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NURS351-Pathophysiology I > Module 5 - Start of Exam 2 > Flashcards

Module 5 - Start of Exam 2 Flashcards

1
Q

Primary Functions of the Respiratory System

A
  1. Provides Oxygen for metabolism in the tissues

2. Removes CO2, the waste product of metabolism

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2
Q

Secondary Functions of the Respiratory System

A
  1. Facilitates Sense of Smell
  2. Produces Speech
  3. Maintains Acid Base Balance (via CO2)
  4. Maintains Body Water Levels
  5. Maintains Heat Balance
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3
Q

How does the respiratory system aid in speech?

A

Sinuses help in resonance of speaking

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4
Q

Where does the lower respiratory system start?

A

at the level of the trachea

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5
Q

Parts of the Upper Respiratory Tract

A 
Nasal Cavity
Sinuses
Pharyngeal Tonsils
Nasopharynx
Pharynx
Larynx
Epiglottis
Esophagus
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6
Q

Purpose of the Nose in the Respiratory Tract?

A

(Upper) Humidifies, warms, and filters inspired air

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7
Q

Purpose of the Sinuses in the Respiratory Tract?

A

(Upper) They are air filled cavities within hollow bone surrounding the nasal passages, and provide resonance during speech. They also help keep the head a lighter weight.

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8
Q

Purpose of the Pharynx in the Respiratory Tract?

A

(Upper) 3 part area behind the oral and nasal cavities that acts as a passageway for BOTH the respiratory and digestive tracts (The Throat)

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9
Q

3 Divisions of the Pharynx?

A

Nasopharynx
Oropharynx
Laryngopharynx

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10
Q

Purpose of the Larynx in the Respiratory Tract?

A

(Upper) “Voice Box” above the trachea and below the pharynx that has two pairs of vocal cords allowing for speech

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11
Q

Purpose of the Glottis in the Respiratory Tract?

A

(Upper) Opening for the vocal cords (Larynx) that also plays an important role in coughing

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12
Q

The most fundamental defense mechanism of the lungs?

A

Coughing

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13
Q

Purpose of the Epiglottis in the Respiratory Tract?

A

(Upper) Leaf shaped elastic structure on top of the larynx that covers the glottis. It prevents food from entering the tracheobronchial tree by sealing the glottis during swallowing (thus preventing aspiration pneumonia)

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14
Q

3 Important Sinuses?

A

Frontal
Ethmoid
Axillary

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15
Q

Parts of the Lower Respiratory Tract

A

Trachea
Bronchus/Bronchi
Bronchioles

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16
Q

Purpose/Description of the Trachea in the Respiratory Tract?

A
  • (lower) located in front of the esophagus (digestive tract)
  • branches into the right and left main stem bronchi at the Carina
  • has cartilage bands to prevent collapse, unlike the esophagus
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17
Q

Why should you make sure a babies chin does not touch their chest?

A

Babies have softer tracheal cartilage rings so their trachea could collapse

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18
Q

Carina

A
  • point at which the trachea divides into the two main stem bronchi
  • it is a soft tissue area that can be injured during suctioning
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19
Q

Main Stem Bronchi (Bronchus)

A
  • (lower) start at carina
  • divide into 5 secondary (lobar) bronchi that enter each of the five lobes of the lung
  • They are lined with cilia that propel mucus away from the lower airway to the trachea for swallowing or expectorating
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20
Q

Are the Bronchus similar sizes?

A

No, the main stem right bronchus is slightly wider, shorter, and more vertical than the left bronchus since the left has to go around the heart at a steeper angle

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21
Q

If an endotracheal tube slips, where is it likely to go ?

A

into the right lung

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22
Q

What happens in the Bronchus in smokers?

A

the cilia become paralyzed and do not move

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23
Q

Bronchioles

A
  • branches from the 5 secondary (lobar) bronchi that subdivide into small terminal bronchioles which then branch into respiratory bronchioles
  • respiratory bronchioles have NO cartilage (smooth muscle), and depend on elastic recoil of the lung for patency
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24
Q

Terminal Bronchioles contain no _____ and do not participate in ____ ____

A

cilia, gas exchange

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25
Q

Where does gas exchange occur?

A

Respiratory Bronchioles Level

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26
Q

Parts of the Alveoli Level?

A

Terminal bronchioles
Respiratory Bronchioles
Alveolus
Alveolar Capillary Network

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27
Q

Alveoli Ducts

A
  • grape like network of ducts branching from the respiratory bronchioles
  • the grape like sacs contain the alveoli clusters
  • Cells in the duct walls secrete surfactant
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28
Q

Alveoli

A
  • the basic units of gas exchange inside the ducts
  • require surfactant to prevent collapse
  • very thin to allow decreased gas exchange resistance
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29
Q

Surfactant

A

Phospholipid protein that is produced in the wall cells of the Alveoli ducts. It reduces surface tension in the alveoli and without it the alveoli would collapse (need alveoli open for gas exchange)

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30
Q

Who may have trouble making surfactant and need a chemical version administered?

A

Premature Infants

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31
Q

Alveoli are considered the ____ Tissue of the respiratory tract

A

Parenchymal (functional)

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32
Q

Acinus/Acini

A

term referring to all structures distal to the terminal bronchiole

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33
Q

When the diaphragm is in an upward arch shape it is…

A

relaxed

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34
Q

When the diaphragm is flat it is …

A

contracted

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35
Q

Lobe Differences of the Lungs?

A

Right: 3 Lobes that are larger than the Left

Left: Narrower and steeper angle to accommodate the heart

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36
Q

Lungs are covered in membranous coverings called ____

A

plurae

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37
Q

Where are the lungs found?

A

In the pleural cavity in the thorax extending from just above the clavicles to the diaphragm

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38
Q

Major muscle of inspiration?

A

The diaphragm

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39
Q

Innervation of Respiratory Structures is Done by What Nerves?

A 
Phrenic Nerve
Vagus Nerve (Parasympathetic - bronchoconstriction)
Thoracic Nerve (Sympathetic - bronchodilation)
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40
Q

Linings in the body are called?

A

Plurae

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41
Q

Parietal Plurae

A

plurae lining the chest wall (thoracic cavity) and the upper surface of the diaphragm

seals everything up

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42
Q

Visceral Plurae

A

plurae lining the lungs/pulmonary surface

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43
Q

Between the Visceral and Parietal Plurae is…

A

Plural fluid

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44
Q

Pleurisy/Pleuritis

A

inflammation of the lung linings rubbing together that feels like the stab of a knife, and a rubbing sound can be auscultated

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45
Q

What does Pleural Fluid do?

A

Prevent Rubbing and Pain of the two plurae by allowing them to glide smoothly and painlessly during respiration

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46
Q

2 Systems allowing Blood Flow through the Lungs?

A

Pulmonary system

Bronchial System

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47
Q

Accessory Muscles of Respiration

A 
Scalene Muscles (elevate the first two ribs)
Sternocleidomastoid Muscles
Trapezius and Pectoralis Muscles
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48
Q

Respiration

A

Inhalation + Expiration

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49
Q

Inhalation

A
  • flattening of the diaphragm (contraction) leading to a negative pressure in the lungs
  • The negative pressure draws air from the greater pressure atmosphere to the lesser pressure lungs
  • air will pass through terminal bronchioles into alveoli to oxygenate body tissues
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50
Q

Exhalation

A
  • elevation/relaxing of the diaphragm and intercostal muscles to original shape
  • As lungs recoil, the pressure becomes greater than the atmosphere making air containing waste like CO2 and water to move from the alveoli to the atmosphere
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51
Q

Which respiratory process is active (needs ATP)?

A

Inhalation

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52
Q

Which respiratory process is passive?

A

Exhalation

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53
Q

Exception to Exhalation being Passive?

A

Patient with Emphysema

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54
Q

Bronchioles/Bronchi rely on what to open and work efficiently?

A

recoil of the lungs (opening and closing)

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55
Q

Risk Factors for Respiratory Disease?

A 
Smoking
Chewing Tobacco use
Allergies
Frequent Respiratory illness
Chest Injury
Surgery
Exposure to Chemicals and Environmental pollutants
Crowded Living conditions (fast mycoplasma pneumonia spread)
Family History of infectious Disease
Geographic Residence 
Travel to Foreign Countries

*these also are areas to prevent/alleviate

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56
Q

What might some respiratory illnesses effect that can be seen in a chest x ray?

A

It might flatten the diaphragm’s normal bowl shape which can be picked up on Xray

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57
Q

Tests to Check/Aid Respiratory Health

A 
Chest X Ray
Sputum Specimen
Bronchoscopy
Pulmonary Angiography
Thoracentesis
Pulmonary Function Tests (PFTs)
Lung Biopsy
Ventilation-Perfusion Lung Scan
Bronchography
Skin Tests
Arterial Blood Gases (ABGs)
Pulse Oximetry
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58
Q

Chest X-Ray (CXR)

A

Test providing information regarding anatomic location and appearance of lungs

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59
Q

What to do pre-procedure for a Chest X Ray?

A
  1. remove all jewelry and other metal objects from chest area
  2. assess ability to inhale and hold breath
  3. question possibility of pregnancy
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60
Q

What to do post-procedure for a Chest X Ray?

A

Assist client to dress (do not assume they can)

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61
Q

Sputum Specimen

A

Test where a specimen is obtained by expectoration (cascade coughing) or tracheal suctioning to assist in identification of organisms or abnormal cells in the respiratory system

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62
Q

The best time to get a sputum specimen done is?

A

very first thing in the morning

63
Q

Cascade cough

A

coughing deeper over and over to bring up lower secretions for a sputum specimen

64
Q

What to do pre-procedure/during procedure for a Sputum Specimen?

A
  1. Determine specific purpose of collection
  2. Get an early morning sterile specimen from suction or expectoration
  3. Obtain 15 mL of sputum
  4. give instructions on obtaining specimen
  5. collect before antibiotics
65
Q

Instructions for Collecting a Sputum Specimen?

A
  1. rinse mouth with water prior
  2. take several deep breaths
  3. cough deeply / cascade cough to obtain sputum
66
Q

Never collect a sputum specimen after…

A

antibiotics have been started since it can indicate wrong results

67
Q

What to do post-procedure for a sputum specimen?

A
  1. Transport immediately to lab

2. Assist with mouth care

68
Q

How much sputum is collected?

A

15 mL (3 tsp)

69
Q

Bronchoscopy

A

Direct visual examination of larynx, trachea, and bronchi with a fiberoptic bronchoscope (camera) weaved in and out of bronchial tubes to look for out of place things/obstructions

*Right lung is larger so things lodge there more often than the left

70
Q

Problems with Bronchoscopy

A

Potential for:

Aspiration
Gagging
Trauma
Bleeding

71
Q

What to do pre-procedure for a Bronchoscopy?

A
  1. Informed Consent
  2. Nothing to eat (NPO) after midnight
  3. Obtain Vitals and Coagulation Studies
  4. Remove and Protect Patient Items (Dentures, Glasses, Etc)
  5. Prepare Suction Equipment incase vomiting or bleeding occurs
  6. Have emergency resus. equipment ready
  7. Administer sedation meds as prescribed
72
Q

What to do post-procedure for a Bronchoscopy?

A
  1. Compare/Monitor Vitals in relation to Baseline
  2. Put in Semi-Fowler’s Position
  3. Assess gag reflex return, and no eating until then
  4. Provide emesis basin for spitting (monitor for bloody sputum or vomit)
  5. Monitor respiratory status, especially if sedation was used
  6. Monitor for complications
  7. Notify MD if fever or difficulty breathing occurs
73
Q

Potential Post-Procedure Complications of Bronchoscopy?

A 
Bronchospasm
Bacteremia
Bronchial Perforation (indicated by neck/facial crepitus)
Dysrhythmias
Fever
Hemmorrhage
Hypoxemia
Pneumothorax
74
Q

Crepitus

A

feelings like rice krispies under the skin

75
Q

Hypoxemia

A

low O2 in the blood

76
Q

Bronchoscopy looks at ____

A

structure

77
Q

Pulmonary Angiography

A

Invasive fluoroscopic procedure following injection of iodine or radiopaque or contrast material via a catheter inserted through the antecubital or femoral vein into the pulmonary artery or one of its branches

(Angio - Blood Vessel; Graphy - Picture)

78
Q

What to do Pre-Procedure for a Pulmonary Angiography?

A
  1. Informed Consent
  2. NPO 8 hours prior
  3. Assess iodine/seafood/radiopaque dye allergies
  4. Monitor vitals and coagulation studies
  5. establish IV access
  6. Administer sedation
  7. Give clients instructions
  8. Prepare emergency resuscitation equipment available
79
Q

Instructions for Patient Prior to Pulmonary Angiography?

A
  • Lie still during

- may feel urge to cough, flushing, nausea, or salty taste from dye injection

80
Q

What to do Post-Procedure for a Pulmonary Angiography?

A
  • Monitor and compare vital signs to baseline
  • avoid BP in the extremity of injection for 24 hours
  • monitor peripheral neurovascular status (look for large pulses)
  • assess insertion site for bleeding
  • monitor for delayed reaction to dye (as this is concerning)
81
Q

Pulmonary Angiography can reveal..

A

a blockage in pulmonary vessels

82
Q

Thoracentesis

A

removal of fluid or air from the pleural space via transthoracic aspiration (but do not puncture the lung)

83
Q

Where does air or fluid go to in the pleural space when a thoracentesis is needed?

A

Air moves upward in the cavity, while fluid settles at the bottom

84
Q

Where do you enter for a Thoracentesis?

A

in between the ribs into the pleural space (according to whether air or fluids have accumulated)

85
Q

Pleural Effusion

A

Extra fluid (2-3 L) in the pleural space (common in cancer patient) making it difficult to inflate the lungs on inspiration

*enough fluid can even push the heart

86
Q

What to do pre-procedure for a Thoracentesis?

A
  1. Informed Consent
  2. Baseline vitals and Coagulation Studies
  3. Get an Ultrasound or CXR if prescribed
  4. Position upright with arms and head supported by bedside table (or on non affected side with 45 degree elevation if they cannot lean)
  5. Inform client not to cough, breathe deeply, or move during the procedure
87
Q

What to do post-procedure for a Thoracentesis?

A
  1. important to monitor vital signs and respiratory status
  2. Apply a PRESSURE DRESSING and assess puncture for bleeding and crepitus
  3. monitor for signs of pneumothorax, air embolism, and pulmonary edema
88
Q

What does Thoracentesis do aside from remove air/fluid?

A

presence of cancer cells or fluid composition, if there is a lot of blood, and potential of need for a chest tube that collects fluid into a thoraclex

89
Q

Pneumothorax

A

Air in the pleural space due to a hole in the chest wall

90
Q

Air Embolism

A

a large amount of air getting into the blood vessels which can then act as a blood clot and kill

91
Q

Pulmonary Edema

A

swelling around the alveoli

92
Q

Pulmonary Function Tests (PFTs)

A

A number of different tests (like spirometry) used to evaluate lung mechanics, gas exchange, and acid base disturbances through spirometry measurements, lung volumes, and arterial blood gases (ABGs)

93
Q

What important things does the PFT look at?

A
  1. Gas Exchange
  2. Lung Mechanics
  3. Acid Base Disturbance
94
Q

Measurements used in PFTs?

A
  1. Static

2. Dynamic

95
Q

Static PFT

A

look at volume of lungs at different points of breathing

96
Q

Dynamic PFT

A

look at flow rates of air (ex: out in 2 seconds, 3, etc)

97
Q

Void

A

go to the bathroom

98
Q

What to do pre-procedure for a PFT?

A
  1. Determine if an analgesic may depress respiratory function is being administered
  2. Consult with physician regarding holding bronchodilators prior to testing
  3. Instruct the client
99
Q

Instructions for the Client during PFT?

A
  1. Void prior
  2. Wear loose clothing
  3. Remove dentures
  4. Refrain from smoking or a heavy meal 4-6 hours prior to the test
100
Q

What to do Post-Procedure for a PFT?

A

Resume normal diet and any bronchodilators/respiratory treatments that were held prior to procedure

101
Q

Pulmonary Function Test Diagrams

A

diagram showing the air volume and capacities of a persons lungs

102
Q

Tidal Volume (TV)

A

normal half liter of air you breath in and out (normal breathing volume)

103
Q

Inspiratory Reserve Volume (IRV)

A

air volume potential when you breath in until you cannot anymore (maximal inspiration)

104
Q

Expiratory Reserve Volume (ERV)

A

air volume potential when you cannot breath out anymore (maximal expiration)

105
Q

Residual Volume (RV)

A

air volume in the lungs that will never leave/void

106
Q

Total Lung Capacity

A

RV + ERV + TV +IRV

107
Q

Vital Capacity (VC)

A

IRV + TV +ERV

108
Q

Inspiratory Capacity (IC)

A

IRV + TV

109
Q

Functional Residual Capacity (FRC)

A

ERV + RV

The amount of air remaining in lungs after a normal tidal volume expiration

110
Q

Important Lung Volumes and Capacities?

A 
Vital Capacity (VC)
Inspiratory Capacity (IC)
Functional Residual Capacity (FRC)
111
Q

Forced Expiratory Volume (FEV)

A

1 second forceful expiration

112
Q

What is the normal amount of forced expiratory volume typical of vital capacity?

A

75-80% in 1 second

113
Q

Normal Volume in lungs for an Adult?

A

6 Liters

  • 0.5 L (500 mL) of which is Tidal Volume
  • 4 Liters of which are part of gas exchange
114
Q

Percutaneous Lung Biopsy

A
  • percutaneous lung biopsy is performed to obtain tissue for analysis by culture or cytologic examination
  • closed biopsy
115
Q

Needle Lung Biopsy

A

performed to identify pulmonary lesions, changes in lung tissue, and the cause of a pleural effusion

-involves interventional radiology using X rays to guide the needle and prevent puncturing wrong organs

open biopsy

116
Q

Danger of Lung Biopsy?

A

Potential for perforation of vessels causing internal bleeding

117
Q

What to do pre-procedure for a Lung Biopsy?

A
  1. Informed Consent
  2. NPO prior
  3. Inform client a local anesthetic is used, but sensation of pressure during needle insertion and aspiration may be felt
  4. Administer analgesics (it hurts, big needle and lots of tissue taken) and sedatives (ease anxiety) as prescribed
118
Q

What to do post-procedure for a Lung Biopsy?

A
  1. Monitor Vital signs and compare to baseline
  2. Apply a pressure dressing to site and monitor for drainage or bleeding
  3. Monitor for signs of respiratory distress and notify physician if it occurs
  4. monitor for pneumothorax or air emboli and notify physician if it occurs
  5. Prepare client for CXR if prescribed
119
Q

Ventilation-Perfusion Lung Scan (VQ Scan)

A

Its a 2 part scan called “VQ Scan: - Ventilation Quotient Scan

Perfusion Scan - evaluated blood flow to lungs

Ventilation Scan - determines patency of the pulmonary airways and detects ventilation abnormalities

*may use a radionuclide injection

120
Q

How are VQ Scan Results Presented?

A

Expressed as a ratio but then changed to a decimal

*The ratio is to the 5 Liters of blood, so if theres 4 L of air over 5 L of blood flow you get a normal 0.8 VQ ratio

121
Q

Total amount of air in respiratory tree?

A

6 Liters

122
Q

Amount of air participating in gas exchange?

A

4 Liters (2 liters are residual volumes)

123
Q

Normal VQ Scan Result

A

0.8

124
Q

Impaired ventilation VQ Scan Results?

A

lower top volume of air in the blood leading to a smaller value than 0,8

ex: 3 L / 5 L of blood = 0.6

125
Q

Impaired blood flow VQ Scan results?

A

Denominator decreases leading to a value larger than 0.8

ex: 4 L / 4 L of blood = 1 (could indicate embolism)

126
Q

What is Ventilation-Perfusion Lung scan very important for as a diagnostic tool?

A

Pulmonary emboli - a high VQ scan can indicate pulmonary embolism

127
Q

What to do pre-procedure for a Ventilation-Perfusion Lung Scan (VQ Scan)?

A
  1. informed consent
  2. assess iodine, dye, seafood allergies
  3. remove jewelry from chest area
  4. review breathing methods which may be required during testing
  5. establish IV access
  6. administer sedation if prescribed
  7. Prepare emergency resus equipment
128
Q

What to do Post-Procedure for a ventilation-perfusion lung scan (VQ scan)?

A

Monitor for a reaction to radionuclide

129
Q

Bronchography

A

A liquid contrast medium is instilled into the trachea, followed by CXR films done of the bronchial tree

130
Q

When is a Bronchography done?

A

Performed to diagnose abnormalities of bronchi, such as narrowing, dilation, and obstruction - but is rarely used nowadays

131
Q

Why is a bronchography not done much anymore?

A

Due to the liquid contract medium being injected into the trachea

132
Q

What does bronchography look at?

A

Structure, but we have better methods of looking at structure now

133
Q

What to do pre-procedure for a bronchography?

A
  1. Informed consent
  2. Assess allergies to dye, iodine, seafood
  3. NPO several hours prior to the test to prevent post-procedure aspiration
  4. Administer sedation as prescribed
134
Q

What to do Post-procedure for a Bronchography?

A
  1. Asses vitals
  2. Assess for dyspnea or bleeding (very alarming if so)
  3. encourage coughing and deep breathing
  4. maintain NPO status until gag reflex returns
  5. encourage fluid intake when gag reflex returns
135
Q

Skin Tests

A

intradermal injection of antigen (ex: Tb MAN2 Screening) used to assist in diagnosing various infectious diseases

136
Q

Skin Test Procedure

A
  1. Free test site of excessive body hair, dermatitis, and blemishes or choose one free of these
  2. Apply needle and antigen at the upper one third of the inner surface of the left arm
  3. circle and mark injection test site
  4. document date, time, and test site
137
Q

What to do pre-procedure for a skin test?

A

determine hypersensitivity or previous reactions to skin tests (ex: a skin test after positive Tb can lead to Tb activation due to memory cells)

138
Q

What to do post-procedure for a skin test?

A
  1. Instruct client not to scratch or scrub test site to prevent infection or abscess
  2. Interpret reaction at injection site 24-72 hours after
  3. Assess test site for induration (hard swelling) in mm and presence of erythema and vesciulation
139
Q

Vesicula

A

small blister like elevations

140
Q

Arterial Blood Gases (ABGs)

A

Test measuring the dissolved O2 and CO2 in the arterial blood, and reveals the acid-base state, and how well the oxygen is being carried by the body

Blood is drawn from the arteries, not veins

141
Q

ABG looks at what kind of oxygen?

A

Dissolved oxygen, NOT Hgb attached oxygen

142
Q

Allen Test

A

Occlude both radial and ulnar arteries and watch the hand turn white, then let up one and see if flow returns and then try with other artery and reocclude the first. After this do it to the other hand.

143
Q

What do you do before an ABG and why?

A

Allen Test - to insure blood flow is not interfered in area where blood is drawn in hand arteries, and prevent the hand undergoing necrosis

144
Q

Who usually draws an ABG?

A

Lab personnel or respiratory therapist so they can get results to a lab fast

145
Q

What to do pre-procedure for an ABG?

A
  1. Allen Test
  2. Client rests for 30 minutes prior to collection (we want baseline, no CO2 buildup)
  3. avoid suctioning prior to drawing blood gasses
  4. do NOT turn off oxygen unless blood gases are ordered to be drawn at room air
146
Q

What to do post-procedure for an ABG?

A
  1. Place specimen on ice
  2. note patient temperature on lab form
  3. note O2 and type of ventilation client is receiving on lab form
  4. apply pressure to puncture site for 5-10 minutes, or longer, if client is on anticoagulation therapy or has a bleeding disorder
  5. transport the specimen to lab WITHIN 15 MINUTES
147
Q

Pulse Oximetry (O2 Sat)

A

NON-INVASIVE test that registers oxygen saturation of clients hemoglobin

148
Q

Normal O2 Sat ?

A

95 - 100 %

149
Q

This test look at what kind of oxygen?

A

that attached to Hgb, NOT dissolved oxygen (thats what an ABG does)

150
Q

When is Hgb oxygen drawn upon?

A

When a hypoxic patient uses up available dissolved O2 (PaO2 in ABG testing), so the reserve O2 on Hemoglobin (SaO2 from Pulse Oximetry) is drawn on to provide tissues with oxygen

151
Q

The pulse oximeter reading can alert the healthcare professional about what?

A

Hypoxemia before clinical S/S occur

152
Q

Pulse Oximetry Procedure

A
  1. Sensor placed on finger, toe, nose, earlobe, or forehead measures O2 Sat which is then displayed on a monitor
  • Transducer maintained at heart level
  • Interferers like acrylic nails and gels must be avoided
  • do not use extremity with a blood flow issue
  • lower than 91% warrants immediate treatment
153
Q

If SaO2 is below 85% what does that mean?

A

the body tissues are having a difficult time becoming oxygenated due to lack of Hgb O2 binding

154
Q

If SaO2 is less than 70% what does that mean?

A

They are in life threatening status and treatment is needed regardless of diagnosis

NURS351-Pathophysiology I (11 decks)

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