Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
BASICS OF PATHOPHYSIOLOGY II Jassin M. Jouria, MD Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. Abstract Every disease or injury incurred by the human body creates a chain reaction of physical responses. Pathophysiology is the study of these changes, ranging from cellular changes to biomechanical changes. Building on the information presented in Basics of Pathophysiology I, this course takes a look at autoimmune disorders, infectious diseases, congenital disorders, neoplastic diseases, blood and lymphatic disorders, endocrine disorders, and neurological diseases. Together, these two courses present critical information for nurses and nurse practitioners to provide early, accurate diagnosis and appropriate treatment to minimize the chain reaction of effects and provide a positive patient outcome. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 Continuing Nursing Education Course Planners William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster, Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 2 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Statement of Learning Need Nurses at all levels of professional development need an enhanced understanding of pathophysiology in order to understand patient treatment and care for certain medical conditions. Course Purpose To provide nursing professionals with knowledge of the basic principles of pathophysiology and associated medical conditions. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Activity Review Information Reviewed by Susan DePasquale, MSN, FPMHNP-BC Release Date: 2/15/2016 Termination Date: 4/11/2018 Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 1. What are the two categories that the lymphocytes are divided into? a. A cells and B cells b. B cells and T cells c. T cells and C cells d. B cells and D cells 2. Which if the following is the criteria used do diagnose a man with polycythemia? a. Hemoglobin >16.5 g/dl b. Hemoglobin >18.5 g/dl c. Hemoglobin < 13.5gm/dl d. Hemoglobin <12.0gm/dl 3. Which of the following is NOT one of the types of diabetes? a. Type II Diabetes b. Hashimoto’s Disorder c. Type I Diabetes d. Gestational Diabetes 4. The overproduction of thyroid hormones is: a. Hypothyroidism b. Hyperparathyroidism c. Hyperthyroidism d. Hypoparathyroidism 5. This autoimmune disorder is characterized by chronic inflammation of the thyroid. a. Diabetes b. Rheumatoid arthritis c. Hashimoto’s Disease d. Crohn’s Disease nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 Introduction Every disease or injury to the human body creates a chain reaction of physical responses. Pathophysiology is the study of these changes, ranging from cellular changes to biomechanical changes. Pathophysiology enables medical professionals to understand diagnosis, treatment, and management options to achieve a best-case scenario for their patients. The ultimate goal of pathophysiology is to be able to answer the following questions: What is the cause/causes of the disease, and why the disease is developing? What are the mechanisms responsible for disease onset, progression, and recovery? What are the mechanisms responsible for development of symptoms and signs of disease? Building on the information presented in Basics of Pathophysiology I, this course takes a look at autoimmune disorders, infectious diseases, congenital disorders, neoplastic diseases, blood and lymphatic disorders, endocrine disorders, and neurological diseases. Together, these two courses present critical information for nurses and nurse practitioners to provide early, accurate diagnosis and appropriate treatment to minimize the chain reaction of effects and provide a positive patient outcome. The Basics of Pathophysiology I course provided a thorough overview of cellular biology, including cellular function and the role of genetics. The course also provided descriptions and key terms for pathology and physiology. This course is intended for individuals who have already completed the Basics of Pathophysiology I course and assumes the reader has already received the introduction to cellular biology, pathology, and nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 physiology. To review these basics, refer to the Introduction section of the Basics of Pathophysiology I course. Autoimmune Disorders Autoimmune disorders occur when an individual’s immune system is unable to differentiate between antigens and healthy body tissue.1 When this happens, the immune system triggers an immune response that attacks the healthy tissue and damages or destroys it.2 In most instances, this causes a hypersensitivity reaction that mimics an allergic reaction.3 It is difficult to identify what causes the immune system to be unable to differentiate between antigens and healthy tissue, but a common theory is that the disorder is triggered by a microorganism or drug response.4 Depending on the type of autoimmune disorder, one of the following may occur:1 The destruction of one or more types of body tissue Abnormal growth of an organ Changes in organ function The most common organs and tissues affected by autoimmune disorders include:3 Blood vessels Connective tissues Endocrine glands such as the thyroid or pancreas Joints Muscles Red blood cells Skin nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 It is possible for an individual to experience more than one autoimmune disorder at a time. In fact, some patients may be prone to multiple disorders.1 The following is a list of the most common autoimmune disorders:2 Addison's disease Celiac disease - sprue (gluten-sensitive enteropathy) Dermatomyositis Graves disease Hashimoto's thyroiditis Multiple sclerosis Myasthenia gravis Pernicious anemia Reactive arthritis Rheumatoid arthritis Sjogren syndrome Systemic lupus erythematosus Type I diabetes Acquired Immunity Acquired immunity refers to any immunity that is not innate. These immunities can be acquired naturally through the development of antibodies that result from contact with an infectious disease.5 Immunities can also be acquired through the transmission of antibodies from mother to child, which occurs through placental transmission or through colostrum and breast milk.6 Immunities can also be transmitted artificially through vaccinations or immune gamma globulin.5 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7 Lymphocytes The lymphocytes are the primary cells responsible for the maintenance of the immune system. There are approximately one trillion lymphocytes in the human body.7 The lymphocytes are divided into two primary categories:8 T Cells – processed within the thymus – interact directly with targets to attack the cells that have been taken over by viruses or malignant cells. B Cells – grow independently of the thymus – secrete antibodies directly into the body’s fluids. The distinctive molecules present on the cell surface are what differentiate lymphocytes. These molecules indicate whether the cell is a B Cell or a T Cell. The molecules also serve as identifiers of the subsets of cells that comprise the lymphocyte.7 Antibodies/Immunoglobins Antibodies, also known as immunoglobins, are proteins that are produced by B Cells to identify and neutralize foreign objects that infiltrate the body.9 The most common foreign bodies are bacteria and viruses. Antibodies seek out antigens and use paratopes to attach to the epitopes that are part of antigens. This binds the antibody to the antigen, thereby allowing the antibody to identify an infected cell for attack by the immune system. In some instances, the antibody can directly neutralize the foreign object.6 Immune System Suppression One method of treating autoimmune diseases is though suppression of the immune system. Immune system suppression is initiated through the use of nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8 drugs. In some instances this treatment has proven effective. However, recent research shows that this may not be the best method to treat autoimmune diseases.10 Infectious Diseases Pathogenic microorganisms are the direct cause of infectious diseases, which can be spread directly or indirectly. Four different germs cause infectious diseases:11 Bacteria One-celled germs that multiply quickly and may release chemicals, which may cause illness Viruses Capsules that contain genetic material and use the body’s own cells to multiply Fungi Primitive plants, like mushrooms or mildew Protozoa One-celled animals that use other living things for food and a place to live Transmission Infectious diseases are primarily transmitted through direct contact, especially person-to-person contact. Some diseases can be transmitted from a pregnant mother to her unborn child through the placenta. Infectious diseases can also be transmitted through indirect contact, such as contaminated objects, long-term airborne transmission, contaminated blood products and medical supplies, insects, and food and water. In some instances, infectious diseases may be transmitted from an animal to a nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9 person. This is especially common with animal bites and scratches. Another area of indirect transmission is through environmental reservoirs. Some organisms are present in soil, water, and vegetation.12 Pathogenic Bacteria Pathogenic bacteria cause diseases in the host, even when the environment is sterile. There are a number of pathogenic bacteria, but some are quite rare and do not pose a significant risk of infection.13 Depending on the type of bacteria, the patient will experience a variety of symptoms and conditions. Therefore, there is no specific physical reaction that occurs when a person comes into contact with pathogenic bacteria.14 The following is a list of the most common types of pathogenic bacteria: Staphylococcus The staphylococcus group of bacteria is a common cause of infection in individuals. In most instances, the bacteria colonize on the skin and mucous membranes of individuals, but do not cause infection.15 However, if certain conditions are present, the staphylococci will produce both superficial and systemic infections. These infections can take different forms, but tend to present as impetigo, boils, and folliculitis.16 In more extreme cases, the bacteria will develop into pneumonia and infections of the bone and wounds.17 Streptococcus Streptococcus pneumoniae is the bacterium that causes pneumococcal pneumonia, which is a severe form of pneumonia. Pneumococcal pneumonia is characterized by its sudden, severe onset.18 Many patients will experience a sudden, severe chill followed by the following symptoms:19 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10 High fever Cough Shortness of breath Rapid breathing Chest pains Nausea Vomiting Headache Tiredness Muscle aches Pneumococcal pneumonia is especially common in unvaccinated children under the age of five and the elderly. The risk of contracting the illness increases significantly when an individual remains unvaccinated. Meningococcus Meningococcus is the bacteria that causes meningococcal meningitis, which is an infection of the lining of the brain and the spinal cord.20 In some instances, the bacteria can also cause other illnesses such as bloodstream infections.21 The bacteria is spread through respiratory secretions.20 Unvaccinated individuals are at risk of developing severe, life-threatening complication from the bacteria. However, those who are vaccinated have minimal risk.22 Antibiotic Therapy Antibiotic therapy is commonly used to treat infectious diseases. Antibiotics are known to significantly reduce illness and death from infectious disease when prescribed and administered correctly. However, due to overuse of antibiotics in recent years, many infectious organisms have developed nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11 resistance to them through mutation.23 Therefore, many individuals with infectious diseases will not respond effectively to antibiotic treatment.24 The onset and duration of antibiotic therapy is dependent on the type and severity of illness. Critically ill patients will require immediate treatment to avoid long-term or permanent damage, even if diagnostic lab reports have not confirmed the strain of bacteria that is causing the infection. These patients will receive empiric antibiotic therapy.25 This often occurs when patients present with septic shock, febrile neutropenia, and bacterial meningitis. Patients who are experiencing less severe infections can delay treatment until after diagnostic test results confirm the type and strain of bacteria. These patients will receive definitive antimicrobial therapy.26 This will ensure that the patient’s treatment is appropriate for the infecting organism. Treatment of Viral Disease Most viral infections are not treatable with medications. Therefore, treatment of viral infections typically involves relief of the symptoms caused by the infection.6 General treatments for viral infections include:27 Acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) for fever, body aches, and pain Drinking extra fluids Getting extra rest and sleep Maintaining good nutrition However, in some instances, other treatment methods will be employed to minimize complications from the virus. For example, antiretroviral medication is used with individuals with human immunodeficiency virus. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12 Antiretrovirals do not eliminate the virus, but they are able to successfully slow the progression. Other antiretroviral drugs are used to treat influenza, shingles, and other viral conditions.28 Congenital And Genetic Disorders Congenital and genetic disorders occur at conception or during fetal development. In some instances, though, congenital disorders will develop in the months following birth. Congenital disorders are defined as those that involve structural deformities that cause defects or damage in the developing fetus.29 Congenital disorders can be caused by a variety of factors, including genetic abnormalities, infection, intrauterine complications, or errors of morphogenesis.30 Genetic disorders include a range of conditions that vary in their presentation and impact on the individual. Many genetic conditions develop at conception when gene pairs form, although they may not appear for a number of years.31 Other genetic conditions are caused by the aging of cells or exposure to external factors such as chemicals or radiation. Congenital Disorders The primary causes of congenital disorders are genetics, intrauterine damage and infection, and multifactorial or unidentified factors. The type of congenital disorder an individual develops will depend on which of the factors is present. Genetics Genetics can cause congenital anomalies. This occurs when the fetus inherits abnormal genes from one of the parents.32 In other instances, the germ cells nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13 can experience mutations that will affect the fetus.33 All genetic disorders are considered congenital. However, many genetic disorders will not appear until years after birth. There are a number of different types of genetic disorders, including:34 Single-gene defects Multiple-gene disorders Chromosomal defects Intrauterine Injuries Intrauterine injuries are known to cause congenital defects, although they are less common than other causes of congenital disorders. In some cases, intrauterine injuries will occur when the environment is damaged through external forces such as blunt impact, accidents, domestic violence, or other events that cause damage to the region. In other instances, complications resulting from illness or improper nutrition can impact the intrauterine environment, thereby impacting the developing fetus.29 Multifactorial Inheritance While a number of causes of congenital disorders have been identified, there are still a number of disorders that have no known cause. Of these, approximately 25% have a multifactorial cause, which means that they have been caused by a complex interaction of a number of smaller genetic anomalies as well as environmental risk factors.34 Genetic Disorders While all congenital disorders are genetic disorders, there are a number of genetic disorders that are not congenital. Therefore, genetic disorders are examined separately from congenital disorders. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 14 Genetic disorders occur when an individual experiences a mutation in one or more genes. These mutations can occur at conception, or they can occur at some point during the individual’s lifetime.35 When mutations occur during an individual’s lifetime, they are typically caused by the aging of cells or exposure to external factors such as chemicals or radiation.36 In many instances, these mutations will be repaired by the cells and will cause no damage. However, in some instances, these mutations cannot be repaired. In these instances, the patient will experience adverse effects such as illness or disability.37 When a gene mutation occurs at conception, the mutation becomes part of the individual’s genetic make up. In these instances, the mutation cannot be repaired by the cell.38 To understand how genes mutate, it is necessary to understand the basics of how genetic patterns are formed. DNA is comprised of four primary chemicals: Adenine Thymine Cytosine Guanine These chemicals bind together to create genetic patterns within the cell. The DNA, which contains the genetic material, binds together to form chromosomes. Typically, a cell contains 23 pairs of chromosomes. When cells replicate, the genetic material is transferred to the new cells.32 If the genetic material is already damaged or mutated, there is a chance that the individual will develop mutated genes. This is determined by the dominant or recessive status of the genes. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 15 There are more than 4,000 diseases that can be caused by gene mutations. When an individual experiences a mutation in a dominant gene, he or she will typically experience the condition and/or symptoms associated with the mutation.39 Examples of common conditions caused by dominant gene mutations include:40 Achondroplasia Marfan syndrome Huntington disease When an individual experiences a mutation in a recessive gene, he or she will not typically develop the condition associated with the mutation. The individual will be a carrier of the mutation, but will not develop the condition because one of the two genes in the pair will still be healthy.33 However, if an individual receives mutated genes from both the X chromosome and the Y chromosome, he or she will develop the condition associated with the recessive gene.32 Examples of common conditions caused by mutated recessive genes include:38 Cystic fibrosis Sickle cell anemia Tay-Sachs disease Prenatal Diagnosis Many genetic disorders and congenital defects can be identified prenatally through the use of advanced diagnostic testing. The following is a list of the non-invasive and invasive techniques used to diagnose genetic and congenital disorders:31 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16 Noninvasive techniques Fetal visualization Ultrasound Fetal echocardiography Magnetic resonance imaging (MRI) Radiography Screening for neural tube defects (NTDs) - Measuring maternal serum alpha-fetoprotein (MSAFP) Screening for fetal Down syndrome Measuring MSAFP Measuring maternal unconjugated estriol Measuring maternal serum beta-human chorionic gonadotropin (HCG) Measuring inhibin Separation of fetal cells from the mother's blood Assessment of fetal-specific DNA methylation ratio Invasive techniques Fetal visualization Embryoscopy Fetoscopy Fetal tissue sampling Amniocentesis Chorionic villus sampling (CVS) Percutaneous umbilical blood sampling (PUBS) Percutaneous skin biopsy Other organ biopsies, including muscle and liver biopsy Preimplantation biopsy of blastocysts obtained by in vitro fertilization Cytogenetic investigations Detection of chromosomal aberrations nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17 Fluorescence in situ hybridization Molecular genetic techniques Linkage analysis using microsatellite markers Restriction fragment length polymorphisms (RFLPs) Single nucleotide polymorphisms (SNPs) - DNA chip, dynamic allelespecific hybridization (DASH) Prenatal diagnosis is a beneficial tool for identifying developmental risks and determining how to progress with the pregnancy and subsequent birth (if applicable). In many instances, treatment for the disorder can begin prenatally, which will improve the outcome after birth. Prenatal diagnosis is recommended in the following cases:31 The pregnant woman is 35 years or older at the time of delivery. She or her parents have had a previous child with a chromosomal abnormality. She has a history of recurrent abortions, or her husband's previous wife experienced several miscarriages. A history of parental consanguinity (common ancestry) is present. The couple is known to be carriers of a chromosomal translocation. The pregnant woman is affected with type 1 diabetes mellitus, epilepsy, or myotonic dystrophy. She is exposed to viral infections, such as rubella or cytomegalovirus. The mother is exposed to excessive medication or to environmental hazards. In the mother’s or her spouse's family, Down syndrome or some other chromosomal abnormality is present. A history of single gene disorder is present in her or her spouse's family. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 18 The mother’s male relatives have Duchenne muscular dystrophy or severe hemophilia. She is suspected of having some other harmful gene on her X chromosomes. The fetus is diagnosed in utero to have some hereditary error of metabolism. The fetus is detected to be at increased risk for a NTD. Neoplastic Diseases Malignant neoplasms, also called cancer, grow relatively rapidly and may metastasize, or spread, to other body parts. The malignant cells multiply excessively and can invade or infiltrate normal tissue, making the condition life threatening if untreated.41 The cancerous cells interfere with normal cell growth and draw nutrients away from body tissue. Compared with normal tissue, cancerous cells appear disorderly and do not look like the tissue of origin.42 Patients with malignant conditions may experience:43 Anorexia Abnormal bleeding or bruising Difficulty swallowing Indigestion Malaise Fever Sores that do not heal or that change to the appearance of a wart or mole Bladder and bowel habit changes Mass growth in the breast or other body site Persistent cough nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19 Weight loss To determine whether a patient has a tumor, various laboratory tests and procedures, such as endoscopies, magnetic resonance imaging (MRI), computed tomography (CT) scans, X-rays, and ultrasound, are used. A biopsy, or the removal of tissue for pathological examination, is completed to differentiate between malignant and benign tumors.44 Treatment Treatment for neoplasms will vary depending on a number of factors, including the type of tumor, whether it is cancerous or noncancerous, the location of the tumor, and the medical status of the patient. With benign tumors, there is a chance that no treatment will be needed. If the benign tumor is in a safe location and is causing no symptoms, there is often little reason to remove it.42 However, in some instances, benign tumors will be removed for cosmetic reasons or because they pose a threat to other parts of the body due to their location (i.e., proximity to brain). Malignant tumors can be treated in a variety of ways. The most common forms of treatment include chemotherapy, radiation, and surgery. In many instances, a patient will receive a combination of the treatments listed above.43 Blood And Lymphatic Disorders The human circulatory system is comprised of two primary fluids: blood and lymph. Lymph is the fluid that is found in the lymphatic vessels that are part of the lymphatic system. The specific composition of the fluid will vary depending on the area of the body it is from. Lymph from some areas of the nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 20 body (i.e., bone marrow, spleen, thymus) have high concentrations of white blood cells.45 This is because the lymph has absorbed the white blood cells intended to fight infection. Other types of lymph will have higher concentrations of other components. For example, intestinal lymph is typically high in fat. This is because the fat is absorbed during digestion.46 The most common disorders and diseases of the blood and lymphatic system include:45 Anemia Burkitt lymphoma Gaucher disease Hemophilia A Leukemia, chronic myeloid Niemann-Pick disease Paroxysmal nocturnal hemoglobinuria Porphyria Thalassemia Anemia Anemia is one of the most common blood disorders, affecting approximately 3 million Americans.47 Anemia occurs when there is a deficit of red blood cells or when the red blood cells are not functioning properly. An anemia diagnosis is made when blood tests show the following results:48 Man – hemoglobin value < 13.5gm/dl Woman – hemoglobin value <12.0gm/dl There are a number of different types of anemia that can occur. They are defined based upon the cause and impact on the body. The following is a list of the most common types of anemia:49 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21 Iron deficiency anemia Vitamin deficiency anemia Pregnancy-related anemia Aplastic anemia Hemolytic anemia Sickle cell anemia Anemia caused by other diseases Polycythemia and Thrombocytopenia Polycythemia Polycythemia occurs when there is an increase in the number of red blood cells in the blood. In these instances, one of the following components will appear elevated when measured as part of the complete blood cell count:50 Hemoglobin Hematocrit Red blood cell A diagnosis is made based upon the following numbers:51 Men: Hemoglobin >18.5 g/dl Hematocrit > 52 Women: Hemoglobin >16.5 g/dl Hematocrit > 48 Polycythemia can occur as a result of internal problems related to the production of red blood cells. This type of polycythemia is called primary nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22 polycythemia. In some instances, other underlying medical conditions can cause polycythemia. This form of polycythemia is called secondary polycythemia. Most cases of polycythemia are secondary.52 Thrombocytopenia Thrombocytopenia refers to a decreased amount of platelets in the blood. The average platelet count is between 150,000 and 400,000 per micro liter (one millionth of a liter) of blood. When a platelet count falls below 150,000 the individual is diagnosed with thrombocytopenia.53 Platelet counts less than 150,000 are termed thrombocytopenia. Decreased platelet levels do not typically impact the function of the platelets. However, the decrease in the number of platelets can impact other areas of the body. In some instances, a low platelet count can result in spontaneous bleeding as the normal clotting process is impacted.54 The most common causes of a decrease in platelets are:55 Decreased platelet production (caused by infection, disease, medications) Increased platelet destruction or consumption (caused by immune and non-immune related medical conditions, medications, pregnancy complications, infections, injury to blood vessels) Increased splenic sequestration/capturing of circulating platelets in the spleen (caused by advanced liver disease, hypertension, blood cancer) In some instances, severe bleeding and the subsequent transfusion of a significant amount of red blood cells over a short period of time can cause thrombocytopenia. In rare instances, a patient may experience pseudothrombocytopenia, which occurs when platelets clump together. This nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23 will produce a false condition in diagnostic testing. Sometimes, thrombocytopenia will occur at birth. In most instances, neonatal thrombocytopenia will occur as the result of one of the factors listed above. However, the condition my also occur as the result of rare genetic disorders.56 Lymphatic Disorders Lymphatic disorders occur when there are is an infection or other condition that occurs in the lymphatic system. The most common lymphatic disorder is lymphadenitis, which is an inflammation of the lymph nodes that occurs when microorganisms become trapped and destroyed within the lymph nodes.45 In some instances, this can lead to blood poisoning. Other lymphatic disorders can occur when infections attack the lymphatic system. Lymphomas are also a common lymphatic disorder. Lymphomas are neoplasms that develop within the lymphatic tissue.57 The lymphomas are divided into two distinct categories: Hodgkin’s Disease Non-Hodgkin’s Lymphoma Most lymphomas begin as an enlarged mass within the lymph nodes. These enlarged masses can compress surrounding structures and initiate complications in other regions of the body. They also impact the immune system, causing the patient to be more susceptible to infections. Lymphomas are typically treated using radiation and medication.58 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 24 Endocrine Disorders The endocrine system (endo- means “within,” and -crin means “secrete”) consists of several different internal groups of glands and structures that produce or secrete hormones. Hormones are chemical substances produced by the body to keep organs and tissues functioning properly. Each hormone has a specific function. When chemical changes occur in the body, hormone release may be either increased or decreased, provided that the organ producing the hormone is functioning properly. Also, when endocrine body structures do not function properly, hormones are not released.59 Diabetes Diabetes is a group of metabolic diseases that are caused by increased blood glucose levels due to insufficient insulin production or improper cellular response to insulin. Initial symptoms of diabetes typically include polyuria, polydipsia, and polyphagia.60 However, blood work will be conducted to provide a definitive diagnosis. The following table provides definitions of the three types of diabetes: Type 1 The body does not produce insulin. Some people may refer to this type Diabetes as insulin-dependent diabetes, juvenile diabetes, or early-onset diabetes. People usually develop type 1 diabetes before their 40th year, often in early adulthood or teenage years. Patients with type 1 diabetes will require insulin injections for duration of their lives. They must also ensure proper blood-glucose levels by carrying out regular blood tests and following a special diet.61 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25 Type 2 The body does not produce enough insulin for proper function, or the Diabetes cells in the body do not react to insulin (insulin resistance). Approximately 90% of all cases of diabetes worldwide are of this type. Some people may be able to control their type 2 diabetes symptoms by losing weight, following a healthy diet, doing plenty of exercise, and monitoring their blood glucose levels. However, type 2 diabetes is typically a progressive disease, and the patient will probably require insulin at some point. Overweight and obese people have a much higher risk of developing type 2 diabetes compared to those with a healthy body weight.62 Gestational This type affects females during pregnancy. Some women have very high Diabetes levels of glucose in their blood, and their bodies are unable to produce enough insulin to transport all of the glucose into their cells, resulting in progressively rising levels of glucose. The majority of gestational diabetes patients can control their diabetes with exercise and diet. Between 10% to 20% of them will need to take some kind of bloodglucose-controlling medications. Undiagnosed or uncontrolled gestational diabetes can raise the risk of complications during childbirth. The baby may be bigger than he/she should be.63 Pituitary Disorders Pituitary disorders can be caused by a variety of factors, including tumors, infections, and autoimmune conditions. Pituitary tumors are the primary cause of pituitary disorders.64 Some tumors will cause an increase in hormone production. However, the majority of tumors do not cause an overproduction of hormones. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26 When hormone production does occur, the consequence is often severe endocrine complications such as acromegaly, Cushing’s syndrome, or prolactinoma.65 When disorders are caused by other factors such as infections and autoimmune conditions, the pituitary gland is often affected and the patient will experience headaches, visual complications and hormonal abnormalities.66 Thyroid and Parathyroid Disorders Thyroid and parathyroid disorders are caused by an overproduction or underproduction of hormones. The parathyroid glands are responsible for producing parathyroid hormone, which regulates the levels of calcium and phosphorous in the body. The thyroid is responsible for producing triiodothyronine and thyroxine, which regulate metabolism, brain development, respiration, cardiovascular and nervous system functions, body temperature, muscle development and strength, menstrual cycles, body weight, and cholesterol levels.67 The production of hormones in the thyroid is regulated by the thyroid-stimulating hormone.68 The following conditions will develop if there is an overproduction or underproduction of the hormones listed above.67 Parathyroid Disorders: Hyperparathyroidism – overproduction of parathyroid hormone Hypoparathyroidism – underproduction of parathyroid hormone Thyroid Disorders: Hyperthyroidism – overproduction of thyroid hormones Hypothyroidism – underproduction of thyroid hormones nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27 Grave’s Disease – autoimmune disorder that is caused when thyroidstimulating immunoglobulin (TSI) are produced and attach to the thyroid cells. The TSI stimulates hormone production in the thyroid, causing the thyroid to produce too much. Hashimoto’s Disease – autoimmune disorder characterized by chronic inflammation of the thyroid gland. The inflammation causes damage to the thyroid that results in hypothyroidism. Neurological Diseases Neurological Infections Neurological infections are common causes of neurological disorders. The type and severity of infection will vary depending on the infecting organism. However, most require immediate treatment to prevent subsequent complications. Most neurological infections are caused by bacterial organisms.69 However, in some instances they may be caused by animal parasites or fungi. Most neurological infections cause pain, swelling, redness, impaired function, and fever. However, some patients may experience additional symptoms such as drowsiness, confusion, and convulsions.70 When a patient develops a neurological infection as the result of a virus, the route of transmission is typically directly through the bloodstream. Viral neurological infections are either acute or chronic.71 The most common neurological infections include:69 Encephalitis Meningitis Fungal infections Parasitic infections Prion diseases nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 28 Bacterial infections such as Lyme disease, tuberculosis, syphilis Brain abscess Viral Infections Brain Tumors Brain tumors are caused by abnormal tissue growth in the brain. In some instances, the tumor will develop directly in the brain. However, in other instances, the tumor will develop in another region of the body and travel to the brain.72 These are mestatic tumors, and they are very common in instances of lung cancer, breast cancer, melanoma, and colon cancer.73 Brain tumors can be either benign or malignant. Benign tumors pose little threat, other than potentially impacting regions of the brain due to growth and/or swelling. Therefore, benign tumors are typically removed. Once they have been removed, benign tumors do not pose any additional risk. Malignant tumors are more concerning as they grow quickly and are cancerous. Therefore, they are treated using a combination of surgery, radiation, and medication. Many brain tumors will cause long-term complications.72 Nerve Injury Nerve injuries can occur as the result of a number of factors. Most nerve injuries occur after some sort of head trauma and are quite common in blunt and penetrating trauma situations. In both instances, nerves will be damaged. However, the causes of damage will differ.74 Blunt trauma is caused by a blunt impact to the head that does not penetrate the skull. In these situations, the injury is caused directly by the force of impact. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 29 In penetrating trauma, the damage is caused when an object penetrates the skull. In these instances, the object severing the nerves typically is the cause of the injury. Both forms of trauma can produce significant damage and may require extensive repair.75 Peripheral Nerve Disorders There are a number of different types of peripheral neuropathy. In general, neuropathy is a disturbance in the function of a nerve or a group of nerves. Peripheral neuropathy is one form of neuropathy, and it mostly occurs in the feet and legs.76 The most common causes of peripheral neuropathy are:77 Diabetes Genetic predispositions Exposures to toxic chemicals Alcoholism Malnutrition Inflammation Injury Nerve compression Medications (i.e., cancer and HIV antiretroviral) Pain Management Neuropathic pain is typically chronic and is often accompanied by tissue injury. In most instances, the nerve fibers will be damaged, dysfunctional, or injured. When such damage occurs, the nerve fibers send incorrect signals to other pain centers throughout the body, resulting in an increase in pain in various locations other than the injured area.78 Most neuropathic pain will radiate into other regions. Typically, nerve fiber injury will have an impact nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 30 on the nerve function at the location of the injury, as well as the areas around the injury.79 In most instances, neuropathic pain can be relieved through the use of nonsteroid anti-inflammatory drugs such as ibuprofen or naproxen sulfate. However, in more severe instances, the individual may require a stronger painkiller that contains morphine.80 Occasionally, patients will respond well to the use of anticonvulsants or antidepressants. Patients can also relieve symptoms by treating the medical cause of the neuropathy. This is especially useful with conditions such as diabetes. In extreme cases that do not respond to the treatment options listed above, a pain specialist may be consulted to administer an implantable device that will manage the pain.81 Other kinds of treatments can also help with neuropathic pain. Some of these include:82 Physical therapy Working with a counselor Relaxation therapy Massage therapy Acupuncture Summary Pathophysiology is the study of disease function and processes. It enables medical professionals to understand diagnosis, treatment, and management options to achieve a best-case scenario for their patients. Recognizing disease and disorder manifestations will assist nurses and nurse practitioners with early diagnosis to improve patient outcomes. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 31 Building on the information presented in Basics of Pathophysiology I, this course provided an overview of autoimmune disorders, infectious diseases, congenital disorders, neoplastic diseases, blood and lymphatic disorders, endocrine disorders, and neurological diseases. Together, these two courses present critical information for nurses and nurse practitioners to provide early, accurate diagnosis and appropriate treatment to minimize the chain reaction of effects and provide a positive patient outcome. Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 32 1. What are the two categories that the lymphocytes are divided into? a. A cells and B cells b. B cells and T cells c. T cells and C cells d. B cells and D cells 2. Which if the following is the criteria used do diagnose a man with polycythemia? a. Hemoglobin >16.5 g/dl b. Hemoglobin >18.5 g/dl c. Hemoglobin < 13.5gm/dl d. Hemoglobin < 12.0gm/dl 3. Which of the following is NOT one of the types of diabetes? a. Type II Diabetes b. Hashimoto’s Disorder c. Type I Diabetes d. Gestational Diabetes 4. The overproduction of thyroid hormones is: a. Hypothyroidism b. Hyperparathyroidism c. Hyperthyroidism d. Hypoparathyroidism 5. This autoimmune disorder is characterized by chronic inflammation of the thyroid. a. Diabetes b. Rheumatoid arthritis c. Hashimoto’s Disease d. Crohn’s Disease nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 33 6. When an individual experiences a mutation in a recessive gene, he or she will a. typically develop the condition associated with the mutation b. *not typically develop the condition associated with the mutation c. pass on the gene mutation only to a female child d. pass on the gene mutation only to a male child 7. True or False. Autoimmune disorders occur when an individual’s immune system is unable to differentiate between antigens and healthy body tissue. a. *True b. False 8. Severe bleeding and the subsequent transfusion of a significant amount of red blood cells over a short period of time can cause __________________. a. anemia b. blood transfusion reaction c. *thrombocytopenia d. low platelet count 9. Polycythemia occurs when there is a(n) _____________ in the number of red blood cells in the blood, measured by the hemoglobin, hematocrit and red blood cell count. a. decrease b. *increase c. reduced cell size d. none of the above 10. True or False. Malignant tumors are more concerning as they grow quickly and are cancerous. Therefore, they are treated only with surgery. a. True b. *False nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 34 Correct Answers: 1. b 6. b 2. b 7. a 3. b 8. c 4. c 9. b 5. c 10. b References Section The reference section of in-text citations include published works intended as helpful material for further reading. Unpublished works and personal communications are not included in this section, although may appear within the study text. 1. Tsonis IA, Avrameas S, Moutsopoulos HM. Autoimmunity and pathophysiology. J. Autoimmun. 2007 Dec;29(4):203–5. 2. Fox PC. Autoimmune diseases and Sjogren’s syndrome: an autoimmune exocrinopathy. Ann. N. Y. Acad. Sci. 2007 Mar;1098:15– 21. 3. Gregersen PK, Behrens TW. Genetics of autoimmune diseases-disorders of immune homeostasis. Nat. Rev. Genet. 2006 Dec;7(12):917–28. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 35 4. El-Badri NS, Hakki A, Ferrari A, Shamekh R, Good RA. Autoimmune disease: is it a disorder of the microenvironment? Immunol. Res. 2008 Jan;41(1):79–86. 5. Malaguarnera L, Cristaldi E, Lipari H, Malaguarnera M. Acquired immunity: immunosenescence and physical activity. Eur. Rev. Aging Phys. Act. 2008 Aug 28;5(2):61–8. 6. Burton DR. Antibodies, viruses and vaccines. Nat. Rev. Immunol. 2002;2:706–13. 7. Larosa DF, Orange JS. 1. Lymphocytes. J. Allergy Clin. Immunol. 2008;121:S364–S369; quiz S412. 8. Hsu E. The invention of lymphocytes. Curr. Opin. Immunol. 2011;23:156–62. 9. Boenisch T, Revised MS, Winther H, Steen S, Ms J. Antibodies. IHC Stain. Methods. 2009. p. 1–9. 10. Zunt JR. Central nervous system infection during immunosuppression. Neurol. Clin. 2002;20:1–22, v. 11. Ostroff SM. Encyclopedia of Infectious Diseases: Modern Methodologies. Emerg. Infect. Dis. 2008;14:356. 12. Wolfe ND, Dunavan CP, Diamond J. Origins of major human infectious diseases. Nature. 2007;447:279–83. 13. Wu H-J, Wang AH-J, Jennings MP. Discovery of virulence factors of pathogenic bacteria. Curr. Opin. Chem. Biol. 2008;12:93–101. 14. Griffin AS, West SA, Buckling A. Cooperation and competition in pathogenic bacteria. Nature. 2004;430:1024–7. 15. Efficacy of intensive hand hygiene for controlling methicillin-resistant Staphylococcus aureus in ICU--《Chinese Journal of Infection and Chemotherapy》2008年01期 [Internet]. Available from: http://en.cnki.com.cn/Article_en/CJFDTOTAL-KGHL200801022.htm nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 36 16. Shorr AF, Tabak YP, Gupta V, Johannes RS, Liu LZ, Kollef MH. Morbidity and cost burden of methicillin-resistant Staphylococcus aureus in early onset ventilator-associated pneumonia. Crit. Care. 2006 Jan;10(3):R97. 17. Rello J, Diaz E. Pneumonia in the intensive care unit. Crit. Care Med. 2003;31:2544–51. 18. Mitchell AM, Mitchell TJ. Streptococcus pneumoniae: virulence factors and variation. Clin. Microbiol. Infect. 2010;16:411–8. 19. O’Brien KL, Wolfson LJ, Watt JP, Henkle E, Deloria-Knoll M, McCall N, et al. Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates. Lancet. 2009;374:893–902. 20. Stephens DS. Conquering the meningococcus. FEMS Microbiol. Rev. 2007;31:3–14. 21. Maiden MCJ, Frosch M. Can we, should we, eradicate the meningococcus? Vaccine. 2012. p. B52–B56. 22. Price AA. Meningococcal vaccines. Curr. Pharm. Des. 2007;13:2009– 14. 23. Perron GG, Kryazhimskiy S, Rice DP, Buckling A. Multidrug Therapy and Evolution of Antibiotic Resistance: When Order Matters. Appl. Environ. Microbiol. 2012. p. 6137–42. 24. Gould IM. Antibiotic resistance: the perfect storm. Int. J. Antimicrob. Agents. 2009;34 Suppl 3:S2–S5. 25. Chaubey VP, Pitout JD, Dalton B, Ross T, Church DL, Gregson DB, et al. Clinical outcome of empiric antimicrobial therapy of bacteremia due to extended-spectrum beta-lactamase producing Escherichia coli and Klebsiella pneumoniae. BMC Res. Notes. 2010;3:116. 26. Holtom PD. Antibiotic prophylaxis: current recommendations. J. Am. Acad. Orthop. Surg. 2006;14:S98–S100. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 37 27. Stoeber K. Principles of Molecular Pathology. Br. J. Cancer. 2005;92:1177. 28. TRIPS flexibilities should help improve access to antiretrovirals. PharmacoEconomics Outcomes News. 2011 Apr;&NA;(625):4. 29. Viruses and Congenital Disorders. Science (80-. ). 2013 Apr 25;340(6131):405–405. 30. Pediatric Congenital Disorders | UCSF [Internet]. [cited 2014 Feb 4]. Available from: http://neurosurgery.ucsf.edu/index.php/pediatric_congenital_disorders .html 31. Prenatal Diagnosis for Congenital Malformations and Genetic Disorders [Internet]. [cited 2014 Jan 30]. Available from: http://emedicine.medscape.com/article/1200683overview#aw2aab6b7 32. Shendure J. Next-generation human genetics. Genome Biol. 2011. p. 408. 33. Levy S, Strausberg RL. Human genetics: Individual genomes diversify. Nature. 2008. p. 49–51. 34. IDPH - Center for Congenital and Inherited Disorders [Internet]. [cited 2014 Jan 28]. Available from: http://www.idph.state.ia.us/genetics/genetic_disorders.asp 35. Bishop DVM. Genes, cognition, and communication: insights from neurodevelopmental disorders. Ann. N. Y. Acad. Sci. 2009;1156:1–18. 36. Holloszy JO. Comprehensive Physiology. Compr. Physiol. 2011. p. 921– 40. 37. Cooke GS, Hill A V. Genetics of susceptibility to human infectious disease. Nat. Rev. Genet. 2001;2:967–77. 38. Vink J. Human molecular genetics. Twin Res. Hum. Genet. 2010;13:404. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 38 39. Nadeau JH, Dudley AM. Genetics. Systems genetics. Science. 2011;331:1015–6. 40. Templeton AR. Genetics and recent human evolution. Evolution. 2007;61:1507–19. 41. Classification and Coding of Neoplasms [Internet]. [cited 2014 Feb 4]. Available from: http://www.iarc.fr/en/publications/pdfsonline/epi/sp95/sp95-chap7.pdf 42. Grivennikov SI, Greten FR, Karin M. Immunity, inflammation, and cancer. Cell. 2010;140:883–99. 43. Lazebnik Y. What are the hallmarks of cancer? Nat. Rev. Cancer. 2010;10:232–3. 44. Vollmers HP, Brändlein S. Natural antibodies and cancer. J. Autoimmun. 2007 Dec;29(4):295–302. 45. Mallick A. Disorders of the lymph circulation: their relevance to anaesthesia and intensive care. Br. J. Anaesth. 2003 Aug 1;91(2):265– 72. 46. Lymph Node Disorders [Internet]. [cited 2014 Feb 4]. Available from: http://emedicine.medscape.com/article/937855-overview 47. Blood Disorders - Anemia, Leukopenia, Thrombocytopenia - Life Extension Health Concern [Internet]. [cited 2014 Feb 4]. Available from: http://www.lef.org/protocols/heart_circulatory/blood_disorders_01.htm 48. Beutler E, Waalen J. The definition of anemia: what is the lower limit of normal of the blood hemoglobin concentration? Blood. 2006;107:1747– 50. 49. Fleischman W. Anemia: determining the cause. Compend. Contin. Educ. Vet. 2012;34:E1. 50. Pappas A, Delaney-Black V. Differential diagnosis and management of polycythemia. Pediatr. Clin. North Am. 2004;51:1063–1086, x–xi. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 39 51. Chen G, Prchal JT. Polycythemia vera and its molecular basis: an update. Best Pract. Res. Clin. Haematol. 2006;19:387–97. 52. Prchal JT. Polycythemia vera and other primary polycythemias. Curr. Opin. Hematol. 2005;12:112–6. 53. Stasi R. How to approach thrombocytopenia. Hematology Am. Soc. Hematol. Educ. Program. 2012;2012:191–7. 54. Gauer RL, Braun MM. Thrombocytopenia. Am. Fam. Physician. 2012;85:612–22. 55. Parker RI. Etiology and Significance of Thrombocytopenia in Critically Ill Patients. Crit. Care Clin. 2012. p. 399–411. 56. Cines DB, Bussel JB, McMillan RB, Zehnder JL. Congenital and acquired thrombocytopenia. Hematology Am. Soc. Hematol. Educ. Program. 2004;390–406. 57. Matasar MJ, Zelenetz AD. Overview of lymphoma diagnosis and management. Radiol. Clin. North Am. 2008;46:175–198, vii. 58. Küppers R. The biology of Hodgkin’s lymphoma. Nat. Rev. Cancer. 2009;9:15–27. 59. Moitra V, Sladen RN. Monitoring endocrine function. Anesthesiol. Clin. 2009;27:355–64. 60. Diabetes N, Clearinghouse I. Diabetes Overview. Diabetes. 2005;1–16. 61. Facts F, Diabetes ON. National Diabetes Fact Sheet , 2011. Centers Dis. Control Prev. U.S. Dep. Heal. Hum. Serv. 2011;CS217080A:1–12. 62. Hirsch IB. The changing faces of diabetes. Prim. Care. 2003;30:499– 510. 63. Pridjian G, Benjamin TD. Update on gestational diabetes. Obstet. Gynecol. Clin. North Am. 2010;37:255–67. 64. Asa SL, Ezzat S. The pathogenesis of pituitary tumors. Annu. Rev. Pathol. 2009;4:97–126. 65. Orrego JJ, Barkan AL. Pituitary Disorders. Drugs. 2000. p. 93–106. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 40 66. Cohen LE. Genetic disorders of the pituitary. Curr. Opin. Endocrinol. Diabetes. Obes. 2012;19:33–9. 67. Vanderpump MPJ. The epidemiology of thyroid disease. Br. Med. Bull. 2011;99:39–51. 68. Erem C. Thyroid disorders and hypercoagulability. Semin. Thromb. Hemost. 2011;37:17–26. 69. Nicolson GL. Chronic Bacterial and Viral Infections in Neurodegenerative and Neurobehavioral Diseases. Lab. Med. 2008. p. 291–9. 70. Kay R, Wu A. Infections of the nervous system: an update on recent developments. Hong Kong Med. J. 2001;7:67–72. 71. McGavern DB, Kang SS. Illuminating viral infections in the nervous system. Nat. Rev. Immunol. 2011;11:318–29. 72. Fouse SD, Costello JF. Epigenetics of neurological cancers. Future Oncol. 2009;5:1615–29. 73. Visvader JE. Cells of origin in cancer. Nature. 2011;469:314–22. 74. Dawodu ST. Traumatic Brain Injury (TBI) - Definition, Epidemiology, Pathophysiology [Internet]. Sport. Med. 2011. p. 1–11. Available from: http://emedicine.medscape.com/article/326510-overview 75. Jin H, Wang S, Hou L, Pan C, Li B, Wang H, et al. Clinical treatment of traumatic brain injury complicated by cranial nerve injury. Injury. Elsevier; 2010 Sep 1;41(9):918–23. 76. Younger DS. Peripheral nerve disorders. Prim. Care. 2004;31:67–83. 77. Fox IK, Mackinnon SE. Adult peripheral nerve disorders: nerve entrapment, repair, transfer, and brachial plexus disorders. Plast. Reconstr. Surg. 2011;127:105e–118e. 78. Dray A. Neuropathic pain: emerging treatments. Br. J. Anaesth. 2008;101:48–58. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 41 79. Baron R, Binder A, Wasner G. Neuropathic pain: diagnosis, pathophysiological mechanisms, and treatment. Lancet Neurol. 2010;9:807–19. 80. Teasell RW, Mehta S, Aubut J-AL, Foulon B, Wolfe DL, Hsieh JTC, et al. A Systematic Review of Pharmacologic Treatments of Pain After Spinal Cord Injury. Arch. Phys. Med. Rehabil. 2010;91(5):816–31. 81. Scholz J, Woolf CJ. The neuropathic pain triad: neurons, immune cells and glia. Nat. Neurosci. 2007;10:1361–8. 82. Management of Nerve Injuries: Grades of Nerve Injury [Internet]. Available from: http://www.medscape.com/viewarticle/774686_3 The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NurseCe4Less.com. The information is designed to assist healthcare professionals, including nurses, in addressing issues associated with healthcare. The information provided in this course is general in nature, and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold NurseCe4Less.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication. The contents of this publication may not be reproduced without written permission from NurseCe4Less.com. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 42