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NR 283 Patho Exam 2 Study guide
Integumentary system SKIN- largest organ, 20% of body weight ACCESSORIES
- hair 3. Gland
- nails 1. PROTECTION
- TEMPERATURE REGULATION
- PROTECT AGAINST MICROOGRANISM
- LOSS OF BODY FLUIDS
- STRESS OF MECHANICAL FORCES
- PRODUCTION OF VITAMIN D
- IMMUNE SURVEILLENCE
- PLEASUREABLE SENSATION EPIDERMIS Layers
- superficial outer layer 4. stratum spinosum
- stratum corneum 5. stratum germinativum
- stratum lucidum 6. Stratum basale Keratinocytes - keratin Melanocytes - melanin
- Vitiligo- autoimmune related loss of melanocytes; depigmentation of patches of skin Langerhan cells - present processed antigen to T- cells Merkel cells - function as slowly adapting mechoreceptors DERMIS
- deeper layer, true skin
- collagen, elastin, reticulum, and a gel-like ground substance
- hair follicles, sebaceous glands, sweat glands, blood vessels, lymphatic vessels, nerves
- Fibroblast- secrete collagen
- mast cells - release histamine
- macrophages - phagocytic immune cells
- Histocytes - loose connective tissue; phagocytize pigments and debris of inflammation SUBCUTANEOUS LAYER 1. fat cell or adipocytes and connective tissue
- dermal collagen is continuous w/ the subcutaneous collagen
- macrophages, fibroblast, fat cells, nerves, fine muscles, blood vessels, lymphatics, and hair root follicles DERMAL APPENDAGES
- hair, nails
- Sebaceous glands - secrete sebum
- Eccrine sweat glands - thermoregulate and cool the body through evaporation
- Apocrine sweat glands – limited function Blood supply and innervation
- papillary capillaries provide a rich supply of blood
- sympathetic nervous system regulates vasoconstriction and vasodilation through a- adrenergic receptors PRIMARY LESIONS
- Macule- flat, circumscribed area that a change in the color of skin (freckles, measles)
- wheal- transient lesion w/ well defined and often changing borders caused by edema of the dermis ( insect bites, allergic reactions)
- Papule- elevated, firm, and circumscribed area, measures less than 1 cm (warts)
- Pustule- elevated, superficial lesion, filled with fluid ( acne, impetigo) SECONDARY LESIONS
- Excoriation- loss of epidermis, linear, hollowed, crusted (scabies, scratches)
- Fissure- linear crack or break from the epidermis to the dermis, maybe moist and dry (athlete’s foot)
- Erosion- loss of a part of the epidermis, depressed area, moist, glisten, rupture of a vesicle or bulla (chicken pox, diaper dermatitis)
- Ulcer- loss of epidermis and dermis, concave, varies in size (pressure sore)
- pressure ulcer- result of an unrelieved pressure on skin, causing underlying tissue damage
- shearing forces, friction, moisture
- occlude capillary blood flow w/ resulting ischemia and necrosis
- STAGE 1 – nonblanchable erythema of intact skin
- STAGE 2- partial thickness, skin loss, involves epidermis or dermis
- STAGE 3- full thickness, skin loss, involving damage or subcutaneous tissue
- STAGE 4- Full thickness, skin loss w/ damage to muscle, bone, or supporting structures
*varicella- zoster virus ( VZV)
- intitial infection w/ varicella, followed yrs later by herpes zoster
- pain and paresthesia localized to dermatom
- vesicular eruptions along a facial, cervical, or thoracic lumbar dermatome
- compresses, calamine lotion, baking soda
- anti-viral drugs w/in 72 hours
- Topical lidocaine patch, anticonvulsant, tricyclic antidepressants Basal cell carcinoma and squamous cell carcinoma (most common) Malignant melanoma (most serious) most common cause of skin cancer
- chronic UV radiation
- sunscreen, protective clothing Kaposi sarcoma vascular malignancy
- drug-induced immunosuppression (after kidney transplant)
- exhibited on lower legs of man (classic form)
- epidemic and nonepidemic form related AIDS *Kaposi- associated herpes virus 8 (HHV-8) found in all forms *purpleish – brown macules, developing into plaques and nodules *local lesions- surgical removal
- multiple disseminated- combination of immunomodulatory, cytotoxic, and antiviral drugs *highly active antiretroviral therapy (HAART) for AIDS Aging skin *reflects environmental and genetic changes *thinner, dryer, wrinkles, and changes in pigmentation *# of capillary loops shorten and decrease
- melanocytes and Langerhan cells decrease *sebaceous, eccrine, and apocrine gland atrophy *wound healing delayed *temp. regulation delayed
- pressure, touch receptors, free nerve endings decrease Pityriasis rosea- *Circular single lesion *well demorcrated
*salmon pink
- secondary lesions extend over trunk and extremities Vegetans pemphigus- large blisters in tissue folds of the axilla and groin area Erythmea multiforme- “BULLS EYE” or target lesions Acne Rosacea *inflammation of the skin *bulbous nose *conjunctivitis Furuncles- inflammation of the hair follicles Tinea capitis- fungal infection of the scalp Scleroderma- massive deposits of collagen w/ fibrosis Pulmonary disease *dyspen and cough * cyanosis
- altered breathing * chest pain
- Hyperventilation * clubbing
- hemoptysis
- abnormal sputum Dyspnea *subjective sensation of uncomfortable breathing
- severe dyspnea
- flaring nostrils
- use of accessory muscles of respiration 3.retraction of intercostal spaces
- shortness of breath w/ activity *orthopynea- dyspynea w/ lying down *paroxysmal nocturnal dyspnea- awaking at night and gasping for air (need to sit or stand up) Cough- protective reflex that helps clear the airways by explosive expiration *acute cough- resolves in 2 to 3 weeks *chronic cough- lnger than 3 wks *abnormal sputum – changes in the amount, consistency, color, odor, provide information about disease Hemoptysis- coughing up blood or bloody secretions
*infection and inflammation of parietal pleura accompanied by pleura stretch during inspiration and pleura friction rub Chest wall pain may due to airway, muscle, or rib pain Hypercapnia- increased carbon dioxide (Co2) in arterial blood *occurs from decreased drive to breathe or an inadequate ability to respond to ventililatory stimulation.
- disease of medulla
- large airway obstruction
- thoracic cage abnormalities
- depression of respiratory center Hypocapnia *assessed for sever anxiety *results in alkalosis *confirmed by PaCO2/sub>36mmHg Hypoxemia- *shunting
- alvelolar dead space – area where alveoli are ventilated but not perfused Pneumonia- infection of lower respiratory tract *responsible for more disease and death than any other infection *streptococcus pneumonia- community acquired pneumonia)
- healthcare associated pneumonia *ventilator – associated pneumonia
- ROUTES OF INFECTION- aspiration, inhalation, endotracheal tubes, and suctioning Pneumoccal pneumonia- acute lung injury (ALI), resulting in inflammatory cytokines and cells, causes alveolar edema *edema aids in the spread of infection into adjacent portions of lung *involved lobe undergoes consolidation *PHASES
- consolidation
- red hepatization
- grey hepatization
- Resolution Viral Pneumonia *seasonal, mild, self-limiting
- can set the stage for secondary bacterial infection *Influenza *chills, malaise, pleuritic chest pain, cough, fever, dyspnea, proceeded upper respiratory infection
- vaccination, antibiotics, isolate, deep breathing, hydration, adequate O2, anti-viral/anti-fungal in severe cases Nosocomial pneumonia- pseudomas aeruginosa ( pathogen)
Aspiration pneumonia risk factors *amount, size, pH, of aspirate *bacterial content present in aspirate Small cell carcinoma= antidiuretic hormone producing lung tumor Acute respiratory distress causes *TB, inhalation of excessive amounts of coal dust, Reumatoid arthritis(pulmonary fibrosis) Chronic cough resulting from viral infection: *return for treatment if cough persists after 8 wks *acess for GERD *acess for allergic rhinitis Risks for chronic upper airway obstruction *congenital malformations *subglottic stenosis Tuberculosis *Myobacterium TB *acid-fast bacillus *leading cause of death from a curable infectious disease
- air borne *granulomatous lesion *causeous necrosis (cheese-like material) *may remain dormant or cause disease *isolation of bacilli *latent TB = asymptomatic *fatigue, weight loss, anorexia, low grade fever in after noon, night sweats, purulent cough
- PPD, chest x- ray, sputum culture *Isoniazid, Rifampin, Pyrazinamide, Ethambutol (for 18 mths, review at 6) Obstructive pulmonary disease *airway obstruction is worse w/ respiration *emptying lungs is slowed, more force/ time is required to expire *wheezing, dyspnea *increased work of breathing *perfusion mismatching *decreased in FEV (Forced expiratory volume) in 1 sec *can lead to asthma, chronic bronchitis, emphysema, COPD Asthma- chronic inflammatory disorder of the bronchial mucosa *causes bronchial hyperrepsoniveness, constriction of airways, obstruction
- one half of all cases develop in childhood *hygiene hypothesis *familial disorder *bronchospasm attacks, bronchial inflammation, mucosal edema, increased mucosal production *Early asthmatic response ***IgE responses
*loss of elastic recoil *primary emphysema (genetic) *secondary ( smoke, environment)
- destruction of alveoli
- oxidative stress *apoptosis of lung’s structural cell *alveolar destruction produces large air spaces w/ in lung parenchyma (bullae) and air spaces adjacent to pleurae (bleb) *dyspnea, tachypnea, BARRELL CHEST, leans forward to increase lung capcity
- O2, inhaled bronchodilators, oral or inhaled corticosteroids, antibiotics, anticholinergenics, beta agonist Pulmonary vascular disease- any condition that affects the blood vessels along the route between the heart and lungs. *causes may be due to pulmonary arterial hypertension, pulmonary venous hypertension, pulmonary embolism, chronic thromboembolic disease RIGHT HEART FUNCTION
- pumps blood throughout the lungs (pulmonary circulation)
- delivers bloods to the lung for O
- low pressure system LEFT HEART FUNCTION
- pumps blood (oxygenated) through the circulation
- delivers metabolic waste products to lungs, kidneys, and liver
- high pressure system Arteries- carry blood away from the heart (thick walls, oxygenated) Veins- carry blood to the heart (deoxygenated) Capillaries- exchange fluids between the blood and interstitial space Pericardium *double walled membranous sac *parietal- surface layer *visceral- inner layer (epicardium) *prevents displacement, acts as a physical barrier, pain & mechanoreceptors, brings force to normalize BP Pericardial cavity *space between parietal and visceral layers *contains pericardial fluids (20mL) Thoracic duct receives lymph from most of the body Angiotension II - vasoconstriction CHAMBERS OF THE HEART
*right atrium *left atrium *interatrial septum *right ventricle *left ventricle *interventricular septum *thickness of each chamber depends on pressure or resistance it must over come to eject blood Atrioventricular valves (AV’S)- one way blood flow from the atria to ventricles Semilunar valves- one way flow from ventricles to either pulmonary artery or aorta Distole- relaxation (ventricles fill) Systole- contraction (blood leaves ventricles) CARDIAC CYCLE *PHASE1- atrial systole or ventricular diastole *PHASE2- isovolumetric ventricular systole *PHASE3- ventricular ejection ( semilunar valves open) *PHASE4- isometric ventricular relaxation (aortic valves close) *PHASE5- passive ventricular filling (mitral and tricuspid valves open) S1- “LUB” S2-“DUB” S3-ventricular gallop (early diastole) S4- atrial gallop (late diastole) Caridiac output- HR X STROKE VOLUME = CO BLOODFLOW
- right atrium from superior vena cavae 8. left ventricle
- tricuspid valve 9. aortic valve
- right ventricle 10. systemic
- pulmonary trunk 11. inferior vena cavae
- pulmonary arteries
- Pulmonary viens
- left atrium Coronary circulation – supplies oxygen and other nutrients to the myocardium *coronary arteries protect form ischemia and formed by arteriogenesis or angiogenesis
- coronary capillaries- where gas exchange of O2 and other nutrients takes place *coronary viens- coronary sinus, great cardia vein, posterior vein of left ventricle CONDUCTING SYSTEM
Myocardial contraction- represents the intrinsic ability of the heart/ myocardium to contract. Changes in the ability to produce force during contraction result from incremental degrees of binding between myosin (thick) and actin (thin) filaments. Excitation contraction coupling- process where action potential triggers the cycle of events, leading to a cross bridge activity and contraction *requires calcium
- calcium troponin complex facilitates contraction Myocardial relaxation- *calcium, troponin, tropomysin needed to facilitate
- troponin release of calcium begins relaxation *vital to optimal cardiac function Cardiac output- volume of blood flowing through wither systemic or pulmonary circuit *HR X STROKE VOLUME= CO
- ejaction fraction- amount of blood ejected per minute ( 55% or higher in normal adult)
- indicator of ventricular function
- stroke volume/ end diastolic volume
- preload- pressure generated at the end of diastole
- AKA- LEFT VENTRICULAR END DIASTOLIC PRESSURE (LVED)
- determined by 2 factors
- amount of venous return to ventricle
- blood left in ventricle after systole or end systolic volume
- when preload exceeds physiologic range, further muscle stretching causes a decline in CO2.
- resistance to ejection during systole
- aortic systolic pressure is a good index of afterload for the left ventricle
- decrease afterload, heart contracts more rapidly
- increase afterload, slows contractions and increase work load Frank’s starling law *volume of blood at the end of diastole *myocardial stretch determines force (more stretch= increase force of contraction) *major way that the right and left ventricles maintain equal minute outputs, despite stroke output variation Myocardial contractibility *stroke volume *changes in stretching of ventricular myocardium caused by changes in ventricular volume (preload) *alterations in nervous system input to the ventricles *adequate of myocardial O2 supply:
- inotropic agent- increase the force of contraction
- norepinephrine – from sympathetic nerves
- epinephrine – from adrenal cortex
- thyroid hormone and dopamine
- negative inotropic agents- decrease the force of contraction
- acetycholine- releases from vagus nerve
- hypoxia- decreases contractility
Hear rate- 70 BPM *cardiovascular control center *neural reflexes
- sinus arrhythmia
- baroreceptors reflex- when BP fall, heart rate increases, arterioles constrict
- brainbridge reflex- changes in heart rate from IV infusions
- atrial receptors *hormones and biochemical Cardio inhibitory center- parasympathetic excitatory neurons Systemic circulation *arteries *viens *arterioles *peripheral vascular system – systemic circulation that *capillaries supplies skin and extremities *venules Angiogenesis- growth of new vessels that branch from existing vessels (branches from small vessels) Arteriogenesis- branching from larger vessels Vasculgenesis- growth of vessels from progenitor or stemlike cells that originate in bone marrow and other body tissue Cigarette smoke can increase thrombotic state Endothelium Roles *transport *coagulation *antithrombogenesis and fibrolysis *immune system function
- tissue growth and wound healing
- vasomotion – contraction and relaxation of vessels Velocity and viscosity affect blood flow Hypertension – (high BP)- increase cardiac output or total peripheral resistances or both *120-130 systolic/ 80-90 diastolic *older age *hypertension can cause damage to the arteries *can cause heart disease, stroke, kidney disease, bone loss *risk factors- obesity, race, gender, high sodium, sedentary lifestyle, stress, age, family history, congestive heart failure (secondary occurenc) CORONARY ARTERY DISEASE (atherosclerosis) *fatty streak, raised fibrous plaque, smooth cell proliferation *insufficient blood supply to the heart, the heart muscle does not receive the oxygenated blood it requires *antiplatelets- nitrates, beta adrenergic blockers, calcium channel blockers *chest x ray, lipid level, ECG, stress test, LDH, coronary angioplasty, tomography, cardiac troponin
Deep vein thrombosis- destruction of venous flow leading to increase venous pressure ( venous stasis can be factor) CONGESTIVE HEART FAILURE- cardiac dysfunction that result in inadequate perfusion of tissues w/ blood borne nutrient *systolic heart failure- pulmonary congestion, left EJ will be greater than 40, filling defect *right heart failure- commonly caused by a diffuse hypoxic pulmonary disease *high output failure- heart can’t keep up w/ demand Mitral regurgitation- *can be due to abnormalities of valves, annulus, chordae, tendinae, papillary muscle of LV *common causes can be degenerative (myxomatous) disease, ischemia heart disease, infectious endocarditis Pericardial effusion- (blood effusion) *endocardium inflamed by staphylococcus aureus *resulting in the presence of frank blood (coagulation defect) Infectious endocarditis *SLE, Marfan’s syndrome, Danlos syndrome *A-fib *forceful, displaced, systolic thrill *soft S1, S *Pansystolic *Barlow’s syndrome- floppy mitral valve Aortic regurgitation *asymptomatic for yrs *develop LV failure (dyspnea, orthopnea, fatigue) *collapsing pulse, laterally displaced apex beat (thrusting), wide pulse pressure *CORRIGAN’S SIGN- carotid pulsations *DE MUSSET’S SIGN- head nodding w/ each beat *QUINCKE’S SIGN- capillary pulsations
- TRAUBE’S- “pistol shot” sound over a femoral A. *AUSTIN FINT MUMUR- mid diastolic murmur over cardiac murmur Aortic stenosis- orifice of the aortic semilunar valves narrow causing diminishing blood flow from left V into aorta Mitral stenosis- impaired blood flow from left atrium to left ventricle Dyslipidemia- low lipoproteins (VLDL) triglycerides and proteins Cellular injury of myocardium – myocardial cells remain viable if blood returns in 20 min. Hemoglobin carries oxgen Hematopoiesis- production of blood cells and platelets Agranulocytes- lymphocytes and monocytes Granulocytes- neutrophils, basophils, eosinophils
Erythropoietin – a hormone released by the kidneys that stimulate RBC production Reticulocyte- immature erythrocyte Thrombopoiesis- endothelial cells primary produced in the liver Red bone marrow- primary site for production and maturation of blood cells and platelets in adults Leukocytosis- increase WBC’s Neutrophilia- increase neutrophil Neutropenia- decrease neutrophil Lymphocytosis- increase lymphocytes Leukopenia- low white blood cell count Ansiocytosis- RBC’s vary in size Polychromasia- insufficient hemoglobin w/in the cell Basophilic stippling- caused by intense regenerative anemia or lead poisioning Rouleaux- grouping of RBC’s in stacks, when increase globulin and fibrinogen Anemia *fewer circulating RBC’S * hemmorage *decreased PCV *decreased HgB *decreased production Regenerative anemia- bone marrow able to respond, increase production, releases reticulocytes Non- regenerative anemia- bone marrow doesn’t respond, no reticulocytes Hypoxia- blood loss/anemia, decrease in RBC OR Hb Polycythemia- excess EPO production by kidneys Micocytic hypochromic anemia- *iron metabolism *globin synthesis *parphyrin synthesis *heme production B12- required for nerve myelination, extended deficiency can cause neurological damage
- absorption of B
- complex w/ intrinsic factor
- transported to ileum
- B12 combines w/ transcobalamin II to be transported to PB and tissues
- stored in liver
- distributed by TC1 (plasma), TC2 ( cells), TC3 ( liver)
- causes of B12 deficiency
- pernicious anemia 6. Ideal resection and
- lack of intrinsic factor and Coron’s diease
Gaucher’s disease- accumulation of glcusycoramide in lysosomes of reticuoendothelial cells due to glucocerebrosidase deficiency Kostmann’s syndrome- neutropenic disease Thalassemia major- anemias w/ bone deformities Stromtolites present in alcoholism and liver disease Factors in increase Iron absorption *acids * iron deficiency *vitamin C * primary hemochromatosis *inorganic iron *sugars/ amino acids Factors in decrease Iron absorption *alkalis * excess iron *Antacids * decrease utilization *organic iron *gastroectomy *Ferric iron *achlohydria
- phytates *intestinal mucosal abnormalities *tea Duodeum and upper jejunum – site of iron absorption Iron deficiency- caused by altered heme synthesis in erythiod cells *hemoglobin of 7g/dl to 8g/dl accompanied by pallor *common in children due to their extremely high need for iron for normal growth Infectious mononucleosis is commonly caused by EBV ( Epstein Barr virus) Lymphoma- palpable and tender nodes Hodgkins lymphoma- peak incidence occurs in the early 20’s through 30’s and then later in life Burkitt lymphoma- fast growing tumor of the jaw and facial bones Spontaneous bleeding w/out trauma is possible when platelet count is less than 10, Heparin is most common drug induced thrombosytopenia Thrombocytopenic Pupura (TTP) *more common in females
- caused by platelet aggregates *occurring more frequently Analgesics – used for chest pain Triad of Virchow *injury to endothelium *abnormalities to blood flow *hypercoagulability of the blood Spinal cord damage will result in VASOGENIC SHOCK
