NUR 301 Exam 3

Rhino-sinus-itis:

▪This is inflammation of the nasal passage and paranasal sinuses.

▪This is generally connected to viral infections or allergies.

▪The sinuses cannot be drained because there is an obstruction of the narrow Ostia.

▪There is also impairment of the cilia, which inhibits the movement of mucus.

▪All facial sinuses will be effected by this.

▪If it is viral it should not last more than 5-7 days, but if it is bacterial it can last weeks.

▪Chronic may no longer have the pain from the sinuses.

Rhino-sinus-itis S/S

Hallmark S/S are purulent nasal discharge and fever.

Influenza:

▪This is the most common cause for infection. It is a virus that survives well in the colder months.

▪Antigenic drift: This is when a new change in the virus that is minor, so the population is only partially protected.

▪Antigenic shift: This is when a new change in the virus is major and the population has no protection. This is much more dangerous.

Three types of influenza:

Uncomplicated upper respiratory infection

Viral pneumonia

Viral infection followed by bacterial infection

Uncomplicated upper respiratory infection:

Peak is 3-5 days, and it will last 7-10.
There is an abrupt onset of fever and chills. There will be a headache and sore throat as well.

Viral pneumonia:

This can occur after uncomplicated in elderly and cardiovascular patients.

This presents with tachypnea, tachycardia, cyanosis, and hypotension.

Viral infection followed by bacterial infection:

These patients will feel better and then get worse.

An opportunistic virus takes control.

Patient will have pleuritic chest pain and productive cough.

Common Cold:

This is an infection of the upper respiratory tract.

It comes from a various amount of different viruses.

The main mode of transmission is through fingers. It is common to get 2-3 colds in one year.

These usually will not last more than 10 days.

Common Cold S/S

The hallmark S/S are a sore and scratch throat and watery rhinorrhea. There will also be nasal congestion, fatigue, and coughing

Legionnaires’ Disease:

This causes severe bronchopneumonia.

It is caused by Legionella pneumophila, which is a gram-negative rod bacteria. It is found in lakes, showers, and dirty air-conditioning units that are in large buildings.

The hallmark S/S is a mismatch in fever and heart rate. There is a normal heart rate with a high fever.

Lobar pneumonia:

This is usually in just one lobe of the lung on one side.

Bronchopneumonia:

This is the bronchioles and alveoli.

The lungs usually will look patchy. It can be on one side or both.

Typical pneumonia:

This is inflammation and exudation of fluid into the air filled alveoli spaces.

S. Pneumonia is the most common cause of bacteria pneumonia.

Later on there can be rust colored purulent sputum.

Atypical pneumonia:

This invades the alveolar space and interstitum of the lung.

Labs: ABG’s and CBC... what do they tell you?

In the early stages of pneumonia, the patient will be in respiratory alkalosis.

In the later stages, the patient will be in respiratory acidosis.

Neurological level of consciousness

Clinical manifestations (lung sounds, pain, sputum etc) pneumonia

The hallmark sign is that the fever will be very high. There will also be severe shaking chills.

Elderly people will present with an altered mental status.

Right-to-Left Pulmonary shunt:

Problem is impaired ventilation

This could be because of mucus. Oxygen will not be able to travel through mucus or obstructions.

Most common examples are obstruction, collapse, or fluid.

Left-To-Right pulmonary shunt:

Problem is impaired perfusion to pulmonary system

This could be due to a thrombus or blood clot. A pulmonary embolism is not in the lungs, its in the vessels feeding the lungs.

Chest x-ray will not pick up a thrombus in circulation.

Patients will be tachypnic, short of breath, and anxious.

Pneumothorax

Pneumothorax is air in the pleura.

There is a negative pressure that keeps the lungs from collapsing.

The air destroys the negative pressure and the lung deflates.

No breath sounds

Open Pneumothorax

Something in the atmosphere has penetrated the pleura. It is open to atmospheric pressure.

tension Pneumothorax

This is a closed tear to the pleura. It cannot be seen from the outside.

These are very common with rib fractures, and they are very dangerous.

Patients will be breathing faster, and it will start to shift the internal composition.

trachea deviation- can compress heart (cardiac tamponade)

bleb Pneumothorax

This is a hereditary condition that is related to smoking.

These are weakened areas on the lungs that can rupture.

To treat a chest tube will be inserted, but most times it will end in a partial lung resection.

This is mostly found in people in their 20s/30s.

Atelectasis

causes: shallow breathing, viscous secretions

clinical manifestations: dyspnea, cough, fever and leukoytosis

Prevention: cough and deep breath (coughing inc neg. pressure and removes secretions, inc gas exchange in aveoli)

How do you prevent atelectasis?

We would have to encourage deep breathing and continually having them cough. Usually we will have them practice breathing with the machine.

Pleural effusions

Pleural effusions are a type of compressive atelectasis. It is fluid in the pleural space.

increased presuure can cause compression atelectasis

Transudative pleural effusion

This fluid is very watery, almost like lemonade.

This is seen in CHF, liver and kidney failure patients

Exudative pleural effusion

This fluid will have an excessive amount of white blood cells and plasma proteins.

This is caused by infection, inflammation, and cancers.

Hemothorax pleural effusion

This is blood in the cavity.

This is caused by trauma.

Chronic Bronchitis

Inflammation of bronchi by irritants.

This will cause the airways to be inflamed.

When the inflammatory process is set off, it allows for all kinds of cells to move into the area. Inflammation will cause irritation in the bronchus and it will become chronic.

Patient will become acidic and have no exercise tolerance. They will also have excessive coughing in the morning. Heart failure can occur.

There will be an increase in mucus production, which will create mucus plugs.

cyanosis/labored breathing

rales/rhonchi

V/Q mismatch

Emphysema

Loss of elasticity.

The alveoli cannot stretch and recoil the way they used to.

Primary emphysema is inherited. Secondary is 20% of all smokers.
• There is an a1-antitrypsin deficit in both.

Protease breaks down elastin, which decreases the elastic recoil.

There is an increase in residual volume and a decreased size of bronchioles.

shortness of breath

little cough/sputum

difficulty eating

A-P diameter inc d/t hyperinflammation

pink puffer (loss of ventilation and perfusion)

RHF

On assessment how do chronic bronchitis and emphysema differ?

Know the population at highest risk for developing COPD & the best ways to halt disease progression

life long smokers

Central chemoreceptors

triggered by a retention of CO2

Peripheral chemoreceptors

triggered by hypoxia

Pathology behind the clinical manifestations of emphysema

Distinguishing pathological difference between primary and secondary emphysema (including how it leads to loss of elastic recoil of the lungs)

What is the primary cause for triggering an extrinsic asthmatic attack?

The primary cause for extrinsic asthma attacks are allergens.

This is also called atopic or extrinsic asthma.

There will be an elevation of IgG.

Asthma is caused by inflammation with hyper responsiveness of upper airway and bronchospasm.

Intrinsic asthma attack is most times an imbalance between your para and sympathetic nervous systems.

Based on pathology, what is the primary cause for a ventilation perfusion mismatch (shunt)?

These are caused by inadequate ventilation of well perfused areas of the lung, like the alveoli.

Tuberculosis: Patient history & clinical presentation

Common in underdeveloped countries.

MDR, XDR, and TDR are strains that are totally resistant to the drugs that are used. There is no treatment available for these patients.

Risks include being in close contact with a positive patient, residents and employees of high risk congregate settings (correctional institutions, nursing homes, mental institutions).

Hallmark S/S are hemoptysis (blood in cough), unintentional weight loss, night sweats, and chills. The cough should last more than 3 weeks.

Tuberculosis : Infecting organism

A single sneeze can release 40,000 droplets, and is extremely contagious.

Mycobacterium tuberculosis is the infecting organism.

Tuberculosis: Early immune response to infecting organism (i.e. Caseous necrosis)

Bacteria reaches alveolar sacs and replicates itself. The body will recognize it as a foreign object and macrophages attempt to eliminate it by phagocytosis.

This forms an envelope called a phagosome. These will combine with lysosomes and try to kill the bacterium.

CD4 activates CD8 and B cells that produce antibodies.

MT has a thick, waxy layer that protects from the phagolysosomes and can reproduce inside of the macrophage. It will eventually destroy it.

The body will then form granulomas to surround the macrophage and contain the MT.

The area inside of the granuloma dies and forms a lesion (Ghon focus). Scar tissue forms (necrosis).

This process will extend to nearby lymph nodes. This is called a Ghon-complex.

Lung cancer: Non-Small cell carcinoma:

Adenocarcinoma (35-40%): In mucus glands. Typically found in women that are non-smokers.

Squamous cell (20-32%): In epithelial tissue. Typically associated with men who smoke.

Large cell carcinoma (14-18%): Usually late in diagnosis will metastasize quickly.

Unspecified (20-25%)

lung cancer: Small cell carcinoma:

This is a tumor of bronchial origin. These are aggressive, locally invasive and widely metastasizing tumors.

Lung cancer: Hormonal secretion seen in Small Oat Cell Carcinoma?

ADH will be secreted with small oat cell carcinoma.

Lung cancer: Risk factors and presenting clinical manifestations

Cigarette smoking is 85-90% of cause. Packs-years are how we talk about how long a person has smoked for. (Number of cigarettes smoked a day/20) x number of years smoked.

Exposure to gases and industrial carcinogens are also causes.

Early there will be a chronic cough and wheezing on one side.

There will be anorexia, dull non-specific chest pain, hemoptysis, and digital clubbing.

ABG interpretations may be applied to multiple pulmonary conditions

Urinary Tract: Organism (most common)

E Coli is the most common bacteria that causes UTIs. The pathogen has hooks which will attach to the bladder wall.

How do UTI symptoms differ among populations?

Elderly people present as asymptomatic. They will have sudden confusing and abdominal pain.

There will be dysuria, lower back pain (flank), cloudy urine, and hematuria.

What helps promote micturition of infecting organism?

Inflammation occurs, and the body will start to dilute the urine.

Acidic urine with presence of glycoproteins are all protective mechanisms that help to eliminate the infecting organism quicker.

Cranberry juice can prevent adherence of the E Coli.

Kidney: Renal calculi (stones)

Renal calculi are massive crystals or proteins.

Risk factors are living in warm climates, older men due to prostate enlargement, and caucasians.

High calcium diets will cause kidney stones. Gout and cancers can increase uric acid, which causes stones. Tea and fruit also increase risk of formation.

clinical manifestations associated with renal calculi (stone)

Hallmark sign for kidney stones is a renal colic. This is a moderate pain that starts in the flank and radiates down to the groin

What does urine pH tell you about the types of stone formations?

Calcium and struvite stones cause alkaline urine.

Cystinuric acid stones make the urine more acidic. This is because these increase the presence of uric acid.

Pyelonephritis: Populations at risk for developing condition

This is 5 times for common in women than in men.

Pregnancy, urinary obstructions, and cystoscopies are also risk factors.

Pyelonephritis: If untreated, what is the primary complication to ensue

Acute is an infection that spreads from the bladder or from blood stream to kidneys.

If it goes untreated, it can become chronic. It will cause scarring, and eventually it will atrophy the tubules. The kidney will no longer be as functional.

Glomerulonephritis

This is the most common form of kidney disease.

It is a dysfunction of specific components of the glomeruli. This will effect filtration.

acute Glomerulonephritis

This is most commonly associated with post untreated strep infection. It will come on about 7-10 days after strep throat.

Very common in children. Treatment is antibiotics, and most recover without significant damage.

Patient will present with proteinuria, hematuria with RBC casts, and decreased GFR.

Peri-orbital edema is a sign of acute glomerulonephritis.

chronic Glomerulonephritis

Immune system is the main cause of infection here. This is more progressive than acute and can be secondary to diabetes/lupus.

Severity is due to size, number, location, duration of exposure, and type of A/A complex.

Decrease renal flow will cause chronic kidney disease.

Urine will turn a smoky brown color and proteinuria will increase. There will also be hypertension.

After 10-20 years, they will develop nephrotic syndrome and then kidney failure.

As kidneys start to fail, there will be a rise in creatinine levels. This is because GFR will lower

chronic kidney failure (CKD)

This is based off of a patients GFR.

Diabetes is a huge risk factor for CKD. This causes microvascular changes in the kidneys, which effects filtration, damaging the neurons.

CKD effects:

Every system in the body will be effected with CKD.

Cardiovascular diseases are the main cause of morbidity with CKD.

There will be a decrease in aldosterone production.

There will be an increase in Ca deposits.

Patients will have uremic breath, which means it smells like urine.

Pre-renal

This caused by lack of blood to the kidneys, causing them to fail. Most common cause is dehydration or decreased perfusion.

BUN will be elevated, but the creatinine will be normal. The ratio between these two will be elevated.

Intra-renal

This is caused by something within the kidney causing it to fail. Most common cause is failure to recognize/treat pre-renal failure.

Post-renal

This is caused by something after the kidney. Most common cause is an obstruction.

BUN and creatinine will be elevated, so there will be a normal ratio.

Recovery can take 3-12 months. It depends on if the basement membrane of the glomerulus is intact. If nephrons were lost, the remaining cells enlarge to compensate.

What is the relationship between anemia, erythropoietin, and the kidneys?

Erythropoietin is made inside of the kidneys. If they are diseased, it cannot be produced the way it is needed.

Patient will develop anemia

Recognize electrolyte imbalances that commonly occur in the acute renal failure and chronic renal failure patient

There will be fluid and electrolyte ambulances. Kidneys cannot regulate K, Na, Phos, and Ca

Understand how metabolic acidosis occurs

Metabolic acidosis can occur because the kidneys are normally in charge of excreting acid into urine. When they are diseased, they cannot excrete acid the same, leading to increased H+.

lab value ranges: GFR, serum BUN, creatinine

normal GFR is over 60

BUN is 6 to 24 ?

creatinine: 0.7-1.3 M 0.6-1.1 W ?

Uremia will cause an increase in BUN

Primary Headaches

These can be migraine headaches, tension-type, cluster, and chronic daily headaches.

Tension:

These are the most common headaches.

They are not severe enough to affect/interfere with daily activities. These are not worsened by activity.

Migraines:

These can be experiences with or without aura.

S/S: throbbing, unilateral headache lasting 1-2 days. It is aggravated by activity and is very sensitive to sound.

With aura means that there will be vision black spots, sensory symptoms, and speech disturbances.

without aura: aggravated with activity, sensitive to sounds, lasts 1-2 days

Cluster:

These are not common. They occur in clusters and reoccur over weeks or months, followed by a long headache-free period.

With these, there will be pain behind the eye.

Myasthenia Gravis:

This is three times more common in women than men.

This is an autoimmune disease where there is a loss of acetylcholine receptors at neuromuscular junction.

Muscle weakness and fatigue are sustained with effort.

Most commonly affected is the eyes. There will be dropping of the eye-lids.

Symptoms are less in the morning and progress throughout the day.

Guillain-Barre Syndrome:

This is caused by immune mechanisms. Epstein-Barr virus will cause this.

This is acute and life-threatening.

There is rapidly progressive ascending limb/muscle weakness and loss of tendon reflexes. There will be a numbness/tingling to paralysis.

A big sign is there will be pain with the slightest movements. Muscle atrophy is not seen here.

Muscular Dystrophy:

It is x-linked recessive, so in boys.

This is a degeneration and necrosis of skeletal muscle fibers and eventual replacement with fat and connective tissue.

This will lead to an increase in muscle size and weakness.

There will be scoliosis, and the postural muscles of the hips and shoulders will be the first effected.

They will be wheelchair bound by 7-12 years.

Carpal Tunnel Syndrome:

This is compression of the median nerve.

There will be pain, numbness of the thumb and first four digits. The pain will worsen at night.

Amyotrophic Lateral Sclerosis (Lou Gehrig Disease):

Loss of motor neurons, which causes muscle atrophy.

Muscle cramps in the legs are an early symptom.

It is slowly progressive, and there is atrophy in distal muscles of one upper extremity.

Entire sensory system, the regulatory mechanisms of control and coordination of movement, and the intellect of the person remain intact.
· Steven Hawking had ALS.

Parkinson’s Disease

This is a progressive disorder of the basal ganglia function.

It results in combinations of tremor, rigidity, and bradykinesia (slowness in initiation of movement).

There is a reduction of the neurotransmitter dopamine. Metabolic toxins destroy these dopaminergic neurons.

Multiple Sclerosis

This is an autoimmune disorder. There is a demyelination of nerve fibers in the white matter of the brain, spinal cord, and optic nerve.

There will be continuous deterioration that can last for days, and then it will partially or completely resolve itself. It will then show up later with newer symptoms.

Intracranial Pressure – as it relates to hemorrhagic strokes

Prolonged high ICP will cause the brain to herniate. The swelling will kill the brain stem, and the patient will die.

▪ Downward herniation will displace the midbrain, pushing up onto the brainstem. This will result in cardiac arrest.
▪ You may initially see heart rate go up and then fall. Irregular/blown pupils (6 mm in diameter and non-reactive to light).are another sign of herniation.

Increased ICP can cause hydrocephalus.

Cerebral Perfusion Pressure:

Mean arterial pressure minus ICP.

Any CPP below 60 is a red flag.

What is the relationship between increased ICP and level of consciousness?

As the ICP goes up, the level of consciousness will go down. Level of consciousness is the biggest indicator of ICP increasing.

Bacterial Meningitis

Bacteria will enter in through the nose. It will travel upstream to the brain, where inflammation will occur.

This will cause a cloudy exudate that will slow the CSF down. It will be more like a syrup rather than a water, and will herniate the brain.

viral meningitis

caused by viruses such as mumps, herpes simplex, polio, and adenovirus.

Viral meningitis is limited to the meninges only.

What is the most common organism responsible for bacterial meningitis?

Meningococcal meningitis is the most dangerous.

Streptococcal is the most common

how do you quickly differentiate between bacterial and viral meningitis?

Viral:
▪ This is less severe than bacterial.
▪ There will be a mild throbbing headache, and a stiff painful neck. There will also be fever and malaise.

Bacterial:
▪ A rash is a hallmark sign.
▪ There will be agitation and confusion before they are in a coma.
▪ Many people who survive will become deaf.

Nuchal Rigidity:

This is a completely stiff neck. There is no movement possible.

Kernig’s Sign:

This is where you have them flex their hip/knee up, while you are pushing down. This should elicit a pain response, because of inflammation.

Brudzinski’s Sign:

This is flexing the neck. The patient will also have to bend their knees in an attempt not to stretch the spinal cord.

Cerebral Vascular Accident (stroke)

Patient needs to be receiving treatment within 4 hours of having the stroke

Transient Ischemic Attack

These are called mini strokes.

These usually clear up on their own.

Signs are aphasia, fast facial dropping, and unequal strength

Large Vessel Thrombotic Stroke:

These are usually located in the large vessels, and are caused by atherosclerotic plaque that narrows the vessel.

Embolic Stroke:

This happens when the clot is let free to move. It will come from the left side of the heart. From there it can go and obstruct an organ in the body or the brain.

Hemorrhagic CVA:

This is the most fatal stroke. It is most closely linked with hypertension.

Can also be caused by an AVM, which will rupture veins. These present most with headaches.

Alzheimer’s Disease

Early on set is caused by an autosomal dominant inheritance.

Downs Syndrome and frequent head trauma patients will be at higher risk for Alzheimers.

Eventually the brain will atrophy so that the folds of the brain no longer touch.

We give these patients mini mental tests. The lower the score, the more progressed the disease is.

what neurotransmitter is involved with Alzheimer’s Disease

Acetylcholine is the neurotransmitter that is involved in making memories. This occurs in the forebrain.

There is a loss of acetylcholine and hippocampus atrophy with this disease.

It is an alteration of chromosome 19, which binds to amyloid proteins and builds antibodies to attack yourself.

what are neurofibrillary tangles with Alzheimer’s Disease

Neurofibrillary tangles are groups of proteins that accumulate inside of neurons.

These will block communication and eventually cause nerve degeneration.

The nerve degeneration will stick together around the amyloid core. These will then become senile plaques.
• These will disrupt transmission by more than 40%.
• These plaques and tangles like to congregate in the hippocampus and the cerebral cortex.

common cold main culprit

fingers

rhino-sinus-itis main S/S

purulent nasal discharge

fever

influenza

fever and chills

influenza: Reye syndrome

interaction of aspirin when PT has influenza and can cause fatty liver and encephalitis (brain swelling-which is fatal)

pneumonia presentation

pleuritic pain (complain as chest pain)