Patho Exam #3 Flashcards
Anatomy
- Oral Cavity: intakes and passage of food
- Esophagus: passage of food, no digestion, no enzymes
- Stomach: mechanical churning of food, beginning breakdown of food, gastric/enzyme “juices”
- Small intestine: most absorption
- Large intestine: absorb water, salts, vitamins, elimination of undigestible food and residue
Carbohydrate Digestion
•Mouth: salivary amylase •Duodenum: pancreatic amylase oPolysaccharides → disaccharides •Brush border enzymes oDisaccharides → monosaccharides oMonosaccharides absorbed in blood
Protein Digestion
•Stomach: pepsinogen oActivated pepsin by acid in stomach oBreaks protein into polypeptides •Duodenum: pancreatic trypsinogen oActivated to trypsin in duodenum oBreaks proteins into polypeptides •Brush border enzymes oBreaks polypeptides into 2-3 amino acid peptides oPeptides absorbed into blood
Fat Digestion
- Duodenum: bile; emulsifies fats
- Duodenum: pancreatic lipase; breaks triglycerides into glycerol and fatty acids
- Jejunum: packages digested fats as chylomicrons; passed to the lymph
Hemorrhage above stomach
frank hematemesis: bright red blood in vomit
Hemorrhage into the stomach with partial digestion of blood
coffee-ground vomitus
Hemorrhage in the intestine with blood mixing into stools
occult blood
Hemorrhage into the intestines with large volumes of blood
melena
Hemorrhage in the rectum
red blood coating stools
Clinical Manifestations in GI Dysfunction: Abdominal pain
oSymptom of a number of GI disorders
oParietal pain
oVisceral pain
oReferred pain
Clinical Manifestations in GI Dysfunction: GI bleeding
oMortality rate 6-10%
oIncrease in older adults, especially in older women
oAssociated with NSAIDS (Non-steroidal anti-inflammatory drug)
oCan be caused by ibuprofen
Clinical Manifestations in GI Dysfunction: Upper GI bleeding
oEsophagus, stomach, duodenum
oMost severe is by sudden onset
oArteriole: bright red
oVenous: darker red
Clinical Manifestations in GI Dysfunction: Lower GI bleeding
bleeding from jejunum, ileum, colon, or rectum
Hematemesis
bleeding in vomit, somewhere above the stomach, Upper GI
Hematochezia
upper GI bleed can manifest itself in stool, bright red stools, several areas can be bleeding
Melena
lower GI, bleeding into intestine with large amounts of blood
Occult bleeding
smear stool and get it tested, lower GI
Dysphagia
difficulty swallowing
Achalasia
smooth muscle in esophagus and lower esophageal sphincter (in relaxed state); Esophagus can slide up and down
Gastroesophageal reflux disease (GRD)
oSymptom of secondary problem
oLower ES weaker and allows gastric contents to go up esophagus
o14-20% people suffer from this once a week
oBurning tight sensation
oReflux of chime from stomach to esophagus
oIf causes inflammation to esophagus, called reflux esophagus
oNormal functioning lower esophageal sphincter maintains a zone of high pressure to prevent chime reflux
oCauses: conditions that increase abdominal pressure can contribute to GER
Diet, stress, overeating, smoking, eating too fast, obesity, pregnancy, chocolate, caffeine, anticholergics
oManifestations: heartburn (burning tight sensation below the lower sternum), regurgitation of chyme, and upper abdominal pain within 1 hour
Acute Gastroenteritis
- Acute inflammation of GI mucosa
- 2nd leading cause of morbidity in US
- Occurs in all age groups
- Epidemic outbreaks due to ingested contaminated foods
- Viral gastroenteritis more common in winter months due to closeness (people are mostly inside and in close proximity)
- Self-limiting: can only treat symptoms
- Very young, elderly and those with concomitant chronic debilitating disease are at a high risk for increased mortality
Acute Gastroenteritis: Etiology
o Commonly due to infectious agents such as bacteria, virus, parasites
Bacteria: exotoxins induce hypersecretion and peristalsis – causing diarrhea and/or vomiting
Staphylococcus: 1-6 hours
E. coli: 24-72 hours
Shigella/Salmonella: 8-24 hours
Botulism: 12-36 hours
Giardia lablia: 7-21 days
Acute Gastroenteritis: Signs and Symptoms
Abrupt onset of nausea or vomiting Explosive flatulence Crampy abdominal pain Frequent, watery stools Myalgia: muscle aches Headache Fever: moderate to high for viral Generalized weakness and malaise
Acute Gastroenteritis: Diagnostic Tests
CBC: normal
Stool guiac: occult, hemoccult
Stool culture: chronic gastritis can break down mucosa in stomach, can be more prone to have ulcers
Caused by renal failure, sepsis, and burn victims
Peptic Ulcer Disease
• Break or ulceration in the protective mucosal lining of the lower esophagus, stomach or duodenum
• Acute and chronic ulcers
• Superficial: erosions
• Deep: true ulcers
• Duodenal ulcers: most common type
o Developmental factors
Helicobacter pylori infection: toxins and enzymes that promote inflammation and ulceration; major cause of ulcers
o Hypersecretion of stomach acid and pepsin
o Use of NSAIDS; second most common cause of ulcers
o High gastrin levels
o Acid production by cigarette smoking
Appendicitis
• Right lower quadrant pain, holds bacteria
o Rebound tenderness
o Serious complication is sepsis (peritonitis)
o Hardened feces
Appendicitis: etiology
o Obstruction with hardened feces, stricture, inflammation due to infection, foreign body or neoplasm
o Occurs in all age groups but commonly in males between 10-30
o Higher mortality rate due to complications in children, adolescents and persons over 55
o RUPTURE → PERITONITIS → DEATH
Appendicitis: Signs and Symptoms
o Acute onset periumbilical or epigastric pain which ranges from mild diffuse to severe
o Anorexia, nausea, and vomiting usually subsequent to pain onset
o Shifting of pain to right lower quadrant (McBurney’s point) after several hours
o Pain aggravated by walking or coughing
o Spasm of abdominal muscle
o Constipation usual
o Diarrhea rare
o Elderly may present with mild symptoms or unexplained weakness, anorexia, tachycardia, and abdominal distention with little pain
o Occasional radiation of pain into ipsilateral testicle or labia
Appendicitis
o Generally may or may not APPEAR SICK
o Fever 100-102
o Slight tachycardia related to pain and fever
o Abdominal point and rebound tenderness in RLQ
o Decreased or absent bowel sounds
• Diagnostics
o CBC with differential: shows leukocytosis with increased bands
o X-ray may show fecalith
Liver functions
- Bile production
- Protein processing and metabolism
- Glycogen synthesis
- Fat synthesis and metabolism
- Detoxification/filtration
- Clotting factor synthesis
- Storage
- Heat production
Metabolic Functions of the Liver
• Carbohydrate, protein, and lipid metabolism
• Sugars → stored as glycogen, converted to glucose, used to make fats
• Proteins → synthesized from amino acids; ammonia made into urea
• Fats → oxidized for energy, synthesized, packaged into lipoproteins
• Drug and hormone metabolism
o Biotransformation into water-soluble forms
o Detoxification or inactivation
• Bile production
• Hematologic disorders
o Anemia, thrombocytopenia, coagulation defects, leukopenia
Liver failure
• Skin disorders
o Jaundice, red palms, spider nevi
• Hepatorenal syndrome
o Azotemia (itching of the skin), increased plasma creatinine, oliguria
• Hepatic encephalopathy: amniotic levels reach toxic level
o Asterixis, confusion, coma, convulsions
Hepatitis
• Inflammation of the liver caused by an infectious agent or response to exposure to a toxin • Manifestations o Vascular congestions o Cellular swelling o Decreased hepatocyte function o Mechanical impairment of circulation o Toxin exposure Direct or indirect hepatocyte damage
Hepatitis A Virus (HAV)
- “Infectious hepatitis”
- Most common hepatitis in the world (61,000)
- Found in underdeveloped countries
- Fecal-oral route
- Oral contamination
- Small RNA virus
- Usually benign
- Self-limiting
- Incubation 2-8 weeks
Hepatitis B virus (HBV)
- “Serum hepatitis:” blood and body fluids (saliva)
- DNA virus
- Parental and sexual contact
- Acute hepatitis
- Incubation 4-26 weeks
- Persistent antigenemia
- Chronic → cirrhosis
- Percutaneously (drug use)
- Perinatal
- Needle sticks
- More infectious that HIV
Hepatitis C virus (HCV)
- Common infection
- 20% end up with cirrhosis in liver within 20 years
- HIV patients
- High risk of sexual behavior
- Body piercing, tattooing
- 170 million infected
- Chronic infection
- 30,000 diagnosed per year
- “Non-A, non-b”
- 90-95% transfusion hepatitis
- Inoculations and blood transfusions
- RNA-virus, unstable
- Associates with cirrhosis and hepatocellular carcinoma
- Incubation period 2-26 weeks
- No immunity
- Percutaneously: IV drug use
- Hemodialysis
Hepatitis D (HDV)
- Chronic progression blood-borne disease
- Terminates in cirrhosis
- Common in Mediterranean countries, Africa, Middle East and rare in US
- HBV can later form
- Coinfection of HDV and HBV can make infection infectious
Hepatitis E virus (HEV)
- Water-borne infection
- Enteric transmission
- Self-limiting
- Common in Asia, Indian continent, Mexico, sub-Saharan Africa
Hepatitis G
- Viral agent similar to HCV
- Transfusion transmitted
- Non-pathogenic
Chronic Viral Hepatitis
- Caused by HBV, HCV, and HDV
- Principal cause of chronic liver disease, cirrhosis, and hepatocellular cancer in the world
- Chief reason for liver transplantation in adults
Cirrhosis
• Irreversible inflammatory disease that disrupts liver function and even structure
• Chronic progressive disease
• Decreased hepatic function caused by nodular and fibrotic tissue synthesis (fibrosis)
• Bilary channels become obstructed and cause portal hypertension. Because of the hypertension, blood can be shunted away from the liver, and a hypoxic necrosis develops
• Alcoholic: oxidation of alcohol damages hepatocytes
• Bilary (bile canaliculi)
o Cirrhosis begins in the bile canaliculi ducts
o Primary bilary cirrhosis (autoimmune)
o Secondary bilary cirrhosis (obstruction)
• 9th leading cause of death
• People 35-54 4th leading cause of death
• Twice as common in men
Alcoholic Liver Disease
• Fatty liver (steatosis)
o Liver cells contain fat deposits; liver is enlarged
• Alcohol hepatitis: liver inflammation and liver cell failure
• Cirrhosis – scar tissue partially blocks sinusoids and bile canaliculi
Cholectasis and Intrahepatic Bilary Disorders
• Bile flow in the liver slows down
• Bile accumulates and forms plugs in the ducts
o Ducts rapture and damage liver cells
Alkaline phosphatase released into blood
• Liver is unable to continue processing bilirubin
o Increased bile acids in the blood and skin
Pruritus
Cholecytitis
• Inflammation of the gall bladder, usually as a result of stone formation (cholelithiasis). Infection may or may not be present. Bile is trapped in the gall bladder, acting as a chemical irritant. Gall bladder ischemia and necrosis can occur. Stone may obstruct bilary tract
Choleithiasis (gallstones)
o Cholesterol, calcium salts, or mixed
o Obese
o Native Americans
Acute and chronic cholecystitis
nflammation caused by irritation due to concentrated bile
Choledocholithiasis
stones in the common bile duct
Cholangitis
inflammation of the common bile duct
sBilary Reflux
- Gallbladder contracts
- Bile is sent down common bile duct
- Blockage forms in ampulla of Vater: bile cannot enter duodenum
- Bile goes up pancreatic duct
- Bile in pancreas disrupts tissues; digestive enzymes activated
Disorders of the Pancreas
• Pancreatitis
• Activated enzymes begin to digest the pancreas cells
o Severe pain results
o Inflammation produces large volumes of serous exudate hypovolemia (autodigestion)
• Enzymes (amylase, lipase) appear in the blood
• Areas of dead cells undergo fat necrosis
o Calcium from the blood deposits in them
Hypocalcemia
Pancreatitis
• Inflammation of the pancreas
• Associated with several other clinical disorders
o Caused by an injury or damage to pancreatic cells and ducts, causing a leakage of pancreatic enzymes into the pancreatic tissue
• Manifestations and evaluation
o Epigastric pain retaining to the back
o Fever and leukocytosis
o Hypotension and hypovolemia
Enzymes increase vascular permeability
o Characterized by an increase in a patient’s serum amylase level
• 3 times higher rate in African Americans than Caucasians
• Alcohol related
• Seen more in females: biliary tract problem
Chronic Pancreatitis and Pancreatic Cancer
• Related to alcohol abuse
• Have signs and symptoms similar to acute pancreatitis
• Often have:
o Digestive problems because of inability to deliver enzymes to the duodenum
o Glucose control problems because of damage to islets of Langerhans
o Signs of biliary obstruction because of underlying bile tract disorders or duct compression by tumors
Nephron Function
• Filters plasma
• Reabsorbs and secretes
o Tubular reabsorption and sercretion
• Forms a filtrate to protein-free fluid
• Regulates the filtrate to maintain fluid volume, electrolytes, and pH
• Glomerular filtration
o Net filtration pressure
Glomerular capillary oncotic/hydrostatic pressure
Bowman capsule oncotic/hydrostatic pressure
o Filtration rate
180 L/day
Glomerular Filtration Rate
125 mL/min & 1.5 L/day
Kidney Functions
• Filters the blood • Remove water-soluble wastes • Help control blood pressure and composition • Help maintain RBC levels • Maintain homeostasis of the blood o Balance water o Balance sodium o Balance potassium o Balance acidity
Components of Urine Formation
- Filtration
- Reabsorption
- Secretion
- Excretion
Kidney stones
o Calculi or urinary stones
Masses of crystals, protein, or other substances that form within and may obstruct the urinary tract
o Risk factors
Gender, race, geographic location, seasonal factors, fluid intake, diet, and occupation
o Kidney stones are classified according to the minerals comprising the stones
o More common in women
Renal Calculi (Kidney Stones)
• Saturation theory: urine is supersaturated with stone components
• Matrix theory: organic materials act as nidus for stone formation
o Precipitation of a salt from liquid to solid state
Temperature and pH
• Inhibitor theory: a deficiency of substances that inhibit stone formation
• Four types of kidney stones:
o Calcium stones (ex: oxalate or phosphate); most common
70-80% of all of stones that require treatment
o Magnesium ammonium phosphate stones (struvite)
o Uric acid stones
o Cystine stones
• Contributing factors
o High purines and gout
Kidney Stones
• Most common sign is pain in lower back
• Manifestation
o Renal colic: stretching of tubules where stone is stuck
• Evaluation
o Stone and urine analysis
o IV pyelogram: ask patient if they are allergic to iodine
o Kidney, ureter, bladder x-ray (KUB)
o Spinal abdominal CT
• Treatment
o High fluid intake, decreasing dietary intake of stone-forming substances stone removal (if stone doesn’t pass on its own)
Lithotripsy: laser beam that breaks up stone and makes it easier to pass
Urinary Tract Infections
• 2nd most common bacterial disease
• Most common in women and pregnant women
• More than 8 million office visits/year
• Greater than 100,000 people hospitalized each year
• Gram-negative bacteria
• Systitis: lower UTI that is localized in the bladder; inflammation in the bladder
• Upper UTI: kidney involvement
• Bacteria usually enter through the urethra
• Host defenses include:
o Washout phenomenon
o Protective mucus
o Local immune responses and IgA
o Normal bacterial flora
• E. coli most common pathogen
UTI Signs & Symptoms
- Burning/itching
- Frequent feeling that they have to use the restroom
- Blood in urine
- Dysuria: pain in urination
- Confusion in elderly
- Urine cloudy and have sediment
- Urinalysis (UA) and urine culture and sensitivity
When Kidneys Fail
• Less waste is removed
• More waste remains in the blood
• Nitrogenous compounds build up in the blood
o BUN: Blood urea nitrogen
o Creatinine: renal function approx. by: initial creatinine level/current creatinine level
Acute Renal Failure: Prerenal
o Decreased blood supply
Shock, dehydration, vasoconstriction
o Oliguria: less than 30 mL/hour
o Glomerular filtration rate (GFR) declines because of decrease in filtration pressure
o Cause is pre- (before) kidney (blood flow to kidney related)
o Most common cause
o Caused by impaired renal blood flow
Acute Renal Failure: Intrinsic (Intrarenal)
o Acute tubular necrosis (ATN): most common cause of intrarenal renal failure o Ischemia occurs o Usually post-op o Sepsis/trauma/burns o Within the kidney o Postischemic or nephrotoxic
Acute Renal Failure: Postrenal
o Urine flow is blocked
Stones, tumors, enlarged prostate
o BPH: benign prostatic hypertrophy: enlarged prostate
o After kidney cause – structural
o Occurs within urinary tract obstructions that affect the kidneys bilaterally
Phases of ARF
• Oliguria phase: less than 30 mL/hour o Seen as kidney disease worsens o Lasts several hours or 1-3 weeks • Diuretic phase o Increase of urine volume o Monitor fluid and electrolyte status o Renal tubules still damaged, but person begins to recover • Recovery phase o Can take 3-12 months to recover o GFR back to baseline status
Chronic Renal Failure (CRF)
• Progressive, irreversible loss of renal function that affects nearly all organ systems • GFR: less than 60 mL/min • Stages o Chronic renal insufficiency o Chronic renal failure o End-stage renal failure: GFR drops to 15 mL/min • Proteinuria and uremia • Creatinine and urea clearance • Fluid and electrolyte balance o Sodium and water balance o Phosphate and calcium balance o Potassium balance o Acid-base balance • Fewer nephrons are functioning • Remaining nephrons must filter more o Hyperperfusion o Hypertrophy
Development of CRF
• Diminished renal reserve
o Nephrons are working as hard as they can
• Renal insufficiency
o Neprons can no longer regulate urine density
• Renal failure
o Neprons can no longer keep blood composition normal
• End-stage renal disease
Uremia
• Urine in the blood • Renal filtering function decreases o Altered fluid and electrolyte balance Acidosis, hyperkalemia, salt wasting, hypertension • Wastes build up in blood o Increased creatinine and BUN Toxic to CNS, RBCs, platelets • Kidney metabolic functions decrease o Decreased erythropoietin o Decreased Vitamin D activation
Hemodialysis
- Filtering blood
- Diffusion of dissolved particles from one compartment to the other through semi-permeable membrane
- Cleanses accumulated wastes, removes excess fluids, metabolic by-products
- Maintains/restores buffer system & electrolyte levels
Peritoneal Dialysis
• Dialyzing membrane
• Uses diffusion and osmosis principles to exchange fluid and solutes
• Peritoneal cavity is rich in capillaries so excellent blood supply for exchange
• Contraindications: peritonitis, recent abdominal surgery, abdominal adhesions, impending transplant
• Types
o Continuous ambulatory peritoneal dialysis dialysis (CAPD)
o Automated peritoneal dialysis (CCPD)
Complications of Peritoneal Dialysis
- Peritonitis
- Abdominal pain
- Insufficient flow
- Leakage around catheter site
Nursing Implementation
- Monitor vital signs, lab values, weights, I&O, adequate nutrition
- Monitor patency of access device
- Hold antihypertensives and sedatives prior to procedure
- Hold medications which can be filtered out during dialysis
- Monitor for post-procedure complications
Complications of Dialysis
- Hypotension & shock
- Muscle cramps
- Electrolyte changes
- Sepsis
- Blood loss
- Hepatitis
Fracture Classifications
Complete (broken all the way through) or incomplete (damaged but still in one piece)
Closed (skin hasn’t been compromised) or open (bone sticking out of skin)
Comminuted: two or more fragments that are broken
Linear: parallel fracture to bone
Oblique: slanted
Spiral: when bone is twisted apart
Transverse: straight across bone
Fracture Classifications 2
• Greenstick: chunk of bone missing, bone bends and cracks
• Torus: (buckling) incomplete fractures of shaft of long bone caused by impaction
• Bowing: incomplete fractures of long bones in children
• Pathologic: caused by disease that led to weakness of bone structure
• Stress: tiny cracks in a bone due to overuse
o Fatigue and insufficiency
o Transchondral: in articular surface of bone
Bone fractures
broken bone can cause damage to the surrounding tissue, the periosteum, and the blood vessels in the cortex and marrow
Hematoma formation
Bone tissue destruction triggers an inflammatory response
Procallus formation
Manifestations of Fractures
- Unnatural alignment, swelling, muscle spasm, tenderness, pain, impaired sensation, and possible muscle spasms
- Deformation and weakness
- Change in alignment
Treatment of Fractures
• Closed manipulation, traction, and open reduction
• Internal and external fixation
• Improper reduction or immobilization
o Nonunion, delayed union, and malunion
Osteoporosis
• Porous bone • Poorly mineralized bone • Bone density o Normal bone: 833 mg/cm2 o Osteopenic bone: 833 – 648 mg/cm2 o Osteoporosis: <648 mg/cm2 • Demonstrated by reduced bone mass/density and an imbalance of bone reabsorption and formation • Bone histology is usually normal but it lacks structural integrity • 80% women • Asian background • Insufficient dietary calcium
Potential Causes of Osteoporosis
- Decreased levels of estrogen and testosterone
- Decreased activity level
- Inadequate levels of vitamins D and C, or Mg++
- Corticosteroids and cancer treatments
- Usually in bigger joints
Osteomyelitis
• Most often caused by a Staphyloccal infection
• Most common cause is open wound (exogenous); also can be from a blood-borne (endogenous) infection
• Manifestations
o Acute and chronic inflammation, fever, pain, necrotic bone
o Night sweats, nausea
o Constant bone pain
o Unrelieved by rest
• Treatment
o Antibiotics, debridement, surgery, hyperbaric oxygen therapy
o Vigorous antibiotics for several weeks
o Surgical removal of tissue
o Hyperbaric oxygen therapy
