Pathopharm EXAM 2

what are the forces that favor filtration (tries to move water OUT of capillary)

capillary hydrostatic pressure and interstitial oncotic pressure

what are the forces that oppose filtration? (tries to move water INTO capillary)

capillary oncotic pressure and interstitial hydrostatic pressure

filtration

movement of fluid in and out of capillary across capillary membrane btw plasma and intesitital fluid

capillary hydrostatic pressure

PRESSURE caused by flow of fluid INSIDE capillary

interstitial oncotic pressure

osmotic PULL generated by large molecules in interstital space; pulling fluid towards IF

capillary oncotic pressure

osmotic PULL generated by large molecules in capillary; pulling fluid towards capillary

interstitial hydrostatic pressure

PRESSURE caused by flow of fluid in interstitial space

what is net filtration

Forces favoring filtration out - forces opposing filtration out

hydrostatic vs oncotic pressure

hydrostatic= force of fluids

oncotic= pull by molecules

what is edema and what is it caused by?

accumulation of fluid in interstitial space caused by an increase in fluids FAVORING force (cap hydro and interstitial oncotic)

what is the major ECF cation

sodium

what is the major ECF anion

Chloride

cation vs anion

pos vs neg

examples of cations and anions

cations= Na, K, Ca, Mg

anions= HCO3, Cl, PO4, proteins

hypernatremia

>145

etio- Na gain or H2O loss

CMs- hyperosmolality, intracellular dehydration, hypervolemia if Na gain

hyponatremia

<135

etio- Na loss, restricted intake, excess H2O gain

CMs- hypoosmolality, altered cellular depol/repolarization (confusion, lethargic)

what is the major ICF cation

Potassium

hyperkalemia

>5

etio- inc intake, renal failure, burns/traumas, acidosis

CMs (r/t cells more excited)- restless, cramps/diarrhea, weakness, arrythmias

hypokalemia

<3.5

etio- dec intake, inc GI/renal loss, alkalosis

CMs (r/t dec excitability)- smooth muscle loss, arrythmias

hypercalcemia

>11

etio- hyperparathyroidism, inc vit D, cancers with bony metastases

CMs- fatigue, weakness, anorexia, constipation, kidney stones, ECG changes

hypocalcemia

<9

etio- inadequate intestinal absorption, vit D/Ca deficiency, inc PO4, malabsorption of fat, hypoparathyroidism

CMs- confusion, facial twitching, spasms, diarrhea, cramps, arrythmias

what are the crystalloid IV fluids?

isotonic, hypotonic, hypertonic

why do we need IVFs?

replaces blood and other fluids, maintains fluid and electrolyte balance, medication support

osmosis

Diffusion of fluids through a selectively permeable membrane from low to high solution

isotonic solution

use- RESCUE! (fluid loss, hypotension)

action- no fluid shift, replaces fluid loss

EX: normal saline, LR, normosol

osmolality= 280

hypotonic solution

use- HYDRATE!, maintain fluid volume status

action- cells swell, leave ECF and enter ICF

EX: <0.9% NS, dextrose 5%

osmolality= <280

hypertonic solution

use- EQUALIZE abnormal electrolytes

action- cells shrink, leaves ICF enters ECF

EX: 10% dextrose, >0.9% NS, electrolyte replacement solutions (KCl) parenteral nutrition

osmolality= >300

when to use isotonic solutions

hypovolemia (n/v/d, burns, sepsis)

hypotension (admin bolus than maintenance)

when to use hypotonic solutions

maintenance (NPO, hypernatremia, hypoglycemia)

when to use hypertonic solutions

hyponatremia (<120 and change in mental status)

neuro pt with Na 140 and inc ICP

TPN interruption

nursing implications for all IVFs

hypo/iso= assess s/s fluid overload, ABCs, diuretics, stop/dec IVF

hyper= central line, telemetry, s/s cerebral edema

what are s/s of fluid overload

crackles/wheezing, inc RR, inc HR, inc BP, edema= TAKES TIME!, JVD, restless, inc weight, inc O2

s/s of cerebral edema if administering hypertonic fluids too fast

dec LOC, slow pupil reaction, vomiting, siezures

Mrs. Jones us an 88 year old women with 5 day history of diarrhea. She is admitted to the hospital via ER with weakness and confusion.

VS are temp 101, HR 120, BP 88/36, RR 12, O2 98%

What fluid orders might you anticipate?

isotonic

Mr. Smith is a 64 year old who had abdominal surgery today and is NPO. What fluids do you anticipate?

hypotonic

Mr. Johnson is a 75 year old gentleman who is hospital day 4 for small bowel obstruction. Hx of COPD, 2L NOC, hyperlipidemia, fib with chronic coagulation, type 2 diabetic. Given hx surgeons are trying to avoid surgery and treating SBO medically with NG to suction and IVF. What fluids do you anticipate?

hypotonic

Subdural hematoma client with ICP 25 (should be <20 with head injury)

Na level 139

What fluids do you anticipate?

hypertonic

Client received 4mg morphine IVP prior to transfer.

VS: BP 65/40 HR 115

What fluids do they need?

isotonic

what are the loop diuretics?

furosemide, Bumex, Demadex

What is the potassium-sparing diuretic?

Spironolactone

what is the thiazide diuretic?

hydrochlorothiazide

what is the osmotic diuretic?

mannitol

furosemide (lasix)

use- pulm edema, safe for children!, BP control, inc UOP

action- inhibits Na/Cl in LOH, works fast

AE- dec K, ototoxic, hypovolemia

contra- anuria, pregnancy

consider- high K diet, inc hypokalemia with digoxin, allergy to sulfonamide

when to use Bumex

when there is no longer a response to lasix (stronger)

when to use Demadex

edema, heart/renal/liver failure (stronger)

hydrochlorothiazide

use- HTN/HF, must have good kidney function (>30GFR)

action- dec electrolyte reabsorption at DT

AE- hyperglycemia, electrolyte imbalance, dec BP

contra- anuria, pregnancy, impaired kidney function

consider- no digoxin or beta-blockers, low sodium diet, allergy to sulfonamide

spironolactone

use- HTN, hyperaldosteronism, need good kidney function

action- blocks aldosterone/Na retention in DT, slow acting!!

AE- cramping, diarrhea, voice deepens, irregular menstruation, gynecomastia, dizzy

contra- critically ill, renal insuffiency

consider- avoid K/salt subs/beta blockers, take at same time, monitor BP

mannitol

use- prevent AKI, dec ICP/IOP

action- pulls water into bloodstream, inc GFR in PT

what is endometriosis

Growth of endometrial tissue outside of uterus (Fallopian tubes, vagina, cervix)

etiology and patho of endometriosis

etio= unknown

patho= 1. abnormal movement of menstrual tissue through Fallopian tubes 2. endometrial cells move from uterus 3. implants and grows outside of uterus

CMs of endometriosis

pelvic pain during sex/menstruation, infertility

HPV

VIRAL infection of epithelial cells in anogenital tract; most common; women more common

CMs of HPV

asymptomatic and temporary, genital warts

Chlamydia etiology and patho

most common BACTERIAL std, occurs commonly with gonorrhea

from sex/birth (can cause conjunctivitis/pneumonia in infants)

CMs of chlamydia

asymptomatic, inflammation in urinary tract, dysuria, yellow drainage, painful urination, vaginal bleeding, scrotal swelling

gonorrhea patho

from sex, can spread to eyes/pharynx; bacteria attaches to walls of urethra or sperm and produces pus (pyogenic)

CMs of gonorrhea

asymptomatic until later, dysuria, pus/discharge,

syphilis patho

from sex and causes chancres (contact with chancres cause transmission from one person to another), four stage progression

four stages of CMs with syphilis

1. primary syphilis-> chancres, usually resolve in 3 months

2. secondary-> systemic through body, alopecia, fever, arthralgia, lymphadenopathy, rash on soles/palms

3. latent-> early CMs resolved, no symptoms but still infectious

4. tertiary-> serious systemic symptoms, aortic aneurysm, meningitis

estrogen uses

oral contraceptive, menopause, dysmenorrhea (pain with menstruation), treats osteoporosis

estrogen adverse effects

thromboembolic events (PE/MI/CVA), inc clots (assess redness in legs/SOB), cancer (encourage self breast exams)

estrogen contraindications

pregnancy, hx of thromboembolic events, cancer, liver disease, undiagnosed vaginal bleeding, tobacco use, family hx of breast cancer, fibroids

how does decreased estrogen affect the body?

brain fog, inc CVD, inc cholesterol, dec bone health, dec muscle mass

how does estrogen effect the women body?

dec cholesterol, preps for menstruation, makes vagina moist, infection protection, adjusts body temp, inc memory, preps breast for feeding, makes skin young, inc bone density

warning signs of thromboembolic events (ACHES)

Abdominal pain

Chest pain/SOB

Headaches

Eye problems

Severe leg pain

Which of the following are contraindications for the use of estrogen? SATA

a) known pregnancy

b) desire to prevent pregnancy

c) treatment of osteoporosis

d) DVT hx

e) tobacco use

f) family hx of breast cancer

a d e f

progesterone uses

dysfunctional uterine bleeding from hormonal imbalance, endometriosis, inhibits ovulation, contraception, prevent premature birth, counter effects on hormone therapy

adverse effects of progesterone

inc CVD/ thromboembolic events, Ca loss, weight gain, vision changes, headaches, irregular vaginal bleeding, skin conditions

contraindications of progesterone

CVD, thromboembolic events/cerebral hemorrhage, renal/hepatic disease, reproductive cancers, undiagnosed vaginal bleeding, hx of DM/siezures

effects of high progesterone in adults, pregnancy, and post menopause

adults= drowsy, migraines, depressed

preg= molar preg

postmeno= joint pain, heart attack s/s

effects of low progesterone in adults, pregnancy, and postmenopause

adults= ovarian cysts, irregular periods, allergies

preg= infertility, miscarriage

postmeno= tender breasts, vaginal dryness, mood swings

estrogen vs progesterone hormonal contraception

E= inhibits ovulation, dec FSH and LH

P= thins endometrium, slows sperm, thickens cervical mucus, dec LH

routes of hormonal contraception

transdermal patch, vaginal ring, IM or SG injection, IUD

what med may have a decrease in effectiveness if a client is taking an oral contraceptive?

a) atenolol

b) amoxicillin

c) furosemide

d) digoxin

b

testosterone uses

androgen defiency, develop sex traits in males, inc sex drive/muscle mass, sex hormone deficiency, inc erythropoietin synthesis

testosterone adverse effects

acne, hair loss, hypercalcemia, jaundice, bitter taste, edema, headache

contraindications of testosterone

liver disease (monitor LFTs), prostate disorders

What is the primary use for the use of androgens such as testosterone?

a) osteoporosis

b) athletic performance enhancement

c) androgen defiencies

d) erectile dysfunction

c

what is the phosphodiesterase type 5 inhibitor?

Sildenafil (viagra)

sildenafil uses

enhance erection (inc blood flow to penis, onset 20-60 min, duration 4 hrs), BPH urinary symptoms, pulm artery HTN

*doesnt CAUSE erection, just enhances

sildenafil adverse effects

inc risk of hypotension, facial flushing, priapism (painful erections), headache

contraindications of sildenafil

not healthy enough for sexual activity, nitrate use (nitroglycerin)

What should the nurse include in the pt education for a client taking sildenafil?

a) take with high fat meal

b) expect erection for 8 hours

c) don't take with nitrates

d) onset is 10 minutes

c

3 pathways that can cause edema

1. dec plasma proteins (malnutrition) -> dec capillary oncotic pressure

2. inc capillary hydrostatic pressure (venous obstruction)

3. inc capillary permeability (burns/allergies) -> protein leakage inc interstitial oncotic and dec capillary oncotic

how fast should the rate of administration be when giving a hypertonic fluid and why

slow to prevent cerebral edema/death

if fluid volume overload occurs, what meds do we give and why

diuretics to inc urine output

what happens if you give a beta blocker and HCTZ together?

hyperglycemia, hyperlipidemia

what happens if you give digoxin and HCTZ together?

hypokalemia

what happens if you give a beta blocker and spironolactone together?

hyperglycemia, hyperlipidemia

action of sodium

regulates osmotic forces and H20 balance, neuro excitability, acid-base balance

action of chloride

passive follows sodium transport

action of potassium

promotes nerve impulses and muscle excitability

action of calcium

bone and teeth growth, inverse relationship with PO4

If capillary oncotic pressure is DECREASED, this will:

A) Cause water to be pulled out from the ECF

B) Decrease filtration out of the capillary

C) Increase the interstitial hydrostatic pressure

D) Favor the formation of edema

d

An individual with hypertension (high blood pressure) would most likely have:

A) An increased interstitial oncotic pressure, therefore favoring the formation of edema

B) An osmotic imbalance between the intracellular fluid (ICF) and the extracellular fluid (ECF)

C) An increased capillary hydrostatic pressure, therefore favoring the formation of edema

D) A decreased capillary oncotic pressure, therefore favoring the formation of edema

c

Intravenous infusion of albumin (a protein) would likely directly lead to:

A) A decreased in capillary hydrostatic pressure

B) An increase in interstitial hydrostatic pressure

C) An increase in interstitial oncotic pressure

D) An increase in capillary oncotic pressure

d

examples of dec production of plasma proteins that lead to edema and dec capillary oncotic pressure

cirrhosis, malnutrition

what causes inc capillary hydrostatic pressure to lead to edema

venous obstruction, retention, hypovolemia, hypertension

examples of dec capillary permeability that leads to edema

burns, allergic reactions

at what rate should you administer a bolus isotonic fluid

1000ml/hr