b
the adrenal cortex secretes:
1) cortisol:
a) a glucocorticoid -- an endogenous steroidal hormone that affects MANY metabolic activities of the body
b) exogenous steroids (made in a lab & given to patients) mimic this glucocorticoid.
2) aldosterone: a mine
b
hypercortisolism and hyperaldosteronism.
1) hypercortisolism-- higher-than-normal levels of cortisol in body
a) usually called______ when the high levels of cortisol are due to receiving chronic steroid treatment (remember, exogenous steroids are essentia
c
there is pathologic oversecretion of adrenocorticotropic hormone (ACTH) from the pituitary gland
(a) normally ACTH & cortisol balance each other out in a normal negative feedback loop
(b) if pituitary malfunctions, such as when there is a pituitary tumor,
d
no matter what the original etiology, increased levels of cortisol & aldosterone cause following S&S:
a. pathologically increased glycogenolysis & gluconeogenesis, so patient will often have _____________, which can lead to the development of Type II diab
a
abnormal breakdown of adipose tissue (lipolysis), resulting in high levels of circulating fat products (hyperlipidemia) and their deposition in certain body areas:
1) trunk ("truncal obesity"); face ("moon face"); and back ("buffalo hump)� this combinatio
a
1) trunk ("truncal obesity"); face ("moon face"); and back ("buffalo hump)� this combination is often known as "cushinoid appearance"
2) high levels of LDL & increased risk for atherosclerosis
3) weight gain in general.
4) Hyperglycemia
c. abnormally cata
a
d. increased break down of bone (increased osteoclastic activity) can lead to:
1) hypercalcemia and its S&S's�lethargy, fatigue, etc
2) spillage of calcium into urine (hypercalcinuria) increased risk of renal calculi.
3) osteoporosis & pathological fractu
d
S&S
1) increased Na & H20 retention fluid volume overloadweight gain, edema, HTN
2) hypokalemia
g. other miscellaneous problems such as acne and hirsutism (increased hair growth, usually in inappropriate places)
A. increase of cortisol & aldosterone
B. Cu
b
dx�draw cortisol levels at different times of the day
6) tx�withdraw or decrease exogenous steroids; fix pituitary or adrenal tumor if that is the problem; give drugs that block aldosterone if necessary.
A. increase of cortisol & aldosterone
B. Cushing's
a
cause: most frequent one is autoimmune attack on adrenal gland with resultant destruction of tissue; other possible causes includes pituitary problem (hypopituitarism).
2) sequelae of hypocortisolism: hypoglycemia, which results in fatigue, weakness, apat
b
severe hypotension due to fluid loss
A. increase of cortisol & aldosterone
B. Addisonian crisis
C. increase of cortisol & lipoproteins
D. hyperaldosteronism
c
hyperglycemia & glucosuria, and also (most of the time) long-term problems that are system-wide
2) usually also polyuria & polydipsia, so DM is a DRY disease.
3) 3rd "P" is polyphagia, excess hunger, seen in Type I.
b. diagnosis / monitoring
1) FBS (fasti
d
diagnosis / monitoring of DM
a. normal fasting serum glucose = ___________ (glucose level normally rises after meals, but should normalize as insulin "ushers" it into cells)
A. 60-100
B. 50-100
C. 80-120
D. 70-110
c
b. diagnosis / monitoring
1) FBS (fasting blood sugar) > 126 on two occasions (norm = 70 to 110)
2) Hgb A1C: the percentage of glucose-carrying Hgb molecules over the lifespan of an RBC; norm around 4%; aim for diabetics�keep it < 7%; high A1C = high aver
a
(used to be called "juvenile onset")-- it is due to a TOTAL lack of insulin secretion from beta cells of pancreas
A. Diabetes Type 1
B. Addisonian crisis
C. Diabetes Type 2
D. hyperaldosteronism
c
(used to be called "adult onset") -- it is caused by:
1) abnormally low insulin production (but there is SOME insulin) and impaired insulin utilization (insulin resistance)
A. Diabetes Type 1
B. Addisonian crisis
C. Diabetes Type 2
D. hyperaldosteronism
a
cause: autoantibodies destroy pancreatic tissue NO INSULIN
2) 2 categories of acute sequelae of no insulin:
hyperglycemia & its untoward effects, including dehydration.
no cellular energy source
3) hyperglycemia & its untoward effects
BS's (blood sugars)
a
ABGs show metabolic acidosis
patient might have acetone breath (ketones are being blown off)
might have Kussmaul respirations to blow off CO2 & bring up pH.
extreme state patient could become unconscious (from irritating effects of acidosis on brain tissu
c
patho begins with increased fat cells in the body, which causes wide spread resistance to insulin
SOME glucose is getting into the cells from the blood, but some is NOT, so the glucose in the blood increases
pancreas reacts to this continued hyperglycemia
c
S&S--
hyperglycemia & glucosuria, like type I, but no DKA or weight loss because there is still SOME glucose getting into cells.
since this is slow process, sometimes S&S very subtle�mild polydipsia & polyuria, fatigue
also, BS's can get very high - 400-9
b
1) angiopathy, from toxic effects of glucose molecules on lining of arterial vessels
microangiopathy�damage to small vessels
o diabetic retinopathyblurred vision, blindness
o kidney arteriolerenal failure
o capillaries of skin easy bruising
macroangiopath
b
2) neuropathy due to angiopathic ischemia to nerves in various tissue (plus direct toxicity of glucose)
o peripheral neuropathy�burning, pain, numbness of legs & feet that can lead to high risk of trauma
o autonomic neuropathy�autonomic nervous system aff
d
a cluster of conditions that greatly increases a person's risk for heart disease�type II DM, elevated LDLs & decreased HDL, HTN, abdominal obesity. 25% of people in US have this!!!
A. Hypoglycemia
B. Diabetes Meillitus
C. Cushing's syndrome
D. metabolic s
a
1) etiology-- decreased food intake & other nutritional factors; in case of diabetes, can occur from too much anti-diabetic medication such as insulin 2) S&S�fatigue, shakiness, irritability, sweating�occur from effect of counter-regulatory hormones.
3) t
diabetes, dry
diabetes, dry
a
if person can swallow ok, give glucose in form of orange juice, packet of sugar, etc
(follow that by complex carb like cracker)
b. if in danger of not being able to swallow and/or is unconscious, give IV glucose; or can give intramuscularly (IM) or subcut
b
dry skin, unconscious, possibility of dying, and treat with insuling are related to:
A. Insulin Coma
B. Diabetic Coma
a
diaphoresis, unconscious, seizures, possibility of dying, treat with glucose and glucagon are related to:
A. Insulin Coma
B. Diabetic Coma
c
A patient with Type I diabetes has a pH of 7.32. This is most likely caused from the byproducts of increased:
a. insulin resistance.
b. hyperinsulinism.
c. gluconeogenesis.
d. glucagon.
B, E, H, J, K, L
Type I and Type II diabetes usually have in common all the following EXCEPT (choose all that apply):
a. macroangiopathy.
b. polyphagia.
c. neuropathy.
d. risk for dehydration.
e. Kussmaul respirations.
f. high serum osmolality.
g. micrioangiopathy.
h. ace
a
The nurse caring for a woman with Cushing's disease may expect assessment finding of all below EXCEPT:
a. exophthalmus.
b. hirsutism.
c. truncal obesity.
d. high blood pressure.
d
A patient presents with S&S of dehydration, weight loss, and a blood glucose of 50. A likely diagnosis is:
a. Cushing's disease.
b. hyperpituitarism.
c. hypothyroidism.
d. Addison's disease.
d
Complaints of polydipsia and polyuria could be linked to all the following disease processes EXCEPT:
a. DM
b. Addison's disease.
c. diabetes insipidus.
d. SIADH.
b
reflux of HCL (hydrochloric acid) and pepsin from the stomach into the esophagus.
b. may be due to a relaxation of the lower esophageal sphincter (LES) and/or delayed emptying of the stomach.
c. may have symptoms of heartburn, epigastric pain, coughing, w
a
herniation of the stomach through the diaphragm so that it protrudes into the thoracic cavity.
b. pt may experience GERD, epigastric pain, dysphagia, or no S&S at all.
c. tx�may need surgery.
a. hiatal hernia
b. gastroesophageal reflux disorder GERD
c. ga
c
a. an inflammation that affects gastric mucosa and can cause erosions (superficial areas of wearing-away of mucosa).
b. S&S include pain or burning over epigastric area, and occasionally bleeding (acute hemorrhagic gastritis).
c. can be acute or chronic:
c
usually results from use of overuse of NSAIDS (suppress protective prostaglandins) or ETOH (direct chemical damage).
b) heals spontaneously once the offending agent is removed.
a. hiatal hernia
b. chronic gastritis
c. acute gastritis
d. peptic ulcer disea
b
thought to be autoimmune etiology
b) occurs mainly in the elderly and causes an atrophy of the gastric mucosa.
c) as a result of the atrophy they develop pernicious anemia because of the loss of intrinsic factor.
a. hiatal hernia
b. chronic gastritis
c. a
d
chronic inflammatory condition of stomach & proximal duodenum in which disturbance of their mucosal lining allows acid to ulcerate the underlying tissue, causing gastric and/ or duodenal ulcers
2. aggressive change factors that can cause mucosal disturban
d
S&S and treatment
a. sometimes it can be painless; others cause burning epigastric pain 1-3 hours after meals or pain that awakens the person during the night
b. if it begins eroding blood vessels, patient can have GI bleeding of various degrees, dependin
d
besides usually having one or more of the above factors, most patients diagnosed with PUD are also positive for an organism called 1) __________ is a bacterium that can be ingested via food, drinking water or other oral/fecal route-- infection more common
dysplasic, precancer
dysplasic, precancer
a
number 3 killer amongst all cancers
b. almost always arises from a pre-existing benign neoplasm, usually in the form of a polyp (stalk-like growth on the wall of the colon) which becomes malignant.
c. risk factors:
1) age over 50
2) high-fat diet, obesity
a
S&S, dx, tx
a. few obvious early S&S but most common are:
1) blood in stool, either visible or occult
2) change in bowel habits
b. dx'd most often by colonoscopy
c. tx
1) if confined to a polyp, a simple polypectomy during the colonoscopy will cure it
2)
b
is a chronic disorder characterized by inflammation of the lining and walls of the intestines.
b. it includes 2 main types�Crohn's disease & ulcerative colitis
c. common features of both:
1) basic problem is inflammation which causes episodes of bloody di
b
along with inflammation that causes diarrhea & cramps, other potential problems include:
a) intestinal obstruction from chronic inflammation and scarring
c) fistula formation --abnormal channels or tracts that develops in the presence of inflammation and
c
pattern of intestinal involvement differs from ulcerative colitis:
1) may involve any portion of the GI tract, but in 70 % of cases involve duodenum, ileum, and/or & cecum; 20% of cases involve rest of large intestines
2) ALL layers of bowel are involved�
d
1) found only in colon, not small intestines-- severe inflammation and ulcerations begin in the rectum & progress to involve entire colon
2) the involved segments are not separated by normal tissue�ie, areas are confluent, not patchy
3) inflammation and u
a
an occlusion of either the small or large intestine that can be partial or complete in nature.
b. pathogenesis / S&S: obstruction ? sequestration of gas and fluid proximal to the obstruction ? abdominal distention (become swollen/stretched)? causes follow
b
scar tissue from surgery or from a chronic inflammation such as IBD.
a. intestinal obstruction
b. adhesions
c. hernia
d. ulcerative colitis
c
intestine protrudes through a weakness in the abdominal muscle or through the inguinal ring
c. tumor in the lumen of the intestine
a. intestinal obstruction
b. adhesions
c. hernia
d. intussusception
d
telescoping of one portion of the bowel into the other, causing strangulation of blood supply; more common in infants.
a. volvulus, AKA torsion
b. adhesions
c. hernia
d. intussusception
a
-- twisting of the intestine with occlusion of blood supply.
a. volvulus, AKA torsion
b. paralytic ileus
c. hernia
d. intussusception
b
loss of peristaltic motor activity in the intestine
1) not a physical obstruction, but a functional one, because all peristalsis stops, & fluids, gases, etc, build up, causing distention, constipation, pain, etc
2) associated with immobility, post-anesthe
c
herniations or saclike outpouchings of mucosa from the muscle layer of the intestine that protrude from the intestine
b. most commonly occur in the sigmoid colon.
a. diverticulosis
b. Appendicitis
c. diverticulum
d. diverticulitis
a
asymptomatic diverticular disease
a. diverticulosis
b. Appendicitis
c. diverticulum
d. diverticulitis
d
inflammation / infection of the diverticula.
a. S&S: pain-- most often LLQ pain; fever; leukocytosis
b. can result in abscess formation, rupture and peritonitis if not treated adequately.
c. tx: increase dietary fiber, avoid certain foods (seeds, nuts); s
b
an inflammation most often caused by fecal matter getting caught in lumen of appendix, inviting infection & inflammation; a slight genetic predisposition
b. the most common surgical emergency of the abdomen; treatment is appendectomy.
2. S&S /complication
b
pain pattern:
1) epigastric or periumbilical pain that then migrates to become RLQ pain.
2) like many inflammatory problems, pain is exacerbated upon movement (patient wants to hold very still)
3) "rebound" tenderness sometimes present.
b. N/V/D, anorexia
a
acute hemorrhagic gastritis
b. esophageal varices - large torturous veins in the esophagus caused by liver disease that can be easily irritated & caused to bleed
c. peptic ulcers
2. S&S that tell you bleeding is coming from UGI area of gut:
a. hematemesis
a
bleeding from esophagus, stomach, duodenum
A. Upper GI
B. Lower GI
a
deposition of excess bilirubin under skin, mucous membranes, sclera of eyes; types (based on the part of the bilirubin cycle that has been altered)�prehepatic, hepatic, posthepatic
a. jaundice (icterus)
b. prehepatic
c. posthepatic, or obstructive jaundic
c
Autoimmue/systemic. bloody stools/diarrhea,
A. Crohn's
B. Ulcerative colitis
C. both
a
ileum, patchy areas, transmural, weightloss, malnurished, thin
A. Crohn's
B. Ulcerative colitis
C. both
b
rectum, confluent, dehydration, non-transmural
A. Crohn's
B. Ulcerative colitis
C. both
b
most common causes:
a. IBD
b. diverticulitis
c. neoplasms
2. S&S that tell you bleeding is coming from LGI area of gut
a. occult bleeding
1) stool may look normal, but actually has small amt of hidden blood from a slower, chronic bleeding situation such a
a
normal physiology of bilirubin
1) bilirubin is the product of RBC break-down
2) there is normally a small amount in the blood, but most is excreted as a waste product:
a) in the stool-- gives stool its normal brownish color.
b) in the urine as urobilinoge
b
occurs because of increase in unconjugated bilirubin (AKA indirect bilirubin)
b. most common causes are hemolytic conditions:
1) increased unconjugated bili occurs when the rate of hemolysis (the breakdown of RBCs) exceeds the liver's ability to handle th
b
can happen in the second (or more) pregnancy when mother is Rh neg & fetus is Rh pos (and mom didn't receive Rhogam with previous similar pregnancy)�the baby becomes severely jaundiced as the mother's antibodies to the Rh factor hemolyzes the fetus's RBCs
b
1) total serum bili high
2) serum indirect bilirubin (ie, unconjugated bili) �high
3) serum direct bilirubin �normal
a. jaundice (icterus)
b. prehepatic
c. posthepatic, or obstructive jaundice
d. diverticulitis
c
blood test results that reflect posthepatic jaundice:
1) total serum bilirubin�high
2) indirect bilirubin�normal
3) direct bilirubin--�high
a. jaundice (icterus)
b. prehepatic
c. posthepatic, or obstructive jaundice
d. diverticulitis
a
1) total serum bili high or normal
2) serum indirect bilirubin (ie, unconjugated bili) �high
3) serum direct bilirubin �low(because the diseased liver cannot conjugate)
a. hepatic jaundice (icterus)
b. prehepatic
c. posthepatic, or obstructive jaundice
d.
c
occurs because of increase in conjugated bilirubin (AKA direct bilirubin) in the blood.
b. liver converts unconjugated bilirubin to conjugated just fine, but there is a problem with the flow of bilirubin actually making its way to the intestines due to an
a
occurs because of increase in unconjugated bili
b. if hepatocytes are diseased, such as in hepatitis & cirrhosis, the liver cannot conjugate the unconjugated bilirubin that arrives remains in blood as unconjugated= higher-than-normal level of indirect bil
b
inflammation of the gall bladder�is almost always caused by irritation of stones inside the gall bladder itself (cholelithiasis) and/or in a nearby duct such as the common bile duct (choledocholithiasis)
2. patho cholelithiasis / cholecystitis:
a. the sto
b
pain in the RUQ & epigastric area
1) often manifested as painful spasms/ contractions of the GB & bile ducts called bilary colic
2) most commonly comes on or worsens after high-fat meal (more fat in intestines = more need for bile to emulsify it secretion
b
risk factors:
a often associated with obesitymore cholesterol in the bile
b. estrogen reduces synthesis of bile acid & increases liver secretion of cholesterol into bilestones more common in women, especially those on contraceptives or have had multiple p
b
1) often leukocytosis (from inflammation & sometimes infection)
2) high direct bilirubin levels (an obstructive process)
b. other tests: ultrasound (can detect stones as small as 1-2cm), CAT scan
c. there are several treatments, but if the is inflamed eno
c
severe, life-threatening disorder associated w/ escape of pancreatic enzymes into pancreas & surrounding tissues, causing autodigestion and hemorrhage
a. cause:
1) can be due to gallstones, in which the pancreatic duct obstruction and/or biliary reflux is
c
S&S
1) pain in epigastric area --abrupt onset of post-prandial or post-alcohol- ingestion epigastric pain that is severe and often radiates to the back
2) jaundice may appear because of biliary obstruction/inflammation
c. diagnosis
1) labs-- serum amylase
d
a. 4th leading cause of death in US�one of most deadly malignancies; risk of getting increases w/age�most occurs 60 to 80 years
b. cause unknown�smoking & diet high in fat, meat, salt, dehydrated foods, fried foods, refined sugars have been linked as majo
d
similar S&S to pancreatitis, but much more insidious onset
1) pain, jaundice, wt loss
2) because so close to common duct & ampula of Vater, tends to obstruct bile flow, so jaundice is frequently presenting symptom
3) but more often than not, by the time t
b
inflammation of the liver
a. overview
1) many causes, including autoimmune problems, microbes, idiopathic.
2) spectrum from very mild & self-limiting to causing cirrhosis and death.
3) S&S vary & may include aching, fatigue, malaise, N,V, D, jaundice.
b v
b
S&S have fairly acute onset (fever, malaise, jaundice); course usually mild with full recovery
b) often transmitted enterally; ex-- tainted food such as oysters c) a vaccine is now available for this, but can also get immunoglobulin shot if you haven't be
d
transmitted parenterally (from "outside" the gut) via IV drug abuse, receiving blood, needlestick of infected patient & sexually
b) insidious onset with potentially devastating destruction of liver cells; can exist without S&S for many years while being p
c
defined as end-stage, IRREVERSIBLE disease of liver
1) usually begins with some inflammatory initiation, which eventually leads to most of normal architecture of entire liver being destroyed and replaced with fibrous tissue and abnormal nodules
2) causes
c
1) the major, most common cause is excessive ETOH (alcohol) intake; alcohol's toxic metabolites gradually destroy hepatocytes & they are replaced by fibrotic tissue & fat cells
2) toxic reactions to drugs & chemicals (ex�too much acetaminophen overtaxes l
c
a) without ____________ liver cannot perform normal metabolic functions & patient will have some or all of the problems / S&S listed below.
b) nutritional problems due to impaired...
(1) production of bile saltsunable to absorb fat & fat- soluble vitamins
c
protein depletion problems
(1) decreased levels of plasma proteins, which contributes to fluid shift problems such as ascites & generalized edema
(2) decreased levels of clotting factors-- fibrinogen, prothrombin, other factors
(a) this is partially due t
c
problems related to metabolic dysfunction:
1) nutritional problems due to impaired:
� bile salt productionmalabsorption of fats & fat-soluble vitamins
� fat & cholesterol metabolism can't synthesize lipoproteins
� ability to create, store, and catabolize
c
3) metabolism of drugs, hormones, & other substances impaired: cannot break down:
� ammonia to urea (normally proteins are catabolized to ammonia then urea then excreted in urine)increased ammonia levels hepatic encephalopathy (confusion, blurred vision,
b
1) ascites�back pressure from venous blood that can't flow through the liver (too stiff & obstructive) fluid backs up into small arteries & capillaries of abdomen increased hydrostatic pressure causes fluid to leak into abdominal tissues swollen abdomen
2
b
A patient with cirrhosis has an RBC count of 2 million, and a low platelet count. These are most likely caused by:
a. cellular hemolysis from pancreatitis.
b. splenomegaly secondary to portal hypertension.
c. esophageal varices secondary to portal strictu
a
The patient in question 1 also has ascites. In reviewing the patient's lab work, the nurse understands that one likely cause of the ascites is: (normal osmolality is 280-295)
a. serum osmolality of 275 due to decreased serum proteins.
b. serum osmolality
c
A jaundiced patient has a higher than normal direct bilirubin. The mechanism most likely responsible for this is ________, and a likely responsible disease process is ____________.
a. prehepatic obstruction; erythroblastosis fetalis
b. increased unconjuga
d
The nurse caring for a patient with cirrhosis notices signs and symptoms of encephalopathy such as confusion and asterixis. The cause of these is most likely:
a. increased serum lipase.
b. prolonged PT & PTT.
c. decreased conjugated bilirubin.
d. increase
b
A patient is having melena stools. This is most likely due to:
a. low level of intrinsic factor in the gut.
b. digested blood from a duodenal ulcer.
c. gastroparesis causing slow emptying.
d. hematemesis from PUD.
b
The patient at most risk for an intestinal obstruction would be one who
a. smokes and consumes large amounts of caffeine.
b. is on prolonged bedrest.
c. is eating a low fiber and high fat diet.
d. has diverticulosis.
d
A patient with ulcerative colitis will have
a. a paralytic ileus.
b. patchy area of inflammation of the jejunum.
c. intestinal polyps.
d. hematochezia
d
All the following are consistent with upper GI problems EXCEPT:
a. GERD.
b. H. pylori.
c. esophageal varices.
d. diverticulitis.
a
A patient with choledocholithiasis is likely to have a _______ because_____.
a. high serum direct bilirubin: obstruction of bile duct results in leakage of conjugated bilirubin into the blood.
b. normal level of conjugated bilirubin; prehepatic breakdown
lower, gi, bleed, in, stool
lower, gi, bleed, in, stool
a
the cause is in the esophagus, stomach, duodenum (ex- PUD):
a. hematemesis (blood in vomit): either be occult, frankly bloody, or coffee ground (digested blood)
b. stools: occult blood or melena (tarry black = digested blood) Ex. GERD, H. pylori, esophage
b
- the cause is in the jejunum, ileum, large intestines (ex- IBD)- stools can contain occult blood or be frankly bloody (hematochezia) EX. Diverticulitis, IBD, neooplasms
A. upper gi
B. Lower gi
macrocytic, pernicious, gastritis
macrocytic, pernicious, gastritis
b
lab tests specific for liver:
a) elevated indirect serum bilirubin; sometimes also low direct bilirubin
1) patho of high indirect bili: normal level of unconjugated bili enters liverthe diseased hepatocytes cannot conjugate itremains in blood as unconjuga
b
2) tx of liver disease
a) enhance nutrition & no alcohol
b) reestablish appropriate fluid balance
(1) give diuretics to mobilize fluid from tissue to blood to urine
(2) sometimes give IV albumin to increase protein in blood so water won't be going out fro
b
splenomegaly�shunting of blood into splenic vein enlarges spleen
(1) syndrome develops called hypersplenism� stasis of blood in the abnormally large spleen causes RBCs, thrombocytes, and WBCs to undergo more breakdown than usual due to their prolonged tim
tachycardia, hyperkalemia, hypolarization
tachycardia, hyperkalemia, hypolarization