Pathophysiology I - Module 1 Case Study

Week 1 in Patho: Introductions and Module 1 Sarah J. Allgood, PhD, RN  What’s on the Agenda? Welcome to Patho – – Meet the team – Questions about the course – Upcoming assignments Module 1 case study Class activity: – Rapid Review – If time…Synthesis Assignmen...

Week 1 in Patho: Introductions and Module 1 Sarah J. Allgood, PhD, RN  What’s on the Agenda? Welcome to Patho – – Meet the team – Questions about the course – Upcoming assignments Module 1 case study Class activity: – Rapid Review – If time…Synthesis Assignment 1 Question Independent work time – remainder of class  Meet Your Patho Team Sarah Allgood, PhD, RN: lead course coordinator – Dr. A – Med-surg, pulmonary, cystic fibrosis, pain and symptom management, clinical trial nursing Colleen King-Goode, DNP, MA, MS, RN: course co- coordinator – Dr. Goode – Family nurse practitioner, med-surg, neuro, nursing education, simulation education Brenda Shelton, DNP, APRN-CNS, RN, CCRN, AOCN, NPD- BC – Dr. Shelton – Clinical Nurse Specialist, Oncology  Our Teaching Assistants Mirna Shaban – Second-year Adult Acute Care DNP student – Current practice: cardio-thoracic ICU nurse Brianna Keefe – First- year Family Primary Care DNP student – Current practice: surgical nurse  Signing Up for Office Hours Go to Patho course in Canvas Click on “View Course Calendar” on right-hand side Click on “Find Appointment” on right-hand side Select “NR.120.504 FA Pathophysiology I Find a day/time that works for you Click on “Reserve” Optional: enter any details on what you’d like to discuss Note: zoom information and put it in your calendar. Unless you link Canvas to your email account, the appointment won’t show up in your regular email  More Questions? Need Help? First: check syllabus Second: watch the Intro to Patho video Third: ask in class and/or send an email to: [email protected] Content help, study tips, etc.: schedule office hours Think a study group might be helpful? Sign up for tutoring with The Learning Collaborative: [email protected]  Upcoming Assignments Patho orientation quiz: due this Friday – Take it as many times prior to the due date to get your desired grade – Can take it with other people and use resources – Must hit submit! – Need 100% to open course modules Synthesis Assignment #1 – Due Sunday, September 22nd at 11:59pm – Worth 15% overall course grade – Late assignments will not be accepted nor can additional time be arranged Answer key released after due date to allow you to use this as a study resource Each week’s modules relates to 3-4 questions on the assignment – should be completing in real time  Pre- and Post-Module Worksheets No pre-module worksheet for module 1 Module 2 (next week) does have a pre-module worksheet Post-Module 1 (A) due this Friday – Optional: Post Module 1 (B) due any time between now and the end of the semester – Highest of the two grades will count towards course grade MODULE 1: CASE STUDY  Please note… You are responsible for all information and course objectives in module 1 – Module 1 consists of several lectures: the cell, fluid regulation, cellular adaptation, neoplasia – Focus on big ticket items, big processes – Use the information found in “Review Information/Exam Prep” section to guide your studies  Introduction… Mr. Smith is a 55 year old who presents to the emergency department (ED) with fever, shortness of breath (SOB) and cough Chest x-ray (CXR) indicates left lung pneumonia Pulse oximeter (pulse ox) shows oxygen saturation (O2 sats) of 89% on room air > 95% – What should be a normal pulse ox? – He is placed on oxygen therapy via nasal cannula He is started on IV antibiotics and is admitted to the hospital for further care  Onto the ICU… Over the next 24 hours, Mr. Smith continues to be febrile (high fevers) and SOB – His oxygen needs are increasing and his nurse notes that his last two blood pressure readings were lower than the earlier measures Tachy = fast – He is increasingly tachycardicCardic, cardia = heart The ICU is called for transfer  Blood Pressure On ICU admission, Mr. Smith is confused and lethargic. Vital signs are as follows: 120/80 – Temp: 39.0 C (102.2 F) mmHg – HR: 138 bpm, RR: 26 bpm, Low BP = low perfusion of blood to organs = low – BP: 85/40 mmHg, O2 sats: 93% on 5L NC oxygen delivery to What is a normal blood pressure? tissues/cells Why do we care about low blood pressure? Low oxygen saturation What is the significance of the low O2 sats? means cells may have to use anaerobic What vital sign(s) indicate that Mr. Smith’s body respiration to make ATP is trying to compensate Heart Resp. for the low O2 and BP? Rate Rate  Electrolytes As Mr. Smith is getting sicker, a set of electrolytes are sent to the lab to evaluate his electrolyte balance and kidney function When we draw bloodExtracellular for labs, are we measuring intracellular fluid or extracellular fluid? What is the difference between sodium (Na) and potassium (K)Higher levelslevels of sodium inside outside cells vs. the of outside cellcells? compared to inside the cell Higher levels of potassium inside the cell compared to outside the cell Na-K ATP-ase pump What helps to maintain this difference?  Edema The labs sent on Mr. Smith also reveal low albumin levels. You wonder if perhaps that’s why his feet look a little puffy Big What is albumin? protein Where is it made? Liver What is the connection between albumin and edema? Low albumin in the blood  decreased capillary oncotic pressure  less reabsorption of fluid back into the vasculature In Mr. Smith, albumin may be low due to inflammation from the pneumonia (Module 3 preview) – Inflammation from the infection  increased capillary permeability (leaky capillaries  albumin leaks out of the vasculature  decreased capillary oncotic pressure  edema  What is the other Starling’s force that influences how fluid moves in and out of the vasculature (blood vessels)? Hydrostatic pressure: force that exerts pressure against the sides of a container Capillary hydrostatic pressure: primary force behind filtration of water out of the blood vessel and into the interstitial space  Back to Mr. Smith… Mr. Smith’s blood pressure has stabilized What hormone systems have we discussed that will help regulate blood pressure? Renin-Angiotensin-Aldosterone System (RAAS) and anti-diuretic hormone (ADH)  RAAS Decreased in blood pressure and/or How is RAAS activated?Decrease in extracellular fluid and/or Decrease in perfusion to the kidneys What organ “controls” RAAS activation? What is the end result of RAAS activation? Increased blood pressure Angiotensin II causes vasoconstriction (makes blood vessel diameter smaller) Aldosterone acts on kidneys to reabsorb water and sodium back into the blood to expand blood volume https://www.niddk.nih.gov/health- information/kidney-disease/kidneys-how-they- work  ADH Increased blood osmolarity How is ADH activated? (concentrated blood) Low blood volume Which organ “controls” ADH release? Hypothalamus What is the end result of ADH release? Increased blood pressure ADH acts on the kidney to reabsorb only water back into the blood to expand blood volume  RAAS vs ADH What effect will RAAS have on blood sodium levels? May increase it, but generally none as both sodium and water are reabsorbed back into the blood stream with RAAS activation What effect will ADH have on blood sodium levels? May decrease sodium levels as only water is reabsorbed back into the blood stream with ADH activation What are some symptoms of hyponatremia? Nausea, vomiting, headache, confusion, muscle weakness, cramping, seizures, coma  Cellular Adaptations Now that Mr. Smith is starting to recover, he is being encouraged to take small walks throughout the day. This will not only promote deep breaths to help improve his lung function, but will also help to prevent which cellular adaptation that can occur as a result of Atrophy immobility? Cells shrink in size What is the difference between this type of cellular adaptation from dysplasia? Dysplasia is an irreversible cellular adaptation  Discharging Mr. Smith? Mr. Smith is scheduled for discharge the next day, but his care team wants one more CXR to make sure the lungs are looking better. The radiograph shows the lungs are clear, but there appears to be a small radiopaque mass on the top portion of the liver that is visible in the image. He is scheduled for further diagnostics as the team is concerned Mr. Smith may have a tumor  Liver Issues… What are the two main classifications of neoplasms? Benign: slow, defined, solid tumors that form in place and don’t spread throughout the body Malignant: slow or fast growth, cancerous cells can spread and cause metastasis If this is a malignant cancer, how might it spread throughout the body? Via blood Via lymph Via seeding of adjacent surfaces  Goodbye Mr. Smith Luckily, further imaging shows that this was a loop of bowel and of no concern to Mr. Smith He is discharged to home the next day   What We Didn’t Cover… Check out the “Review Information/Exam Prep” section in Module 1 for details on where to focus your studies STYLES OF EXAM QUESTIONS  Application Question NARP (neuropathy, ataxia, retinitis pigmentosa) is an inherited disease that results from mutations in the ATP6 gene contained in mitochondrial DNA Use your knowledge of the function of the mitochondria to choose the most likely impact of this mutation on cellular function a. It is most likely that this mutation affects the ability to make albumin and maintain capillary oncotic pressure b. It is most likely that this mutation affects the ability to make cellular membrane proteins c. It is most likely that this mutation affects the ability to make functional ATP d. It is most likely that this mutation affects the ability to remove free radicals from the intracellular matrix C  Interpretation Question You are taking care of a 12 year old who experienced a traumatic brain injury while playing football with the following clinical findings: – Temp: normal, HR: elevated, Respirations: normal, BP: elevated, urine output: decreased. They are confused, lethargic, and are having muscle twitching – An electrolyte panel results with: Na: 121 mEq/L, K: 4.3 mEq/L, Ca: 9.8 mg/dl. (Normal ranges: Na: 135-145 mEq/L, K: 3.5-5.5 mEq/L, Ca: 8-10.2 mg/dl). What condition is this child is experiencing? a. Hyponatremia A b. Hypernatremia c. Hypokalemia d. Hyperkalemia  Select all that Apply SELECT ALL THAT APPLY: Choose one, some, or all of the following to answer this question What are some characteristics of physiological cellular adaptations? a. They are reversible b. Dysplasia is an example A, C, E c. Hypertrophy is an example d. They always lead to disease development e. Atrophy is an example  Select “N” Choose the four (4) correct responses to answer this question Which of the following are hallmarks of malignant cancer cells? a. Ability to evade the immune system b. Ability to promote angiogenesis A, B, E, F c. Ability to increase aerobic metabolism d. Ability to increase T-cell functions e. Ability to be immortal f. Ability to be insensitive to growth inhibition  Fill in the Blanks One of the mechanisms responsible for HTN (hypertension) development is over-activation of RAAS. The actions of RAAS cause _________ of the blood vessels and the reabsorption of ______ and _______ from the nephron. The end result is _________ blood pressure and _________ blood The actions volume. of RAAS cause vasoconstriction of the blood vessels and the reabsorption of water and sodium from the nephron. The end result is increased blood pressure and increased blood volume. RAPID REVIEW  Rapid Review Purpose: – To promote peer to peer learning – To provide a concrete example for an active study technique – The purpose IS NOT to create a bank of peer developed resources. Why not? 1. Faculty will not be checking this work for accuracy 2. Being provided with what other groups created in this activity removes the ”active” part of active studying  Break into pairs and introduce yourself if you haven’t already Your group will be given a specific topic 5 minutes: Partner 1 should tell Partner 2 in no more than three sentences all they know about this topic (e.g., where the edema might be, what change in Starling forces contributed to the edema, etc.) 5 minutes: Partner 2 will reiterate what Partner 1 told them, clarify any incorrect information and add in any missing information 10 minutes: Co-develop a simple diagram, cartoon, or flow chart demonstrating this concept Use this technique on other concepts related to Module 1  Current Assignments Post Module 1A worksheet: due this Friday – Can use notes/course resources, but must complete alone – Graded for accuracy – Optional 1B worksheet: due anytime before Nov. 18th, 11:59pm – Highest grade of the two accepted Synthesis Assignment 1 – Have enough knowledge to answer at least 3 questions – Should be completing in “real time” – use it as a study resource – See syllabus for due date Pre-module 2 worksheet: due next Tuesday – Work on alone or with peers – each person must turn it in for a grade – No late assignments accepted – Graded for completion only SYNTHESIS ASSIGNMENT 1 (IF TIME)  SA 1 Open note, open book, open any resource EXCEPT other people! All questions are designed to be answerable with only the course-provided content You may (and should!) use any answers we give you to questions in class. Copy and paste with no citation is 100% OK in this instance  Answer key is released 2 minutes after the due date. For this reason, we cannot grant extensions for any reason nor accept late assignments – You may work on this or any other assignment during appointed class time  Case Scenario Case Scenario: Sam is a 67-year-old male sex at birth (self-report gender identity male) with a history of HTN (hypertension = high blood pressure) presenting to your outpatient clinic for an annual physical exam. You check him in, take vital signs, and update the medical history record. Of note, Sam reports losing his health insurance coverage 9 months ago, and was only just able to get it reinstated. As a result, he has not been able to afford his HTN medications. The medical history is unchanged from his last appointment, but Sam says he's noticed that his shoes seem much tighter than a few months ago, and he gets deep indentations on his lower legs from his socks. A quick look at his lower legs reveal +1 bilateral pitting edema (swelling caused by excess fluid in the interstitial space of tissues). Vital signs: Temp: 98.2 degrees F (~36.8 degrees C) (normal), HR (heart rate): 94 beats per minute (elevated), R (respirations): 16 breaths per minute (normal), BP (blood pressure): 171/99 mmHg (very elevated), pulse ox (oxygen saturation): 98% (normal) Height: 5'7" (170.2 cm), Weight: 186.7 lbs. (84.7 kg) with a body mass index of 29.2 (Overweight) The medications Sam was prescribed for HTN last year included a diuretic (type of medication that makes the body produce more urine, thus decreasing blood volume) and an ACE-inhibitor (type of medication that prevents the production of angiotensin II). You know that disruptions in RAAS can cause HTN.  Question 2 Use your understanding of RAAS and Starling’s forces to explain why Sam is experiencing edema – Maximum 3 sentences – To address this question, include: an explanation of how Starling’s forces will be influenced by RAAS over-activation and what is happening to filtration and reabsorption at the capillary level  Question 2 Answer A hyperfunctioning RAAS and subsequent hypertension can cause increased capillary hydrostatic pressure since RAAS activation causes vasoconstriction and causes increased blood volume from salt and water reabsorption in the kidney. This change in Starling’s forces will increase filtration of fluid out of the capillary space, moving it to the interstitial tissues. Normally, this filtrate will be reabsorbed due to the complementary Starling’s force of capillary oncotic pressure, but if filtration exceeds reabsorption, edema will form.  Questions?? Use remainder of class to work on worksheet or synthesis assignment, ask questions or to recoup a few minutes of your day 