Adults II exam 3 review

Where does venous and arterial blood in the liver come from?

Stomach, spleen, intestines, and pancreas

What is the functional unit of the liver?

lobules

What type of blood flow does the liver have?

Dual arterial and venous supply that allows the liver to filter blood from the GI system to get rid of toxins(protal vein) and still get tis O2 (hepatic artery)

What are the functions of the liver?

• Produces bile salts

• Eliminates bilirubin

• Metabolizes sex hormones, drugs, carbohydrates, fat, proteins

• Stroes glycogen

• Synthesizes clotting factors and proteins (albumin)

• Stores vitamins and minerals

• Filters blood and removes bacteria from the GI system

• Filters toxins

Based on the functions of the liver, what adverse effects are expected?

• Decrease in bile leads to decrease in fat breakdown (emulsification)

• Increased bilirubin leads to increased yellow pigment

• Increased sex hormones leads to gynecomastia and hirsutism

• Lack of glycogen storage leads to glucose imbalance

• Lack of clotting factors increases risk for bleeding

• Decreased albumin causes fluid shifts leading to dehydration

• Increased toxins in body

What is the location of the galllbladder?

Sac-like organ sitting underneath the liver and it helps store, concentrate, and release bile

How does the gallbladder work?

When food (fat) reaches the duodenum, the body releases hormones that cause the gallbladder to contract and release bile into the duodenum to help fact get emulsified to make absorption easy

What are the 2 functions of the liver?

• Endocrine: regulate blood sugar through insulin (decreased blood sugar) and glucagon (increase blood sugar) production

• Exocrine: production and release of digestive enzymes (lipase, amylase, protease)

Where do pancreatic enzymes go to enter the duodenum?

common bile duct

What are key things to know about total parenteral nutrition (TPN)?

• It’s delivered intravenously through central access

• Given at night and has a 24hr run time

• Always change bag after 24 hr to prevent infection

• Only one line should be used when giving TPN

• Monitor glucose and electrolytes

• Wean off TPN if discontinuing

What’s a risk when giving TPN?

Since the fluid is hyperosmolar, it pulls fluid from the interstitial spaces which can lead to dehydration

What do you want to monitor when giving someone TPN?

Glucose levels since TPH normally has high glucose concentrations and could make a person hyperglycemic (q4h)

What should you do if TPN is unavailable to a patient who has been receiving TPN?

Give D50 so that they don’t suddenly become hypoglycemic. This is because their body builds a dependence to high levels of glucose, so they can easily bottom out

What are complications of TPN?

• Hyperglycemia (initially)

• Hypoglycemia (when TPN is suddenly stopped)

• Infection (from central like or glucose while is ideal for bacterial growth)

• Fluid shifts

What’s key info to know about Hep A?

• Display mild flu like symptoms

• Mode of transmission: fecal-oral or contaminated food/water

What’s key info to know about Hep B?

• Typical presentation

• Mode of transmission: unprotected sex with an infected individual or blood-blood

What’s key info to know about Hep C?

• Chronic disease

• Mode of transmission: Blood to blood (needle sharing)

What’s key info to know about Hep D?

• A result of Hep B (HBV)

• Mode of transmission: parenteral routes

What’s key info to know about Hep E?

• Flu like symptoms (similar to HAV)

• Mode of transmission: fecal oral or contaminated food or water

• No endemic to the US

What are reasons for certain manifestations in hepatitis?

• Flu-like symptoms and fatigue: body’s response to viral infections

• Hepatomegaly: inflammation of the liver

• RUQ abdominal pain: pain from the inflammation spreading

• Clay-colored stool: lack of bilirubin elimination

• Dark urine: black of bilirubin elimination in stool

• Pruritis: toxin buildup

• Bruising: decreased clotting factor synthesis

• Jaundice: impaired bile production

What are components of a Liver Function Test?

• ALT: found in liver

• AST: found in other places besides liver

• ALP: indicates problems with bile flow

• GGT

What is one risk with a liver biopsy?

Risk for bleeding so check INR beforehand

What are the indications of using interferon for Hepatitis?

• It’s for chronic hepatitis (Hep C) to suppress the virus

What are the indications of using Sofosbuvir for Hepatitis?

Oral med for Hep C that targets reproduction of the virus

What are both lactulose and rifaximin used for?

Hepatic encephalopathy

Why is portal hypertension a complication of hepatits?

Inflammation of the liver decreases perfusion and causes fluid to build up in the GI system

What are key things to know about alcohol withdrawal in hepatitis patients?

• Delirium Tremens (DTs) are a severe form of alcohol withdrawal

  • Onset: 8-96hrs of last drink

  • S&S: tremors, hallucinations, confusion, seizures, electrolyte imbalances, severe tachycardia and hypotension

  • Diag: CAGE screening

  • Txt: Benzos

How can cardiac failure lead to cirrhosis of the liver?

Severe HF leads to blood backup which goes down to the liver. Causing it to overflow with blood and can lead to inflammation. This happening in the long-term can lead to cirrhosis 

What are reasons for certain manifestations in cirrhosis?

• Altered status: hepatic encephalopathy

• Asterixis: Ammonia buildup

• Peripheral edema and ascites: lack of albumin

• Dysrhythmias: electrolyte imbalance

• Weight loss: severe anorexia and loss of appetite

• Esophageal varices: Portal HTN

• Gynecomastia: lack of regulation of sex hormones

What would labs show for cirrhosis?

• LFTs: elevated

• Serum bilirubin: elevated

• Serum protein: low d/t liver synthesis

• Serum albumin: low d/t liver synthesis

• CBC: anemia, thrombocytopenia, leukopenia since bone marrow is affected

• Chem panel: hypokalemia and hyponatremia

• INR: elevated

• Ammonia: elevated

• BUN/Creatinine: elevated d/t fluid shifts

What is the purpose of an EGB?

To go down the esophagus and determine varices presence

Why should medication be administered cautiously for a cirrhosis patient?

There’s a cumulative effect since they can’t be properly metabolized

What are key things to know about TIPS procedures for cirrhosis?

• When the portal vein is occluded by cirrhotic tissue, rupture of vessels (esophageal varices) is a high risk, so the TIPS procedure creates a bypass so that blood can flow easier

NOT CURATIVE, BUT HELPS WITH SYMPTOM MANAGEMENT

What are key things to know about paracentesis procedures for cirrhosis?

• Helps drain ascitites to releive pressure and can be done with either a needle or catheter

• Infection risk

NOT CURATIVE, BUT HELPS WITH SYMPTOM MANAGEMENT

What are key things to know about liver transplants for cirrhosis?

• can be done with whole liver or partial

• Pts are put on life-long immunosuppressants

What is hepatorenal syndrome?

A complication of cirrhosis where fluid shifts can cause hypoperfusion to kidneys. Also, ascites inhibits fluid from cycling through the body and stay down

What are key things to know about hepatic encephalopathy?

• Damage to the liver leads to the inability of the liver to process ammonia from protein breakdown. The increase in serum ammonia affects the neuro system

• S&S: altered mental status, somnolence, tremors, coma

• Txt: lactulose and rifaximin

What are key things to know about portal hypertension and esophageal varices

• Backup of blood flow from a scarred liver pushes blood to veins in the esophagus. This high pressure causes the veins to bulge and can easily rupture varices in the esophagus

• S&S: esophageal bleeding, hematemesis

• Txt: non-selective beta blockers (reduce pressure), endoscope w/ banding, NO NGTs (risk of rupture)

What’s the difference between calcified and non calcified stones?

• Calcified: shows on ultrasound

• Non-calcified: doesn’t show on ultrasound

What are reasons for certain manifestations in cholethiasis and cholecystitis?

• Vomiting after fatty meal: lack of bile to breakdown fat

• Steatorrhea: d/t lack of fat breakdown stool is fatty and watery d/t fluid shifts

• Murphy’s sign: push below liver and rebound tenderness is peritonitis

• Blumberg’s sign: push against ribcage to show liver inflammation

What is a HIDA scan?

Helps determine if bile is being used properly

What are components of a cholecystectomy?

• Laparoscopic: minimally invasive

• Open: only used for certain circumstances

T-tube can be used in both if the common bile duct needs to be explored

What are key things to know about T-tubes?

• Drainage is sanguineous at first then transitions to bile

• Expect 400 ml within 24hr ml then it’ll decrease (no drainage indicates obstruction)

• Don’t raise tube above level of gallbladder and clamp before and after meals to prevent bile from coming out the bag

• Empty bag q8h

• Monitor for inflammation and how client tolerates diet

What do patients complain about after cholecystectomy and how can it be resolved?

Patients complains of right shoulder pain d/t CO2 buildup, but ambulating can help expel that CO2

During pancreatitis, what effect does Lipase and Ca have?

When Lipase and Ca combine, they form a foamy substance that lowers serum Ca

What is chronic pancreatitis associated with?

Long-term alcohol use

Why are acute pancreatitis patients put on NPO?

You don’t want to work the GI system d/t dysregulation of pancreatic enzymes. So, you put the patients on NPO orders and place an NG tube to decompress rather than feed the pt. You will also look into TPN for possible nutrition

What is the priority care for pancreatitis patients?

Monitor and treat pain

What are risks that pancreatic cancer patients face when being treated with the Whipple procedure?

• Diabetes

• Hemorrhage

• Infection

• Bowel obstruction

• Abscess

• Peritonitis

What are neurons composed of?

• Cell body

• Axon (covered in myelin sheath)

• Dendrites

What’s a rule of thumb when dealing with injuries to neurons?

• The closer it is to the cell body, the worse the outcome.

• Also, a cut injury is worse than a crush injury

• Oligodendrocytes prevent the CNS from properly repairing

What’s the pathway for neurotransmitters?

• Neurons respond to an impulse by releasing chemical substances in the synaptic cleft that are taken up by the postsynaptic cleft

• When bound to the postsynaptic cleft neuron, there’s a change in permeability allowing for excitability or inhibition of membrane potential

What are common neurotransmitters?

• Ach, norepinephrine, serotonin, dopamine, histamine

What are key things to know about the CNS?

• Composed of the brain and spinal cord

• Forebrain

  • Motor, sensory, vision, and activities

  • Contralateral control

• Midbrain

  • Voluntary or involuntary visual motor movements (eyes, limbs), hearing, dopamine production

• Hindbrain

  • Balance, posture, automatic activities (breathing, HR, BP)

  • Ipsilateral control

How is the spinal cord divided up?

• 8- cervical

• 12- thoracic

• 5- lumbar

• 1- coccygeal

What’s key to know about damage to the spinal cord?

The higher up the damage, the more is affected

What are the protective structures of the CNS?

• Meninges

  • Dura (outermost), Arachnoid (weblike middle), Pia (innermost providing support for blood vessels)

• CSF

  • Clear fluid that helps protect and cushion brain and spinal cord. Should NEVER be yellow or red

• BBB

  • Inhibit access to brain tissue through the body

  • Inhibits: protein, non-lipid soluble molecules

  • Allows: O2, water, CO2, lipid soluble substances

What are key things to know about the PNS?

• 31 pairs of spinal nerves and 12 cranial nerves

• ANS: regulates involuntary function of organs

  • SNS

  • PSNS

What are the 4 components that influence pressure and perfusion in the brain?

• Cranium

• Brain

• CSF

• Blood

How are cerebral hemodynamics measured?

• Intracranial Pressure (ICP)

  • Normal: 5-15 mmHg

• Cerebral Perfusion Pressure (CPP)

  • Normal: 60-80 mmHg

  • CPP= MAP-ICP

What’s the relationship between ICP and CPP?

• Increases in ICP causes there to be increased pressure to the brain but also decreases CPP

• Increases in CPP can potentially increase ICP if the body’s normal compensation isn’t working, but usually high CPP indicates high MAP

What are the 3 ways ICP is measured?

• Subarachnoid bolt: pressure monitoring device that goes through the skull and gives an ICP reading

• Epidural: similar mechanism as the bolt

• Intraventricular drain: goes through the skull and into the ventricles where the CSF is located. It helps with both pressure monitoring or draining CSF

What causes cerebral edema and how is it managed?

• CE increases ICP which decreases CPP

• RFs:

  • Trauma

  • Infection

  • Ischemia

  • Infarction

  • Osmotic shift (hyponatremia)

• Txt:

  • Hypertonic solutions (for osmotic shift)

  • Osmotic diuretics (mannitol)

  • Corticosteroids (for inflammation)

What’s the progression of symptoms as one’s ICP increases?

• Stages

  • 1: minimal changes, equal and reactive pupils, normal BP and pulse

  • 2: confusion, lethargy, restlessness (hypoperfusion to the brain), pupils are still equal and reactive

  • 3: very lethargic, small reactive pupils, breathing changes (issues with brainstem), changes in BP/pulse pressure increases (to try to maintain CPP), slow pulse

  • 4: Cushing's triad (Cheyne-Stokes breathing, increased pulse pressure, and bradycardia) is a late symptom and indicates decompensation and herniation. Pupils are dilated and fixed

How is ICP managed?

• Osmotic diuretics (mannitol)

• Hypertonic solutions

• Craniotomy

• Tumor removal

• External Ventricular Drain

What are the first manifestations that show for a person with a neuro injury?

Confusion, altered LOC, lethargy) d/t hypoperfusion to the brain

How can fevers cause seizures?

• Esp in kids, when they have a fever, the body gets overexcited by the rapid rise in temperature causing a shift in polarization

What are the phases of a seizure?

• Prodrome

  • Days to weeks before seizure

  • S&S: malaise, HA, depression

• Aura (possible)

  • Diaphoresis, tachy, altered LOC, sensation (smell, vision)

• Ictal

  • Muscle contraction (tonic) then jerking (clonic)

• Postictal

  • Post-seizure

  • S&S: confusion, aphasia, memory loss, paralysis, deep sleep

How does a ketogenic diet help with seizures?

Glutamate encourages and GABA suppresses seizure activity. The ketogenic diet helps decrease Glutamate and increases GABA

How is Deep Brain Stimulation (DBS) similar to a pacemaker?

Similar to a pacemaker, a DBS senses a possible seizure and counterfires a check to disrupt it

What is a Transient Ischemic Attack (TIA)?

Episodes of ischemia in the brain without an actual infarction, So, the symptoms are a warning sign of a possible CVA/stroke

When would you want to give Fibrinolytics to a person having and ischemic stroke?

Within the first 4.5 hours from when symptoms started

What medications help control Afib?

• Calcium Channel Blockers “__pine”

• Beta Blockers “__olol”

• Amiodarone

• Digoxin

What meds do you want to be cautious about when giving them to seizure patients?

• Pain meds because they alter LOC

What’s the difference between a primary and secondary TBI?

• Primary: Caused by direct force

  • Focal: affects one area of the brain

  • Diffuse: affects more areas of the brain

• Secondary: Indirect effects of the primary injury

  • Ex. edema, hemorrhage, increased ICP, infection

What are the different types of bleeding in the brain?

• Epidural hematoma

  • Bleeding between the dura mater and skull

  • Arterial bleed causing rapid LOC, then regaining, then progressive LOC

  • Commonly seen in ski accidents

• Subdural hematoma

  • Bleeding between the dura mater and brain

  • Venous bleed causing slower build to LOC

  • Seen in elderly pts. on anticoags when they fall

• Intracerebral hematoma

  • Bleeding within the brain d/t penetrating trauma

  • Slower LOC

  • Commonly seen in stroke pts.

• Dissfuse axonal injury

  • Damage to axon d/t shearing force and can lead to long-term dementia/dysfunction

Why are corticosteroids not recommended for a TBI?

The adverse effects outweigh the benefits

What’s unique about a chronic traumatic encephalopathy (CTE) in TBIs?

It can only be diagnosed during an autopsy

How is the spinal cord sectioned?

• Cervical: C1-7

• Thoracic: T1-12

• Lumbar: L1-5

• Sacrum:S1

• Coccyx:S2

How is the severity of a SCI assessed?

ASIA scale

How is an ASIA scale for SCI scored?

• A (complete): No sensory or motor function below the level of injury

• B (sensory incomplete): Sensory preserved below level of injury, but no motor function

• C (Motor incomplete): motor function is preserved below level of injury

• D : motor function preserved below level of injury

• E: motor and sensory function are normal

What is spinal shock in those with a SCI?

• Acute loss of function (motor and sensory) at or below the level of injury immediately after the damage

• S&S: flaccid paralysis below level of injury, loss of bladder control, hypotension, hypothermia

• Manage with vasopressors

What is neurogenic shock in those with SCI?

• MEDICAL EMERGENCY

• It’s occurs in T6 or higher and is when your SNS losses control so the body can’t regulate normal functions so your PSNS tries to regulate, but it can lead to hypoperfusion of vital organs and lead to ischemia

• S&S: profound hypotension, bradycardia, hypothermia

What is autonomic dysreflexia in those with SCI?

• Patho: Occurs at T6 or above. A stimulus (full bladder, skin, irritation, UTI, clogged foley) triggers the SNS to send a signal to the brain, BUT the impulse stops at the level of injury and begins to stimulate sympathetic neurons rather than the brain. The brain senses a change in functioning and activates the PSNS, but the signal can’t go below the level of injury

• S&S:

  • Above level of injury: decreased HR, vasodilation (flushing), HA (1st sign), diaphoresis

  • Below level of injury: vasoconstriction, hypertension, cold skin

• Tx

  • sit upright, empty bladder, straighten lines in bed

What are the 4 major organs of the immune system?

• Bone marrow

• Thymus

• Spleen

• Lymph nodes

What are the 3 main processes of the immune system?

• Inflammation (innate)

• Antibody-mediated immunity (adaptive)

• Cell-mediated immunity (adaptive)

What is innate immunity?

• It’s the inflammatory response initiated when there’s an accident that occurs (NOT AN INFECTION). It’s an immediate short-term response that works to resolve the issue without creating future immunity

• S&S: warmth, redness, swelling, pain, decreased function

What is antibody-mediated immunity (adaptive)?

• Also called humoral immunity

• It’s when B cells make antibodies and memory cells to specific antigens. This way, they’re able to attack the antigens when they enter the body as well as have a specific immune response to the same antigen if they come again in the future

What is cell-mediated immunity (adaptive)?

• This is composed of T cells that are made in the bone marrow, released in the thymus, lay in the lymph nodes, and are activated by cytokines

• Helper T cells activate macrophages, suppressor T cells control the immune response, and Cytotoxic T cells kill antigens they’ve been exposed to

What are cytokines?

It’s the messaging system of the immune system produced by WBCs

What is Type I hypersensitivity?

• It’s when there’s an increased release in IgE leading to the release of mast cells/histamine causing a reaction (bronchoconstriction and vasodilation)

• Ex. anaphylaxis, asthma, exposure to allergens

What is Type II hypersensitivity?

• It’s when the body creates antibodies (IgG or IgM) to attack itself

• Ex. transfusion reaction, autoimmune hemolytic anemia (body recognizes its own blood cells as foreign), myasthenia gravis

What is Type III hypersensitivity?

• Foreign antigen causes a huge immune response bringing in antibodies (IgG). As the antibodies begin to bind to the antigens, they form complexes that precipitate out/move out of the vessels and into small vessels (kidneys, eyes, heart) and damage them. These complex deposits trigger an inflammatory response that causes damage

• Ex. Serum sickness, Lupus, Rheumatoid arthritis

What is Type IV hypersensitivity?

• Delayed allergic reaction that’s cell mediated by T-cells that recruit macrophages to attack hours following the initial exposure

• Ex. poison ivy, graft infection, positive TB skin test, sarcoidosis

What are key things to know about DMARDs?

• Blocks certain enzymes in the immune response which decreases the immune response stopping it from attacking itself

What are key things to know about Biological Response Modifiers?

• Bind to specific components of the inflammatory process to reduce the inflammatory/immune reaction

• First rule out Tuberculosis or Multiple Sclerosis since the BRM decrease immune response, so the patient is at risk for a flare

What nutrition modifications do you want to give a person with an autoimmune disorder?

• Low-calorie diets to prevent overload on joints

• Encourage mindfulness with caloric intake since some of the meds (corticosteroids) can easily cause weight gain

What’s the rationale for the labs drawn for RA?

• Rf: It’s an antibody commonly found in people with RA. A positive result can suggest RA

• Anti-CCP antibodies: Antibodies specific to RA and their presence suggests RA

• ANA (antinuclear antibody): it’s for all autoimmune disease assessments and a positive could indicate RA, but also indicates general autoimmune processes

• Serum Complement (C3, C4): component of the immune system that decreases with high levels of inflammation. Indicates general autoimmune processes

• HLA: presence of specific genes are associated with higher risk of developing RA

When would you use heat and cold for RA?

• Heat: stiffness

• Cold: inflammation and redness

Why is pregnancy a risk when you have lupus?

You’re at a high risk of having a flare which can cause organ failure. When this occurs, treatment of organ failure can affect the fetus