Unit 3 - NURS 350

Who is the high risk groups for head injury?

Children and older adults

What are the most common causes of head injury?

Falls, unintentional blunt trauma, and motor vehicle accidents

What is coup?

Injury at site of impact

What is contrecoup?

Injury from brain rebounding and hitting opposite side of the skull

What is primary head injury?

The initial damage to the brain that results from the traumatic event
Types: focal and diffuse

What is secondary head injury?

Indirect result of primary brain injury, including trauma and stroke syndromes

What is tertiary head injury?

overtime/delayed injury occuring as a result of primary

What a CVA?

Cerebrovascular accidents

What are the 3 main types of CVA?*

Ischemia Thrombotic
Ischemia Emoblic
Hemorrhagic

What is Ischemia CVA?

When there is sudden neurologic dysfunction caused by focal brain ischemia
2 types: Thrombotic and Emoblic

What is Thrombotic strokes?

Arterial occlusions are caused by thrombi formed in the arteries that supply the brain or in intracranial vessels due to atherosclerosis and inflammatory disease processes

What is Embolic stroke?

Fragments break from a thrombus (clot) that is formed outside of the brain; A second stroke usually occurs; most dangerous type of Ischemia CVA?

What are embolic strokes associated with?

Atrial fibrillation, rheumatic heart disease, artificial valves, atrial septal defects, arterial disorders

What is Ischemia CVA Manifestations?

§ Neurons surrounding the ischemic or infarcted areas undergo changes that disrupt plasma membranes
§ Cellular edema causes compression of capillaries
§ Depends on the artery affected
§ Contralateral weakness in arms, legs, and/or face
§ Possible motor, speech, and/or swallowing problems

What is TIA?

Transient ischemic attacks (TIAs); They are a warning sign of an impending stroke. Neurologic deficits are not permanent.

What is stroke-in-evolution?

a stroke that is actively occurring and progressing

What is a completed stroke?

a stroke that has reached its full extent and is no longer evolving

what is Crytogenic CVA?

strokes with no identifiable cause

What is Intracranial aneurysm and types?

Weak bulging area of an arterial vessel wall. From from wall defects. Looks like thin balloon on blood vessels. Asymptomatic and treatment is done to lower risk factors or surgery.
Types: Saccular (berry) aneurysms, Fusiform (giant) aneurysms, Mycotic aneurysms, and Traumatic (dissecting) aneurysms

What is Subarachnoid hemorrhage, risk factor, manifestations, and main issue?

Blood escapes from defective or injured vasculature into the subarachnoid space, family history is biggest risk factor, and 50% mortality.
Clinical manifestations are Leaking vessels, Ruptured vessel, etc. Main issue with this is the potential for hematoma.

What are seizure disorders?

Condition characterized by Seizure, A sudden, transient disruption in brain electrical function caused by abnormal excessive discharges of cortical neurons.

What is Epilepsy?

A recurrence of seizures but no cause is found

What are diseases and conditions associated with seizure disorders?

o Any conditions that affects the CNS or neuronal environment
o Metabolic disorders, congenital malformations, genetic predisposition, perinatal injury, postnatal trauma, myoclonic syndromes, infection, brain tumor, vascular disease, drug/alcohol abuse

What is myasthenia crisis?

Condition of sever muscle weakness treated by cholinesterase drugs

What is cholinergic crisis?

Arises from anti-cholinesterase drug toxicity; too much acetylcholine at junctions

myasthenia crisis vs cholinergic crisis

clinically look similar but cholinergic crisis also has Increased intestinal motility, diarrhea, intestinal cramps, bradycardia, pupillary constriction, increased salivation and sweating

Schizophrenia [neurotransmitters are altered/reduced, or receptor binding is affected, clinical manifestations and treatments]

-Is characterized by thought disorders that reflect a break between the cognitive and the emotional side of one's personality.
-1% of the population has this.
-Men > women.
-Genetic predisposition. -Vulnerable to get during prenatal.
-Dopamine and Glutamate altered.
o Positive symptoms -> Hallucinations and Delusions
o Negative symptoms -> Affective flattening, Anhedonia, alogia, and avolition

Depression [neurotransmitters are altered/reduced, or receptor binding is affected, clinical manifestations and treatments]

States such as sadness become prominent. A mood disorder. Genetic predisposition. Environment can also effect..

o causes:
§ dysregulation of various neurochemicals like dopamine, nor epinephrine and perhaps or serotonin
§ High levels of cortisol due to HPT system
§ High levels of thyrotropin-releasing hormone [unipolar]
§ Issues with neuroanatomy

o Treatment:
§ Antidepressants (MAOIs, TCAs, SSRIs)
§ Psychotherapy
§ Combination of both

Generalized anxiety disorder [neurotransmitters are altered/reduced, or receptor binding is affected, clinical manifestations and 'treatments']

-characterized by intense autonomic arousal and people report feelings of tachycardia.
-Types: Panic disorder, Social anxiety disorder, and Generalized anxiety disorder.
-Norepinephrine and serotonin abnormalities and GABA-BZ receptor alterations occur to cause
[Need to add treatment]

What are the major classes of antidepressant treatments?

MAOIs
Tricyclic antidepressants (TCAs)
Selective serotonin reuptake inhibitors (SSRIs)

antidepressant: MAOIs

block enzyme that normally degrades neurotransmitters, increases presynaptic concentration

antidepressants: TCAs and SSRIs

both reduces the uptake of neurotransmitters from the synapse, which increases levels

obsessive-compulsive disorders [define and treatment options]

Define: Repetitive, intrusive thoughts and/or compulsions
includes: obsessions and compulsions
Treatment:
i. SSRIs - first drugs of choice
ii. Antipsychotic drugs in combination with SSRIs
iii. Psychotherapy, or combination of other treatments

what is obsession when it comes to OCD?

involve a preoccupation with contamination, doubting, religious or sexual themes, or the belief that a negative outcome will occur if a specific act is not performed

what is compulsions when it comes to OCD?

physical and mental ritualized acts

main functions of the endocrine system

· Differentiation of the reproductive system and CNS in the fetus
· Stimulates growth and development in childhood and adolescence
· Coordinates the reproductive system
· Maintains optimal internal environment
· Initiates corrective and emergency responses when needed

first vs second messengers

First messenger -> water soluble hormone cannot enter cell so it bind to something on outside
Ex -> Hormone and Signal transduction

Second messenger molecules -> after 1st messenger binds, something on the inside of cell makes this; link between first messenger and inside cells
ex -> Calcium, cAMP!, cGMP, IP3!, and Tyrosine kinase system

what is SIADH?

Syndrome of inappropriate antidiuretic hormone; · Too much ADH therefore retain too much water

What re the key features of SIADH?

symptoms: Water retention, low urine output, nausea, vomiting, mental changes
-increased water reabsorption by the kidneys
-dilutional hyponatremia
-high urinary osmolarity
-high urinary sodium concentration
-absence of edema
-clinical signs of volume depletion

what is DI?

Diabetes insipidus; · Too little ADH
· Feel thirsty so drink lots of water, but then loses all the water, still thirsty because lack of liquid, repeats.

What re the key features of DI?

symptoms: polyuria (frequent urination), nocturia, continuous thirst, and polydipsia (frequent drinking)
-hypernatremia
-low urinary osmolarity
-low urinary sodium concentration
-higher urine output

What are the manifestations of hyperthyroidism?*

· Increased metabolic rate with heat intolerance*
· Increased tissue sensitivity to sympathetic stimulation*
· Goiter usually present
· Bruit heard over thyroid
· Cortisol degradation
· Hypercalcemia and reduced parathyroid hormone (PTH)
· Oligomenorrhea
· Excessive sweating and flushing
· Elevated upper eyelids (staring quality)
· Fine eyelid tremor
· Infiltrative ocular changes
· Increased CO and HR
· Loud heart sounds
· Arrhythmias
· Restlessness
· Insomnia and dyspnea

What is crushing disease?

Lose the ability to increase ACTH and cortisol with chronic stress

what is crushing syndrome?

Associated with osteoporosis and joint pain and endogenous obesity. Tumor in thyroid gland dodged as obesity and swelling around eyes.

look like humpty dumpty

what is Hyperaldosteronism?

Increased aldosterone secretion; can cause increased sodium and water reabsorption, Hypervolemia, and hypokalemia

what is Addison disease?

High ACTH and inadequate cortisol synthesis and release; Primary cortisol hyposecretion

What is Pheochromocytoma?

Secretes catecholamines on a continuous or episodic basis due to tumors derived from chromaffin cells of the adrenal medulla; Adrenal medulla hyperfunction

What is Cerebral infarction and causes?

A condition that occurs when an area of the brain loses its blood supply because of vascular occlusion.
Causes: acute vascular occlusion, gradual vessel occlusion, and partial occlusion of stenotic vessels.

What is Cerebral hemorrhage?

bleeding in the brain

What is AV malformation?

Arteriovenous malformation; A mass of dilated vessels between the arterial and venous systems (arteriovenous fistula) that lacks a muscularis layer and an intervening capillary bed

What is hemorrhagic stroke?

Third most common cause of CVA, hypertension is primary cause, bleeding accumulates and causes displaced/compressed brain tissue, leading to ischemia, edema, increased ICP and necrosis

What are the early manifestations of cerebral hemorrhage?

Sudden, severe headache, sometimes associated with nausea, vomiting and a brief loss of consciousness

Identify at least 5 general mechanisms by which abnormal hormonal conditions occur

- Failure of feedback systems
-Dysfunction of an endocrine gland
-Secretory cells are unable to produce, obtain, or convert hormone precursors
-Increased hormone degradation or inactivation
-Ectopic hormone release

factors that result in an imbalance of oxygen supply and demand*

Factors that decrease coronary artery blood flow (e.g., atherosclerosis) or increase demand for myocardial blood supply;
Coronary Artery Disease (CAD) is one of these things

What are the effects of nitrates on the body and how they are used?

nitrates are often used for angina associated with myocardial ischemia in order to relax the vessel and increase blood flow to the tissues. They are used to cause balance between supply and demand.
--Demand: Decreases systolic blood pressure, Decreases ventricular volume, Increases heart rate
--Supply: Increases coronary blood flow, Decreases coronary vascular resistance, Decreases coronary spasm, Increases collateral blood flow

non-STEMI vs. STEMI

non-STEMI -> Death of tissue involves only myocardium directly beneath the endocardium (sub-endocardial MI)

STEMI -> Transmural myocardial death

What is CAD?

Coronary Artery Disease; Vascular disorder that narrows or occludes the coronary arteries

What is ACS?

Acute Coronary Syndrome; Term is used for ischemic disorders of the heart that occur

What is Angina Pectoris and its symptoms?

the chest pain that arises from myocardial ischemia

Symptoms:
· Often referred pain in left shoulder/elbow, mid-back, jaw ([build up of] lactic acid affecting afferent nerve fibers entering C3-T4)
· Accompanied by diaphoresis, pallor, and/or nausea

what is stable angina?

Angina Pectoris that is usually predictable, sometimes a chronic condition that's monitored and it's usually relieved by medications and rest.

what is unstable angina?

Angina Pectoris that is very unpredictable and can occur during periods of rest or REM sleep. Can turn into Prinzmetal angina or variant angina.

What is Prinzmetal angina?

Vasospastic/variant angina; Chest pain attributable to transient ischemia of the myocardium that occurs unpredictably and often at rest

What are the signs and symptoms of acute MI?

o Diaphoresis
o Dyspnea
o Extreme anxiety
o Levine's sign (fist to chest)
o Pallor
o Retrosternal crushing chest pain that radiates to shoulder, arm, jaw, or back
o Weak pulses

What is the treatment for unstable angina and MI?

M = morphine
O = oxygen
N = nitroglycerin
A = aspirin

What is nitroglycerin?

Nitroglycerin -> med someone takes to stop unstable angina, if taking 3 does not work then issue is MI.

Nitroglycerin (NTG) side effects:
--NTG and other nitrate preparations can cause severe hypotension
--NTG should not be administered with sildenafil (Viagra®) because of risk of severe hypotension

What is the goal of treatment for myocardial ischemia and myocardial infarction?**

restore balance of oxygen supply and demand and relieve symptoms

What is post-traumatic stress disorder?

PTSD; Exposure to terrifying, life-threatening that leaves a lasting impact on you

What are symptoms of PTSD?

Brain structure susceptible to damaging effects of the stress hormone cortisol and excitatory amino acids

What structural changes occur to the brain with PTSD?

i. Adults: smaller hippocampus
ii. Pediatric: reducing total brain volume

Trace a drop of blood flowing through the heart, pulmonary vasculature and system vasculature.

Deoxygenated blood -> right atrium/ventricle -> pulmonary -> 'gas exchange' -> oxygenated blood -> pulmonary veins -> left atrium/ventricle -> systemic vasculature [Oxygen and nutrients are delivered to cells, and carbon dioxide and waste products are picked up] -> Deoxygenated blood

What are the phases in the cardiac cycle?

Phase 1: Atrial systole or ventricular diastole
Phase 2: Isovolumetric ventricular systole
Phase 3: Ventricular ejection (SL valves open)
Phase 4: Isovolumetric ventricular relaxation (aortic valve closes)
Phase 5: Passive ventricular filling (AV valves open)

What is Frank-Starling's Law?

the stroke volume of the left ventricle will increase as the left ventricular volume increases due to the myocyte stretch causing a more forceful systolic contraction

What are the 4 main factors that directly effect cardiac performance?

Preload
Afterload
Heart rate
Contractility

What are the components of a typical ECG trace?

All parts: P,Q,R,S,T
○ P wave: atrial depolarization
○ PR interval: time from the onset of atrial activation to the onset of ventricular activation
○ QRS complex: sum of all ventricular depolarizations
○ ST interval: ventricular myocardium depolarized
○ QT interval: "electrical systole" of the ventricles

how does sympathetic and parasympathetic activity alters cardiac function?

Sympathetic -> increase conductivity and contractions strength.
Parasympathetic -> decreases conductivity and contractions strength.

What is stroke volume and its determinants?

Amount of blood ejected with each heartbeat (L/min).
Determinants: Preload, Afterload, contractility.

What is Inotropic?

Modifying the force or speed of contraction of muscles; this can be positive/negative

positive vs negative inotropic agents

Positive inotropes: increase force of contraction (norepinephrine, epinephrine)
Negative inotropes: decrease force of contraction (acetylcholine)

What is cardiac output?

the volume of blood flowing through either the systemic or pulmonary circuit; Measured by multiplying stoke volume and heart rate.

What is ejection fraction?

Amount of blood ejected per beat; measured by dividing stoke volume over End-diastolic volume

What is hypertension?

sustained systolic blood pressure (SBP) of 130 mm Hg or a diastolic blood pressure (DBP) of 80 mm Hg or greater

Hypertension is caused by increased cardiac output and/or total peripheral resistance

What are the risk factors for hypertension?

Positive family history,
Advancing age,
Sex (men > women before age 55, women > men after 55),
Race: Black,
High Na+ intake,
Glucose intolerance (diabetes mellitus),
Heavy alcohol consumption,
Obesity,
Cigarettes (nicotine is a vasoconstrictor; ↑ BP),
K+, Mg++, Ca++

parameters for normal blood pressure and the updated classifications of hypertension

Normal BP <120 mm Hg (SBP) AND <80 mm Hg (DBP)
Elevated BP is 120 to 129 mm Hg (SBP) AND <80 mm Hg

Hypertension -> 130-139 mm Hg (systolic) or 80-89 mm Hg (diastolic)

What is orthostatic (postural) hypotension? [manifestation and treatment]

Decrease in systolic and diastolic blood pressures on standing by 20 mmHg and 10 mmHg or more, respectively. Usually the body is able to compensate for this change.
Clinical manifestation: Fainting upon standing
Treatment: Liberalize salt intake, raise HOB, wear compressive stockings, medications. Do not get up to fast.

What are factors that may precipitate an acute hypotensive episode?*

Dehydration
Severe Bleeding
Heart Condition
Medications
Infections
Allergic Reactions
Neurological Causes
Endocrine Disorders
Orthostatic Hypotension
Hypovolemia

What is an Aneurysm?

Local dilation or outpouching of a vessel wall or cardiac chamber; Atherosclerosis is a very common cause

What is embolsim?

Bolus of matter that circulates in the bloodstream, lodges, and obstructs blood flow

What is peripheral artery disease?

Atherosclerotic disease of arteries that perfuse the limbs, especially lower extremities

What are the 3 main layers of a typical artery?

Tunica intima--inner most layer of endothelium, connective tissue and a basement membrane.
Tunica media--middle layer of smooth muscle with elastic fibers.
Tunica externa (adventitia)--outer layer of connective tissue containing elastic and collagenous fibers

What is Arteriosclerosis?

"Hardening of the arteries"; General term for several pathologic conditions where the walls of the arteries thicken, harden and lose elasticity

What is Atherosclerosis?

A type of arteriosclerosis; Characterized by calcification and plaque buildup; Process is very long and slow

What is Coronary artery disease?

primary cause of heart disease in the US. CAD can diminish the myocardial blood supply until it causes myocardial ischemia'
· Arteriosclerosis contributes to this

What is Fatty streak?

Foam cells along with WBCs; Aggregation of lipid-rich macrophages and T cells in tunica intimal; first/earliest recognizable lesion

What is Fibrous plaque?

Complex occlusive lesions that grow and projects into vessel lumen possibly impeding blood flow

What is Intermediate lesion?*

narrowing or blockage in a coronary artery, not yet severe but can lead to ischemia

what is Complicated lesion?

lesions that can break off and can expose the underlying tissue and can also trigger clots to form; Last stage of atherosclerosis

What is "Response to Injury" hypothesis simplified?

Disease is actually an inflammatory disorder. Goes to injury site and does the whole process which would lead to plaque buildup; emphasis is on role of oxidative mechanisms

Sources of injury: Atherosclerosis

· Altered hemodynamic forces (hypertension)
· Harmful chemicals (nicotine, catecholamines)
· Bacterial infections (C. pneumoniae)
· Hyperlipidemia
· Mechanical trauma (flow patterns/forces; angioplasty)
· Inflammatory cells and mediators
· Oxidative stress and injury
· Increased serum fibrinogen
· Insulin resistance
· Periodontal disease

How are Endothelial cells altered during atherosclerosis?

becomes "sticky" and "thrombogenic" which allows monocytes and T cell attachment and movement between the cells. Injured endothelium also releases growth factors and cytokines contributing to process

How are Monocytes/macrophages altered during atherosclerosis?

monocytes move through endothelial cells and proliferate, then Macrophages engulf lipids and become foam cells [eventually leads to plagues]