Exam 2

asthma

chronic disorder of the airways that causes episodes of airway obstruction, bronchial hyperresponsiveness, airway inflammation, and airway remodeling

hyperresponsiveness to stimuli → mast activate → bronchospasm (swelling and mucus) → air trapped → wheezing, chest tightness, SOB

tests: pulmonary function tests, spirometry, challenge test

monitoring: peak flow meter

bronchiolitis / RSV

viral infection of the lower airways (most commonly caused by RSV)

virus damages bronchiole lining → swelling, mucus, and dead cells plug the lower airways → trapped air causes collapsed areas and low oxygen → cold symptoms, fast breathing, wheezing, retractions

tests: physical exam, pulse ox, viral testing

monitoring: pulse ox, monitor respirations

epiglottitis

inflammatory edema of the supraglottic area

bacteria (strep or staph) → severe swelling of epiglottis → airway blocked from above within hours → pallor, lethargy, tripod position, stridor, drooling

tests: direct visualization in OR, lateral neck X-ray

monitoring: pulse ox, monitor respirations, monitor swelling

chronic bronchitis

airway obstruction of major and small airways

irritated airways (from smoking/infections) → mucus glands enlarge and goblet cells multiply → mucus plugs narrow the airways → low oxygen + high CO2 → chronic productive cough, cyanosis, edema from right HF

tests: spirometry, lung volume test, chest x-ray, ABG, pulse ox

monitoring: pulse ox, ABG

emphysema

a type of COPD where alveolar walls are destroyed and lungs lose elasticity causing air to get trapped (not fully exhaled)

smoking or alpha 1 antitrypsin deficiency → too much elastase and not enough AAT → alveolar walls destroyed and elasticity lost → airways collapse and air is trapped → pink puffer, pursed lip breathing

tests: spirometry, lung volume test, serum AAT level, chest x-ray

monitoring: pulse ox, ABG

croup

viral infection that affects the larynx, trachea, and bronchi

parainfluenza virus → inflamed larynx, trachea, and bronchi → swelling in the narrow subglottic airway → barking cough, inspiratory stridor, hoarseness

tests: physical exam, pulse ox

monitoring: pulse ox, monitor respirations, monitor airway patency

common cold

viral infection of the upper respiratory tract

virus passes from hands to nose or eyes → upper airway swells → red, swollen membranes and extra mucus → clear runny nose, congestion, and a sore throat from postnasal drip

tests: none

monitoring: be mindful of symptoms that last longer than 10 days

histoplasmosis

fungal lung infection

H. capsulatum inhaled from bird or bat droppings in dirt → spores become yeast in the alveoli → spore spread to lymph and blood before immunity develops → can be asymptomatic, mild fever, dry cough

smokers → TB symptoms (productive cough, night sweats, weight loss)

immunocompromised → high fever, low blood count, meningitis

tests: cultures, fungal stains, antigen detection, serologic tests, sputum culture, chest x-ray, biopsy

monitoring: monitor respirations, monitor typical antifungal side effects

pneumonia

inflammation of lung structures (alveoli and bronchioles)

infectious agent (bacteria, virus, mycoplasma, fungus) or aspiration → inflammation of the alveoli and bronchioles → fever, chills, productive cough, pleuritic chest pain and crackles, fatigue

tests: chest x-ray, sputum culture, labs, blood culture, pulse ox, ABG

monitoring: pulse ox, monitor respirations, monitor sputum color, monitor hydration and mental status

tuberculosis

bacterial infection that the immune system walls off

inhaled M. tuberculosis droplet → macrophages engulf but can’t kill the bacteria → T cells wall macrophages off in granulomas → hypersensitivity response → necrosis and cavitation in upper lobes → latent TB (asymptomatic and noncontagious), active TB (low grade fever, night sweats, weight loss, fatigue, dry to productive cough, bloody cough

tests: tuberculin test, quantiferon tb test (blood test), chest x-ray

monitoring: airborne precautions, monitor respirations, sputum culture

influenza

viral infection that kills the cells lining the airway

influenza virus (A, B, or C) inhaled in droplets → enters through hemagglutinin to kill ciliated airway cells → fluid leaks and spreads to lower airways → strips bronchial and alveolar lining → allows bacteria to stick → sudden fever, chills, fatigue, muscle aches, runny nose, dry cough

tests: nasal swab

monitoring: monitor respirations, monitor hydration, droplet precautions, high risk for pneumonia

tracheobronchitis

inflammation of the trachea and bronchi

virus (bacteria or irritants) after a cold or flu → cause inflammation and swelling of trachea → extra mucus and damaged cilia → dry to productive couch, burning chest pain, low grade fever, rhonchi, wheezes

tests: physical exam, chest x-ray, nasal swab

angina

chest pain caused by the heart muscle not getting enough oxygen

stable: fixed atherosclerotic blockage in coronary artery → lack of blood flow during exertion, cold, and stress → temporary MI → squeezing pain radiating to left arm, shoulder, or jaw

unstable: atherosclerotic plaque ruptures → partial clot forms → blood flow drops → resting ischemia → resting chest pain, increasing intensity

variant: sympathetic overactivity or abnormal calcium in smooth muscle → coronary artery spasm → temporary cut off of blood flow → MI → resting chest pain, night time occurrence, ECG irregularities

tests: ECG, exercise stress test, labs

monitoring: ECG, monitor vitals

anticoagulant therapy

therapy that prevents clots from forming or growing

heparin: boosts antithrombin, IV or subQ, monitor using aPTT, antidote is protamine sulfate (watch for bleeding)

enoxaparin: inactivates factor Xa, subQ, antidote is protamine (watch for bleeding)

warfarin: blocks vitamin K, oral, monitor using PT/INR, antidote is vitamin K (watch for bleeding and drug interactions

apixaban: directly blocks factor Xa, oral, antidote is andexanet alfa (watch for bleeding)

aspirin: blocks COX-1 so platelets don’t clump, oral (watch for GI bleed)

clopidogrel: blocks platelet ADP receptor, oral (watch for bleeding)

aortic aneurysm

weakened bulging section of the aorta

atherosclerosis or degeneration of aortic media → weakened aortic wall bulges → wall tension grows and widens → blood clot forms inside the wall → rupture → chest, neck, and back pain, stridor, brassy cough, hoarseness, dysphagia, JVD, abdominal pain

tests: physical exam, US, ECG, CT, MRI, abdominal x-ray

monitoring: monitor vitals, no straining

orthostatic hypotension

10-20 mmHG BP drop when standing

older age, meds, low blood volume, ANS dysfunction → blood pools in legs when standing → ANS fails to compensate → CO and BP fall → brain blood flow drops → BP drops → dizziness, lightheadedness, weakness, blurred vision, fainting, fals

tests: orthostatic vitals

monitoring: orthostatic vitals, monitor hydration, fall risk

sodium imbalance

hyponatremia: brain cells swell → confusion, headache, nausea, seizures, lethargy

hypernatremia: brain cells shrink → confusion, restlessness, thirst, seizures

potassium imbalance

hypokalemia: muscle weakness, constipation, arrythmias, ECG shows flat T and U wave

hyperkalemia: dangerous arrythmias, cardiac arrest, ECG shows peaked T waves

calcium imbalance

hypocalcemia: tetany, tingling around moth and fingers, positive chvostek and trousseau signs

hypercalcemia: muscle weakness, kidney stones

magnesium imbalance

hypomagnesmia: tremors, tetany, arrythmias, occurs with low K and Ca

hypermagnesmia: lethargy, low reflexes, low BP

cholecystitis

inflammation of the gallbladder

gallstone blocks cystic duct (calculous) or sepsis, trauma or burns (acalculous) → phospholipase makes toxic lysolection → protective mucus breaks down → concentrated bile salts damage lining → gallbladder swells → sudden RUQ pain, mild fever, anorexia, nausea, vomiting, elevated WBC, mildly elevated liver enzymes and bilirubin

tests: labs, US, CT, cholescintigraphy, positive murphy’s sign

monitoring: monitor for gangrene or perforation, watch for worsening pain

cholelithiasis

gallstones (substances in bile - mainly cholesterol or bilirubin - harden into stones)

obesity, pregnancy, estrogen or oral contraceptives, rapid weight loss, or malabsorption, hemolysis, cirrhosis → excess cholesterol or bilirubin bile + bile stasis → substances turn to sludge → sludge becomes gallstones → asymptomatic, when stones block flow it can cause RUQ pain radiating to right shoulder or upper back, and jaundice

tests: US, HIDA scan, CT, labs

monitoring: jaundice, fever, positive murphy’s, monitor hydration

peptic ulcer disease

chronic disorder where acid and pepsin eat through the lining of the stomach or duodenum

H. pylori or NSAIDs (worsened by smoking, alcohol, older age, warfarin, steroids) → GI lining protective defenses fail → acid and pepsin erode the mucosa → imperfect scar that leads to recurrence → burning, gnawing midline pain, risk of bleeding, perforation, penetration, obstruction

tests: labs, H. pylori testing, endoscopy, barium x-ray

monitoring: watch for any signs of bleeding, perforation, penetration, or obstruction, stop aspirin or NSAID use

duodenal ulcer

chronic disorder where acid and pepsin eat through the lining of the stomach or duodenum

H. pylori infection in stomach → high gastrin and extra acid injure the duodenum → gastric metaplasia + gastrin and pepsin erode lining → burning pain 2-3 hrs after meals

tests: labs, H. pylori testing, endoscopy, barium x-ray

monitoring: watch for any signs of bleeding, perforation, penetration, or obstruction, stop aspirin or NSAID use

esophageal varices

swollen, fragile veins in lower esophagus

cirrhosis → scarred liver blocks portal blood flow → portal hypotension → blood reroutes through thin-walled esophageal veins → veins swell into varices → rupture → sudden vomiting of bright red blood, shock, jaundice, ascites, splenomegaly

tests: CBC, PT/INR, liver function tests, US, CT

monitoring: monitor vitals, avoid straining, no aspirin or NSAIDs

GERD

damage caused by weak esophageal sphincter allowing acid back up the esophagus

weak esophageal sphincter → acidic stomach contents reflux into esophagus → lining becomes eroded and inflamed → heartburn, regurgitation after eating, belching, chest pain, chronic cough, asthma, laryngitis

tests: PPI trial, esophagoscopy, 24 hr pH monitoring

monitoring: monitor dysphagia, respirations, chest pain, and heartburn

hepatitis

inflammation of the liver

hepatitis virus infects the liver → virus and immune response damage liver cells → inflammation → fatigue, nausea, loss of appetite, jaundice

tests: serologic tests, liver enzyme tests, PT/INR

monitoring: monitor liver function, jaundice, hydration

liver cancer

hepatocellular carcinoma: chronic hep B or C, cirrhosis, aflatoxin → repeated liver damage and regrowth → DNA mutations → uncontrolled cell growth → weakness, fatigue, weight loss, anorexia, swelling, enlarged liver

cholangiocarcinoma: chronic bile duct inflammation → repeated injury to duct lining causing cancerous changes → duct blocks bile flow → abdominal pain, weight loss, anorexia, RUQ mass, jaundice

tests: AFP, US, CT, MRI, biopsy

type I alveolar cells

thin and flat (squamous)

95% of alveolar surface

responsible for gas exchange

can’t divide

easily damaged

type II alveolar cells

cube-shaped (cuboidal)

5% of alveolar surface

responsible for making surfactant

can divide

can turn into type I cells

tuberculin test

measures the delayed hypersensitivity (cell-mediated, type IV) that follows exposure to tubercule bacillus

positive = exposure to TB (immune response)

false positive = cross reaction with non-TB myobacteria

false negative = immune system is too weak to react

negative feedback

response reverses the change and brings things back to normal to maintain homeostasis

ex. sweating and shivering, release of insulin and glucagon

positive feedback

response amplifies change pushing it further in the same direction until and end is reached

ex. labor, blood clotting, breast feeding

regulated feedback

feedback controlled by a control center that adjusts the body around a set point (often through hormones)

ex. hypothalamus releases hormone → pituitary responds by releasing a hormone → thyroid responds by releasing a hormone → hypothalamus and pituitary respond by turning production down

sensory feedback

information from sensory receptors sent to nervous system so it can adjust what the body is doing

ex. proprioception, pain, stretch receptors

endocytosis

membrane folds inward around substances and pinches off in a vesicle inside the cell

ex. phagocytosis, pinocytosis, receptor-mediated endocytosis

phagocytosis

“cell eating”

large particles (bacteria and dead cells)

macrophages, neutrophils

pinocytosis

“cell drinking”

fluid and small dissolved substances

receptor-mediated endocytosis

specific molecules that bind to receptors on the membrane

ex. cells taking in LDL cholesterol

exocytosis

vesicle inside cell moves to the membrane, fuses with it, and releases content outside

ex. hormone secretion, neurotransmitter release, surfactant release

paracrine signaling

chemical messenger acts on nearby cells of a different type to affect their function

how can a nurse help a patient lose weight?

• assist pt in setting SMART goals (specific, measureable, achievable, relevant, time bound)

• teach portion control

• encourage high fiber and low fats

• encourage low sugar and low sodium

• refer to dietitian

• encourage 150 minutes per week of moderate activity

• assess readiness

• offer support

fat soluble vitamins

stored in the body and may reach toxic levels if over-consumed

A, D, E, K

water soluble vitamins

can be excreted in the urine

thiamine, riboflavin, niacin, pyridoxine, pantothenic acid, vitamin B12, folic acid, biotin, and vitamin C

white fat

stores energy

main fat after birth through adulthood

contains triglycerides stored as oil at body temp

energy reserve

brown fat

makes heat (thermogenesis)

mainly in newborns and hibernating animals

decreases with age

contains specialized mitochondria to make heat

minimal effect on energy expenditure

edema

palpable swelling produced by the buildup of excess fluid in the interstitial space (between cells)

causes of edema

increased capillary pressure (too much pushing out)

decreased colloidal osmotic pressure (not enough pulling back in due to low albumin)

increased capillary permeability (leaky capillaries let fluids and proteins escape)

obstruction of lymphatic flow (fluids can’t be drained back)

types of energy expenditure

basal metabolic rate (BMR)

diet-induced thermogenesis

exercise-induced thermogenesis

non-exercise activity thermogenesis (NEAT)

environmental (adaptive) thermogenesis

basal metabolic rate (BMR)

energy to keep the body alive at rest (breathing, HR, brain function, cell repair, body temp)

diet-induced thermogenesis

energy to digest, absorb, and store food

exercise-induced thermogenesis

energy from everyday movement that isn’t exercise

environmental thermogenesis

energy to adjst to environmental conditions (mainly temperature)w

what macronutrients are necessary for cell metabolism?

carbohydrates, fats, and proteins

LDL

low density lipoprotein

cholesterol in liver → body cells

excess LDL causes atherosclerosis → CAD, angina, MI, stroke

IDL

intermediate density lipoprotein

turns into LDL from VLDL

carries triglycerides and cholesterol

small amounts

VLDL

very low density lipoprotein

made by the liver

carries triglycerides to tissue

turns into IDL which turns into LDL

HDL

high density lipoprotein

carries excess cholesterol from tissues back to the liver for removal (reverse transport)

protects against atherosclerosis

what should nurses tell pts with orthostatic hypotension?

• promote gradual ambulation

• change positions slowly

• wear compression stockings

• avoid hot showers

• avoid alcohol

• stay hydrated

• sit down when dizzy

what are the causes of vomiting?

• drugs and toxins → chemoreceptor trigger zone (CTZ)

• GI tract problems → visceral nerves to the vomiting center

• motion → vestibular apparatus

• hypoxia → directly on the vomiting center

dehydration

signs: tachycardia, hypotension, orthostatic hypotension, dry mucous membranes, poor skin turgor, delayed cap refill, less urine and dark in color, AMS

symptoms: thirst, dry mouth, fatigue, weakness, headache, muscle cramps

prevention: hydration, increase fluids when exerting, limit alcohol and excess caffeine, eat water rich foods

tests: elevated BUN, elevated sodium, elevated serum osmolarity, elevated hematocrit, elevated urine specific gravity

phototherapy

• exposure to fluorescent light in the blue range to reduce bilirubin levels in jaundiced infants

• bilirubin in the skin absorbs the light and is converted into an isomer that is more water soluble and can be excreted

extrinsic pathway

• faster for clotting (15 seconds)

• triggered by tissue factor from outside the vessel

• PT/INR (warfarin)

intrinsic pathway

• slow for clotting (1-6 min)

• triggered by factor XII and collagen inside the vessel

• defects cause worse bleeding

• aPTT (heparin)

what treats low WBC?

• colony stimulating factors (filgrastim)

• neutropenic precautions (strict hand hygiene, no flowers, no visitors)

• broad spectrum IV antibiotics for neutropenic fever

whats the body’s total blood volume?

adult male → 5-6 L

adult female → 4-5 L

how are T lymphocytes produced?

hematopoietic stem cell in bone marrow → becomes immature T cell → travels through blood to thymus → mature in the thymus → differentiates into helper or cytotoxic

ventilator modes

• assist control (AC) → full support

• SIMV → partial support and weaning

• pressure control (PC) → stiff lungs; protects against lung injury

• pressure support (PSV) → weaning (pt can breathe on their own)

• CPAP → weaning, sleep apnea, keeps alveoli open

• BiPAP → COPD flare ups, to avoid intubation

ventilator settings

• FiO2 → percent of O2 delivered

• TV → volume of air per breath

• RR → breaths per min delivered

• PEEP → pressure kept in lungs at the end of exhale

• pressure support (PS) → helps spontaneous breaths

• I:E ratio → inhale time to exhale time

• peak inspiratory pressure (PIP) → highest pressure during a breath

amylase

breaks down starch into disaccharides (maltose, isomaltose, alpha dextrins) in the mouth

antidiuretic

against urination

ex. antidiuretic hormone (ADH) acts on kidneys to reabsorb water back into the blood → less urine or more concentrated urine

biliary colic

gallstone blocking cystic duct causing severe URQ pain that radiates to upper back, right shoulder, or midscapular region

calcitonin

lowers blood calcium

• inhibits osteoclasts

• increases calcium excretion

clopidogrel

reduces platelet aggregation by inhibiting the ADP pathway in platelets (prevents clots)

coumadin (warfarin)

• anticoagulant that blocks vitamin K (decreased production of clotting factors)

• monitor using PT/INR

creatinine kinase (CPK)

enzyme in the muscle that leaks into the blood when muscle is damaged, indicating muscle injury

• skeletal muscle → muscular dystrophy

• heart muscle → MI

• brain → stroke

dopamine

neurotransmitter that has vasodilator effects on renal, splanchnic, and coronary blood vessels when given intravenously; treats shock

epinephrine

neurotransmitter and hormone that triggers “fight or flight”

used during anaphylaxis, cardiac arrest, severe asthma

• raises BP, increases HR, brochodilates

erythropoietin

kidney hormone that stimulates bone marrow for erythrocyte production

first messenger

extracellular factors that can cause a response within a cell

fluid overload

hypervolemia: too much fluid in the body

caused by heart failure, kidney failure, liver cirrhosis, excess IV fluid, high sodium, too much ADH

low labs

heparin

fast acting anticoagulant used to prevent and treat blood clots

boosts antithrombin to inactivate thrombin and factor Xa

used for DVT and pulmonary embolism

monitor using aPTT

intracellular

inside the cell

intracellular catalyst

a substance inside a cell that speeds up a chemical reaction

ex. metabolic enzymes, protein kinases, lysosomal enzymes

pre hepatic

problem starts before the liver (sickle cell, newborn jaundice)

too much bilirubin made from RBC breakdown

intrahepatic

problem that starts inside the liver (hepatitis, cirrhosis, liver cancer)

liver can’t process bilirubin

post hepatic

problem starts after the liver (gallstones, cholangiocarcinoma)

bile can’t drain out from blocked bile duct

lipase

enzyme that facilitates the release of fatty acids from lipoproteins so that they can be used by tissues

receptor agonist

a substance that binds to a receptor and activates it → produces the same effect as the body’s natural chemicals

second messenger

intracellular substances released by the cell in response to a first messenger