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SECTION I Pathophysiology: Background and Overview, 1

CHAPTER 1 Introduction to Pathophysiology, 1

CHAPTER 2 Fluid, Electrolyte, and Acid-Base Imbalances, 14

CHAPTER 3 Introduction to Basic Pharmacology and Other Common Therapies, 40

CHAPTER 4 Pain, 53

SECTION II Defense/Protective Mechanisms, 65

CHAPTER 5 Inflammation and Healing, 65

CHAPTER 6 Infection, 88

CHAPTER 7 Immunity, 114

SECTION III Pathophysiology of Body Systems, 142

CHAPTER 8 Skin Disorders, 142

CHAPTER 9 Musculoskeletal System Disorders, 161

CHAPTER 10 Blood and Circulatory System Disorders, 184

CHAPTER 11 Lymphatic System Disorders, 213

CHAPTER 12 Cardiovascular System Disorders, 223

CHAPTER 13 Respiratory System Disorders, 272

CHAPTER 14 Nervous System Disorders, 325

CHAPTER 15 Disorders of the Eyes, Ears, and Other Sensory Organs, 385

CHAPTER 16 Endocrine System Disorders, 400

CHAPTER 17 Digestive System Disorders, 427

CHAPTER 18 Urinary System Disorders, 488

CHAPTER 19 Reproductive System Disorders, 514

SECTION IV Factors Contributing to Pathophysiology, 545

CHAPTER 20 Neoplasms and Cancer, 545

CHAPTER 21 Congenital and Genetic Disorders, 565

CHAPTER 22 Complications of Pregnancy, 579

CHAPTER 23 Complications of Adolescence, 588

CHAPTER 24 Complications of Aging, 597

Section V Environmental Factors and Pathophysiology, 606

CHAPTER 25 Immobility and Associated Problems, 606

CHAPTER 26 Stress and Associated Problems, 611

CHAPTER 27 Substance Abuse and Associated Problems, 617

CHAPTER 28 Environmental Hazards and Associated Problems, 624

Appendices, 631

Glossary, 654

Index, 663

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GOULD’S Pathophysiology for the Health Professions

SIXTH EDITION

Robert J. Hubert, BS Laboratory Coordinator Iowa State University Department of Animal Sciences Ames, Iowa

Karin C. VanMeter, PhD Independent Consultant, Biomedical

Sciences Ames, Iowa

3251 Riverport Lane St. Louis, Missouri 63043

GOULD’S PATHOPHYSIOLOGY FOR THE HEALTH PROFESSIONS, SIXTH EDITION

ISBN: 978-0-323-41442-5

Copyright © 2018, 2014, 2011, 2006, 2002, 1997 by Saunders, an imprint of Elsevier Inc.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions

Senior Content Development Manager: Luke Held Content Development Specialist: Jennifer Wade Publishing Services Manager: Julie Eddy Senior Project Manager: Richard Barber Design Direction: Brian Salisbury

Printed in Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Notices

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

ISBN: 978-0-323-41442-5

http://www.elsevier.com/permissions
We would like to dedicate this book to the memory of Barbara E.

Gould, MEd. We hope that this book, the legacy of her work, will

instill her passion for teaching and learning and will continue to

inspire health profession students and educators worldwide.

Robert Hubert Karin VanMeter

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vii

Reviewers

Julie Alles, MSCTE, RHIA Assistant Professor/Program Director Health

Information Management Allied Health Sciences Grand Valley State University Grand Rapids, Michigan

Zoe Atamanchuk Canada

Janet Ballard, Med., BSN, RN Director of Allied Health and Practical Nursing EHOVE Adult Career Center Allied Health Department Milan, Ohio

Jason Berry, MSN, RN Nursing Instructor Nursing Department Winston Salem State University Winston Salem, North Carolina

Bonnie Carmack, MN, ARNP, NP Adjunct Faculty Seminole State College Department of Health Sciences Sanford, Florida

Teresa Cowan, DA, BS, MS Department Chair of Health Sciences Baker College of Auburn Hills Health Sciences Department Auburn Hills, Michigan

Heather Duval-Foote, BAS, RDMS Instructor/Clinical Coordinator Diagnostic Medical

Sonography The University of Findlay Diagnostic Services Department College of Health Professions Findlay, Ohio

Daniel F. Muñoz González, MSMLS, MLS(ASCP) CMPBT MB Assistant Professor of Medical Laboratory Sciences,

Clinical Chemistry, and Molecular Diagnostics Department of Medical Laboratory Sciences School of Health Professions Andrews University Berrien Springs, Michigan

Marina Hdeib, MA, RDMS Clinical Associate Professor School of Health Professions University of Missouri-Columbia Department of Clinical and Diagnostic Sciences Columbia, Missouri

Lily Mauer, RPh, BSc. Pharm. PEBC Registered Pharmacist Instructor NorQuest College Allied Health Careers, Faculty of Health and

Community Studies Edmonton, Alberta, Canada

Susan Stout, MHS, BS, RN Program Director of Science Baker College of Muskegon, Michigan Department of Health Science Muskegon, Michigan

viii

Preface

This textbook provides an introduction to pathophysiology for students in a variety of academic programs for the health professions at colleges and universities. Major disorders are described as well as selected additional diseases with the intention of providing information on a broad spectrum of diseases with one or more distinguish- ing features for each. It is anticipated that additional information and resources pertinent to the individual’s professional needs may be added to classroom presenta- tions and assignments. We trust that students will enjoy studying these topics and proceed with enthusiasm to more detailed studies within their individual specialties.

Organization

The textbook is organized into five major sections followed by the appendices:

Section I—Basic Concepts of Disease Processes • Introduction to pathophysiology includes medical

terminology and basic cellular changes. • Topics such as fluid, electrolyte, and acid-base imbal-

ances, basic pharmacology and pain are covered. • The core information for each topic is complemented

by the inclusion of a specific disease/condition as an immediate clinical application at the end of each chapter.

Section II—Defense/Protective Mechanisms • Topics such as inflammation and healing, infection,

and immunity are covered. • Specific areas included are a review of body defenses,

healing involved in specific trauma such as burns, basic microbiology, review of the immune system components, and mechanisms.

Section III—Pathophysiology of Body Systems • Selection of specific disorders is based on incidence

and occurrence, as well as on the need to present a variety of pathophysiological processes and etiologies to the student.

• For major disorders, information is provided on pathophysiology, etiology, clinical manifestations,

significant diagnostic tests, common treatment modali- ties, and potential complications.

• Other selected diseases are presented in less detail, but significant, unique features are highlighted.

Section IV: Factors Contributing to Pathophysiology • Normal physiological changes related to cancer,

adolescence, pregnancy, and aging, with their relevance and effect on disease processes and the treatment of the affected individual, are described.

• Specific disorders associated with cancer and the developmental stages are discussed.

Section V: Environmental Factors and Pathophysiology • Factors such as immobility, stress, substance abuse,

and environmental hazards are the major components in this section.

• Effects of the various environmental factors on the various body systems and potential complications beyond physical pathologies are discussed.

• New research and data are included as these are areas of increasing concern with regard to pathophysiology and patient health.

Appendices—additional information: • Ready References include lists of anatomic terms,

abbreviations and acronyms, a selection of diagnostic tests, an example of a medical history, a disease index, and drug index.

• A glossary and a list of additional resources complete this resource.

Format and Features

The basic format as well as the straightforward, concise approach remains unchanged from the previous editions. Some material has been reorganized to improve the flow of information and facilitate comprehension. Many features related to the presentation of information in this textbook continue as before. • Generic learning objectives are included in each chapter.

Instructors may modify or add applicable objectives for a specific professional program.

P R E FAC E ix

What’s New?

• Information on specific diseases has been updated throughout.

• The specific disorders for each body system have been expanded to reflect current trends and research.

• A broader emphasis on all allied health professions has been incorporated.

• Sections and chapters have been reorganized to present the student with a building block approach: basic science and how it relates to human biology, the body’s various mechanisms that respond to the disorders/diseases, the general overview of body systems and their specific disorders, other biological factors outside of the physiology of each system that contribute to instances of disorders/disease and, finally, those environmental factors not directly attributed to a biological function or condition that may contribute to pathophysiology throughout a number of body systems.

• Figures have been updated with new photographs and illustrations to help in the recognition and identification of the various concepts and specific disorders.

• Tables have been updated with new information that has been made available since the previous edition.

• Additional resources have been expanded and updated. • Study questions and Think About questions have been

reviewed and updated to cover new material in the chapter. The Apply Your Knowledge questions have replaced the Challenge questions in the previous editions.

• The Study Guide associated with this text has been updated to reflect the most recent information regard- ing various disorders.

Guidelines for Users

Certain guidelines were developed to facilitate the use of this textbook by students with diverse backgrounds studying in various health science programs. As well as ongoing general changes, some professional groups have developed unique practice models and language. In some disciplines, rapid changes in terminology have occurred, creating difficulty for some students. For example, current terms such as chemical dependency or cognitive impairment have many synonyms, and some of these are included to enable students to relate to a more familiar phrase. To avoid confusion, the common, traditional terminology has been retained in this text. • The recipient of care or service is referred to as a patient. • When a disease entity refers to a group of related

disorders, discussion focuses on either a typical rep- resentative of the group or on the general characteristics of the group.

• Key terms are listed at the beginning of the chapter. They are presented in bold print and defined when initially used in the chapter. Key terms are not indicated

• Cross-references are included, facilitating access to information.

• In the discussion of a particular disorder, the pathophysi- ology is presented first because this “sets the stage,” describing the basic change(s) in the body. Once the student understands the essence of the problem, he or she can easily identify the role of predisposing factors or causes and relate the resulting signs and symptoms or complications. Diagnostic tests and treatment also follow directly from the pathophysiology.

• Changes at the cellular level are included when significant.

• Brief reviews of normal anatomy and physiology are presented at the beginning of each chapter, to remind students of the structures and functions that are fre- quently affected by pathological processes. A review of basic microbiology is incorporated into the chapter on infections. Additional review material, such as the pH scale or the location of body cavities, may be found in the Appendices.

• Numerous illustrations, including flow charts, schematic diagrams, and photographs, clarify and reinforce textual information, as well as offer an alternative visual learning mode, particularly when complex processes are involved. Illustrations are fully labeled, including anatomical structures and pathologic changes. Different colors may be used in a figure to distinguish between the various stages or factors in a process.

• Tables summarize information or offer comparisons, which are helpful to the student in selecting the more significant information and for review purposes.

• Brief reference to diagnostic tests and treatment measures promotes understanding of the changes occurring during a disease.

• Questions are found in boxes throughout the text to stimulate application and review of new concepts. “Apply Your Knowledge” questions are based on review of normal physiology and its application, “Think About” questions follow each small section of informa- tion, and “Study Questions” are located at the end of each chapter. Questions may relate to simple, factual information, potential applications, or the integration of several concepts. These questions are helpful in alerting a student to points initially overlooked and are useful for student self-evaluation before proceeding to the next section. These features may also serve as a tool for review and test preparation. Brief answers are provided on the Evolve website.

• Brief, adaptable case studies with questions are incor- porated at the end of many chapters and are intended to provide a basis for discussion in a tutorial, an assignment, or an alternative learning mode. It is expected that specific clinical applications may be added by instructors for each professional group.

• Chapter summaries precede the review questions in each chapter.

x P R E FAC E

as such in subsequent chapters, but may be found in the glossary at the back of the book.

• Italics are used to emphasize significant words. • It is assumed that students have studied anatomy and

physiology prior to commencing a pathophysiology course.

• Concise, readable style includes sufficient scientific and medical terminology to help the student acquire a professional vocabulary and appropriate communica- tion skills. An effort has been made to avoid over- whelming the student with a highly technical approach or impeding the learning process in a student who comes with little scientific background.

• The presence of numeric values within textual informa- tion often confuses students and detracts from the basic concepts being presented; therefore, specific numbers are included only when they promote understanding of a principle.

• Suggested diagnostic tests and treatments are not individualized or necessarily complete but are pre- sented generally to assist the student’s application of the pathophysiology. They are also intended to provide students with an awareness of the impact of certain diseases on a client and of possible modifications in the individualized care required. Diagnostic tests increase student cognizance of the extent of data collection and sifting that may be necessary before making a diagnosis, as well as the importance of monitoring the course of a disease or the response to treatment.

• A brief introduction to pharmacology is included in Section I and specific drugs are referred to during the discussion of certain disorders. Drugs are identified by generic name, followed by a trade name. Examples provided in the appropriate chapter are not recom- mendations, but are suggested only as frequently used representatives of a drug classification. A drug index with references to the applicable chapter is located in the appendices.

• Information regarding adverse effects of drugs or other treatment is included when there may be potential problems such as high risk for infection or special precautions required of members of the health care team.

• Every effort has been made to present current informa- tion and concepts simply but accurately. This content provides the practitioner in a health profession with the prerequisite knowledge to recognize and under- stand a client’s problems and the limitations and implications of certain treatment measures; to reduce exacerbating factors; to participate in preventive programs; and to be an effective member of a health care team. The student will develop a knowledge base from which to seek additional information. Individual instructors may emphasize certain aspects or topics, as is most appropriate for students in a specialty area.

Resources

In the textbook: • Selected additional resources are listed in the appen-

dices in Ready Reference 9. • Reference tables are located inside the front book cover.

These comprise common normal values for blood, cerebrospinal fluid, and urine; a pH scale for body fluids; a list of blood clotting factors; and diagnostic tests.

• The chapter introducing pharmacology and therapeu- tics is limited in content, but combined with the brief references to treatments with individual disorders, is intended to complement the pathophysiology. This chapter also introduces a few traditional and non- traditional therapeutic modalities to facilitate the student’s understanding of various therapies and of the impact of diverse treatments on the patient and on care by all members of the health care team. Also included are brief descriptions of a few selected forms of therapy, for example, physiotherapy, in hopes of clarifying the roles of different members of a health care team.

• The appendices at the back of the textbook are intended to promote effective use of study time. They include:

• A brief review of anatomical terms describing body cavities and planes with accompanying illustrations as well as basic body movements

• Selected numerical conversions for temperature, weights, and volumes

• Lists of anatomical terms and combining forms, common abbreviations, and acronyms; because of the broad scope of pathophysiology, a medical dictionary is a useful adjunct for any student in the health-related professions

• A brief description with illustrations of common diagnostic tests such as ultrasound and magnetic resonance imaging

• An example of a medical history, which can be modified to fit the needs of a particular professional group

• A disease index, with a brief description and references to the relevant chapter

• A drug index, identifying the principal action and references to the appropriate chapters

• A list of additional resources; websites consist primarily of health care groups or professional organizations that will provide accurate information and are likely to persist. Additional specific journals and websites are available for individual professions.

• A glossary, including significant terms used to describe diseases as well as key words

• Accompanying this textbook and developed for it, the ancillaries available include: A study guide for students provides learning activities

such as complex test questions, matching exercises, crossword puzzles, diagrams to label, and other assignments

P R E FAC E xi

The interactive Evolve web site includes self-evaluation tools, and can be found at http://evolve.elsevier. com/Hubert/Goulds/

We appreciate the time and effort of reviewers and users of this text, of sales representatives, and of the editors, who have forwarded comments regarding the first four editions. We have attempted to respond to these suggestions while recognizing that comments come from a variety of perspectives, and there is a need to respect

the primary focus of this textbook, space constraints, and student concerns.

We hope that teachers and students will enjoy using this textbook, and that it will stimulate interest in the acquisition of additional knowledge in this dynamic field.

Robert Hubert Karin VanMeter

http://evolve.elsevier.com/Hubert/Goulds/
http://evolve.elsevier.com/Hubert/Goulds/
xii

Acknowledgments

The authors would like to acknowledge and dedicate this edition to the original author, Barbara E. Gould, who passed away. Dr. Gould always kept “student learning” in the forefront as the guideline for writing this book. We also would like to thank all the editorial and produc- tion staff at Elsevier for their support and encouragement. Furthermore, we would like to thank the reviewers for their valuable input.

I would first like to thank my co-author and friend Karin VanMeter. This is our third major project together and it is her continued dedication to education and professionalism that has contributed so much to the overall teamwork and fun working relationship that we enjoy. I would also like to thank Dr. Joan Cunnick and all of the faculty and staff in the microbiology program at Iowa State University for all of your encouragement and support. As with any and all challenges I have tackled in my life, I give my love and thanks to my family—my parents, John and Ann, and my sister Donna, for their unwavering love and support throughout my life. Finally, I lift up my thanks to Jesus Christ, my Lord and Savior, who makes this all possible—to Him be the glory and honor forever.

Robert J. Hubert

My special thanks goes to my co-author Rob Hubert. He has been my friend and collaborator for many years and I am looking forward to many years of working together. Without him all the projects we have done together would have lacked his incredible insight into the topics we have addressed in this new edition. I also would like to thank my mother, Theresia, and my brother, Hermann, and his family for the love, support, and understanding. To my children, Christine and Andrew—thanks for your continu- ous love.

Karin C. VanMeter

xiii

SECTION I Pathophysiology: Background and Overview, 1

CHAPTER 1 Introduction to Pathophysiology, 1 What Is Pathophysiology and Why Study It?, 1

Understanding Health and Disease, 2 Concept and Scope of Pathophysiology, 2 Beginning the Process: A Medical History, 4 New Developments and Trends, 4 Basic Terminology of Pathophysiology, 5

Introduction to Cellular Changes, 8 Terms Used for Common Cellular Adaptations,

8 Cell Damage and Necrosis, 9

CHAPTER 2 Fluid, Electrolyte, and Acid-Base Imbalances, 14

Fluid Imbalance, 15 Review of Concepts and Processes, 15 Fluid Excess: Edema, 16 Fluid Deficit: Dehydration, 20 Third-Spacing: Fluid Deficit and Fluid Excess,

21 Electrolyte Imbalances, 21

Sodium Imbalance, 21 Potassium Imbalance, 24 Calcium Imbalance, 26 Other Electrolytes, 28

Acid-Base Imbalance, 29 Review of Concepts and Processes, 29 Control of Serum pH, 30 Acid-Base Imbalance, 32

Treatment of Imbalances, 36

CHAPTER 3 Introduction to Basic Pharmacology and Other Common Therapies, 40

Pharmacology, 40 Basic Principles, 40 Drug Effects, 41 Administration and Distribution of Drugs, 42 Drug Mechanisms and Receptors, 45 Responses, 46 Drug Classifications and Prescriptions, 46

Traditional Forms of Therapy, 48 Physiotherapy, 48 Occupational Therapy, 48 Speech/Language Therapy, 48 Nutrition/Diet, 48 Registered Massage Therapy, 48

Contents

Osteopathy, 48 Chiropractic, 49

Complementary or Alternative Therapies, 49 Noncontact Therapeutic Touch, 49 Naturopathy, 49 Homeopathy, 49 Herbal Medicine, 49 Aromatherapy, 49 Asian Concepts of Disease and Healing, 49

CHAPTER 4 Pain, 53 Etiology and Sources of Pain, 53 Structures and Pain Pathways, 54 Physiology of Pain and Pain Control, 55 Characteristics of Pain, 57

Signs and Symptoms, 57 Young Children and Pain, 57 Referred Pain, 57 Phantom Pain, 57 Pain Perception and Response, 57

Basic Classifications of Pain, 59 Acute Pain, 59 Chronic Pain, 59 Headache, 59 Central Pain, 60 Neuropathic Pain, 60 Ischemic Pain, 61 Cancer-Related Pain, 61

Pain Control, 61 Methods of Managing Pain, 61 Anesthesia, 62

SECTION II Defense/Protective Mechanisms, 65

CHAPTER 5 Inflammation and Healing, 65 Review of Body Defenses, 66 Review of Normal Capillary Exchange, 67 Physiology of Inflammation, 67

Definition, 67 Causes, 67 Steps of Inflammation, 67

Acute Inflammation, 69 Pathophysiology and General Characteristics,

69 Local Effects, 70 Systemic Effects, 71 Diagnostic Tests, 71 Potential Complications, 72

xiv CO N T E N TS

Chronic Inflammation, 72 Pathophysiology and General

Characteristics, 72 Potential Complications, 73

Treatment of Inflammation, 73 Drugs, 73 First Aid Measures, 75 Other Therapies, 75

Healing, 75 Types of Healing, 75 Healing Process, 76 Factors Affecting Healing, 76 Complications Due to Scar Formation, 78

Example of Inflammation and Healing, 78 Burns, 78 Classifications of Burns, 79

CHAPTER 6 Infection, 88 Review of Microbiology, 89

Microorganisms, 89 Types of Microorganisms, 90 Other Agents of Disease, 99 Resident Flora (Indigenous Normal Flora,

Resident Microbiota), 99 Principles of Infection, 100

Transmission of Infectious Agents, 100 Host Resistance, 101 Virulence and Pathogenicity of

Microorganisms, 102 New Issues Affecting Infections and

Transmission, 102 Control of Transmission and Infection, 103

Physiology of Infection, 105 Onset and Development, 105 Patterns of Infection, 106 Signs and Symptoms of Infection, 106 Methods of Diagnosis, 107 Treatment and Antimicrobial Drugs, 107 Example of Infection: Influenza (Flu), 110

CHAPTER 7 Immunity, 114 Review of the Immune System, 115

Components of the Immune System, 115 Elements of the Immune System, 115 Immune Response, 118 Diagnostic Tests, 119 Process of Acquiring Immunity, 120 Outcome of Infectious Disease, 121 Emerging and Reemerging Infectious Diseases

and Immunity, 121 Bioterrorism, 121

Tissue and Organ Transplant Rejection, 121 Rejection Process, 122 Treatment and Prevention, 122

Hypersensitivity Reactions, 122 Type I: Allergic Reactions, 123 Type II: Cytotoxic Hypersensitivity, 126 Type III: Immune Complex

Hypersensitivity, 127 Type IV: Cell-Mediated or Delayed

Hypersensitivity, 127 Autoimmune Disorders, 128

Mechanism, 128

Example: Systemic Lupus Erythematosus, 128

Immunodeficiency, 131 Causes of Immunodeficiency, 131 Effects of Immunodeficiency, 132 Acquired Immunodeficiency Syndrome, 132

SECTION III Pathophysiology of Body Systems, 142

CHAPTER 8 Skin Disorders, 142 Review of the Skin, 143 Resident Microbial Flora, 144 Skin Lesions, 144

Diagnostic Tests, 146 Skin Inflammatory Disorders, 146

Contact Dermatitis, 146 Urticaria (Hives), 147 Atopic Dermatitis, 147 Psoriasis, 148 Pemphigus, 149 Scleroderma, 149

Skin Infections, 150 Bacterial Infections, 150 Viral Infections, 152 Fungal Infections, 154 Other Infections, 155

Skin Tumors, 157 Malignant Melanoma, 157 Kaposi Sarcoma, 158

CHAPTER 9 Musculoskeletal System Disorders, 161 Review of the Musculoskeletal

System, 162 Bone, 162 Skeletal Muscle, 164 Joints, 166 Diagnostic Tests, 166

Trauma, 167 Fractures, 167

Bone Disorders, 172 Osteoporosis, 172 Rickets and Osteomalacia, 173 Paget Disease (Osteitis Deformans), 173 Osteomyelitis, 173 Abnormal Curvatures of the Spine, 173 Bone Tumors, 174

Disorders of Muscle, Tendons, and Ligaments, 175 Muscular Dystrophy, 175 Primary Fibromyalgia Syndrome, 176

Joint Disorders, 176 Osteoarthritis, 176 Rheumatoid Arthritis, 178 Juvenile Rheumatoid Arthritis, 180 Infectious (Septic) Arthritis, 180 Gout (Gouty Arthritis), 180 Ankylosing Spondylitis, 181 Other Inflammatory Joint Disorders, 182

CHAPTER 10 Blood and Circulatory System Disorders, 184