Pathology - Exam 3
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What is the largest organ in the body?
How often are cells replaced?
Every 26-28 days
What are the basic functions of the skin?
- environmental barrier
- sensory reception
What are the layers of the skin from the outermost layer to deepest?
- --stratum corneum
- --stratum lucidium
- --stratum granulosum
- --stratum spinosm
- --stratum basal (germinativum)
- subcutaneous tissue (hypodermis)
- deeper tissue
What are the five layers of the epidermis?
- stratum corneum
- stratum lucidium
- stratum granulosum
- stratum spinosm
- stratum basal (germinativum)
Describe the epidermis
- stratisfied squamous epithelial
- 0.06-0.6mm thick
- thickest on the palms and soles of feet
Describe the stratum corneum
- "horny" outermost layer
- 20-30 cells thick
- thickest in the palms and soles of feet
- callus forms from pressure
Describe the stratum lucidium
- clear layer of dead flattened keritinocytes
- thicker and most prominent in hands and feet
Describe the stratum granulosum
- forms waterproof layer
- --prevents water loss
- langerhans help with immune system
Describe the stratum spinosum
- "spiny" appearance due to kerotin fibers
- progressive maturation and migration of germinal cells
Describe the stratum basale
- aka: germinativum
- single undulating layer of columnar and cuboidal cells
- undulations produce fingerprints
- provides germinal kerotinocytes for regeneration of epidermis
- melonin produced here
Name and describe the epidermal cells
- Melanocytes: pigment, UV protection
- Merkel cells: light touch, mechanoreceptors
- Langerhan Cells: fight infection, decrease as we age, risk of skin cancer increases, dendritic cells
What are the epidermal appendages?
- hair follicles (soft keratin)
- sebaceous glands (lubrication)
- sudoriferous glands (sweat)
Describe the basement membrane and what layer of skin it is found in.
- Part of the epidermis
- attaches stratum basale to dermis
- scaffolding for epidermis
- filters substances and moving between dermis and epidermis
- semipermeable - nutrients from dermis
- blisters occur here due to friction between basement membrane and papillary dermis
- anchors epithelial to loose tissue
Describe the dermis layer of the skin
- --capillary beds
- --rosy/pink color
- lymphatic system
- --returns water, proteins, other substances to the blood
- high water content
- 2.0-4.0mm thick
What are the functions of the dermis?
- nutritional support to epidermis
- houses epidermal cells and growth factors for epidermal replication and dermal repair after trauma
- thermoregulation through control of skin blood flow
- contains immune cells
- --defense against foreign invaders
- sensory assist to epidermis for info on environment
What are the dermal cells?
- fibroblasts (collagen/elastin) flexability
- --modulate lymphocyte function and promote growth
- mast cells - histamines
What are the structures of the dermis?
- hair follicles
- erector pilae muscles
- sweat glands
- sebaceous glands
- pacinean corpuscle and free nerve endings (vibration and pressure)
Describe the subcutaneous tissue in the skin.
- aka - hypodermis
- highly vascularized
- more moist
- adipose tissue
- --shiny whitish yellow in color
- if cut -> see blood
- stores energy and vitamins A D E and K
- cushioning over bony prominences
- deeper lymphatic vessels here
- --fibrous white connective tissue
- --seperate structures facilitating movement
Describe the deeper tissue in the skin
- muscle: bloody red is normal
- tendons: white regularly arranged fibers
- ligaments: white regularly arranged fibers
- joint capsule: white irregularly arranged fibers
- bone: milky white, hard when probed
What are superficial thickness wounds?
- wounds caused by shearing, friction, and mild burn
- healing occurs by regeneration of epithelial cells on wound surface an migration of epidermal cells across the surface
- affects epidermis layer only
- skin remains intact
- examples - blisters, 1st degree burns
Describe partial thickness wounds
- effects epidermis and part of the dermis
- accessory structures are spared (hairs and glands stay in tact)
- heals similarly to superficial thickness wounds
- eschar may form
- --dessicated necrotic tissue
- --black color
- examples - road rash, deeper burns
Describe full thickness wounds
- effects epidermis, dermis, and into subcutaneous tissue
- muscle, tendon, and bone can be involved
Describe the biomechanics of the skin
- normal skin has elastic, tensile and viscous properties
- much of elasticity comes from viscous elements (viscoelastic)
- tendons are very stiff and elongate very little
- --due to parallel arrangement of thick collagen
- --due to different proportions of glycosaminoglycans
- --ability of skin to recoil when pinched
- --decreases with dehydration
What type of wounds heal by re-epithelialization?
superficial and partial thickness wounds
What are the three phases of healing?
Describe the inflammation phase of healing
- "exudative" phase for homeostasis and fight infection
- platelet aggregation
- --forms plug to stop bleeding
- coagulation and fibrin formation
- --controls bleeding
- neutrophils, macrophages, and mast cells
- --assist with destruction and removal of bacteria and cellular debris
- --secrete inflammatory mediators
- --phagocytosis and proteolysis
What are the cardinal signs of inflammation?
- swelling (tumor)
- redness (rubor)
- warmth (calor)
- pain (dolar)
- decrease in function (functio laesa)
Describe the proliferation phase of healing
- begins as early as 48 hours
- --sprouting of capillaries
- --tiny red dots in wound bed
- granulation tissue
- --tissue fills wounds
- --temporary matrix of vascular connective tissue formation (laid down by fibroblasts)
- --red, beefy, shiny, granular beds
- --very fragile
- --if trauma -> may cause bleeding
- wound contraction
- --decrease in size of wound
- --actin-rich myofibroblasts pull wound margins together
- --keratinocytes migrate across wound
- --slowed by debris
- --clean/moist facilitates movement
- needs warm environments with high oxygen and nutriant demands
Describe maturation/remodeling phase of healing
- "differentiation" phase
- maturation of collage, scar formation, and epithelialization
- rosy, pink scar
- remodeling of collagen fibers as they thicken, reorganize and mature
- --scar color similar to surrounding tissues
- 9 days - 2 years after injury
- tissue strength - 15-20% initially, 80% of original when healed
What are the three types of wound healing?
- Primary Intention
- Secondary Intention
- Teritiary Intention
What is primary intention of wound healing?
- primary closure
- uses sutures, staples, adhesives
- minimal inflammatory phase
- fastest closure
- proliferation is epithelialization
What is secondary intention of wound healing?
- secondary closure
- allow wounds to heal on own
- used for wounds with tissue loss, irregular edges, tissue necrosis, high microbial count, or presence of debris
- increased healing time
- granulation has to be generated to close
- increased healing time
- increased scarring
What is tertiary intention of wound healing?
- delayed primary closure
- leaving wound open until closing is prudent
- wound is not allowed to granulate
- closure of wound after time to start healing
- combo of primary and secondary
- needs cleansing of wound prior to closure
What factors affect healing?
- necrotic tissue
- mechanical stress
- foreign body
What intrisic factors affect healing
- chronic disease
- perfusion and oxygenation
- neurologically impaired skin
What extrinsic factors affect healing?
- irradiation and chemo
- psychophysiological stress
- necrotic tissue
What iatrogenic factors affect healing?
- local ischemia
- inappropriate wound care
- sheer injuries
How does age affect the healing process?
- decreased immune system
- --decreased inflammatory response
- --delays angiogenesis
- dermal and epidermal atrophy
- --increased risk of skin tears
- decreased collagen synthesis
- decreased dermal vascularity (decreased nutrition)
- decreased oil and sweat activity decreased barrier
How does nutrition affect the healing process?
- malnourished: increased wound complications
- water: vital to wound healing
- protein: risk of protein depletion
- carbs: provide energy for repair and regeneration
- vitamins: needed to build new tissue and aid in immune function
- fats: essential fuel and vitamin transport
How do comorbidities affect healing?
- disease processes that affect tissue perfusion affect wound healing (PVD, anemia, COPD)
- immunocompromised patients
- --ineffective immune system increases infection risk (HIV/AIDS, steroids, chemo)
- activity limitations
- --increased risk of skin breakdowns and delayed repairs
How does temperature affect healing?
as temperature decreases, speed of healing decreases
What is involved in a wound assessment?
- systems review
- tests and measures
- --assistive/adaptive decives
- --gait, locomotion, balance
- --ROM, MMT, posture
What is involved in a wound evaluation?
- clues concerning the cause of the wound and prognosis for healing
- surrounding skin color
How does color affect a wound evaluation?
strong indication for vascular supply
How does odor affect a wound evaluation?
- indicates infection
- clean wounds have no smell
- sweet (fruity)
- --suggests psudeomonas
- foul (fecal smell)
- --gram negative bacteria
How does drainage affect a wound evaluation?
- thick, creamy drainage indicates infection
- type - serous (clear), sanguinous (pinkish)
Why does evaluating the surrounding skin color help?
- melanin and hemoglobin
- --primary determinates of skin color
- palor suggests arterial insufficiency
- purplish hue
- --due to desaturated hemoglobin
- --severe arterial insufficiency
- --severe CHF or pulmonary disease
- heavy pigmented skin
- --hyperemia produces violet/eggplant color
- look at nail beds and lips
- trophic changes
- --indicators of poor arterial circulation
- --dry, scaly, leathery skin
- --brittle nails
- --hair loss (epidermal appendage)
What are the different types of tissue?
- slough: yellow or white strings or thick clumps
- granulation: pink or beefy red tissue, shiny, moist, granular appearance
- epithelial: new pink or shiny tissue, grows in from edges
- necrotic: eschar, black , firmly adheres to the wound bed
- closed/resurfaced: wound completely covered
What is involved in a physical exam of a wound?
- limb girth
What does shape determine about a wound?
- highly regular: associated with pressure
- irregular: associated with vascular insufficiency
- extremely irregular: has "peninsulas and bays", areas of healthy skin surrounded by necrosis, associated with venous insufficiency
What do edges determine about a wound?
- attached: quicker to heal
- unattached: slower to heal
- rolled: signs of chronic wound
- callused: diabetic
What does temperature determine about a wound?
- check severity of inflammatory response by temperature of surrounding skin
- increased in skin temperature due to developing cellulitis or infection
- decreased temperature caused by arterial insufficiency
- decreased temperature delays healing by reducing oxygen release
What does size determine about a wound?
- length and width
- --tracing, photographic grid
- greatest length by greatest width method
- depth, tunneling
- --cotton tip applicator, tunneling stick
- surrounding skin errythema
How do you determine the volume of a wound?
fill wound with Hydrogel from a syringe
Limb girth of a wound
- document landmarks for reproductability
- pitting, or firm?
Describe vascular testing of a wound
- --dorsal pedis, posterior tibial, popliteal pulses
- capillary refill
- --tests surface arterial blood flow
- -- ~30 seconds to normally return
- dependent rubor test
- --tests arterial flow
- --supine, lift leg, observe initial color, after 1 minute, observe change in color of foot. ~15-20 seconds to return. >40 seconds with insufficiency
- ankle brachial index (ABI)
- --measure BP on arm and on ankle
- --divide ankle pressure by arm pressure
- --normal indext is 1.0
- --<0.95 - narrowing
- --<0.8 - intermittent claudation
What are the different patterns of PT treatment for wounds?
- Pattern A: prevention/risk reduction
- Pattern B : superficial skin involvement
- Pattern C: partial-thickness skin involvement
- Pattern D: full thickness skin involvement
- Pattern E: skin involvement extending into fascia, muscle, or bone, and scar formation
What does the endocrine system regulate and control?
- works with the nervous system
- water and salt balance
- blood pressure
- sexual reproduction
What are the major glands of the endocrine system?
- repoductive glands
What is the role of the hypothalamus?
- link between endocrine and nervous system
- nerve cells control pituitary gland by producing chemicals that either stimulate or supress hormone secretion
What is the role of the pituitary gland?
- controls other glands
- anterior lobe secretes: ACTH, TSH, GH, LH, FSH, prolactin (produced after childbirth, stimulates milk production)
- posterior lobe secretes:
- --ADH (controls body water and balance by acting on kidneys to modify urine out)
- --oxytocin (triggers contraction of uterus during labor
What is the role of the thyroid gland?
- regulates metabolic rate, growth and development and protein synthesis
- thyroid hormones:
- --thyroxin (T4) - blood stream
- -- triiodothyroix (T3) - cell functioning
- --calcitonin - stimulates calcium deposits in bone
What is the role of the parathyroid gland?
- increases blood levels of calcium by removal of calcium from bone to increase levels in the blood
What is the role of the adrenal gland
- --acts primarily on kidney to promote absorption of sodium and excretion of potassium
- --increase of sodium levels contribute to retention of water and increased blooe volume
- absence of aldosterone
- --sodium is excreted resulting in decrease blood volume and decreased blood pressure
- --produced in response to stress
- --increase blood glucose by stimulating liver to produce glucose from stored, non-glucose sources
- --decreased swelling by inhibiting immune system response to injury or infection
- --prednisone produced from cortisol
What is the role of the adrenal medula?
- composed of modified neurons
- secretes hormones in response to stress
- --epinepherine (adrenaline)
- --norepinepherine (non-adrenaline)
- stimulate fight or flight response of sympathetic nervous system
- --increase HR and BP
- --dilate airways to facilitate oxygen flow to lungs
What is the role of the pancreas?
- digestive and endocrine gland
- islet or langerhans are cells that secrete
- --insulin (removal of glucose from blood to store as glycogen, promotes build up of fats and proteins and uses as energy source)
- --glucagon (increases levels of glucose in blood, released from alpha cells)
- secretes digestive enzymes into duodenum through pancreatic duct
What is the role of the adipose tissue?
- considered endocrine
- pear shaped
- apple shaped
- secretes hormones responsible for:
- --cell growth and development
What is the role of the gonads?
- LH from pituitary gland stimulates sex hormones
- responsible for secondary sex characteristics such as facial hair and breast development
What is the role of the pineal gland?
- secretes melatonin
- light from eye stimulates gland through optic nerve
- melatonin is formed at night
- longer nights = increased levels of melatonin
- --levels vary with seasons and time of day
- melatonin helps regulate (rhythms):
Describe basis for Endocrine Disorders
- more prevalent in women than in men
- most disorders prepresent hypofunction of gland secondary to:
- --defects in development
- --enzyme deficiencies
- --autoimmune destruction
- --decrease hormone stimulation
- --infection, neoplasia, hemorrage, or infarction
Muscle weakness, myalgia, and fatigue associated with what endocrine diseases?
- thyroid disease
- parathyroid disease
- acromegaly (GH - pituitary)
- diabetes (pancreas)
- cushings syndrome (Cortisol - adrenal)
Bilateral carpal tunnel syndrome associated with what endocrine diseases?
- diabetes mellatus
- hormone imbalance
- --oral contraceptives
Neuromuscular signs and symptoms of the endocrine system
- --deposits of calcium salts in joint cartilage
- --5-10% have underlyng endocrine or metabolic disease
- within anterior pituitary gland
- growth hormone deficiency
- --short stature
- --delayed grouth and puberty
- --adrenocorticol insufficiency
- --gonadal failure
- --neurologic signs if caused by tumore
- --lifetime hormone replacement
What is hypofunction of the posterior pituitary?
- result from the posterior pituitary gland
- diabetes insipidus -> RARE
- --lack of secretion of vasopressin antidiuretic (ADH)
- --water not reabsorbed in kidneys
- --excretion of large amounts of dilute urine
- --expect patient to be fatigued and irritable due to nocturia
What are the symptoms and treatment for hypofunction posterior pituitary?
- imbalance of water
- hydration and replacement of ADH
What is hyperfunction of the posterior pituitary?
- acromegaly (adults)
- abnormal enlargement of skeleton due to hypersecretion of GH
- clinical signs and symptoms
- --enlargemnet of face, hands, and feet
- associated musculoskeletal signs
- --carpal tunnel, hand pain and stiffness, back pain (thoracic and/or lumbar)
- giantism (Childhood)
- overgrowth of long bones
- grows past growth plate
- timely diagnosis is key
- drug therapy
- removal of tumor (if present)
What are thyroid gland diseases?
What is a goiter?
- enlargement of the thyroid gland due to iodine, deficient diet, inflammation or tumor
- pressure on trachea and esophagus causes difficultly breathing and swallowing
- may or may not be regional
- surgery if affecting trachea
What is thyroiditis?
- inflammation of thyroid due to infection or autoimmune process
- Hashimoto Thyroiditis is most common form
- --early disease hyperfunction
- --late disease hypofunction
- long term hormone therapy
What are the different types of hyperthyroidism?
- execessive secretion of thyroid hormone
- causes general increase in body metabolism
- Graves Disease (most common)
- gerneralized enlargement of gland
- protruding eye (exopthalamus)
- heat intolerance
- weight loss
What are they signs of hyperthyroidism in adults >50
- hyperactive reflexes
- heat intolerance
- purple anterior tibia
- increased appetite
- weight loss
What is hypothyroidism?
- insufficient production of thyroid hormone
- generalized depression of body metabolism
- untreated congenital hypothyroidism in infants was called Cretinism (now: neonatal hypothyroidism)
- mostly 30-60 years old, 50% in families, 95% impaired
What are the signs and symtoms of hypothyroidism?
- proximal muscle weakness
- slowed speeched and mental function
- carpal tunnel
- muscle and joint edema
- respitory muscle weakness
- poor wound healing
What is the treatment for thyroid gland diseases?
ongoing synthetic hormones
What are the musculoskeletal effects of hypothyroidism?
- CTs may develop before other signs
- proximal muscle weakness
- myalgias and trigger points
- muscle and joint edema
- back pain
What is hyperparathyroidism?
- usualled caused by tumor
- causes release of calcium by bone and accumulation of calcium in the blood stream
- excessive calcium leads to bone damage, hypercalcemia, kidney damange
What are the symptoms of hyperparathyroidism?
- bone demineralisation and bone pain
- proximal muscle weakness and fatigability
- GI problems and pancreatitis
- slow mental ability, personality changes
- concurrent illness and surgery can induce acute arthritic episodes
- --condrocalcinos and calcified tendinitis
What is hypoparathyroidism?
- usually back accidental removal of the parathyroid gland, but sometimes genetic disease, tumor/trauma
- muscles weakness and pain
- thinning hair
- brittle nails
- hypocalcemia leading to muscle spasms, parethesias, tetany, and cardiac arrythmias
- actue episodes can be life theratening and treated with calcium replacement
- can be idiopathic - children 9x>adults, women 2x > men
- treatment: pharmacologic management
What are the adrenal gland diseases?
- hypofunction (Addisons disease)
- hyperfunction (Cushings)
What are the risk factors for hypofunction of the pituitary gland?
- salt loss from profuse diaphoresis
- treated by administering exogeneous cortisol
- fatal if not treated
What is Cushings Disease?
- hyperfunction of the adrenal gland
- hypercortisolism from over secretion of ACTH from the pituitary
What is Cushings Syndrome?
- hyperfunction of the adrenal gland
- hypercortisolism from adrenal oversecretion or excessive corticosteroid meds
- corticosteroid administration must be stopped gradually so normal adrenal function can resume
What are the symtoms of hyperfunction of the adrenal gland?
- abnormal fat distribution
- moon shaped face
- "buffalo hump"
- enlarged supraclavicular pads
- protuberant abdomen with purple striae
What are the two categories of adipose tissue?
- Brown: specialized tissue for thermoregulation "baby fat"
- White: storage of triglycerols as long-term reservoir of energy
What is the role of adipose tissue in the endocrine system?
secretes proteins which have important roles in fat metabolism, feeding behavior, hemostasis, vascular tone, energy balance and insulin sensitivity
What are the proteins of adipose tissue?
- good adipokines: leptin and adiponectin
- bad adipokines: tumor necrosis factor, resistin, interleukin-6, IL-8, acylation-stimulation protein, and angiotension and plasma activator inhibitor
Obesity and cancer are increasing link for:
- colon cancer
- pancreatic cancer
- non-hodgkins lymphoma
- uterine cancer
- breast cancer (after 65 years)
- prostate cancer
- greater risk for cancer
- --worst outcome - recurrance, malignancy and lifespan
How is adipose tissue and Type 2 diabetes related?
- excessive white adipose tissure
- visceral and hepatic fat are key
- subcutaneous fat (little insulin resistance)
What is visceral fat?
- fat that accumulates around organs
- intra abdominal deposits
- --omental fat
- --intrahepatic fat
What is diabetes?
- persistnt elevation in blood glucose caused by a relative or absolute deficiency in insulin production by the beta cells of the pancreas (in the presence or absence of insulin resistance)
What impact on health does diabetes have?
- 6th leading cause of death
- changes life expectancy 5-10 years
- vascular disease 2x to 4x
- nontraumatic amputation
- nerve damage in 60-70%
- kidney failure
- kills 1 in every 3 minutes
Types of cells involved in glucose regulation
- Alpha Cells
- --acts on liver to release glucagon
- --increase blood sugar
- Beta Cells
- insulin (decrease blood sugar)
- Delta Cells
- --stops glucagon and GH
- --decrease blood sugar
Role of Islet Cells in Glucose Regulation after intake of food
- after intake of food, blood glucose increases
- beta cells release insulin
- insulin transports glucose
- cascade leads to decreased blood glucose
- homeostasis restored
Role of Islet Cells in Glucose Regulation When Hemoglycemic
- decreased blood glucose
- alpha cells release glucagon
- stimulated liver to release glucose
- increases blood glucose and homeostasis restored
Type 1 Diabetes
- about 10% of all cases
- cell-mediated autoimmune destruction of beta cells
- --usually leading to absolute insulin deficiency
- --insulin dependent
- requires injection
- onset before age 30
- beody weight at onset is normal or thin
- --envirnomental exposure
- --genetic mutation
Type 2 Diabetes
- about 90% of all cases
- onset usually after age 35
- insulin production may be below or above normal
- ineffective insulin action at cellular level
- 20-30% require insulin injections
- body weight at onset:obese in 80%
- diabesity - obesity dependent DM in children
- oral hypoglycemic agents
- Other Characteristics:insidious
- obesity or weight gain
- related to other IRS signs (hyperlipidemia, acanthosis nigricans)
- older (increased obesity =decreased age, fatter and younger)
- ethnic links
- family Hx
- no ketones
Physiology of Type 2 Diabetes
- impaired insulin secretion = insulin deficiency
- increased hepatic glucose production
- carbohydrate absorption
- decreased glucose uptake = insulin resistance
Criteria for adult screening for diabetes
- test a fasting plasma glucose in:
- all adults over age 45 years (repeat every 3 years)
- particularly those with BMI >25
- younger adults if BMI >25 and one or more risk factors
Risk factors for Type 2 Diabetes
- primary relative with diabetes
- high-risk ethinic group
- previous gestational diabetes
Diagnostic Criteria to Determine Diabetes
- fasting plasma glucose:
- <70: hypoglycemic
- <100: good
- 100-126: prediabetic
- >126: diabetic
- measures percentage of glycated hemoglobin or HbA1c, in blood
- how dody handles sugar
- look back over time
- ~120 days (lifespan of blood cell)
What is prediabetes?
- occurs when body can't utilize glucose
- incomplete transfer of glucose into cells (for use as energy) by insulin due to:
- --body cells don't recognize insulin (decreased insulin sensitivity)
- --cells top responding to action on insulin (increased insulin sensitivity)
- increases blood glucose (but not as high as DM)
- inslin resistant cells stop responding to action of insulin
What is metabolic syndrome?
- a group of risk factors that occur together and increase the risk for coronary artery disease, stroke, and T2DM
- diagnosis is established when >3 risk factors are present
What are the risk factors for metabolic syndrome?
- abdominal obesity
- --men - >102cm (>40 in)
- --women - >88cm (>35in)
- TG >150 mg/dl
- --men - < 40mg/dl
- --women - < 50 mg/dl
- BP - > 130/85
- fasting glucose > 110 mg/dl
Signs and symptoms of Diabetes
- polyuria (T1DM>T2DM)
- polydipsia (T1DM>T2DM)
- polyphagia (T1DM>T2DM)
- weight loss (T1DM>T2DM)
- recurring badder infection in skin and gums
- numbness and tingling in hands and feet
- slow healing of cuts and bruises
- assymptomatic becaue of physical adaption
- blurred vision
- fatigue and weakness
What is acanthosis nigricans?
- hyperpigmented velvety patches of skin in axillary regions and in neck
- prediabetic and diabetics
Insulin resistace may lead to
- glucose intolerance
- --high TG and low HDL
- cardiovascular diseasse
Complications of diabetes
- macrovacular diseases:
- --cerebrovascular disease
- --cornoary artery disease
- --venal artery disease
- --peripheral vascular disease
- microvascular diseasesneuropathy
- decreased microcirculation to skin and organs
- decreases in wound healing and blood flow
- neurological complications
How does hyperglycemia affect diabetic patients?
- eye:retinopathy, cataracts and glaucoma
- --lead to blindness
- --cause death or disability
- kidneyneuropathy, microalbuminuria, and gross albuminuria
- --lead to kidney failure
- --can cause death or disability
- nervesneuropathy (peripheral and autonomic)
- --lead to amputation
- --can cause death and disability
What is diabetic retinopathy, treatments and preventions
- bood vessels in back of eye affected
- hemmorages and exudates
- --growth of new vessels
- --leads to vision loss
- --yearly dilated rentinal exam
- --blood glucose control (intensive combined therapy)
- --BP control (ace inhibitors)
- --lipid control
- --no contraindication to asprin
- laser therapy for proliferative retinopathy or macular edema
- more prevelant in T1DM
- 25x increase in diabetics
What are the two types of neurological complications with diabetes?
- autonomic:gastroparesis, diarrhea, incontinence
- postural hypotension
- decreased HR
- peripheral:diabetic foot
- charcot's join - arthropathy
- carpal tunnel
How do you approach a patient in PT when they arrive in a confused lethargic state?
- finger-stick glucose test
- immediate physician referral
- alteration in mental status caused by
Treatment for diabetes
- exogenous insulin
- diet whole grains
- serving size
What are the causes of hyperglycemia?
- acute stress
- chronic liver disease
- renal disease
What are the symptoms of hyperglycemia?
- increased urine
- blurred vision
- sever dehydration
- abdominal pain
What is ketoacidosis?
- ketones in blood and urine
- fruity acetone breath
- rapid pulse
- immediate care is essential
- kussmaul resperation
- defer Rx if BS > 300-350 or 240 with ketosis until levels are corrected
- critical level BS >450 - NO EXERCISE
What are the symptoms of hypoglycemia?
- increased heart rate
- double/blurred vision
- slurred speech
- numbness in lips/tounge
- blood glucose <70
- can appear <60-70
- rapid large drop (ie. 400 to 200) can also hae glycemic effects
- hold Rx until BS is corrected
- critical level <50
How does exercise affect patients with diabetes?
- musculosckeletal activities increase glucose homeostasisnew activity at a well-tolerated intensity and duration
- patients with active retinopathy and neuropathy should aboid anything that auses increased BP
- increases in BP may cause further damage
- ok to do low impact activities, strength training preferred (initially)
- pre-existing conditions may limit working to goal HR
- may have difficult with thermoregulation
- no resistance training, valsalva
- do not exercise alone
- when initiating exercise program, T1DM may:
- monitor BG beofre exercising, every 30 min and then 15 min after
- exercise >20min continuous aerobic activity
- reduce insulin dose
- increase food intake
- eat 10-15g carbo snack for each 30 min of exercise
- place fluid loss adequetly
- avoid:high intensity exercise
- exercise placing head below waist (bad for retinopathy), increases BP
- avoid insulin injection to active extremities
PT implications for diabetics
- gentle, progressive program
- patient education - self management
- monitor vitals
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