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L sided CVA R sided CVA
Aphasia Disorientation
↓ of verbal skills Impaired judgment
Personality changes ↓ in performance
skills
Reduced retention of Time orientation
verbal materials problems
Right paralysis Left paralysis or
paresthesia
Embolic stroke: fragments that break from a thrombus formed outside of the brain or in the heart,
aorta, common carotid or thorax
Hemorrhagic stroke (intracranial hemorrhage): third most common cause of CVA.
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O smotic diarrhea: a nonabsorbable substance in the intestine draws water into the lumen by
osmosis…the excess H20 & nonabsorbable substance cause large volume diarrhea (LACTASE
DEFICIENCY most common cause)
S ecretory diarrhea: caused by excessive mucosal secretion of fluid & lytes or inhibition of sodium
chloride absorption.
Cause: bacterial enterotoxins, i.e. E. coli & neoplasms, gastrinoma or thyroid carcinoma
major cause
LG VOLUME: Cause: excessive motility, i.e. lesion that impairs autonomic control of
motility, such as diabetic neuropathy
SM VOLUME: inflammatory disorder of int, such as ulcerative colitis or Chron disease
M otility diarrhea: caused by resection of small intestine, surgical bypass of an area of int or
fistula formation between loops of intestine…food is not mixed properly & there is impaired
digestion & motility
Disorders of motility:
Dysphagia: difficulty swallowing; can result from mechanical obstruction or disorder that impairs
esophageal motility likely from a neural or muscular disorder that interferes w/voluntary swallowing
or paralysis
Achalasia: denervation of smooth muscle in (middle/lower) esophagus from neural dysfx, probably a
↓ in the number of myenteric ganglion cells & atrophy of smooth muscle cells
GERD (reflux of chyme from stomach to esophagus)
LES is weakened, relieved when sitting up
1-2 hours after meal
Vomiting, coughing, lifting contribute to pressure
Eso wall: hyperemia, cap perm, edema, tissue fragility, erosion, ulcerations, fibrosis & basal
cell hyperplasia & elongation of papillae are common
“heartburn” sensation
symptoms can exist when no acid is in esophagus or ↓ eso motility results in dysphagia
alcohol & citrus fruits cause discomfort during swallowing
endoscopy = edema & erosion
Hiatal Hernia (type of diaphragmatic hernia…protrusion of upper part of stomach thru the
diaphragm & into thorax)
1. Sliding (most common): stomach slides or moves into thoracic cavity thru eso hiatus
(opening for vagus nerves)
2. paraesophageal (rolling) the membrane becomes thinned out or defective, allowing a true
peritoneal sac to protrude into the posterior mediastinum where negative intrathoracic
pressure causes it to enlarge.
ASYMPTOMATIC: difficult to distinguish, manifestations include gastroesophogeal reflux,
dysphagia, heartburn & epigastric pain…regurgitation & discomfort after eating are common
Pyloric Obstruction (narrowing or blocking of opening between
stomach/duodenum)
vague epigastric fullness…more distressing after eating & later in the day
s&s: nausea, fullness, anorexia, weight loss, distention, succession splash (rolling or
jarring of abd prod sloshing sound)
Vomiting = undigested food but no bile (cardinal sign of obstruction)
Intestinal Obstruction (ANY condition that prevents flow of chyme thru
int. lumen)
Simple: mechanical blockage of lumen by lesion (ie fibrous adhesions, most common type)
Fx: failure of motility (ie paralytic ileus)Can’t absorb h20 easily, h20 in lumen, gas buildup & absorption of lytes ↓
s&s: colicky pain followed by vomiting, sweating, n/v, distention and dehydration, metabolic alkalosis if @
pylorus or high in sm intestine (excessive loss of H+ ions OR metabolic acidosis if in lower intestine because
bicarb from panc & bile can’t be resorbed) TX: OR
Gastritis (inflammatory disorder of gastric mucosa)
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Causes: injury from drugs, alcohol, chemicals, h. pylori, antiinflamatory rx such as aspirin, ibuprofen,
naproxen, indomethacin (b.c they inhibit prostaglandins…which NORMALLY stimulates secretion of
mucus) also H. Pylori!!!!
S&s: bleeding may be only sign!!!, tenderness, pain, n/v…
Tx: smaller bland meals, cimetidine (tagamet)
Peptic Ulcer Disease (PUD: break in mucosal lining…5 million people!)
Causes: H. pylori, NSAIDS, genetics, STRESS
Chronic intermittent pain, worse when stomach is empty
Duodenal Ulcer (younger people, type O blood)
Cause: H. pylori, Hypersecretion of acid & pepsin…inadequate secretion of bicarb, rapid gastric
emptying, number of parietal cells, failure of feedback mechanism whereby acid in gastric antrum
inhibits gastrin release)
Ulcerative Colitis (inflammatory bowel disease)
o Common @ 20-40 yrs of age, Jewish descent, family hx
o Disease is most severe in rectum & sigmoid colon, mucous layer thinner than normal
Bleeding, pain, diarrhea (large volumes, watery), fluid loss & urge to defecate (purulent
mucus/blood passed in stool)
o Patho lesions of inflammation on LG intestine
o Immunologic factors (anticolon antibodies)
o Dx by lower GI study (barium enema?)
Chron Disease (idiopathic inflammatory disorder effecting any pt. of int.
tract)
o 4-10% of population, greater in Caucasian & Jewish
o Genetic (20-40%)
o S&s: Pt claims “irritable bowel”…diarrhea most common sign w/passage of blood/mucus
o PAIN after meals, weight loss & insidious onset
o Environmental, pesticides, additives, tobacco, radiation)
o T cells & alterations in IgA
o continues for life
o Begins in submucosa int wall mucosa/serosa …MOST common site = ileocolon
o “skip lesions” discontinuous inflammation affects some haustral segments but not others
o Tx: steroids, antiD, antiB, psychotherapy or removal of inflammed bowel
Diverticulitis
Diverticulum: outpouching of mucous membrane that lines the bowel & goes out through the muscle,
anywhere in GI tract, but 95% in sigmoid colon
o Most common over 60 yrs….high refined food diet
o More common in men (congenital predisposition)
o Sx: cramps, LLQ pain, constipation before disease s&s irregularity/diarrhea
o Tx: surgery…rest bowel w/meds
IBS (Irritable Bowel Syndrome)
o Relatively common 1:6, but 3:1 women vs. men
o Onset 20-30yrs
o Cause…???
o Disorder of int. motility, CNS alterations to motor & sensory fx of bowel
o peristaltic intensity, secretion of mucus in color but NO inflammed tissue
o s&s: abd. Pain, bouts of diarrhea/constipation, change in bowel patterns & stimulated by
certain foods and STRESS!
o Dx: rule out other GI…nursing dx=pain, ineffective coping, diarrhea/constipation…assess
what stimulates the condition & work with the PT to rule out those factors i.e. bulk diet
o Rx: Anticholinergics to interfere w/PNS; antiD, antisposmodics, herbal remedies (peppermint,
sage, anise)
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Structure & Fx of the Pulmonary System Ch. 31 (Fx: ventilate alveoli,
diffuse gases in & out of blood, perfuse lungs so organs and tissues
receive 02 rich blood)
Neurochemical control of ventilation
o Respiratory center: in brain stem, composed of several groups of neurons located
bilaterally…
DRG: dorsa respiratory group sets basic automatic rhythm of respirations also receives
impulses from peripheral chemoreceptors in carotid & aortic bodies
VRG: ventral respiratory group (in medulla)…contains both inspiratory & expiratory
neurons
The pneumotaxic & apneustic centers
o Lung receptors: send impulses from lungs to DRG: (lungs are innervated by ANS)
Irritant receptors: found in epi of conducting airways…sensitive to noxious aerosols,
gases, etc & cause bronchoconstriction and ventilatory rate (proximal airways mostly)
Stretch receptors: located in smooth muscles of airways & are sensitive to size/volume
of lungs….these are responsible for ↓ ventilatory rate & volume when stimulated
J receptors: sensitive to pulm cap pressure & initiate rapid, shallow breathing,
hypotension & bradycardia
o Chemoreceptors: monitor pH, Paco2, Pao2 of arterial blood
Central chemoreceptors: monitor arterial blood, by sensing changes in pH of CSF…pH in
the CSF reflects Paco2 because unlike H+, co2 in arterial blood diffuses across blood-brain
barrier
o Co2 that enters CSF combiners with H20 to form carbonic acid, which disassociates
into H ions & stimulate central chemoreceptors…VERY SENSITIVE to small changes
in pH.
Peripheral chemoreceptors: located in aortic & carotid bodies, the aortic arch
o Primarily sensitive to o2 levels in arterial blood & responsible for all the in
ventilation that occurs in response to arterial hypoxemia…sends signals to resp
center to ventilation
BARORECEPTORS: located in aortic arch & carotids: respond to BP & changes in ventilation
PROPRIOCERPTORS: in peripheri…respond to body mvmt and ventilation
Alveolar surface tension:
o Law of Laplace: The pressure (P) required to inflate a sphere is = to 2x the surface tension
divided by the radius or
o P=[2T/r] …as the radius of the sphere becomes smaller, more and more pressure is required
to inflate it. RELATES TO PRESSURE!
Elastic recoil: tendency of the lungs to return to normal state after inspiration
Compliance: measure of lung and chest wall distensibility; it represents the relative ease with which
these structures can be stretched. C =(v/p)
One half to two thirds of airway resistance occurs in the nose! p.1092
Physiologic dead space: amojnt of air that remains in alveoli & tracheobronchial tree between
breaths
Oxygen content of blood: depends on the amount of O2 combined w/hemoglobin, as well as that
dissolved in the blood
Must know: 1) hemoglobin concentration available to bind with O2 (hb in gr/dL) and 2) O2
sat or % of available hemoglobin bound to O2 (SaO2) …and 3) the partial pressure of O2
(paO2)
Oxyhemoglobin Association & Disassociation
When hemoglobin binds w/O2, oxyhemoglobin is formed. Binding occurs in the lungs and is
called oxyhemoglobin association or hemoglobin saturation curve.
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Shift to the RIGHT depicts hemoglobins ↓ affinity for O2 or an increase in the ease in which
oxyhemoglobin dissociates and O2 moves into the cells…i.e. acidosis (low pH) & hypercapnia
( PaCo2) and hyperthermia
Shift to the LEFT depicts hemoglobins affinity for O2, which promotes assoc in the lungs
and inhibits disassociation in the tissues…i.e. alkalosis (high pH) & hypocapnia (↓PaCo2)
and hypothermia
The shift byh changes in Co2 & H+ concentration is called the Bohr effect.
Oxyhemoglobin curve is shifted also by changes in body temp and or ↓ levels of 2,3-DPG, a
substance normally present in RBCs (hyperthermia to RIGHT, hypothermia to LEFT)
Carbon dioxide transport:
Co2 equilibrates with carbonic acid & must be eliminated to prevent acidosis
Acid base balance…. CO2 + H20 H2CO3 H+ + HCO3-
Tests of Pulmonary Fx
Spirometry: measures forced expiration…measures volume & flow
Restrictive lung disease: restricts lungs VOLUME…lungs are unable to expand normally, diminishing the
amt of gas that can be inspired. (ARDS, viral infx, cancer of lung, TB)
Obstructive lung disease: affect gas flow, airflow into &
out of lungs is obstructed (COPD, emphysema,
bronchitis, asthma)
VC = TV + IRV + ERV
VC (Vital Capacity): max volume of air that is
exhaled after full inspiration
TV (Tidal Volume): volume of air normally inhaled or
exhaled
IRV (Inspiratory Reserve Volume): max volume of
air that can be inhaled after normal inhalation
ERV (Expiratory Reserve Volume): max volume of
air that can be exhaled after normal exhalation
RV (Residual Volume): volume of air in the lungs
after max exhalation
TLC (Total Lung Capacity): volume of air in lungs after max inhalation
FRC (Functional Residual Capacity): volume of air in lungs at resting & exhalation
Diffusing capacity: measure of 02 & Co2 exchange
Perfusion: actual blood flow through pulmonary circulation…greater pressure = greater
perfusion
Route of blood thru lungs: right ventricle pulmonary artery supplies BOTH lungs
Shunting: normally about 2% of blood pumped by right ventricle does not perfuse alveolar
caps and does not have gas exchange…the HIGHER the amount of shunted blood, the MORE
the HYPOXIA
Alterations of Pulmonary Fx Ch. 32 p.1105
Dyspnea: sensation of uncomfortable breathing, or unable to get enough air…usually caused by
extensive pulmonary disease
Orthopnea: pulmonary congestion that causes dyspnea by the vertical position, b/c body water is
redistributed & abd contents exert pressure on diaphragm and the efficiency of the respiratory
muscles
Obstructed breathing: occurs if airways are obstructed as in COPD…slow vent rate, large TV,
effort & prolonged inspiration or expiration
Restricted breathing: pulm fibrosis, or disorders that stiffen the lungs or chest wall and
compliance…small TV & rapid vent rate (tachypnea)
Hypercapnia (Co2): most causes are a result of decreased drive to breathe or inadequate ability to
respond to vent stim:
o Depression of resp center by drugs
o Diseases of medulla; infx of CNS or trauma
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o Abnormalities of the spinal conduction pathway; i.e. poliomyelitis
o Diseases of the nm junction or the resp muscles, i.e. MG (myasthenia gravis) or muscular
dystrophy
o Large airway obstruction; tumors or sleep apnea
o work of breathing or physiologic dead space as in emphysema
Hypoxemia ( o2 of arterial blood): Causes:
1. o2 content of inspired gas
2. hypoventilation; i.e. unconscious person…sedation, and COPD
3. diffusion abnormalities
4. abnormal vent-perfusion ratios MOST COMMON CAUSE:
5. pulmonary RIGHT to LEFT shunt (when blood passes through portions of cap bed that
receive no vent, b/c alveoli are collapsed or filled w/fluid & cellular debris…blood flows
thru pulm circ without being oxygenated which results in systemic Pa02 & hypoxemia.
Hypoxemia resulting from shunting does NOT respond to in supplemental inspired O2
(i.e. nasal cannula) b/c a portion of the pulm cap bed is never exposed to the o2 gas…
this makes hypoxemia resulting from shunting VERY difficult to treat; i.e. ARDS & RDS of
newborn…High V/Q (look on pg 1109 table 32-2) = most common cause is pulmonary
embolus
Hypoxia: (↓ o2 of tissues) Causes:
1. Low CO
2. cyanide poisoning\
Acute Respiratory Failure: inadequate gas exchange…can result from direct injury to lungs, airways
or chest wall or indirectly due to another body system such as brain (resp centers)
Pulmonary edema: excess h20 in the lung…MOST COMMON CAUSE is HEARTDISEASE
(when left ventricle fails, filling pressures on left side of heart and cause a concomitant
in pulm cap hydrostatic pressure…when this pressure exceeds oncotic pressure, fluid
moves into interstitial space)
o Another cause of pulmonary edema=cap injury that cap permeability…i.e. ARDS or
inhalation of toxic gases such as ammonia
o Another cause of pulm edema: obstruction of lymphatic system
o Sx: dyspnea, orthopnea, hypoxemia, work of breathing…crackles & dullness over lung
bases
o Cardiomegaly {}…severe = pink frothy sputum
Aspiration: passage of fluids/solid particles into lung (commonly caused in individuals whose normal
swallowing mechanism & cough reflex are impaired by a LOC or CNS abnormality)
o Substance abuse, sedation, anesthesia, seizure disorder, CVA, myasthenia gravis (nm
disorder) & Guillain-Barre syndrome (inflammation of nerves)
o In children: tracheoesophageal fistula
o SEVERE PNEMONIA can result….50% will death rate from aspiration pneumonia
Atelectasis: Collapse of lung tissue…two common types: Compression & absorption
1. Compression: ext pressure by tumor, fluid, or air in pleural space, or by abd distention
pressing on lung causing alveoli to collapse
2. Absorption: removal of air from obstructed/hypovent alveoli or from inhalation of
CONCENTRATED O2 or anesthetic agents
s&s: dyspnea, cough, fever, leukocytosis…tends to occur post OP, pain, shallow breathing, reluctant to change
positions & viscous secretions produced…DEEP breathing (spirometer) beneficial! b/c it promotes ciliary clearance
and stabilizes alveoli by redistributing the surfactant, and permits collateral vent thru pores of Kohn in alveolar
septa (which open only during deep breathing & allows you to pass air from well vent alveoli to obstructed
alveoli…minimizing their collapse.
COPD: inflammation, edema, fibrosis of bronchial wall, loss of elastic fiber, loss of
alveolar tissue, loss of elastic fibers which impairs expiratory flow SOB
w/exertion, sputum in a.m., cough w/sputum, fatigue
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*pursed lip breathing ><can help relieve dyspnea (p 1125) ..teach, nutritional counseling, resp hygiene, early
s&s of infx
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Progressive respiratory distress, severely ill, LOC
Tx: Trach, suctioning, semi fowlers or prone positioning, psych support vent, PEEP, IV, enteral feeding,
high 02 concentration, partial liquid ventilation, sedation to 02 consumption, drugs to CO….HIGH
mortality
Rapid, shallow breathing, resp alkalosis; dyspnea, lung compliance;
Hypoxemia unresponsive to o2 tx & diffuse alveolar infiltrates on chest radiographs
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Review:
1. Review first unit, hypo/hypercorticoids, adrenal medulla, humoral & cell
5. Nervous system…know R & L hemi CVA s&s, one vs. the other…know common
11. Nausea & CTZ center, physiologically what activates, cellularly with the
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13. Respiratory conditions: TB, resp, overall category for restrictive vs. obstructive
disorders OK
they do? OK
20. o2 therapy & admin of O2, overload & toxicity to o2, typical sx? Symptoms
similar to ARDS, occurring with o2 conc 50-75% in 24 to 48 hrs…severe
inflammatory response, mediated by 02 radicals, damage to alveolocapillary
membranes, disruption of surfactant production, insterstitial and alveolar
edema, in compliance
21. review section on shunting of blood & what it refers to OK
heart …???
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