?

gall stones / pancreatic duct obstruction alcohol use

endoscopy

general term for passing a scope into GI tract for direct visualization

diffuse problems usually associated with:

generalized S&S such confusion & other signs of decreased LOC (spectrum of changes, depending on degree of IICP) - usually fairly symmetric changes in the body bilaterally, including reflex changes.

S&S of MS

generally S&S are variable, individualistic, and usually asymmetrical, since plaques are unevenly distributed in brain (can be symmetric, but this would be more uncommon) b) have periods of remission & exacerbation in an irregular fashion, often related to stressors such as heat, cold, and emotional pressures. 2) typical S&S: a) parasthesias --unusual sensory sensation such as numbness, shooting pains, etc b) weakness of certain muscles asymmetrically—one leg affected, or one arm, etc. c) if cerebellum also affected, can have vertigo, incoordination, & ataxia--staggering gait d) other possibilities (depending on areas of lesions): dysarthria (difficulty speaking due to actual jaw muscle weakness); double vision, bladder control problems

IBD treatment

generally directed at controlling inflammation by giving steroids & other meds; sometimes surgery to remove parts of bowel

treatment for Parkinson's

give medication containing dopamine (L-dopa) and anticholinergic medications (benadryl)

What counterregulatory hormones are secreted when hypoglycemia occurs?

glucagon (which stimulates glycogenesis and gluconeogenesis) growth hormone, epinephrine, and cortisol (which cause s/sx of shakiness, irritability, and sweating)

glucosuria

glucose in urine due to state of hyperglycemia-> glucose surpasses renal threshold (amount peritubular cells can "hold onto" before the glucose spills into urine ).

S&S that tell you bleeding is coming from UGI area of gut

hematemesis _—sudden vomiting of blood blood in stools melena-loose tarry stools

What are the s/sx of an upper GI bleed?

hematemesis, occult hematemesis, occult bleeding in stool detected by a hemoccult test, and / or melena.

What are some cause causes of prehepatic jaundice?

hemolytic conditions (when the rate of hemolysis exceeds the liver's ability to handle the bilirubin load). Ex. hemolytic anemia, erythroblastosis fetalis

type of stroke important in deciding further interventions—ischemic vs hemorrhagic?

hemorrhagic—may need surgical intervention for certain types of hemorrhagic strokes b) ischemic: (1) correct underlying problem such as atrial fibrillation with drugs, etc (2) thrombolytic drugs (clot-busters) but must be within 3-4.5 hours of start of incident ("with a brain attack, time is brain!") (3) institution of anticoagulant therapy: at first Heparin, then send home on Coumadin c.later interventions will probably include rehabilitation and depend on site of stroke—what areas of brain were affected? Will patient need speech therapy, swallowing

What are diverticulum / diverticula?

herniations or saclike outpouchings of mucosa from the muscle layer of the intestine that protrude from the intestine. They occur most commonly in the sigmoid colon.

What lab tests will be specific for cirrhosis / liver disease?

high indirect bili / low direct bili elevated liver enzymes: AST, ALT, & ALP

at any given time there is a certain, normal amount of calcium in circulation; when the serum calcium is HIGHER than normal called

hypercalcemia

Cushing's syndrome / disease has two main components. What are they?

hypercortisolism and hyperaldosteronism

What are the s/sx of increased levels of cortisol and aldosterone?

hyperglycemia lipolysis with hyperlipidemia and deposition of fat in certain body areas abnormally catabolized protein (muscle wasting / skin fragility) increased breakdown of bone suppression of prostaglandin activity retention of Na+ and H20 with hypokalemia acne and hirsutism

Type II DM SS

hyperglycemia & glucosuria, like type I, but no DKA or weight loss because there is still SOME glucose getting into cells. - since this is slow process, sometimes S&S very subtle—mild polydipsia & polyuria, fatigue - also, BS's can get very high - 400-900—without patient realizing it;

In general, what is diabetes mellitus characterized by?

hyperglycemia and glucosuria, They have problems in multiple body systems as a result of this chronic disease.

the commonality of all DM disease is that pathologic

hyperglycemia is present

What is the "extreme state" for type II diabetes?

hyperglycemia-hyperosmolar-nonketotic syndrome This is abbreviated in a variety of ways depending on which resource you look at: HHNKS, HHNK, HHNS, etc.

Most endocrine disorders are problems of either ________ or ________.

hypersecretion or hyposecretion

S/S of Parkinson's disease

hypertonia (rigidity) manifestations include: a) overall rigidity, often noticed in the face—mask-like face b) "cog-wheel rigidity" of forearm c) dysarthria (difficulty forming words) d)dysphagia (difficulty swallowing dyskinesia (movement disorder) manifested as: a) involuntary facial & trunk movements such as "Parkinson's tremor"—a pattern of alternating movements between thumb & forefinger described as "pill-rolling" b) inability to make appropriate posture adjustment when tipping or falling, so walking takes on typical pattern called "basal ganglion gait" AKA "Parkinsonian gait"—stooped, shuffling posture; decreased arm swing

hypoglycemic crisis states:

if glucose gets low enough for the brain to run out of fuel, patient can become unconscious—called hypoglycemic shock or coma-- and can also have seizures 2) in medical settings we often most commonly see severe hypoglycemia / coma in the context of taking too much insulin or taking it without eating; in this case the crisis state is often called _insulin shock _or insulin coma

tx for hypoglycemia

if person can swallow ok, give glucose in form of orange juice, packet of sugar, etc (follow that by complex carb like cracker) b. if in danger of not being able to swallow and/or is unconscious, give IV glucose; or can give glucagon intramuscularly (IM) or subcutaneously (subQ).

What are the most common complications of a hip fracture?

immobility, infection, DVT and PE (collectively known as VTE), fat embolism, pneumonia, hemorrhage, and shock.

sequelae of HYPERaldosteronism:

increased Na & H20 retention-> fluid volume overload->weight gain, edema, HTN 2) hypokalemia -hypersecretion of androgens-> acne and hirsutism (increased hair growth, usually in inappropriate places)

What types of problems with metabolism (breakdown of many substances) with the patient with cirrhosis have?

increased blood amonia levels difficulty breaking down sex hormones (gynecomastia and hirsutism) hypercortisolism hyperaldosteronemia drugs can't be broken down plus there is not enough available albumin for them to bind to (causing an increased effect of the drug due to their accumulation in the blood).

abnormal LOC findings often means there has been some sort of event that has led to

increased cerebral edema and IICP in certain areas of the brain

Type II DM patho

increased fat cells in the body, which causes wide spread resistance to insulin (insidious onset chronic disease) - SOME glucose is getting into the cells from the blood, but some is NOT, so the glucose in the blood increases - pancreas reacts to this continued hyperglycemia by increasing secretion of insulin-> hyperinsulinemia - no matter how much insulin gets secreted, still can only get a small portion of glucose into cells due to their insulin resistance-> eventually pancreas "poops out"— beta cells "run out of steam" & there is decreased insulin production-> continued hyperglycemia

diverticulitis

inflammation / infection of the diverticula. a. S&S: pain-- most often LLQ pain; fever; leukocytosis b. can result in abscess formation, rupture and peritonitis if not treated adequately. c.tx: increase dietary fiber, avoid certain foods (seeds, nuts); sometimes antibiotics, occasionally surgery is required

gastritis

inflammation of stomach lining - acute—usually due to ETOH, NSAIDS; heals when cause is taken away - chronic—may be autoimmune etiology; important possible sequela is development of pernicious anemia due to decrease in intrinsic factor production.

What is cholecystitis?

inflammation of the gall bladder

cholecystitis

inflammation of the gall bladder—is almost always caused by irritation of stones inside the gall bladder itself (cholelithiasis) and/or in a nearby duct such as the common bile duct (choledocholithiasis)

hepatitis

inflammation of the liver 1) many causes, including autoimmune problems, microbes, idiopathic. 2) spectrum from very mild & self-limiting to causing cirrhosis and death. 3) S&S vary & may include aching, fatigue, malaise, N,V, D, jaundice. viral hepatitis: 3 most common strains: A(HAV) , B (HBV), C (HCV)

What is choledocholithiasis?

inflammation of the nearby common bile duct and the stones within it.

What is cholelithiasis?

inflammation of the stones inside of the gall bladder

Patho/Cause of Parkinson's disease

is a basal ganglia dysfunction disease caused by unknown source, but suspected to be genetic, viral, or environmental toxin-induced depletion in dopamine a) a decrease in dopamine tips the scales of balance towards cholinergic, excitatory activity --not actually more acetylcholine, but more effect.) b)the result of the increased cholinergic effect gives S&S related to hypertonia (rigidity) & dyskinesia (movement disorder)

cerebral hemispheric brain attack general patho:

lack of blood flow OR bleeding of the left or right middle cerebral artery (MCA) or its many branches -> results in swelling & edema from hypoxia to the right or left hemisphere of the cerebrum -> S&S are from three possible sets of deficits:

dx and labs of bacterial meningitis

is lumbar puncture ("spinal tap") -- specimen of CSF obtained and sent to lab for analysis; CSF will show: a) high WBC count b) higher-than-normal protein count because of the presence of bacteria and protein exudates (from inflamed meningeal blood vessels & increased vascular permeability) c) lower glucose than usual, because bacteria is "eating" the glucose d) blood in CSF

hemorrhagic brain attack patho

is usually caused by the effects of blood that leaks out directly onto brain tissue (in most areas of brain there is normally NO blood directly on brain tissue—is carried in arteries & veins, and when arrives at capillary beds, O2 & nutrients diffuse into tissue cells & CO2 & other wastes diffuse out of cells)

What can cause cerebral edema?

ischemia from a blockage of an artery in the brain (hypoxia), brain tumors, injuries, irritants (infections, acidosis), hypertension / hypotension, etc.

What are the two main types of brain attacks?

ischemic brain attacks and hemorrhagic brain attacks (although...actually the negative effects of a stroke come from cerebral edema and IICP (which are the result of the stroke)...no matter what type of stroke it is.)

Type I DM cause

it is due to a TOTAL lack of insulin secretion from beta cells of pancreas -autoantibodies destroy pancreatic tissue-> NO INSULIN acute onset disease- after that chronic

What symptoms are specific to ulcerative colitis?

it is found only in the colon, not in the small intestines begins in the intestines and progresses to involve the entire colon inflammation and ulcerations are in the submucosa and are confluent greater risk for dehydration.

dx of cirrhosis

lab tests specific for liver: a) elevated indirect serum bilirubin; sometimes also low direct bilirubin (1) patho of high indirect bili: normal level of unconjugated bili enters liver->the diseased hepatocytes cannot conjugate it -> remains in blood as unconjugated= higher- than-normal level of indirect bilirubin in the blood. (2) patho of low direct bili: diseased liver cells cannot conjugate bilirubin -> low serum direct bili. b) elevated serum liver enzymes: AST (aspartate aminotransferase), ALT (alanine aminotransferase), and ALP (alkaline phosphatase)—all abnormally increase in the blood when hepatocytes are damaged

long-term problems associated with both types DM

large numbers of glucose molecules plus abnormal numbers of fat molecules in the blood are very damaging to the linings of all arteries in the body, giving rise to angiopathy (damaged arteries) 1) macroangiopathy: glucose toxicity->damage to large & medium-sized arteries -> atherosclerosis in brain, heart, aorta, femoral arteries (stroke, CAD, aneurysms, PAD) 2) microangiopathy—damage to small vessels such as: a) retinal arterioles-> retinopathy-> blurred vision, blindness b) capillaries of kidneys -- DM is major cause of chronic renal failure c) skin—easy bruising b. angiopathic ischemia to nerves plus direct toxic effects of glucose also cause neuropathy: 1) peripheral neuropathy —burning, pain, itching, numbness of feet-> lack of feeling also cause increase risk of trauma and infection 2) autonomic neuropathy—damage to nerves of the autonomic system a) slowing of gut (gastroparesis), causing altered nutrition absorption & constipation b) bladder control problems c) "silent MI" - pain transmission during MI is dysfunctional, so sometimes diabetic can be having MI without pain (would have other S&S, though) c. toxic effects of high glucose also impairs phagocytic function 1) patient has increased susceptibility to infections 2) usually manifested as recurring UTIs, yeast infections, non-healing sores

sequelae of HYPOaldosteronism

less aldosterone = body can't hang on to water due to decreased tubular absorption of Na+ -> increased urination (polyuria) -> decreased blood volume 2) decreased blood volume -> hypotension & other S&S of fluid volume deficit.-> dehydration c.Addisonian crisis—severe hypotension due to fluid loss

Give some examples of abnormal LOC findings.

lethargy or inability to waken patient at all (coma) not oriented to some or all of self, time, place, or events doesn't follow commands speech might be garbled or no speech at all verbal responses might show confusion, delirium, dementia, or behavioral changes.

SUMMARY Hepatic jaundice

liver is sick-jaundice that occurs because the liver is not capable of conjugating the unconjugated (indirect) bilirubin. Think: "CIRRHOSIS."

What is a paralytic ileus?

loss of peristaltic activity in the intestine. This may be due to: immobility, post-ansethesia effects, surgery (especially abdominal), peritonitis, electrolyte imbalances, and spinal trauma. It is important to increase patient mobility in the hospital as soon as possible to prevent this from happening.

HYPOthyroidism causes

low thyroid hormone secretion 1) congenital defects 2) direct removal of tissue (tumor) or direct destruction of tissue (ex-- radiation) - one of most common causes is Hashimoto's thyroiditis—autoimmune disease in which autoantibodies directly destroy tissue-> scarring, nonfunctional tissue - another cause, uncommon these days because we add iodide to our salt—endemic iodide deficiency (since iodide is a key ingredient in molecular structure of T3 & T4); if mother is iodine-deficient, her fetus won't develop properly -> child is born with stunted mental & physical growth -> called cretinism

What are the long term problems of diabetes, especially if it is not treated effectively?

macro and microangiopathy (damaged arteries) angiopathic ischemia to nerves (peripheral and autonomic neuropathy) impaired phagocytic function (increased susceptibility to infections, poor wound healing)

in most people, the left hemisphere controls

many aspects of speech, dysphasia (difficulty speaking due to neuro disorder) or aphasia (absence of speaking)— general terms referring to varying degrees of inability to comprehend, integrate, and express language (b) ability to do math, organize, reason, and analyze, so these faculties might be impaired with left hemispheric stroke.

In most people, the left hemisphere controls...

many aspects of speech, so the patient may have dysphasia or aphasia the ability to do math, organize, reason, and analyze

Crohn's disease

may involve any portion of the GI tract, but in 70 % of cases involve duodenum, ileum, and/or & cecum; 20% of cases involve rest of large intestines 2) ALL layers of bowel are involved—ie, entire wall -- transmural involvement 3) random segments of inflamed tissue are separated by normal tissue ie, Crohn's has a "patchy" pattern b. S&Ss—see "common features" above; also, malabsorption, malnutrition, weight loss, since most nutrients are absorbed in small intestines, especially duodenum.

treatment of osteopenia and osteoporosis

medication to decrease osteoclastic activity, such as nasal calcitonin and biphosphonates (Fosamax).

HBV

more insidious onset & more devastating; transmitted parenterally via blood & bodily fluids; vaccine available

tx of BA

most important! - prevention of further increase in ICP (this is true of ANY brain patho): a) O2 b) BP management (this is part of managing CPP)—not too high or low c) monitoring & control of cerebral edema: (1) HOB up at least 30 degrees (2) diuretics (3) sometimes ICP monitor

Tx for HYPOthyroidism

most often is synthetic thyroid hormone -- levothyroxine (Synthroid)

What systems are effected by immobility?

musculoskeletal (weakness, disuse atrophy) integumentary (skin breakdown, pressure ulcers) pulmonary (atelectasis, pneumonia) GI (constipation, paralytic ileus) cardiovascular (DVT / PE, deconditioning of the cardiac system) miscellaneous: renal calculi, osteoporosis, hypercalcemia

Ischemic brain attack is usually caused by a ________ or _______ of the arteries that supply the brain or are in the brain.

narrowing or blockage. This means that a stroke can be thrombotic or embolic in nature.

The endocrine system is dependent on a series of _______ feedback systems.

negative so...a high blood level of a circulating hormone will automatically supress the gland that secreted it and a low blood level of a circulating hormone will automatically stimulate the gland that secreted it.

Unequal pupil size -one fixed (not responding to light exposure) and dilated and one pupil constricted - is a potentially important sign of a

neurologic disorder such as increased ICP or intracranial hemorrhage (bleeding in the brain).

What are some typical s/sx of parkinson's disease?

overall muscle rigidity, difficulty forming words / swallowing, tremors, a stooped, shuffling posture due to a dysfunction in the basal ganglion in which there is a depletion of dopamine.

etiology of IBD

no proven primary etiology but possible causes include: a) infectious agents (bacteria, viruses) b) links to familial occurrence c) autoimmune response: (1) formation of autoantibodies against glycoproteins in walls of the intestines-> inflammation. (2) sometimes patient has manifestations of systemic autoimmune features as well—arthritis, vasculitis, iritis

What is often one indicator that areas in the brain that control respiration, etc, (ie, brain stem) are working normally—that is, have no cerebral edema & IICP.

normal VS (vital signs—BP, HR, RR, temp)

meaning of reflex assessment findings

normal peripheral reflexes: include an expected degree of response, which is equal bilaterally (therefore symmetric), and reflects good connections in the reflex arc of the spine and also normal interpretation in the brain. 2) normal central reflexes include appropriate cough, swallow, gag, etc. 3) with any kind of brain lesion, some reflexes might diminish or become absent; ex: a) deep tendon reflexes might become hyporeactive. b)gag, swallowing, coughing reflexes would fail to protect adequately

What are the possible etiologies of hypoglycemia?

not eating or food is unable to be absorbed natural hyperinsulinism taking too much insulin

When hepatocytes do not function properly, what types of problems will the patient have?

nutritional problems due to impaired production of bile salts, impaired fat and cholesterol metabolism, and impaired glycogenolysis and gluconeogenesis. decreased levels of plasma proteins and clotting factors

diminished hepatocyte function a) without proper hepatocyte function, liver cannot perform normal metabolic functions & patient will have some or all of the problems / S&S listed below.

nutritional problems due to impaired... (1) production of bile salts->unable to absorb fat & fat- soluble vitamins—will have many vitamin deficiencies, weight loss (2)can't create & metabolize lipoproteins-inappropriate distribution of lipoproteins—low HDLs, more circulating LDLS. (3) glycogenolysis & gluconeogenesis, may easily become HYPOglycemic protein depletion problems (1) decreased levels of plasma proteins, which contributes to fluid shift problems such as ascites & generalized edema, peripheral edema; pulmonary edema (cough, SOB, crackles heard in lungs) (2) decreased levels of clotting factors-- fibrinogen, prothrombin, other factors (a) this is partially due to inability to create these proteins (b) result-- will tend to bleed easily & labs reflecting clotting times will be abnormal; ex--PT, PTT will be prolonged (note: contributing to bleeding problems will be thrombocytopenia from splenomegaly [hypersplenism]) problems with metabolism (breakdown) of many substances, including ammonia, drugs & hormones (1) decreased ability to break down ammonia into urea, resulting in increased blood ammonia levels (a) at toxic levels the ammonia affects CNS, resulting in brain inflammation, called hepatic encephalopathy (2) sex hormones can't be broken down, so men may get gynecomastia (breast growth in men), & women may get hirsutism (abnormal hair growth). (3) glucocorticoids can't be broken down-> hypercortisolism-> Cushing's syndrome (4) aldosterone can't be broken down-> hyperaldosteronemia ->salt & fluid retention-> ascites and generalized edema. (5) drugs can't be broken down PLUS not enough albumin to bind to-> this would cause increased effect of drugs due to their accumulation in the blood. othe:r (1) Kupffer cells no longer function properly to filter out bacteria, plus leukopenia from splenomegaly = increased risk of infection (2) jaundice from inability to conjugate bilirubin (3) LAB HIGH unconjugated, LOW conjugated

· treatment for brain disorders: most interventions for brain-related problems are geared towards lowering ICP by:

o keeping head of bed up at ~ 30 degrees o keeping BP not too high & not too low o sometimes giving diuretics.

PUD SS

o painless; OR can have pain after meals o hematemesis (coffee ground or bloody); melena from digesting blood o anemia o perforation possible

What are the risk factors for gall bladder disease?

obesity, female, use of contraceptives, multiple pregnancies, starvation / rapid weight loss diets, family history of GB disease, caucasian, over 40 years old.

pathogenesis / S&S: of intestinal obstructions

obstruction → sequestration of gas and fluid proximal to the obstruction → abdominal distention (become swollen/stretched)→ causes following S&S: 1) severe, colicky abdominal cramping 2) N &V 3) can have either constipation or, with partial obstruction, sometimes can have diarrhea

S&S that tell you bleeding is coming from LGI area of gut

occult bleeding 1) stool may look normal, but actually has small amt of hidden blood from a slower, chronic bleeding situation such as a cancer or diverticulitis. 2) detected by using hemoccult test b. frank bleeding--red blood mixed with stool (would NOT have melena because digestion occurs in upper GI areas, not lower GI.)

blood in stools

occult bleeding a) stool may look normal, but actually has small amt of hidden blood from a slower, chronic bleeding situation such as a cancer irritating the walls of one of the UGI structures. b) detected by using hemoccult test

thrombotic stroke

occurs from a clot or plaque that blocks off the artery in which it has developed & causes ischemia distally.

risk factors of GB

often associated with obesity-> more cholesterol in the bile b. estrogen reduces synthesis of bile acid & increases liver secretion of cholesterol into bile-stones more common in women, especially those on contraceptives or have had multiple pregnancies c. starvation, rapid weight loss can increase GB "sludge"—thickened GB mucoprotein d. may be strong genetic component e.classically GB disease is characterized by the 5 "F's"—female, fat, forty, fertile, fair (statistically more typical in whites)

causes of increased ICP (IICP):

often caused by cerebral edema secondary to: · CPP abnormalities- ischemia & hypoxia; · irritants like hemorrhage, infection, acidosis · ... almost any kind of brain problem has potential to generate cerebral edema & therefore increased ICP.

What are the s/sx of syndrome of inappropriate antidiuretic hormone (SIADH) oversecretion?

oliguria, edema, fluid overload

SS of myasthenia gravis

one of main signs is progressive muscle weakness with motor activity-- 1) this is because with each repeating nerve impulse the amount of acetylcholine released usually declines b. so, hallmark of myasthenia gravis is muscle weakness that increases during periods of activity and improves after periods of rest 1) this weakness can include muscles that control eye and eyelid movements, facial expression, chewing, talking, and swallowing, and neck and limb movements 2) if affects breathing, called myasthenia crisis

What disorders are caused by calcium movement alterations?

osteopenia and osteoporosis electrical issues (changes in RMP) clotting disorders when calcium levels are low kidney stones when calcium levels are high

SS of cholelithiasis / cholecystitis

pain in the RUQ & epigastric area: 1) often manifested as painful spasms/ contractions of the GB & bile ducts called biliary colic 2) most commonly comes on or worsens after high-fat meal (more fat in intestines = more need for bile to emulsify it-> secretion of bile puts strain on inflamed GB & causes pain) b. may also have referred pain to the back, above waistline and especially to R shoulder, R scapula. c. almost always there is nausea & vomiting d. if a large stones completely blocks common bile duct, may also cause obstructive jaundice & gray stools.

DM 3 P's

polyuria (lots of peeing) , polydipsia (great thirst), polyphagia (excess hunger)

SS of DI

polyuria -> void a lot of dilute urine, -> extreme thirst. With loss of water -> serum osmolality INCREASES -> causing water to shift from T to B. --> S&S of dehydration -> sunken eyes, dry mucous membranes, and poor skin turgor.

What are the s/sx of diabetes insipidus?

polyuria, thirst, higher serum osmolality, dehydration, poor skin turgor, dry mucous membranes

What are the three major categories of jaundice?

prehepatic jaundice hepatic jaundice posthepatic jaundice

CPP—cerebral perfusion pressure

pressure required to get oxygenated blood into the brain to perfuse the cells of the brain b. if EITHER too low (as happens in hypovolemia, hypotension, etc) OR too high (ex— hypertension), the result is ineffective perfusion->ischemia to brain-> cellular hypoxia-> cell injury & death-> loss of cell membrane integrity-> water & other cell contents are released-> results in cerebral edema and increased ICP -> further loss of effective perfusion. c. summary: ___ is either too high OR too low, can lead to cerebral edema and increased ICP

hiatal hernia

protrusion of part of stomach into thorax

What is miosis?

pupillary constriction that usually occurs equally in both pupils upon exposure to more light as a result of the parasympathetic fibers within CN III releasing acetylcholine.

miosis

pupillary constriction, usually occurs equally in both pupils upon exposure to light b. results from parasympathetic fibers within cranial nerve III (the oculomotor nerve) releasing acetylcholine, which act on receptors on iris. c. damage from ischemia and/or bleeding in the brain, and/or IICP may cause compression of CNIII. This may cause the loss or diminish the ability of the pupil to constrict. The pupil will remain abnormally dilated & will not respond to light (or respond sluggishly to light).

What is mydriasis?

pupillary dilation that usually occurs equally in both pupils upon exposure to less light as a result of the SNS releasing norepinephrine.

mydriasis

pupillary dilation, usually occurs equally in both pupils upon exposure to less light—ie, the less the light, the more the dilation. b. results from sympathetic nervous system releasing norepinephrine and stimulating alpha-1 adrenergic receptors on iris.

Barrett's esophagus

relatively uncommon disorder almost always caused by GERD b. certain areas in esophagus tissue become dysplastic-- if left untreated can lead to esophageal cancer.

nystagmus

rhythmic, involuntary, unilateral or bilateral movement of the eyes. a. can be horizontal or vertical movement. b. can be congenital or can be a sign of cerebellum or inner ear dysfunction— associated with vertigo and balance problems.

What is nystagmus?

rhythmic, involuntary, unilateral or bilateral movement of the eyes. It can be horizontal or vertical movement. It can be congenital or a sign of cerebellum or inner ear dysfunction and associated with vertigo and balance problems.

What would be some typical s/sx of a diffuse injury stroke?

s/sx are seen equally throughout the body (above and below the shoulders) sensation, muscle tone, movement, strength, and reflexes would be weaker bilaterally and often fairly symmetrically. you may also observe brain stem abnormalities due to diffuse cerebral edema and IICP which will result in diminished LOC, heart rate, breathing, and/ or blood pressure changes.

What are the s/sx of pancreatic cancer?

s/sx similar to pancreatitis and also includes: pain, jaundice, weight loss onset is insidious

HCV

same as HBV but no vaccine available; devastating problem because often no S&S at all but can still be transmitted

in most people, the right hemisphere controls

spatiality—where you are in space, & where things are around you; sometimes people with a right hemispheric lesion develop what is called left sided neglect - a tendency to completely ignore the environment on the left side. (ex—pt won't perceive that there is anything on the left side of a plate of food or that there is a nurse standing on his left) (b) also is the seat of insight (including insight to his/her disease), creativity, face recognition, musical ability, etc.

Labs and SS of HYPOthyroidism

serum T4 will be lower than normal range and serum TSH will be higher than normal 1) psych/CNS—confusion, slow speech & thinking, memory loss, depression. 2) circulatory—anemia, bradycardia, decreased CO 3) pulmonary—dyspnea, hypoventilation, CO2 retention 4) GI—decreased appetite, constipation 5) hair is dry and brittle, and may fall out (alopecia); 6) skin- often patient has myxedema, patient takes on overall puffy appearance. - also skin is very coarse and dry. 7) goiter—, the enlargement is caused by two factors: a) hyperplasia & hypertrophy of the tissue as a compensatory response trying to "desperately" increase thyroid hormone secretion b) inflammation and eventual scar tissue from autoimmune attack 8) other body changes: a) weight gain despite decreased appetite. b)decreased body temp and cold-intolerance.

what labs are done when thyroid problems are suspected

serum TSH and T4

What are the s/sx of pancreatitis?

severe post prandial or alcohol pain in the epigastric area that radiates to the back. jaundice may occur elevated serum amylase, lipase, and WBCs

acute pancreatitis

severe, life-threatening disorder associated w/ escape of pancreatic enzymes into pancreas & surrounding tissues, causing autodigestion and hemorrhage cause: 1) can be due to gallstones, in which the pancreatic duct obstruction and/or biliary reflux is believed to activate enzymes in the pancreatic duct system 2)other main cause is alcohol—exact mechanism unknown, but is known to be potent stimulator of pancreatic secretions

What are some of the potential etiologies of diabetes insipidous?

sick kidneys (which have a decreased response to ADH secretion) a pituitary tumor or cerebral edema / IICP near the pituitary gland (causes less ADH secretion by the pituitary) ...without the influence of ADH, water will indiscriminately flow from the peritubular capillaries of the kidneys into the tubules and you will create very dilute urine.

What are the usual places where jaundice can be seen?

skin, sclera, under the tongue, and in the palate of the mouth.

What are some potential etiologies of syndrome of inappropriate antidiuretic hormone (SIADH) oversecretion?

small-cell bronchogenic cancer various drugs that affect the brain, especially general anesthetics trauma to the brain, head injuries, brain tumors that can cause cerebral edema, increased ICP, and put pressure on the pituitary gland (causing it to malfunction)

In most people, the right hemisphere controls...

spatiality (where you are in space and where things are around you). These patients have a tendency to develop left-sided neglect. The right hemisphere is also the seat of insight, creativity, face recognition, musical ability, etc.

cirrhosis

state of irreversible damage to hepatocytes; can be mild (small amount of liver involvement) to severe (most of liver involved) · causes: ETOH, too much drug use (acetaminophen); hepatitis; chronic GB dz; genetic disorders—hemochromatosis (pathologic iron deposition in liver) & Wilson's dz (copper deposits in liver)

tx for Addisons disease

steroids, aldosterone, high-salt diet (within reason!) daily oral steroids (prednisone) and aldosterone (Florinef)

purpose of GB

stores bile, which is secreted into intestines to help emulsify fats (ie, makes fats easier to digest)

seizures

sudden, chaotic discharge of neurons in brain -called epilepsy if a chronic, usually congenital origin -2 categories of szres— general (pt always unconscious, tonic-clonic movement) & partial (varied degrees of consciousness & motor involvement, usually local) - post-seizure state of re-organization of brain signals called post-ictal state—pt groggy, confused. - if seizure continues unremitting, not responsive to medications it is called status epilepticus.

What is a "brain attack" or a stroke?

the process of any interruption of the normal blood supply to a part of the brain or the entire brain, resulting in damaged brain tissue. AKA: stroke, cerebral vascular accident (CVA)

osteopenia

the condition of having somewhat less than normal bone density

physiologic jaundice is due to

the immaturity of the conjugating enzyme glucuronyl transferase (c) the treatment is UV light therapy, which helps to convert the unconjugated bilirubin to conjugated. (d) the baby's glucuronyl transferase usually soon matures & takes over this job.

assessing deficits that are special / specific to each hemisphere

the left hemisphere controls- speech, ability to do math, organize, reason, and analyze, the right hemisphere controls-spatiality, also is the seat of insight (including insight to his/her disease), creativity, face recognition, musical ability

SUMMARY Posthepatic jaundice ("obstructive jaundice")

the liver is fine-jaundice that occurs because conjugated (direct) bilirubin is prevented from reaching the intestines and it "backs up" into the blood . Think: "OBSTRUCTION" (such as choledocholithiasis).

SUMMARY Prehepatic jaundice

the liver is just fine- there is too much unconjugated (indirect) bilirubin for even a healthy liver to conjugate. Think: "OVER-HEMOLYSIS." (More RBC destruction -> more breakdown products such as unconjugated bilirubin)

Damage to CN III will cause what to happen?

the loss or diminishing of pupillary constriction abilities, so that the pupil will dilate abnormally and not respond to light (or respond sluggishly).

What happens in healthy individuals when there is a drop in T3 & T4 in the bloodstream?

the pituitary gland senses the low T3 / T4 levels and releases TSH. TSH circulates back to the thyroid gland and stimulates it to release more T3 and T4 until normal serum levels of T3 and T4 are re-established. Normal levels of T3 and T4 then suppress the secretion of TSH by the pituitary.

What are some possible causes of a hemorrhagic brain attack?

the pressure from hypertension weakened arterial walls from atherosclerosis the presence of aneurysms congenital vascular malformations bleeding into a tumor coagulation disorders

What is cerebral perfusion pressure (CPP)?

the pressure required to get oxygenated blood into the brain to perfuse the cells of the brain. If it is too low or too high, cerebral edema and increased ICP can result.

patho cholelithiasis / cholecystitis

the stones are caused by situations in which either: 1) cholesterol increases (cholesterol is normal part of bile) OR 2) there is less water in the body, such as in dehydration b. result of above situations is formation of small (2-8mm) to large stones (3- 4cm) made of cholesterol & bilirubin precipitant. c. the chemical irritation of concentrated bile in the gall stones causes swelling of the GB & generalized inflammation in the biliary area

portal system

the system of veins & venous flow between organs in the abdomen—spleen, stomach, liver, pancreas, intestines.

What is intracranial pressure (ICP)?

the totality of pressures in the brain: arterial pressures + venous pressures + CSF pressures, etc. because the cranium is a bony structure, very little increase in pressure in the brain can be tolerated.

What are the s/sx of myasthenia gravis?

this is a chronic auto-immune disease that blocks, alters or destroys the receptors for acetylcholine. This results in progressive muscle weakness with motor activity that improves with rest.

What is the role of insulin after eating?

to assist glucose into the cells to be used as an energy source to induce the liver to store unneeded glucose as glycogen to stimulate amino acids to build protein mass

What is the job of calcitonin?

to increase the movement of calcium from the blood into the bone

prehepatic jaundice

too much unconjugated bilirubin in blood lab results: high indirect bilirubin & normal direct bilirubin basic etiology = hemolytic problems · RBCs are being broken down at greater than normal rate or amount-> greater amount of unconjugated bilirubin in blood because liver can only normally conjugate a certain amount-> high indirect bilirubin · ex—erythroblastosis fetalis—when Rh-negative mom's antibodies attack fetus' RBCs-> accumulation of unconjugated bili-> jaundice (different from physiologic jaundice that is due to "normal" immaturity of enzymes in liver that do the conjugating; this type easily "fixed" w/ UV light tx).

hepatic jaundice

too much unconjugated bilirubin in blood & too little conjugated etiology—hepatitis or cirrhosis-> diseased hepatocytes unable to conjugate, so unconjugated accumulates PLUS conjugated output low. - high indirect, low direct bili. The liver is sick,

Summary of differences upper & lower GI bleeding:

upper- the cause is in the esophagus, stomach, duodenum (ex- PUD): a. hematemesis (blood in vomit): either be occult, frankly bloody, or coffee ground (digested blood) b. stools: occult blood or melena (tarry black = digested blood) 2. lower- the cause is in the jejunum, ileum, large intestines (ex- IBD) stools can contain occult blood or be frankly bloody (hematochezia)

What is a hemorrhagic brain attack (stroke)?

usually caused by the effects of blood that leaks out directly onto brain tissue. This causes an inflammatory process-> swelling -> and cerebral edema -> increased ICP ->cellular ischemia, injury, and possibly infarction of the surrounding area.

if there is focal cerebral edema around the right CN II, that transmits visual images to the brain, you would expect

visual defects in the two left halves of BOTH eyes. (homonymous hemianopia)

Homonymous hemianopia

visual deficit in one side (the same side) of both eyes

esophagogastroduodenoscopy (EGD)

visualization of the esophagus, stomach and duodenum.

colonoscopy

visualization of the rectum, colon and distal small bowel; important tool in detecting colon cancer early

meaning of sensorimotor findings BELOW the shoulders :

what you are assessing: certain parts of the sensorimotor apparatus that connects brain to spine to muscles in torso, arms, and legs— the corticospinal tracts & the spinothalamic tracts.

embolic stroke

when fragments that break from an arterial thrombus (as above) & travel "downstream" until they "get stuck" in a smaller artery and cause ischemia to brain distally.

Why are women more likely to have problems with a decrease in bone density?

women's bones are significantly less dense than those of men. the menopausal loss of estrogen results in less bone building / lower bone density Was women age

Calcitonin release does what?

· is triggered by hypercalcemia · decreases osteoclastic activity · results in decreased resorption so that calcium moves from blood to bone instead of bone to blood is suppressed by hypocalcemia

PTH release does what?

· is triggered by hypocalcemia · increases osteoclastic activity · results in increased resorption (calcium moving from bone to blood) · is suppressed by hypercalcemia

syndrome of inappropriate antidiuretic hormone (SAIDH) causes

· oversecretion of ADH ectopically produced by lung cancer (the lung cancer makes and then secretes ADH), certain drugs such as anesthetics, brain tumor or any head trauma or injury - head injury/trauma or brain tumors can cause either an oversecretion or an undersecretion of ADH.

Diabetes Insipidus (DI) cause

· undersecretion of ADH (antidiuretic hormone) - diabetes means to pass too much urine; insipidus means flavorless urine. -renal related ("sick" kidney does not respond to ADH), -CNS etiology such as a brain tumor or any head trauma/injury. Each will cause a decrease in the secretion of ADH. whatever the etiology, without the influence of ADH, you won't "hold onto" water effectively --water will indiscriminately flow from the peritubular capillaries of the kidneys into the tubules and becomes very dilute urine

•Identify possible etiologies for Cushing's disease? Cushing's disease occurs from?

• a pathologic over secretion of ACTH from the pituitary gland OR •Tumor or malfunction of the adrenal cortex •Chronic steroid use (called Cushing's syndrome -symptoms are the same) Over secretion of aldosterone, in our course, MUST also be linked with over secretion of cortisol

•A patient arrives in the ED with complaints of; -"wobbly" walk; can't seem to walk without tipping over. -dizziness -Nausea and vomiting •What is a likely diagnosis? Identify additional S&S associated with this illness.

•A cerebellar stroke. Identify additional S&S associated with this illness. Additional S&S of a cerebellar BA are vertigo, nystagmus, loss of coordination and falling down

Identify causes of osteoporosis.

•Aging (affects men and women) and menopause (reason why women affected more than men) will result in more bone breakdown then build up. In addition, conditions that cause chronic hypocalcemia (such as kidney disease) will cause the normal functioning body to pull stored calcium from the bone (bone resorption). Osteoporosis will occur when PTH is abnormally over produced by the parathyroid gland ("ill" parathyroid gland) or when the thyroid gland under produces calcitonin = less calcium moved into the bone for storage.

§The NP (nurse practitioner) is examining the bottom of the patient's foot and notes an infected wound. She asks the patient if the wound is painful. The patient states "I am not feeling any pain. I didn't even know that I had a sore on the bottom of my foot." What is the cause of this scenario?

•Angiopathic ischemia to nerves = hyperglycemia will cause damage to blood vessels, reducing the blood vessels patency -> reducing blood flow to the nerve. In addition direct toxic effects of hyperglycemia can cause neuropathy (nerve damage). S&S of peripheral neuropathy = burning, pain, itching or NUMBNESS of feet. A patient can injure the bottom of their feet without knowledge. •Hyperglycemia can also impair phagocytic function, making the patient more susceptible to infections. The infections are manifested as UTIs, yeast infections and non-healing sores (such as in our scenario).

what we would as the nurse would need to do/monitor whether the patient has an ischemic or hemorrhagic

•BP management. Hypertension is a cause / etiology of ischemic and hemorrhagic BA (brain attacks). In addition, to ensure cerebral perfusion (brain oxygenation), blood pressure management is very important. •HOB (head of bed) elevation. This facilitates venous drainage OUT of the head and reduction of the ICP •ICP monitoring ---an ICP that is markedly elevated will decrease cerebral perfusion. •Diuretics -to ensure normal fluid volume levels in the blood -> helps maintain the ICP

The patient is experiencing nuchal rigidity with a positive Brudinski and Kernig's sign with a fever. He has vomited twice while in the ED and appears ill. A lumbar puncture is performed to rule out viral or bacterial meningitis. •How is the diagnosis of bacterial meningitis confirmed? •What additional S&S, not listed previously, is seen only with bacterial meningitis?

•Bacterial meningitis is confirmed when the following are present in the CSF; •High WBC count •Higher than normal protein count •Low CSF glucose •Blood in the CSF -•restlessness and decreased LOC, Petechiae and purpura -ominous sign which indicates sepsis. •Purpura occurs when small blood vessels burst, causing blood to pool under the skin. This can create purple spots on the skin that range in size from small dots to large patches. Petechiae are small (1-3 mm), red, nonblanching macular lesions

§A woman is brought to the ED because of confusion. Her husband states she has been drinking a lot of fluids and "peeing a lot" over the last 3 days. The nurse notes poor skin turgor, dry mucous membranes and warm dry skin. What might be the cause of these S&S?

•HYPERglycemia. Hyperglycemia will lead to polyuria and polydipsia. Polyuria and polydipsia then caused a HYPERosmolar state.

A surgical repair of the fracture is scheduled. Prior to surgery, the patient's blood pressure is measured at 150/95. The nurse also notes that the patient's BUN and serum creatine are slightly elevated. What might be the cause of her hypertension and decreased kidney function?

•Hypercortisolism suppresses the production of pro-inflammatory prostaglandins (a steroid -the medication--is taken to reduce inflammation) AND suppresses the production of the protective prostaglandins. Protective prostaglandins ensure "normal" vasomotor tone".-- Without the protective prostaglandin that ensures "just right/normal" vasomotor tone, hypercortisolism will cause increased peripheral vasoconstriction -> causing hypertension (HTN). In addition, hyperaldosteronism (the 2 are always present together) will cause the kidney to retain Na -> causing H2O retention -> causing fluid volume overload - which can also lead to HTN. Protective prostaglandins also ensure "good" renal function. Without the protective prostaglandin that ensures "good" renal function, hypercortisolism will cause decreased renal function-- which can lead to a decreased GFR and the accumulation of serum wastes. Serum wastes include BUN and creatinine.

What clinical manifestations are expected as the RN (registered nurse) assesses a patient diagnosed with Addison's disease

•Hypoglycemia -which can cause weakness, fatigue and mental confusion anorexia, nausea, vomiting an diarrhea as a consequence from hypocortisolism. Polyuria, fluid volume deficit and hypotension as a result of hypoaldosteronism.

A CT scan is performed and the patient is diagnosed with a left hemispheric ischemic brain attack. •What is the pathophysiologic reason for the right-sided facial drooping and the visual defects in both right halves of each eye? •What is the pathophysiologic reason for the right-sided arm and leg weakness and a positive Babinski sign on the right foot? •

•Left cranial nerve II controls the right visual field of the right and left eye. If there is ischemia and/or subsequent cerebral edema around the left cranial nerve II, then there will be a disruption in the nerve's ability to transmit visual images to the brain- causing visual deficits. Left cranial nerve VII controls the right facial muscles. If there is ischemia and/or subsequent cerebral edema around the left cranial nerve VII, then there will be facial drooping on the right side. •What controls or rules movement? The left-sided corticospinal "or motor tracts . What is their nickname "pyramidal. •So why do we see deficits on the contralateral side? The left control the right arm and leg because these axons cross over, or decussate, from their point of origin in the left cerebral cortex to the opposite side of the body at the junction between the spinal cord and brain stem. the pyramidal tracts carry impulses that produce voluntary movements of purpose and skill from brain via spinal cord to various peripheral spinal nerves to neuromuscular junctions between nerve & muscles.

The patient's bedside glucose is measured at 600. The RN knows that hyperglycemia can be caused by type I or type II diabetes mellitus. What additional assessments should be obtained (HINT-S&S of either extreme state of DM) by the nurse?

•The nurse should smell the patient's breath. Is acetone (fruity) breath present? The nurse should also check the urine for ketones and glucose. Ketones and acetone breath with rapid, deep respirations (kussmaul respirations) indicate an extreme state of type I diabetes known as DKA (diabetic ketoacidosis). If acetone breath is present with ketonuria, then ABGs would also be drawn and measured. Glucosuria is likely to be present with either extreme state of DM à the serum glucose of 600 is elevated - exceeding the renal glucose threshold and the cause of the polyuria and polydipsia-> fluid volume deficit and the hyperosmolar state. •The S&S of dehydration (poor skin turgor, polyuria, polydipsia) with glucosuria and hyperglycemia WITHOUT ketonuria could indicate HHNKS (hyperglycemic-hyperosmolar-nonketotic syndrome. •Confusion is seen with either DKA or HHNKS.