exam 6 patho

8/2/2019 Exam 6 Patho

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Neurovascular•The nervous system consists of two main divisions.

•Central nervous system•Structure: Brain & Spinal cord•Function: Integrative & control centers

•Peripheral nervous system•Structure: Cranial & Spinal nerves•Function: Communication lines between the CNS and the rest of the body•Further broken into:

•Sensory Division

•Structure: Somatic & visceral sensory nerve fibers•Function: Conducts impulses from receptors to the CNS

•Motor Division•Structure: Motor nerve fibers•Function: Conducts impulses from the CNS to effectors (muscles and glands)

•Further broken into:•Autonomic Nervous System

•Structure: Visceral motor (involuntary)•Function: Conducts impulses from the CNS to cardiac muscles, smooth muscles, andglands

•Somatic Nervous System•Structure: Somatic motor (voluntary)•Function: Conducts impulses from the CNS to skeletal muscles

•Further broken into:

•Sympathetic Division•Function: Mobilizes body systems during activity (fight or flight)

•Parasympathetic Division•Function: Conserves energy, promotes housekeeping functions during rest (& digest)

•The basic functional unit of the nervous system are the neurons. They consists of axons, dendrites, and cell bodies.•Neurotransmitters

•Communicate messages between neurons or to target tissues•Can excite or inhibit activity•Many neuro disorders are due to abnormal levels of neurotransmitters

•Serotonin•“Good mood”•Affects mood, sleep, hunger, anxiety, and behavior •Inhibits pain pathways

•Degrades into melatonin•Disruption of serotonin associated with depression and schizophrenia•Low serotonin is treated with SSRIs which reduce the uptake of serotonin from the synaptic cleft

•Celexa, Lezapro, Prozac, Paxil, Zoloft•Dopamine

•Affects voluntary movement, cognition, motivation, emotional response, ability to experience pleasure pain•Reduced levels associated with Parkinson’s, spasticity, decreased motivation•Low dopamine is treated with levodopa which increases the amount of dopamine activity in the brain.

•The Brain•Frontal Lobe

•Concentration•Abstract thought•Judgement

•Personality•Inhibition•Motor function•Information storage•Affect•Memory•Left hemisphere contains Brocca’s area which is responsible for speech

•Parietal Lobe•Sensory information analysis•Size/shape perception•Awareness of body position

•Temporal Lobe•Memory•Sound

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•Music sensory•Occipital Lobe

•Memory•Interpretation•Vision

•Cerebellum•Balance & coordination

•Hypothalamus•Endocrine function•Temperature

•Hunger/thirst•Sleep/wake cycle•Blood pressure•Emotional responses

•Brain Stem•Midbrain

•Connects pons & cerebellum together •Cranial nerves III (Oculomotor) & IV (Trochlear) located here

•Pons•Bridge between two hemispheres and between midbrain and medulla•Cranial nerves V-VIII (Trigeminal, Abducens, Facial, Vestibulocochlear) located here

•Medulla Oblongata•Motor fibers and sensory fibers connecting brain and spinal cord•Cranial nerves IX-XII (Glossopharyngeal, Vagus, Accessory, Hypoglossal) located here

•Responsible for regulation of vitals: Respirations, BP, Pulse, Coughing, Vomiting, Sneezing•Blood Brain Barrier

•Called the Gatekeeper •Controls what substances affect the brain•Does not develop until childhood•Substances that cannot pass the BBB

•Highly water soluble substances (antibiotics)•Substances that can pass the BBB

•O2, CO2, other gases, glucose, highly lipid soluble substances (nicotine, heroin, alcohol)•Cranial nerves

•I - Olfactory - Sensory - Smell•Have patient identify familiar smell

•II - Optic - Sensory - Vision•Check visual acuity and visual fields

•III - Oculomotor - Motor - Eye movement of extraocular muscles•PERRLA, Cardinal fields of gaze, & Nystagmus

•IV - Trochlear - Motor - External eye movement•Same as III

•V - Trigeminal - Mixed - Impulses from mouth, nose, and eyes; chewing muscles•Have patient touch face and clench jaw

•VI - Abducens - Motor - Eye movement•Same as III

•VII - Facial - Mixed - Facial expressions, lacrimal and salivary glands, taste buds on anterior tongue•Have patient smile, wrinkle face, puff cheeks

•VIII - Vestibulcochlear - Sensory - Equilibrium and hearing•Snap fingers by ears of patient for recognition of sound, use the Romberg’s test

•IX - Glossopharyngeal - Mixed - Gag reflex, taste posterior 1/3 of tongue•Have patient swallow and say Ah

•X - Vagus - Mixed - Throat muscles/smooth muscles of abdominal organs, visceral impulses•Test gag reflex

•XI - Accessory - Motor - Sternocleidomastoid & trapezius muscles, Pharynx, larynx, and soft palate•Watch neck motions and shoulder shrugging

•XII - Hypoglossal - Motor - movement of tongue•Have patient stick out tongue, apply pressure to tongue and have patient push against it

•Dermatomes•Areas of body innervated by a specific spinal nerve

•Meningitis & Encephalitis•Meninges

•Dura matter •“Tough mother”•Outer membrane

•Arachnoid

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•Production of CSF•Middle membrane

•Pia mater •Vascular, inner membrane

•Cerebral Spinal Fluid•Clear fluid that surrounds and cushions brain and spinal cord•Circulates between pia matter and subarachnoid space

•Meningitis•Inflammation of meninges

•Encephalitis

•Inflammation of the brain•Clinical manifestations of Encephalitis & Meningitis

•LOC changes/confusions•Headache•Seizures•Fever •Vomiting•Photophobia•Nuchal rigidity•Brudzinski’s sign

•Kernig’s Sign•Supine with leg bent at hip, knee at 90º - further extension of leg will result in pain if positive

•Brudzinski’s Sign•When neck is flexed, the involuntary flexion of knees results in positive sign

•Diagnostic tests for Meningitis & Encephalitis•CT/MRI•Lumbar Puncture•Nursing Interventions for these tests

•Encourage fluids post procedure to prevent headache•Treatments for Meningitis/Encephalitis

•IV or intrathecal antibiotics (for bacterial)•Corticosteriods (for increased ICP)•Anticonvulsants (for seizures)•Fluids (for dehydration)•Antipyretics (for fever)•Analgesics (for pain)

•Anticonvulsants•Action

•Suppress seizure activity by suppressing rapid firing of neurons•Side Effects

•Sedation/somnolence•Cognitive/memory impairment•Dissociation•Hypotension•Bradycardia•Respiratory depression

•Dilantin• Available in PO/IV form•Nursing interventions

•Give slowly•Monitor levels•Oral care!!!

•Tegretol•Available in PO form•May cause blood diseases, liver toxicity, CNS depression

•Phenobarbital•Available in PO/IV/IM/SQ•CNS depression

•Valium•Available in PO/IM/IV•CNS depression

•Anticonvulsant effects of these drugs can be reversed with Romazicon•Electroencephalography (EEG)

•Records the electrical activity produced by firing neurons within brain•Epilepsy•Coma activity

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•Clinical manifestations•Early

•Stiffness, cramping, slurred or nasal speech, stumbling, decreased manual dexterity, decreased swallowability

•Late•Decreased muscle tone, difficulty forming words, muscle atrophy, swallowing ability worsens, breathidifficulty

•Treatment/Nursing interventions for ALS•Safety/support/quality of life

•Protect airway

•PT/OT•Nutrition•Speech therapy

•Level of Consciousness•How to assess

•A&O x3•Arousal•Lethargy•Somnolence•Arousal only to pain•No response to pain

•Stages of altered LOC•Confusion

•Loss of rapid/quick thinking or impaired judgement and decision making

•Disorientation•Unable to identify Person, Place, Time

•Lethargy•Limited speech/movement but can respond to touch/vocal stimulation

•Obtundation•Mild to moderate reduction in arousal/limited response to environment

•Stupor •Vigorous, repeated stimulation required

•Coma•Lack of response

•What can cause a coma?•Cerebral PO2 <30•Glucose <20 mg/dl•Head Trauma

•How do you grade a coma?•Glascow coma scale

•What is brain death?•Irreversible state of unconsciousness

•Complete loss of cerebral function but heart continues to beat•May result from lack of O2 for 4-5 minutes

Gastrointestinal•Tissue layers

•Mucosal•Inner layer where secretion occurs; food absorption occurs here

•Submucosal•Contains the first of the nerve networks of the gut called the submucosal plexus and a system of blood vessels alymphatics

•Muscularis Externa

•Made of two muscle layers•Thick circular muscle layer that contracts and causes mixing of the food in the gut•Thin longitudinal muscle layer that contracts and shortens the tube

•The end result of cell depolarization in these muscles result in slow muscle contractions. The contractions of thmuscles at each gut segment determines that segment’s mobility (the propulsion of food and secretions forward)Contains the second nerve network of the gut called the myenteric plexus.

•Neural regulation of the gut•The nervous system of the gut is called the enteric nervous system•It is composed of two neural networks

•Submucous plexus•Myenteric plexus

•Although external stimuli can affect the rate of an impulse firing, the nervous system of the GI tract can functionindependently•When an impulse is fired, it spreads throughout the entire length of the gut. The neurons in this system include:

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•Adrenergic•Cholinergic•Nerves that release neurotransmitters

•Anatomy of the GI tract•The GI tract is a continuous hollow organ•Structures

•Mouth•Digestion begins as the food is chewed and saliva is released•Carbohydrate digestion

•Begins in the mouth with enzyme salivary amylase and is completed in the small intestines by

enzyme pancreatic amylase•Esophagus

•Peristalsis (the movement of food) begins here•As food enters the esophagus, it stretches the muscle causing a peristaltic wave to begin. The wave thecarries the food downward.•When the food reaches the lower esophageal sphincter, it relaxes allowing food to enter the stomachthrough the cardiac orifice.•After this peristaltic wave is complete, the esophageal sphincter returns to its relaxed closed positionwhich prevents reflux of stomach contents back into the esophagus.•The lower esophageal sphincter is anatomically the same as the rest of the esophagus and is not a truesphincter.

•Stomach•Can hold 1,000-1,500 ml of liquid•Holds food for 30 minutes - few horus

•Stores food until it is passed into the small intestines•As the food enters the stomach, the peristaltic wave continues.•As the food enters the antrum (lower end of stomach) the strength of the wave increases to mix the foo•The pyloric sphincter is located between the end of the stomach and the beginning of the duodenum.•The peristaltic wave causes this sphincter to open allowing small amounts of food to pass into the smaintestines. The more food that is in the stomach, the more that is passed initially into the small intestine•The pyloric sphincter is a true sphincter and remains closed unless food has entered the stomach.•Gastric secretions

•Eating stimulates the production of gastric secretions.•The gastric mucosa produces mucous, acid, enzymes, hormones, and intrinsic factor.•The parietal glands secrete HCL & intrinsic factor (which is necessary for the intestinalabsorption of B12)•Gastric acid helps to dissolve food, acts as a bactericide against swallowed bacteria, and conv

pepsinogen to pepsin (proteolytic enzyme).

•Gastric juice is high in K+ and CL-, low in Na+•Vomiting and gastric suction can deplete the body’s NA+ and K+

•Digestion of proteins• Beings in the stomach with the enzyme pepsin and is completed in the small intestines by theenzymes trypsin and chymotrypsin

•Small intestines•Although digestion occurs in the stomach, the small intestines are the primary site for digestion andabsorption. The digestive juices break the food down chemically into its simplest form so that it can beabsorbed.•Classified into 3 divisions

•Duodenum•Jejunum•Ileum

•In the small intestines, food is called chyme. It is propulsed slowly through the small intestines by a

process called segmentation.•Segmentation is a process of more frequent contractions than the lower gut. This is to ensure the mixinchyme and intestinal juices, and to allow for absorption through the intestinal wall.•There is also a small amount of bacteria in the duodenum and jejunum•Digestion of fats

•Fats are broken down in the small intestines by the pancreatic enzymes lipase by the process emulsification (division of large fat molecules into smaller droplets).

•Large intestines•Classifications include

•Cecum & appendix•Colon: ascending, transverse, descending & sigmoid

•Rectum and anus•Pulls water

•Disorders of the GI tract

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•Anorexia•Physiologic stimuli present, but no desire to eat•Usually associated with other GI conditions

•N/V/D•Motility issues•Inflammation•Impaction

•Anorexia nervosa•Appetite present•Altered body image

•Psychological disorders•Nausea & vomiting

•Nausea - discomfort that precedes vomiting•Vomiting - forceful emptying of stomach contents•Vomiting Center (CTZ)

•Located in pons (upper medulla)•Triggered by distended stomach, pressure on brain stem, balancing systems in ear (motion sickness)

•Concerns•Dehydration, electrolyte imbalances, metabolic alkalosis

•Treatment•Anti-emetics (promethazine, odansetron)•Prokinetics (metoclopramide)•IVF•Electrolyte replacement

•Projectile vomiting•Direct stimulation of vomiting center by increased ICP

•Tumors•Aneurysm•Trauma

•Diarrhea•Viral or bacterial infection

•Pathogens irritate mucosal lining of intestines, increased water from capillary beds, increased volume,increased motility

•Psychological factors•Stress, fear

•Physiological factors•IBS, Crohn’s, Ulcerative Colitis, meds, colectomy, bacterial overgrowth

•Treatment

•Bind excess water with Kaopectate•Slow down with Lomotil or Imodium

•Use caution with Ulcerative Colitis and bacterial infections•IVF•Electrolyte replacement

•Escherichia Coli (E. coli)•Normal intestinal bacteria•Certain strains are dangerous•Food contaminant

•Under-cooked hamburger meat•Unpasteurized milk •Contaminated vegetables

•May be fatal•Children under 2

•Elderly•Immunocompromised

•Toxins cause severe damage to intestinal epithelial cells•Altered GI mucosa

•Loss of fluid and electrolytes•Blood vessels damaged•Severe, bloody diarrhea•Dehydration, electrolyte disturbance, anemia

•Hemolytic Uremic Syndrome (HUS)•Lysis of RBCs•Kidney failure•Approximately 5% to 10% of children progress to this stage of disease

•Primary prevention•Fully cook hamburger meat

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•Avoid unpasteurized milk and ciders•Separate children from those with diarrhea•Proper hand washing

•Treatment•Antibiotics•Monitor F&E, CBC, BMP•Dialysis (HUS)

•Crohn’s Disease•Subacute and chronic inflammation of the GI tract wall that extends through all layers•Patho

•Edema and thickening of the mucosa•Ulcers begin on inflamed mucosa•Cobblestone appearance•Can cause fistulas, fissures, and abscesses•Later, thick and fibrotic bowel can cause adhesions

•S/S•RLQ pain•Bleeding rare/mild•Diarrhea mild to moderate•Abd mass common•Fistula common•Rectal involvement 20%

•Tx•Corticosteroids, sulfasalazine, Antibiotics, TPN, surgery with anastamosis

•Ulcerative Colitis•Recurrent ulcerative and inflammatory disease of colon and rectum

•Superficial layers (mucosal, submucosal)•Multiple ulcerations (bleeding)•Diffuse inflammation•Shedding of colonic epithelium•Colon resection if severe

•S/S•LLQ pain•Bleeding common/severe•Diarrhea severe•Abd mass rare•Fistulas rare•Rectal involvement in 99%

•Tx•Corticosteriods, sulfasalazine, antibiotics, surgery with ostomy

•Laboratory evaluation of inflammation associated with Crohn’s and UC•ESR (Erythrocyte Sedimentation Rate)

•Measures how quickly RBCs settle when placed in test tube•Inflammation alters RBC proteins causing them to clump and settle faster

•C-Reactive protein (CRP)•Protein in blood which increases in response to inflammation and dead/dying cells

•Peritonitis•Inflammation of the peritoneum, the serous membrane lining of the abdominal cavity and covering the viscera

•Usually the result of a bacterial infection•Can be a result of trauma•Can be the result of inflammation from an organ outside the peritoneum

•Patho

•Bacterial proliferation•Edema of tissues and exudation of fluid•Fluid becomes turbid•Hypermotility•Paralytic ileus

•Clinical manifestations•Dependent on location and extent of inflammation•Diffuse pain becomes constant and more localized•Abd tender and distended•A/N/V•Fever •Tachycardia•Hypotension in late stage

•Lab/Diagnostics

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•Elevated WBCs•Altered K+, Na+, & Cl-•X-ray = air and fluid “bowel loops” (dark spots on xray)•US - abscesses and fluid•CT - abscesses•Peritoneal aspiration

•Culture and sensitivity•Tx

•Fluid, colloid, electrolyte replacement•Isotonic fluid replacement

•Analgesics•Antiemetics•Intestinal intubation and suction•O2 therapy if needed•Antibiotics•Surgical interventions

•Diverticulitis•Diverticulum

•Saclike herniation can occur anywhere in colon•Diverticulosis

•Multiple diverticuli without inflammation•Diverticulitis

•Infection and inflammation of diverticuli•Retained food and bacteria

•May perforate or form abscess•Patho

•Herniation through the muscular wall•Bowel contents cause inflammation and infection•Diverticulum can become obstructed

•Abscesses•Perforation

•Can cause peritonitis•Clinical Manifestations

•Bowel irregularity•Acute LLQ pain•N/V•Fever •Elevated WBC

•Peritonitis and septicemia if untreated•Dx

•Colonoscopy - biopsy•CT with contrast•Abd x-rays•CBC•Elevated WBCs•Elevated ESR (erythrocyte sedimentation rate)

•Tx•Outpatient

•Clear liquid then high-fiber, low-fat diet•Analgesics, antispasmodics, antibiotics

•Inpatient•NPO

•IVF•NGT to suction•Analgesics, antispasmodics, antibiotics

•Surgery for perforation or peritonitis•Adhesions

•Scar tissue adheres to adjacent structures•Develops over time after abd surgery

•May cause•Bowel strangulation•obstruction

•S/S•Abd pain and distension•Emesis of stool (yes, that means throwing up poop Brandon)•BS absent below adhesion, hyperactive above adhesion

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•Surgical emergency!!!•Hemorrhoids

•Dilated veins of anal canal•External or internal

•Tx•Non surgical

•Good personal hygiene•Avoid excessive straining•High residue diet•Increase fluid intake

•Warm compresses, sitz bath•Analgesic ointments, suppositories, astringents•Laser therapy

•Surgical•Rubber band ligation•Cryosurgical hemorrhoidectomy

•Anal Fistula•Patho

•Obstruction of anal gland•Clinical manifestations

•Swelling•Redness•Tenderness•Foul-smelling pus

•Tx•Sitz baths•Analgesics•I&D

•Irritable Bowel Syndrome•Functional disorder of motility

•Etiology unknown•Constipation, diarrhea, or both!

•Pain, bloating, abd distention•Onset of symptoms with eating

•Relief of symptoms with defecation•Diagnosis

•Recurrent abd pain (3 days in past 3 months) (must have this symptom to be dx-ed plus at least one offollowing:)

•Improved with defecation•Change in frequency of stool•Change in appearance of stool

•Treatment•Identify and avoid triggers•Fiber = good•ETOH/Tobacco = bad•Stress management

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exam 6 patho

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