1 - Sample - Porth's Essentials of Pathophysiology 5e 5th Edition

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To my husband, Stephen Sr., and children—Richie, Robby,
Stephen Jr., and Rachel—who always inspire me.
To those pursuing or continuing a love for healthcare,
with a special thanks for your dedication, compassion, and selflessness.
Contributors
Contributors to Essentials of Pathophysiology, Fourth Edition
Jacqueline M. Akert, RNC, MSN, WHNP-BC

Nurse Practitioner
Women’s Health Aurora Health Care
Waukesha, Wisconsin
(Chapters 40, 41 with Patricia McCowen Mehring)
Diane Book, MD
Associate Professor, Neurology
Co-Director Stroke & Neurovascular Program
Froedtert Hospital & Medical College of Wisconsin
Milwaukee, Wisconsin
(Chapter 37)
Freddy W. Cao, MD, PhD

Clinical Associate Professor
College of Nursing
University of Wisconsin–Milwaukee
(Chapters 18, 34)
Paula Cox-North, PhD, ARNP

Clinical Assistant Professor
Hepatitis & Liver Clinic
Harborview Medical Center
University of Washington School of Nursing
Seattle, Washington
(Chapters 29, 30)
Herodotos Ellinas, MD, FAAP, FACP

Assistant Professor
Department of Anesthesiology
Med–Anesthesia and PGY-1 Program Director
Medical College of Wisconsin
(Chapters 11, 12, 13)
Jason R. Faulhaber, MD
Assistant Program Director, Fellowship in Infectious Diseases
Division of Infectious Diseases, Carilion Clinic
Assistant Professor, Virginia Tech, Carilion School of Medicine
Adjunct Professor, Department of Biomedical Sciences, Jefferson College
of Health Sciences
Roanoke, Virginia
(Chapters 15, 16)
Anne M. Fink, RN, PhD

Postdoctoral Research Associate
College of Nursing
University of Illinois–Chicago
Chicago, Illinois
(Chapters 19, 20 with Karen M. Vuckovic)
Susan A. Fontana, PhD, APRN-BC

Associate Professor and Family Nurse Practitioner
College of Nursing
(Chapter 38)
Kathleen E. Gunta, MSN, RN, OCNS-C
Clinical Nurse Specialist
Aurora St. Luke’s Medical Center
(Chapter 43)
Nathan A. Ledeboer, PhD, D(ABMM)

Associate Professor of Pathology
(Chapter 14)
Kim Litwack, PhD, RN, FAAN, APNP

Associate Dean for Academic Affairs
Family Nurse Practitioner
Advanced Pain Management
(Chapter 35)
Glenn Matfin, MSc (Oxon), MB, ChB, FACE, FACP, FRCP

Medical Director
International Diabetes Center
Clinical Professor of Medicine
University of Minnesota
Minneapolis, Minnesota
(Chapters 10, 31, 32, 33, 39)
Patricia McCowen Mehring, RNC, MSN, WHNP

Nurse Practitioner
Women’s Health
(Chapters 40, 41 with Jacqueline M. Akert)
Carrie J. Merkle, PhD, RN, FAAN

Associate Professor
College of Nursing
The University of Arizona
Tucson, Arizona
(Chapters 1, 2, 3, 4, 7)
Kathleen Mussatto, PhD, RN

Nurse Scientist
Herma Heart Center
Children’s Hospital of Wisconsin
Assistant Clinical Professor of Surgery
(Chapter 19, Heart Disease in Infants and Children)
Debra Bancroft Rizzo, RN, MSN, FNP-BC

Nurse Practitioner
Division of Rheumatology
University of Michigan
Ann Arbor, Michigan
(Chapter 44)
Jonathan Shoopman, MD
Assistant Professor of Anesthesiology and Critical Care
(Chapters 22, 23)
Gladys Simandl, RN, PhD

Professor
Columbia College of Nursing
(Chapters 45, 46)
Aoy Tomita-Mitchell, PhD

Associate Professor
Department of Surgery
Children’s Research Institute
(Chapters 5, 6)
Karen M. Vuckovic, RN, PhD, ACNS-BC
Assistant Clinical Professor
College of Nursing
University of Illinois–Chicago
Chicago, Illinois
(Chapters 19, 20 with Anne M. Fink)
Jill M. Winters, RN, PhD, FAHA

President and Dean
Columbia College of Nursing
(Chapter 9)
Contributors to Porth’s Pathophysiology, Tenth Edition
Sawsan Abuhammad, PhD

Assistant Professor, Maternal and Child Health
Jordan University of Science and Technology
Irbid, Jordan
Chapter 42: Structure and Function of the Male Genitourinary System
Maeghan Arnold, MNSc, APRN, AGACNP-BC

Clinical Instructor
Practice Department
College of Nursing
University of Arkansas for Medical Sciences
Little Rock, Arkansas
Chapter 20: Disorders of Hearing and Vestibular Function
Michele R. Arwood, DNP, MSN, BSN, CNS-BC, NE-BC, CJCP

System Director, Quality and Accreditation
Baptist Memorial Health Care Corporation
Memphis, Tennessee
Chapter 8: Disorders of Fluid and Electrolyte and Acid Base Balance
Chapter 29: Structure and Function of the Respiratory System
Trina Barrett, DNP, RN, CNE, CCRN

Assistant Professor
College of Nursing
University of Tennessee Health Science Center
Memphis, Tennessee
Chapter 3: Cellular Adaptation, Injury, and Death
Cynthia Bautista, PhD, CCRN, SCRN, CCNS, ACNS-BC, FNCS

Associate Professor
Marion Peckham Egan School of Nursing and Health Studies
Fairfield University
Fairfield, Connecticut
Chapter 13: Organization and Control of Neural Function
Chapter 14: Somatosensory Function, Pain, Headache, and Temperature
Chapter 15: Disorders of Motor Function
Chapter 16: Disorders of Brain Function
Hallie Bensinger, DNP, APN, FNP-BC

Kaplan Nurse Consultant
New York, New York
Chapter 44: Structure and Function of the Female Reproductive System
Chapter 45: Disorders of the Female Reproductive System
Jami S. Brown, DHEd, RN, CNN

Assistant Professor
College of Nursing
Memphis, Tennessee
Chapter 34: Acute Kidney Injury and Chronic Kidney Disease
Melissa Brown, MS, RN

Instructional Academic Staff
College of Nursing
Chapter 43: Disorders of the Male Reproductive System
Jacqueline Rosenjack Burchum, DNSc, FNP-BC, CNE

Associate Professor
College of Nursing
Memphis, Tennessee
Chapter 21: Blood Cells and Hematopoietic System
Chapter 23: Disorders of Red Blood Cells
Kathy Diane Butler, DNP, APRN, FNP/GNP-BC, NP-C

College of Nursing
University of Memphis
Memphis, Tennessee
Chapter 49: Disorders of Musculoskeletal Function: Developmental and
Metabolism Disorders, Activity Intolerance, and Fatigue
Freddy W. Cao, MD, PhD

College of Nursing
Chapter 36: Structure and Function of the Gastrointestinal System
Chapter 37: Disorders of Gastrointestinal Function
Chapter 38: Disorders of Hepatobiliary and Exocrine Pancreas Function
Jaclyn Conelius, PhD, FNP-BC, FHRS

Associate Professor & FNP Track Coordinator
Marion Peckham Egan School of Nursing & Health Studies Fairfield
University
Chapter 28: Disorders of Cardiac Conduction and Rhythm
Herodotos Ellinas, MD, FAAP/FACP

Associate Professor
Department of Anesthesiology
Residency Program Director
Chapter 27: Disorders of Cardiac Function, and Heart Failure and
Circulatory Shock
Deena Garner, DNP, RN

Clinical Instructor
Practice Department
College of Nursing
Sandeep Gopalakrishnan, PhD

Assistant Professor
College of Nursing
Chapter 7: Stress and Adaptation
Chapter 9: Inflammation, Tissue Repair, and Wound Healing
Chapter 12: Disorders of the Immune Response
Lisa Hight, EdD

Professor of Biology
General Education–Biomedical Sciences – Biology
Baptist College of Health Sciences
Memphis, Tennessee
Chapter 51: Structure and Function of the Skin
Chapter 52: Disorders of Skin Integrity and Function
Deborah L. Hopla, DNP, APRN-BC, FAANP

Associate Professor
Director MSN/FNP and DNP Programs
Amy V. Cockcroft Leadership Fellow
Department of Nursing
School of Health Sciences
Francis Marion University
Florence, South Carolina
Chapter 46: Sexually Transmitted Infections
Teresa Kessler, PhD, RN, ACNS-BC, CNE
Professor, Kreft Endowed Chair for the Advancement of Nursing Science
College of Nursing and Health Professions
Valparaiso University
Valparaiso, Indiana
Chapter 8: Disorders of Fluid, Electrolyte, and Acid–Base Balance
Christine Paquin Kurtz, DNP

Associate Professor
Nursing and Health Professions
College of Nursing
Valparaiso University
Valparaiso, Indiana
Chapter 17: Sleep and Sleep-Wake Disorders
Elizabeth M. Long, DNP, APRN-BC, CNS

Assistant Professor
School of Nursing
Lamar University
Beaumont, Texas
Chapter 18: Disorders of Thought, Emotion, and Memory
Tracy McClinton, DNP, AG-ACNP, BC

Assistant Professor
College of Nursing
Memphis, Tennessee
Chapter 30: Respiratory Tract Infections, and Neoplasms
Chapter 31: Disorders of Ventilation and Gas Exchange
Linda C. Mefford, PhD, MSN, APRN, NNP-BC, RNC-NIC

Associate Professor of Nursing
Lansing School of Nursing and Clinical Sciences
Bellarmine University
Louisville, Kentucky
Chapter 26: Disorders of Blood Flow and Blood Pressure Regulation
Chapter 32: Structure and Function of the Kidney
Chapter 33: Disorders of Renal Function
Chapter 40: Mechanisms of Endocrine Control
Chapter 41: Disorders of Endocrine Control
Sarah Morgan, PhD, RN

College of Nursing
Chapter 47: Structure and Function of the Musculoskeletal System
Chapter 48: Disorders of Musculoskeletal Function: Trauma, Infection,
Neoplasms
Chapter 50: Disorders of Musculoskeletal Function: Rheumatic Disorders
Nancy A. Moriber, PhD, MSN, BSN, CRNA, APRN

Assistant Professor
Nurse Anesthesia
School of Nursing
Fairfield University
Chapter 11: Innate and Adaptive Immunity
Emma Murray, DNP, APRN, ACNP-BC

Assistant Professor
College of Nursing
Memphis, Tennessee
Chapter 30: Respiratory Tract Infections, Neoplasms, and Childhood
Disorders
Chapter 31: Disorders of Ventilation and Gas Exchange
Cheryl Neudauer, PhD, MEd

Faculty
Department of Biology
Minneapolis Community and Technical College
Minneapolis, Minnesota
Chapter 2: Cell and Tissue Characteristics
Stephanie Nikbakht, DNP, PPCNP-BC

Assistant Professor
College of Nursing
PNP, Division of Genetics
Le Bonheur Children’s Hospital
Memphis, Tennessee
Chapter 30: Respiratory Tract Infections, Neoplasms, and Childhood
Disorders
Alyssa Norris, MS, RD, LDN, CLC

Clinical Dietitian II
Nutrition Therapy
Le Bonheur Children’s Hospital
Memphis, Tennessee
Chapter 39: Alterations in Nutritional Status
Keevia Porter, DNP, NP-C

Assistant Professor
College of Nursing
Memphis, Tennessee
Chapter 35: Disorders of the Bladder and Lower Urinary Tract
Michelle Rickard, DNP, CPNP-AC

Assistant Professor
College of Nursing
Memphis, Tennessee
Chapter 6: Neoplasia
Archie Sims, MSN

Nurse Practitioner
Hospitalist
Palmetto Health Tuomey
Sumter, South Carolina
Chapter 1: Concepts of Health and Disease
Diane Smith, DNP, FNP-BC

Clinical Professor
Chapter 19: Disorders of Visual Function
Ansley Grimes Stanfill, PhD, RN

Assistant Professor
College of Nursing
Memphis, Tennessee
Chapter 4: Genetic Control of Cell Function and Inheritance
Chapter 5: Genetic and Congenital Disorders
Sharon Stevenson, DNP, APRN, PPCNP-BC

Clinical Assistant Professor
Practice Department
College of Nursing
James Mark Tanner, DNP, RN

BSN Program Director
UAMS College of Nursing
Chapter 25: Structure and Function of the Cardiovascular System
Janet Tucker, PhD, RNC-OB

Assistant Professor
Loewenberg College of Nursing
University of Memphis
Memphis, Tennessee
Chapter 39: Alterations in Nutritional Status
Reba A. Umberger, PhD, RN, CCRN-K

Assistant Professor
College of Nursing
Memphis, Tennessee
Chapter 10: Mechanisms of Infectious Disease
Chapter 32: Structure and Function of the Kidney
Chapter 33: Disorders of Renal Function
Melody Waller, PhD, RN

Assistant Professor
College of Nursing
Memphis, Tennessee
Chapter 44: Structure and Function of the Female Reproductive System
Chapter 45: Disorders of the Female Reproductive System
Paige Wimberley, PhD, APRN, CNS-BC, CNE

Associate Professor
College of Nursing and Health Professions
Arkansas State University
Jonesboro, Arkansas
Chapter 22: Disorders of Hemostasis
Chapter 24: Disorders of White Blood Cells and Lymphoid Tissues
Sachin Yende, MD, MS

Professor
Department of Critical Care Medicine and Clinical and Translational
Sciences
University of Pittsburgh
Pittsburgh, Pennsylvania
Chapter 10: Mechanisms of Infectious Disease
Reviewers
Jennifer Armfield, DNP, RN, ACNP-BC

School of Nursing
Northern Arizona University
Flagstaff, Arizona
Debbie Ciesielka, DEd, MSN, ANP-BC

Associate Professor, MSN Program Coordinator
Clarion University
Clarion, Pennsylvania
Karen Cooper, MSN

Assistant Professor
Research College of Nursing
Kansas City, Missouri
Catherine Hogan, PhD, MPH, RN

Assistant Professor
Catherine MacAuley School of Nursing
Maryville University
St. Louis, Missouri
Angela Jupiter-McCon, PhD

Associate Professor
Joseph and Nancy Fail School of Nursing
William Carey University
Hattiesburg, Mississippi
Katie R. Katz, DNP, FNP-BC, RN

Assistant Professor
School of Nursing
Radford University
Radford, Virginia
Keerat Kaur, PhD

Adjunct Professor
School of Nursing & Healthcare Professions
College of New Rochelle
New Rochelle, Texas
Christine Kessel, PhD, MSN, RN, CNE

Interim Dean, Professor
Trinity College of Nursing & Health Sciences
Rock Island, Illinois
Heather LaPoint, RN, MSN-Ed, CNE, CCRN-E

Assistant Professor
State University of New York at Plattsburgh
Plattsburgh, New York
Debra Marsala, DNS, ANP

Adjunct Instructor
Division of Nursing
Keuka College
Keuka Park, New York
Sandra Nash, PhD, RN

Assistant Professor
Western Illinois University
Macomb, Illinois
Catherine Pankonien, DNP, RNC-NIC

Assistant Professor
Wilson School of Nursing
Midwestern State University
Wichita Falls, Texas
Diane Ryan, PhD, AGPCNP

Associate Professor
Daemen College
Amherst, New York
Jennifer Sipe, MSN, CRNP

Assistant Professor
School of Nursing and Health Sciences
La Salle University
Philadelphia, Pennsylvania
Monica Sousa, EdD, ACNS-BC, APRN

Associate Professor
Western Connecticut State University
Danbury, Connecticut
Ann Tritak, EdD, RN

Associate Dean, DNP Program Director
School of Nursing
Felician University
Lodi, New Jersey
Renee Wenzlaff, DNP, RN

Associate Professor
School of Nursing
Milwaukee School of Engineering
Jean Yockey, PhD, FNP, RN, CNE
Assistant Professor
University of South Dakota
Vermillion, South Dakota
Preface
This book was written with the intent of presenting the subject matter of
pathophysiology as the foundation for all future studies in the health
sciences. The text provides necessary content for the beginning student to
build upon while also serving those furthering their education by
reinforcing the link between comprehending complex disease process and
clinical decision-making. This text will serve as a reference long after the
coursework is completed.
This edition considers the many technologic advances allowing health
care providers to diagnose earlier and with more accuracy. A diverse array
of contributors for Porth’s Pathophysiology, 10th Edition (from which this
Essentials book is derived)was selected based on subject expertise.
This text focuses on the scientific basis upon which the practice
components of the health professions are based. The evidence-based
information provides data for best practices, ultimately improving health
care outcomes.
A holistic conceptual framework uses body systems as an organizing
structure and demonstrates how the systems are interrelated. Selection of
content was based on common causes of morbidity and mortality across the
life span, and recent advances in the fields of genetics, epigenetics,
immunology, microbiology, and molecular biology are included. Content is
presented in a manner that is logical and understandable for students. One
goal of the new edition is to provide critical information needed to
understand complex health alterations while delivering the content in a
reader-friendly format. The chapters are arranged so that fundamental
concepts such as cellular adaptation, inflammation and repair, genetic
control of cell function and inheritance, and immunologic processes appear
in the early chapters before the specific discussions of particular disease
states.
Strengths of the text include the expanded chapters on health and disease;
nutrition; sleep and sleep disorders; and thought, emotion, and mood
disorders. Advances in health care are presented through the inclusion of
international studies, World Health Organization guidelines, updated
standards, and the health variants of diverse populations.
Organization
Many of the units have an introductory chapter that contains essential
information about the structure and function of the body systems that are
being discussed in the unit. Each such chapter provides the foundation for
understanding the pathophysiology content presented in the subsequent
chapters. The chapter outline that appears at the beginning of each chapter
provides an overall view of the chapter content and organization.
Features of This Book

This book includes the following special features to help you master the
essential content.
Objectives
Objectives appear at the beginning of each chapter to provide a focus for

your study. After you have finished each of these areas of content, you may
want to go back and make sure that you have met each of the objectives.
Learning Objectives
After completing this chapter, the learner will be able to meet the
following objectives:
1. Contrast disorders due to multifactorial inheritance with those

caused by single-gene inheritance.
2. Cite the most susceptible period of intrauterine life for development
of defects because of teratogenic agents.
3. State the cautions that should be observed when considering use of
drugs during pregnancy, including the possible effects of alcohol
abuse, vitamin A derivatives, and folic acid deficiency on fetal
development.
4. Describe the process of genetic assessment.
5. Describe screening methods used for prenatal diagnosis including
specificity and risks.
Key Terms and Glossary
To enable you to better use and understand the vocabulary of your

profession, throughout the text you will encounter key terms in bold purple.
This is a signal that a word and the ideas associated with it are important to
learn. In addition, a glossary is provided to help you expand your
vocabulary and improve your comprehension of what you are reading. The
glossary contains concise definitions of the key terms. If you are unsure of
the meaning of a term you encounter in your reading, check the glossary in
the back of the book before proceeding.
Lysosomes play an important role in the normal metabolism of certain

substances in the body. In some inherited diseases known as lysosomal
storage disorders, a specific lysosomal enzyme is absent or inactive,
preventing digestion of certain cellular substances and allowing them to
build up in cells.6 There are approximately 50 lysosomal storage
disorders, each caused by a lack of activity of one or more lysosomal
enzymes, and each disorder is rare.
Boxes
Boxes are used throughout the text to summarize and highlight key
information.
“Key Points” Boxes

One of the ways to approach learning is to focus on the major ideas or
concepts. Because health care is an applied science, it is imperative that
rather than trying to memorize a list of related and unrelated bits of
information, you understand the content and relate it to cases you encounter.
Health care providers must apply these concepts in the clinical setting,
which requires an understanding of the underlying etiology, histology,
symptoms, risk factors, and hallmark features of a particular disease. As
you have probably already discovered, it is impossible to memorize
everything that is in a particular section or chapter of the book. It has been
said that pathophysiology is a new language for many students. So not only
does your brain have to figure out where to store all the information, it must
also be able to retrieve the information when you need it. This is best
accomplished by understanding rather than memorizing information. Most
important of all, memorized lists of content can seldom, if ever, be applied
directly to an actual clinical situation. The “Key Points” boxes guide you in
identifying the major ideas or concepts that form the foundation for truly
understanding the major areas of content. When you understand the
concepts in the “Key Points” boxes, you will have a framework for
remembering and using the facts given in the text.
KEY POINTS
Cellular Adaptations
Cells are able to adapt to increased work demands or threats to

survival by changing their size (atrophy and hypertrophy), number
(hyperplasia), and form (metaplasia).
Normal cellular adaptation occurs in response to an appropriate
stimulus and ceases once the need for adaptation has ceased.
“Summary Concepts” Boxes

The “Summary Concepts” boxes at the end of each main section provide a
review and a reinforcement of the important content that has been covered.
Use the summaries to ensure that you have covered and understood what
you have read.
SUMMARY CONCEPTS
Neonates are protected against antigens in early life as a result of
passive transfer of maternal IgG antibodies through the placenta and
IgA antibodies in colostrum and breast milk. Many changes occur
with aging, but the exact mechanisms are not completely understood.
However, the elderly population is more prone to infection and
autoimmune disorders secondary to altered response in both innate
and adaptive immune function.
“Understanding” Boxes
“Understanding” boxes focus on the physiologic processes and phenomena
that form the basis for understanding disorders presented in the text. This
feature breaks a process or phenomenon down into its component parts and
presents it in a sequential manner, providing an insight into the many
opportunities for disease processes to disrupt the sequence.
UNDERSTANDING The Complement System
The complement system provides one of the major effector mechanisms

of both humoral and innate immunity. The system consists of a group of
proteins (complement proteins C1 through C9) that are normally present
in the plasma in an inactive form. Activation of the complement system
is a highly regulated process, involving the sequential breakdown of the
complement proteins to generate a cascade of cleavage products capable
of proteolytic enzyme activity. This allows for tremendous amplification
because each enzyme molecule activated by one step can generate
multiple activated enzyme molecules at the next step. Complement
activation is inhibited by proteins that are present on normal host cells;
thus, its actions are limited to microbes and other antigens that lack these
inhibitory proteins.
The reactions of the complement system can be divided into three
phases: (1) the initial activation phase, (2) the early-step inflammatory
responses, and (3) the late-step membrane attack responses.
1 Initial Activation Phase

There are three pathways for recognizing microbes and activating the
complement system: (1) the alternative pathway, which is activated on
microbial cell surfaces in the absence of antibody and is a component of
innate immunity; (2) the classical pathway, which is activated by certain
types of antibodies bound to antigen and is part of humoral immunity;
and (3) the lectin pathway, which is activated by a plasma lectin that
binds to mannose on microbes and activates the classical system pathway
in the absence of antibody.
Tables and Charts
Tables and charts are designed to present complex information in a format

that makes it more meaningful and facilitates recall of the information.
Tables, which have two or more columns, are often used for the purpose of
comparing or contrasting information. Charts, which have one column, are
used to summarize information.
TABLE 20-1 Common Disorders Affecting the Vestibular System

Type of Disorder Pathology
A noncancerous growth or tumor on the
Acoustic neuroma
vestibulocochlear nerve
Benign paroxysmal
Disorder of otoliths
positional vertigo
Dislodgement of otoliths that participate in the
Ménière disease
receptor function of the vestibular system
Repeated stimulation of the vestibular system such as
Motion sickness
during car, air, and boat travel
Acute viral or bacterial infection of the vestibular
Labyrinthitis
pathways
Dizziness or vertigo occurs with or without headache;
Vestibular migraine
related to the neurotransmitter serotonin
Illustrations and Photos
The detailed, full-color illustrations will help you to build your own mental
image of the content that is being presented. Each drawing has been
developed to fully support and build upon the ideas in the text. Some
illustrations are used to help you picture the complex interactions of the
multiple phenomena that are involved in the development of a particular
disease; others can help you to visualize normal function or understand the
mechanisms that enable the disease processes to exert their effects. In
addition, photographs provide a realistic view of selected pathologic
processes and lesions.
FIGURE 23-3 Diagrammatic representation of the iron cycle, including
its absorption from the gastrointestinal tract, transport in the
circulation, storage in the liver, recycling from aged red cells
destroyed in the spleen, and use in the bone marrow synthesis of
red blood cells.
Concept Mastery Alerts

Concept Mastery Alerts clarify fundamental nursing concepts to improve
the reader’s understanding of potentially confusing topics, as identified by
Misconception Alerts in Lippincott’s Adaptive Learning Powered by prepU.
Concept Mastery Alert

Smoking is an independent risk factor for the development of
coronary artery disease and should be avoided, but it has not been
identified as a direct cause of hypertension.
Interactive Learning Resources
Interactive learning tools available online enrich learning and are identified
with icons in the text.
Concepts in Action Animations bring physiologic and
pathophysiologic concepts to life, explaining concepts that are difficult
to understand.
Interactive Tutorials include graphics and animations and provide
interactive review exercises.
Review Exercises
The Review Exercises at the end of each chapter are designed to help you
integrate and synthesize material and to help you verify your understanding
of the material presented. If you are unable to answer a question, reread the
relevant section in the chapter. (Answers are available for instructors at
http://thepoint.lww.com/PorthEssentials5e.)
Review Exercises
1. A 32-year-old woman with diabetes is found to have a positive

result on a urine dipstick test for microalbuminuria. A
subsequent 24-hour urine specimen reveals an albumin
excretion of 50 mg (an albumin excretion >30 mg/day is
abnormal).
A. Use the structures of the glomerulus in Figure 32-5 to
provide a possible explanation for this finding. Why
specifically test for the albumin rather than the globulins or
other plasma proteins?
B. Strict control of blood sugars and treatment of
hypertension have been shown to decrease the
progression of kidney disease in person with diabetes.
Explain the physiologic rationale for these two types of
treatments.
2. A 54-year-old man, seen by his physician for an elevated blood
pressure, was found to have a serum creatinine of 2.5 and
BUN of 30. He complains that he has been urinating more
frequently than usual, and his first morning urine specimen
reveals dilute urine with a specific gravity of 1.010.
A. Explain the elevation of serum creatinine in terms of renal
function.
B. Explain the inability of people with early renal failure to
produce concentrated urine as evidenced by the
frequency of urination and the low specific gravity of his
first morning urine specimen.
Appendix
The appendix “Lab Values” provides rapid access to normal values for
many laboratory tests, as well as a description of the prefixes, symbols, and
factors (e.g., micro, μ, 10−6) used for describing these values. Knowledge of
normal values can help you to put abnormal values in context.
A Comprehensive Package for Teaching and Learning

To further facilitate teaching and learning, a carefully designed ancillary
package has been developed to assist faculty and students.
Instructor Resources
Tools to assist you with teaching your course are available upon adoption of
this text on at http://thepoint.lww.com/PorthEssentials5e.
A Test Generator features NCLEX-style questions mapped to chapter
learning objectives.
An extensive collection of materials is provided for each book chapter:
Pre-lecture Quizzes (and answers) allow you to check students’
reading.
PowerPoint Presentations provide an easy way to integrate the
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and true/false questions are included to promote class participation.
Guided Lecture Notes walk you through the chapter, learning
objective by learning objective, with integrated references to the
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Discussion Topics (and suggested answers) can be used in the
classroom or in online discussion boards to facilitate interaction with
your students.
Assignments (and suggested answers) include group, written,
clinical, and Web assignments to engage students in varied activities
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Case Studies with related questions (and suggested answers) give
students an opportunity to apply their knowledge to a client case
similar to one they might encounter in practice.
Answers to the Review Exercises in the book facilitate review of
student responses to these exercises.
Sample Syllabi are provided for 14-week and 28-week courses.
An Image Bank lets you use the photographs and illustrations from this
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An ebook serves as a handy resource.
Strategies for Effective Teaching provide general tips for instructors
related to preparing course materials and meeting student needs.
Dosage Calculation Quizzes and Drug Monographs are convenient
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Access to all Student Resources is provided so that you can understand
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Student Resources
An exciting set of free learning resources is available on to help
students review and apply vital concepts. Multimedia engines have been
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front of their textbooks.
NCLEX-Style Review Questions for each chapter help students review
important concepts and practice for NCLEX.
Interactive learning resources appeal to a variety of learning styles. As
mentioned previously in this preface, icons in the text direct readers to
relevant resources:
Concepts in Action Animations bring physiologic and
pathophysiologic concepts to life, explaining concepts that are
difficult to understand.
Interactive Tutorials include graphics and animations and
provide interactive review exercises.
Journal Articles offer access to current articles relevant to each chapter
and available in Wolters Kluwer journals to familiarize students with
nursing literature.
Learning Objectives from the book.
A Spanish–English Audio Glossary provides helpful terms and phrases
for communicating with patients who speak Spanish.
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Acknowledgments
The expertise of the contributors for Porth’s Pathophysiology, 10th Edition

(from which this Essentials book is derived) keeps the book at the forefront
of advances in science and medicine. Their attention to detail and desire to
share current, relevant, and essential information with learners are primary
strengths of the text. For the fifth edition, several chapters were merged to
improve flow of content, and chapters that include new discoveries were
added. Thanks also to Dr. Rupa Lalchandani Tuan for her time and talent in
helping to ensure the accuracy of the information and assisting in
condensing it to reflect only essential content needed to understand disease
processes.
I would like to thank Jonathan Joyce, senior acquisitions editor, for
keeping us on task so the project remained on track. Many thanks go to
Meredith Brittain, senior development editor, for her edits and comments
that kept the focus of this book consistent. I also want to thank Jennifer
Forestieri, director of product development, who stepped in to help, and
especially for all her encouragement. Thanks also to Tim Rinehart, who
provided the chapter tracking updates.
Lastly, I want to thank my family for their inspiration during this difficult
time of transition in my life. I also want to thank all the professors who
have kept in touch with me throughout this project, cheering me forward to
produce a text that is understandable yet concise and that meets the learning
needs of today’s health care professional.
Contents
UNIT 1 • Concepts of Health and Disease
Chapter 1 Concepts of Health and Disease

Concepts of Health and Disease
Health and Disease in Populations
UNIT 2 • Cell Function and Growth
Chapter 2 Cell and Tissue Characteristics

Functional Components of the Cell
Integration of Cell Function and Replication
Movement across the Cell Membrane and Membrane Potentials
Body Tissues
Chapter 3 Cellular Adaptation, Injury, and Death

Cellular Adaptation
Cell Injury and Death
Chapter 4 Genetic Control of Cell Function and Inheritance

Genetic Control of Cell Function
Chromosomes
Patterns of Inheritance
Gene Technology
Chapter 5 Genetic and Congenital Disorders
Genetic and Chromosomal Disorders
Disorders due to Environmental Influences
Diagnosis and Counseling
Chapter 6 Neoplasia
Characteristics of Benign and Malignant Neoplasms
Etiology of Cancer
Clinical Manifestations
Screening, Diagnosis, and Treatment
Childhood Cancers
UNIT 3 • Disorders of Integrative Function
Chapter 7 Stress and Adaptation

Homeostasis
Stress and Adaptation
Disorders of the Stress Response
Chapter 8 Disorders of Fluid, Electrolyte, and Acid–Base

Balance
Composition and Compartmental Distribution of Body Fluids
Sodium and Water Balance
Potassium Balance
Calcium, Phosphorus, and Magnesium Balance
Mechanisms of Acid–Base Balance
Disorders of Acid–Base Balance
UNIT 4 • Infection, Inflammation, and Immunity
Chapter 9 Inflammation, Tissue Repair, and Wound Healing

The Inflammatory Response
Tissue Repair and Wound Healing
Chapter 10 Mechanisms of Infectious Disease

Infectious Diseases
Mechanisms of Infection
Diagnosis and Treatment of Infectious Diseases
Bioterrorism and Emerging Global Infectious Diseases
Chapter 11 Innate and Adaptive Immunity

The Immune Response
Innate Immunity
Adaptive Immunity
Developmental Aspects of the Immune System
Chapter 12 Disorders of the Immune Response, Including

HIV/AIDS
Disorders of the Immune Response
Immunodeficiency Disorders
Hypersensitivity Disorders
Transplantation Immunopathology
Autoimmune Disease
Acquired Immunodeficiency Syndrome and Human
Immunodeficiency Virus
The AIDS Epidemic and Transmission of HIV Infection
Pathophysiology and Clinical Course
Prevention, Diagnosis, and Treatment
HIV Infection in Pregnancy and in Infants and Children
UNIT 5 • Disorders of Neural Function
Chapter 13 Organization and Control of Neural Function

Nervous Tissue Cells
Neurophysiology
Developmental Organization of the Nervous System
Structure and Function of the Spinal Cord and Brain
The Autonomic Nervous System
Chapter 14 Somatosensory Function, Pain, Headache, and

Temperature Regulation
Organization and Control of Somatosensory Function
Pain
Alterations in Pain Sensitivity and Special Types of Pain
Headache and Associated Pain
Pain in Children and Older Adults
Body Temperature Regulation
Increased Body Temperature
Decreased Body Temperature
Chapter 15 Disorders of Motor Function

Organization and Control of Motor Function
Disorders of the Motor Unit
Disorders of the Cerebellum and Basal Ganglia
Upper Motor Neuron Disorders
Chapter 16 Disorders of Brain Function

Manifestations and Mechanisms of Brain Injury
Traumatic Brain Injury
Cerebrovascular Disease
Infections and Neoplasms
Seizure Disorders
Chapter 17 Sleep and Sleep–Wake Disorders

Neurobiology of Sleep
Sleep Disorders
Sleep and Sleep Disorders in Children and Older Adults
Chapter 18 Disorders of Thought, Emotion, and Memory

Psychiatric Disorders
Types of Psychiatric Disorders
Disorders of Memory and Cognition
UNIT 6 • Disorders of Special Sensory Function
Chapter 19 Disorders of Visual Function

Disorders of the Accessory Structures of the Eye
Disorders of the Conjunctiva, Cornea, and Uveal Tract
Intraocular Pressure and Glaucoma
Disorders of the Lens and Lens Function
Disorders of the Vitreous and Retina
Disorders of Neural Pathways and Cortical Centers
Disorders of Eye Movement
Chapter 20 Disorders of Hearing and Vestibular Function

Disorders of the Auditory System
Disorders of Vestibular Function
UNIT 7 • Disorders of the Hematopoietic System
Chapter 21 Blood Cells and the Hematopoietic System

Composition of Blood and Formation of Blood Cells
Diagnostic Tests
Chapter 22 Disorders of Hemostasis

Mechanisms of Hemostasis
Hypercoagulability States
Bleeding Disorders
Chapter 23 Disorders of Red Blood Cells

The Red Blood Cell
Blood Types and Transfusion Therapy
Anemia
Polycythemia
Age-Related Changes in Red Blood Cells
Chapter 24 Disorders of White Blood Cells and Lymphoid

Tissues
Hematopoietic and Lymphoid Tissues
Non-neoplastic Disorders of White Blood Cells
Neoplastic Disorders of Lymphoid and Hematopoietic Origin
UNIT 8 • Disorders of Cardiovascular Function
Chapter 25 Structure and Function of the Cardiovascular

System
The Heart as a Pump
Organization of the Circulatory System
Principles of Blood Flow
The Systemic Circulation and Control of Blood Flow
The Microcirculation and Lymphatic System
Neural Control of Circulatory Function
Chapter 26 Disorders of Blood Flow and Blood Pressure

Regulation
Blood Vessel Structure and Function
Regulation of Systemic Arterial Blood Pressure
Disorders of Systemic Arterial Blood Flow
Disorders of Systemic Venous Circulation
Disorders of Blood Pressure Regulation
Chapter 27 Disorders of Cardiac Function, and Heart Failure

and Circulatory Shock
Disorders of Cardiac Function
Disorders of the Pericardium
Coronary Artery Disease
Cardiomyopathies
Infectious and Immunologic Disorders
Valvular Heart Disease
Heart Failure and Circulatory Shock
Heart Failure in Adults
Heart Disease in Infants and Children
Heart Failure in Children and Older Adults
Circulatory Failure (Shock)
Chapter 28 Disorders of Cardiac Conduction and Rhythm

Cardiac Conduction System
Disorders of Cardiac Rhythm and Conduction
UNIT 9 • Disorders of Respiratory Function
Chapter 29 Structure and Function of the Respiratory

System
Structural Organization of the Respiratory System
Exchange of Gases between the Atmosphere and the Lungs
Exchange and Transport of Gases
Control of Breathing
Chapter 30 Respiratory Tract Infections, Neoplasms, and

Childhood Disorders
Respiratory Tract Infections
Cancer of the Lung
Respiratory Disorders in Children
Chapter 31 Disorders of Ventilation and Gas Exchange

Physiologic Effects of Ventilation and Diffusion Disorders
Disorders of Lung Inflation
Obstructive Airway Disorders
Chronic Interstitial (Restrictive) Lung Diseases
Disorders of the Pulmonary Circulation
Acute Respiratory Disorders
UNIT 10 • Disorders of Renal Function
Chapter 32 Structure and Function of the Kidney

Kidney Structure and Function
Tests of Renal Function
Chapter 33 Disorders of Renal Function

Congenital and Inherited Disorders of the Kidneys
Obstructive Disorders
Urinary Tract Infections
Disorders of Glomerular Function
Tubulointerstitial Disorders
Malignant Tumors of the Kidney
Chapter 34 Acute Kidney Injury and Chronic Kidney Disease
Acute Kidney Injury
Chronic Kidney Disease
Chronic Kidney Disease in Children and Older Adults
Chapter 35 Disorders of the Bladder and Lower Urinary Tract

Control of Urine Elimination
Alterations in Bladder Function
Cancer of the Bladder
UNIT 11 • Disorders of Gastrointestinal Function
Chapter 36 Structure and Function of the Gastrointestinal

System
Structure and Organization of the Gastrointestinal Tract
Motility
Hormonal, Secretory, and Digestive Functions
Digestion and Absorption
The Gastrointestinal Immunity
Chapter 37 Disorders of Gastrointestinal Function

Common Manifestations of Gastrointestinal Disorders: Anorexia,
Nausea, and Vomiting
Disorders of the Esophagus
Disorders of the Stomach
Disorders of the Small and Large Intestines
Chapter 38 Disorders of Hepatobiliary and Exocrine

Pancreas Function
The Liver and Hepatobiliary System
Disorders of Hepatic and Biliary Function
Disorders of the Gallbladder and Exocrine Pancreas
Chapter 39 Alterations in Nutritional Status

Nutritional Status
Nutritional Needs
Overweight and Obesity
Undernutrition and Eating Disorders
UNIT 12 • Disorders of Endocrine Function
Chapter 40 Mechanisms of Endocrine Control

The Endocrine System
Chapter 41 Disorders of Endocrine Control of Growth and

Metabolism
General Aspects of Altered Endocrine Function
Pituitary and Growth Disorders
Thyroid Disorders
Disorders of Adrenal Cortical Function
General Aspects of Altered Glucose Regulation
Diabetes Mellitus and the Metabolic Syndrome
Complications of Diabetes Mellitus
UNIT 13 • Disorders of Genitourinary and Reproductive

Function
Chapter 42 Structure and Function of the Male Genitourinary

System
Structure of the Male Reproductive System
Spermatogenesis and Hormonal Control of Male Reproductive
Function
Neural Control of Sexual Function and Changes with Aging
Chapter 43 Disorders of the Male Reproductive System

Disorders of the Penis
Disorders of the Scrotum and Testes
Disorders of the Prostate
Chapter 44 Structure and Function of the Female

Reproductive System
Reproductive Structures
Menstrual Cycle
Breasts
Chapter 45 Disorders of the Female Reproductive System

Disorders of the External Genitalia and Vagina
Disorders of the Cervix and Uterus
Disorders of the Fallopian Tubes and Ovaries
Disorders of Pelvic Support and Uterine Position
Menstrual Disorders
Disorders of the Breast
Infertility
Chapter 46 Sexually Transmitted Infections

Infections of the External Genitalia
Vaginal Infections
Vaginal–Urogenital–Systemic Infections
Other Infections
UNIT 14 • Disorders of Musculoskeletal Function
Chapter 47 Structure and Function of the Musculoskeletal

System
Bony Structures of the Skeletal System
Articulations and Joints
Chapter 48 Disorders of Musculoskeletal Function: Trauma,

Infection, Neoplasms
Injury and Trauma of Musculoskeletal Structures
Bone Infections
Osteonecrosis
Neoplasms
Chapter 49 Disorders of Musculoskeletal Function:

Developmental and Metabolic Disorders, Activity
Intolerance, and Fatigue
Alterations in Skeletal Growth and Development
Metabolic Bone Disease
Activity Intolerance and Fatigue
Chapter 50 Disorders of Musculoskeletal Function:

Rheumatic Disorders
Systemic Autoimmune Rheumatic Diseases
Seronegative Spondyloarthropathies
Osteoarthritis Syndrome
Crystal-Induced Arthropathies
Rheumatic Diseases in Children and Older Adults
UNIT 15 • Disorders of Integumentary Function
Chapter 51 Structure and Function of the Skin

Structure and Function of the Skin
Chapter 52 Disorders of Skin Integrity and Function

Manifestations of Skin Disorders
Primary Disorders of the Skin
Ultraviolet Radiation and Thermal and Pressure Injuries
Nevi and Skin Cancers
Age-Related Skin Manifestations
Appendix
Glossary
Index
UNIT 1
Concepts of Health and

Disease
CHAPTER 1

Health
Disease
Etiology
Pathogenesis
Morphology and Histology
Diagnosis
Clinical Course
Epidemiology and Patterns of Disease
Incidence and Prevalence
Morbidity and Mortality
Determination of Risk Factors
Cross-Sectional and Case–Control Studies
Cohort Studies
Natural History
Preventing Disease
Evidence-Based Practice and Practice Guidelines
Learning Objectives
After completing this chapter, the learner will be able to meet the
1. Compare the World Health Organization definition of health to the

Healthy People 2020 definition.
2. Define pathophysiology.
3. Describe the process of disease to include etiology, pathogenesis,
morphologic changes, clinical manifestations, diagnosis, and clinical
course.
4. Define the term epidemiology.
5. Compare the meaning of the terms incidence and prevalence as they
relate to measures of disease frequency.
6. Differentiate primary, secondary, and tertiary levels of prevention.
7. Compare morbidity and mortality.
T he term pathophysiology, which is the focus of this book, may be

defined as the physiology of altered health. The term combines the
words pathology and physiology. Pathology (from the Greek pathos,
meaning “disease”) deals with the study of the structural and functional
changes in cells, tissues, and organs of the body that cause or are caused by
disease. Physiology deals with the functions of the human body. Thus,
pathophysiology deals not only with the cellular and organ changes that
occur with disease but also with the effects that these changes have on total
body function (Fig. 1-1). Examples of atrophy of the brain (Fig. 1-1A) and
hypertrophy of the myocardium (Fig. 1-1B) illustrate pathophysiologic
changes from a cerebrovascular accident to long-standing unmanaged
hypertension and how this impacts the myocardium. Pathophysiology also
focuses on the mechanisms of the underlying disease and provides
information to assist with planning preventive as well as therapeutic health
care measures and practices such as following a healthy diet, exercising,
and being compliant with prescribed medications. This chapter is intended
to orient the reader to the concepts of health and disease, various terms that
are used throughout the book, the sources of data and what they mean, and
the broader aspects of pathophysiology in terms of the health and well-
being of populations.
FIGURE 1-1 (A) Atrophy of the frontal lobe of the brain. The gyri are
thin and the sulci are extremely wide. (B) Myocardial hypertrophy.
This cross section of the heart illustrates left ventricular hypertrophy
because of long-standing hypertension. (From Strayer D. S., Rubin
R. (2015). Rubin’s pathology: Clinicopathologic foundations of
medicine (7th ed., p. 16). Philadelphia, PA: Lippincott Williams &
Wilkins.)
What constitutes health and disease often is difficult to determine because

of the way different people view the topic. What is defined as health is
determined by many factors, including genetics, age, gender, cultural, and
ethnic differences, as well as individual, group, and governmental
expectations. Most importantly, health is what the individual perceives it to
be, which may vary across time and the factors mentioned.
Health
In 1948, the Preamble to the Constitution of the World Health Organization
(WHO) defined health as a “state of complete physical, mental, and social
well-being and not merely the absence of disease and infirmity,” a
definition that has not been amended since that time.1 Although ideal for
many people, this was an unrealistic goal. The U.S. Department of Health
and Human Services in Healthy People 2020 describes the determinants of
health as
1. Attain lives free of preventable disease, disability, injury, and

premature death.
2. Achieve health equity and eliminate disparities.
3. Promote good health for all.
4. Promote healthy behaviors across the life span.2
Every decade, the U.S. Department of Health and Human Services leads
initiatives to facilitate the goals of the new decade in their report such as the
current Healthy People 2020. These consensus reports are developed to
specifically assist in preventing some health problems and to offer advice to
promote health as defined by the WHO.
Disease
A disease is an acute or chronic illness that one acquires or is born with and
that causes physiologic dysfunction in one or more body systems. Each
disease generally has specific signs and symptoms that characterize its
pathology and identifiable etiology. The aspects of the disease process
include etiology, pathogenesis, morphologic changes, clinical
manifestations, diagnosis, and clinical course.
Etiology
The causes of disease are known as etiologic factors. Among the

recognized etiologic agents are biologic agents (e.g., bacteria, viruses),
physical forces (e.g., trauma, burns, radiation), chemical agents (e.g.,
poisons, alcohol), one’s genetic inheritance, and nutritional excesses or
deficits.
Most disease-causing agents are nonspecific, and many different agents
can cause disease of a single organ. On the other hand, a single agent or
traumatic event can lead to disease of a number of organs or systems. For
example, in cystic fibrosis, sickle cell anemia, and familial
hypercholesterolemia, a single amino acid, transporter molecule, or
receptor protein produces widespread pathology. Although a disease agent
can affect more than a single organ and a number of disease agents can
affect the same organ, most disease states do not have a single cause.
Instead, the majority of diseases are multifactorial in origin. This is
particularly true of diseases such as cancer, heart disease, and diabetes. This
is illustrated in Figure 1-2, which traces the five causes of cancer and the
pathophysiology that evolves from the disease mechanisms triggered by the
causes. The multiple factors that predispose to a particular disease often are
referred to as risk factors.
FIGURE 1-2Summary of the general mechanisms of cancer. DNA,
deoxyribonucleic acid. (From Strayer D. S., Rubin R. (2015). Rubin’s
pathology: Clinicopathologic foundations of medicine (7th ed., p.
231). Philadelphia, PA: Lippincott Williams & Wilkins.)
One way to view the factors that cause disease is to group them into
categories according to whether they were present at birth or acquired later
in life. Congenital conditions are defects that are present at birth, although
they may not be evident until later in life or may never manifest. Congenital
conditions may be caused by genetic influences, environmental factors
(e.g., viral infections in the mother, maternal drug use, irradiation, or
gestational position in utero), or a combination of genetic and
environmental factors. Acquired defects are those that are caused by events
that occur after birth. These include injury, exposure to infectious agents,
inadequate nutrition, lack of oxygen, inappropriate immune responses, and
neoplasia. Many diseases are thought to be the result of a genetic
predisposition and an environmental event or events that serve as a trigger
to initiate disease development. There are 35,000 genes in the human
genome, 1 to 10 million proteins, and 2 to 3000 metabolites of the human
metabolome.3 Huge advances in molecular biology and the wide variability
of people have led to evolution in systems biology and personalized
medicine. This will assist in identifying the etiology of disease and in the
development of individualized interventions.3
Pathogenesis
Although etiology describes what sets the disease process in motion,

pathogenesis explains how the disease process evolves. In other words,
pathogenesis is the sequence of cellular and tissue events that take place
from the time of initial contact with an etiologic agent until the ultimate
expression of a disease. Although etiology and pathogenesis are two terms
often used interchangeably, their meanings are quite different. For example,
atherosclerosis often is cited as the etiology (or cause) of coronary artery
disease. In reality, the progression of the inflammatory process from a fatty
streak to the occlusive vessel lesion seen in people with coronary artery
disease represents the pathogenesis of the disorder. The true etiology of
atherosclerosis remains largely uncertain.
Morphology and Histology
Morphology refers to the fundamental structure or form of cells or tissues.

Morphologic changes are concerned with both the gross anatomic and
microscopic changes that are characteristic of a disease. Histology deals
with the study of the cells and extracellular matrix of body tissues. The
most common method used in the study of tissues is the preparation of
histologic sections—thin, translucent sections of human tissues and organs
—that can be examined with the aid of a microscope. Histologic sections
play an important role in the diagnosis of many types of cancer. Diagnostic
pathology has evolved greatly in the last few years to include immunologic
and molecular biologic tools for studying disease states (Fig. 1-3).4
FIGURE 1-3Granulation tissue. A photomicrograph of granulation
tissue shows thin-walled capillary sprouts immunostained to highlight
the basement membrane collagens. The infiltrating capillaries
penetrate a loose connective tissue matrix containing mesenchymal
cells and occasional inflammatory cells. (From Rubin R., Strayer D.
S. (2015). Rubin’s pathology: Clinicopathologic foundations of
medicine (7th ed., p. 113. Figure 3–9). Philadelphia, PA: Lippincott
Williams & Wilkins.)
Diseases can manifest in a number of ways. Sometimes, the condition
produces manifestations, such as fever, that make it evident that the person
is sick. In other cases, the condition is silent at the onset and is detected
during examination for other purposes or after the disease is far advanced.
Signs and symptoms are terms used to describe the structural and
functional changes that accompany a disease. A symptom is a subjective
complaint that is noted by the person with a disorder, whereas a sign is a
manifestation that is noted by an observer. Pain, difficulty in breathing, and
dizziness are symptoms of a disease. An elevated temperature, a swollen
extremity, and changes in pupil size are objective signs that can be observed
by someone other than the person with the disease. Signs and symptoms
may be related to the primary disorder, or they may represent the body’s
attempt to compensate for the altered function caused by the pathologic
condition. A syndrome is a compilation of signs and symptoms (e.g.,
chronic fatigue syndrome) that are characteristic of a specific disease state.
Complications are possible adverse extensions of a disease or outcomes
from treatment. Sequelae are lesions or impairments that follow or are
caused by a disease.
Diagnosis
A diagnosis is the designation as to the nature or cause of a health problem

(e.g., bacterial pneumonia or hemorrhagic stroke). The diagnostic process
requires a careful history, physical examination (PE), and diagnostic tests.
The history is used to obtain a person’s account of his or her symptoms and
their progression and the factors that contribute to a diagnosis. The PE is
done to observe for signs of altered body structure or function. Diagnostic
tests are ordered to validate what is thought to be the problem. They are
also performed to determine other possible health problems that were not
obtained from the history and PE, but may be present given the signs and
symptoms identified.
The development of a diagnosis involves weighing competing
possibilities and selecting the most likely one from among the conditions
that might be responsible for the person’s clinical presentation. The clinical
probability of a given disease in a person of a given age, gender, race,
lifestyle, genetic background, and locality often is influential in arrival at a
presumptive diagnosis. Laboratory tests and imaging are used to confirm a
diagnosis.
An important factor when interpreting diagnostic test results is the
determination of whether they are normal or abnormal. Is a blood count
above normal, within the normal range, or below normal? What is termed a
normal value for a laboratory test is established statistically from test results
obtained from a selected sample of people. A normal value represents the
test results that fall within the bell curve or the 95% distribution. Thus, the
normal levels for serum sodium (136 to 145 mEq/L) represent the mean
serum level for the reference population ±2 standard deviations. The normal
values for some laboratory tests are adjusted for gender, other
comorbidities, or age. For example, the normal hemoglobin range for
women is 12.0 to 16.0 g/dL and for men, 14.0 to 17.4 g/dL.5 Serum
creatinine level often is adjusted for age in the elderly, and normal values
for serum phosphate differ between adults and children.
Laboratory parameters are interpreted based on the reliability, validity,
sensitivity, and specificity of the measurement.5,6 Validity refers to the
extent to which a measurement tool measures what it is intended to
measure. For example, the validity of blood pressure measurements
obtained by a sphygmomanometer might be compared with those obtained
by intraarterial findings, which are measurements obtained from invasive
arterial catheters inserted into radial arteries of acutely ill people. Reliability
refers to the extent to which an observation, if repeated, gives the same
result. A poorly calibrated blood pressure machine may give inconsistent
measurements of blood pressure, particularly of pressures in either the high
or low range. Reliability also depends on the person’s skill in taking the
measurements. For example, blood pressure measurements may vary from
one person to another because of the technique that is used (e.g., different
observers may deflate the cuff at a different rate, thus obtaining different
values), the way the numbers on the manometer are read, or differences in
hearing acuity.
In the field of clinical laboratory measurements, standardization is aimed
at increasing the trueness and reliability of measured values.
Standardization relies on the use of written standards, reference
measurement procedures, and reference materials.7 In the United States, the
Food and Drug Administration reviews information to decide whether a
product may be marketed in the United States.
Measures of sensitivity and specificity are concerned with determining
how likely or how well the test or observation will identify people with the
disease and people without the disease (Fig. 1-4).5,6 Sensitivity refers to the
proportion of people with a disease who are positive for that disease on a
given test or observation (called a true-positive result). If the result of a
very sensitive test is negative, it tells us the person does not have the
disease and the disease has been excluded or “ruled out.” Specificity refers
to the proportion of people without the disease who are negative on a given
test or observation (called a true-negative result). Specificity can be
calculated only from among people who do not have the disease. A test that
is 95% specific correctly identifies 95 of 100 normal people. The other 5%
are false-positive results. A false-positive test result can be unduly stressful
for the person being tested, whereas a false-negative test result can delay
diagnosis and jeopardize the outcome of treatment.
FIGURE 1-4 The relationship between a diagnostic test result and the
occurrence of disease. There are two possibilities for the test result
to be correct (true positive and true negative) and two possibilities for
the result to be incorrect (false positive and false negative). (From
Fletcher R. H., Fletcher S. W. (2014). Clinical epidemiology: The
essentials (5th ed., p. 109). Philadelphia, PA: Lippincott Williams &
Wilkins.)
Predictive value is the extent to which an observation or test result is able
to predict the presence of a given disease or condition.8 A positive
predictive value refers to the proportion of true-positive results that occurs
in a given population. In a group of women found to have “suspect breast
nodules” in a cancer screening program, the proportion later determined to
have breast cancer would constitute the positive predictive value. A
negative predictive value refers to the true-negative observations in a
population. In a screening test for breast cancer, the negative predictive
value represents the proportion of women without suspect nodules who do
not have breast cancer. Despite unchanging sensitivity and specificity, the
positive predictive value of an observation rises with prevalence, whereas
the negative predictive value falls.
Clinical Course
The clinical course describes the evolution of a disease. A disease can have
an acute, subacute, or chronic course. An acute disorder is one that is
relatively severe, but self-limiting. Chronic disease implies a continuous,
long-term process. A chronic disease can run a continuous course or can
present with exacerbations (aggravation of symptoms and severity of the
disease) and remissions (a period during which there is a decrease in
severity and symptoms). Subacute disease is intermediate or between acute
and chronic. It is not as severe as an acute disease and not as prolonged as a
chronic disease.
The spectrum of disease severity for infectious diseases, such as hepatitis
B, can range from preclinical to persistent chronic infection. During the
preclinical stage, the disease is not clinically evident but is destined to
progress to clinical disease. As with hepatitis B, it is possible to transmit a
virus during the preclinical stage. Subclinical disease is not clinically
apparent and is not destined to become clinically apparent. It is diagnosed
with antibody or culture tests. Most cases of tuberculosis are not clinically
apparent, and evidence of their presence is established by skin tests.
Clinical disease is manifested by signs and symptoms. A persistent chronic
infectious disease persists for years, sometimes for life. Carrier status
refers to a person who harbors an organism but is not infected, as evidenced
by antibody response or clinical manifestations. This person still can infect
others. Carrier status may be of limited duration or it may be chronic,
lasting for months or years.
SUMMARY CONCEPTS
The term pathophysiology may be defined as the physiology of

altered health. A disease has been defined as any deviation from or
interruption of the normal structure or function of any part, organ, or
system of the body that is manifested by a characteristic set of
symptoms or signs and whose etiology, pathology, and prognosis may
be known or unknown. The causes of disease are known as etiologic
factors. Pathogenesis describes how the disease process evolves.
Morphology refers to the structure or form of cells or tissues;
morphologic changes are changes in structure or form that are
characteristic of a disease.
A disease can manifest in a number of ways. A symptom is a
subjective complaint, such as pain or dizziness, whereas a sign is an
observable manifestation, such as an elevated temperature or a
reddened, sore throat. A syndrome is a compilation of signs and
symptoms that are characteristic of a specific disease state.
A diagnosis is the designation as to the nature and cause of a health
problem. Having a comprehensive understanding of pathophysiology
will assist the health care provider to best identify problems during
the history and PE and to use laboratory data as further validation.5
The clinical course of a disease describes its evolution. It can be
acute (relatively severe, but self-limiting), chronic (continuous or
episodic, but taking place over a long period), or subacute (not as
severe as acute or as prolonged as chronic). Within the disease
spectrum, a disease can be designated preclinical, not clinically
evident; subclinical, not clinically apparent and not destined to
become clinically apparent; or clinical, characterized by signs and
symptoms.

The health of people is closely linked to the health of the community and to
the population it encompasses. The ability to traverse continents in a matter
of hours has opened the world to issues of populations at a global level.
Diseases that once were confined to local areas of the world now pose a
threat to populations throughout the world. The focus of health care also has
begun to emerge as a partnership in which people are asked to assume
greater responsibility for their own health.
Epidemiology and Patterns of Disease

Epidemiology is the study of disease occurrence in human populations.8 It
was initially developed to explain the spread of infectious diseases during
epidemics and has emerged as a science to study the risk factors for
multifactorial diseases, such as heart disease and cancer. Epidemiology
looks for patterns of people affected with a particular disorder, such as age,
race, dietary habits, lifestyle, or geographic location. The epidemiologist is
more concerned with whether smoking itself is related to cardiovascular
disease and whether the risk of heart disease decreases when smoking
ceases. Much of our knowledge about disease comes from epidemiologic
studies. Epidemiologic methods are used to determine how a disease is
spread, how to control it, how to prevent it, and how to eliminate it.
Epidemiologic methods also are used to study the natural history of disease,
to evaluate new preventive and treatment strategies, to explore the impact
of different patterns of health care delivery, and to predict future health care
needs. As such, epidemiologic studies serve as a basis for clinical decision
making, allocation of health care dollars, and development of policies
related to public health issues.
Incidence and Prevalence
Measures of disease frequency are an important aspect of epidemiology.

They establish a means for predicting what diseases are present in a
population and provide an indication of the rate at which they are increasing
or decreasing. A disease case can be either an existing case or the number
of new episodes of a particular illness that is diagnosed within a given
period. Incidence reflects the number of new cases arising in a population
at risk during a specified time. The population at risk is considered to be
people without the disease but who are at risk for developing it. It is
determined by dividing the number of new cases of a disease by the
population at risk for development of the disease during the same period
(e.g., new cases per 1000 or 100,000 people in the population who are at
risk). The cumulative incidence estimates the risk of developing the disease
during that period of time. Prevalence is a measure of existing disease in a
population at a given point in time (e.g., number of existing cases divided
by the current population).8 The prevalence is not an estimate of risk of
developing a disease because it is a function of both new cases and how
long the cases remain in the population. Incidence and prevalence are
always reported as rates (e.g., cases per 100 or cases per 100,000).
Morbidity and Mortality
Morbidity and mortality statistics provide information about the functional

effects (morbidity) and death-producing (mortality) characteristics of a
disease. These statistics are useful in terms of anticipating health care
needs, planning of public education programs, directing health research
efforts, and allocating health care dollars.
Morbidity describes the effects an illness has on a person’s life. Many
diseases, such as arthritis, have low death rates but a significant impact on a
person’s quality of life. Morbidity is concerned with persistence and the
long-term consequences of the disease.
Mortality statistics provide information about the causes of death in a
given population. In most countries, people are legally required to record
certain facts such as age, gender, and cause of death on a death certificate.
Internationally agreed classification procedures (the International
Classification of Diseases by the WHO) are used for coding the cause of
death, and the data are expressed as death rates.1 Crude mortality rates (i.e.,
number of deaths in a given period) do not account for age, gender, race,
socioeconomic status, and other factors. For this reason, mortality often is
expressed as death rates for a specific population, such as the infant
mortality rate. Mortality also can be described in terms of the leading
causes of death according to age, gender, race, and ethnicity. For example,
among all people 65 years of age and older, leading causes of death in the
United States are heart disease, cancer, chronic lower respiratory disease,
and cerebrovascular diseases.9
Determination of Risk Factors
Conditions suspected of contributing to the development of a disease are
called risk factors. They may be inherent to the person (high blood pressure
or overweight) or external (smoking or drinking alcohol). There are
different types of studies used to determine risk factors, including cross-
sectional studies, case–control studies, and cohort studies.
Cross-Sectional and Case–Control Studies
Cross-sectional studies use the simultaneous collection of information

necessary for classification of exposure and outcome status. They can be
used to compare the prevalence of a disease in those with the factor (or
exposure) with the prevalence of a disease in those who are unexposed to
the factor, for example, by comparing the prevalence of coronary heart
disease in smokers and nonsmokers. Case–control studies are designed to
compare people known to have the outcome of interest (cases) and those
known not to have the outcome of interest (controls).8 Information on
exposures or characteristics of interest is then collected from people in both
groups. For example, the characteristics of maternal alcohol consumption in
infants born with fetal alcohol syndrome (cases) can be compared with
those in infants born without the syndrome (controls).
Cohort Studies
A cohort is a group of people who were born at approximately the same

time or share some characteristics of interest.8 People enrolled in a cohort
study (also called a longitudinal study) are followed over a period of time to
observe a specific health outcome.
Framingham Study
One of the best-known examples of a cohort study is the Framingham
Study, which was carried out in Framingham, MA.10 This longitudinal
study, which began in 1950, was set up by the U.S. Public Health Service to
study the characteristics of people who would later develop coronary heart
disease. The study consisted of 5000 persons, between 30 and 59 years of
age, selected at random and followed for an initial period of 20 years.
During this time, it was predicted that 1500 of them would develop
coronary heart disease. The advantage of such a study is that it can explore
a number of risk factors at the same time and determine the relative
importance of each. Another advantage is that the risk factors can be related
later to other diseases such as stroke.
Nurses’ Health Study

Another well-known cohort study is the Nurses’ Health Study, which was
developed by Harvard University and Brigham and Women’s Hospital. The
study began in 1976 with a cohort of 121,700 female caregivers, 30 to 55
years of age, living in the United States.11 The study expanded in 1989 to
include a group of 238,000 female caregiver participants.11 Initially
designed to explore the relationship between oral contraceptives and breast
cancer, caregivers in the study have provided answers to detailed questions
about their menstrual cycle, smoking habits, diet, weight and waist
measurements, activity patterns, health problems, and medication use. They
have collected urine and blood samples and even provided researchers with
their toenail clippings. In selecting the cohort, it was reasoned that
caregivers would be well organized, accurate, and observant in their
responses and that physiologically they would be no different from other
groups of women. It also was anticipated that their child-bearing, eating,
and smoking patterns would be similar to those of other working women.
Natural History
The natural history of a disease refers to the progression and projected
outcome of the disease without medical intervention. By studying the
patterns of a disease over time in populations, epidemiologists can better
understand its natural history. Knowledge of the natural history can be used
to determine disease outcome, establish priorities for health care services,
determine the effects of screening and early detection programs on disease
outcome, and compare the results of new treatments with the expected
outcome without treatment.
There are some diseases for which there are no effective treatment
methods available, or the current treatment measures are effective only in
certain people. In this case, the natural history of the disease can be used as
a predictor of outcome. For example, the natural history of hepatitis C
indicates that 75% to 85% of people who become infected with the virus
fail to clear the virus and progress to chronic infection.12 Information about
the natural history of a disease and the availability of effective treatment
methods provides directions for preventive measures. In the case of
hepatitis C, careful screening of blood donations and education of
intravenous drug abusers can be used to prevent transfer of the virus.
Prognosis refers to the probable outcome and prospect of recovery from
a disease. It can be designated as chances for full recovery, possibility of
complications, or anticipated survival time. Prognosis often is presented in
relation to treatment options, that is, the expected outcomes or chances for
survival with or without a certain type of treatment. The prognosis
associated with a given type of treatment usually is presented along with the
risk associated with the treatment.
Preventing Disease
There are three fundamental types of prevention—primary prevention,
secondary prevention, and tertiary prevention (Fig. 1-5).8
FIGURE 1-5Levels of prevention. Primary prevention prevents disease

from occurring. Secondary prevention detects and cures disease in
the asymptomatic phase. Tertiary prevention reduces complications
of disease. (From Fletcher R. H., Fletcher S. W. (2014). Clinical
epidemiology: The essentials (5th ed., p. 153). Philadelphia, PA:
Lippincott Williams & Wilkins.)
Primary prevention is directed at keeping disease from occurring by

removing risk factors. Examples of primary prevention include the
administration of folic acid to pregnant women and women who may
become pregnant to prevent fetal neural tube defects, giving immunizations
to children to prevent communicable disease, and counseling people to
adopt healthy lifestyles as a means of preventing heart disease.8
Secondary prevention detects disease early when it is still asymptomatic
and treatment measures can effect a cure or stop the disease from
progressing. The use of a Papanicolaou (Pap) smear for early detection of
cervical cancer is an example of secondary prevention. Screening also
includes history taking, blood pressure measurement, laboratory tests, and
other procedures such as a colonoscopy that can be “applied reasonably
rapidly to asymptomatic people.”8 Tertiary prevention is directed at clinical
interventions that prevent further deterioration or reduce the complications
of a disease that is already present. An example is the use of β-adrenergic
drugs to reduce the risk of death in people who have had a heart attack.8
Another example is support groups for people with alcohol addiction.
Evidence-Based Practice and Practice Guidelines

Evidence-based practice and evidence-based practice guidelines have
gained popularity with providers and the public as a means of improving
the quality and efficiency of health care.13 Their development has been
prompted by more educated consumers who are fueled by published
information about diagnostic and treatment measures for various disease
conditions as well as demands for better and more cost-effective health
care.
Evidence-based practice refers to making decisions in health care based
on scientific data that have shown a specific way of managing a disease,
patient symptoms, and complaints. Using evidence-based practice mandates
that health care providers cannot practice according to only “their” way or
according to “how it has always been done before.”13
Clinical practice guidelines are systematically developed statements
intended to inform practitioners and people in making decisions about
health care for specific clinical circumstances.6,13 Providers must consider
benefits versus risks or impact on quality of life when applying these
guidelines. The development of evidence-based practice guidelines often
uses methods such as meta-analysis to combine evidence from different
studies to produce a more precise estimate of the accuracy of a diagnostic
method or the effects of an intervention method.14 Practitioners with
expertise in clinical content, experts in guideline development, and potential
users of the guideline are best at evaluating the guidelines.13
Once developed, practice guidelines must be continually reviewed and
changed to keep pace with new research findings and new diagnostic and
treatment methods. For example, both the Guidelines for the Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure, first
developed in 1972 by the Joint National Committee, and the Guidelines for
the Diagnosis and Management of Asthma,15 first developed in 1991 by the
Expert Panel, have undergone multiple revisions as new evidence from
research has evolved.
SUMMARY CONCEPTS
Epidemiology refers to the study of disease in populations. It looks

for patterns such as age, race, and dietary habits of people who are
affected with a particular disorder. These patterns are used to
determine under what circumstances the particular disorder will
occur. Incidence is the number of new cases arising in a given
population during a specified time. Prevalence is the number of
people in a population who have a particular disease at a given point
in time or period. Incidence and prevalence are reported as
proportions or rates (e.g., cases per 100 or 100,000 population).
Morbidity describes the effects an illness has on a person’s life. It is
concerned with the incidence of disease as well as its persistence and
long-term consequences. Mortality, or death, statistics provide
information about the causes of death in a given population.
Conditions suspected of contributing to the development of a
disease are called risk factors. Studies used to determine risk factors
include cross-sectional studies, case–control studies, and cohort
studies. The natural history refers to the progression and projected
outcome of a disease without medical intervention. Prognosis is the
term used to designate the probable outcome and prospect of
recovery from a disease.
The three fundamental types of prevention are primary prevention,
secondary prevention, and tertiary prevention. Primary prevention,
such as immunizations, is directed at removing risk factors so disease
does not occur. Secondary prevention, such as a Pap smear, detects
disease when it still is asymptomatic and curable with treatment.
Tertiary prevention, such as use of β-adrenergic drugs to reduce the
risk of death in persons who have had a heart attack, focuses on
clinical interventions that prevent further deterioration or reduce the
complications of a disease.
Evidence-based practice and evidence-based practice guidelines
are mechanisms that use the current best evidence to make decisions
about the health of people. They are based on the expertise of the
individual practitioner integrated with the best clinical evidence from
systematic review of credible research studies. Practice guidelines
may take the form of algorithms, which are step-by-step methods for
solving a problem, written directives, or a combination thereof.
REFERENCES
1. World Health Organization. (2003). About WHO: Definition of health; disease
eradication/elimination goals. [Online]. Available: www.who.int/about/definition/en/. Accessed
January 12, 2011.
2. U.S. Department of Health and Human Services. (2010). Healthy People 2020—The mission,
vision, and goals of 2020. [Online]. Available:
https://www.healthypeople.gov/sites/default/files/HP2020_brochure_with_LHI_508_FNL.pdf.
Accessed January 22, 2011.
3. Carlsten C., Brauer M., Brinkman F., et al. (2014). Genes, the environment and personalized
medicine: We need to harness both environmental and genetic data to maximize personal and
population health. EMBO Reports 15(7), 736–739.
4. Kumar V., Abbas A., Aster J. C. (2014). Robbins and Cotran pathologic basis of disease (9th ed.,
p. 40). Philadelphia, PA: Elsevier Saunders.
5. Fischbach F., Dunning M. B. (2014). A manual of laboratory and diagnostic tests (9th ed., pp. 12–
13, 96). Philadelphia, PA: Lippincott Williams & Wilkins.
6. Benjamin I. J., Griggs R. C., Wing E. J., et al. (2016). Andreoli and Carpenter’s Cecil essentials of
medicine (9th ed., pp. 266–270). Philadelphia, PA: Elsevier Saunders.
7. American Association for Clinical Chemistry. (2017). How reliable is laboratory testing? [Online].
Available: https://labtestsonline.org/articles/laboratory-test-reliability. Accessed April 8, 2019.
8. Fletcher R. H., Fletcher S. W., Fletcher G. S. (2012). Clinical epidemiology: The essentials (5th
ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
9. Centers for Disease Control and Prevention. (2017). FastStats. Older persons’ health. [Online].
Available: https://www.cdc.gov/nchs/fastats/older-american-health.htm.
https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm. Accessed October 8, 2017.
10. Framingham Heart Study. (2001). Framingham Heart Study: Design, rationale, objectives, and
research milestones. [Online]. Available: https://www.nhlbi.nih.gov/science/framingham-heart-
study-fhs. Accessed January 6, 2011.
11. Channing Laboratory. (2008). The nurse’s health study. [Online]. Available:
http://www.channing.harvard.edu/nhs/. Accessed January 29, 2011.
12. Center for Disease Control and Prevention. (2017). Hepatitis C FAQs for health professionals.
[Online]. Available: https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm. Accessed October 8, 2017.
13. Duke University Medical Center. (2017). What is evidenced-based practice? [Online]. Available:
http://guides.mclibrary.duke.edu/ebmtutorial. Accessed October 8, 2017.
14. Berlin J. A., Golulb R. M. (2014). Meta-analysis as evidence building a better pyramid. JAMA
312(6), 603–606. doi:10.1001/jama.2014.8167.
15. National Asthma Education and Prevention Program. (2007). Expert Panel Report 3: Guidelines
for the diagnosis and management of asthma. [Online]. Available:
https://www.nhlbi.nih.gov/sites/default/files/media/docs/asthgdln_1.pdf. Accessed May 22, 2013.
UNIT 2
Cell Function and Growth

CHAPTER 2
Cell and Tissue Characteristics

Protoplasm
The Nucleus
The Cytoplasm and Its Organelles
Ribosomes
Endoplasmic Reticulum
Golgi Complex
Lysosomes and Peroxisomes
Proteasomes
Mitochondria
The Cytoskeleton
Microtubules
Microfilaments
The Cell (Plasma) Membrane
Cell Communication
Cell Receptors
Cell Surface Receptors
Intracellular Receptors
The Cell Cycle and Cell Division
Cell Metabolism and Energy Sources
Movement across the Cell Membrane and Membrane Potentials
Movement of Substances across the Cell Membrane
Passive Transport
Active Transport and Cotransport
Endocytosis and Exocytosis
Ion Channels
Membrane Potentials
Graded Potentials
Action Potential
Body Tissues
Cell Differentiation
Embryonic Origin of Tissue Types
Epithelial Tissue
Basement Membrane
Cell Junctions and Cell-to-Cell Adhesions
Types of Epithelial Tissues
Connective or Supportive Tissue
Muscle Tissue
Skeletal Muscle
Cardiac Muscle
Smooth Muscle
Nervous Tissue
Extracellular Matrix
Learning Objectives
After completing this chapter, you should be able to meet the

1. Predict the effects of dysfunction in each cellular organelle.

2. Differentiate the four functions of the cell membrane.
3. Order the pathway for cell communication, from the receptor to the
response, and explain why the process is often referred to as signal
transduction.
4. Link the phases of the cell cycle to cell replication.
5. Predict how changes in oxygen delivery to cells change cellular
respiration and levels of adenosine triphosphate and carbon dioxide.
6. Compare and contrast membrane transport mechanisms: diffusion,
osmosis, active transport, endocytosis, and exocytosis.
7. Predict changes in membrane potentials based on diffusion of ions.
8. Link the process of cell differentiation to the development of organ
systems in the embryo and the regeneration of tissues in postnatal
life.
9. Compare and contrast the characteristics of the four different tissue
types.
In most organisms, the cell is the smallest functional unit that has the
characteristics necessary for life. Cells combine to form tissues based on
their embryonic origin. These tissues combine to form organs. Although
cells of different tissues and organs vary in structure and function, certain
characteristics are common to all cells. Because most disease processes start
at the cellular level, we need to understand cell function to understand
disease processes. This chapter discusses the structural parts of cells, cell
functions and growth, movement of substances such as ions across the cell
membrane, and tissue types.
Most organisms, including humans, contain eukaryotic cells that are made
up of internal membrane-bound compartments called organelles (“small
organs” within cells); an example of an organelle is the nucleus. This is in
contrast to prokaryotes, such as bacteria, that do not contain membrane-
bound organelles. When seen under a microscope, three major components
of a eukaryotic cell become evident—the nucleus, the cytoplasm, and the
cell membrane (Fig. 2-1).
FIGURE 2-1Cell organelles. DNA, deoxyribonucleic acid. (Reprinted
from Leeper-Woodford. (2016). Lippincott illustrated reviews:
Integrated systems (Fig. 2.1, p. 39). Philadelphia, PA: Wolters
Kluwer, with permission.)
Protoplasm
Biologists call the intracellular fluid protoplasm. Protoplasm is composed
of water, proteins, lipids, carbohydrates, and electrolytes.1
Water makes up 70% to 85% of the cell’s protoplasm.1
Proteins make up 10% to 20% of the protoplasm. Proteins are polar and
soluble in water. Examples of proteins include enzymes necessary for
cellular reactions, structural proteins, ion channels, and receptors.1
Lipids make up 2% to 3% of the protoplasm. Lipids are nonpolar and
insoluble in water. They are the main parts of cell membranes
surrounding the outside and inside of cells. Examples of lipids include
phospholipids and cholesterol. Some cells also contain large quantities of
triglycerides. In fat cells, triglycerides can make up as much as 95% of
the total cell mass.1 Carbohydrates make up approximately 1% of the
protoplasm. These serve primarily as a rapid source of energy.1
The major intracellular electrolytes include potassium, magnesium,
phosphate, sulfate, and bicarbonate ions. Small quantities of the
electrolytes sodium, chloride, and calcium ions are also present in cells.
These electrolytes participate in reactions that are necessary for the cell’s
metabolism, and they help generate and send signals in neurons, muscle
cells, and other cells.
Two distinct regions of protoplasm exist in the cell:
The karyoplasm or nucleoplasm is inside the nucleus.
The cytoplasm is outside the nucleus. The cytosol is the fluid of the
cytoplasm (cytoplasm = cytosol + organelles).
KEY POINTS
The Functional Organization of the Cell
Organelles in the cytoplasm perform functions within cells similar to

how organs in the body perform functions within the organism.
The nucleus is the largest and most visible organelle in the cell. The
nucleus is the control center for the cell. In eukaryotic cells, it
contains genetic information that we inherit from our parents.1
Other organelles include the mitochondria, which help to make energy
molecules that cells can use, and the lysosomes and proteasomes,
which function as the cell’s digestive system. Ribosomes, which are
not surrounded by membranes, are the cellular structures that make
proteins; those proteins may help to make other molecules needed for
cell function.
The Nucleus
The cell nucleus is a rounded or elongated structure near the center of the
cell (see Fig. 2-1). All eukaryotic cells have at least one nucleus. Some cells
contain more than one nucleus; osteoclasts (a type of bone cell) usually
contain 12 or more nuclei.1
The nucleus can be thought of as the control center for the cell because it
contains the instructions to make proteins, and proteins can then make other
molecules needed for cellular function and survival.1 The nucleus contains
deoxyribonucleic acid (DNA), which contains genes. Genes contain the
instructions for cellular function and survival. For example, the insulin gene
contains instructions to make insulin protein. In addition, genes are units of
inheritance that pass information from parents to their children.
The nucleus also is the site for the synthesis of the three main types of
ribonucleic acid (RNA). These RNA molecules move from the nucleus to
the cytoplasm and carry out the synthesis of proteins. These three types of
RNA are as follows:
Messenger RNA (mRNA), which is made from genetic information
transcribed from the DNA in a process called transcription. mRNA
travels to ribosomes in the cytoplasm so these instructions can be used to
make proteins.
Ribosomal RNA (rRNA) is the RNA component of ribosomes, the site
of protein production.
Transfer RNA (tRNA) transports amino acids to ribosomes so that
mRNA can be turned into a sequence of amino acids. This process,
known as translation, uses the mRNA template to link amino acids to
synthesize proteins.1
The Cytoplasm and Its Organelles

The cytoplasm includes the fluid and organelles outside the nucleus but
within the cell membrane surrounding the cell. Cytoplasm is a solution that
contains water, electrolytes, proteins, fats, and carbohydrates.1 Pigments
may also accumulate in the cytoplasm. Some pigments are normal parts of
cells. One example is melanin, which gives skin its color. Some pigments
are not normal parts of cells. For example, when the body breaks down old
red blood cells, pigments in red blood cells are changed to the pigment
bilirubin, which the body can excrete. Embedded in the cytoplasm are
various organelles that function as the organs of the cell. In addition to the
nucleus, which was discussed in the previous section, these organelles
include the ribosomes, the endoplasmic reticulum (ER), the Golgi complex,
lysosomes, peroxisomes, proteasomes, and mitochondria.1
Ribosomes
The ribosomes are the sites of protein synthesis in the cell. There are two
subunits of ribosomes that are made up of rRNA and proteins. During
protein synthesis, the two ribosomal subunits are held together by a strand
of mRNA.1 These active ribosomes either stay within the cytoplasm (Fig. 2-
2) or are attached to the membrane of the ER, depending on where the
protein will be used.1
FIGURE 2-2Endoplasmic reticulum (ER), ribosomes, and Golgi
apparatus. The rough ER (RER) consists of intricately folded
membranes studded with ribosomes. Ribosomes are made of
protein and ribosomal ribonucleic acid organized together. Golgi
apparatus processes proteins synthesized on ribosomes. (Reprinted
from Leeper-Woodford. (2016). Lippincott illustrated reviews:
Integrated systems (Fig. 2.3, p. 41). Philadelphia, PA: Wolters
Kluwer, with permission.)
Endoplasmic Reticulum
The ER is an extensive system of paired membranes and flat vesicles that

connect various parts of the inner cell (see Fig. 2-2).1 Two forms of ER
exist in cells—rough and smooth.
Rough ER has ribosomes attached, and the ribosomes appear under a
microscope as “rough” structures on the ER membrane. Proteins made by
the rough ER usually become parts of organelles or cell membranes, or are
secreted from cells as a protein. For example, the rough ER makes (1)
digestive enzymes found in lysosomes and (2) proteins that are secreted,
such as the protein hormone insulin.
The smooth ER is free of ribosomes and has a smooth structure when
viewed through a microscope. Because it does not have ribosomes attached,
the smooth ER does not participate in protein synthesis. Instead, the smooth
ER is involved in the synthesis of lipids including steroid hormones. The
smooth ER of the liver is involved in storage of extra glucose as glycogen
as well as metabolism of some hormone drugs.
If proteins build up in the ER faster than they can be removed, the cell is
said to experience “ER stress.” The cell responds by slowing down protein
synthesis and restoring homeostasis. Abnormal responses to ER stress,
which can cause inflammation and even cell death, have been implicated in
inflammatory bowel disease,2 a genetic form of diabetes mellitus,3 and a
disorder of skeletal muscle known as myositis,4 as well as many other
diseases.
Golgi Complex
The Golgi apparatus, sometimes called the Golgi complex, consists of four
or more stacks of thin, flattened vesicles or sacs (see Fig. 2-3).1 Substances
produced in the ER are carried to the Golgi complex in small, membrane-
covered transfer vesicles. The Golgi complex modifies these substances and
packages them into secretory granules or vesicles. In addition to making
secretory granules, the Golgi complex is thought to make large
carbohydrate molecules that combine with proteins produced in the rough
ER to form glycoproteins. The Golgi apparatus can receive proteins and
other substances from the cell surface by a retrograde transport
mechanism. Several bacterial toxins, such as Shiga and cholera toxins, and
plant toxins, such as ricin, that have cytoplasmic targets have exploited this
retrograde pathway.1
FIGURE 2-3The processes of autophagy and heterophagy, showing
the primary and secondary lysosomes, residual bodies, extrusion of
residual body contents from the cell, and lipofuscin-containing
residual bodies.
Lysosomes and Peroxisomes
Lysosomes can be thought of as the digestive system or the stomach of the

cell. These small, membrane-enclosed sacs contain powerful enzymes that
can break down excess and worn-out cell parts as well as foreign substances
that are taken into the cell (e.g., bacteria taken in by phagocytosis). All of
the lysosomal enzymes require an acidic environment, and the lysosomes
maintain a pH of approximately 5 in their interior compared to the pH of
the cytoplasm, which is approximately 7.2, protecting other cellular
structures from being broken down by these enzymes should leakage occur.
Primary lysosomes are membrane-bound intracellular organelles that
contain a variety of enzymes that have not yet entered the digestive process.
They receive their enzymes as well as their membranes from the Golgi
apparatus. Primary lysosomes become secondary lysosomes after they fuse
with membrane-bound vacuoles that contain material to be digested.
Lysosomes break down phagocytosed material by either heterophagy or
autophagy (Fig. 2-3).
Heterophagy (hetero, different; phagy, eat) refers to digestion of a
substance phagocytosed from the cell’s external environment.5 An infolding
of the cell membrane takes external materials into the cell to form a
surrounding phagocytic vesicle, or phagosome. Primary lysosomes then
fuse with phagosomes to form secondary lysosomes. Heterophagocytosis is
most common in phagocytic white blood cells such as neutrophils and
macrophages.
Autophagy involves the digestion of damaged cellular organelles, such as
mitochondria or ER, which the lysosomes must remove if the cell’s normal
function is to continue.5 Autophagocytosis is most common in cells
undergoing atrophy (cell degeneration).
Lysosomes play an important role in the normal metabolism of certain
substances in the body. In some inherited diseases known as lysosomal
storage disorders, a specific lysosomal enzyme is absent or inactive,
preventing digestion of certain cellular substances and allowing them to
build up in cells.6 There are approximately 50 lysosomal storage disorders,
each caused by a lack of activity of one or more lysosomal enzymes, and
each disorder is rare.
In Tay–Sachs disease, an autosomal recessive disorder, cells do not make
hexosaminidase A, a lysosomal enzyme needed for degrading the GM2
ganglioside found in nerve cell membranes. Its accumulation in the nervous
system and retina of the eye causes the most damage.6
Smaller than lysosomes, round membrane-bound organelles called
peroxisomes contain a special enzyme that degrades peroxides (e.g.,
hydrogen peroxide) in the control of free radicals.6 In liver cells,
peroxidases help make bile acids.5
Proteasomes
Three major cellular mechanisms are involved in the breakdown of

proteins, or proteolysis.5 One of these is by the previously described
lysosomal degradation. The second mechanism is the caspase pathway
that is involved in apoptotic cell death. The third method of proteolysis
occurs within an organelle called the proteasome. Proteasomes are small
organelles made up of protein complexes in the cytoplasm and nucleus.
These organelles recognize misformed and misfolded proteins that have
been targeted for degradation.
Mitochondria
The mitochondria are the “power plants” of the cell because they contain
enzymes that can change carbon-containing nutrients into energy that is
easily used by cells. This multistep process is often referred to as cellular
respiration because it requires oxygen.1 Cells store most of this energy as
high-energy phosphate bonds in substances such as adenosine triphosphate
(ATP) and use the ATP as energy in various cellular activities. Mitochondria
are found close to the site of energy use in the cell (e.g., near the myofibrils
in muscle cells). A large increase in mitochondria occurs in skeletal muscle
repeatedly stimulated to contract.
Mitochondria contain their own DNA and ribosomes and are self-
replicating. Mitochondrial DNA (mtDNA) is inherited from the mother and
thought to be linked to certain diseases and aging. mtDNA is a double-
stranded, circular molecule that contains the instructions to make 13 of the
proteins needed for mitochondrial function. The DNA of the nucleus
contains the instructions for the structural proteins of the mitochondria and
other proteins needed for cellular respiration.5,7
Most cells in the body can be affected by mtDNA mutations.5
Mitochondria also function as key regulators of apoptosis, or
programmed cell death. In cancer, there is too little apoptosis and in
neurodegenerative diseases, there is too much apoptosis.
The Cytoskeleton
In addition to its organelles, the cytoplasm contains a cytoskeleton, or the
skeleton of the cell. The cytoskeleton is a network of microtubules,
microfilaments, intermediate filaments, and thick filaments (Fig. 2-4).5 The
cytoskeleton controls cell shape and movement.
FIGURE 2-4 Cytoskeleton. The cytoskeleton is made up of
microfilaments, microtubules, and intermediate filaments. (Reprinted
with permission from Wingerd B. (2014). The human body (3rd ed.,
Fig. 3.10, p. 55). Philadelphia, PA: Wolters Kluwer.)
Microtubules
Microtubules are formed from protein subunits called tubulin.

Microtubules are long, stiff, hollow structures shaped like cylinders.7
Microtubules can rapidly disassemble in one location and reassemble in
another. This constant reassembling forms elements of the cytoskeleton by
continuously shortening and lengthening the tubulin dimers, a process
known as dynamic instability.6
Microtubules function in the development and maintenance of cell
formation. Microtubules participate in transport mechanisms inside cells,
including transport of materials in the long axons of neurons and melanin in
skin cells. Microtubules are also part of other cell structures such as cilia
and flagella7 (Fig. 2-5).
FIGURE 2-5 Microtubules and microfilaments of the cell. The
microfilaments are associated with the inner surface of the cell and
aid in cell motility. The microtubules form the cytoskeleton and
maintain the position of the organelles.
Another important role of microtubules is participating in mitosis (cell

division). Some cancer drugs (e.g., vinblastine and vincristine) bind to
microtubules and inhibit cell division.8
Cilia and Flagella
Flagella and cilia (plural) are microtubule-filled cellular extensions
surrounded by a membrane that is continuous with the cell membrane.
Eukaryotic flagellated cells are generally classified as having only one
flagellum (singular), whereas ciliated cells typically have a large number of
cilia.7 In humans, sperm cells are the only cell type with flagella. Cilia are
found on surfaces of many epithelial linings, including the nasal sinuses and
bronchi in the upper respiratory system. Damage to cilia or ciliated cells
causes a cough, which is then used to help remove these substances from
the airways.
Genetic defects can result in incorrect assembly of cilia.7 For example,
primary ciliary dyskinesia, also called immotile cilia syndrome, causes
problems in the cilia of the respiratory tract so that inhaled bacteria cannot
be removed, leading to a chronic lung disease called bronchiectasis.
Genetic defects can also cause fertility problems by affecting the cilia in the
fallopian tubes or the flagella on sperm.7,9 A condition called polycystic
kidney disease is linked to a genetic defect in the cilia of the renal tubular
cells.
Microfilaments
Microfilaments are thin, thread-like cytoplasmic structures. There are three

classes of microfilaments:
1. Thin microfilaments, which are similar to thin actin filaments in

muscle
2. Intermediate filaments, which are a group of filaments with diameters
between those of the thick and thin filaments
3. Thick myosin filaments, which are in muscle cells but may also exist
temporarily in other cells5
Muscle contraction depends on the interaction between the thin actin

filaments and thick myosin filaments. Microfilaments are also present in the
microvilli of the intestine. The intermediate filaments help support and
maintain the shape of cells.5 The neurofibrillary tangles found in the brain
in Alzheimer disease are formed by aggregated microtubule-associated
proteins and result in abnormal cytoskeletons in neurons.
The Cell (Plasma) Membrane
The cell is surrounded by a thin membrane that separates the intracellular

contents from the extracellular environment. (Note that this is different
from a cell wall.) Cell walls add structure and strength. Human cells do not
have cell walls because of the development of tissues, organs, and organ
systems, which must have the ability to communicate.
The cell membrane is one of the most important parts of the cell acting as
a semipermeable structure that helps determine what can and cannot enter
and exit cells. The cell membrane contains receptors for hormones,
neurotransmitters, and other chemical signals, as well as transporters that
allow ions to cross the membrane during electrical signaling in cells (such
as neurons and muscle cells). It also helps regulate cell growth and division.
The cell membrane is a dynamic and fluid structure made up of organized
lipids, carbohydrates, and proteins (Fig. 2-6). The main part of the
membrane is the lipid bilayer, made up mostly of phospholipids, with
glycolipids and cholesterol.7 This lipid bilayer is a mostly impermeable
barrier to all but lipid-soluble substances.
FIGURE 2-6 Structure of the cell membrane showing the hydrophilic

(polar) heads and the hydrophobic (fatty acid) tails. (From McConnell
T. H., Hull K. L. (2011). Human form, human function: Essentials of
anatomy & physiology (p. 67). Philadelphia, PA: Lippincott Williams
& Wilkins.)
Phospholipid molecules are arranged so their hydrophilic, water-loving
heads face outward on each side of the membrane, where there is watery
extracellular or intracellular fluid, and their hydrophobic tails project
toward the middle of the membrane.
Although the lipid bilayer provides the basic structure of the cell
membrane, proteins carry out most of the functions. The way proteins are
associated with the cell membrane often determines their function. The
integral proteins, called transmembrane proteins, cross the entire lipid
bilayer and function on both sides of the membrane or transport molecules
across it. Many transmembrane proteins form ion channels and are selective
for which substances move through them. Mutations in channel proteins,
often called channelopathies, can cause genetic disorders.10 For example,
cystic fibrosis involves an abnormal chloride channel, which causes the
epithelial cell membrane to be impermeable to the chloride ion. The
defective chloride secretion with excessive sodium and water causes
abnormally thick and viscid respiratory secretions, blocking the airways.
Water channels or pores called aquaporins are also transmembrane
proteins in the cell membrane. Changes in water transport through
aquaporin can cause diseases, including diabetes insipidus. Carriers are
another type of transmembrane protein that allows substances to cross
membranes. Glucose transporters are examples of carriers, and changes in
the movement of glucose through these carriers are involved in diabetes
mellitus.8
The peripheral proteins are temporarily bound to one side or the other
of the membrane and do not pass into the lipid bilayer, and they have
functions involving the inner or outer side of the membrane where they are
found. Several peripheral proteins are receptors for chemical signals or are
involved in intracellular signaling systems.
SUMMARY CONCEPTS
The cell is a self-sufficient structure that functions similarly to the

total organism. In most cells, a single nucleus controls cell function.
It contains DNA, which provides the information necessary to make
the various proteins the cell needs to stay alive and to transmit
genetic information from one generation to another. The nucleus also
is where RNA is made. The three types of RNA (mRNA, rRNA, and
tRNA) move to the cytoplasm to make proteins.
The cytoplasm contains the cell’s organelles and cytoskeleton.
Ribosomes are sites for protein synthesis in the cell. The ER
transports substances from one part of the cell to another and makes
proteins (rough ER), carbohydrates, and lipids (smooth ER). Golgi
bodies modify substances made in the ER and package them into
secretory granules for transport within the cell or for export from the
cell. Lysosomes, which are viewed as the digestive system of the cell,
contain enzymes that digest worn-out cell parts and foreign materials.
The proteasome digests misformed and misfolded proteins. The
mitochondria serve as power plants for the cell because they change
nutrient energy into ATP to power cell activities. Mitochondria
contain their own DNA, which is important for making mitochondrial
RNAs and proteins used in oxidative metabolism. The cytoplasm also
contains microtubules, microfilaments, intermediate filaments, and
thick filaments. Microtubules help determine cell shape, provide a
means of moving organelles through the cytoplasm, and help move
cilia and chromosomes during cell division. Actin microfilaments
and myosin thin filaments interact so that muscle cells can contract.
The cell membrane is a lipid bilayer that surrounds the cell and
separates it from its surrounding external environment. Although the
lipid bilayer provides the basic structure of the cell membrane,
proteins carry out most of the specific functions of the cell
membrane. Peripheral proteins often function as receptor sites for
signaling molecules, and transmembrane proteins frequently form
transporters for ions and other substances.
Cell Communication
Cells in multicellular organisms need to communicate with each other to
coordinate their function and control their growth. The human body has
several ways of sending information between cells. These include direct
communication between neighboring cells through gap junctions, autocrine
and paracrine signaling, and endocrine or synaptic signaling.7
Autocrine signaling (auto: self) occurs when a cell releases a chemical
into the extracellular fluid that affects its own activity (Fig. 2-7).
FIGURE 2-7Examples of endocrine (A), paracrine (B), and autocrine

(C) secretions.
Paracrine signaling acts mainly on nearby cells.
Endocrine signaling relies on hormones carried in the bloodstream to
cells throughout the body.
Synaptic signaling occurs in the nervous system, where
neurotransmitters are released from neurons to act only on neighboring
cells at synapses.
KEY POINTS
Cell Communication
Cells communicate with each other and with the internal and
external environments in a number of ways; for example, electrical
and chemical signaling systems control electrical potentials, the
overall function of a cell, and gene activity needed for cell division
and cell replication.
Chemical messengers bind to protein receptors on the cell surface
or inside of cells in a process called signal transduction.
Cells can regulate their responses to chemical messengers by
increasing or decreasing the number of receptors.
Cell Receptors
Signaling systems include receptors found either in the cell membrane (cell
surface receptors) or within the cells (intracellular receptors). Receptors are
activated by a variety of extracellular chemical signals or first messengers,
including neurotransmitters, hormones and growth factors, and other
chemical messengers. Receptors are proteins, and the chemicals that bind to
them are called ligands.
Signaling systems also include transducers and effectors that are involved in
changing the signal into a response. The pathway may include additional
intracellular molecules called second messengers.7 Many molecules
involved in signal transduction are proteins because proteins can change
their shape or conformation, thereby changing their function and
consequently the functions of the cell. Often during signal transduction,
enzymes called protein kinases catalyze the addition of a phosphate to
proteins, and this changes their structure and function.7
Cell Surface Receptors
Each cell type in the body contains a unique set of surface receptors that
allow the cell to respond to a set of signaling molecules in a specific way.
These proteins can increase or decrease in number according to the needs of
the cell. When excess chemical signals are present, the number of active
receptors decreases in a process called downregulation. When there are
decreased chemical signals, the number of active receptors increases
through upregulation. The three classes of cell surface receptor proteins are
G-protein linked, ion channel linked, and enzyme linked.5
G-Protein–Linked Receptors
With more than 1000 members, G-protein–linked receptors are the largest
family of cell surface receptors.5 These receptors rely on the activity of
membrane-bound, intracellular regulatory proteins to convert external
signals (first messengers) into internal signals (second messengers).
Because these regulatory proteins bind to guanosine diphosphate (GDP) and
guanosine triphosphate (GTP), they are called G-proteins. G-protein–
linked receptors participate in cellular responses for many types of first
messengers.5
Although there are differences between the G-protein–linked receptors,
all share a number of features.7 They all have an extracellular receptor part
that binds to the chemical signal (first messenger). They all undergo shape
changes when the receptor binds to a signal, and the shape change activates
the intracellular G-protein. The G-proteins use a GTPase cycle, which
functions as a molecular switch. In its activated (on) state, the G-protein
binds GTP, and in its inactivated (off) state, it binds GDP.5
When GTP is bound, the G-protein is active. The activated G-protein has
GTPase activity, which changes the bound GTP (with three phosphate
groups) to GDP (with two phosphate groups), and the G-protein changes to
its inactive state. Receptor activation causes the α subunit to separate from
the receptor and the β and γ subunits and to send the signal from the first
messenger to its effector protein.
Often, the effector is an enzyme that converts an inactive precursor
molecule into a second messenger, which diffuses into the cytoplasm and
carries the signal beyond the cell membrane. A common second messenger
is cyclic adenosine monophosphate (cAMP). It is activated by the enzyme
adenylyl cyclase, which generates cAMP by transferring phosphate groups
from ATP to other proteins.1 This transfer changes the shape and function of
these proteins. Such changes eventually produce the cell response to the
first messenger, whether it is a secretion, muscle contraction or relaxation, a
change in metabolism, or the opening of ion channels.
Enzyme-Linked Receptors
Like G-protein–linked receptors, enzyme-linked receptors are
transmembrane proteins, with their ligand-binding site on the outer surface
of the cell membrane.5 Instead of having an intracellular part that associates
with a G-protein, their intracellular part either has enzyme activity or binds
directly with an enzyme.
There are several classes of enzyme-linked receptors, including those that
activate or have tyrosine kinase activity. Enzyme-linked receptors stimulate
cellular responses such as calcium entry into cells, increased sodium–
potassium exchange across the cell membrane, and stimulation of glucose
and amino acid entry into cells. Insulin, for example, acts by binding to a
surface receptor with tyrosine kinase activity. The intracellular signaling
cascades are involved in the function of growth factors.
All growth factors function by binding to specific receptors that deliver
signals to target cells. These signals have two general effects: (1) they
stimulate protein synthesis from many genes that were silent in resting cells
and (2) they stimulate cells to enter the cell cycle for cell division.
Ion Channel–Linked Receptors

Ion channel–linked receptors are involved in the rapid signaling between
electrically excitable cells such as neurons and muscle cells.5 Remember
that ions have charge, and when ions move through the membrane, they
change local charges, or voltages, and there is an electrical signal in cells.
Many neurotransmitters stimulate this type of signaling by opening or
closing ion channels in the cell membrane.
Intracellular Receptors
Some signals, such as thyroid hormone and steroid hormones, do not bind
to cell surface receptors but move across the cell membrane and bind to
intracellular receptors, and they influence DNA activity. Many of these
hormones bind to a cytoplasmic receptor, and the receptor–hormone
complex enters the nucleus. In the nucleus, the receptor–hormone complex
binds to DNA to change protein synthesis.1
The Cell Cycle and Cell Division
The life cycle of a cell is called the cell cycle. It is usually divided into five
phases (Fig. 2-8):
FIGURE 2-8The cell cycle. G0, nondividing cell; G1, cell growth; S,
deoxyribonucleic acid (DNA) replication; G2, protein synthesis; and
M, mitosis. (From Wingerd B. (2014). The human body. Concepts of
anatomy and physiology (3rd ed.). Philadelphia, PA: Lippincott
Williams & Wilkins.)
1. G0 is when the cell may leave the cell cycle and either remain in a state
of inactivity or reenter the cell cycle at another time.
2. G1 is when the cell begins to prepare for mitosis by increasing proteins,
organelles, and cytoskeletal elements.
3. S phase is the synthesis phase, when DNA synthesis or replication
occurs and the centrioles begin to replicate.
4. G2 is the premitotic phase and is similar to G1 in terms of RNA activity
and protein synthesis.
5. M phase is when cell mitosis occurs.7
Tissues may be made up mostly of cells in G0, but most tissues contain a
combination of cells that are continuously moving through the cell cycle
and cells that occasionally enter the cell cycle. Nondividing cells, such as
neurons and skeletal and cardiac muscle cells, have left the cell cycle and
are not capable of mitotic division in postnatal life.7
Cell Metabolism and Energy Sources

Energy is the ability to do work. Cells use oxygen to transform nutrients
into the energy needed for muscle contraction, the active transport of ions
and other molecules across cell membranes, and the synthesis of enzymes,
hormones, and other macromolecules. Energy metabolism refers to the
processes by which the calorie-containing fats, proteins, and carbohydrates
from the foods we eat are changed into energy or energy sources in the cell.
Catabolism and anabolism are the two phases of metabolism. Catabolism
breaks down nutrients and body tissues to produce energy. Anabolism
builds more complex molecules from simpler ones.
The special carrier for cellular energy is ATP. ATP molecules consist of
adenosine, a nitrogenous base; ribose, a five-carbon sugar; and three
phosphate groups (Fig. 2-9). The phosphate groups are attached by two
high-energy bonds.7 Large amounts of free energy are released when ATP is
cleaved to form adenosine diphosphate (ADP), which contains two
phosphate groups. The free energy released from the cleaving ATP is used
to drive reactions. Energy from nutrients is used to change ADP back to
ATP. Because energy can be “saved or spent” using ATP, ATP is often
called the energy currency of the cell.
FIGURE 2-9 Adenosine triphosphate (ATP) is the major source of
cellular energy. (A) Each molecule of ATP contains two high-energy
bonds, each containing about 12 kcal of potential energy. (B) The
high-energy ATP bonds are in constant flux. They are generated by
substrate (glucose, amino acid, and fat) metabolism and are
consumed as the energy is expended. ADP, adenosine diphosphate.
Energy transformation takes place within the cell through two types of
energy production pathways:
The anaerobic (i.e., without oxygen) glycolytic pathway occurs in the
cytoplasm.
The aerobic (i.e., with oxygen) pathway occurs in the mitochondria.
UNDERSTANDING Cell Metabolism

Cell metabolism is the process that changes the calorie-containing
nutrients (carbohydrates, proteins, and fats) into ATP, which provides for
the energy needs of the cell. ATP is formed through three major
pathways: (1) the glycolytic pathway, (2) the citric acid cycle, and (3) the
electron transport chain. Without oxygen, cells will use the glycolytic
pathway in the cytosol and make two molecules of ATP from one glucose
molecule. With oxygen and mitochondria, cells will make much more
ATP per glucose molecule.
Cells start the energy metabolism process with the anaerobic glycolytic
pathway in the cytoplasm, and if oxygen is present, the pathway moves
into the mitochondria for the aerobic pathway. Both pathways involve
oxidation–reduction reactions involving an electron donor, which is
oxidized in the reaction, and an electron acceptor, which is reduced in the
reaction. In energy metabolism, the breakdown products of carbohydrate,
fat, and protein metabolism donate electrons and are oxidized, and the
coenzymes nicotinamide adenine dinucleotide (NAD+) and flavin adenine
dinucleotide (FAD) accept electrons and are reduced.7
1 Anaerobic Metabolism
Glycolysis (glycol, sugar; lysis, breaking down) is the process by
which energy is released from glucose. It is an important energy provider
for cells that lack mitochondria, the cell organelles where aerobic
metabolism occurs. Glycolysis also provides energy in situations when
delivery of oxygen to the cell is delayed or impaired (e.g., in skeletal
muscle during the first few minutes of exercise).
Glycolysis, which occurs in the cytoplasm of the cell, involves the
splitting of the six-carbon glucose molecule into 2 three-carbon
molecules of pyruvic acid. Because the reaction that splits glucose
requires two molecules of ATP, there is a net gain of only two molecules
of ATP from each molecule of glucose that is metabolized. The process is
anaerobic and does not require oxygen (O2) or produce carbon dioxide
(CO2). When O2 is present, pyruvic acid moves into the mitochondria,
where it enters the aerobic citric acid cycle. Under anaerobic conditions,
such as cardiac arrest or circulatory shock, pyruvate is converted to lactic
acid, allowing glycolysis to continue as a means of supplying cells with
ATP when O2 is lacking.
Converting pyruvate to lactic acid is reversible, and after the oxygen
supply has been restored, lactic acid is converted back to pyruvate and
used for energy or to make glucose.
2 Aerobic Metabolism
Aerobic metabolism occurs in the cell’s mitochondria and involves the
citric acid cycle and the electron transport chain. It is here that the carbon
compounds from the fats, proteins, and carbohydrates in our diet are
broken down and their electrons combined with oxygen to form carbon
dioxide, water, and ATP. Unlike lactic acid, which is an end product of
anaerobic metabolism, carbon dioxide and water are generally harmless
and easily eliminated from the body.7
Under aerobic conditions, both of the pyruvate molecules formed by
the glycolytic pathway enter the mitochondria, where pyruvate combines
with acetyl coenzyme to form acetyl coenzyme A (acetyl-CoA). The
formation of acetyl-CoA begins the reactions in the citric acid cycle, also
called the tricarboxylic acid or Krebs cycle. Some reactions release
CO2, and some transfer electrons from the hydrogen atom to NADH or
FADH. In addition to pyruvate from the glycolysis of glucose, fatty acid
and amino acid breakdown products can also enter the citric acid cycle.
Fatty acids, which are the major source of fuel in the body, are oxidized
to acetyl-CoA for entry into the citric acid cycle.1,6,7

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Vice President and Publisher: Julie K.

Copyright © 2020 Wolters Kluwer.

Printed in the United States of America

Library of Congress Cataloging-in-Publication Data

ISBN-13: 978-1-975107-19-2 | eISBN: 9781975107208

Library of Congress Control Number: 2019911909

Contributors to Essentials of Pathophysiology, Fourth Edition

Jacqueline M. Akert, RNC, MSN, WHNP-BC

Freddy W. Cao, MD, PhD

Paula Cox-North, PhD, ARNP

Herodotos Ellinas, MD, FAAP, FACP

Anne M. Fink, RN, PhD

Susan A. Fontana, PhD, APRN-BC

Nathan A. Ledeboer, PhD, D(ABMM)

Kim Litwack, PhD, RN, FAAN, APNP

Glenn Matfin, MSc (Oxon), MB, ChB, FACE, FACP, FRCP

Patricia McCowen Mehring, RNC, MSN, WHNP

Carrie J. Merkle, PhD, RN, FAAN

Kathleen Mussatto, PhD, RN

Debra Bancroft Rizzo, RN, MSN, FNP-BC

Gladys Simandl, RN, PhD

Aoy Tomita-Mitchell, PhD

Jill M. Winters, RN, PhD, FAHA

Contributors to Porth’s Pathophysiology, Tenth Edition

Sawsan Abuhammad, PhD

Maeghan Arnold, MNSc, APRN, AGACNP-BC

Michele R. Arwood, DNP, MSN, BSN, CNS-BC, NE-BC, CJCP

Trina Barrett, DNP, RN, CNE, CCRN

Cynthia Bautista, PhD, CCRN, SCRN, CCNS, ACNS-BC, FNCS

Hallie Bensinger, DNP, APN, FNP-BC

Jami S. Brown, DHEd, RN, CNN

Melissa Brown, MS, RN

Jacqueline Rosenjack Burchum, DNSc, FNP-BC, CNE

Kathy Diane Butler, DNP, APRN, FNP/GNP-BC, NP-C

Freddy W. Cao, MD, PhD

Jaclyn Conelius, PhD, FNP-BC, FHRS

Herodotos Ellinas, MD, FAAP/FACP

Deena Garner, DNP, RN

Sandeep Gopalakrishnan, PhD

Lisa Hight, EdD

Deborah L. Hopla, DNP, APRN-BC, FAANP

Christine Paquin Kurtz, DNP

Elizabeth M. Long, DNP, APRN-BC, CNS

Tracy McClinton, DNP, AG-ACNP, BC

Linda C. Mefford, PhD, MSN, APRN, NNP-BC, RNC-NIC

Sarah Morgan, PhD, RN

Nancy A. Moriber, PhD, MSN, BSN, CRNA, APRN

Emma Murray, DNP, APRN, ACNP-BC

Cheryl Neudauer, PhD, MEd

Stephanie Nikbakht, DNP, PPCNP-BC

Alyssa Norris, MS, RD, LDN, CLC

Keevia Porter, DNP, NP-C

Michelle Rickard, DNP, CPNP-AC

Archie Sims, MSN

Diane Smith, DNP, FNP-BC

Ansley Grimes Stanfill, PhD, RN

Sharon Stevenson, DNP, APRN, PPCNP-BC

James Mark Tanner, DNP, RN