Maslovian Approach to Clinical Reasoning Physiological Needs (Ground Floor of Hierarchy) Basic Human Function in Health Examples of Pathological

l Conditions Need (not a comprehensive list) Oxygenation Partial pressure of oxygen in Sudden cabin decompression at altitude atmosphere favors diffusion Altitude sickness into the cells All airways are patent (larynx Foreign body aspiration (steak-house coronary) alveolar ducts) Post anesthesia laryngospasm Epiglottitis Loss of protective reflexes with depressed level of consciousness Bronchiectasis Acute (i.e., reversible) and chronic obstructive pulmonary disease Ability to move chest wall Respiratory control centers stop functioning or are and attached lung in and out severely depressed (inhale/exhale) (Heroin OD, Brain stem herniation, , etc.) Motor neuron connections from brain to respiratory muscles fail (Guillian-Barr syndrome, high cervical spinal cord transection, botulism, etc) Chest wall not intact (flail chest) does not move symmetrically Capillarity in potential space between parietal and pleural membranes is disrupted (Hemothorax, pneumothorax, pleural effusion)

Pulmonary parenchyma has the right amount of elastic tension

Alveolar perfusion matches alveolar ventilation (V/Q balance)

There are enough RBCs and hemoglobin to transport oxygen to the tissues There is enough volume in the vasculature to transport oxygen Deoxygenated blood transits to the lungs under low

Massive obesity (particularly with sleep and/or general anesthesia) Severe chest/abdominal pain causing splinting and hypoventilation Too little elastic recoil producing high functional residual capacity (overinflated lungs, i.e., emphysema) Too much recoil producing small, stiff lungs and a low functional residual capacity (Restrictive lung diseases such as rheumatoid lung, ARDS) Note: early pulmonary edema causes heavy lungs that are more difficult to ventilate, causing a functionally restrictive lesion Some alveoli are perfused but not ventilated (i.e., intrapulmonary shunt returning desaturated blood to the left side of the heart) Examples: Pneumonia, atelectasis Alveoli are ventilated but not perfused (pulmonary embolus) Anemia (ex: nutritional, blood loss, radiation/chemo, hemolytic) Carbon monoxide poisoning Shock (hemorrhagic, neurogenic, toxic, anaphylactic) Severe dehydration Third spacing Pulmonary hypertension (Cor pulmonale) Tricuspid and/or mitral valve are stenotic or

pressure

Oxygenated blood from the lungs transits to the body (via the aorta) under high pressure Oxygen-rich blood travels to the tissues with no arterial obstruction

Oxygen-poor blood returns to the heart from the periphery Oxygen diffuses into cell, enters mitochondria and participates in oxidative phosphorylation and ATP production

insufficient Right sided heart failure (Ischemic heart disease, cardiomyopathy) Electrical disturbances (A-fib, SVY, V-fib, heart block, asystole, etc.) Aortic stenosis or insufficiency Left sided heart failure (chronic hypertension, CAD, cardiomyopathy) Electrical disruptions in myocardium (A-fib, SVY, V-fib, heart block, asystole, etc.) Aortic aneurysm, atherosclerotic plaque in any artery (coronary, carotid, femoral-popliteal) vasospasm (as in post subaracnoid hemorrhage) Transection of major arteries (as in trauma) Compression of arteries (compartment syndrome) Venous return to the heart is impeded (varicosities, venous stasis, portal hypertension and consequent varicies in gut) Deep vein thrombosis Re-feeding syndrome Cyanide

Fluid and Electrolytes and Acidbase Balance

Inability to drink (loss of consciousness, lack of water) Excessive loss (vomiting, diarrhea, excessive sweating, insensible loss, polyuria, diuretic overuse) Psychogenic polydipsia, inadequate output (as in renal failure) Intravascular volume stays in Decreased intravascular oncotic pressure (decreased homeostatic relationship with serum proteins) interstitial fluid and between Increased hydrostatic pressure (portal hypertension, other fluid compartments prolonged standing) Vasculature becomes leaky and/or profoundly dilated (anaphylaxis and burns) Blockage of lymphatic system (radical mastectomy with node resection) Portal hypertension and/or heart failure = fluid to moves into pleural space and/or abdominal cavities) + [Na ] is physiological ([Cl ] Hypernatremia: usually reflects [Na+] excessive intake of Na+ dehydration excessive sweating with Na+-poor replacement Hyponatremia: SIADH Polydipsia Extreme hyperglycemia (hypothalamus signals kidneys to dump Na+ to maintain physiologic osmolality)

Intake and output are balanced

[K+] is physiological

[HCO3- ] in peripheral blood and extracellular fluid is physiological

[Ca2+] is physiological

Hypokalemia: Excessive loss due to loop diuretics, vomiting and diarrhea Hypokalemia after excessive infusions of K+ poor fluid, Hypokalemia from intemperate correction of DKA Hyperkalemia: reduced obligatory loss via kidneys Crush injuries and burns Acidosis (Excess H+ move into cells and displace K+ to maintain electrical neutrality ) Reduced serum bicarbonate almost always secondary to metabolic acidosis (fixed acids provide H+ ions that bind to and consume available buffers) Elevated serum bicarbonate Excessive (psychogenic?) intake of bicarbonate Most common cause is chronic respiratory acidosis (Renal compensation for chronic alveolar hypoventilation associated with COPD) Hypercalcemia: Rapid bone demineralization (multiple myeloma, hyperparathyroidism) Reduced renal excretion Hypocalcemia: Hypoparathyroidism

[Mg2+] is physiological

Vit. D deficiency pseudo-hypocalcemia is due to serum albumin (to which Ca2+ is bound) and seen in conditions such as liver failure. Ionic [Ca2+] (active form) is not perturbed Hypermagnesemia: Decreased excretion (as in renal failure) Excessive intake of Mg2+ containing antacids Hypomagnesemia: Inadequate intake (starvation, alcoholism) Refeeding syndrome ( Intemperate correction of DKA Hyperphosphatemia: Reduced renal excretion of PO4- (renal failure) Abnormal intake of [PO4-] (Phospho-soda laxative abuse) Hypoparathyroidism Hypophosphatemia: Inadequate intake (starvation) Sudden consumption by cells previously starved (refeeding syndrome) Hypovitaminosis D Hyperparathyroidism Acidosis ( [H+])

[PO4-] is physiological

[H+]balance is maintained

Nutrition

Alveolar hypoventilation (with retained CO2 and consequent dissociation of carbonic acid) Metabolic acidosis (production of fixed acids that consume available buffers) o Renal failure (inability to excrete accumulating end-products of metabolism) o Diabetic ketoacidosis (ketone body production) o Sepsis (lactate) Alkalosis ([H+]) Hyperventilation (overblowing the ventilator, psychogenic dyspnea) Excessive intake of buffers (antacids) very rare Availability of foods of high Famine nutritional value and access Poverty to them Food deserts Knowledge of principles of Eating habits centered around foods with high good nutrition and a taste for sugar, fat and/or salt content balanced diet Lack of knowledge about quality nutrition (RDAs, food pyramid) Budgetary constraints Ability to take in food (a Depressed sensorium (level of consciousness) normal appetite) Impaired swallow, gag, cough reflexes Poor dentition, mucocitis (as in chemo-related), broken/wired jaw Nausea and vomiting

between pH 7.35 and 7.45 (arterial)

GI tract that absorbs nutrients and water from diet

Pancreatic enzymes and bile that break food into simple sugars, fatty acids and peptides

Intake of nutrients meet metabolic needs Sugar moves from the circulation into the cells Large bowel evacuates normal, soft stool every 1-3 days

Elimination (Urine and Stool)

Anorexia nervosa/Bulimia Diseases of GI tract Esophageal achalasia H. pylori, gastric/duodenal ulcers Inflammatory bowel diseases Ileus and pseudoileus Tumors of the GI tract Pernicious anemia (lack of intrinsic factor) Disruption of excretion of digestive enzymes (cystic fibrosis) Pancreatitis Cholelithiasis and obstruction of the common bile duct Damage to bile caniculae of liver inflammation (hepatitis) scarring (cirrhosis) Hypermetabolic states malignancy fever Lack of insulin (DM Type I) Insulin resistance (DM Type II) Motility is too fast, or bowel is too short. Water is inadequately reabsorbed and/or water exudes into the GI tract infection/inflammation (cholera, dysentery, norovirus)

Bladder sequesters urine from kidney via ureters and empties on demand

Rest and Recovery

The body can relax while awake and asleep. Normal diurnal rhythm

short gut (surgical removal or rerouting of small bowel) Vagal nerve hyperexcitability Irritable bowel syndrome (diarrhea) Motility and secretory functions of bowel are impaired Dehydration Anticholinergic medications Autonomic neuropathy Irritable bowel syndrome (constipation) Obstructed ureter(s) Tumor Renal calculi Outflow from bladder is impaired Anticholinergic drug effects Enlarged prostate Neurogenic bladder Bladder is incontinent Spastic bladder Stress incontinence Enuresis Depressed level of consciousness Pain Muscle spasm Anxiety Abuse of benzodiazepines and other sedating

Sleep cycles normally during the night

Mobility

Normal weight-bearing ability, range of motion and muscle tone

Neuromotor and sensory connections between brain and limbs/trunk are intact

Tactile and kinesthetic senses are intact (position sense)

medications Use/abuse of caffeine, nicotine, amphetamines (Ritalin, Aterol) Delirium and dementia (sundowning) Depression Anxiety Sleep apnea Over-use of hypnotics Noisy or chaotic environment (as in most nursing units) Excessive weight Cartilage deterioration, bone-on-bone pain Rheumatoid arthritis Muscle weakness (chronic debility, pain, radiculopathy) Fractures Sprains, strains, dislocations Paralysis/weakness of one or more limbs Stroke Spinal cord injury Guillian-Barr syndrome ALS Multiple sclerosis Neuropathy Diabetic Vica alkaloids Lesions in cerebellum and/or basal ganglia

PPhysiological Homeostasis

Intact cortex interprets environment and context

Special senses are intact Autonomic stability

Functioning and wellregulated immune system

Pathogens remain outside the body

Blood remains in the

Frontal lobe injury Intracranial bleeds Increased intracranial pressure Intoxication/delirium Blindness, visual field cuts, presbyopia Hardness of hearing Autonomic neuropathy (Parkinsons disease, chronic hyperglycemia) Sympathetic blockade (Ganglionic and -blockers) Inflammatory processes suppressed chronic disease glucocorticoids anti-rejection medications Inflammatory system is weaponized to attack self (autoimmune diseases) Multiple sclerosis Crohns disease/ulcerative colitis Rheumatoid arthritis Type-I allergic reactions Hay-fever, eczema, anaphylaxis Break in skin or mucous membrane Ischemic bowel Aspiration of GI contents into lungs Destruction of normal flora (candida, c-diff) Trauma, severing of large veins/arteries

 Super-therapeutic doses of anticoagulants Erosions through mucosa to large blood vessels (peptic/duodenal ulcers, esophageal varices) Consumption of clotting factors (disseminated intravascular coagulopathy) Blood flows freely Hypercoagulability throughout arteries to tissue Dehydration and stasis beds and back into central o Prolonged bedrest circulation and to the right o DVT/PE side of the heart Coagulopathy o Factor V Leiden o Antithrombin deficiency Anterior pituitary regulates Adenomas or other tumors of pituitary cause hyper or rate of cell growth, fertility hypopituitarism and metabolism ACTH secreting tumors Classic Cushings disease TSH secreting tumors Secondary hyperthyroidism Growth hormone secreting tumors Acromegaly, hyperglycemia LH/FSH secreting tumors hypogonadism Thyroid gland regulates rate Primary hyperthyroidism (toxic nodules, Graves of cell metabolism disease) Secondary hyperthyroidism (see above) Parathyroid gland controls Hyperparathyroidism causes hypercalcemia and

vasculature and clots appropriately in the event of injury

 Serum Ca2+ levels decalcification of bone Complementary action Hypoparathyroidism produces hypocalcemia (shifts Ca2+ of osteoclasts and to bone and decreases absorption of Ca2+ from the gut osteoblasts to keep bone healthy Increases conversion of inactive Vit. D to active forms Decreases reabsorption of phosphate by kidneys Adrenal glands produce Hypersecretion from one or both adrenal glands cortisol that prepares the (adenomas/carcinomas) produces Cushings body for stress syndrome Exogenous glucocorticoids are taken (prednisone, methylprednisolone) Hyposecretion from both adrenal glands (primary failure or secondary to ACTH from pituitary) produces Addisons disease