HAN 477 Quiz 4 Lectures

Why is anatomy of the abdomen helpful?

- can direct you to the problem

- location of the pain often correlates to the involved organ

- know your surface anatomy landmarks**

Abdominopelvic quadrants

- Right Upper quadrant

- Right Lower quadrant

- Left Upper quadrant

- Left Lower quadrant

Umbilicus

Also known as the umbilical region; located in the central part of the abdomen, around the navel.

McBurney's point

Most common location for the base of the appendix

Questions we ask for clinical presentations?

- where is the pain?

- what else is going on?

- who is the patient?

- any associated symptoms?

It is often useful to direct the assessment using the following; abdominal pain or discomfort with...

- unstable vital signs

- gastrointestinal bleeding

- nausea and vomiting

- diarrhea

- jaundice

- vaginal bleeding

referred pain

pain that is felt in a location other than where the pain originates

Acute cholecystitis

- has higher frequency in women

- pregnant women are at risk for developing cholecystitis due to biliary stasis.

- older patients are at greater risk

usually detected on an ultrasound

Acute cholecystitis; pain

- pain usually begins in the epigastric area and migrates to the right upper quadrant

- the pain may be crampy initially and then becomes constant

- pain may radiate to right scapula/back area

- positive murphy's sign is present

Ongoing management of cholecystitis

- support of airway- have suction available; vomiting is common

- oxygen

- IV fluid

- position of comfort

- antiemetics

- analgesics

- sonogram at the facility

Risk factors of pancreatitis

- there is a higher frequency in African American, white and Native American males, in that order

- history of alcohol abuse is the number one risk factor; onset after binge consumption is common, ingestion of alcohol can be recent or within several days

- biliary disease is also a common risk factor

Pain presentation of pancreatitis

- pain usually begins in the epigastric area or upper left quadrant

- may come on suddenly or gradually

- pain is described as going through the body to the back, not around the body.

- abdomen is usually distended with rigidity and guarding

When would Grey Turner sign and/or Cullen sign may be present?

Due to hemorrhaging pancreatitis

Grey Turner's sign

A clinical sign that refers to bruising (ecchymosis) of the flanks, which are the sides of the body between the ribs and the hip.

often a late indicator of retroperitoneal bleeding

Cullen sign

A clinical sign characterized by bluish or purplish discoloration around the umbilicus (belly button) and indicates bleeding in the abdominal cavity.

Ongoing management of pancreatitis

- may be life threatening, so be prepared to support the ABCs

- support airway; have suction available as vomiting may occur

- NPO (sometimes)

- oxygen

- IV fluid; crystalloids or blood if hemorrhage is present

- pain medication (fentanyl or dilaudid)

Risk factors of Sigmoid diverticulitis

- inflammation of the diverticula

- diverticulosis

- NSAID use

- low fiber use

- chronic constipation

- elderly patients

- most commonly presents with lower left quadrant pain

What are diverticula?

Pouches that have developed in the bowel

True or False- diverticulosis is one of the common causes of lower GI bleeding.

True

Pain in sigmoid diverticulitis

- usually localized to the lower left quadrant

- often severe, may be preset for several days

- change in bowel habits

- bleeding may be present

- urinary symptoms may also be present

Other presentations to consider for sigmoid diverticulitis

- fever is common due to inflammation

- peritonitis may be present

- a mass may be palpated if an abscess develops

- CT may be used to confirm disease and severity.

Ongoing management of sigmoid diverticulitis

- IV fluid; crystalloids or blood if hemorrhage is present

- pain medication

- possibly antibiotics

Why is assessment and diagnosis in the abdomen difficult?

The abdomen contain multiple organ systems

What is the key to assessment, diagnosis and ultimately treatment in the abdomen?

To consider life threats and to use history and assessment skills to sort through the disorders

abdominopelvic regions

- top row: right hypochondriac region, epigastric region, and left hypochondriac region

- middle row: right lumbar region, umbilical region, and left lumbar region

- bottom row: right iliac region, hypogastric region, and left iliac region

What is another name for the iliac regions?

Inguinal regions (right and left)

What is another name for the hypogastric region?

Pubic region

Right upper quadrant organs

- liver

- gallbladder

- duodenum

- right kidney and adrenal gland

- small and large intestines

Left upper quadrant organs

- stomach

- spleen

- pancreas

- left kidney and adrenal gland

- jejunum

- small and large intestines

Right lower quadrant organs

- cecum

- appendix

- right reproductive organs

- small and large intestines

Left lower quadrant organs

- descending colon

- sigmoid colon

- left reproductive organs

- small and large intestines

Gastric ulcer

presents as initial epigastric pain

An ulcer that forms in the lining of the stomach when the protective mucous layer is damaged and the stomach acid eats away at the tissue underneath.

S/S: burning stomach pain, bloating, weight loss, indigestion, vomiting blood.

Ectopic pregnancy

implantation of the fertilized egg in any site other than the normal uterine location.

S/S: positive pregnancy test, mild vaginal bleeding, pelvic/abdominal pain, shoulder pain, dizziness, and rectal pressure or pain

Gastroenteritis

initial presentation of epigastric pain, nausea and vomiting

Inflammation of the stomach and intestines, usually causes by a viral, bacterial or parasitic infection.

S/S: diarrhea, nausea, abdominal cramps, fever, headache, and dehydration

Food posioning

initial presentation of epigastric pain, nausea, and vomiting

An illness caused by eating contaminated food and usually happens when food is infected with harmful bacteria, viruses, parasites, or toxins.

S/S: nausea and vomiting, diarrhea, stomach cramps, fever, and weakness.

Bowel perforation

initial presentation of peritoneal irritation and abdominal pain

A hole or tear in the wall of the intestines- either the small intestine or the large intestine.

S/S: severe abdominal pain, fever, chills, nausea, bloating, inability to pass gas or stool, and signs of sepsis.

Kidney stones

pain radiates into the back

Solid crystalline masses formed in the kidney, resulting from an excess of insoluble salts or uric acid crystallizing in the urine; may become trapped anywhere along the urinary tract.

S/S: severe pain and cramping, pain during urination, hematuria, nausea and vomiting, fever and chills and cloudy urine.

Spleen inflammation/infarct

initial presentation is an elevated temperature and pain in left upper quadrant

S/S: fever, fatigue, enlarged spleen, and systemic illness depending on cause

Ruptured aortic abdominal aneurysm (AAA)

initial presentation is pain radiating into the back

A life-threatening emergency that occurs when an aneurysm bursts, leading to massive internal bleeding.

S/S: pulsatile abdominal mass, hypotension, tachycardia, and signs of hypovolemic shock.

Urinary tract infection

initial presentation is dependent on pain location, also dysuria symptoms may present with diverticulosis or diverticulitis due to irrigation

An infection that can occur in any part of the urinary system including the kidneys, ureters, bladder and urethra.

S/S: burning sensation during urination, frequent urge to urinate, pelvic pain, blood in urine and fever/chills.

Irritable bowel syndrome

initial presentation is similar to that of diverticulosis

A common disorder that affects the large intestine; it's a chronic condition but it doesn't cause permanent damage to the intestines or lead to serious disease.

S/S: abdominal pain/cramping, bloating and gas, diarrhea and/or constipation, changes in stool appearance and urgency to make a bowel movement.

Peritonitis

initial presentation is due to inflammation and possible rupture of diverticula and fever

Inflammation for the peritoneum.

S/S: severe abdominal pain, bloating, fever and chills, nausea, loss of appetite, diarrhea, rapid heartbeat and confusion.

Role of kidneys in the body

1. Fluid and electrolyte balance

2. Blood pressure regulation

3. Red blood cell synthesis

4. Metabolic waste removal

5. Medication metabolism

6. Acid-base balance

Where is the renal system located?

In the retroperitoneal space at level of costovertebral angle (T12-L3).

receives about 25% of cardiac output; 1,200 mL of blood/min

Nephron

- functional unit of the kidney

- responsible for filtrating, reabsorbing, ad secreting fluids, electrolytes, and waste products by forming urine

Each nephron contains...

1. Bowman's capsule

2. Glomerulus

3. Proximal tube

4. Loop of henle

5. Distal tube

6. Collecting duct

Secretion in the renal system

- filtrate what's not reabsorbed by nephron which travels to the distal collecting tubule

- secreted as urine

kidney can concentrate urine based on physiologic requirements

What is the composition of normal urine?

95% water and 5% solute

What is the normal urine output?

>500 mL/day

Oliguria urine output

<500 mL/day

Renal failure

- inability of kidneys to cleanse blood

- resultant buildup of waste products

classifications of acute failure: prerenal, intrarenal, and postrenal

Causes of acute renal failure

1. Prerenal: sudden and severe drop in blood pressure (shock) or interruption of blood flow to the kidneys from severe injury/illness

2. Intrarenal: direct damage to the kidneys by inflammation, toxins, drugs, infection or reduced blood supply.

3. Postrenal: sudden obstruction of urine flow due to enlarged prostate, kidney stones, bladder tumor or injury

Prerenal renal failure

- decreased renal perfusion results in decreased glomerular filtration rate (GFR) and decreased urine output

secondary to:

- hypovolemia

- cardiac failure

- decreased cardiac output

- accumulation of metabolic waste products in the blood

- increased blood urea nitrate (BUN), creatinine

Treatment of prerenal renal failure

- correction of underlying cause of hypo perfusion

- hypovolemia

- control active hemorrhaging

- IV crystalloids, blood and blood products

- cardiac failure; diuretics, nitrates, inotropic agents, and vasopressors

Intrarenal renal failure

- results from direct damage to the kidney parenchyma

- secondary to trauma, infection, or disease

Postrenal renal failure

- renal failure secondary to obstruction of urine flow

- urine backs up into the kidneys, filtration cannot occur

- causes of obstruction: prostatic hypertrophy, renal calculi, and neoplasms

Treatment of postrenal Renal failure

- correction of obstruction

- urine clearance

- Foley catheter

- suprapubic urinary catheter

Dialysis

- method of removing toxins from the blood when the kidneys cannot

- used in patents with kidney failure and/or acute poisoning

- blood circulated through filters

Complications of dialysis

common

- hypotension

- muscle cramps

- nausea/vomiting

- headache

- chest/back pain

- febrile reactions

- first-use syndromes

- pruitis

uncommon but serious

- arrhythmias

- cardiac tamponade

- intracranial bleeding

- hemolysis

- air embolism

- hypoxemia

BUN (diagnostic test)

- urea formed by liver, excreted by kidneys

- urea accumulates in blood if renal dysfunction occurs

- value increases with renal failure

- can be affected by hydration status

Normal BUN value

5-20 mg/dl

Creatinine (diagnostic test)

- waste product of creatinine phosphate, a high-energy molecule found in skeletal muscle tissue, released into blood

- best indicator of renal function

- increases with renal failure

- creatinine of 3-4 mg/dl indicates decrease of GFR by 50%

What is a normal creatinine value?

0.5-1.2 mg/dl

Other lab values used to evaluate renal failure include....

- urinalysis

- proteinuria indicates intrarenal or postrenal renal failure

- ketoneuria, glycosuria, elevated specific gravity indicates prerenal origin of renal failure

- serum protein

- serum albumin

- complete blood count

Chronic renal failure

- permanent loss of renal function

- 80% of nephrons in the kidneys are destroyed

- s/s include changes in urinary habits, nausea, vomiting, dyspnea, or acute coronary syndrome

Treatment for chronic renal failure

- fluid administration

- administration of diuretics (long-term solution)

- pain medication

- dialysis

- kidney transplant

Hyperkalemia

- serum potassium is greater than 5.5 men/L

- electrolyte disorder caused by ingestion of potassium supplements, acute or chronic renal failure, blood transfusions, sepsis, addison's disease, acidosis, and crush syndrome.

- diagnoses by ECG (peaked T waves) and lab values

Signs and symptoms of hyperkalemia

- weakness

- muscle cramps

- tetany

- paralysis

- palpitations

- arrhythmias

Acid-base physiology

- body can adjust for pH functions

- buffering systems used for short-term pH control; ties up H+

- respiratory and renal systems used for long-term acid-base balance; removes H+ from body, manipulate pH with CO2, HCO3, and H+ secretion/retention

True or false- the renal system is the slowest of the three systems ( buffers and respiratory)

True

may take 24-48 hours to react to pH changes

Metabolic alkalosis

- pH >7.45

- result of increased HCO3 intake and increased H+ loss

- can occur secondary to: excessive bicarbonate ingestion, blood transfusion, vomiting, nasogastric suctioning, and drug therapy/abuse

Metabolic acidosis

- pH <7.35

- result of increased H+ reabsorption, decreased HCO3 production, decreased HCO3 intake, and impaired HCO3 reabsorption

- can occur secondary to: hypermetabolic state, anaerobic metabolism, ketoacidosis, acute or chronic renal, hepatic and pancreatic failure, and diarrhea.

Kidney stones

- AKA: renal lithiasis, nephrolithiasis

- small mineral deposits that form inside kidneys (mineral and acid salts)

- for when urine becomes concentrated and minerals crystallize and stick together

- calcium, oxalate and uric acid

Risk factors for kidney stones

- family or personal history

- being obese; high BMI

- dehydration

- certain diets; high in protein, sodium, and sugar

- other medical conditions

- digestive diseases and surgery

Symptoms of Kidney stones

- severe pin in the side, back, and below ribs

- pain that spreads to the lower abdomen and groin

- pain that comes in waves and fluctuates in intensity

- pain on urination

- pink, red or brown urine

- cloudy or foul-smelling urine

- nausea and vomiting

- persistent need to urinate (usually small amounts)

- fever and chills if an infection is present

Tests/diagnosis of kidney stones

- blood testing; too much calcium or uric acid in your blood

- urine testing

- imaging

- analysis of passed stones

Treatment of kidney stones

small stones/minor symptoms

- drinking water; 2-3 quarts/day

- pain relievers

- medical therapy; alpha blockers to relax muscles in ureter

large stones

- lithotripsy; sound waves to break up stones

- surgery

- scope through urethra, bladder and ureters

- parathyroid gland removal

Pyelonephritis

- can be life-threatening if sepsis or complications develop

- may present with few symptoms to severe symptoms

- may or may not have associated dysuria

- may have no fever to a fever greater than 103 degrees F

- costovertebral tenderness is a common presentation over the affected kidney.

Human body temperature is maintained between....

35.6 and 37.8 degrees Celsius

averages at 38.6 degrees Celsius

At elevated temperatures (human body temperature)....

- enzymes cease to function

- proteins denature

- cellular metabolism is hampered

What is the critical thermal maximum?

Core temperature > 43 degrees Celsius

Hypothalamus

- part of diencephalon

- responsible for: temperature regulation, preoptic region of hypothalamus, water balance, and "set point" for thermoregulation.

Factors that affect temperate regulation

1. Patient age

2. Patient health

3. Medications

4. Exposure time

Most heat production in the body comes from....

deep organs

- liver

- brain

- heart

- skeletal muscles during activity

The _____________ system transfers heat throughout the body.

Circulatory

transfers heat from organs to tissues

Cooling (heat loss)

- heat transferred from deep structures to skin

- blood vessels in the skin dilate; fill with warm blood and heat transfers to skin

- heat lost from skin to surrounding environment

Rate of heat loss is determined by....

- heat conduction from deep tissues

- heat transfer from skin to environment

Radiation

mechanism of heat loss

- heat loss in the form of infrared radiation

- 60% of heat loss in unclothed person via radiation

- greater the temperature difference between body and environment, greater the rate of loss.

Conduction

mechanism of heat loss

- loss of body heat via direct transfer through physical contact

- ineffective way to exchange heat

- about 3% of total heat loss

Convection

mechanism of heat loss

- conductive heat loss to air flowing over body

- greater the air flow over the body, greater the heat loss

- about 15% of heat loss

Evaporation

mechanism of heat loss

- water changes from liquid to vapor when it evaporates

- evaporation results in neat heat loss

- evaporation without sweating

- respiratory tract

- evaporation is more effective at low humidity.

Involuntary heat loss methods

- activation of peripheral and/or central chemoreceptors results in: activation of sweat glands, production of sweat

- activation usually occurs at >32.8 degrees Celsius

- capillary dilation

- inhibition of mechanisms that produce heat

- shivering, chemical thermogenesis

Voluntary heat loss methods

- limit; limit activity

- move; move to cool environment

- clothing; remove clothing- cause return to hypothalamic "set point"

Involuntary heat production methods

- constriction of peripheral blood vessels

- pilorection

- release of thyroxine from thyroid gland

- increased production and release of epinephrine

- shivering, increased BMR

Voluntary heat production methods

1. Add heavy clothing

2. Increase activity

3. Reduce exposed skin

Hyperthermia categories

- heat tetany (hottest)

- heat cramps

- heat exhaustion

- heat syncope

- heat stroke (coolest)

Heat tetany

- hyperventilation is a common cooling mechanism

- leads to respiratory alkalosis

- carpopedal spasms possible

- self-limiting, corrects when hyperventilation stops

Heat cramps

- brief, painful muscle cramping

- common in athletes, outdoor workers

- salt depletion, electrolyte abnormalities are common

- treatment of symptoms

Heat exhaustion

- ill-defined syndrome

- associated with high air temperatures, excessive sweating

- those at risk: athletes, outdoor workers, elderly, and young

- treatment: remove patient from environment and replace fluids and electrolytes

Signs and symptoms of heat exhaustion include...

- dizziness, fatigue, irritability, and anxiety

- headache, chills, nausea, vomiting

- heat cramps

- tachycardia, hyperventilation, hypotension, and syncope