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Psychiatric Mental Health Nursing

Posted by BHERU LAL on January 10, 2011 at 9:22 AM

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Psychiatric Mental Health Nursing

Chapter One

Foundations of Psychiatric Mental Health Nursing

Mental Health

• The WHO defines health as a state of complete physical, mental, and social wellness, not merely the absence of disease or infirmity.

• Mental health is influenced by individual factors, including biologic makeup, autonomy, and independence, self-esteem, capacity for growth, vitality, ability to find meaning in life, resilience or hardiness, sense of belonging, reality orientation, and coping or stress management abilities; by interpersonal factors, including effective communication, helping others, intimacy, and maintaining a balance of separateness and connectedness; and by social/cultural factors, including sense of community, access to resources, intolerance of violence, support of diversity among people, mastery of the environment, and a positive yet realistic view of the world (damn, that was a mouthful!).

Mental Illness

• The APA (2000) defines a mental disorder as “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom”.

• Deviant behavior does not necessarily indicate a mental disorder.

Diagnostic and statistical manual of mental disorders

• The DSM-IV-TR is a taxonomy published by the APA. The DSM-IV-TR describes all mental disorders, outlining specific criteria for each based on clinical experience and research.

• The DSM-IV-TR has 3 purposes:

o To provide standardized nomenclature and language for all mental health professionals.

o To present defining characteristics or symptoms that differentiates specific diagnoses.

o To assist in identifying the underlying causes of disorders.

• A multiaxial classification system that involves assessment on several axes, or domains of information, allows the practitioner to identify all the factors that relate to a persons condition.

o Axis I is for identifying all major psychiatric disorders except MR and personality disorders. Examples include depression and schizophrenia.

o Axis II is for reporting mental retardation and personality disorders as well as prominent maladaptive personality features and defense mechanisms.

o Axis III is for reporting current medical conditions that are potentially relevant to understanding or maintaining the person’s mental disorder as well as medical conditions that might contribute to understanding the person.

o Axis IV is for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders. Included are problems with the primary support group, the social environment, education, occupation, housing, economics, access to health care, and the legal system.

o Axis V presents a Global Assessment of Functioning which rates the person’s overall psychological functioning on a scale of 0 to 100. This represents the clinician’s assessment of the person’s current level of functioning.

• All clients admitted to a hospital or psychiatric treatment will have a multiaxis diagnosis from the DSM-IV-TR.

Period of Enlightenment and Creation of Mental Institutions

• In the 1790’s Phillippe Pinel in France and Willian Tukes of England formulated the concept of asylum as a safe refugee or haven offering protection at institutions where people had been beaten, whipped, and starved for their mental illness.

• In the US, Dorothea Dix (1802-1887) began a crusade to reform the treatment of mental illness after a visit to the Tukes’ institution in England. She was instrumental in opening 32 state hospitals that offered asylum to the suffering.

• 100 years after establishment of the first asylum, state hospitals were in trouble. Attendants were accused of abusing the residents, the rural locations of the hospitals were viewed as isolating patients from their families and homes, and the phrase insane asylum took on a negative connotation.

Development of Psychopharmacology

• In the 1950’s the development of psychotropic drugs were used to treat mental illness.

• Chlorpromazine (Thorzine), an antipsychotic drug, and lithium, an anti-manic agent, were the first drugs to be developed.

• 10 years later, monoamine oxidase inhibitors, haloperidol (Haldol), an antipsychotic; tricyclic antidepressants; and antianxiety agents (benzodiazepines), were introduced.

• Because of these new drugs, hospital stays were shortened, and many people were well enough to go home.

Move toward Community Mental Health

• The enactment of the Community Mental Health Centers Act came about in 1963.

• Deinstitutionalization, a deliberate shift from institutional care in state hospitals to community facilities, began.

• In addition to deinstitutionalization, federal legislation was passed to provide an income for disabled persons: SSI and SSDI. This allowed people with mental illnesses to be more independent financially and not to rely on family for money.

Mental Illness in the 21st Century

• The Department of Health and Human Services (DHHS) estimates that 56 million Americans have a diagnosable mental illness.

• The term Revolving door effect is used to explain how people with severe and persistent mental illness have shorter hospital stays, but they are admitted more frequently. People with severe and persistent mental illness may show signs of improvement in a few days but are not stabilized. Thus, they are discharged into the community without being able to cope with community living. Substance abuse issues cannot be dealt with in the 3-5 days typical for admissions in the current managed care environment.

• Many providers believe today’s clients are to be more aggressive than those in the past. Between 4% and 8% in clients seem in Psychiatric ER’s are armed. People not receiving adequate mental health care commit about 1,000 homicides each year.

• In state prisons, 1 in 10 prisoners take psychotropic medications and 1 in 8 receives counseling or therapy for mental health issues.

• 85% of the homeless population has a psychiatric illness and/or a substance abuse problem.

• The United States has the largest percentage of mentally ill citizens (29.1%) and provided care for only 1 in 3 people who needed it (Bijl et al., 2003).

• Persons with minor or mild cases are most likely to receive treatment while those with severe and persistent mental illness were least likely to be treated.

Cost containment and managed care

• Managed Care is a concept designed to purposely control the balance between the quality of care provided and the cost of that care. In a managed care system, people receive care based on need rather than request.

• Case management or management of care on a case-by-case basis represented an effort to provide necessary services while containing costs. The client is assigned a case manager, a person who coordinates all types of care needed by the client.

• In 1996, Congress passed the Mental Health Parity Act, which eliminated annual and lifetime dollar amounts for mental health care for companies with more than 50 employees. However, substance abuse was not covered by this law, and companies could limit the number of days in the hospital or the number of clinic visits per year. Thus, parity did not really exist.

Psychiatric Nursing Practice

• In 1873, Linda Richards improved nursing care in psychiatric hospitals and organized educational programs in state mental hospitals in Illinois. Richards is called the first American psychiatric nurse.

• The first training of nurses to work with persons with mental illness was in 1882. The care focused on nutrition, hygiene and activity. Nurses adapted medical-surgical principles to the care of clients with psychiatric disorders and treated them with tolerance and kindness.

• Treatments such as insulin shock therapy (1935), psychotherapy (1936), and electroconvulsive therapy (1937) required nurses to use their medical skills more extensively.

• John Hopkins was the first school of nursing to include a course on psychiatric nursing in its curriculum.

• In 1950, the National League for Nursing (which accredits nursing programs) required schools to include an experience in psychiatric nursing.

• In 1973, the ANA developed Standards of care, which states the responsibilities for which nurses are accountable.

• Psychiatric nursing practice has been profoundly influenced by Hildegard Peplau and June Mellow, who wrote about the nurse-client relationship, anxiety, nurse therapy, and interpersonal nursing therapy.

Psychiatric Mental Health Nursing Phenomena of Concern

• The maintenance of optimal health and well-being and the prevention of psychobiologic illness.

• Self-care limitations or impaired functioning related to mental and emotional distress.

• Deficits in the functioning of significant biologic, emotional, and cognitive symptoms.

• Emotional stress or crisis components if illness, pain, and disability.

• Self-concept changes, developmental issues, and life process changes.

• Problems related to emotions such as anxiety, anger, sadness, loneliness, and grief.

• Physical symptoms that occur along with altered psychological functioning.

• Alterations in thinking, perceiving, symbolizing, communicating, and decision making.

• Difficulties relating to others

• Behaviors and mental states that indicate the client is a danger to self or others or has a significant disability.

• Interpersonal, systemic, sociocultural, spiritual, or environmental circumstances or events that affect the mental or emotional well-being of the individual, family, or community.

• Symptom management, side effects/toxicities associated with psychopharmacologic intervention, and other aspects of the treatment regimen.

Standards of Psychiatric mental health clinical nursing practice.

• Standard I. Assessment

o The psychiatric-mental health nurse collects health data

• Standard II. Diagnosis

o The psychiatric-mental health nurse analyzes the data in determining diagnoses.

• Standard III. Outcome identification.

o The psychiatric-mental health nurse identifies expected outcomes individualized to the client.

• Standard IV. Planning.

o The psychiatric-mental health nurse develops a plan of care that prescribes interventions to attain expected outcomes.

• Standard V. Implementation

o The psychiatric-mental health nurse implements the interventions identified in the plan of care.

• Standard Va. Counseling

o The psychiatric-mental health nurse uses counseling interventions to assist clients in improving or regaining their previous coping abilities, fostering mental health, and preventing mental illness and disability.

• Standard Vb. Milieu Therapy

o The psychiatric-mental health nurse provides structures, and maintains a therapeutic environment in collaboration with the client and other health care practitioners.

• Standard Vc. Self-care activities.

o The psychiatric-mental health nurse structures interventions around the client’s activities of daily living to foster self-care and mental and physical well-being.

• Standard Vd. Psychobiologic Interventions.

o The psychiatric-mental health nurse uses knowledge of psychobiologic interventions and applies clinical skills to restore the client’s health and prevent further disability.

• Standard Ve. Health teaching.

o The psychiatric-mental health nurse, through health teaching, assists clients in achieving, satisfying, productive, and healthy patterns of living.

• Standard Vf. Case Management.

o The psychiatric-mental health nurse provides case management to coordinate comprehensive health services and ensure continuity of care.

• Standard Vg. Health promotion and maintenance.

o The psychiatric-mental health nurse employs strategies and interventions to promote and maintain mental health and prevent illness.

Areas of practice

• Counseling

o Interventions and communication techniques

o Problem solving

o Crisis intervention

o Stress management

o Behavior modification

• Milieu therapy

o Maintain therapeutic environment

o Teach skills

o Encourage communication between clients and others

o Promote growth through role modeling

• Self-care activities

o Encourage independence

o Increase self-esteem

o Improve function and health

• Psychobiologic interventions

o Administer medications

o Teaching

o Observations

• Health teaching

• Case management

• Health promotion and maintenance

Advanced level functions

• Psychotherapy

• Prescriptive authority for drugs (in many states)

• Consultation

• Evaluation

Self-awareness issues

• Self-awareness is the process by which the nurse gains recognition of his or her own feelings, beliefs, and attitudes.

Chapter Two

Neurobiologic Theories and Psychopharmacology

The Nervous system and how it works

• The cerebrum is the center for coordination and integration of all information needed to interpret and respond to the environment.

• The cerebellum is the center for coordination of movements and postural adjustments.

• The brain stem contains centers that control cardiovascular and respiratory functions, sleep, consciousness, and impulses.

• The limbic system regulates body temperature, appetite, sensations, memory, and emotional arousal.

Neurotransmitters

• Neurotransmitters are the chemical substances manufactured in the neuron that aid in the transmission of information throughout the body.

o They either excite or stimulate an action in the cells (excitatory) or inhibit or stop an action (inhibitatory).

o After neurotransmitters are released into the synapse (point of contact between the dendrites and the next neuron) and relay the message to the receptor cells, they are either transported back from the synapse to the axon to be stored for later use (reuptake) or are metabolized and inactivated by enzymes, primarily monoamine oxidase (MAO).

• Dopamine, a neurotransmitter located primarily in the brain stem. Dopamine is generally excitatory and is synthesized from tyrosine, a dietary amino acid.

o Antipsychotic medications work by blocking dopamine receptors and reducing dopamine activity.

• Norepinephrine and Epinephrine

o Norepinephrine, the most prevalent neurotransmitter, is located primarily in the brain stem. It plays a role in mood regulation.

o Epinephrine is also known as noradrenaline and adrenaline. Epinephrine has limited distribution in the brain but controls the fight-or-flight response in the peripheral nervous system.

• Serotonin

o A neurotransmitter found only in the brain, is derived from tryptophan, a dietary amino acid.

o The function of serotonin is mostly inhibitory, involved in the control of food intake, sleep and wakefulness, temperature regulation, pain control, sexual behavior, and regulation of emotions.

o Some antidepressants block serotonin reuptake, thus leaving it available longer in the synapse, which results in improved mood.

• Histamine

o The role of histamine in mental illness is under investigation.

• Acetylcholine

o Acetylcholine is a neurotransmitter found in the brain, spinal cord, and peripheral nervous system. It can be excitatory or inhibitory. It is synthesized from dietary choline found in red meat and vegetables and has been found to affect the sleep-wake cycle and to signal muscles to become active.

o Studies have shown that people with Alzheimer’s disease have decreased acetylcholine secreting neurons.

• Glutamate

o Glutamate is an excitatory amino acid that at high levels can have major neurotoxic effects.

• Gamma-Aminobutyric Acid (GABA)

o GABA is a major inhibitory neurotransmitter in the brain and has been found to modulate other neurotransmitter systems rather than to provide a direct stimulus.

o Drugs that increase GABA function such as benzodiazepines are used to treat anxiety and to induce sleep.

Neurobiologic causes of mental illness

• Current theories and studies indicate that several mental disorders may be linked to a specific gene or combination of genes but that the source is not solely genetic; nongenetic factors also play important roles.

• Two genetic links to Alzheimer’s disease are chromosomes 14 and 21.

• The Human Genome Project, funded by NIH and the US Department of Energy, is the largest of its kind. It has identified all human DNA. In addition, the project also addresses the ethical, legal, and social implications of human genetics research.

Stress and the Immune system (Psychoimmunology)

• This is a relatively new field of study, which examines the effect of psychological stressors on the body’s immune system.

Infection as a possible cause

• Some researchers are focusing on infection as a cause of mental illness. Studies such as this are promising in discovering a link between infection and mental illness.

The Nurse’s role in research and education

• The nurse must ensure that client’s and families are well informed about progess in these areas and must also help them to distinguish between facts and hypotheses. The nurse can explain if or how new research may affect a client’s treatment or prognosis. The nurse is a good resource for providing information and answering questions.

Psychopharmacology

• Efficacy refers to the maximal therapeutic effect that a drug can achieve.

• Potency describes the amount of the drug needed to achieve that maximum effect; low-potency drugs require higher doses to achieve efficacy, whereas high-potency drugs achieve efficacy at lower doses.

• Half Life is the time it takes for half of the drug to be removed from the bloodstream. Drugs with shorter half-life may need to be given three or four times a day, but drugs with a longer half-life may be given once a day.

• The FDA may issue a black-box warning when a drug is found to have serious or life-threatening side effects. This means that package inserts must have a highlighted box, separate from the text, which contains a warning about the serious side-effects.

Antipsychotic drugs

• Also known as neuroleptics, are used to treat the symptoms of psychosis, such as the delusions and the hallucinations seen in schizophrenia, schizoaffective disorder, and the manic phase of bipolar disorder.

• Antipsychotic’s work by blocking receptors of the neurotransmitter, dopamine.

• Dopamine receptors are classified into subcategories (D1, D2, D3, D4, and D5) and D2, D3, and D4 have been associated with mental illness.

• The typical antipsychotic drugs are potent antagonists (blockers) of D2, D3, and D4. This makes them effective in treating target symptoms but also produces many extrapyramidal side effects because of the blocking of the D2 receptors.

• Newer, atypical antipsychotic drugs such as clozapine (Clozaril) are relatively weak blockers of D2, which may account for the lower incidence of extrapyramidal side effects.

• The newer antipsychotics also inhibit the reuptake of serotonin, increasing their effectiveness in treating the depressive aspects of schizophrenia.

Extrapyramidal Side Effects

• (EPS) are the major side effects of antipsychotic drugs. They include acute dystonia (prolonged involuntary muscular contractions that may cause twisting of the body parts, repetitive movements, and increased muscular tone), pseudoparkinsonism, and akathisia (intense need to move about). Blockage of the D2 receptors in the midbrain region of the brain stem is responsible for the development of EPS. Included in the EPS are:

o Torticollis: twisted head and neck

o Opisthotonus: tightness of the entire body with head back and an arched neck.

o Oculogyric crisis: eyes rolled back in a locked position.

• Immediate treatment with anticholinergic drugs usually brings rapid relief.

• Pseudoparkinsonism, or drug-induced Parkinsonism if often referred to by the generic label of EPS. Symptoms include a stiff, stooped posture; mask-like facies; decreased arm swing; a shuffling. festinating gait; drooling; tremor; bradycardia; and coarse pill rolling movements of the thumb and fingers while at rest.

• Treatment of these symptoms can include adding an anticholinergic agent or amantadine, which is a dopamine agonist that increases transmission of dopamine blocked by the antipsychotic drug.

Neuroleptic Malignant syndrome

• (NMS) is a potentially fatal idiosyncratic reaction to an antipsychotic. Death rates have been reported at 10% to 20%.

• Symptoms include rigidity, high fever; autonomic instability such as unstable blood pressure, diaphoresis, and pallor; delirium; and elevated levels of enzymes, particularly creatine and phosphokinase.

• Clients with NMS are confused and often mute; they may fluctuate from agitation to stupor.

• Dehydration, poor nutrition, and concurrent medical illness all increase the risk of NMS.

• Treatment includes immediate discontinuation of the antipsychotic and the institution of supportive medical care to treat dehydration and hyperthermia.

Tardive Dyskinesia

• (TD) is a syndrome of permanent involuntary movements. This is most commonly caused by the long-term use of antipsychotic drugs.

• There is no treatment available.

• The symptoms of TD include involuntary movements of the tongue, facial, and neck muscles, upper and lower extremities, and truncal musculature. Tongue thrusting and protruding, lip smacking, blinking, grimacing, and other excessive unnecessary facial movements are characteristic.

• One TD has developed, it is irreversible.

Agranulocytosis

• Some antipsychotics produces agranulocytosis. This develops suddenly and is characterized by:

o Fever

o Malaise

o Ulcerative sore throat

o Leucopenia

• The drug must be discontinued immediately if the WBC drops by 50% or to less that 3,000.

Antidepressant drugs

• Although the mechanism of action is not completely understood, antidepressants somehow interact with the two neurotransmitters, norepinephrine and serotonin.

• Antidepressants are divided into four groups:

o Tricyclic and the related cyclic antidepressants

o Selective serotonin reuptake inhibitors (SSRIs)

o MAO inhibitors (MAOIs)

o Other antidepressants such as venlafaxine (Effexor), bupropion (Wellbutrin), duloxetine (Cymbalta), trazodone (Desyrel), and nefazodone (Serzone).

• MAOIs have a low incidence of sedation and anticholinergic effects, they must be used with extreme caution for several reasons:

o A life-threatening side effect, hypertensive crisis, may occur if the client ingests food containing tyramine (an amino acid) while taking MAOIs.

 Mature or aged cheeses

 Aged meats (sausage, pepperoni)

 Tofu

 ALL tap beers and microbrewery beer.

 Sauerkraut, soy sauce, or soybean condiments

 Yogurt, sour cream, peanuts, MSG

o MAOIs cannot be given in combination with other MAOIs, tricyclic antidepressants, Demerol, CNS depressants, and hypertensives, or general anesthetics.

o MAOIs are potentially lethal in overdose and pose a potential risk for clients with depression who may be considering suicide.

• SSRIs, venlafaxine, nefazodone, and bupropion are often better choices for those who are potentially suicidal or highly impulsive because they carry no risk of lethal overdose in contrast to the cyclic compounds and the MAOIs. However, SSRIs are only effective for mild to moderate depression.

• The major actions of antidepressants are with the monoamine neurotransmitter systems in the brain, particularly norepinephrine and serotonin.

o Norepinephrine, serotonin, and dopamine are removed from the synapses after release by reuptake into presynaptic neurons. After reuptake, these three neurotransmitters are reloaded for subsequent release or metabolized by the enzyme MAO.

o The SSRIs block the reuptake of serotonin; the cyclic antidepressants and venlafaxine block the reuptake of norepinephrine primarily and block serotonin to some degree; and the MAOIs interfere with enzyme metabolism.

Mood stabilizing drugs

• Mood stabilizing drugs are used to treat bipolar disorder by stabilizing the client’s mood, preventing or minimizing the highs and lows that characterize bipolar illness, and treating acute episodes of mania.

• Lithium is considered the first-line agent in the treatment of bipolar disorder.

o Lithium normalizes the reuptake of certain neurotransmitters such as serotonin, norepinephrine, acetylcholine, and dopamine. It also reduces the release of norepinephrine through competition with calcium.

o Lithium produces its effects intracellularly rather than within neuronal synapses.

o Lithium serum levels should be about 1.0 mEq/L. Levels less than 0.5 mEq/L are rarely therapeutic, and levels of more than 1.5 mEq/L are usually considered toxic.

o If Lithium levels exceed 3.0 mEq/L, dialysis may be indicated.

• The mechanism of action for anticonvulsants is not clear as it relates to their off-label use as mood stabilizers.

o Valporic acid and topiramate are known to increase the levels on the inhibitatory neurotransmitter, GABA. Both are thought to stabilize mood by inhibiting the kindling process.

 The kindling process can be described as the snowball-like effect seen when minor seizure activity seems to build up into more frequent and severe seizures. In seizure management, anticonvulsants raise the level of the threshold to prevent these minor seizures. It is suspected that this same kindling process may occur in the development of full-blown mania with stimulation by more frequent, minor episodes.

Antianxiety drugs (Anxiolytics)

• Benzodiazepines mediate the actions of the amino acid GABA, the major inhibitory neurotransmitter in the brain. Because GABA receptor channels selectively admit the anion chloride into neurons, activation of GABA receptors hyperpolarizes neurons and thus is inhibitory.

• Benzodiazepines produce their effects by binding to a specific site on the GABA receptor.

Stimulants

• Today, the primary use of stimulants is for ADHD in children and adolescents, residual attention deficit disorder in adults, and narcolepsy.

• Stimulants are often termed indirectly acting amines because they act by causing release of the neurotransmitters (norepinephrine, dopamine, and serotonin) from presynaptic nerve terminals as opposed to having direct agonist effects on the postsynaptic receptors. They also block the reuptake of these neurotransmitters.

• By blocking the reuptake of these neurotransmitters into neurons, they leave more of the neurotransmitter in the synapse to help convey electrical impulses in the brain.

Cultural considerations

• I’m not going to go much into this. Just know that clients from various cultures may metabolize medication at different rates and therefore require alterations in standard dosages.

Psychosocial Theories and Therapy

Sigmund Freud, the Father of Psychoanalysis

• Founded the personality components; Id, Ego, and Superego

o Id: The part of ones nature that reflects basic or innate desires such a pleasure seeking behavior, aggression, and sexual impulses. The id seeks instant gratification, causes impulsive thinking behavior, and has no rules or regard for social convection.

o Superego: The part of ones nature that reflects moral and ethical concepts, values, parental and social expectations; therefore, it is the directional opposite to the id.

o Ego: The balancing or mediating force between the id and the superego. The ego represents mature and adaptive behavior that allows a person to function successfully.

• Psychosexual development

o Oral (birth to 18 months)

o Anal (18 to 36 months)

o Phallic/Oedipal (3 to 5 years)

o Latency (5 to 11 or 13 years)

o Genital (11 or 13 years)

• Transference and Countertranference

o Transference occurs when the client onto the therapist/nurse attitudes and feelings that the client previously felt in other relationships.

o Countertranference occurs when the therapist/nurse displaces onto the client attitudes or feelings from his or her past.

Developmental Theorists; Erikson and Piaget

• Erikson focused on personality development across the life span while focusing on social and psychological development in life stages.

o Trust vs. Mistrust (infant)

o Autonomy vs. Shame and Doubt (toddler)

o Initiative vs. guilt (preschool)

o Industry vs. Inferiority (school age)

o Identity vs. Role confusion (adolescence)

o Intimacy vs. isolation (young adult)

o Generativity vs. stagnation (middle adult)

o Ego integrity vs. despair (maturity)

• Erikson believed that psychosocial growth occurs in sequential stages, and each stage is dependent on the completion of the previous stage/life task.

• Piaget explored how intelligence and cognitive functioning develop in children.

o Sensorimotor (birth to 2 years): The child develops a sense of self as separate from the environment and the concept of object permanence. Begins to form mental images.

o Preoperational (2-6 years): Child begins to express himself with language, understands the meaning of symbolic gestures, and begins to classify objects.

o Concrete operations (6-12 years): Child begins to apply logical thinking, understands reversibility, is increasingly social and able to apply rules; however, thinking is still concrete.

o Formal operations (12 to 15 years and beyond): Child learns to think and reason in abstract terms, further develops logical thinking and reasoning, and achieves cognitive maturity.

Harry Stacks Sullivan: Interpersonal Relationships and Milieu therapy

• The importance and significance of interpersonal relationships in one’s life was Sullivan’s greatest contribution to the field of mental health.

• Sullivan developed the first therapeutic community or milieu with young men with schizophrenia in 1929. He found that within the milieu, the interactions among clients were beneficial, and then the treatment should emphasize on the roles of the client-client interaction.

o Milieu therapy is used in the acute care setting; one of the nurses’ primary roles is to provide safety and protection while promoting social interaction.

Hildegard Peplau: Therapeutic nurse-patient relationship (The bomb-diggity of nursing)

• Developed the concept of the therapeutic nurse-patient relationship, which includes 4 phases: orientation, identification, exploitation, and resolution.

o The orientation phase is directed by the nurse and involves engaging the client in treatment, providing explanations and information, and answering questions. During this time the nurse would orient the patient to the rules and expectations (if in an acute setting).

o The identification phase begins when the client works interdependently with the nurse, expresses feelings, and begins to feel stronger. This phase can begin either within a few hours to a few days; the patient can identify the nurse and environment on his own. They “come together”. Kinky.

o In the exploitation phase, the client makes full use of the services offered. He moves toward independence.

o In the resolution phase, the client no longer needs professional services and gives up dependent behavior.

o Keep in mind that after the resolution phase, the client can regress and move back into the above mentioned phases.

• Paplau defined anxiety as the initial response to a psychic threat, describing 4 levels of anxiety: acute, moderate, severe, and panic.

o Acute anxiety is a positive state of heightened awareness and sharpened senses, allowing the person to learn new behaviors and solve problems. The person can take in all available stimuli (perceptual field).

o Moderate anxiety involved a decreased perceptual field (focus on immediate task only); the person can learn new behavior or solve problems only with assistance. Another person can redirect the person to the task. Remember, this is the ideal anxiety state for teaching a client regarding health concerns such as diabetes, as Cathy says so. 

o Severe anxiety involves feelings of dread or terror. The person CANNOT be redirected to a task; he focuses only on scattered details and has physiologic symptoms such as tachycardia, diaphoresis, and chest pain. The client may go to the ER thinking he is having a heart attack. In lecture, Cathy stated that this person can still be “talked down”. The first priority is to move the person away from all stimuli, and then attempt to talk with them to calm down.

o Panic anxiety can involve loss of rational thought, delusions, hallucinations, and complete physical immobility and muteness. The person my bolt and run aimlessly, often exposing himself and others to injury.

Humanistic Theories; Maslow’s Hierarchy of needs.

• Everyone should know this one. It is outlined on page 56 in your book.

• He used a pyramid to arrange and illustrate the basic drives or needs to motivate people.

o The most basic needs, physiologic needs, need to be met first. This includes food, water, shelter, sleep, sexual expression, and freedom of pain. These MUST be met first.

o The second level involves safety and security needs, which involve protection, security, freedom from harm or threatened deprivation.

o The third level is love and belonging needs, which include enduring intimacy, friendship, and acceptance.

o The fourth level involves esteem needs, which includes the need for self-respect and esteem from others.

o The highest level is self-actualization, the need for beauty, truth, and justice. Few people actually become self-actualized.

o Remember, traumatic life experiences or compromised health can cause a person to regress to a lower level of motivation.

Pavlov: Classic conditioning (Behavior theory)

• Pavlov believed that behavior can be changed through conditioning with external or environmental conditions or stimuli.

Crisis Intervention

• Maturational crises, sometimes called developmental crises, are predictable events in the normal course of a life, such as leaving home for the first time, getting married, having children, etc.

• Situational crises are unanticipated or sudden events that threaten an individuals integrity; such as a death of a loved one and loss of a job.

• Adventitious crises, sometimes called social crises, include natural disasters like floods, earthquakes, or hurricanes; war, terrorist attacks; riots; and violent crimes such as rape or murder.

Non-violent crisis intervention

The heart of crisis intervention is:

• Care

• Welfare

• Safety (#1!)

• Security

People in crisis need care and welfare.

Staff responses should be safety and security.

Anxiety:

• Increase or change in behavior. Can be anything different from usual behavior (excitement, pacing).

• Nursing interventions:

o Ask “What’s going on?”

o Give supportive care and let the patient know that you’re there.

Defensive:

• Loss of rationality.

• Nursing interventions:

o Direct approach to setting limits.

o Take away privileges.

o Give the patient some control and choices.

Acting out person:

• Loss of rational control.

• Nursing interventions:

o Everything Cathy showed us on non-violent physical crisis intervention

Tension-Reduction:

• Subsiding of energy.

• Nursing interventions:

o Establish therapeutic rapport

o Prime time to talk and teach about preventions of behavior.

What if the patient simply refuses?

• Set limits!

• Make the limits reasonable and enforceable.

Releasing… Venting… Mad as heck!

• Allow the patient to do this!

• Just stay calm as a nurse

• While they’re venting, they’re also releasing. This is a good thing.

Intimidation:

• This is NOT A GOOD THING.

• What if the patient tells you…?

o I know what car you drive.

o I know your last name.

o I know you have 2 dogs and I’m going to kill them.

• Nursing interventions:

o Get a witness! Do not be by yourself with this patient!

Non-verbal behavior that affect proxemics

• Factors that affect:

o Size, gender, disability, environment, agitation, history, and speed.

• 18-36” is personal space (usually how wide ones arm length is).

• Always be the closest to the door.

Kinesics (Body language)

• Facial expressions, stance, posture, breathing, hand gestures

• When approaching a client, stand at 45 degree angle

• Stand with hands to side (especially when with a paranoid client)

• Move when the patient moves.

• Be as calm as possible.

Paraverbal communication

• 55% nonverbal

• 7% verbal

• 38% paraverbal it’s not what you say; it’s how you say it!

• TVC (total voice control)

o Tone

o Volume

o Cadence

Always remember not to lose eye contact.

If you’re being grabbed…

• Gain physiologic advantage

o Know where the weak point of grab is

o Leverage- use what you have!

o Momentum—it comes in handy 

• Gain psychological advantage

o Stay calm

o Have a plan

o Don’t forget the element of surprise

Non-Violent physical control and restraint should be used as a LAST RESORT.

Mood disorders

Categories of Mood disorders

• Unipolar

o Major depression

• Bipolar

o Mania

o Depression

o Period of normalcy

Unipolar: Major depression

• Sad mood or lack of interest in life for 2 or more weeks

• Another 4 symptoms must also be present

o Change in appetite (increase or decrease)

o Change in sleep patterns (too much or too little)

o Unable to concentrate and make decisions

o Loss of self-esteem (guilt- how you were raised; how worthy a person perceives themselves).

• Those at risk:

o PMS/PMDD

o Suffering from anxiety and irritability

o PP depression

o Chronic illness (dialysis)

o PTSD

o Grief and loss

• Can be observed by others, or the depression is just in one’s “head”

Incidence

• Major depression occurs at least twice as often in women

• Single and divorced people have the highest rates of depression

Treatments

• Psychotherapy (groups, counselor)

• Psychopharmacology (Meds)

• ECT

Electroconvulsive therapy

• The biggest concern is memory loss.

• Patient is pre-medicated, much like a pre-op patient

• Elders are treated for depression with ECT more frequently than younger persons.

o Elder persons have increased intolerance of side effects of antidepressants

o ECT produces a more rapid response

Suicidal Ideation

• Safety is primary concern

• Watch for overt cues of suicide (Obvious)  active

• Covert cues are more subtle—passive

• People who suddenly are happier are of great concern; may have made the suicidal plan are content with their decision.

• People whose meds are finally working—have enough energy to carry out the act

Client’s Affect

• Compare verbal with non-verbal behaviors—do they match up?

• Asocial: Withdrawal from family and friends

• Anhedonic: Lose sense of pleasure

• When confronting these client’s about their behavior, use “I” statements

o “I really wish you’d join the group”

Judgment

• Feel overwhelmed with normal activities

• Difficulty with task completion

• Always exhausted

Self Concept

• Ruminate: Worry to excess.

• Lack energy for normal activities (always tired)

Interventions

• Assess safety for client (PRIORITY!)

• Perform suicide lethality assessment

• Orient client to new surroundings (they need structure)

• Offer explanations of unit routine (again, need structure)

• Start to promote a therapeutic relationship; schedule short interaction times.

Patient and Family teaching

• Stress importance of follow-up care—keep it structured; make appointment for them.

• Stress importance of continuing medications; assess if they can afford them

• Make phone number lists of how to get help if they need it.

Bipolar disorder

• Condition with cyclic mood changes

• Person has manic episodes, periods of profound depression, and times of normal behavior in-between

• Occurs equally in men and women; often seen in highly educated people.

Clinical course of mania

• Episode of unusual, grandiose, or agitated mood lasting at least one week with three or more of the following symptoms:

o Exaggerated self-esteem

o Sleeplessness

o Pressured speech

o Flight of ideas

o Reduced ability to filter out stimuli

o Distractibility

o More activities with increased energy

Drug treatment

• Lithium

o Lithium is not metabolized; rather, it is reabsorbed by the proximal tubule and excreted in the urine.

o Thought to work in the synapse to increase destruction of dopamine and norepinephrine; decreases sensitivity to postsynaptic receptors (Basically- when a person is in a manic phase, they are synapsing super fast. Lithium helps slow this synapsing down).

o Onset of action is 5-14 days; other drugs must be used during the acute phases to reduce symptoms of mania or depression.

o Maintenance lithium level is 0.5-1.0 mEq/L.

 3 is toxic! Duh.

o Lithium is a salt contained in the human body. It not only competes for salt receptor sites but also affects calcium, potassium, and magnesium ions as well as glucose metabolism.

 MUST complete an electrolyte blood panel (focus on Chloride).

o Having too much salt in the diet can cause the lithium level to be too low.

o Not having enough dietary salt can cause the lithium levels to be too high.

o Persistent thirst and diluted urine can indicate the need to call the MD; lithium dosage may need to be reduced.

• Anticonvulsant drugs: mechanism is unclear, but they raise the brains threshold for dealing with stimulation; this prevents the person from being bombarded with external and internal stimuli.

o Tegretol

 Huge concern about agranulocytosis (a decrease in WBC).

 Need serum levels monitored 12 hours after last dose.

o Depakote

 Need to monitor serum level, CBC with platelets, liver function including ammonia level (ammonia is a by-product of liver metabolism)

o Klonopin

 Anticonvulsant and benzodiazepine

 Drug dependence can occur

 Monitor CBC, liver function

 Withdrawal drug slowly to prevent GI issues

 Cannot be used alone to manage bipolar; must be used in conjunction with lithium or another mood stabilizer.

Helpful hints to care for bipolar clients

• You can’t teach a manic client

• Safety is a huge issue because their judgment is poor.

• Only spend short periods of time with patient

• Must be flexible in taking intake assessment; may need to obtain data in several short sessions as well as talking to family members.

• Ask the client to explain any coded speech

• Assist the client to meet socially accepting behaviors. “Kathy, you are too close to my face. Please stand back two feet.”

• Feed them finger foods high in calories while in a manic phase; provide nutritional support!

• Use simple sentences when communicating. It is also helpful to ask client to repeat brief messages to ensure they have heard and incorporated them.

o “Please speak more slowly. I’m having trouble following you.”

• Avoid becoming involved in power struggles over who will dominate the conversation.

Suicide

• 4 out of 5 who actually commit suicide have made at least one prior attempt

• In a majority of cases, there are clear indicators hat the person was very troubled.

• Few than 15% of suicide victims leave suicide notes

• The suicide risk is greatest in the 90 days following a major depressive episode.

• “survivor guilt” happens when 1 or more family members feel guilty that they are still living

• “Separation anxiety” may cause they surviving to “join the beloved deceased”

• Make the patient sign a “contract for life”

• Crisis intervention—may need 1:1 care. The client is no more than 2-3 feet away from a staff member at any time, including going to the bathroom.

Anxiety disorders & Substance abuse

Incidence

• Most common emotional disorder in the U.S.

• Prevalent in women; age <45

Physiologic responses

• Flight or fight responses

• Sympathetic fibers increase the vital signs

• Adrenal glands release adrenalin which causes the body to:

o Take in more oxygen

o Dilate the pupils (brings more light into eyes; better vision)

o Increase the arterial blood pressure and heart rate

o Constrict peripheral vessels (makes skin cool and pale)

o Increase glycogenolysis to free glucose for fuel (glycogen is being broken down in the liver)

o Shunt blood from GI and reproductive organs

Psychological response

• Difficulty with logical thought

• Increased agitation with motor activity

• Increased vital signs

• Client will try to change the feelings of discomfort by:

o Changing behavior by adaptation

o Changing behavior with defense mechanisms

Anxiety disorders

• Panic disorder

• Phobic disorder

• Agoraphobia

• Obsessive-compulsive

• PTSD

• Generalized anxiety

• Anxiety related to medical conditions

• Substance-induced anxiety disorder

Development of Anxiety Disorders

• Predisposing factors

o Onset: Acute or insidious (builds up)

o Precipitating event

o Chronic stressors

o Unusual behavior

o Fears disproportionate to reality

Levels of anxiety

• Mild:

o Psychological: Wide perceptional field, sharpened senses, increased motivation, effective problem solving, increased learning ability, irritability.

o Physiologic: Restlessness, fidgeting, “butterflies”, difficulty sleeping, hypersensitivity to noise.

• Moderate:

o Psychological: perceptual field narrowed to immediate task, selectively attentive, cannot connect thoughts or events independently, increased use of automatisms

o Physiologic: Muscle tension, diaphoresis, pounding pulse, HA, dry mouth, high voice pitch, faster rate of speech, GI upset, frequent urination

• Severe:

o Psychological: Perceptual field narrowed to one detail or scattered details; cannot complete tasks; cannot solve problems or learn effectively; behavior geared toward anxiety relief and is usually ineffective; doesn’t respond to redirection; feels awe, dread, or horror; cries; ritualistic behavior.

o Physiologic: Severe HA, N/V, diarrhea, rigid stance, vertigo, pale, tachycardia, chest pain.

• Panic:

o Psychological: Perceptual field reduced to focus on self; cannot process any environmental stimuli; distorted perceptions; loss of rational thought; doesn’t recognize potential danger; can’t communicate verbally; possible delusions or hallucinations; may be suicidal.

o Physiologic: May bolt and run OR totally immobile and mute; dilated pupils, increased blood pressure and pulse; flight, fright, or freeze.

Seyle Response to stress

• Alarm reaction

o Physiologic response

o Body prepares to defend itself

• Resistance stage

o Body will defend by flight or fight

o If the stress is gone; body relaxes

• Exhaustion stage

o Negative response to anxiety and stress

o Body stores are depleted

Panic disorders

• An episode lasting 15-30 minutes in which a client experiences rapid, intense, escalating anxiety; great emotional discomfort; and physiologic discomfort.

• Defined as recurrent, unexpected panic attacks followed by a month of persistent concern or worry about having another attack.

• 75% with panic disorder have spontaneous attacks with no triggers

• Others have attacks stimulated by phobias or chemical changes within the body.

Treatment

• Psychotherapy

o Positive reframing

o Assertiveness training

• Psychopharmacology

o SSRIs

o Anxiolytics

o Antidepressants

o MAOIs

Phobias

• An illogical, intense, persistent fear of a specific object or social situation that causes extreme distress and interferes with having a normal life.

• Treatment for phobias:

o Psychopharmacology

 Anxiolytics

 Benzodiazepines

 SSRIs

 Beta Blockers

o Psychotherapy

 Behavioral therapy

 Systemic desensitization

 “Flooding” Getting rid of fear all at one time

Obsessive-Compulsive Disorder (OCD)

• Obsessions: Recurrent thoughts, ideas, visualizations, or inappropriate impulses that disturb a person’s life; has no control over them.

• Compulsions: Behaviors or rituals continuously carried out to get rid of the obsessive thoughts and reduce anxiety.

• Higher incidence with groups in higher economic status and with more education

• Nursing interventions:

o Remember, a lot of the time people feel guilty about their thoughts and behaviors.

o Do not try to stop the act unless the act is harmful (dangerous)

o Talk to them! Use “I” statements

o If they are too down on themselves—limit your time with them. For instance, “I hate myself. No one cares about me. I’m fat and ugly.” The nurse would then say, “I am going to come back in 30 minutes. In that time frame, I want you to think of your good qualities.”

o Do not argue with OCD person.

o Inject reality. If a teenager thinks she is pregnant despite a negative pregnancy test, tell her the TEST IS NEGATIVE. Take them back into reality.

o If they repetitively do an act over and over again; help them set a goal. For instance, “Let’s try to only wash your hands once every ten minutes.”

Post Traumatic Stress disorder

• Three clusters if symptoms are present

o Reliving the event

 Memories, dreams, or flashbacks

o Avoiding reminders of the event

 Staying away from any stimuli that could be associated with the trauma.

o Being on guard (hyper-arousal)

 Less responsive to stimuli

 Insomnia, irritability, or angry outbursts

• At risk people include:

o Combat veterans

o Victims of violence

o Abused victims

o Children in traffic accident (and the parents)

 Only 46% of parents sought help for their children. KIDS NEED HELP.

• Symptoms of PTSD occur 3 months or more after the trauma.

• Some more signs of PTSD:

o Have issues with authority figures

o Their first emotions are anger, rage, and guilt

o Their guilt comes out as anger (violent behavior)

o Isolate themselves

o Cry

o Don’t want to talk about it

o Drug and alcohol abuse

o Nightmares

o Manifests in physiological symptoms (HA, GI distress)

o Irritable

o Insomnia

• Nursing interventions:

o Have specific staff members assigned to client to facilitate building trust

o Consistency is the key

o Be non-judgmental; encourage client to talk

o Help them acknowledge where grief is coming from

o Involve family

o Give positive feedback

• Goals for PTSD:

o Short term: Safety, decrease insomnia, identify source, grieve!

o Long term: Accept the fact that the experience happened and live healthy.

Substance abuse

• I’m not going to go much into these notes; there wasn’t much information in the lecture that is not in the packet.

• Overdose of alcohol:

o Alcohol is a depressant; decreased respirations and blood pressure, vomiting may cause aspiration.

• Overdose of benzodiazepines require a gastric lavage including instillation of activated charcoal.

• Stimulants

o Cocaine, amphetamines, and Ritalin

o Increases HR and BP; decreases cardiac output and oxygen

o Cocaine specifically causes MI’s

Withdrawal

• Two purposes:

o Safe withdrawal with medication

 Suppress symptoms of abstinence

 Around the clock schedule and PRN

 Never, ever go cold turkey.

o Prevent relapse

 May need to go to AA for rest of life.

Cognitive disorders

Delirium

• Disturbance of consciousness accompanied by change in cognition; disoriented

o Alert and oriented to person only

o Typically have problems recalling on memory and time.

• Develops over a short period of time

• Easily distracted

• Difficulty concentrating

• Illusions, hallucinations

• Onset is rapid

• Brief duration

• Level of consciousness is impaired

• Slurred speech

• Anxious mood

Causes of Delirium

• Metabolic

• Infection—UTI

• Low sodium

o Normal is 135-145 mEq/L

o Always check electrolytes!

• Drug related

o Or, withdrawal from drugs and alcohol

o Sedatives and benzodiazepines cause confusion

• Effects of anesthesia

The nursing process: Assessment

• Interview with simple questions and explanations

• Frequent breaks

• History of onset; not reliable from client

o Interview family members; ask: “Is the how your mom typically acts?”

• Mood/Affect

o Frequently assess moods; moods change quickly

• Thought process/content

o Many have visual hallucinations

o Very restless; hard to keep in bed.

Nursing process: Goals

• Free from injury

o Fall precautions

• Demonstrate increased orientation

o Use reality orientation and validate feelings

• Adequate balance of activity and rest

o Help the patient keep days and nights straight

• Adequate nutrition

o Often forget to eat; needs nutritional supplements

• Return to optimal level of functioning

• A goal needs a timeline to make it measurable!

Nursing process: Intervention

• Patient safety

• Managing confusion

o Often frightened at night.

• Promote comfort and rest

• Adequate fluids and nutrition

o Always offer little sips of water!

Nursing process: Evaluation

• Successful treatment of underlying causes for delirium returns client to former level of functioning

• Client and family education about avoidance of recurrence

• Monitor chronic health problems

• Careful use of medications

• No alcohol or other non-prescribed drugs

Dementia

• More progressive, gradual, and permanent

• Involves multiple cognitive deficits

o Primarily memory impairment

• Involves at least one of the following:

o Asphasia (deterioration of language function)

o Apraxia (impaired ability to execute motor functions)

o Agnosia (inability to name or recognize objects)

o Disturbance in executive functioning (ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior)

• May also present:

o Echolalia (echoing what is heard)

o Palilalia (repeating words or sounds over and over)

Clinical course of Dementia

• Mild:

o Forgetfulness

o Difficulty finding words

o Frequently loses objects and experiences anxiety about these losses.

o Occupational and social settings are less enjoyable, and the person may avoid them.

• Moderate:

o Confusion is present along with memory loss

o The person cannot complete complex tasks but remains oriented to person and place.

o Still recognizes familiar people.

o Some assistance with care

o Executive functioning suffers (especially with ADLs)

• Severe:

o Personality and emotional changes occur

o May be delusional, wander at night, forget the names of spouse and children and require assistance in ADLs.

o Most live in ECF.

Causes of Dementia

• Decreased metabolic activity

• Genetic component

• Infection

• Alzheimer’s disease (#1)

• Creutzfeld-Jacob disease (CNS disorder; develops at 40-60 years. Causes by infectious particle that is resistant to boiling)

• Parkinson’s disease

• Huntington’s disease (inherited gene; brain atrophy, demyelination, and enlargement of the brain ventricles. Begins in late 30’s)

• Vascular Dementia (#2)

o Symptoms similar to Alzheimer’s, but more abrupt, followed by rapid changes in functioning; a plateau; more abrupt changes, another plateau, and so on.

o Caused by decreased blood supply to the brain.

Culture

• Native Americans and Eastern countries hold elders in a position of authority, respect, power, and decision making for family; this does not change despite memory loss or confusion.

• May feel they are being disrespectful and reluctant to make decisions or plans for elders with dementia.

Treatment for Dementia

• Underlying cause

o Example: Vascular dementia can be helped by diet, exercise, control of hypertension or diabetes.

• Psychopharmacology

o Cognex and Aricept are cholinesterase inhibitors and have shown therapeutic effects; slow the progress of dementia. They do not reverse damage already done.

 Must have liver function tests done with Cognex.

 Flu-like symptoms, diarrhea, sleep disturbances are common.

o Tegretol and Depakote help stabilize mood and diminish aggressive outbursts.

 These doses are often ½-2/3 less lower than prescribed for seizures, therefore, does not need to be in the “therapeutic level” for blood work.

o Benzodiazepines may cause delirium and can worsen already compromised cognitive abilities.

Nursing process: Assessment

• History

o Remember, interview family

• Motor behavior and general appearance

o Display aphasia

o Conversation repetitive

o Apraxia (such as combing hair)

o Gait disturbance

o Uninhibited behavior; never have displayed these behaviors before.

• Mood and Affect

o Grieve at first

o Emotional outbursts are common

o Pattern of withdrawal; lethargic, apathetic, look dazed and listless.

• Thought process and content

o Executive functioning impaired

o Have to stop working

o Client may accuse others of stealing lost objects

• Sensorium and Intellectual Processes

o First affects recent and immediate memory, eventually impairs the ability to recognize family members and oneself.

o Confabulation: clients make up answers to fill in memory gaps; often inappropriate words or fabricated ideas (SCREW YOU, ASSHOLE).

o Visual hallucinations are common.

• Judgment and insight

o Underestimate risk

• Self concept

o Initially grieve, and then slowly lose sense of self.

• Roles and Relationships

• Physiologic and self-care considerations

o Altered sleep-wake cycle

o Some clients ignore internal cues such as hunger or thirst

o Neglect bathing and grooming; become incontinent.

Read the Nursing Diagnoses and Nursing Goals on your own. Too damn lazy to type out.

Nursing Process: Interventions

• Demonstrate caring attitude

• Keep clients involved; relate to environment

• Validate client’s feelings of dignity

• Offer limited choices

• Reframing (offering alternate points of view to explain events)

• See page 487—there’s a good table there a

PEDIATRICS HEALTH NURSING

Posted by BHERU LAL on January 10, 2011 at 9:20 AM

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PEDIATRICS HEALTH NURSING

CHILD HEALTH NURSING

Child Health Nursing

• Focuses on protecting children from illness and injury

• Assists children to obtain optimal levels of wellness

Primary roles of the Pediatric Nurse

• Care provider

• Educator

• Advocate

Pediatric Health Statistics

• Infant Mortality

o Number of deaths per 1000 live births during 1st year of life.

o Infant mortality rate is an indicator of how healthy the nation is.

o This rate is used to compare national health care to previous years and to other countries.

o There has been a great decrease in the number of deaths over the past century.

 In 1997, 6.9 per 100 live births.

Childhood Mortality

• For children older than one year, death rates have always been less than those for infants.

• In later adolescence, there is a sharp rise in deaths.

Injuries; the leading killer in childhood

• Injuries cause more death and disabilities in children than any diseases.

• Some examples include:

o Motor vehicle accidents are the leading cause of death in children over 1 year of age.

o Majority of deaths are due to no use of seatbelts.

• Drowning is 2nd leading cause of death in boys 1-14; both sexes 15-24 years old. Drowning is the 3rd leading cause of death for girls 1-14.

• Burns are the 2nd leading cause of death from injury in girls and the 3rd in boys from 1-14 years old.

Childhood Morbidity (Illness)

• An illness or injury that limits activity, requires medical attention or hospitalization, or results in a chronic condition.

• Examples:

o Congenital heart defects

o Asthma

o Cerebral Palsy

o Cystic Fibrosis

• Concerned with helping to decrease these statistics as children miss school and other activities when ill.

Advanced Practice roles for nurses in Child health nursing

• Family nurse practitioner

• Neonatal nurse practitioner

• Pediatric nurse practitioner

• Nurse midwife

Growth and Development

• Growth: used to show an increase in physical size or a significant change.

• Includes:

o Height

o Weight

o Head circumference

• Development: Used to denote an increase in skill or ability to finction.

• Measured by:

o Observing child do specific tasks

o Parents description of child’s ability

o Using standardized testing (Denver II screening test)

Principles of Growth and development

• G & D is a continuous process from birth to death

o Rate of growth varies at different times

• G & D proceeds in an orderly manner

o Growth from smaller to larger

o Development: from sitting to crawling to walking

• Different children pass through the predictable stages at different rates

• All body systems do not develop at the same time.

• CNS, Cardiac develops quickly.

• Lungs are typically the last to develop.

Development is Cephalicaudal, which is the 3rd principle of G & D. “Head to toe”.

Development goes from proximal to distal, which is the 4th principle.

• Example: Development proceeds from gross to refined.

• A child cannot learn tasks until the nervous system is ready.

• Neonatal reflexes must be lost before development can proceed.

Factors that influence growth and development

• Genetics

• Gender

• Health

• Intelligence

Temperament

• Inborn in all of us

• A way of reacting to the world around us

Reaction Patterns:

• Activity level

o Level of activity differs widely among children

• Rhythmicity

o Have a regular rhythm is physiologic terms

• Approach

o Child’s response to a new situation

• Adaptability

o Is the child able to adapt to new situations?

• Intensity of reaction

• Distractibility

• Attention span and persistence

• Mood quality

Categories of temperament

• The “Easy” Child

o Easy to care for if they have predictable rhythmicity, approach and easily adapt to new situations, have a mild to moderate intensity of reaction, and an overall positive mood quality.

o 40-50% of children fall into this category

• The “Difficult” child

o Children are “difficult” if irregular in habits, have negative mood quality, and withdraw from new situations

o 10% of children fit this image.

• “Slow to warm up” child

o Describes children who are overall fairly inactive, respond only mildly, adapt slowly to new situations, and have a general negative mood.

o 15% of children display this pattern.

Other factors that impact growth and development

• Environment

• Socioeconomic level

• Parent-child relationship

• Position of birth in the family

• Health

• Nutrition

• As a child normally develops somewhat predictably in growth and physical development, he also matures emotionally, intellectually, and spiritually along certain paths.

Review:

• Erikson’s theory of Psychosocial development

• Piaget’s theory of cognitive development

• Kohlberg’s theory of Moral development

ASSESSMENT OF THE CHILD

Basic Principles

• Know norms; child vs. adult

• A & P variations are farthest from adult norms at birth

o Most of these variations mature quickly in the first year

o By 5-7 years of age, body is that of a “Small adult”; however, a child is not a miniature adult and should not be treated as such.

• As a child normally develops somewhat predictably in growth and physical development, he also matures emotionally, intellectually, and spiritually along certain paths.

• Try to see the child’s world and body through his/her mind. If you do this, you will connect with the child.

Approach to exam

• Always think of where the child is developmentally.

• Approach must be individualized

• Usually the child will be frightened and anxious. May lack verbal skills to express fear or ask for information.

• Use both hands on child when possible – comforting touch.

o Place left hand on shoulder while auscultating the heart.

o Move unhesitatingly, firmly, and gracefully.

o Talk pleasantly and reassuringly.

• Instructions to the child:

o Use a directive voice

o Have specific instructions

o Do not ask, but instead tell a child

 Example: Say “Roll over on your belly” rather than “Will you roll over on your belly?”

Physical Exam

• Can take place almost anywhere

o On parents lap

o On the floor

o Examiners lap

Conducting the exam

• Perform the least distressing procedures first and the most distressing last.

o Heart and lungs; have the child lie down.

o Abdomen, throat, and ears (throat and ears are the worst)

o Genitalia and rectum

Physical exam technique

• Inspection

o Observe before you touch

• Auscultation

o Use diaphragm of stethoscope for high pitched sounds (bowel sounds)

o Use bell of stethoscope to help localize sounds for infant

• Palpation

o Use pads of fingers to determine tenderness and pulsations

o Use palmar surface of fingers to determine masses and organ enlargement

o Observe reaction to palpation rather than to ask if it hurts (don’t suggest that it does)

• Percussion

o A more advanced technique usually done by physicians and advanced practice nurses.

The general survey

• Vital signs

• General appearance

• Mental status

• Body measurements

Vital signs

• Temperature

o Body temperature in infants is less constant than in adults

o Use ax/tympanic for children less than 4 years of age

o Values are the same as in adults

• Axillary: hold child’s arm firmly

• Tympanic:

o Less than 3 years of age

 Insert gently into ear

 Pull down on ear

o Over 3 years of age

 Pull up on ear

• Rectal temperature

o Most hospitals are done only with doctors order, or there is a standing order.

o Lubricate tip well

o Insert 1 inch

• Pulse

o Apical is best

o May use femoral arteries, brachial arteries

o Radials only in older children (at least 2 years old)

• Respirations

o The younger the child, the more abdominal breathing

o Observe the abdomen instead of the chest in infants and small children

o May need to auscultate the chest or put the stethoscope in front of the mouth and nose.

• Oxygen saturations

• Blood pressure

o Wide enough to over 75% of the upper arm

o Narrow cuff elevates reading, wide cuff lowers reading

o In infants less than 1 year:

 Thigh BP = arm BP

o Older than 1 year:

 Systolic in thigh is 10-40 mm Hg higher than in arm

 Diastolic is same in thigh and arm

o If BP in thigh is less than in arm:

 Cardiac anomaly or decreased circulation to extremities

 Be sure to use correct size cuff

 Use the same extremities, the same size cuff, and same position whenever possible when trending values for an individual patient.

o Diastolic BP

 Diastolic pressure reaches about 55 mm Hg at one year of age

 Gradually increases to 70 throughout childhood

o The most common cause of hypertension in children are:

 Anxiety (increases BP in children)

 Renal disease (78%)

 Coarctation of the aorta (2%)

General appearance

• To form a general impression of child’s health and well-being

• To pin-point specific areas that may require more detailed assessment

Initial observations

• Degree of illness or wellness

• Mood

• State of nutrition

• Speech, cry, facial expression, posture

• Apparent chronological and emotional age

• Respiratory pattern

• Parent and child interaction

Parent and child interaction

• Amount of separation tolerated

• Displays of affection

• Response to discipline

• Look for signs of:

o Anxious parents

o Disengaged parents

o Stressed families

o Possible abusive parents (no separation anxiety when removed from parent, or over-affectionate)

Child cries or clings to parent

• Ignore the child temporarily

• Engage the parents in conversation, then place a small game, toy, or your stethoscope within reach of the child while continuing your discussion

Mental status

• Is the child alert?

• Able to respond to questions easily?

• Assess appropriateness of behavior

• Assess memory

Assessing Growth/Body measurements

• Height, weight, head circumference—important indicators of growth

• Measured and plotted on standard growth charts

• These charts are used to determine if the baby/child’s growth is falling within the accepted percentile for age

Length

• Birth to 36 months

o Fully extend the body by:

 Holding the head midline

 Grasping the knees together gently

 Pushing down on the knees until the legs are fully extended and flat against the table.

o Hold pencil at right angle to the table and mark the head and toes (which are pointed toward the ceiling)

Height

• Child’s back is to the wall, with heels, buttocks, and back of the shoulders touching the wall and the medial melleoli touching if possible.

• Check for bending of the knees, slumping of the shoulders, or raising the heels of the feet

Weight

• Birth to 36 months, weigh nude

• Older children with panties and light gown

• Balance (or zero) scale prior to weighing

Head circumference

• Measure at greatest circumference

• Slightly above the eyebrows and pinna of the ears

o Around the occipital prominence at the back of the skull

o Compare to 36 months

Denver Developmental

• The standard for measuring the attainment of developmental milestones throughout infancy and childhood.

• Designed for birth to 6 years

• Includes screening for:

o Personal social skills

o Fine motor adaptive

o Language

o Gross motor

• Denver screening for articulation and eyes

Example of DDST for One year of age:

• Personal/Social

o Drink from a cup, imitate activities, play ball with examiner, indicate wants, play pat-a-cake

• Fine motor/adaptive

o Scribbles, puts block in cup

• Language

o Dada/Mama specific, one word

• Gross motor

o Stands alone

ANATOMY AND PHYSIOLOGY

Posted by BHERU LAL on January 10, 2011 at 9:17 AM

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ANATOMY AND PHYSIOLOGY

Table of Contents

Syllabus 3

Lecture Schedule 8

Correcting tests 9

Disease presentation project 10

People parts and cat anatomy 16

Unit 1 19

Study guide 21

Organ system overview: cat dissection 23

Lecture notes 25

Unit 2 43

Study guide 45

Heart lab 47

Lecture notes 51

Unit 3 71

Study guide 73

Blood review 75

Lecture notes 79

Unit 4 109

Study guide 111

Urinary lab 113

Digestion lab 115

Lecture notes 117

Digestive system flash cards 149

Unit 5 151

Study guide 153

Respiratory lab 155

Reproductive systems lab 159

Lecture notes 161

The End 179

Five steps to better critical thinking

Use when evaluating primary or secondary literature.

1. Identify the study question and hypotheses.

• Are the hypotheses adequate potential answers to the question(s), or did the authors omit better potential answers?

2. Gather information.

• Learn more about the study questions. If you don’t understand a word, concept or phrase, look it up!

• How did the authors approach the problem (look at the experimental design)?

• Is their approach logical?

• Is there a better approach you can suggest?

3. Evaluate the evidence.

• Where did the information (or study sample) come from?

• Does it represent a random sample?

• What biases could be expected in the experimental design?

• How accurate are the data collecting methods?

• Are the researchers receiving funding from a company/agency that would like them to come to a particular conclusion?

4. Consider alternatives and implications.

• Return to the two hypotheses and examine them in light of the results. Identify the advantages and disadvantages of both. What do you conclude is the best hypothesis?

• Does the authors’ conclusion(s), based on the results, make sense?

• Are there other conclusions the authors didn’t consider?

5. Choose and implement the best hypothesis.

• Now that we have an answer (or maybe we don’t if the data were inconclusive) where do we go from here? This is called implication for future research and is part of any comprehensive research paper.

• How will the results of this study affect biology/medicine in general?

A few fundamental errors of experimental design

Certain fundamental fallacies you need to avoid in your work and to watch out for in others’ work.

1. Circular reasoning—assuming the truth of the thing you are trying to support (remember: you can never “prove” something) in the process of trying to support it.

2. Confusing theorems with their converse—e.g. just because a victim of leukemia becomes anemic doesn’t mean that anyone who’s anemic has leukemia.

3. Concluding a causal relationship between two events that actually are both a result of a third factor—frequently happens in medicine and often leads to treating the symptoms rather than the disease. May also occur in biology where researchers study complex systems.

4. Arriving at incorrect conclusions due to failure to fully consider the possibility of chance occurrences—usually result from lack of proper controls or insufficient replications.

5. Bias—outcome of experiment affected by the criteria used to select the study group (sample MUST be random and should have at least 20 individuals), or by the preconceived ideas of the experimenter or the subject.

6. Failure to consider variables other that those under study.

People Parts

Below are all the human parts (please see also the cat anatomy list) you are responsible for knowing for the lab exam. Use your textbook and lab manual pictures to help you study. Page and figure (F) numbers correspond to your textbook.

Endocrine

Know on pictures, torso and muscle models

Pituitary gland thymus

Pineal gland pancreas

Thyroid adrenal glands

Parathyroids ovary

Testis hypothalamus

Heart—Know on beef hearts, heart and torso models

Epicardium tricuspid valve

Myocardium bicuspid (mitral) valve

Endocardium chordae tendineae

Atria (R/L) papillary muscles

Marginal branch pulmonary veins

Great cardiac vein ascending aorta

Middle cardiac vein R/L coronary artery

Small cardiac vein circumflex branch

Coronary sinus posterior interventricular

branch

Pulmonary trunk pulmonary arteries (R/L)

Ventricles (R/L) pulmonary semilunar valve

Interarterial septum aortic semilunar valve

Trabeculae carneae interventricular septum

Superior vena cava Inferior vena cava

anterior interventricular branch (left anterior

descending artery)

Blood vessels-- Know the circulatory and torso models, and textbook figures/tables.

Blood—See your textbook! Know on microscope slide:

Erythrocytes

Leukocytes:

Basophils Eosinophils

Neutrophils Lymphocytes

Monocytes

Platelets

Urinary—Know on urinary and torso models

Kidneys Urinary bladder

Ureters urethra

Kidneys—Know on kidney model

Renal capsule renal sinus

Renal cortex minor calyx

Renal medulla major calyx

Renal columns renal pelvis

Renal pyramids renal papilla

Respiratory—Know on torso and muscle models

Internal nares nasopharynx

External nares oropharynx

Lingual tonsils laryngopharynx

Pharyngeal tonsil trachea

Palantine tonsil lungs—superior, (middle),

inferior lobes

Epiglottis larynx

Bronchioles bronchi—primary, secondary,

tertiary

Teeth

Know types: incisor, cuspid (canine), bicuspid (premolar), molar, in addition to figure listed above.

Reproductive—Know on torso model

Male—

Ejaculatory duct seminal vesicle

Prostatic urethra ampulla

Ductus deferens prostate gland

Corpus cavernosum Prepuce

Corpus sponginosum testis

bulbourethral gland Penile urethra epididymis Glans penis membranous urethra

Female—

Mons pubis cervix

Prepuce suspensory ligament

Clitoris ovary

Vestibule uterine (fallopian) tube

Labia majora fimbriae

Labia minora round ligament

Urethral orifice uterus

Vaginal orifice vagina

Broad ligament

Cat Anatomy

Ventral body cavity organs

Greater omentum heart

Lungs thymus

Diaphragm stomach

Spleen small intestine

Large intestine

Endocrine glands

Thyroid thymus

Pancreas adrenal glands

Ovaries testes

Digestive system

Gall bladder Pancreas

Esophagus

Liver

Stomach + rugae

Small intestine + villi

Duodenum Jejunum

Ileum

Large intestine

Cecum Ascending colon

Transverse colon Descending colon

Rectum Mesentery

Respiratory

Trachea Diaphragm

Lungs

Urinary

Urinary bladder kidneys

Urethra ureters

Reproductive (IF, and only if, we have time for this lab, you will be responsible for this material)

Male—see LAB MANUAL figure 46.11, 46.12

Spermatic cord (vas deferens) testis

Scrotum prostrate gland

Urethra penis

Bulbourethral gland epididymis

Female—see LAB MANUAL figure 47.12

Fimbriae uterine tube

Ovary uterine horn

Body of uterus vagina

Unit One

Study Guide

1. Explain the relationship between thyroid hormone production and the body’s response to cold weather.

2. How do lipophilic and lipophobic hormones differ with regard to their method of entry into the cell? Give two examples of lipophilic and two examples of lipophobic hormones.

3. Describe the fundamental differences between the neurohypohysis and the adenohypohysis. Which one is not considered a true gland? Why?

4. What determines if a cell is a target for a hormone?

5. What is the difference between the parenchyma and the stroma of a gland?

6. Identify the organs of the endocrine system and their location. Can you describe their position using anatomically correct terms in a fill-in-the-blank question? E.g.: The adrenals are ____________ to the kidneys in humans. Also, if you were given a drawing of a human, could you label the organs?

7. What is the hypothalamo-hypophysis portal system and the hypothalamo-hypophyseal tract?

8. What two general types of hormones (you don’t need to identify specific hormones) are secreted by the hypothalamus? Five of these hormones are ____ hormones and two of them are _____ hormones.

9. What are the four general classes of hormones? Be sure you can identify examples of each type.

10. What are the general functions of ADH and Oxytocin? What endocrine gland produces them?

11. What are the general functions of FSH, LH, TSH, TH, ACTH, PRL and GH?

12. What is the difference between hypertrophy and hyperplasia?

13. Secretion of most hormones is controlled by ______ feedback loops. Which hormone operates via the other type of feedback loop during childbirth?

14. Distinguish between synergistic, antagonistic and permissive effects.

15. Distinguish between these pituitary disorders: pituitary dwarfism, gigantism, acromegaly, diabetes insipidus.

16. What gland produces serotonin and where is it located? What is serotonin converted into?

17. What is myxedema and what causes it?

18. Briefly describe the differences between endemic and toxic goiter, including cause and some symptoms.

19. What is the relationship between calcitonin and parathyroid hormone?

20. The adrenal medulla secretes _________ which are important in the fight-or-flight response.

21. The adrenal cortex secretes corticoids, mineral corticoids and glucocorticoids. What are the general functions of each of these groups of hormones? Explain the following terms in relationship to these hormones: glycogenolysis, gluconeogenesis, glycogenesis, lipid catabolism, protein catabolism.

22. In the pancreas what do alpha, beta and delta cells secrete respectively?

23. Briefly and generally identify the differences between Cushing’s and Addison disease. What causes each?

24. Identify the three types of diabetes. Describe the major differences between each. Which is the most common type? How are type I and type II treated? What specifically causes type I and II?

25. Why is exercise so beneficial for diabetics? Be sure you discuss GLUT-4s, resistin and bovine insulin!

26. From the moment insulin enters the bloodstream, it works much more quickly than estrogen. Considering how each hormone acts on its target cells, explain this difference.

27. Explain specifically why cortisol suppresses the immune system.

28. What are primary, secondary and tertiary literature and what are the defining features of each?

29. What is a peer-reviewed journal?

30. What is a double-blind study?

31. Distinguish between a prospective and a retrospective trial.

32. Identify the stages of clinical trials and what happens in each stage.

And, if you have a little extra time, try quizzing yourself with:

• Testing your recall, Ch. 17, all.

• Testing your comprehension, Ch. 17, questions 2 and 3. Note: Answers to these questions are in the comprehension tests for each chapter at the class website.

Good luck and don’t panic!

The Universe is a friendly place! 

Organ System Overview: Cat Dissection

The questions in italics are ones which you have to complete in class.

The other questions you can answer outside of class if you run out of time.

 Prepare to dissect a cat by first donning gloves and obtaining a dissection tray and tools. Follow the instructions given in class, along with the guidelines in your lab text. After opening your specimen, see if you can identify the following organs:

 Heart

 Lungs

 Kidneys

 greater omentum (large sheet of fat covering digestive organs)

 stomach

 small intestines

 large intestines

 liver, bladder

 trachea

2. Now locate on your specimen the endocrine organs listed in the table below. Spaces have been left for you to fill in LATER (i.e. when you’re not wearing gloves) regarding the general function of each organ. Note: some organs you will not be able to locate during your dissection for any of the following reasons: poor dissection technique destroys a gland, inconspicuous nature of the gland, involution (atrophy) of the gland, gland located in an area not dissected such as the cranium.

Organ Location Function(s)

Hypothalamus Immediately superior to the pituitary gland; forms the walls and base of the third ventricle. Connected to the pituitary via the infundibulum.

Anterior pituitary gland Immediately superior to the sella turcica, anterior to the posterior pituitary gland.

Posterior pituitary gland Immediately superior to the sella turcica, posterior to the anterior pituitary gland.

Thyroid gland Inferior to the larynx (voice box), superficial and lateral to the trachea. Consists of two lobes linked together by a thin mass of tissue called the isthmus. Can be difficult to locate depending on how careful a dissection job you did.

Parathyroid glands Set into the posterior side of the thyroid. Two or more small, round glands per side. Very difficult to locate; you probably won’t find them.

Adrenal glands Superior and medial to the kidneys in cats (superior only in humans), these are bean-shaped and hard. Try rubbing your finger along the area where you would expect the adrenal to be. You may be able to feel it before you see it.

Pancreas Deep and somewhat superior to the stomach. Looks a bit like fatty tissue but it’s not.

Thymus Deep to the sternum, but superficial and superior to the heart. Atrophies over time; depending on the age of your specimen, you may not see the thyroid.

Pineal gland This small, pine-shaped (thus the name pineal) gland sits in the roof of the third ventricle of the brain.

Ovaries/Testes Ovaries: bilateral glands shaped like almonds located in the pelvic cavity. Refer to lab illustrations for help in locating. Testes: also bilateral glands. Located in the scrotum. May not be present if your specimen was neutered.

3. Identify three things you notice about the cats internal organs which is similar to what you see in humans.

4. Identify three things you notice about cats which is NOT like what you see in humans.

The Endocrine System

What are hormones?

• Hormon = “to excite”

– “troph” = to nourish, grow, change

• Chemical messengers

• Target most cells in the body

• Note: endocrine system is not continuous

• Endocrine glands produce

– Vs. exocrine glands

– Parenchyma (function) vs. stroma (form)

What do they do?

• Alter activity (metabolism) of target cell

• Alter PM permeability or voltage

• Stimulates production of proteins/enzymes

• Activates/deactivates enzymes

• Stimulates mitosis

• Induces secretory activity

How does the endocrine sys. compare to the nervous sys.?

• Slow messages

• Prolonged, continued response

• Via blood

• Can continue to adapt/respond to conditions for day or even weeks

• Often general, widespread effects on many organs

What are the types of hormones?

• Eicosanoids (paracrines)

• Monoamines

• Steroids

• Peptides

What are the types of hormones?

• Eicosanoids (paracrines)

– More localized, lipids

– Not true hormones

– Leukotrines (inflammation)

– Prostaglandins

• Inc. bp, dec. uterine contractions, enhance clotting, etc.

• Biogenic amines

– AKA monoamines

– From tyrosine (except melanin from tryptophan)

– Includes some neurotransmitters

• NE, epinephrine, dopamine (catecholamines)

• NE from SNS, E from adrenal medulla

– Also thyroid hormones (TH)

What are the types of hormones?

• Steroids

– From cholesterol: lipid sol.

– Sex steroids

– Corticosteroids (cortisol, aldosterone, etc.)

• Passes through PM

– travel to cell via transport protein

• proteins extend half-life

– Bind to DNA receptor in nucleus

• Activates transcription

• 3 binding sites on DNA receptor molecule

– Hormone

– Chromatin acceptor site

– DNA activation site

• Peptides

– 3 to 200 aa’s

• ADH, oxytocin

– All releasing/inhibiting from hypothalamus

• Most from anterior pituitary

– Bind to PM receptor

• Can’t pass through PM

• Act through secondary messengers

How do secondary messengers work again?

• cAMP

– Hormone binds to G protein

– Activates adenylate cyclase

• causes cAMP production

– cAMP activates/deactivates kinases

• By contrast: T3, T4 (direct cell entry, no secondary messenger)

– binds to:

• mitochondria

– Stimulates oxidative metabolism

• Ribosomes

– Stimulates translation

• Nucleus

– Stimulates transcription

– Na+-K+ pump controlled this way

What are the mechanisms of hormonal action?

• Only cells w/ appropriate receptors respond to hormone

– These are target cells

– Receptors on PM, nucleus, mitochondria, other organelles

• Receptors

– Specificity

– Saturation

– Amplification

– Up-regulation

• More receptors

• Greater sensitivity

• Oxytocin receptors in late pregnancy

– Down-regulation

• Fewer receptors

• Response to high concentrations

• Adipocytes & insulin

How do hormones interact with each other?

• Synergistic effects

– Greater than sum

– FSH + testosterone = adequate sperm production

• Permissive effects

– Hormone enhances target’s response to second hormone

• Estrogen stimulates up regulation of progesterone receptors

• Antagonistic effects

– Opposing actions

– Insulin vs. glucagon

– Estrogen vs. prolactin

What is the hypothalamus-hypophysis axis?

• Hypothalamus secretes: releasing/inhibiting hormones

• Hypophysis = __________________

• No nerve connection to adenohypophysis (anterior __________)

• Releasing and inhibiting hormones sent via blood

• hypothalamo-hypophyseal portal system

• Neurohypophysis—not a true gland (posterior _________)

• Mass of axons from hypothalamus

• Hypothalamo-hypophyseal tract

• Hormones stored in neurohypophysis

• Oxytocin

• ADH

• Nerve signal stimulates release

Anterior pituitary hormones

Hormone Target cell(s) Action

Follicle-stimulating hormone (FSH) Ovaries, testes

(A gonadotropin) Stim egg dev.

Stim. Sperm prod.

Luteinizing hormone (LH) Ovaries, testes

(a gonadotropin)

Peak at mid-menstrual cycle Stim. Egg release & corpus luteum to release progesterone

Stim. Interstitial testicular cells to release testosterone

Hormone Target cell(s) Action

Thyroid-stimulating hormone (TSH) Thyroid gland

Stim. thyroid growth and hormone secretion (metabolism)

Adrenocorticotropic hormone (ACTH) Adrenal cortex

Pancreas (insulin release) Reg. Stress response

Stim. Ad. cortex to secrete glucocorticoids (glucose, fat and protein metabolism)

Prolactin (PRL) Mammary glands

Testes Stim. milk synthesis after birth

Sensitizes testes to testosterone (permissive)

Growth Hormone (GH) or Somatotropin

Many

Esp. liver

Secreted mainly at night

Stim. Hyperplasia (growth by mitosis) and hypertrophy (growth by cells getting larger) of tissues

Increases fatty acid metabolism and decreases muscle uptake of glucose

Liver: stim. Somatomedins production (insulin-like growth factors, IGF); this stim. fat, cartilage, bone, tissue

Bone growth at epiphyseal plates

What does the posterior pituitary secrete?

• ADH--antidiuretic hormone

– AKA vasopressin

• Causes vasoconstriction at very high levels

– Inc. water retention (lower urine vol.)

– Prevent dehydration

• Oxytocin

– Stims uterine contractions

– Stims milk secretion after birth

• Nerve system stimulation controls both

– Nursing stimulus

– Osmoreceptors in blood vessels detect inc. osmolarity and stim. ADH

– Stretching of baroreceptors inhibits ADH

How do negative feedback loops control secretion?

• Important: Almost all hormonal regulation operates on negative feedback loops!

• Products from target organs often inhibit further secretion of hormone

• Example:

– Dehydration lowers blood volume and pressure

– Osmoreceptors detect

– Stimulates hypothalamus to secrete ADH via posterior pituitary

– Blood volume/pressure increases

– Osmoreceptors detect

– Inhibit further ADH release

• Another example: thyroid hormone (see p. 645 (new) (646, old) if you’re interested)

What are some pituitary disorders?

• In juveniles

– Hyposecretion (hypopituitarism)

• Pituitary dwarfism

– Hypersecretion: gigantism

• In adults

– Hypersecretion: acromegaly

• Posterior lobe hyposecretion: diabetes insipidus (which is: _______________________)

– WHY?

What is the pineal gland?

• Roof of third ventricle

• Produces serotonin

– Converted to melatonin

– Possible sexual maturation control

• Prevent early maturation?

What is the thymus?

• Location: mediastinum

• Involution after puberty (shrinks like pineal)

• Secretes thymopoietin

– Regulates development of T-lymphocytes

What is the thyroid?

• Largest endocrine gland

– Wraps around trachea

• Contains

– Sacs: thyroid follicles

• Lined with follicular cells which secrete T3 and T4

• Increases BMR, HR and heart contraction

– C cells

• Produce calcitonin

– Stores calcium by stimulating osteoblasts, inhibiting osteoclasts

• Antagonistic to parathyroid hormone (PTH)

• Regulation via the hypothalamo-hypophyseal-thyroid axis

What are some thyroid diseases?

• Hyposecretion

– Congenital hypothyroidism

• facial thickening, low body temp, lethargy, brain damage

– Adults: myxedema

• Low BMR, sluggish, sleepy, weight gain, cold, tissue swelling

What is goiter?

• Another thyroid disorder; two types

• Endemic goiter: dietary deficiency of iodine

– No TH produced so pituitary receives no neg. feedback and more more TSH produced

– Results in hypertrophy

• Toxic goiter (Grave’s disease)

– Autoimmune disease

– Abnormal antibodies mimic TSH, raising TH levels

• Called thyroid-stimulating immunoglobin

– Causes high BMR & HR, sleeplessness, weight loss, exophthalmos (eyes bulge)

What are the parathyroids?

• PTH: stim’s osteoclasts, inhibits osteoblasts

– Calcium released

• Hypoparathyroidism

– If parathyroid removed:

• Decreased calcium levels

• tetany and death without HRT

• Hyperparathyroidism:

– Bone softening, fragility, deformity

– Renal calculi formation

What are the adrenal glands?

• Adrenal medulla

– Sympathetic neurons innervate

– Secrete catecholamines

• Adrenal cortex

– Makes more than 25 corticoids (AKA corticosteroids)

– Small amounts of sex steroids (androgen/estrogen)

• Including DHEA (an androgen) which is converted to testosterone

– Mineralcorticoids

• Mostly aldosterone (retain Na+, secrete K+)

– Glucocorticoids

• Secreted in response to ACTH

• Cortisol (hydrocortisone) is most important

– Stimulate gluconeogenesis (fat and protein catabolism) and glycolysis

– Stress response

– Suppresses immune system

What are some adrenal disorders?

• Regulated by hypothalamo-hypophyseal-adrenocortico axis

. Cushing syndrome

– Via adrenal tumor or ACTH excess

• Hyperglycemia, hypertension, muscular weakness, edema, “moon face”, “buffalo hump”

• Addison disease

– Hyposecretion of glucocorticoids and mineralcorticoids

• Hypoglycemia, Na/K imbalance, loss of stress resistance, hypotension,

• Via excess ACTH secretion (b/c no neg. feedback)

• Bronzing b.c ACTH stimulates melanin production

• Fatal if not treated with corticoids

What does the pancreas secrete?

• Mostly exocrine digestive tissue

• Some endocrine tissue in pancreatic islets

– Islets of Langerhans

These secrete:

– Insulin via beta cells

• A peptide hormone

• Stimulates glycogenesis and inhibits glycogenolysis and gluconeogenesis

• Recruits glucose transporter proteins (GLUTs)

– Glucagon via alpha cells

• Stimulates gylcogenolysis (glycogen hydrolysis)

– Somatostatin (GHIH) via delta cells

• Paracrine secretion

• Modulates beta and alpha cell secretions

What are some pancreatic disorders?

• Hyperinsulinism

– Sometimes pancreatic tumor causes

– Sometimes accidental over-injection

– Causes hypoglycemia, weakness, hunger,

• Hypoglycemia stimulates E, glucagon, GH secretion

– Anxiety, hi HR, sweating

– Insulin shock—brain deprived of glucose

» Disorientation, convulsions, unconsciousness

What are some pancreatic disorders?

• Diabetes mellitus (DM)

– Diabetes = “to syphon or run through)

– Mellitus = “sweet”; insipidus = “tasteless”

• Hyposecretion or inaction of insulin

• Three signs:

• Polyuria (excessive urine output)

• Polydipsia (intense thirst)

• Polyphagia (intense hunger)

– Tests reveal hyperglycemia, glycosuria, ketonuria

What types of DM can patients have?

• Type I—insulin-dependent (IDDM)

– 10% of cases

– Autoimmune destruction of beta cells

– AKA juvenile diabetes (age 12)

• Type II—non-insulin dependent (NIDDM)

– Insulin resistance

• Adipocytes secrete resistin?

• Shortage of insulin receptors?

• Heredity, age, obesity

• AKA adult onset (age 40)

What do the gonads secrete?

• Exocrine products: egg and sperm

• Endocrine products: gonadal hormones

• We’ll cover this more at the end of the semester

What is stress and how do we adapt to it?

• Any stimulus that upset homeostasis

– Body copes via stress response (AKA general adaptation syndrome, GAS)

• Alarm reaction

– NE from sympathetic, E from adrenals = Fight or flight

• Stage of resistance

– If stress continues, glycogen reserves drop

– Cortisol dominates to provide fuels for metabolism

• Long-term cortisol exposure suppresses immune system

• Stage of exhaustion

– Fat reserves exhausted, rely on protein

• Body wasting and weakening

– Rapid decline and death: heart/kidney failure, infection

Unit Two

Exam Study Guide

1. Why does the right atrium contract before the right ventricle? Why do the atria contract together? Do the ventricles contract as a unit?

2. Trace the pathway of blood, beginning at the right atrium until it returns to the right atrium again. Don’t worry about anything aside from the major blood vessels connected to the heart but do include all valves, chambers, etc. What portion of the pathway is defined as the pulmonary circuit? The systemic circuit?

3. What is the role of the foramen ovale (in adults, called the fossa ovalis)?

4. Describe the role of coronary circulation. What four major arteries and two major veins help form this circuit? Explain why anastomoses are important to coronary circulation.

5. Identify and explain these diseases/procedures: MI, mitral valve prolapse, valvular stenosis, rheumatic fever, coronary vascular disease (CHD) AKA atherosclerosis; thrombus, embolus, arrhythmia, fibrillation, laser and balloon angioplasty, coronary bypass surgery, artificial pacemaker, ischemia, angina pectoris, hypertension.

6. Why are the pulmonary arteries called arteries if they carry de-oxygenated blood?

7. What are the risk factors for CHD?

8. Beginning with the SA node, explain how myocytes function to make the heart autorhythmic.

9. Identify the major components of an ECG (P wave, QRS complex, T wave). What does each represent? Why is there no repolarization wave for the atria? Can you identify irregular ECGs such as those on your lecture outline?

10. Which is more serious, atrial or ventricular fibrillation? Why?

11. What is the formula for calculating stroke volume? What three factors regulate stroke volume? What factors can affect contractility?

12. Compare/contrast: systole, diastole; tachycardia, bradycardia; inotropic, chronotropic.

13. Distinguish between the cardioaccelatory and cardioinhibitory centers. Where are they located? Explain this statement: the heart is controlled by the nervous system but doesn’t require the nervous system in order to function.

14. What are propioceptors and baroreceptors?

15. What hormones do the kidneys, hypothalamus and adrenals secrete which affect blood pressure?

16. Identify the phases of the cardiac cycle.

17. Discuss the relationship between blood flow, pressure gradients and vascular blood resistance. How does atherosclerosis affect this relationship?

18. What factors control peripheral (vascular) resistance? How do these factors affect arterial pressure, venous return, and local blood flow?

19. What are the general characteristics of a blood vessel? What are some reasons why blood pressure drops as blood moves from arteries to veins? Check out figure 20.8 to help answer this question.

20. What mechanisms allow gases and nutrients to move across the capillary wall? How do lipid-soluble, non-lipid-soluble and very large particles make the journey?

21. Generally explain how blood pressure and osmotic (oncotic) pressure oppose one another and how this determines which way fluids flow on the arteriole side of the capillary bed. Compare this to the direction of flow on the venous side.

22. What are portal systems and anastomoses? Define varicose veins, conducting arteries, distributing arteries, capillaries (fenestrated, continuous), venules, veins, thoroughfare channel (also called a shunt), perfusion, hypertension, hypotension, aneurysm, vasomotion, vasodilation, vasoconstriction, autoregulation, angiogenesis, reactive hyperemia, hypoxia, baroreflex, chemoreflex, capillary exchange, diffusion, transcytosis, filtration, reabsorption, thoracic pump, pressure gradient, thoracic pump, cardiac suction, skeletal muscle pump, venous pooling, edema, orthostatic hypotension, septal defects, peripheral vascular disease, metabolic theory of autoregulation,

23. In what ways do arteries and veins differ? How does this relate to their functions?

24. What mechanisms and anatomical features do veins use to help return blood to the heart?

25. How does the body re-direct blood during exercise?

26. What is circulatory shock? Distinguish between hypovolemic shock, obstructed venous return shock, vascular shock, septic shock, anaphylactic shock, neurogenic shock.

27. What’s the difference between compensated and non-compensate shock? Which is a negative and which is a positive feedback loop?

28. Why do you get dizzy if you get up after sunbathing?

29. Vascular resistance can change for a variety of reasons. Predict specifically how it would change if the following variables were altered: blood viscosity, vessel radius, vessel length.

30. Which type of artery is most important in controlling blood flow routing? Why?

31. What role does the medulla oblongata play in controlling blood flow? How (in very general terms) does the limbic system affect blood flow?

Also, quiz yourself using your textbook:

• Testing your recall, Ch. 19 (1-2, 4-20); Ch. 20 (1-20).

o Note: You can find the answers to these questions in Appendix B of your textbook.

• Testing your comprehension, Ch. 19 (questions 1, 2, 4, 5); Ch. 20 (questions 3, 4, 5).

o Note: You can find the answers to these questions in the comprehension tests for each chapter at the class website.

Good luck and don’t panic!

The Universe is still a friendly place!



Heart Lab

1. Using the heart models, identify the following structures so you’re well prepared for the lab practical. If another team is already using the models, skip to another question and come back to this one later.

 R/L atria

 R/L ventricles

 Aorta

 Superior vena cava

 Inferior vena cava

 R/L pulmonary arteries

 R/L pulmonary veins

 R/L coronary arteries

 Marginal artery

 Circumflex artery

 Anterior interventricular a.

 Posterior interventricular a.

 Great cardiac vein

 Middle cardiac vein

 R/L AV valves

 R/L semilunar valves

 Chordae tendineae

 Papillary muscles

 Base

 Apex

2. Examine the beef heart. Locate as many of the structures listed below as you can.

 R/L atria

 R/L ventricles

 Aorta

 Superior vena cava

 Inferior vena cava

 R/L AV valves

 R/L semilunar valves

 Chordae tendineae

 Papillary muscles

 Base

 Apex

3. Compare the size of the L and R ventricular walls in the beef heart. Which has a thicker wall? _______________

4. Explain why this would be.

5. Determining heart rate. Locate your pulse either radially (at the wrist, just medial to the radius) or at the carotid (the carotid arteries are lateral to the larynx in the neck). Count the number of pulses for 15 seconds, then multiply by 4 to get your beats per minute (heart rate or HR).

4. Number of beats _____________ X 4 = ____________________ beats per minute (bpm)

5. A cardiac cycle is the amount of time it takes the heart to complete one beat and is measured in seconds (usually is a value of less that one second). If there are 60 seconds in one minute, and your heart rate is ___________bpm, then how long does it take your heart to complete one cardiac cycle? Show your work below.

6. Auscultation means to listen to sounds in the body, such as using a stethoscope to hear the heart beat. Obtain a stethoscope and use it to listen to the lubb, dupp sound your lab partner’s heart makes each time it beats. The lubb sound (S1) results from turbulence of the blood as the AV valves close (during systole). The dupp sound (S2) occurs at diastole as the semilunar valves close and the ventricles relax to receive more blood.

4. Which sound (S1 or S2) is louder in a patient at rest? ______________________

5. Why?

7. Familial hypercholesterolemia is an autosomal recessive genetic disorder with incomplete dominance. In this disease, an individual’s cells are not able to dock LDL proteins on their surface. As a result, the LDL proteins cannot unload their lipids and the lipids remain in the blood, increasing LDL and cholesterol levels drastically. If an individual is born with two copies of the Hf allele 9the recessive, mutated form), they die of heart attack, usually by age 4. Those born with one version of the normal allele (HF) and one of the recessive allele can dock some of their LDL proteins but not many, and their blood cholesterol levels are high, too. These individuals typically die of heart attack by their mid-20s. Individuals who are homozygous dominants live normal lifespans.

8. Imagine a man who is a carrier for this disease marries at 18 to a woman who is also a carrier. For this problem, show all five steps to solving a genetics problem which you learned from last semester. If you didn’t have Kerry last semester, find a classmate who did and get the five steps from them.

a. What are the chances that a child of theirs will die as a toddler?

b. What are the chances a child of theirs will die in their 20s?

Blood Pressure Lab

Health professionals use a sphygmomanometer to measure arterial blood pressure in mmHg (millimeters of mercury). Usually, this measurement is done at the brachial artery in the antecubital area with the help of a stethoscope. As the inflatable cuff of the sphygmomanometer fills with air, the pressure in the cuff eventually exceeds the pressure of blood flowing through the brachial artery. This stops blood flow through the artery. As air is slowly released from the cuff and air pressure drops, it eventually falls below the pressure of the blood and the artery opens, allowing blood flow to resume. As blood flow returns to normal, turbulent sounds of the blood (Korotkoff sounds) can be heard through the stethoscope.

a. Find a partner and take turns determining each other’s blood pressure. If you have never taken someone’s blood pressure before, ask Kerry or a fellow student with experience for help.

b. The systolic pressure value is measured when you hear the first sound as blood begins to flow again through the still partially occluded artery. Normal average systolic pressure for an adult is _____________________ mmHg.

c. The diastolic pressure value is measured when the last, faint beating sound is heard as the pressure cuff deflates. Normal average diastolic pressure for an adult is ______________ mmHg.

d. Record the values you obtained for your partner and for yourself below. Be sure to label your values in mmHg.

i. Partner systolic __________________, diastolic __________________.

ii. Your systolic __________________, diastolic __________________.

e. Repeat blood pressure measurements for both you and your partner and record your second values below. Be sure to label your values in mmHg.

i. Partner systolic __________________, diastolic __________________.

ii. Your systolic __________________, diastolic __________________.

f. Calculate the average systolic and then average diastolic for your partner by A) adding the systolic values together, then dividing by two and B) adding the diastolic values together, then dividing by two. Do the same thing for your values and record the averages below. Be sure to label your values in mmHg.

i. Partner’s average systolic ___________________, average diastolic________________

ii. You average systolic______________________, average diastolic________________

g. The pulse pressure is the difference between the systolic and diastolic values. Calculate the pulse pressures for you and your partner, using your average values. Be sure to label your values in mmHg.

i. Partner’s pulse pressure _______________________

ii. Your pulse pressure __________________________

h. Mean arterial pressure (MAP) is the average blood pressure (BP) over the course of the cardiac cycle. It increases when cardiac output increases, or when vessel resistance increases. Because the heart spends more time in ventricular diastole than in other portions of the cycle, the equation for calculating MAP is weighted accordingly.

MAP = diastolic BP + (pulse pressure/3)

i. Calculate your partner’s MAP and your MAP below.

Partner’s MAP = diastolic BP ___________________ + (pulse pressure _____/ 3) = _______

Your MAP = diastolic BP ___________________ + (pulse pressure _____/ 3) = _______

Cardiovascular System:

THE HEART

What does the heart do?

• 100,000 hb/day

• ~3B hb/lifetime

• 4,000 gallons (15,000 L) blood pumped/day

• ~60% of blood in veins at any given time

What are the heart parts?

• In thoracic cavity: mediastinum

– Apex points slightly to left

– Base at “top” of heart

• Around heart: pericardium

• Heart: three layers

– Epicardium

– Myocardium

– Endocardium

What is the pericardium?

• Parietal pericardium

– Fibrous layer: dense irregular c.t. (outside)

– Serous layer: moist (inside)

• Turns inward at base (top of heart) to form visceral pericardium

• Visceral pericardium

– Covers heart surface (epicardium)

• Pericardial cavity

– Between parietal and visceral pericardium

– Contains pericardial fluid

• Pericarditis

Cardiac tamponade

What are the three layers of the heart?

• Epicardium = visceral pericardium

– Contains fat deposits in sulci

– Other areas: thin and transparent

• Myocardium

– Cardiac muscle fibers

– Held together by fibrous skeleton (collagenous and elastic fibers)

– Recall: intercalated discs which contain gap junctions, desmosomes

• Endocardium

– Endothelium

• Continuous with vascular endothelium

What’s inside the heart?

• Four chambers

– Two atria + auricles

• Interatrial septum

– Fossa ovalis

– Two ventricles

• Interventricular septum

• Four valves

– Atrioventricular valves

• Right: tricuspid

• Left: bicuspid (mitral)

• Chordae tendineae

• Papillary muscles

• Prolapse

What’s inside the heart?

• Four valves

– Semilunar valves

• Right: pulmonary semilunar

• Left: aortic semilunar

• Valve disorders

– Stenosis

• Stiffened cusps; scar tissue occludes opening

• Often rheumatic fever causes

– Autoimmune disease attacks mitral valve: scarring and more heart work

– Incompetent valve causes regurgitation and turbulence = heart murmur

– Mitral valve prolapse (MVP)

What blood vessels lead to/from the heart?

• Superior/inferior vena cava

– Empty into R atrium

• Pulmonary trunk

– At pulmonary semilunar valve: R/L pulmonary arteries

• R/L pulmonary veins empty into L atrium

• Ascending aorta

– Brachiocephalic trunk

• R common carotid artery and R subclavian artery

– L common carotid artery

– L subclavian artery

• Ductus arteriorsus: pulm. a. to aorta in fetus

• Systemic vs. pulmonary circuit

• Cor pulmonale

What are the coronary arteries?

• Heart doesn’t get blood from chambers, it has its own blood vessels instead

• Two stem immediately from ascending aorta

• Left coronary artery (two branches)

– Anterior interventricular branch

– Circumflex branch

• Right coronary artery (two branches)

– Posterior interventricular branch

– Marginal branch

• Anastomoses

– Prevent myocardial infarction

What are the coronary veins?

• Coronary sinus

– 20% of blood directly into right atrium

– 80% dumps into:

• Greater cardiac vein

• Middle cardiac vein

• To coronary sinus to right atrium

What are some coronary diseases?

• Coronary artery disease (atherosclerosis)

– Risk factors (8)

– Atherosclerotic plaque

– Thrombus and embolism

• Heparin

• Coumadin (warfarin) (blocks synth. Of II, VII, IX, X)

• Angioplasty

• Coronary artery bypass grafting

What are some coronary diseases?

• Ischemia

• Angina pectoris

• Myocardial infarction

What path does blood take through the heart?

• Trace the blood flow through the heart, systemic and pulmonary circuits beginning at the right atrium. Be sure to include all valves, chambers and major blood vessels connected to the heart.

How does the heart beat?

• Myogenic cells

• Sinoatrial (SA) node: innate rate: ~100 b/min

– Right atrial myocardium

– Primary pacemaker; slow Na+ inflow

– ANS regulates

• Atrioventricular (AV) node (Bundle of His)

– Single point of electrical connection bet. atria and ventricles

• 40-50 bpm = nodal rhythm

• Damage = total heart block

– 100 msec delay

– ANS regulates

• AV bundle (right and left)

• Purkinje fibers (conduction fibers)

• Ectopic focus

How do myocytes create a potential?

• Myogenic cells

– -60 mV potential

– “leak” to generate pacemaker potential

• Slow Na+ leak w/no K+ outflow

• -40 mV threshold

– Fast Ca2+ gates open (depolarize)

– Then repolarization = K+ gates open

• Myocytes

– Slow Ca2+ channels prolong contraction

What is the cardiac cycle?

• Terminology

– Systole

– Diastole

– Normal sinus rhythm: 60-100 b/min; 70 ave.

– Tachycardia; >100

– Bradycardia; < 60

– Palpitation

What is an electrocardiogram (ECG)?

• Wrists, ankles, six chest locations

• Basic ECG waves

– P wave: atrial depolarization and systole

• When SA fires

– QRS complex: ventricular depolarization

• When AV node fires

• Note: this masks atrial repolarization and diastole

• S-T segment: beginning of ventricular systole

– T wave: ventricular repolarization and diastole

How do we interpret ECGs?

• Size and timing of waves

• Significance of large waves

– P wave: mitral valve stenosis

– Q wave: MI

– R: ventricular hypertrophy

• Arrhythmias

– AV block

– Fibrillation

What are the phases of the cardiac cycle?

• All this happens in less than a second!

• Relaxation phase (quiescent period)

– T wave initiates at end of heart beat

– All chambers: diastole

– Ventricular pressure falls below atrial pressure

• Causes AV valve to open and ventricles to begin filling

• Ventricular filling

– SA node fires (P wave begins)

– Atrial systole follows

– End-diastolic volume (EDV) pushed into ventricles (~25 ml)

What are the phases of the cardiac cycle?

• Ventricular systole

– AV node sends impulse to Purkinje fibers

– Ventricles begin to depolarize and contract = isovolumetric contraction

– Ventricular ejection (~70 ml ejected = stroke volume)

– Blood remaining in ventricles (end systolic volume, ESV ~60 ml)

What are the phases of the cardiac cycle?

• Isovolumetric relaxation

– Early ventricular diastole

• Ventricular filling

– Further relaxation of ventricles lowers pressure to below that of atria

– AV valves open and blood pours in

• Murmur = turbulence

• Incompetent = swish sound from not closing completely

• Stenotic = whistle b/c stiff

What are the phases of the cardiac cycle?

• Stroke volume

– SV = EDV – ESV (amt of blood in one cycle)

– Three factors regulate SV

• Preload

– Stretch on ventricles before contraction

– Starling’s law (think of rubber bands)

– Ventricles eject as much as they receive

– Keep both sides equal

» Congestive heart failure if sides not equal

What are the phases of the cardiac cycle?

– Contractility; determined by other factors than preload

• Force of the contraction

• ANS controls

– Sympathetic and epinephrine

– Parasympathetic: vagal tone

» Abnormal electrolytes can affect

• Inotropic agents (vs. chronotropic agents)

– Hyperkalemia = negative inotropic agent

– NE/E = positive inotropic agents

– Afterload

• Pressure in aorta and pulmonary trunk

What is cardiac output?

• CO (ml/min) = SV (ml/beat) X HR (beat/min)

– Total amount ejected from right OR left ventricle in one minute

• Auscultation

– Lubb: blood turbulence from AV valve closure

– Dubb: blood turbulence from closure of semilunar valves

What regulates the heart?

• Chronotropic effects and agents

• Nervous system doesn’t initiate heart beat

– Instead modifies its rate and force via autonomic innervation

• Medullary Cardiovascular Center (CV)

– Cardioacceleratory center (sympathetic): NE

– Cardioinhibitory center (parasympathetic): acetylcholine

• Vagus nerve to SA and AV node

• Ach opens K+ channels = hyperpolarization

– NE and acetylcholine action

• Beta adrenergic receptors on cardiac fibers

– Use of beta blockers to control hypertension

What regulates the heart?

– Baroreceptors

– Potassium

• Hyperkalemia: slows beat, may arrest in diastole

– Too much potassium raises membrane potential making repolarization difficult

• Hypokalemia: leaves cells hyperpolarized

– Need more stimulus to reach threshold

• Hormonal regulation of bp

– Kidneys: renin production (raises bp)

– Hypothalamus: ADH production

– Adrenals: aldosterone production

Blood Vessels and Circulation

What is circulation?

• Deliver oxygen, nutrients to tissues

– Remove waste products

• Different organs/regions receive varying amounts of blood at different times

• Perfusion: blood flow per volume or mass

What is the general anatomy of blood vessels?

• Generalized route: heart, arteries, arterioles, capillaries, venules, veins

– Recall: definition of artery

• Only through one capillary bed

– Portal systems are exceptions

• Hypothalamo-hypophyseal portal system

• Kidneys

• Small intestines to liver

– Anastamoses also exceptions

• Arterial or venous anastomoses

• Arteriovenous shunts

What walls make up blood vessels?

• Three layers (tunics) in arteries and veins

– Tunica external (tunica adventitia): outermost

• Loose CT; anchors vessel in place

• Elastic and collagen fibers

– Tunica media: middle layer, thickest of three

• Smooth muscle; some elastic fibers

• Vasodilation/vasoconstriction

– Tunica interna (tunica intima)

• Endothelium over basement membrane

• Some fibroconnective tissue

• Secretes vasodilators and vasoconstrictors

• Smooth so blood passes easily

What are arterioles and metarterioles?

• Tolerate surges in blood pressure

• Different sizes

– Conducting (elastic): largest

• Expand and recoil

• Pressure reservoir during diastole

– Distributing (muscular): to specific organs

• More smooth muscle; thicker, most vasodynamic

– Resistance (arterioles—small): primary controllers of blood flow and route

• Major site of pressure regulation/distribution

• Metarterioles: short vessels linking arterioles and capillaries

– With capillary sphincter

What are capillaries?

• Distributions of gases, nutrients

• Only endothelium (one layer) and basement membrane

– Very thin; 0.2 to 0.4 micrometers

– About 1B in body

– No cell in body is more than about 60-80 micrometers away!

• Except: cartilage, tendons, ligaments, epithelia, cornea and lens

What are capillary beds?

• 10-100 capillaries with a shunt (thoroughfare channel) directly connected to venule

– Precapillary sphincters along metarteriole

– ~75% of all capillaries closed at any one time

– Blood travels SLOWLY

• Types of capillaries

– Continuous: most tissues

• Endothelial cells with tight junctions

• Narrow intercellular clefts for small solute passage

– Fenestrated: kidneys, small intestines, endocrine glands

• Endothelial cells with many holes

• Rapid passage of small solutes

What are capillary beds?

• Sinusoids: irregular blood-filled spaces

– Bone marrow, liver, spleen

– Conform to organ shape, some fenestrated

– How liver delivers albumin, other proteins to the blood

What are veins and venules?

• Phlebotomy: incision in vein to draw blood

• Venules collect capillary blood

• Venous sinuses: veins with v. thin walls, large lumens, no smooth muscle (e.g. heart, brain)

• Lower bp than arteries. Why???

• Internal valves prevent backflow

– Help when skeletal muscles relaxed

• So does thoracoabdomino action (thoracic pump)

– Mostly in medium-sized veins of arms/legs

– About 54% of blood in systemic veins at rest

• Varicose veins: veins stretched, valves become incompetent = blood pools

– Hemorrhoids: type of varicose veins

What affects blood flow?

• Without it = necrosis or even death

• Affected by blood pressure, vascular resistance

– Blood flow = force (pressure gradient)/resistance

• Measure bp with sphygmomanometer

What is blood pressure?

• Force of blood on vessel wall

– Pressure gradients occur

• Capillaries to interstitial fluid

• Ventricle to atria for blood to flow through pulmonary or systemic circuits

– Measure diastole and systole

• Pulse pressure = systole – diastole

• Mean arterial pressure (MAP) = average over cardiac cycle

– MAP = dias + 1/3 pulse pressure

– MAP also = CO X R

How is blood pressure regulated?

• Recall MAP = CO X R

• SV and HR affect b/c CO = SV X HR

• Peripheral resistance via arterioles changing diameter

– Vasoconstriction: sympathetic, adrenal medulla

– Vasodilation: parasympathetic

• Blood volume also affects

• Hormonal

– Aldosterone, ADH: long-term effects

– Angiotensin II (ACE inhibitors)

– Atrial natriuretic peptide (antagonizes aldosterone)

What is vascular resistance?

• Friction between blood and vessel wall

– Peripheral resistance: sum of all vessel resistance in systemic circuit

– Albumin and erythrocytes, mainly

• Blood flow inversely related to resistance

– Garden hose vs. straw

• More surface area contact in straw for same amount of water = more resistance

• Causes: blood viscosity, vessel length, vessel diameter, vessel elasticity, lumen occlusion

– Diameter regulated to change resistance

What is atherosclerosis?

• Damage to endothelium initiates process

– Progresses to fatty streak stage: lipids/macrophages in tunica intima

• Become fibrous plaque

– Increases with smooth muscle and protrudes into lumen

– Plaque is unstable

• Break, tear leads to thrombus, possible embolism

What are some blood pressure characteristics?

• Pressure gradient from aorta (~120 mmHg) to right atrium (~0 mmHg)

– Elastic arteries: highest pressure, lowest R

– Muscular arteries: some pressure loss (smaller diameter, less elastic)

– Arterioles: smallest diameter, largest R, largest decrease

– Capillaries: small, numerous, small gradient with ECF but enough

• Why need low pressure? Edema

– Venules, veins: pressure gradient still toward heart

• Valves, skeletal muscle pump and diaphragm help

What are some blood pressure deviations?

• Hypertension: 140/90; receptors reset

– Strains heart (higher afterload)

– Can lead to swelling which can cause vessel rupture (aneurysm), kidney failure

– Risks: obesity (fat = greater vessel length), atherosclerosis, smoking (nicotine = vasoconstrictor)

– Treat with diet, anti-hypertensive drugs

• Hypotension: 100/60

– Causes: blood loss, dehydration, anemia

What monitors blood pressure?

• Neural reflex arcs

– Baroreceptors (baroreflex)

• Aortic arch (systemic)

• Carotid sinus (to brain)

• Right atrium (monitors venous return)

– Propioceptors: in muscles

• Not a true monitor, but does affect bp

– Chemoreceptors (chemoreflex)

• Respond to decrease O2, increased CO2 and pH decrease

• Aortic body, carotid body

What are some nervous system controls?

• Medulla oblongata

– Cardiac center: stimulate or inhibit

– Vasomotor center: blood vessel diameter

• Higher centers can also influence

– Hypothalamus (limbic system)

What are local controls?

• Autoregulation: ability of tissues to regulate own blood supply

– Metabolic theory of autoregulation

• inadequate perfusion leads to accumulation of metabolites

• This stimulates vasodilation

– Short-term hypoxia

• respond with reactive hyperemia (above normal flow increase)

– Long-term hypoxia

• tissue can undergo angiogenesis

What is va

661 POSTS OF STAFF NURSE BPS-16

Posted by BHERU LAL on August 14, 2010 at 1:28 AM

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B) HEALTH DEPARTMENT

661 POSTS OF STAFF NURSE BPS-16

(MALE & FEMALE) AGE: MIN: 18, MAX: 35 YEARS

R + U = T

Male & Female

389 + 259 = 648

2 % for disables persons quota

08 + 05 = 13

QUALIFICATIONS:

For Male: i. Diploma in General Nursing in Ward Administration or Technician or any in lieu of Midwifery.

ii. Registration with Pakistan Nursing

Council.

For Female: i. Diploma in General Nursing, Midwifery.

ii. Registration with Pakistan Nursing

Council.

APPLICATIONS SHOULD REACH THE HEAD OFFICE OF SINDH PUBLIC SERVICE COMMISSION, THANDI SARAK, HYDERABAD ON OR BEFORE THE CLOSING DATE IN THE OFFICE HOURS.

Closing Date: 23.08.2010

SANA FAME FUND SCHOLARSHIPS

Posted by BHERU LAL on May 6, 2010 at 3:30 PM

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BHERU LAL

News

Psychiatric Mental Health Nursing

PEDIATRICS HEALTH NURSING

ANATOMY AND PHYSIOLOGY

661 POSTS OF STAFF NURSE BPS-16

R + U = T

Male & Female

389 + 259 = 648

For Male: i. Diploma in General Nursing in Ward Administration or Technician or any in lieu of Midwifery.

For Female: i. Diploma in General Nursing, Midwifery.

SANA FAME FUND SCHOLARSHIPS

SANA FAME FUND SCHOLARSHIPS

Latest Announcements for Academic Year 2009-2010

For the academic year 2009-20010, our target is award of 80 Scholarships.

1. Fifty Six (56) scholarships for Undergraduate Studies in Sciences. Each $250.00

2. Six (6) scholarships for Post-graduate Studies in Social Sciences and Humanities. Each $500.00

3. Six (6) scholarships for Undergraduate Studies with major in Sindhi Language, Sindhi Literature, Sindh History, etc. Each $250.00

4. Four (4) scholarships for Post-graduate Studies in Sindhi Language, Sindhi Literature, Sindh History, etc. $500.00 each.

5. Eight (8) scholarships of $250.00 each for students of Nursing Colleges.

http://www.sanalist.org/ or www.famefund.net

LAST DATE JUNE15, 2010

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