Biology Final Exam 2 Study Guide, Study Guides, Projects, Research of Biology

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Final Exam Study Guide Exam #2 Liver Anatomy: Liver produces prothrombin/Bile (bile is STORED in gallbladder) Stores Vitamin A, B, E, K Breaks down proteins/Ammonia Synthesizes glucose Very vascular (450ml blood) NAFLD (Non-Alcoholic Fatty Liver Disease) – usually linked to insulin resistance & Metabolic syndrome Hepatic Assessment (Liver Disease): Common Symptoms: - Lethargy, weakness, fatigue, fever, jaundice, pruritis - AMS, personality changes, sleep disturbances, confusion & coma (acute failure or chronic disease) - Dyspnea due to fluid retention - Abdominal pain, increasing abdominal girth, anorexia, N/V, hematemesis, melena - Increased bruising, spontaneous bleeding, dependant/pedal edema - Decreased libido Examination Findings - Jaundice, ecchymosis, spider angiomas, palmar erythema, scleraicterus, clubbing - Slurred speech, confusion, poor recall - Muscle wasting, tremors, hand flap - Abdominal distension, dilated veins visible thru skin, umbilical hernia, striae, excoriations, petechiae, enlarged liver - Pitting edema, gynecomastia, testicular atrophy Splenomegaly - Congestion from portal hypertension - Causes: cirrhosis, viral infection - S/S: from none to pain or fullness in LUQ; may spread to left shoulder; feeling full without eating, anemia, fatigue, bleeding TIPS – Tranjugular Intrahepatic Portosystemic Shunt - Cannula is threaded into portal vein via transjugular route - Stent is inserted to serve as an intrahepatic shunt between portal circulation and hepactic vein Balloon Tamponade (used in esophageal varices) 4 openings gastric/esophageal aspiration/inflation Nursing management - After treatment for acute hemorrhage observe for bleeding, perforation of esophagus, aspiration pneumonia and esophageal stricture - Antacids, H2 antagonists or proton pump inhibitors may be administered - No fluids until gag reflex returns - Parenteral nutrition may be initiated - Gastric suction - Frequent oral hygiene - Vitamin K therapy & blood transfusions - ***MONITOR PATIENT CLOSELY SO THEY DON’T DISLODGE TUBE*** Post-necrotic cirrhosis Necrotic parenchymal tissue replaced with fibrous bands of connective tissue that eventually constricts and partitions organ into irregular nodules - Abdominal pain, swelling, hematemesis; dependent edema, jaundice - Advancedd: ascites, portal HTN, CNS disorders Biliary Cirrhosis - Bile backs up into liver due to duct blockage; liver becomes inflamed; caused by gallstones. Cardiac Cirrhosis - When suffering from chronic heart failure, blood backs up into liver; congestion causes swelling and pain Jaundice – bilirubin >3; urine bilirubin (not normally found in urine) Ascites- Cirrhosis with portal hypertension  splanchnic arterial vasodilation Decrease in circulating arterial blood volume  activation of renin-angiotensin and Sympathetic nervous systems and antidiuretic hormone  kidney retains NA and H2O Hypervolemia  persistent activation of systems for retention of NA and H2O Ascites and edema formation  continued arterial underfilling – cycle repeats Spontaneous Bacterial Peritonitis – due to decreased immune function; bacteria from gut in ascetic fluid via lymph; inflammation; fever, chills, ab pain & tenderness, washboard ab; paracentesis shows INCREASED WBC in fluid Hepatorenal Syndrome - Poor prognosis; One of the leading causes of death in patient with cirrhosis - Hyperperfusion to kidneys causing them to shut down - Sudden decrease in Urinary output; INC BUN/Creatinine/INC urine Osmo (more concentrated) - Nursing Intervention: o Eliminate causative agent o Monitor ALOC, VS, Labs, I/O q2-4 hrs o Weight patient/abdominal girth daily o Stool for occult blood and bleeding tendencies o Diet (moderate protein, low sodium, complex carbs, frequent meals) Cultural/population statistics - Only 3.4% of 65+ lived in institutional settings - 50% of women over 75 live alone - Most older persons have 1 chronic condition, many have multiple - Longer hospital stays and 3x as many hospitalizations compared to younger people Important to assess functional status when they enter the facility. It should be the benchmark that is met or exceeded when they go home. The aging body - Decreased alveolar surface area  DEC exercise capacity - Decrease in efficiency of liver to metabolize drugs - Decreased blood blow to kidneys  DEC hormone regulation - Lower oxygenation of blood  DEC endurance - Decreased effectiveness of cough - Visual impairments (adjust to light/dark, depth perception) o Rearrange their environment o Intermittent catheterization for overflow - Confusion o Avoid anticholinergics o Consider other meds for dementia - Skin Breakdown - Sensory impairments o Vision, hearing, taste, smell o Proprioception – balance o Glasses, hearing aids and dental (care not paid for by medicare) Coordinated management - Hartford Institute for Geriatric Nursing o Geriatric Interdisciplinary Teams ▪ Integrates nursing, pharmacology, psych, social work, hospice and palliative care, etc. o Specialized units (ACE) – Acute care for Elderly ▪ Specialized units within healthcare orgs/hospitals that are designed to improve health outcomes and meet the special needs fo adults >65. Special floors, lights, furniture, calming environment. Daily interdisciplinary rounds, board certified geriatricians and palliative care physician. Focused on whole patient – mind, body and spirit. o NICHE programs (Nurses improving care) ▪ Provides acute care nurses with mentorship and resources that supports excellence in patient-centered geriatric care. Provides facilities and staff with EBP clinical protocols “never events”, and J.C. compliance. State of the art training tools and resources, online leadership training programs, online knowledge center and benchmark services. o Models of care – get patient well, keep them healthy and get them to whatever level of care they need next. Chronic conditions - HTN o Increases with aging o Structure /functional changes in heart/blood vessels o Systolic HTN with widened pulse pressure is more common in older adults - Arthritis o Diagnosis and treatment is crucial in improving the quality of life - Heart Disease - Cancer o Increased risk with age o Life expectancy increasing, more cancer related care needed o Oncology nurses must understand the normal physiological changes that occur with aging - Diabetes o Overall incidence of diabetes is increasing, with the greatest increase in the aging population o Poor diet, physical inactivity, altered insulin secretion and insulin resistance could be contributing o Normal [physiologic changes of aging may mask the symptoms of diabetes – makes diagnosis more difficult o Polypharmacy, depression, cognitive impairment, urinary incontinence, fall and chronic pain increase the risk for complications ▪ Renal function changes – decreased function, decreased drug clearance ▪ Chronic diseases – HTN, arthritis, neoplasms, acute/chronic infections ▪ Potential Drug interactions – use of another person’s meds, consulting multiple health providers for different illnesses, alcohol use/abuse - Sensory Alternations o Visual/hearing loss can cause confusion, anxiety, disorientation, misinterpretation of the environment, and feelings of inadequacy. PMI – 5th ICS/Left mid-clavicular line Diastole – atria/ventricles relaxed; allows ventricles to fill; tricuspid & mitral valves open Systole – myocardial contraction Automatcity – cardiac cells’ ability to spontaneously generate an electrical impulse (depolarize). The cells dedicated to this purpose are called pacemaker cells. SA Node 60-100 – Primary pacemaker of the heart AV Node 40-60 – if SA fails; AV assumes function Ventricle 20-40 – can contract on own if nodes fail Starling’s Rule – Force of contraction is equal to length of muscle fiber (the strength of the hearts systolic contractions directly proportional to its diastolic expansion (the heart pumps out of the right atrium all the blood returned to it without backing up into the veins). Stroke Volume – amount of blood ejected with each heartbeat (~70ml) Cardiac Output – Stroke volume times heart rate (SV x HR) – volume of blood pumped per minute by each ventricle of the heart CVP (Central Venous Pressure) – amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system (normal is 3-8mmHg) Blood pressure in right atrium and vena cava. Preload – end diastolic volume Afterload – systemic vascular resistance (pressure) AFIB – loss of atria kick; doesn’t push blood into ventricle; left ventrical reduced preload/reduced cardiac output Ejection Fraction (EF) – percent of blood ejected from left ventricle with each beat ~70% (easily measured by echocardiogram) If it goes down the heart is failing. PCWP – Pulmonary Capillary Wedge Pressure – indirect measure of left atrial pressure/preload of left ventricle. Need Swan-gans catheter (Normal 8-12) LVEDP – Level ventricle End Diastolic Pressure RAAS – Renin-Angiotensin-Aldosterone-System Pulse Pressure (difference between systolic and diastolic) if <30 – SERIOUS. Reduction in cardiac ouput – requires further evaluation. Pulse Deficit – difference between apical and peripheral pulses Ischemia – impediment of blood flow – deprives heart muscle of oxygen needed for survival Assessment of CVS - Subjective Data o Cardiovascular symptoms o Past medical history o Family History o Personal history - Objective data o Vital signs o Peripheral vascular systems (radial/pedal pulses) o Heart rate, rhythm, quality Inspect: size and shape of chest, PMI visibility, pulsations Palpate: PMI, thrills, other pulsations Percuss: doesn’t have much meaning Auscultate: S1, S2, S3/S4 gallops (suggests left ventricle dysfunction), murmurs, pericardial rub, listen in all valve areas (ape to man)) Abdomen: ascites develops in late HF from increased pressure in Rt ventricle. Fluid build up – hepato/splenomegaly. Aortic aneurysm – pulsatile mass in middle upper adbdomen. Myocardial Damage - Angina o Usually result in ischemia (if decrease in blood supply significant and/or long duration) o Mismatch between Oxygen supply and oxygen demand o Aggravated by exercise o Relieved by rest and/or nitroglycerin o S/S mild indigestion, heavy sensation in upper chest, pain radiating to neck, jaw, shoulder and left arm. SOB, pallor, diaphoresis, anxiety, dizziness and N/V - Prinzmetal’s Angina o Angina at rest that occurs in cycles o Caused by spasm in coronary artery Acute coronary syndrome - Unstable angina (change in baseline/pattern) o Chest pain/discomfort o ECG/Cardiac biomarkers show no evidence of AMI o Occurs with rest or exercise - NSTEMI – sub-endocardial MI o Inner lining within heart; NO ST elevations o Elevated cardiac biomarkers but no definitive ECG evidence of AMI - STEMI – MI o ST elevations in at least 2 leads o ECG evidence of AMI - Sudden Cardiac Death o Massive MI, lethal arrhythmia like VFIB or complete outlet obstruction Women & Heart Disease - Women are older than men when presenting with 1st AMI - In post menopausal women, risk of MI quadruples - Few women present with classic signs/symptoms. Suffer more with silent AMI’s - Women report more disability after cardiac event than men - Women tend to have more complications after CABG than men What happens in ACS? - Reversible o Severe & abrupt cessation of blood supply (lack of 02) – leads to ischemia o Ischemia, when persists, causes injury - Irreversible Afterload – Resistence Use ACE/ARB to lower BP S3 Heart sound – heart begins to fail – increased flood volume fills ventricle with each beat S4 Heart sound – increased resistance to ventricle filling (increased stiffening of ventricle myocardium) IABP - Intra Aortic Balloon Pump Balloon is placed in descending aorta via femoral artery. Balloon can be inflated/deflated. Inflates during diastole, pushes blood back to cardiac muscle and brain. Deflates just before ejection phase of systole - acts as a vacuum that pulls blood into aorta with less effort from left ventricle. Decreases workload of the heart. LVAD – Left Ventricular Access Device Mechanical blood pump which augments or replaces function of ventricle Surgically implanted Requires CBP Reduces myocardial ischemia and workload; restores adequate cardiac perfusion ICDs Used for arrhythmias; can prevent sudden cardiac death Range of therapies: cardioversion, defibrillation and pacing Hemodynamic Monitoring CVP – catheter in vena cava or right atrium - Reflects Right ventricle preload - Normal 2-8 - >8 indicates hypervolemia or RHF - <2 indicates reduction in preload or hypovolemia - Complications – infection, pneumo and/or air embolism - Placement confirmed by chest xray Pulmonary Artery Pressure – Swanz-Ganz catheter inserted through large vein to rt side of heart into pulmonary artery - Measures pulmonary cap wedge pressure, cardiac output, right atrial pulmonary artery systolic and diastolic pressure - Connected to a pressure monitoring system - Reflects left ventricle preload - Balloon tip inflated and measurement taken, then deflated. Occlusive maneuver so done quickly. Assess catheter placement to ensure correct position - Placement confirmed via chest xray Intra-Arterial BP monitoring - Continuous systolic, diastolic and Mean Arterial pressure readings and blood sampling. - Reflects perfusion pressure to major organs (requires MAP of 60) - Perform Allen test before insertion to ensure patent ulnar artery Core Measures - Written discharge instructions o Immunizations o Medications, o Diet and fluid restrictions o Activity level o Follow up appointments o Symptom management (increased swelling, fatigue, SOB) o Weight monitoring o Medication reconciliation - LV function must be assessed o EF <40% should have ACEI prescribed - Use of ACE Inhibitors - Smoking Cessation Rheumatic Fever - Inflammatory disease that develops as a complication of untreated strep throat (or scarlet fever). - Group A strep infection - Significant risk factor in mitral stenosis Risk factors - Poor hygienic conditions - Overcrowding - No running water - Poor socioeconomic status Clinical significance/diagnosis of acute rheumatic fever - 2 major or 1 major and 2 minor criteria - Jones modified criteria o Major ▪ Carditis (serious manifestation) ▪ Polyarthritis (inflammation of jt) ▪ Erythema Marginatum ▪ Syndenham’s chorea (jerky, spontaneous movement that is self-limiting) ▪ Subcutaneous nodules o Minor ▪ Arthralgia (jt pain) ▪ Fever ▪ ASO titer (Antistretolysines) ▪ History of Rheumatic Fever or Rheumatic Heart Disease - Histopathology slides will show Aschoff’s bodies – collagen fibers/leukocytes Collaborative care - Bedrest - Manage symptoms - Steroids/NSAIDs - Antibiotics may be given but it is now 2 weeks post infection Cardiomyopathy - Disorder of myocardium - Mechanical and/or electrical dysfunction - Can lead to severe HF, lethal arrhythmias and death - All result in impaired cardiac output Dilated Cardiomyopathy (DCM) - MOST COMMON of the cardiomyopathies - Description o Significant irreversible dilation of the ventricles o Poor systolic function o Decreased blood volume ejected (some remains in ventricle, less enters from atrium) o Increased chamber size; thin left ventricle muscle - Signs/Symptoms o Dyspnea & fatigue o Volume overload, weight gain o Chest pain due to CAD or PE o Abdominal discomfort, hepatomegaly - Assessment o S3 gallop and murmurs o Crackles in lungs o Marked cardiomegaly o Decreased contractility o Decreased cardiac output - Risk for clots/DVT need to be on prophylaxis Hypertrophic Cardiomyopathy - Description o Hypertrophied, non-dilated left ventricle o Leads to obstruction of left ventricular outflow o Obstructive/Non-obstructive o Decreased chamber size/thickened intraventricular septum - IHSS – Idiopathic Hypertrophic Subaortic Stenosis - Etiology o More common in men than women o Common cause of death in athletes o Strong genetic component o Aortic stenosis - Clinical Manifest o Septal hypertrophy with or without LV outflow obstruction o Diastolic dysfunction – dec filling, dec LVEDV, dec C/O; EF is good - S/S o Most are asymptomatic o Angina (massive ventricle size, forceful ventricular contraction) o Arrhythmias o Forceful PMI o S3/S4 gallop o Syncope o Dyspnea o Bisferiens pulse (double pulse felt) Restrictive Cardiomyopathy - Description o Diastolic dysfunction that “restricts” the heart’s ability to fill with blood o Uncommon cardiomyopathy o “stiff ventricular walls” - Causes o Rheumatic fever (most common cause) o Calcium deposits o Atrial myxoma (tumor sits in atrium near opening of mitral valve) o Thrombus formation - Patho o Blood backs up into pulmonary veins; pressure rises (circulation become congested) o Right ventricle increases in size and contracts against the abnormal high pulmonary pressure o RV & RA become enlarged – eventually leads to RV failure Mitral Regurgitation - Incompetence - Patho o Valve leaks as it does not close completely during systole o Blood flows back into left atria o Can lead to failure of both left and right ventricles - Causes o Rheumatic fever o Infective carditis o Papillary muscle dysfunction - S/S o Dyspnea on exertion, fatigue, tachycardia, weakness, SOB, orthopnea o JVD o PND (from pulmonary congestion) o Hemoptysis (blood tinged sputum) o Pulmonary edema (left atrial failure) o Right sided HF o Afib – leads to embolic phenomenon o Irregularly, irregular pulse o Right para-sternal pulsations/heave o Loud first heart sound, opening snap o Diastolic murmur (between S2 and S1) Mitral Valve Prolapse - Portion of one or both valve leaflets bulges back into left atrium during systole - S/S o Commonly asymptomatic o SVT, VT usually present o Mid-systolic click o If also have regurgitation, could present with infective endocarditis Aortic stenosis - Narrowing of the valve opening between LV and aorta causing obstruction of blood flow through valve - LV fails from pressure, then LA pressure, then pulmonary congesting, then RHF - S/S o Can be symptomatic for decades o Chest/angina pain – from diminished blood flow o Dyspnea (due to increased pulmonary venous pressure) o Syncope on exertion - Dx o LV hypertrophy o Thrill, vibration felt in aortic area (for the turbulent blood flow through narrowed valve) o Systolic ejection murmur (between S1-S2) Aortic Regurgitation - Backward flow of blood into LV from the aorta during diastole - Afterload increases, systolic increases - Causes o Rheumatic fever o Endocarditis o Syphilis o Marfan’s Syndrome o Aortic dissection - S/S o Increased stroke volume o Palpitations, visible neck vein pulsations o Dyspnea, fatigue, orthopnea o Angina, pulmonary congestion Pacemakers - Pre-Op o Know reason for pacemaker (ie bradycardia – atropine at bedside) o Obtain consent o Clip hair from chest near insertion sites o Baseline vitals and ECG o Labs (coag study, BMP) o IV access o Prophylaxis antibiotic, if ordered o Allergies ( contrast dye?) - Post Op o Assess site for redness, bleeding, signs of infection o Watch for pace/sense, capture (know settings) o Avoid lifting >10lbs for 2-4 weeks o Wear loose clothing o Do not remove steri strips o Pain assessment o Shower after 24 hours o Flu shot - Discharge instructions o Carry card specifying pacemaker info o Assess for signs of infection o No lifting (>10lbs for 2-4 weeks) o Keep scheduled appointments o Avoid arc welding o MRI – let them know you have a pacemaker! Pace: electrical stimuli delivered per minute; the rate its set at i.e. HR of 60; causes spikes on EKG Sense: ability of pacemaker to sense the intrinsic electrical signal of the heart Capture: appropriate complex follows the pacing spike (i.e. spike, QRS, spike, QRS, etc) ICD - Indications o Cardiomyopathy o Symptomatic v-tach o Survivors of sudden cardiac death (usually caused by VFib) o Ventricular arrhythmias that fail other treatments - Discharge teaching o Continue to take anti-arrhythmics o Driving only after cleared by cardiologist o If ICD delivers shock and you feel fine, call HCP during regular business hours o If ICD delivers shock and you don’t feel well, or multiple shocks delivered, lie down and call 911 CABG - Pre-Op o Hold anticoagulants/digoxin o Baseline peripheral vascular system perfusion (color, sensation, temp, cap refill) o o o o o o o o o o o NPO Baseline vital signs, height and weight Void before procedure Allergies Labs, EKG, CBC, Type & Cross for blood Prep (shave) ABX prophylaxis Cough/deep breath/IS/splint incision Expected pain at graft site and sternum Lots of IVs/tubes/intubation/ventilator Early Ambulation - Post-Op o By pass patients are chilled/stilled – afterwards need to warm them, watch renal/GI function o Post periph vascular system – assess affected extremity q15min for 1st hour) – concerned about o tissue perfusion Watch for pleural effusion (dyspnea, cough, decreased breath sounds) o o Tubes – NG, endotrach, CV catheter, Swanz-Ganz Pain management Heart Transplant - Criteria o <70 yo o < 1 yr life expectancy o No alcohol/drug history o No active infection o No psychological issues - Patients waiting for transplant should report palpitations, dizziness, illness, dyspnea, acute worsening