Pathophysiology

2020 2021 Ilker Gelisen MD

0533 855 9367
 Pathology
• Definition – the study of disease
– the basic structural and functional changes
associated with disease
– The study of causes that leads to these changes
– Sequence of events that leads from structural
and functional abnormalities to clinical
manifestations
 Pathophysiology,
• ‘pathos’ meaning disease,
• ‘physis’ meaning nature and
• ‘logos’ meaning science,
refers to the study of the physical and biological
manifestations of a disease in correlation with the
physiological disturbances and abnormalities that are
present within.
• Basically deals with the study and understanding of the
changes in the activities at the cellular level, once a
particular organ or area has been affected by a disease.
 Why is Pathophysiology
important?
• Understanding the changes that are occurring or
have occurred in a diseased body part goes a long
way in determining the treatment and care of a
patient after the disease has been diagnosed.
 Homeostasis

1. The human body strives to maintain internal

stability.
2. The process of maintaining normal balance
within the body is called homeostasis.
3. When homeostasis is not maintained, disease
ensues.
4. Pathology is a result of disease and changes in
homeostasis
Concepts of Health and Disease
■ Health
The World Health Organization affirms that health is “more than
the absence of disease,” but rather a state of “complete physical,
mental, and social well-being,” This definition sets a lofty goal
for patients seeking health as well as for health care professionals.

●Factor in health
▲ physical well-being
▲ mental well-being
▲ social well-being
 What is the Disease?
• It is the “State in which an individual exhibits
an anatomical, physiological, or biochemical
deviation from the normal”

•Disease may be defined as :

an abnormal alteration of structure or function in any part of the body.

 Disease
• Disease is a condition in which the presence of an
abnormality of the body causes a loss of normal
health
• Idiopathic – no identifiable causes
• Iatrogenic – occur as a result from medical treatment
• Congenital – disease existing at birth or before birth,
involves in the development of fetus Acquired -
developed after birth : not congenital or hereditary
• Nosocomial – due to being in hospital environments
 Etiology
• Refers to the study of the cause of the
disease
• General categories of etiological agents;
genetic abnormalities,
• infective agents,
• chemical, radiation,
• mechanical trauma,
• malnutrition
 Etiology
The etiology of disease is its cause (term literally
means the study of causes).
• 1. If the cause of a disease has never been
discovered (disease is unknown), the cause is
referred to as idiopathic.
• 2. One may also refer to an idiopathic disease as
“unknown etiology”.
 Etiology:
What is the cause?
 Environmental agents:
• Physical
• Chemical
• Nutritional Multifactorial
• Infections As Diabetes,
Hypertension
• Immunological Cancer
• Psychological
 Genetic Factors:
• Age
• Genes
 Etiology

Disease Disease
Disease
Disease
Disease

One etiologic • Several etiologic • One etiologic

agent
agent agents one
several
- one disease, disease, as diabetes .
diseases, as
as Malaria.
smoking.
 Predisposing factors

.Factors that increase probability of a

person’s becoming ill
 Predisposing Factors
• Age
• Young are prone to accidents
• Getting diseases such as diabetes, heart disease, and
certain cancers increase with age
• Very old are prone to drug interactions
• Sex
• More frequent in woman: MS, osteoporosis
• More frequent in men: gout, Parkinson’s disease
• Lifestyle
• Examples of harmful lifestyle:
» Perilous occupation
» Smoking
» Excess alcohol
» Poor nutrition
» Sedentary activity
 Predisposing Factors
• Environment
• Air pollution
• Water pollution
• Poor living conditions
• Excessive noise
• Chronic psychological stress
• Heredity
• Deals with genetic predisposition (inheritance)
» Genetic predisposition + certain type of environment =
mental retardation , lung cancer, etc.
• Preventive health care
• The best treatment of a disease is prevention !!
• Deals with altering risk factors that can be changed
 Predisposing factors for
colorectal Cancer
• Poor diet (more fresh food, increase fiber)
• Sedantary life style
• Decreased regular physical activity
• Heredity (regular screening)
• Age (digestion slows)
COLONOSCOPY after 50
 Epidemiology
• is the study of the patterns, causes, and
effects of health and disease conditions in
defined populations. It is the cornerstone
of public health, and informs policy
decisions and evidence-base medicine by
identifying risk factors for disease and
targets for preventive medicine.
 Iatrogenic disease
• (-iatro = medicine, physician) means that
the disease arose as a result of a prescribed
treatment
• *examples:
– i. Cushing-like Syndrome as a result of
steroid therapy
– ii. immunosupression and/or anemia as a
result of chemotherapy
 A nosocomial disease
• is one that was acquired from a clinical setting (e.g.
hospital; physician’s office; clinic).
– 1. postoperative patient develops staph infection from surgical
instrument that wasn’t properly sterilized
– 2. child develops cold after being exposed to other sick
children at the pediatrician’s office
 Outbreaks of Diseases
• Endemic : regularly found among particular
people or in a certain area
• Epidemic: a widespread occurrence of an
infectious disease in a community at a
particular time.
• Pandemic: prevalent over a whole country
or the world.
 The traditional model of clinical
practice
Diagnosis – identification of the specific
disease

Therapy – the treatment of the disease to

either effect a cure or reduce the patient’s
signs and symptoms

Prognosis – prediction of a disease’s outcome

 Diagnosis
– a. Process of assigning a name to a patient’s
condition.
– b. When clusters of findings with more than
one disease are found, they are called
syndromes.
– c. Diagnosis is needed to determine the
treatment and potential outcome of a disease.
 Manifestations of Disease

– a. To treat a patient, a physician must first

know the manifestations of a disease.
– b. Manifestation refers to how a disease
“presents or shows itself”.
– c. Manifestation is also called clinical
presentation and includes both signs and
symptoms.
 Signs
– i. objective physical observations as
noted by the person who examines the
patient
– ii. this examination is called a physical
or the physical examination
• Health care exam
• Observable phenomena
• Objective
 Symptoms
• Symptoms refer to the patient’s awareness
of abnormalities or discomfort. Symptoms
are not measurable and are based on the
patient’s subjective perception, i.e. pain,
nausea, weakness, fatigue, dizziness
• Patient Report
• Subjective
The written description of symptoms in the
patient’s record is referred to as the patient
history.
 Signs vs symptoms
• Signs are the physical
• symptoms are what a
manifestation of injury,
patient experiences
illness or disease.
about the injury, illness
• A high temperature or disease
a rapid pulse, • Chills, shivering, fever,
low blood pressure, nausea, shaking and
bruising can be called as vertigo are the
signs symptoms.
People vomit (sign) when they
are feeling nauseated
(symptom).
Signs vs symptoms
Asymptomatic (Sub-clinical) disease

• a disease in which symptoms are not

noticeable to the patient;

• presence of disease (signs) is detected by

routine physical or tests
 The course of a disease

• An acute disease has relatively sudden onset

and lasts for a short term,

• a chronic disease, sometimes begins with

an acute phase, usually lasts for a long
period of time.
 Prefixes and Suffixes and Roots
• Root- the foundation of the word
• Prefix – place before the root to modify its
meaning
• Suffix – places after root to modify and give
essential meaning to the root
1. Hyperlipoproteinemia
Prefix : hyper (higher)
Roots : lipoprotein
 Prefixes and Suffixes and Roots
• 2. Hepatosplenomegaly
Root : hepato (hepar), spleno (spleen)
Suffix : -megaly (enlargement)
3. Meningitis
Root : mening (meninges)
Suffix : - itis (inflammation)
4. Tachycardia
Root : cardia (heart)
 Treatment (therapy)
– a. Treatment of a disease should be as precise
as possible in order to attempt a cure.
– b. Treatment interventions may include:
exercise, nutritional modifications, physical
therapy, medications, surgery, and education
 Outcome

• Expected
– Prognosis
• Actual
– Cure
– Remission
– Exacerbation
– Complication
– Palliative
– Death
Outcome of disease

• Complete recovery
• Incomplete recovery
• Death
Complete recovery

The best outcome of a disease:

•the etiological factors disappear
•the pathologically altered metabolism, structure and
function are perfectly restored
•the symptoms and signs of the disease disappear entirely
• homeostasis is recovered
Incomplete recovery

The main symptoms and signs disappear but some

pathological changes are left behind, namely sequela.
Sequela is generally brought about by the compensatory
response to maintain a relatively normal activity.
For example, the permanent damage to the heart valve
after rheumatic fever.
Death
■

The cessation of heart-beats and breath is used as the

criterion of death of a body.

●Brain death
The functions of cerebrum and brain stem stop forever.
 Levels of Prevention
• Primary prevention
• Primary prevention aims to prevent disease
or injury before it ever occurs. This is done
by preventing exposures to hazards that
cause disease or injury, altering unhealthy
or unsafe behaviours that can lead to disease
or injury, and increasing resistance to
disease or injury should exposure occur.
• e.g. immunization against infectious
Hematological
system
2020
 Physical Characteristics of Blood
• Thicker than water

• 8 % of total body weight

• Blood volume
» 70 mL/kg of body weight
» 5 - 6 liters in males
» 4 - 5 liters in females

• pH - 7.35 to 7.45
 Functions
1. Respiratory
 Transport O2 from lungs to tissues
 Transport CO2 from tissues to lungs

• 2. Nutrition
 Transport “food” from gut to tissues

• 3. Excretory
 Transport waste from tissues to kidney (urea, uric acid)

• 4. Protective
 White blood cells , antibodies, antitoxins.
 Functions
5. Regulatory

regulate body temperature

 regulate pH through buffers
 vasodilatation of surface vessels dump heat
 regulate water content of cells by interactions with dissolved
ions and proteins

6. Body Temperature
 Water- high heat capacity, thermal conductivity, heat of
vaporization
 Typical heat generation is 3000 kcal/day
 Peripheral Blood

• About 55% of blood is liquid

• The liquid portion of blood
(before clotting) = plasma
• The liquid portion of blood
(after clotting) = serum
• The cellular part of blood (45%
of volume) is made up of a
variety of different cell types
• The hematocrit (Hct) measures
the volume occupied by the cells
in the blood
Blood composition
 Plasma
• Straw colored clear liquid
• Contains 90% water
• 7% plasma proteins
 created in liver
 confined to bloodstream
 albumin
 maintain blood osmotic pressure
 immunoglobulins
 antibodies bind to foreign
substances called antigens
 form antigen-antibody complexes
 fibrinogen
 for clotting
• 2% other substances
 Nutrients, electrolytes, gases, hormones, waste products
 Cellular Components of Blood
• Erythrocytes
– Also called red blood cells
(RBCs)
• Leukocytes
– Also called white blood cells
(WBCs)
– 5 majors types:
• Neutrophils (60%)
• Lymphocytes (30%)
• Monocytes (7%)
• Eosinophils (2%)
• Basophils (1%)
• Platelets
– Also called thrombocytes
 Normal Ranges
 RBC: Female 3.6-5.0x106mm3
Male 4.2-5.4x106mm3

 WBC: 4.5-10.5x103mm3

 HCT: female 36-48% male 42-52%

 Hb: female 12-16 g/dL male 14-17.4 g/dL

 Platelets: 140-400x103mm3
 Types of Leukocytes
• Neutrophil:
– Active Phagocyte & 1st Responder
– Increase in number during infection

• Eosinophil: Kill larger parasites + allergins

• Basophils: Cause Infection Response

– Release Histamine  Dilating Blood
Vessels
• Lymphocytes:
– B = produce antibodies
– T = respond to antibodies on foreign
tissue

• Monocytes:
– Largest + Most Active phagocytes
– Used for chronic, widespread infections
 Functions of neutrophils
1. First line of defence against invading micro-organisms.

2. Powerful and effective killer machine – contains enzymes

like protease, elastase, metalloproteinase, NADPH oxidase;
antibody like substances called defensins.
Defensins – antimicrobial peptides active against bacteria
and fungi.

3.Secrete Platelet Aggregation Factor (PAF) – accelerates the

aggregation of platelet during injury to the blood vessels
 Functions of eosinophils
Secrete lethal substances at the time of exposure to foreign
proteins/parasites

1. Eosinophill peroxidase – detroy worms, bacteria and

tumor cells.

2. Major basic protein – damage parasites

3. Eosinophill cationic protein (ECP)- destroys helminths.

4. Eosinophill derived neurotoxin – destroys nerve fibres

(myelinated nerve fibres)
 Functions of basophils
Basophill granules release some important substances like –

1. Histamine – Acute hypersensitivity reaction- vascular changes, increase

capillary permeability

2. Heparin – prevents intravascular blood clotting

3. Hyaluronic acid – necessary for deposition of ground substances in

basement membrane

4. Proteases – exaggerate inflammation

• Basophill have IgE receptor – hypersensitivity reaction

 Thrombocytes (Platelets)
• Platelets – the smallest of the solid components of the
blood

• Responsible for the clotting process

• Coagulation: term for clotting

• Embolism: a blood clot which is moving through the body

 Functions of Platelets
1. Blood clotting

2. Clot retraction

3. Defence mechanism

4. Homeostasis

5. Repair and rupture of blood vessel

 Blood Types
 Four Major Groups
A B AB O

 Blood types are inherited from your parents

 Antigen is present on the red blood cell; typing is done

w/rbc

 Antibody is present in the plasma; antibody screening

done on plasma
 Blood Types
 O negative
Universal donor
It carries no antigen

 AB positive
Universal recipient
It carries no antibodies in the plasma

 43% of population are O, 42% A, 12% B and

3% AB
 ABO & Rh compatibility
 Blood is classified according to the presence of these
antigens:
 Group A contains antigen A
 Group AB contains both antigens
 Group O contains neither antigen

 Blood plasma contains antibodies against the opposite

antigen:
 A person with Type A blood has antibodies against the B
antigen
 A person with Type AB blood has no antibodies
(Universal Recipient)

 A person with Type O blood has antibodies against the A,

B & AB antigens (Universal Donor)
 Hematological Symptoms
• Neutropenia—defined as ANC<1000/mm3
• Anemia--↓RBC & Hgb
• Thrombocytopenia—low PLT <100,000
• Leukopenia—decrease in WBC, below the
lower limit
• Pancytopenia-an abnormal deficiency in all
blood cells, RBC, WBC, & PLT; usually
associated with bone marrow tumor or with
aplastic anemia)
 Anemia
• Is a condition in which the hemoglobin concentration is lower
than normal (low RBCs).

• As a result, the amount of oxygen delivered to the tissue is lower

than normal.

• It is not a disease but a sign of underlying disorders.

 Anemia
Ertyhropoiesis:

• Is the production Of RBC in the bone marrow

• When RBCs are low, the kidney releases erythropoietin to

stimulate the bone marrow to produce more RBCs

• People who lve at high at high altitudes with lower atmospheric

concentration, have more erythropoietin level in their bodies.

• Bone marrow required substances to produce RBCs which

include: Iron, Vit B12 &6, flote, proteins, and others.

•
 Anemia
• Type of RBC Disease/Disorder

• Cause:
–Low RBC count
–Low hemoglobin concentration
–Deformed RBC

• Result:
–Decreased Oxygen availability
 Iron-Deficiency Anemia
Etiology: Inadequate dietary intake, malabsorption, blood loss, or hemolysis
Clinical Manifestations:
– Pallor
– Glossitis – inflammation of the tongue
– Cheilitis – inflammation of the lips
– Headache, paresthesia, burning sensation of the tongue

Diagnostic Studies: Lab Studies, Endoscopy to identify GI bleed

Treatment:
• Oral Iron replacement (Iron absorbed best in duodenum)
• Ferrous sulfate – take about one hour prior to meal

Nursing Management – Diet & Medication Instruction

• Special Case = Sickle Cell Anemia
– Deformed RBC does not allow Oxygen to bind
– Sickled cells can also clog blood vessels

• Treatments:
– Iron & Vitamin Supplements
– Blood Transfusions / Bone Marrow Transplant
– Goal  Solve & Fix Underlying Problem, not
“cover up”
 Thalassemia
Genetic disorder of inadequate production of normal hemoglobin
– Hemolysis occurs
– Abnormal Hb synthesis
– Ethnic groups of Mediterranean Sea & near equatorial regions of Asia and
Africa
Clinical Manifestation:
– mild – moderate anemia with hypochromia (pale cells) or microcytosis (small
cells)
– Minor: one thalassemic gene – mild
– Major: two thalassemic genes – severe – physical & mental growth retarded -
cardiac failure is fatal
Medical Management:
– Medication: Chelation Therapy IV deferoxamine (Desferal) – iron binding
agent to reduce iron overload
– Transfusions to maintain Hg >10g/dl

Nursing Management: Supportive

 Anemia of Chronic Disease
• Associated with underproduction of RBCs and decreased RBC
survival
• Causes: Renal failure; advanced liver cirrhosis; chronic
inflammation; malignancy; immunosuppression
• Medical Management:
– Correct underlying disorder
– Erythropoietin Therapy – Epogen, Procrit
• Nursing Management: Care of the debilitated patient – dietary &
medication compliance
 Anemia Caused by Blood Loss
• Acute Blood Loss
– Hemorrhage
• Chronic Blood Loss
– Body maintains its blood volume by slowly increasing plasma volume < RBCs

• Clinical Manifestations:
– Range from fatigue with melena to orthostatic BP changes to shock

• Medical Management:
– Treat underlying cause –
– Blood replacement – packed RBCs
– Supplemental Iron
 Diseases of Erythrocytes
• Polycythemia
– Overproduction of erythrocytes.
• Occurs in patients > 50 years old or with secondary
dehydration.
• Most deaths due to thrombosis
– Results in bleeding abnormalities:
• Epistaxis, spontaneous bruising, GI bleeding.
– Management:
• Follow general treatment guidelines.
 Diseases of Leukocytes
• Leukopenia/Neutropenia
– Too few white blood cells or neutrophils.
– Follow general treatment guidelines and
provide supportive care.
• Leukocytosis
– An increase in the number of circulating white
blood cells, often due to infection.
• Leukemoid reaction
 Diseases of Leukocytes
• Lymphomas
– Cancers of the lymphatic system
• Hodgkin's
• Non-Hodgkins
– Presentation
• Swelling of the lymph nodes
• Fever, night sweats, anorexia, weight loss, fatigue, and pruritis
– Management
• Follow general treatment guidelines.
• Utilize isolation techniques to limit risk of infection.
 CVS

Ilker Gelisen 2020

 Symptoms that may indicate
cardiovascular problems
• Heart rhythym problems ( heart to beat too fast, too
slow or irregularly… bradycardia, tachycardia...)
• Chest pain
• Cyanosis (bluish or purplish discolouration of the
skin or mucous membranes)
• Dyspnea (shortness of breath, air hunger)
• Edema (swelling)
• Pallor (pale appearance)
• Palpitation (feeling or sensation that your heart is
pounding or racing.)
 Ischaemic Heart Diseases
• This is a generic name for a group of
closely related syndromes that result from
myocardial ischaemia.
• In over 90%, this is due to a reduction in
coronary blood flow. (Decrease in supply)
• Other conditions arise as a result of
increases in demand e.g. hypertrophy,
shock, increase heart rate, etc.
 Risk factors

MODIFIABLE UNMODIFIABLE
- Increased age
– Smoking
- Gender (male)
– Obesity - Ethnicity
– Diet -Family History
– No exercise -Diabetes?

– Hypercholesterolaemia
– Hypertension
– Diabetes?
ATHEROSCLEROSIS

START

END
Atherosclerosis
 Angina Pectoris
• Episode of chest pain or pressure due to
insufficient artery flow of oxygenated
blood.
• Myocardial 02 demand exceeds 02 supply.
Coronary Artery Disease (CAD) is the most
common cause.
• One coronary artery branch becomes
completely occluded; therefore, 02 is not
perfused to the myocardium, resulting in
transient ischemia and subsequent
retrosternal pain.
 Myocardial Infarction
• Leading cause of death in US
• Thrombosis in atherosclerotic artery causes
90% of MIs.
• A region of the myocardium is abruptly
deprived of blood supply due to restricted
coronary blood flow
• Ischemia results and may lead to necrosis
within 6 hours
 Gender Differences in MI
Females, when compared to males:
-present with MI later in life
-have poorer prognosis and high morbidity
-are 2x as likely to die in the first weeks
-are more likely to die from the first MI
-have higher rates of unrecognized MI
-NSTEMI MI vs STEMI
 Heart Failure
• At first the heart tries to make up for this by:
• Enlarging. When your heart chamber enlarges, it stretches more and
can contract more strongly, so it pumps more blood. With an enlarged
heart, your body starts to retain fluid, your lungs get congested with
fluid and your heart begins to beat irregularly.
• Developing more muscle mass. The increase in muscle mass occurs
because the contracting cells of the heart get bigger. This lets the heart
pump more strongly, at least initially.
• Pumping faster. This helps to increase the heart's output.
• The body also tries to compensate in other ways:
• The blood vessels narrow to keep blood pressure up, trying to make up
for the heart's loss of power.
• The body diverts blood away from less important tissues and organs
(like the kidneys), the heart and brain
Symptoms X
 Left-sided cardiac failure
– Left ventricle unable to pump blood that enters
from the lungs
– Characteristics:
• Dyspnea
• Moist sounding cough
• Fatigue
• Tachycardia
• Restlessness
• Anxiety
 Right-sided cardiac failure
– Right side of heart cannot empty blood received from
venous circulation
– Characteristics:
• Edema of lower extremities (pitting edema)
• Weight gain
• Enlargement of liver (hepatomegaly)
• Distended neck veins
• Ascites
• Anorexia
• Nocturia
• Weakness
 Signs and symptoms
left Ventricular Failure X
– fatigue
– Anxiety
– Orthopnea is shortness of breath (dyspnea) that occurs
when lying flat, causing the person to have to sleep
propped up in bed or sitting in a chair
– Dysnea shortness of breath
– Crepitations, or rales are the clicking, rattling, or
crackling noises that may be made by one or
both lungs of a human with a respiratory
disease during inhalation. They are often heard only
with Stethoscope.
 Mitral Valve Prolapse
• Defined
– Drooping of one or both cusps of the mitral
valve back into the left atrium during
ventricular systole
• Results in incomplete closure of the valve and mitral
insufficiency
 Myocarditis
• Defined
– Inflammation of the myocardium
• May be viral or bacterial infection
• May be result of systemic disease
• May be caused by fungal infections, serum sickness,
or chemical agent
 Pericarditis
• Defined
– Inflammation of the pericardium (saclike
membrane) that covers the heart muscle
• May be acute or chronic
 Endocarditis
• Defined
– Inflammation of the membrane lining of the valves
and chambers of the heart
• Caused by direct invasion of bacteria or other organisms
• Leads to deformity of valve cusps
 Rheumatic Fever
• Defined
– Inflammatory disease that may develop as a
delayed reaction to insufficiently treated Group A
beta-hemolytic streptococcal infection of the upper
respiratory tract
– Rheumatic fever can cause permanent damage to
the heart, including damaged heart valves and heart
failure. Treatments can reduce tissue damage from
inflammation, lessen pain and other symptoms, and
prevent the recurrence of rheumatic fever.
 Sinus Tachycardia
• Rate above 100 beats/minute
• The rhythm is regular
• All intervals are within normal limits
• There is a P for every QRS and a QRS for every P
• The P waves all look the same
• Caused by fever, stress, caffeine, nicotine, exercise, or by
increased sympathetic tone
• Treatment is to take care of the underlying cause
 Sinus Bradycardia
• Rate is lower than 60 beats/minute
• The rhythm is regular
• All intervals are within normal limits
• There is a P for every QRS and a QRS for every P
• The P waves all look the same
• Caused by beta-blocker, digitalis, or calcium channel blockers.
Normal for athletes
• Don’t treat unless there are symptoms. Can use pacing or
atropine
 Sinus Arrhythmia
• Rate is between 60 and 100 beats/minute
• The rhythm is irregular. The SA node rate can increase or
decrease with respirations
• All intervals are within normal limits
• There is a P for every QRS and a QRS for every P
• The P waves all look the same
• More common in children and athletes
• Ask the patient to stop breathing and the rate will become regular
Premature Atrial Contraction (PAC)

• Can occur at any rate

• The rhythm is irregular because of the early
beat but is regular at other times
• All intervals can be within normal limits
• There is a P for every QRS and a QRS for
every P
• The P waves all look the same except the P
in front of the PAC will be different
 Supraventricular Tachycardia
(SVT)

• Rate is between 150 and 250 beats/minute

• The rhythm is regular
• QRS intervals can be within normal limits
• There can be a P wave, but more likely it will be hidden
in the T wave or the preceding QRS wave
• Starts and stops abruptly
 Atrial Fibrillation

• Atrial rate is between 350 and 600

beats/minute; ventricular rate can vary
• The rhythm is irregular
• There is no PR interval; QRS may be
normal
• There are many more f waves then QRS
• Unlike flutter where the f wave will appear
the same, in fib the f waves are from
different foci so they are different
 Atrial Flutter
• Atrial rate is between 250 and 350 beats/minute.
Ventricular rate can vary
• The rhythm is regular or regularly irregular
• There is no PR interval. QRS may be normal
• 2:1 to 4:1 f waves to every QRS
• There are no P waves; they are now called flutter waves
• Problem: Loss of atrial kick and ventricular conduction is
too fast or too slow to allow good filling of the ventricles
 Ventricular Tachycardia

• Impulse is initiated from the ventricle itself

• Wide QRS, Rate is 140-250
• Nonsustained ventricular tachycardia needs no treatment
 Ventricular Fibrillation

• Most common in acute MI, also drug overdose,

anesthesia, hypothermia & electric shock can
precipitate
• Absence of ventricular complexes
• Usually terminal event
 Aneurysm
• Defined
– Localized dilatation of an artery formed at a
weak point in the vessel wall
• Weakened area balloons out with each pulsating of
artery
 Arteriosclerosis
• Defined
– Arterial condition in which there is thickening,
hardening and loss of elasticity of the walls of
arteries (hardening of the arteries)
• Results in decreased blood supply, especially to lower
extremities and cerebrum
 Blood Pressure
• Blood Pressure
– Pressure exerted by blood on walls of arteries
• Systolic Pressure
– Maximum pressure reached within the ventricles
• Diastolic Pressure
– Minimum pressure reached within the ventricles
• Sphygmomanometer = blood pressure cuff
– Used to measure blood pressure
 Control of Blood Pressure:

Humoral Factors
Vasoconstrictors
Angiotensin II Vasodilators
Blood Volume Catecholamines Pg & Kinins
Na+, Aldosterone

Cardiac Peripheral
BP
Output Resistance
Cardiac Factors
Rate & Contract.. Neural Factors Local Factors
Adrenergic – Cons pH, Hypoxia
ß Adrenergic - Dil
 SYSTEMIC HYPERTENSION

Elevated arterial blood pressure

is a major cause of premature
vascular disease leading to
cerebrovascular events,
ischaemic heart disease and
peripheral vascular disease.
 Systemic HTN - Pathophysiology

Desmukh, et al. Pathophysiology of Heart Disease, Ch 13. 1997

 Renovascular HTN -
Pathophysiology
• Decrease in renal perfusion pressure activates RAAS, renin
release converts angiotensinogen Ang I; ACE converts
Ang I Ang II
• Ang II causes vasoconstriction (among other effects)
which causes HTN and enhances adrenal release of
aldosterone; leads to sodium and fluid retention
• Contralateral kidney (if unilateral RAS) responds with
diuresis/ Na, H2O excretion which can return plasma
volume to normal
 Renin-Angiotensin-Aldosterone System
• Angiotensin II
1. Stimulates aldosterone production
2. Stimulates ADH secretion from pituitary
3. Highly potent vasoconstrictor
4. Stimulates thirst
5. Stimulates release of catecholamines by
adrenal medulla
 Regulation of Aldosterone
• Angiotensin II and III stimulate aldosterone release
• Changes in volume ( long Negative feedback loop)
• Inhibition of renin secretion by angiotensin II (short
negative feedback loop)
• Endothelin and vasopressin stimulate aldosterone
secretion
• ANP is a potent inhibitor, dopamine also inhibits it.
sphygmomanometer
• Predisposing Factors for HTN
Hereditary Predisposition (Family History)
• Sodium intake
• Weight
• Diabetes Mellitus
• Alcohol Consumption
• Smoking
• Serum Lipid Levels (Cholesterol and LDL)
• Sedentary Lifestyle
• Ethnicity
• Age
• Gender
• Socioeconomic Status
• Stress
 REGULATION OF BLOOD PRESSURE

• Baroreceptor reflex – changes in arterial pressure – medulla

(brain stem)
• Location : left and right carotid sinuses, aortic arch
• Renin – angiotensin system (RAS)
• Long – term adjustment of arterial pressure
• Kidney - compensation
• Endogenous vasoconstrictor – angiotensin I
• Aldosterone release (adrenal cortex)
• Stimulates sodium retention and potassium excretion by
the kidney
• Increases fluid retention and indirectly arterial pressure
 HYPERTENSION

• Chronic medical condition in which blood pressure is

elevated

• Systemic, arterial hypertension

• Essential (primary) hypertension

• Secondary hypertension
 pathophysiology

• Inability of the kidneys to excrete sodium

• An overactive renin – angiotensin system,

vasoconstriction and retention of sodium and
water – hypertension

• An overactive sympathetic nervous system

 Classification of Hypertension

• Primary (Essential) Hypertension

- Elevated BP with unknown cause
- 90% to 95% of all cases
• Secondary Hypertension
- Elevated BP with a specific cause
- 5% to 10% in adults
 PRIMARY HYPERTENSION

No medical cause

Risk factors :
 Sedentary lifestyle
 Obesity ( body mass index greater than 25)
 Salt ( sodium) sensitivity
 Alcohol, smoking
 Family history
 SECONDARY HYPERTENSION

• High blood pressure is a result of another condition

• Adrenal cortical abnormalities :
– Cushing’s syndrome ( adrenal glands overproduce the hormone cortisol)
– More than 85 % of patients with Cushing’s syndrome have hypertension
– Primary aldosteronism ( overproduction of aldosterone by adrenal glands)
– Aldosteronism causes sodium and water retention, potassium excretion in the
kidneys - arterial hypertension

• Diseases of the kidney (polycystic kidney disease – genetic disorder of

the kidneys)
• Diseases of the renal arteries supplying the kidney –
RENOVASCULAR HYPERTENSION
• Neuroendocrine tumors (pheochromocytoma)
• Medication side effects (NSAID)
 Blood Pressure Ranges
• Normal blood pressure range < 120/80
• Pre-Hypertension >120/80 but <140/90
• Hypertension - >140/90
• Both systolic and diastolic pressures do not
have to be out of range
• Only Systolic or Diastolic must be out of
range to qualify as hypertension
COMPLICATIONS OF HYPERTENSION
 Target Organs
• CVS (Heart and Blood Vessels)
• The kidneys
• Nervous system
• The Eyes
 (3) Target Organ Damage
• Heart
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
• Brain
Stroke or transient ischemic attack
• Chronic kidney disease
• Peripheral arterial disease
• Retinopathy
Urinary System
 Urologic Disorders
• Urolithiasis
• Urinary tract infections
• Benign Prostatic Hyperplasia
 Urolithiasis
• The process of forming stones in the kidney,
bladder, and/or urethra.
• The development of the stones is related to
decreased urine volume or increased excretion of
stone-forming components such as calcium,
oxalate, urate, cystine, xanthine, and phosphate.
The stones form in the urine collecting area (the
pelvis) of the kidney and may range in size from
tiny to staghorn stones the size of the renal pelvis
itself.
 Urolithiasis

• Signs & Symptoms

First sym severe pain
• Other sym
• nausea and vomiting,
frequency,
• chills,
• fever,
• hematuria
 Urolithiasis
Management
• Conservative
– Hydration
– Analgesia
– Antiemetic
– Stones (<5mm ) >90% spontaneous Passage
• Indication for admission
– Renal impairment
– Refractory pain
– Pyelonephritis
– intractable N/V
 Urolithiasis
Management
• Shock Wave lithotripsy (SWL)
• Ureteroscopy
• Percutaneous Nephrolithotripsy (PNL)
• Open Sx
 Hydronephrosis
• Hydronephrosis is a "stretching" or
dilation of the inside, or collecting
part, of the kidney.
• It often results from a blockage in the
ureter where it joins the kidney that
prevents urine from draining into the
bladder.
• Urine is trapped in the kidney and
causes it to stretch.
• Hydronephrosis may also be due to
abnormal backwash or "reflux" of
urine into the bladder.
 Urinary Tract Infection (UTI)
Pathophysiology
1. Pathogens which have colonized urethra, vagina, or
perineal area enter urinary tract by ascending mucous
membranes of perineal area into lower urinary tract
2. Bacteria can ascend from bladder to infect the kidneys
3. Classifications of infections
• a. Lower urinary tract infections: urethritis,
prostatitis, cystitis
• b. Upper urinary tract infection: pyelonephritis
(inflammation of kidney and renal pelvis)
Cystitis
• Cystitis is the medical
term for inflammation of
the bladder. Most of the
time, the inflammation is
caused by a bacterial
infection, and it's called a
urinary tract infection
(UTI). A bladder infection
can be painful and
annoying, and it can
become a serious health
problem if the infection
spreads to kidneys
 Cystitis/Symptoms
Cystitis signs and symptoms often include:
• A strong, persistent urge to urinate
• A burning sensation when urinating
• Passing frequent, small amounts of urine
• Blood in the urine (hematuria)
• Passing cloudy or strong-smelling urine
• Pelvic discomfort
• A feeling of pressure in the lower abdomen
• Low-grade fever
 Pyelonephritis
• Kidney infection
(pyelonephritis) is a
type of urinary tract
infection (UTI) that
generally begins in
urethra or bladder and
travels to one or both
of the kidneys..
 Pyelonephritis
• Acute pyelonephritis is a sudden and severe kidney
infection. It causes the kidneys to swell and may
permanently damage them. Pyelonephritis can be life-
threatening.
• When repeated or persistent attacks occur, the condition is
called chronic pyelonephritis. The chronic form is rare, but
it happens more often in children or people with urinary
obstructions.
Manifestations
• 1. Rapid onset with chills and fever
• 2. Malaise
• 3. Vomiting
• 4. Flank pain
• 5. Costovertebral tenderness
• 6. Urinary frequency, dysuria
 (UTI) Prevention
Nursing Care: Health promotion to prevent UTI
a. Fluid intake 2 – 2.5 L daily, more if hot weather or strenuous
activity is involved
b. Empty bladder every 3 – 4 hours
c. Females
• 1. Cleanse perineal area from front to back
• 2. Void before and after sexual intercourse
• 3. Maintain integrity of perineal tissues
– a. Avoid use of commercial feminine hygiene products or
douches
– b. Wear cotton underwear
– d. Maintain acidity of urine (use of cranberry juice, take
Vitamin C, avoid excess milk and milk products, sodium
bicarbonate)
 Glomerulonephritis
• is inflammation of glomeruli.
• Acute or chronic nephritis that involves
inflammation of the capillaries of the
renal glomeruli, has various causes (such as
streptococcal infection, lupus, or vasculitis) or
may be of unknown cause, and is marked
especially by blood or protein in the urine and
by edema, and if untreated may lead to kidney
failure
 Benign Prostatic Hyperplasia
(BPH)

• BPH is a nonmalignant enlargement of the prostate gland

caused by cellular hyperplasia of both glandular and
stromal elements that leads to troublesome lower urinary
tract symptoms (LUTS) in some men

• It is the most common benign tumor in men and is not a

precancerous condition
 Pathophysiology of Clinical BPH: Predictive
Risk Factors

• Increasing age
• Prostatic enlargement
• Lower-urinary-tract symptoms (LUTS)
• Decreased urinary flow rate
• Elevated prostate-specific antigen (PSA)

Slide I.4
 Definitions
Enuresis Glycosuria Nocturia Polyuria

Bedwetting Sugar in Frequent Large

urine urination at amounts of
night urine
 Definitions Continues
Pyuria Anuria Hematuria Diuretic

Pus in No urine Blood in Drug or

urine produced urine substance to
increase
urine
production
Questions?