Nursing: Circulatory, Pulmonary, Renal Systems

• These notes cover Pathophysiologic Processes and Implications for Nursing, focusing on disorders of the circulatory and pulmonary systems, as well as renal and genitourinary systems
• The notes cover content for the Spring 2025 Exam Three

Exam Question Styles

• Multiple choice questions are on the exam
• Multiple answer questions, where you select all that apply, are on the exam
• There will be fill in the blank questions
• Some questions will be true or false
• There may be short answer questions
• There may be essay questions

Cognitive Level and NCLEX Client Needs

• Questions can be categorized by Bloom's Taxonomy to assess student thinking, learning, and understanding
• NCLEX client needs is a testing framework that provide a universal structure for defining Nursing actions and competencies
• Client needs categories include
• Safe & Effective Care environment
• Management of Care
• Safety and Infection Control
• Health Promotion and Maintenance
• Psychosocial Integrity
• Physiological Integrity
• Basic Care & Comfort
• Pharmacological/Parental Therapy
• Reduction of Risk Potential
• Physiological Adaptation

General Test Information

• Question numbers are proportionate to lecture time, but are estimations
• Critical thinking tests may include material from different subject sections in one question
• The blueprint covers most, but not all, content and students should review all material

Disorders of the Circulatory System (Weeks 6 & 7)

• 18-20 questions will cover this topic

Key Concepts

• Understanding of normal blood flow (forward and backward)
• Knowledge of structural and hemodynamic derangements, etiological factors, clinical manifestations, diagnostics and treatments

Arterial Peripheral Vascular Disorders

• Healthy arteries have normal muscle tone allowing flexibility, compliance, and patency for good perfusion
• Measuring good perfusion includes:
• Capillary refill ≤ 2 seconds
• Pink, warm skin
• Normal pulses
• Good urine output and mentation

Bad Arteries (Arterial Problems & Ischemia)

• Problems include alterations in tone (constricted/dilated) and/or alterations in lumen (blockage)
• Arteriosclerosis and Atherosclerosis are big causes of bad ateries
• Arteriosclerosis involves stiffening and thickening of arteries with age, HTN, diabetes, and hyperlipidemia, abnormal tone and resistance, and decreased elasticity and compliance
• Atherosclerosis involves fatty deposits settling into micro-injuries in arteriosclerotic vessels, triggering inflammation and plaque formation that narrows artery lumens
• Risk/ severity of arterial disease increases with
• higher LDLs
• lower HDLs
• smoking
• sedentary lifestyle
• diet
• hyperglycemia
• heavy alcohol consumption

Ischemia S&S

• Ischemic pain worsens with exertion and eases with rest known as intermittent claudication in leg arteries and angina in coronary arteries
• Poor arterial perfusion shown in
• pain
• diminished pulses
• delayed cap refill
• pale, cool skin (poikilothermia)
• delayed healing
• Heart hypoxia leads to decreased contractility and cardiac output
• Mental state can be altered

HTN

• Hypertension means consistent BP > 130s/80s
• Primary hypertension is more common than secondary
• Risk factors include arterial diseases plus increased sodium
• Atherosclerosis and/or overdrive of SNS and/or RAAS can lead to hypertension

Overdrive Effects

• Elevated epinephrine stimulates heart beta receptors, causing tachycardia and increased contractility
• Greater ejection pressures increase driving pressure and BP
• Overdrive in RAAS sustains vasoconstriction, increased blood volume and higher BP

Sequelae of Overdrive Situations

• High pressures damage arteries, worsening atherosclerosis
• Arterial walls hypertrophy, narrowing lumens
• S&S: often asymptomatic initially but affect neurologic (strokes), renal (hematuria, proteinuria), and circulatory systems (MI, HF, PAD)
• Treatment targets overdrive situations via ACE inhibitors, diuretics, beta-blockers, sodium reduction and lifestyle modifications

Peripheral Arterial Insufficiency

• Peripheral arterial disease (PAD)
• Arterial disease outside heart causes ischemia, especially in legs often
• S&S include intermittent claudication, pain, diminished pulses, skin ulcers, no hair, cool temperature, pale or mottled skin

Aneurysms

• Outpouching of arterial walls caused by stiff arteries plus hypertension
• Can be found in brain, aorta, or femoral arteries
• S&S include pain (if large/ruptured), diminished pulses, and ischemia

Arterial Thrombi & Emboli

• Clots form in pockets of sluggish arterial flow or arterial injury
• Examples include atrial fibrillation & thrombus of femoral artery
• Atrial fibrillation has chaotic electrical impulses, quivering atria, causing blood pockets in atria and potential thrombus formation due to platelets/fibrin collection
• If clots become emboli in left atrium, flow to brain and other parts arterial system can occur
• Other areas of thrombi in femoral artery could cause ischemia to distal tissue, pain, paresthesia, pallor, poikilothermia & prolonged cap refill

Venous Peripheral Vascular Disorders

• Chronic Venous Insufficiency (CVI), peripheral venous congestion and edema

Chronic Venous Insufficiency

• Valves in leg veins become "floppy"
• Blood backflow can lead to congestion and stasis in lower legs/feet causing edema
• Complications include venous stasis ulcers and thrombi Venous Thrombi & Emboli
• VTE includes DVT (deep vein thrombosis) and PE (pulmonary embolism)

Virchow's Triad

Virchow's triad include venous stasis, injury to vein lining, and hypercoagulability

DVT and PE

• DVT symptoms include inflammation, swelling, pain, erythema, warmth
• PE symptoms include shortness of breath, chest pain, hemoptysis, hypotension
• Venous problems often include venous backflow, congestion, and edema, and stasis with immobility
• Treatment: encourage mobility and hydration; elevate feet; use anticoagulants

Factors Affecting Cardiac Output

• Cardiac output (CO) = HR x SV; abnormalities of HR, rhythm, contractility, preload, or afterload
• Assess for S&S of good vs poor perfusion
• Rate and rhythm abnormalities may decrease CO
• Normal sinus rhythm (NSR) outside of norm can affect cardiac output
• HR normal mean 60-100, higher means tachycardia, and lower means bradycardia Normal Rhythym is regular, NSR, with irregular rhythms including atrial fibrillation, and ventricular fib.
• Neurohormonal influences: epinephrine and norepinephrine from sympathetic activity increase HR and contractility, while acetylcholine parasympathetic activity via the vagus nerve decreases HR.
• Electrolyte disturbances includes hypokalemia leads to hyperpolarization as well as bradycardia, decrease in contractility, adn weakness. Hyperkalemia leads to hypopolarization, irritability, and later a picture of hypokalemia.
• Contractility = how toned, how well heart ejects blood (pump power).

Contractility and Stroke Volume

• Stroke volume can be decreased with diminished contractility and therefore reduce perfusion
• Negative inotropic effect will decrease contractility and positive inotropic effect will increase contractility (ex-Certain meds like digoxin are positive inotropes)
• Preload = blood coming back to heart = volume-related issues
• Low preload leads to fluid volume deficit S&S dehydration, and a low amount of blood sent to left heart = low SV and CO
• High preload leads to fluid volume overload S&S fluid overload, and high amt of blood sent to left = cause too much workload on left ventricle.
• Afterload = resistance to flow the end result is SV, CO, and perfusion. It can affect the right or left heart.

Coronary Artery Disease

Caused by same problems as any other arterial disease (atherosclerotic process, HTN, etc), but coronary arteries are the ones affected ,and the coronary arteries perfuse the heart muscle ischemia/infarction of cardiac cell has a negative inotropic effect CAD also linked to high homocysteine levels (free radical-type behavior) and CRP (inflammatory component). Angina occurs due to ischemic pain in the heart muscle • classic S&S-- chest pain that may be described as crushing, tight, left arm, jaw, or upper back pain

Ischemic Pattern And Cardiac Ischemia

• pain pattern very stable & predictable, usually rated on low end of pain scale • The cause of stability usually due slow plaque development that allows development of collateral circulation (arteriogenesis) over time.

Acute Coronary Syndrome

usually there is sudden blockage or worsening of preexisiting plaque ○ 2 subdivisions of ACS: ■ unstable angina (ischemia worsening) relates to plaque rupture causing a partial occlusion of the coronary artery by a thrombus ORMI (cells beginning to die) relates to plaque rupture causing a total coronary artery occlusion by a thrombus. sequela of CAD-related situations can be hypertrophy of cardiac muscle➔ cardiomegaly or heart failure.

Heart Failure

basic definition / characteristic: failure of heart to eject all of blood in normal forward fashion pump problem example: MI weakens the heart & decreases contractility increased afterload-increased resistance such as narrowed, atherosclerotic arteries decreased ability of heart to easily eject blood. increased preload-fluid volume overload can have increased workload of heart

Left HF

etiological mechanisms: ■ can't pump can be process such as Ml weakens left heart muscles (example: Ml from a blockage of the LCA→ damage to left heart myocardium→ can't eject blood forward low CO →kidneys perceive a low blood volume / pressure→ RAAS triggered ■ HIGH afterload high BP and/or chronically constricted, inflexible arteries as in atherosclerosis (the aorta is narrowed & stiff from atherosclerosis so LV can't eject blood into it very well back-up of fluid into lungs (AND / OR high preload - too much blood volume = too much workload on the heart diagnosis of both LHF & RHF-- BNP level increases the in the more HF there is.

Right HF

etiological mechanisms: ■ high afterload (resistance): increased pulmonary resistance (ex from lung dz's like chronic bronchitis) S&S-peripheral venous congestion which involves fluid back-up from right side of heart into periphery the commanility is usually a murmur is heard along with S&S of poor perfusion.

Disorders of Respiratory System (Week 8)

• Topics include key aspects of normal pulmonary function and pathophysiology

ABGS

• If PCO2 is out of normal range, the problem is respiratory, if HCO3 is out of normal range, the problem is metabolic.
• Respiratory Opposite shows that PH is low and the PCO2 is high

Restrictive Lung Diseases

• Inhalation problems
• Cannot get air into the lung tissue (alveoli) OR cannot be able to get blood to alveoli to be oxygenated at the end point.
• Hypoxemia (low pO2 & SO2)

Pulmonary Embolism

• pulmonary embolus is typical perfusion defect problem • Risk factors

• DVT, anything contributing to Virchow's triad obstructive diseases (exhalation problems)

Asthma

• genetic predisposition can caused hyper-responsiveness of airways to environmental allergens through an inflammatory response, edema of bronchial lining + bronchial constriction & spasm, the end result is narrowed airways wheezing.

Renal & Genitourinary Systems (Week 9)

• Female disorders: endometriosis, ovarian cancer, PID
• Male disorders: testicular cancer, BPH, prostate cancer
• Urologic problems: UTIs, STIs, urologic obstructions

Male Reproductive Health

• Testicular cancer is seen in younger men, which is usually manifested by painless mass
• Prostate problems include
  • BPH which occurs in proliferration of prostate tissure and is seen in older men
    • largest problem is compressing urethra cancer - diet high in saturated fat, high testosterone, family history and African American race, S&S similar to BΡΗ

Female Reproductive Health

• uterus
  • dysmenorrhea is painful heavy menstrual periods
  • endometriosis where ectopic endometrium in pelvis and abdomen that respond to monthly hormonal cycle

Non-Gender Specific

• STI's like chlamydia and gonorrhea
  • obstructive disorder is with any serious sequela urinary obstruction can lead to hydronephrosis

Renal Problems

• AKI - usually a problem of blood flow to kidneys, that has can cause either a vessel problem or decreased cardiac output ■ intrarenal-something has caused acute tubular necrosis (ATN) postrenal-obstruction cases backup of urine into kidney that interfere with tubular function can result in intrarenal AKI if not that.