Methodological instruction

to practical lesson of nurse-bachelour students

LESSON2

 

Theme 1. Inflammation.

Theme 2. Fever.

 

Aim: To analyze local symptoms of inflammatory process, to distinguish the main stages of circulation blood disorders in inflammation area and explain their mechanisms, to differentiate the types of exudates on their morphological composition

 

Professional motivation

Knowledge of clinical features of inflammation is necessary for differential diagnostic of inflammation illnesses. Remember that appearance of all five classical features are typical only for acute inflammation of the skin and mucous membranes. If inflammation arises in the inner organs these features are expressed weakly. In those cases it is necessary to take into consideration general displays of inflammation reaction. For chronic inflammation, some features can be absent. Disorder of microcirculation is one of the most important components of the inflammation. Expression of the vessel changes depends on the intensity and duration of injured factor action and the organism reactivity. Knowledge of mechanisms of microcirculatory vessels reaction helps to evaluate the character of the disorder (acute, chronic) and to apply the pathogenetic therapy. Diverse damaging elements, in dependences on their nature and influence intensity, and also physical and chemical changes, which arise at inflammation, affect amount and composition of exudates, on maintenance in it of proteins, salts, cellular elements.

In all hospitals it is obligatory is carried out patients’ thermometry. In the case history there is a temperature list where is the morning and evening temperature put down, as well as the diagram of its changes. For characteristic of the curve it is necessary to define the type of the fever. It has diagnostical significance because a lot of infectious diseases are accompanied with fever with characterized temperature curve. Fever has mainly protective role. Only in the persons with serious disorders of cardiovascular, nervous and other systems and in children the high temperature (above 39 °C) can be dangerous. Doctor has to evaluate the fever significance in the patient and will plan the treatment.

 

1. Program of independent students prepare to lesson

Theme 1 practical lesson

1.     Determination of concept of inflammation

2.     Classifications of inflammation (immune, nonimmune; infectious, noninfectious; acute, chronic; normo-, hypo-, hyperergic, etc

3.     Etiology of inflammation: classification and characteristic of phlogogenic factors

4.     General and local signs of inflammation

5.     Pathogenesis of acute inflammation, stages of inflammation

6.     Alteration (primary and secondary), reasons and mechanisms of secondary alteration

7.     Biochemical, physical-chemical violations in the area of inflammation

8.     Disturbance of vessels permeability in case of inflammation

9.     Mediators of inflammation, their classification, plasma mediators (proteins of acute phase, proteins of the complement system, pro- and anticoagulants, fibrinolysis, kinins

10. Mediators of cellular origin, specific and nonspecificm cytokins: types, characteristic of action, mediators from tissue basophilies, eicosanoids

11. Violation of local circulation of blood in the focus of acute inflammation

12. Experiment of  Konheim

13. Pathogenesis of ischemia and arterial hyperemia

14. Reasons of transition of arterial hyperemia into venous

15. Changes of rheologic properties of blood in the focus of acute inflammation

16. Exudation in the focus of acute inflammation, reasons and mechanisms

17. Characteristic of exudates

18. Emigration of leucocytes in the focus of  inflammation

19. Stages, reasons and mechanisms of emigration of leucocytes

20. Adhesive molecules of leucocytes and endotheliocytes

21. Reasons and mechanisms of chemotaxis of leucocytes

22. Mechanisms of neutralizing of microbes by leucocytes: stages, mechanisms of elimination of objects of phagocytosis.

23. Role of the reactivity of organism, pathological immune response in the development of inflammation (normo-, hypo-, hyperergic inflammation)

24. Principles of anti-inflammatory therapy

 

Theme 2 practical lesson

1.     Determination of concept «fever»

2.     General characteristic of fever, its development in ontogenesis and phylogenesis

3.     Etiology of fever, characteristic of pirogens, primary and secondary pyrogens

4.     The formation of pyrogens at an infection, aseptic damage and immunoreactions

5.     Chemical nature and origin of secondary ("real") pyrogens, mechanisms of influence on the center of thermoregulation

6.     Stages of fever

7.     Principles of classification, types of fever

8.     Role of the nervous, endocrine and immune systems in the development of fever

9.     Changes of metabolism and physiological functions during the fever

10. Protective value and pathological signs of fever

11. Pathophysiological principles of antipyretic therapy

12. Basic differences between the fever, exogenous overheat and other types of hyperthermia.

 

 

2. Examples of the tests and real-life tasks

Choose the correct answer

Test 1.  Among of enumerated below lymphokines the most important in the development of inflammation is

А. Interferon 

В. Factor of blasttransformation  

С. Carrying factor (Lowrence's)  

D. Factor of suppression   

E. Migration inhibiting factor

Test 2. Among the humoral mediators of the inflammation the most meaning is

А. Hageman's factor 

В. Bradikinin  

С. α2 globulin  

D. Complement system  

E. Prekalicrein

Test 3. Humeral mediators of inflammation include:

А. Histamine   

В. Interleukine   

С. Prostaglandin Е2  

D.  Serotonin 

Е. Bradykinin

Test 4. The first cells which migrate in area of inflammation are

A. Eosinophiles 

B. Lymphocytes 

C. Monocytes 

D. Neutrophiles

E. Basophiles

 

Task 1. In the result of burn of a shoulder an inflammation developed with sharply expressed pain.

1. Why did the pain appear?

2. Enumerate other possible displays of inflammatory reaction

3. What is their pathogenesis?

Task 2. A patient addressed to doctor with complains on the pain and noise in the left ear, lowering of hearing. During the examination of the tympanic membrane the dense net of dilated vessels is revealed. Upper part of tympanic membrane is dark red, the lower ones is brighter.

1. What pathological process did develop in the ear?

2. Why different parts of the tympanic membrane do have different color?

3. What is the mechanism of the found vessel disturbances?

Task 3. From pleural cavity of the patient doctor got exudate of such composition: protein 58 g/l, leucocytes – 6200/mcl, prevail neutrophiles, much wholes and destroyed cells, рН 6,6.

1. What exudate did doctor get in the patient?

2. Explain mechanism of exudate formation in pleural cavity.

3. What is the origin of found cells?

4. What is the positive and negative role of exudate in inflammation.

 

3. Answers to the assessments and questions of the real-life tasks

Tests. 1 – Е, 2 – В, 3 – E, 4 – D.

 

Task 1.  

1. In the result of irritation of the nervous ending by acids, ions of potassium.

2. Redness, swelling, fever, dysfunction.

3. Increase of the temperature: a) arterial hyperemia; b) the heat release in the result of metabolism increase. Redness is caused by arterial hyperemia as arterial blood consists of a lot oxyhemoglobin. Redness with cyanosis is associated with increase of the desoxyhemoglobin level. Swelling: a) increase of permeability of the capillaries and venules under  influence of biological active substances; b) increase of blood pressure in the vessels; c) increase of the osmotic and oncotic pressure outside the vessels. Dysfunction is associated with pain, development of swelling and destruction of the tissues.

Task 2.

1. Complains of the patient and objective examinations testify about inflammation of tympanic membrane.

2. In the lower part of tympanic membrane we can see the stage of the arterial  hyperemia, in the upper ones there is the venous hyperemia.

3. During the affection of tympanic membrane mediators of inflammation excrete. It causes at first the short spasm and then long dilatation of the vessels, which causes hyperemia. Tympanic membrane becomes bright red. After some time blood flow slowing down and venous hyperemia develops.

Task 3.  

1. Doctor got purulent exudate.

2. Increase of vascular wall permeability, increase of blood pressure, increase oncotic and osmotic pressure in area of inflammation.

3. From blood – neutrophiles, eosinophiles, basophiles, monocytes, lymphocytes,from tissues – peritoneal macrophages and cell local origin (mesotheliocytes).

4. Positive role is accumulation of phagocytes, antibodies, lysosomal enzymes, components of complement system; negative role – disturbance of organs function.

 

4. Informational sources

Basic

1.     Pathological physiology / Yu.I. Bondarenko, M.R. Khara, V.V. Faifura, N. Ya. Potikha. ‑ Ternopil: Ukrmedkniga, 2006. – 312 p.

2.     Methodological instructions

Additional:

1. Robbins basic pathology, 7/e / Kumar et al. – Indian reprint, 2004. – 873 p.

 

5. Students’ practical activities

Theme 1 practical lesson

Work 1. Anaphylactic inflammation of the rat's extremity (experiment)

It is necessary to inject 0.05 ml of the egg's protein into the hind extremity. In order to do this you should input the needle between 3 and 4 fingers and push it to the middle of the paw. In a few minutes examine the extremity. Observe local signs of inflammation. Write down the experiment results in protocol.

Work 2. The change of the vessels permeability for anaphylaxy-like inflammation (experiment)

It is necessary to inject trypanic blue under the back skin of the rat in the quantity of 1-2 ml. 20 minutes after cause the inflammation on the rear extremity using the method mentioned above. After some time examine the skin colour change of the animal and also compare the colour of injured and opposite extremities. Analyse the mechanism of the permeability change. Write down the experiment results and protocol of experiment according to scheme. For discussion of the results it is necessary to give answer for questions.

1. Enumerate local signs of inflammation.

2. What biological active substances do appear in the area of inflammation?

3. How and why the permeability of the vessels in the area of the inflammation does change?

4. What changes of the metabolism do promote the development of the inflammation signs?

5. What meaning does inflammation have for organism?

 

Work 3. Vessels reactions at inflammation of mesentery in a frog (Congaim's experiment)

Fix the frog on the board with the back up. Make the side cut of the abdominal skin. Open the abdominal cavity, stretch out intestine, strain out the mesentery above opening in the board and fix the intestine with the pins. Look over the microscope development of the vessel reactions for the inflammation (change of the vessels diameter, change of the blood flow speed, margination of leucocytes, thrombosis). Differentiate up stages. Draw down their. Write down the experiment results and protocol of experiment according to scheme.

Questions for discussion:

1. Enumerate the stages of the microcirculatory disorders in the area of the inflammation.

2. What is the main in the development of arterial hyperemia?

3. What processes promote the slowing down of blood flow and development of the venous hyperemia ?

4. Which stages of the leucocytes migration did you see?

Work 4. Microscope investigation of exudates.

1. Serous-purulent exudate, got from abdominal cavity of guinea-pig 3 hour after injection 1 ml of suspension of staphylococcus culture. (There are more segmental and stable neutrophiles, lymphocytes, monocytes, cells of mesothelium specimen. There are visible cocci accumulations. It is observed microbes engulfed by neutrophiles and monocytes. There are fragment of blood cells and mesothelium).

2. Serous-purulent exudate, got from abdominal cavity of guinea-pig 24 hour after injection of 1 ml suspension of staphilococcus culture. In comparison with previous specimen, here is observed many monocytes. Part from them engulfed remains of diverse cells (cultural phagocytosis), many destroyed cells (purulent bodies).

3. Purulent exudate taken in the patients. It is observed large number of destroyed leucocytes and cultural elements in vision sight compact shapeless mass, in which difficult to distinguish the structural tissues elements.

To draw and to note morphological peculiarities of exudates. Write down the experiment results and protocol of experiment according to scheme.

Questions for discussion.

1. What is it purulent bogy?

2. What origin do have the enzymes in inflammatory exudate?

3. What is the mechanism of leucocytes destroying in inflammation area?

Theme 2 practical lesson

Work 5. Experimental fever in rabbit

Before experiment it is necessary to check rabbit’s rectal temperature and temperature of ear skin, determine the respiratory rate. Then inject pyrogenal (0,5 mg/kg) in the rabbits angular ear vein. Every 15 minutes check body’s temperature in the rectum and ear skin and also determine the respiratory rate. The results put down in the table. Show these changes of the rectal temperature, the temperature of the ear skin, and the respiratory rate graphically. Do protocol of experiment according to scheme, for discussion answer for control question.

Time

Rectal temperature (C)

Skin temperature (C)

Breathing rate

 

 

 

 

 

1. What stages of fever did you observe?

2. Explain mechanism and significance of skin temperature changes.

3. Why did the breathing rate change?

4. What parts of nervous system does take part in the thermoregulation?

5. What cells are the main producers of the interleukin-1?

 

 

6. Discussion of theoretical questions and practical work results 

1.     General character of inflammation, vessel and tissue components of inflammation, causes

2.     The role of mediators in inflammation development

3.     Meaning of reactivity in  inflammation development

4.     Main symptoms of inflammation (Cells-Galen's pentade), general displays of the  inflammation, conditions for which displays of inflammation symptoms depend

5.     Changes of vessels permeability in the area of inflammation, causes and mechanisms

6.     Importance of permeability disorder in the development of exudation and arise of inflammation edema

7.     Biological active substances (mediators of the inflammation), their role in the change of permeability

8.     The role of physical and chemical disorders in area of inflammation Methods of permeability studying in the area of the inflammation

9.     Stages of the vessel reactions in inflammation area, their mechanisms

10. Leucocytes migration in inflammation area

11. Mechanisms of exudate formation

12. Types of exudates

13. Inflammation complications prophylaxis possibilities

14. The causes of infectious fevers, etiology of uninfectious fevers

15. Properties of exogenous pyrogens and endogenous pyrogens - interleukin-1(IL-1)

16. The effect of the exo- and endopyrogens, role of the termoregulatory center in the pathogenesis of the fever

17. The mechanisms of temperature rise, significance of the endocrine glands

18. Dynamic of the fever, pathogenesis of temperature change in every stages

19. The types of temperature curves

20. Change of the organs and systems functions at fever

21. Positive role of fever

8. Student should know:

1. Definition of the notion "inflammation", causes of the inflammation, classifications of the inflammation

2. The meaning of the organism reactivity in the development of inflammation

3. Local and general symptoms of the inflammation

4. Causes and mechanisms of the vascular permeability disorders in the area of inflammation

5. The methods of the studying of vascular permeability in the area of inflammation

6. Stages of the vessel reaction during inflammation

7. Nervous-reftectory and humoral mechanisms of capillaries spasm and development of arterial hyperemia

8. Intervessel, vessel and out vessel factors of venous hyperemia and stasis development

9. Mediators of inflammation their types and genesis, role in the development of the inflammation

10. Types of exudates, their composition

11. Factors, from which depends character of exudate

12. Change of cultural composition of exudate in inflammation dynamics

13. Difference between exudate and transudate

 

Students should be able to:

1.     Explain the essence of three main components of the inflammation

2.     Reveal the mechanisms of the development of external inflammatory symptoms

3.     Reveal dependence between expression intensity of the inflammatory symptoms and reactivity of the organism

4.     Explain the mechanisms of the vescular permeability disorders in the area of   inflammation

5.     To carry out an experiment by Conhain

6.     Define under the microscope main stages of vessel changes in the dynamics of an inflammation

7.      Give the characteristics of the each stage; explain the mechanism of its genesis

8.     Differentiate the leukocytes on different stages going out through vascular wall

9.     Explain, what one composition of exudate depends of

10. Differentiate the types of purulent exudates according to composition of exudate under microscope

11. Explain changes dynamics of cultural composition of exudate during inflammation

12. Scetch and to describe microscopy specimen

13. Evaluate the role of different etiological factors in the fever development

14. Explain the fever pathogenesis

15. Determine the fever stage

16. Determine type of temperature curve at fever

17. Ground using of pyrotherapy in clinic

 

  

Methodological instruction made by prof. Yu.I. Bondarenko, as. prof. N.Ya. Potikha.

 

The methodological instruction was discussed

and confirmed at the Department sitting 

“29” of August, 2013.  Minute № 2.