Infection, Neoplasms, Fluid/Electrolyte/Acid-Base Balance AND Pregnancy, Immobility, Stress, and Pain

It is the whole second half of the objectives

 List factors determining host resistance

Host Resistance	Increased Microbial Virulence
Intact skin and mucous membrane	Production of exotoxins and endotoxins
Body secretions–stomach acid, tears	Production of destructive enzymes
Nonspecific phagocytosis	Spore formation
Effective inflammatory response	Entry of large number of organisms into body
Absence of disease	Presence of bacterial capsule and pili
Effective immune system
Interferon production (virus)

 Differentiate between a neoplasm, a benign tumor, and a malignant tumor.

	Benign Tumors	Malignant Tumors
Cells	Similar to normal cells Differentiated Mitosis fairly normal	Varied in size and shape with large nuclei Many undifferentiated Mitosis increased and atypical
Growth	Relatively slow Expanding mass Frequently encapsulated	Rapid growth Cells not adhesive, infiltrate tissue No capsule
Spread	Remains localized	Invades nearby tissues or metastasizes to distant sites through blood and lymph vessels
Systemic effects	Rare	Often present
Life-threatening	Only in certain locations (e.g., brain)	Yes, by tissue destruction and spread of tumors

• A neoplasm, or tumor, is a cellular growth that no longer responds to normal body controls.

  • This excessive growth deprives other cells of nutrients.

 Describe the local effects of malignant tumors.

• Local effects: 

• Pain is not usually an early symptom of cancer; rather, it occurs when the tumor is well advanced.

• Obstruction can result when a tumor compresses a duct or passageway from an external position or grows inside a passageway or around a structure

• Tissue necrosis and ulceration may lead to infection around the tumor, particularly in areas where normal flora can become opportunistic.

 Describe the systemic effects of malignant tumors.

• Weight loss and cachexia (severe tissue wasting) occur with many malignancies.

• Anemia or decreased hemoglobin is a common problem resulting from anorexia and decreased food intake, chronic bleeding with iron loss, and bone marrow depression.

• Severe fatigue may be caused by inflammatory changes, cachexia, anemia, stress, and treatment schedules.

• Infections such as pneumonia occur frequently as host resistance declines.

• Bleeding may occur because the tumor cells may erode the blood vessels or cause tissue ulceration

•  Paraneoplastic syndromes are additional problems associated with certain tumors, such as bronchogenic carcinoma in the lungs. 

Invasion

• refers to local spread, in which the tumor cells grow into adjacent tissue and destroy normal cells

Metastasis

means spread to distant sites by blood or lymphatic channels. Lymph nodes, which localize the tumor cells for a time.Usually the lymph nodes are removed or treated to eradicate any micrometastases. Lungs and liver are common secondary sites for many tumors

Seeding

 refers to the spread of cancer cells in body fluids or along membranes, usually in body cavities. Ovarian cancer

Primary vs Secondary:

Primary: never been there before

Secondary: caused by another disease

signs of fluid excess

Edema –

• excessive amount of fluid in the ISF; 

• swelling and enlargement of tissue;

• more severe in dependent portions

Causes of Edema

• Inc capillary hydrostatic pressure;

• BP & hypervolemia – pregnancy, CHF, renal failure

• Loss of plasma proteins;

• Loss of osmotic pressure - renal failure; malabsorption/nutrition; liver dz; burns

• Inc capillary permeability;

• fluid and protein loss into ISF - burns; bacterial toxins;  inflammatory response

• Lymphatic obstruction

• Increases hydrostatic pressure in the lymph vessels – swelling, tumors

Effects of edema

Swelling

• Pitting

• Increased body weight

• Functional impairment

• Pain

• Impaired arterial circulation

Explain the causes fluid deficit.

 Insufficient intake or excessive loss or both

• Comes from ECF first

• More serious in young and old – fluid reserves and conservation mechanisms

Causes of dehydration

- Vomiting; diarrhea; sweating; diabetic ketoacidosis; insufficient water intake

Effects dehydration

first decrease in ISF and IVF; dry mucous membranes and decreased skin turgor; lower BP; weak pulse; fatigue; increased hematocrit

Dehydration Compensation

Increased thirst

• Increased heart rate

• Constriction of cutaneous blood vessels – pale, cool, skin

• Decreased urine output – renal vasoconstriction, increased ADH and Aldosterone

Hyponatemia

• Causes: 

• either deficit of Na or excess of water

•  loss from sweat, vomit, diarrhea, diuretics, hormonal imbalances aldosterone, ADH), renal failure or excessive water intake

-  Signs: 

• Anorexia, nausea, cramps

• Fatigue, lethargy, muscle weakness

• Headache, confusion, seizures

• Decreased blood pressure

• Effects: 

  • impaired nerve conduction, muscle cramps, abdominal discomfort or cramps with N/V

  • decreased osmotic pressure in ECF causing fluid to shift into cells, resulting in hypovolemia and decreased BP; swelling of brain cells confusion, headache, weakness, or seizure

Hypernatremia

• Causes: 

  • ingestion of large amts of Na or loss of water faster than loss of Na

  • insufficient ADH

  • loss of thirst mechanism

  • watery diarrhea

• Effects: 

  • fluid shift out of the cells and into the ECF

  • weakness, agitation, firm subq tissues

  •  increased thirst

  • dry mucous membranes

  • decreased urine output – ADH is secreted

• Signs: 

  • Thirst; tongue and mucosa are dry and sticky

  • Weakness, lethargy, agitation

  • Edema

  • Elevated blood pressure

Hypermagnesemia

• Causes: 

  • Renal Failure 

• Effects: 

  • depressed neuromuscular function; lethargy; dysrhythmias

Hypomagnesemia

• Causes: 

  • malabsorption or malnutrition; diruetics; diseases

• Effects: 

  • neuromuscular hyperirritability; tremors; dysrhythmias

Hypokalemia

• Causes: 

  • diarrhea

  •  diuretics

  • excessive aldosterone or glucocorticoids – retain Na and excrete K

  • decreased dietary intake

• Effects: 

  • cardiac dysrhythmias

  •  interference with neuromuscular function

  •  Paresthesias

  •  decreased digestive motility (anorexia/nausea)

  •  weak shallow respirations

  •  renal function impaired – increased urine output

• Signs: 

  • Cardiac arrhythmias, cardiac arrest

  • Anorexia, nausea, constipation

  • Fatigue, muscle twitch, weakness, leg cramps

  • Shallow respirations, paresthesias

  • Postural hypotension, polyuria, and nocturia

  • Serum pH elevated—7.45 (alkalosis)

Hyperkalemia

• Causes: 

  • renal failure

  •  deficit of aldosterone

  •  potassium-sparing diuretics

  •  leakage of ICF K into the ECF with extensive tissue damage

  •  displacement of K from cells by severe acidosis

• Effects: 

  • cardiac dysrhythmias 

  • muscle weakness (paralysis)

  • fatigue 

  • nausea 

  • Paresthesias

• Signs: 

  • Arrhythmias, cardiac arrest

  • Nausea, diarrhea

  • Muscle weakness, paralysis beginning in legs

  • Paresthesias—fingers, toes, face, tongue

  • Oliguria

  • Serum pH decreased—7.35 (acidosis)

Hypercalcium

• Causes: 

  • increased release of calcium from bone (PTH, immobility, tumors)

  • increased intake of calcium

• Signs/Effects: 

  • Apathy, lethargy

  • Anorexia, nausea, constipation

  • Polyuria, thirst

  • Kidney stones

  • Arrhythmias, prolonged strong cardiac contractions, increased blood pressure

Hypocalcium

• Causes: 

  •  Hypoparathyroidism—decreased parathyroid hormone results in decreased intestinal calcium absorption

  • Malabsorption syndrome—resulting in decreased intestinal absorption of vitamin D or calcium

  • Deficient serum albumin

  • Increased serum pH—resulting in alkalosis

• Effects/Signs: 

• Tetany—involuntary skeletal

• muscle spasm, carpopedal spasm, laryngospasm

• Tingling fingers t

• Mental confusion, irritability

• Arrhythmias, weak heart contractions

Explain how metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis develop and their effects on the body

	Acidosis	Alkalosis
Causes	Slow shallow respirations (e.g., drugs) Respiratory congestion	Hyperventilation (anxiety, aspirin overdose)
Effects	Increased PCO2	Decreased PCO2
Compensation	Kidneys excrete more hydrogen ion and reabsorb more bicarbonate	Kidneys excrete less hydrogen ion and reabsorb less bicarbonate

Metabolic: 

	Acidosis	Alkosis
Causes	shock,  Diabetic ketoacidosis,  renal failure,  diarrhea	vomiting,  excessive antacid intake
Effects	decreased serum bicarbonate ions	increased bicarbonate ions
Compensation	rapid, deep respirations,  kidneys excrete more acid and increase bicarbonate reabsorption	slow, shallow respirations,  kidneys excrete less acid and decreased bicarbonate absorption

Embryonic Development

• 3 to 8 weeks after fertilization

• Organogenesis – formation of basic functional elements of organ systems

• Critical time in development of all organs and structures

• By end of 8 weeks – all organs are formed

• Exposure to the embryo to teratogens

• Can cause serious congenital abnormalities

Teratogen

• Any substance or situation that causes a developmental abnormality

  • Viruses

  • Smoking or exposure of mother to second-hand smoke

  • Alcohol

  • Radiation

  • Certain medications including herbal remedies

Development of fetus

• Most organs have completed formation.

• Teratogens have less effect on development.

  • Functional impairment can still result.

  • Particularly in the central nervous system

• Elementary functions can be observed.

• Fetus gains weight.

• Organs such as lungs mature.

Effects of Expanding Uterus pregnancy

• Pressure of expanding uterus 

• Can interfere with digestive function

• Reduces vital capacity

• Increases pressure on bladder and rectum

• Changes center of gravity

Digestive System changes pregnancy

• Nausea and vomiting

  • Common in first trimester

    • Not just in the morning

•  Change in eating pattern often reduces discomfort

•  Decreased motility in the digestive tract

  • Relaxation of smooth muscle by progesterone

  • Slower emptying of the stomach

    • Reflux of stomach contents (heartburn)

    •  Constipation

Musuloslektal Changes pregnancy

• Marked postural changes

  •  Pelvic joints relax or loosen

    • Hormones prepare for delivery

    •  Loss of stability – waddling gait

• Increased abdominal weight

  • Tendency toward lordosis

  • Balance and coordination may be impaired.

• Backache caused by these changes

Cardiovascular changes in pregnancy

• Increased blood volume

  •  Both fluid and erythrocytes

  •  Increase production of red blood cells for fetus

    •  Requires increased iron intake by the mother

• Heart rate may increase slightly.

• Blood pressure

  •  Frequently drops slightly in first two trimesters

  •  Rises to normal levels in last trimester

•  Varicose veins

  • Frequently develop during pregnancy

Changes in Skin and Mucosa aging

• Some related to genetic factors

• Many based on exposure to sun and weather

• Skin and mucous membranes become thin and more easily damaged.

• Dermis thinner – subcutaneous tissue diminished

• Number of specialized structures declines:

  • Sweat glands

  • Receptors

• Skin dry because of reduced sebum

• Appears wrinkled

  • Elastic fibers reduced; Collagen fibers less flexible

• Hair becomes gray.

• Thinning of hair

Cardiovascular Changes aging

• Size and number of cardiac muscle fibers decrease; Fatty tissue and collagen fibers accumulate.

•  Reduced strength of contraction

• Heart valves thicken, become less flexible

• Vascular changes may cause a decrease in oxygen supply to the heart.

Respiratory aging

• Ventilation is limited by

  • Elasticity in lung tissue is reduced.

  • Costal cartilage calcifies, reducing rib movement

  • Skeletal (intercostal) muscles weaken

• Expiration is reduced.

  • Residual volume increased

  • Decreased expansion for deep breathing and coughing

• Vascular changes

  • Decreased perfusion

  • Reduced gas exchange in alveoli

Gastrointestinal Changes and Nutrition aging

• Maintenance of good nutrition may be a problem.

• Decreased sense of smell and taste leading to anorexia

• Lack of money for adequate nutrition

• Muscle weakness and fatigue

• Obesity in older individuals

  •  Increases cardiac workload; Atherosclerosis and hypertension; Type 2 diabetes

• Atrophy of mucosa and glands

  • Reduces digestive secretion; Impaired absorption of vitamin B12, calcium, and iron

• Constipation common in older adults

  • Frequently leads to hemorrhoids

Urinary System Changes 

• Kidney function reduced

  •  Loss of nephrons; Diminished ability to adapt to changes in electrolyte and acid levels; Reduced capacity to excrete drugs

• Weakened urinary sphincter and bladder

  • Nocturia (frequent urination)

  • Incontinence (involuntary voiding of urine)

Explain the increased incidence of infections and cancer seen in the aging population

• Infections

  • Delayed healing

    •  Reduced rate of mitosis

•  Less rapid immune responses

•  Cancer

  •  Higher cumulative

• exposure to carcinogens

• Autoimmune disorders

Musculoskeletal immobility

• Inactive muscle 

  • Loss of strength, endurance, and mass; Muscle atrophy

• Loss of bone mass

  • Lack of weight-bearing activity and muscle action

    •  Reduces osteoblastic activity

    •  Osteoclastic activity continues

Skin immobility

• Factors that promote skin breakdown

  • Poor general circulation or anemia

  • Edema

  • Inadequate subcutaneous tissue in

  • older adults or disabled persons

  • Loss of sensation

  • Mechanical irritation or friction

  •  Excessive moisture from perspiration or urine

  •  Inadequate personal hygiene

  •  Inadequate nutrition or hydration

  • Trauma to the skin

Cardiovascular effects immobility

• Full immobilization –

  • Initially

    •  Blood pools in trunk

    •  Venous return may increase

•  Prolonged immobility Cardiovascular effects

• Full immobilization –

  • Initially

    •  Blood pools in trunk

    •  Venous return may increase

•  Prolonged immobility

  • Venous return and cardiac output reduced

  • Orthostatic hypotension – at change of position

    •  Short periods of dizziness;

    • Fainting; Pallor and sweating; Rapid pulse

  • Patient becomes mobile after long bedrest

    • May take weeks for cardiovascular reflex controls to return to normal

  •  Blood pooling – stasis

    • Increased capillary pressure and edema

    • Promotes thrombus formation in veins

    • Blood clotting in patients with dehydration or cancer

  • Thrombi may break away with movement or massage

Respiratory Effects immobility

• Respiration slow and shallow

  • Deep breathing and coughing more difficult

•  Drugs

  •  Sedatives and analgesics - Depress neuromuscular activity and respiratory control center

•  Increased secretions in the lungs

  •  Pneumonia

  • Atelectasis

Gastrointestinal Effects immobility

• Decreased dietary intake

  •  Appetite reduced; Negative nitrogen imbalance

    •  From protein deficit

•  Constipation

  • Due to muscle inactivity and body position

  •  Reduced food, fiber, fluid intake

•  Obesity

  • When prolonged immobility occurs and caloric intake exceeds energy need

Urinary Effects immobility

• Stasis of urine

  •  In kidneys or bladder - Normal drainage by gravity impeded

•  Infection

  •  Stasis of urine and calculi are predisposing factors

•  Renal calculi (stones)

  •  More likely in people with hypercalcemia

•  Bladder infection

  • Common if catheters are used

Describe the causes of pain.

• Discomfort due to stimulation of pain receptors

signs and symptoms of pain

• Nausea and vomiting

  •  May occur with acute pain

•  Fainting and dizziness

  •  May occur with acute pain

• • Anxiety and fear

  •  Frequently evident in people with chest pain or trauma

•  Clenched fists or rigid faces

•  Restlessness or constant motion

• Guarding area to prevent stimulation of receptors

Referred Pain

• Source may be difficult to determine.

• Pain may be perceived at sites distant from the source. 

  • Characteristic of visceral damage in the abdominal organs

  • Heart attack or ischemia in the heart

Phantom pain

• Usually in adults

• More common if chronic pain has occurred

• Following an amputation - Pain, itching, tingling

• Usually does not respond to common pain therapies

• May resolve within weeks to months

• Phenomenon not fully understood

Provide the factors that may influence the perception pain and response to pain.

• Pain tolerance

  • Degree of pain, intensity, or duration

  • May be increased by endorphin release

  • May be reduced due to fatigue or stress

  • Varies among people in different situations

•  Response to pain

  • Influenced by personality, emotions,and cultural norms