Patho Exam 2 Flashcards
Sickle cell anemia is a(n) ____ [genetic inheritence] disorder where there is an abnormality in ___. People of what descent are most likely to have it?
Sickle cell = AUTOSOMAL RECESSIVE, Abnormality in HEMOGLOBIN. Common in patients decendent from Sub-Saharan Africa, India, Saudia Arabia, Mediterranean countries.
In sickle cell anemia, the RBC changes shape from __ to __ after they are ___. This leads to ___.
Sickle cell = RBC changes from BICONCAVE DISC to SICKLE CELL after it is DEOXYGENATED. Leads to VASO-OCCLUSION
What physiologic stressors can cause a sickle cell crisis/episode?
- Viral/bacterial infection
- Hypoxia
- Dehydration
- Extreme temperatures
- EtOH
- Fatigue
What are symptoms of a sickle cell episode/crisis?
- Pain
- Bone & Joint involvement
- Vascular complications
- Pulmonary issues
- Neurologic issues
- Renal and spleen complications –> pain
A pt with sickle cell anemia would likely present with high or low values of the following: Hgb, Hct, WBC
Hgb - LOW
Hct - LOW
WBC - HIGH
In polycythemia vera, we see [increased/decreased] RBC.
In primary Polycythemia vera, the RBC change is due to an abnormality in __. In secondary, it is caused by natural or artificial increases in the production of __ that results in increased production of ___ generally caused by ___.
In polycythemia vera, we see INCREASED RBC.
In primary Polycythemia vera, the RBC change is due to an abnormality in BONE MARROW. In secondary, it is caused by natural or artificial increases in the production of ERYTHROPOEITIN that results in increased production of ERYTHROCYTES generally caused by PROLONGED HYPOXIA SECONDARY TO ALTITUDE OR OBSTRUCTIVE LUNG DISORDERS. Renal disorders are also associated with inappropriate erythropoeitin production
General signs and symptoms of RBC disorders include…
Low RBC
- Fatigue
- SOB
- Decreased distal sensation
High RBC
- Increased hematocrit
- Headache or dizziness
- Clubbing of fingers
- Weight loss
- High blood pressure
- Easy bruising
- Peripheral neuropathies due to blocking of distal capillaries
- Gout (sometimes a complication)
What are clinical manifestations of leukemia?
Anemia Infection Bleeding Fever Weight loss Fatigue Bone marrow suppression Lymph node and spleen enlargement
In leukemia, we might see low (aka ___) or high (aka ___) WBC. Describe the patient risks with each
Low WBC = Leukopenia
- Increased risk of catching an infection with low WBC count (neutropenia)
- Increased precautions that are facility dependent
High WBC = Leukocytosis
- Dehydration
- Tachycardia
- Mental Status changes
___ is a decreased number of platelets in the blood. ___ is an increased number of platelets in blood.
Decreased # platelets = Thrombocytopenia
Increased # platelets = Thrombocytosis or Thrombocythemia
What causes platelet dysfunction?
Congenital or caused by drugs
___ is a plasma clotting protein abnormality resulting from a deficiency in Factor __ or __.
HEMOPHILIA is a plasma clotting protein abnormality. Deficiency of Factor VIII or IX
Adverse clinical presentations associated with hemophilia include…
- Hemoarthrosis (bleeding into joints with subsequent contractures)
- Bleeding into muscle tissue
- Retroperitoneal bleeding
Describe acute vs. chronic leukemias (in terms of naming conventions)
Acute = rapid increase in immature cells, generally seen in children and young adults
Chronic = Build-up of relatively mature but abnormal cells, generally seen in older adults
Leukemia naming conventions: Lympho- = Myelo- = -blastic = -cytic =
Lympho- = Involves lymphoid or lymphatic system Myelo- = Bone marrow involving hematopetic stem cells -blastic = Large, immature cells -cytic = Mature, smaller cells
Describe the difference between hemophilia and thrombocytopenia
Hemophilia = platelets could be normal, but you’re missing a factor in the clotting cascade, thereby putting you at risk for bleeding
Thrombocytopenia = low platelets, and therefore at risk for bleeding
What data is displayed on a cardiac monitor?
BP (plus a # in parentheses = Mean arterial Pressure) PA (pulmonary artery) CVP (central venous pressure) A-line (arterial line) SpO2 Respiratory Rate
Other data:
- PWP: pulmonary wedge pressure
- CO: cardiac output
- CI: cardiac index
- SVR: systemic vascular resistance
- PVR: pulmonary vascular resistance
A ___ is used to deliver medications or fluids. It is frequently called a __ as it used to be flushed by heparin. An air filter on the IV tubing for PFO is used to decrease the risk of __
PERIPHERAL IV
- Frequently called a HEP LOCK
- Air filter decreases risk of AIR BUBBLES
A chest tube includes any tube placed into the chest. It acts to drain ___ in order to ___. How is the tube secured?
Chest tube drains BLOOD, FLUID, or AIR to REXPAND the LUNG. Tube is STITCHED into place and often placed to wall suction to facilitate drainage.
Patients [can/cannot] mobilize with a chest tube. It is crucial to keep the drainage container [above/below] insertion site - why? If there is bubbling in the container, what might it indicate? If the chest tube pulls out, what do you do?
Patients CAN mobilize with a chest tube. It is crucial to keep the drainage container BELOW insertion site because it drains by GRAVITY. If there is bubbling in the container, it might indicate an AIRLEAK or a PNEUMOTHORAX, or in other systems may just indicate that the Chest tube is attached to SUCTION. If the chest tube pulls out, APPLY PRESSURE OVER SITE and TELL NURSE. If the chest tube is on wall suction, it needs a portable suction setup to mobilize pt.
A pigtail catheter is placed in the __ or __ to ___. It has a [curved/straight] end to prevent ___ during insertion and a __ to allow controlled drainage. How does this impact PT?
A pigtail catheter is placed in the HEART or LUNG to DRAIN FLUID COLLECTIONS (e.g. tamponade or pericardial effusion, pleural effusion, etc.). It has a CURVED end to prevent PUNCTURE during insertion and a STOPCOCK to allow controlled drainage.
PT impact: consider the pathology requiring the pigtail (is it in heart or lung?) as it may impact cardiac output, ventilation, or gas exchange.
___ promote LE circulation via air pumping through boots. They reduce the risk for __ in immobile populations. You should [keep them on/remove them] for PT mobility. What patients might you not want to use these with?
VENODYNE BOOTS
Reduce risk fro DVT in immobile patients.
REMOVE them for mobility
In confused patients, may want to NOT use them as a DVT prevention in order to reduce fall risk. Also if patient is very edematous, these may cause pitting edema, so consider alternate compression therapy
Hemodialysis is a method for removing ___ from blood for patients in __ failure. Physicians surgically ananstamose the __ and ___ systems via a graft under the skin, allowing for indirect access to the [arterial/venous] system via a ___ or ___. This generally occurs for ___ (duration), ___ (Frequency).
PT implication: don’t do…?
Hemodialysis is a method for removing WASTE PRDUCTS from blood for patients in RENAL failure. Physicians surgically ananstamose the ARTERIAL and VENOUS systems via a graft under the skin, allowing for indirect access to the VENOUS system via a CENTRAL LINE or ARTERIOVENOUS FISTULA. This generally occurs for 3-4 HRS (duration), EVERY OTHER DAY (Frequency).
PT implication: DO NOT TAKE BP ON THIS SIDE!
Similar to hemodialysis, ___ removes waste products continuously to eliminate large fluid shifts. PT treatment in these pts depends on __ and the location of the ___
Continuous venovenous hemofiltration (CVVH)
PT depends on MEDICAL STABILITY and the LOCATION OF THE LINE…if those are good, then you can mobilize
In a person on (esp. in one new to) dialysis, monitor for ___ response to activity. In a pre-dialysis patient, you’re likely to see [increased/decreased] BP due to [increased/decreased] blood volume. In a post-dialysis patient, you’re likely to see [increased/decreased] BP due to [increased/decreased] blood volume.
Monitor for HEMODYNAMIC response to activity.
Pre dialysis: INCREASED BP due to INCREASED blood volume
Post dialysis: DECREASED BP due to DECREASED BV
How does a VAC dressing work? Its goals are to… (3!)
System provides NEGATIVE PRESSURE (intermittent or continuous settings) to wound to approximate wound edges.
Goals:
- decrease edema
- increase perfusion
- promote granulation tissue formation
Patient has a VAC dressing. What do we do as PTs?
- Keep it attached?
- Can you disconnect it?
- Mobilize pt?
BEST to keep VAC attached to pt to promote healing
- most units have a battery back-up to allow for mobility
- if it needs to come off, get a nurse or an MD who is TRAINED to do it (it will likely require MD orders)
BUT consider implications of mobility on the wound: if it’s a weight bearing surface, if there would be strong tensile forces through the wound if it’s near a joint, etc.
What is a PICC line? What is it used for? What vein is it generally placed in? Where does the tip advance to?
PICC line = Peripherally inserted central catheter
- Used for extended antibiotics or medications, chemotherapy, or total parenteral nutrition (TPN)
- Usually placed in CEPHALIC, BASILIC, or BRACHIAL vein. The tip advances through large veins until it rests in SUPERIOR VENA CAVA or CAVO-ATRIAL JUNCTION (R atrium)
Potential complications of a PICC line
Catheter occlusion Phlebitis Hemorrhage Thrombosis (remove with lytic agents) Infection
*If tip of catheter advances too far into RA, it can cause arrythmias due to irritation of SA node
What are the PT implications when you see a PICC line? Why would you avoid taking BP over a PICC line? Can you exercise this arm?
Trace all IVs to origin and avoid pulling them out. Duh.
By taking BP over the PICC line, you could cause the tube to move and this could cause PHLEBITIS
You CAN exercise this arm!!
What are your options for surgical drains? How do they work? Do they impact PT treatment?
Tube placed in surgical/infection site to drain fluid. Many operate via a suction mechanism. Not much impact on PT treatment.
Options:
- Jackson-Pratt (JP) = Blake = Bulb Drain
- Hemovac
Options for auxillary feeding include ___, ___, and ___. Describe how each works and where the tubes go.
*In all of these, the stomach is working and pt CAN digest food!
Nasogastric tube (NG Tube) - Tube placed through NARES and ESOPHAGUS into stomach
Gastric Feeding Tube (G-Tube) or Percutaneous Endoscopic Gastrostomy Tube (PEG)
- Tube placed THROUGH ABDOMEN directly into STOMACH
J-Tube
- Placed through abdomen into 1st part of JEJUNUM
- This is more of a permanent solution to feeding
When a patient is being fed via an auxillary feeding source, what do you need to consider if you must disconnect the feeding tube?
What to consider when mobilizing? When positioning?
Consider implications if pt has DM or labile blood sugars. Insulin dosing is based around how many calories they’re getting, so may lead to HYPOGLYCEMIA
When mobilizing, SECURE the tube to prevent sheering or friction at insertion site and to decrease infection risk
Consider aspiration risk when positioning
What is a Foley Catheter?
What do you do if it’s full?
- Tube placed in bladder to drain urine
- Drains by GRAVITY: place it LOW when working with pt to promote drainage
- If it’s full, have a caregiver empty it to prevent extra pulling
Diabetes is predicted to become the __th leading cause of death by the year __
7th leading cause of death by 2030
Cardiovascular disease is responsible for __% of deaths in pts with diabetes. What % of pts with diabetes have CVD?
CVD = 50-80% of diabetes deaths
20-25% of pts with diabetes have CVD
Diabetes is the leading cause of __, __, and __ failure
Blindness, amputation, kidney failure
Describe symptoms of DM1 vs DM2
DM1
- Frequent urination
- Unusual thirst
- Extreme hunger
- Unusual weight loss
- Extreme fatigue and irritability
- Accelerated atherosclerosis, decreased lifespan
DM2
- ANY of the type 1 symptoms
- Frequent infections
- Blurred vision
- Cuts/bruises that are slow to heal
- Tingling/numbness in hands/feet
- Recurring skin, gum or bladder infections
- Assoc highly with obesity
How is diabetes diagnosed? Provide normal and diagnostic values for lab tests.
HgA1c:
Diabetes =/> 6.5%
(normal 126 mg/dL
(normal 8 hours
Oral Glucose Tolerance Test:
2 hour plasma glucose > 200mg/dL
(normal <140 mg/dL)
Describe the Oral Glucose Tolerance Test
A baseline blood sample is drawn (time = 0). Pt is given measured dose of glucose solution to drink within a 5 min time frame. Blood is drawn at intervals to measure glucose (blood sugar) and sometimes insulin levels. The 2 hour sample is the most important one for simple diabetes test
Type 1 diabetes involves ___ destruction with a lack of ___. Type 2 diabetes involves ___ resistance with ___ deficiency. Gestational diabetes is generally a combination of __ resistance with ___ dysfunction, and generally peaks around ___ and goes away ___ (when?)
Type 1: BETA CELL distruction with LACK OF insulin
Type 2: INSULIN resistance with INSULIN deficiency
Gestational: COMBO of INSULIN resistance and BETA CELL DYSFUNCTION. Generally goes away when BABY IS BORN or turns into DM2. Peak onset is in 5th or 6th month
DM1 involves ___ destruction of ____ in the ____. What do these cells produce? Who is prone to DM1? What envirnmental factors may be involved? What are protective factors?
DM1: AUTOIMMUNE destruction of INSULIN PRODUCING BETA CELLS IN THE ISLETS OF LANGERHANS
Pts are likely genetically susceptible (but only about 33% contribution of genetics) and exposed ot environmental triggers:
- Maternal age >25
- Preeclampsia (dangeriously high BP during pregnancy)
- Neonatal respiratory dz
- Jaundice, especially due to ABO group incompatibilty
Protective factors: low birth weight, short birth length; viruses
DM2 accounts for __% of diabetes worldwide. It is __-__x more prevalent in people descendent from what? What should be emphasized clinically to prevent it? What are independent risk factors for DM2?
- DM2 = 90% of DM worldwide
- 2-6x more prevalent in African Americans, Native Americans, Pima Indians, and Hispanic Americans in US than in whites
- Focus on diet, weight loss, activity level, and smoking sessation
- Decreased insulin secretion and insulin resistance (decreased sensitivity to insulin in metabolic tissues [liver, skeletal muscle, adipose] results in insufficient insulin usage)
In DM2, ___ can impair beta cell fxn and exacerbate ___. This makes it difficult to tell how bad the ___ is. In short, we see [increased/decreased] insulin secretion in response to __ exposure. ___ do not adequately respond to blood glucose levels. Increased release of __ from the liver coupled with suppression of ___ by ___ results in [decreased/increased] glucose. Finally, __ receptors in the liver, skeletal muscle, and adipose are unresponsive (unable or resistant to using __).
In DM2, HYPERGLYCEMIA can impair beta cell fxn and exacerbate INSULIN RESISTANCE. This makes it difficult to tell how bad the HYPERGLYCEMIA is. In short, we see DECREASED insulin secretion in response to GLUCOSE exposure. BETA CELLS do not adequately respond to blood glucose levels. Increased release of GLYCOGEN from the liver coupled with suppression of INSULIN by GLUCAGON results in INCREASED glucose. Finally, INSULIN receptors in the liver, skeletal muscle, and adipose are unresponsive (unable or resistant to using INSULIN).
How does obesity play into DM2?
Obesity increases insulin resistance by releasing FREE FATTY ACIDS and CYTOKINES from adipose cells which disrupt insulin receptors on the target cell plasma membrane and prohibit insulin from facilitating the entry of glucose into the liver, muscle, and adipose tissue
What other body systems should be considered in DM treatment?
- Cardiovascular (microvascular and macrovascular disesase)
- Integumentary (skin checks)
- Musculoskeletal
- Sensory (neurologic)
- Visual (retinopathy)
- Renal
In ___, glucose binding to collagen and proteins in blood vessel walls (glycosylation) causes hardening and thickening of the ___. This leads to obstruction or rupture of the capillaries, which leads to necrosis and loss of function in tissues being supplied.
MICROVASCULAR DISEASE: glycosylation (glucose binding to proteins and collagen in vessel walls) results in hardening/thickening of BASEMENT MEMBRANE
In macrovascular disease, higher concentrations of __ in patients with DM lead to accelerated ___.
Macrovascular disease: higher LDL concentrations –> accelerated ATHEROSCLEROSIS
What is the protective sensation cutoff? Why is this important in DM?
Protective sensation = 10g of pressure, assessed via Semmes-Weinstein Monofilaments (5.07 monofilament). In peripheral neuropathy associated with DM, more uncontrolled blood sugar = worse risk for neuropathy. Daily skin checks are necessary to ensure no wounds
Wound healing in DM is complicated by __ and/or __
Peripheral artery disease
Venous stasis
___ from macro and microvascular disease leads to tissue ___, and subsequently poor delivery of __ and __.
ISCHEMIA from macro and microvasc. disease –> NECROSIS and poor delivery of O2 and nutrients
__ is pain in legs when DM patient is walking. Why does this occur? What makes it better?
CLAUDIFICATION. Happens b/c ischemia: blood supply can’t meet demand of peripheral muscles b/c pain. Goes away with REST b/c blood supply is restored
What is the relationship between peripheral artery disease and diabetic neuropathy?
Diabetes is frequently associated with PAD with atherosclerosis developing at a younger age in more distal arteries. Along with diabetic neuropathy, contributes to higher rates of non-healing ulcers and limb loss
Neuropathy associated with diabetes affects __, __, and __ nerves.
Neuropathy assoc. with diabetes affects SENSORY, MOTOR, and AUTONOMIC nn.
Labile blood sugars can also make DM patients prone to __. Describe the effect on WBC.
Labile blood sugars make pts more prone to IMMUNOSUPPRESSION. WBC are impaired without adequate glucose support and are unable to engulf and remove pathogens. Increased glucose also provides an optimal environment for some pathogens.
In DM, we also see impaired __ healing and poor quality __ tissue and __ accumulation. Risk of amputation in DM is __-__x greater than in non-DM patients
DM: impaired BONE healing, poor quality GRANULATION tissue and COLLAGEN accumulation. Risk of DM amputation is 15-40x greater compared to non-DM pts.
What is silent ischemia DM? Denervation of what might contribute to this?
In diabetic patients, they may not have pain with ischemia (heart attack) due to reduced sensation.
AUTONOMIC DENERVATION contributes to abnormal/lack of sensation. Correlated with Circadian rhythms in setting of increased myocardial O2 demand at this time (happens in morning most often)
Why might we see hypoglycemia or hyperglycemia with exercise?
HYPOglycemia: due to decreased foot intake, rapid absorption of insulin @ injection site and exercising at peak insulin effect
HYPERglycemia: if there is an insulin deficit and hyperglycemia @ the onset of exercise, the muscle is unable to uptake insulin and the liver produces more glucose, thereby increasing the hyperglycemia
Blood vessel abnormalities occur in DM with atherosclerosis via damage to the ___ membrane. HTN is __x more likely in DM.
Blood vessel abnormalities due to Damage to BASEMENT CAPILLARY MEMBRANE
HTN 2x as likely in DM
In the presence of autonomic dysfunction in DM, resting HR is [elevated/decreased]. Pts tend to be [hypo/hyper]tensive with exercise and [hyper/hypo] tensive after exercise. In DM, we see a blunted __ response; these pts reach anerobic metabolism at [higher/lower] HRs.
In the presence of autonomic dysfunction in DM, resting HR is ELEVATED. Pts tend to be hypertensive with exercise and HYPOtensive after exercise. In DM, we see a blunted HR response; these pts reach anerobic metabolism at LOWER HRs.
Give normal plasma glucose levels for children, adults, and adults >60
Child: 60-100 mg/dL
Adult: 70-100 mg/dL
Adult >60: 80-110mg/dL
