Werner’s A Massage Therapist’s Guide to Pathology (Fifth Edition)

Chapter 5— Circulatory System Conditions

Werner’s A Massage Therapist’s Guide to Pathology (Fifth Edition)

Lesson Plans

Chapter 5 — Circulatory System Conditions

Goals of the Lesson:

Cognitive: Students will be able to understand the general functionality of the circulatory system, as well as the circulatory system conditions and blood disorders.

Motor: N/A

Affective: Students will be able to aid in the early detection of circulatory conditions as well as identify the proper modality treatments required.

Learning Objectives:

The lesson plan for each objective starts on the page shown below.

5-1Name two deficiencies that may cause nutritional anemia...... 03

5-2Name the most likely final destination for loose blood clots on the venous side of the systemic circuit...... 05

5-3Name three possible destinations for loose blood clots or other debris on the arterial side of the systemic circuit..08

5-4Identify the most likely consequence of untreated hemophilia...... 10

5-5Name two signs or symptoms of deep vein thrombosis...... 13

5-6Name the tissue that is damaged first in chronic hypertension...... 16

5-7Name three controllable risk factors for the development of atherosclerosis...... 19

5-8Name the difference between primary and secondary Raynaud syndrome...... 23

5-9Name two factors that determine the severity of a heart attack...... 26

5-10Describe how right-sided heart failure can develop as a result of left-sided heart failure...... 29

You Will Need:

Gather the following materials and teaching aids for the following lessons:

5-5Freshly cut stalks of celery, glasses half full of water, and dark food coloring.

5-6Depending on the size of the class, you will need table salt, soda, water, milk, and bowls for each group of students.

Legend: IR = instructor’s resource;SR = student resource;PPt = PowerPoint.

Objective 5-1

Name two deficiencies that may cause nutritional anemia.Date:

Lecture Outline

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Figures, Tables, and Features

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Resources and

In-Class Activities

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Outside Assignments

Evaluation

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Instructor’s Notes

Content / Text page / PPt slide
Circulatory System Conditions
Blood Disorders
  • Anemia
  • Embolism, thrombus
  • Hematoma
  • Hemophilia
  • Leukemia
  • Malaria
  • Myeloma
  • Sickle cell disease
  • Thrombophlebitis, deep vein thrombosis
Vascular Disorders
  • Aneurysm
  • Atherosclerosis
  • Hypertension
  • Raynaud syndrome
  • Varicose veins
Heart Conditions
  • Heart attack
  • Heart failure
Anemia = Insufficient oxygen-carrying capacity
Often a symptom or complication rather than freestanding problem
Affects about 3.4 million people in US
  • Most are women or peoples with chronic disease
Several kinds of anemia
  • Idiopathic anemias
  • Nutritional anemias
  • Hemorrhagic anemias
  • Hemolytic anemias
  • Aplastic anemia
  • Secondary anemias
Nutritional anemias
Some deficiency in diet; massage won’t have much affect
Cautions for pernicious anemia
Iron deficiency anemia
  • Needed to form hemoglobin
  • Most common in women: need twice as much iron as men; get fewer calories
  • Pregnant women especially
Folic acid deficiency anemia
  • Needed to form RBCs
  • Water soluble: any excess can’t be stored
Pernicious anemia
  • Inadequate Vitamin B12: not enough in diet (vegans) or poor access in stomach (lack of intrinsic factor)
  • Can lead to central nervous system (CNS) damage, anemia
Other nutritional deficiencies
  • Copper, protein, others
/ 228-232 / 12-23 / Features
Anemia
p. 229
Figures
5.2: Different types of white blood cells
p. 229
5.3: Iron deficiency anemia
p. 230 / Resources
Answer to Chapter Objectives (SR)
Answers to Chapter Review Questions (SR)
In-Class Activities
Through discussion, provide a list of symptoms describing a blood disorder, asking students to identify the appropriate disorder. / Outside Assignments
Certain kinds of nutritional anemia can be prevented or treated through diet. Have students research iron deficiency anemia, listing foods that counteract, as well as those foods that can continue the deficiency.
Evaluation
Chapter review questions: Circulatory System Conditions.
p.270

Legend: IR = instructor’s resource;SR = student resource;PPt = PowerPoint.

Objective 5-2

Name the most likely final destination for loose blood clots on the venous side of the systemic circuit. Date:

Lecture Outline

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Figures, Tables, and Features

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Resources and

In-Class Activities

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Outside Assignments

Evaluation

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Instructor’s Notes

Content / Text page / PPt slide
Embolism: traveling clot
Platelets flow through circulatory system; activated by any rough spot or inflammatory chemicals
Clots form at sites of damage, areas of slow, irregular blood flow
Emboli travel until vessel is too small
Pulmonary embolism
The lungs are the one and only destination for clots or debris anywhere on the venous side of the systemic circuit
  • Unless the heart has patent foramen ovale
From a clot that forms on venous side of systemic circuit (Fig. 5.5)
650,000 pulmonary emboli/year
200,000 deaths
Often related to deep vein thrombosis (DVT), complications of trauma, orthopedic surgery
Risk factors for pulmonary embolism
Other types of cardiovascular disease, recent trauma, bed rest, surgery, pregnancy, recent childbirth, overweight, smoking, birth control hormones, hormone replacement therapy
  • Number 3 cause of death in hospital setting
Signs and symptoms of pulmonary embolism
Usually none until after damage has occurred
Dyspnea, chest pain, coughing with bloody sputum
Can look like heart attack
Complications of pulmonary embolism
Increased risk of another event
Loss of lung function → right-sided heart failure
Treatment
Thrombolytics, anticoagulants
Surgery if necessary
Prevention
Identify risk
Low-dose presurgical anticoagulants
Elevation of legs
External compression of legs
Early ambulation / 232-235 / 25-30 / Features
Embolism, Thrombus
p. 232
Sidebar 5.1 DVT+PE = VTE
p. 235
Figures
5.4: A thrombus is a
lodged clot; an embolus is a
moving piece of debris
p. 233
5.5: Sites of origin for pulmonary emboli
p. 233 / Resources
Answer to Chapter Objectives (SR)
Answers to Chapter Review Questions (SR)
In-Class Activities
The signs and symptoms of pulmonary embolism can look like a heart attack. Through discussion, ask students to identify key differentiating factors between the two. / Outside Assignments
The term “embolism” was coined in 1848 by Rudolph Carl Virchow. Ask students to research Virchow and his significance in the study of pathologies.
Evaluation
Chapter review questions: Circulatory System Conditions.
p.270

Legend: IR = instructor’s resource; SR = student resource; PPt = PowerPoint.

Objective 5-3

Name three possible destinations for loose blood clots or other debris on the arterial sideof the systemic circuit. Date:

Lecture Outline

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Figures, Tables, and Features

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Resources and

In-Class Activities

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Outside Assignments

Evaluation

/

Instructor’s Notes

Content / Text page / PPt slide
Arterial embolism
Complication of atherosclerosis
  • Could also be from bacterial infection, atrial fibrillation, rheumatic heart disease
Emboli are usually clots
  • Can also be plaque, bone chip, bubble, knot of cancer cells
When septum is intact
  • All venous emboli travel to lungs
  • Arterial emboli can go anywhere except the lungs
  • Coronary artery (heart attack)
  • Carotid/ cervical artery (stroke)
  • Renal artery (renal infarction)
  • Femoral artery (muscle infarction)
  • Other
Signs and Symptoms
May be silent
May involve sharp tingling pain, tissue damage, and death
Treatment
Prophylactic anticoagulants
Massage
Rigorous circulatory massage is contraindicated for clients who tend to form clots
Cautions with anticoagulant medications / 234-235 / 31-36 / Figure
5.6: Arterial infarction sites / Resources
Answer to Chapter Objectives (SR)
Answers to Chapter Review Questions (SR)
Related Chapters
Cerebral aneurysms are discussed in the section on
stroke in Chapter 4.
In-Class Activities
Most modality recommendations for embolism are contraindicated except PNF/MET/Stretching. Through discussion, ask students to identify why this modality is considered supportive. / Outside Assignments
The most commonly used method to predict clinical probability of pulmonary embolism is the Wells score. Ask students to research how this prediction rule has evolved since 1995.
Evaluation
Chapter review questions: Circulatory System Conditions.
p.270

Legend: IR = instructor’s resource;SR = student resource;PPt = PowerPoint.

Objective 5-4

Identify the most likely consequence of untreated hemophilia.Date:

Lecture Outline

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Figures, Tables, and Features

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Resources and

In-Class Activities

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Outside Assignments

Evaluation

/

Instructor’s Notes

Content / Text page / PPt slide
Hemophilia = Genetic disorder characterized by absence of various clotting factors
Affects about 18,000 men in US
About 400 new cases/year
  • Carried on X-chromosome: women are carriers who pass it to their sons
About one-third of cases are spontaneous mutations
It is possible but rare for women to have hemophilia
Etiology
Hemophilia A (80% of cases)
  • Deficiency in clotting factor VIII
Hemophilia B (also called Christmas disease) (15% of cases)
  • Deficiency in clotting factor IX
Other: much rarer than A or B
Person with hemophilia has difficulty forming solid, long-lasting clots
  • Don’t bleed faster, do bleed longer than others
Rated as mild, moderate, severe
  • Severe hemophilia = 60% of diagnoses; <1% normal clotting factors
Signs and Symptoms
Signs at birth: umbilical cord bleeds excessively
Early childhood: infant/toddler accidents
Bruising, hematomas, nosebleeds, hematuria, joint pain from bleeds into capsule
Complications
Leading cause of death in children with hemophilia is intracranial bleeding
Bleeding into joint capsules with inflammation and extensive damage
  • Hemophiliac arthritis
  • Ankles, knees, elbows
Muscle and nerve damage
Infected blood products
  • Vaccinate for hepatitis A, B
Resistance, hypersensitivity to synthetic clotting factors
Treatment
Supplement clotting factors
  • Can be done at home now, prophylactically or after injury
Careful exercise, weight control
Massage
Rigorous mechanical massage is contraindicated
Energetic work appropriate and helpful for stress, pain relief / 235-237 / 38-46 / Features
Hemophilia
p. 235 / Resources
Answer to Chapter Objectives (SR)
Answers to Chapter Review Questions (SR)
In-Class Activities
The word hemophilia is formed from the word roots “hemo” and “philia.” Pair students into groups of two. Ask the groups to come up with as many different medical terms as possible using either “hemo” or “philia.” / Outside Assignments
Hemophilia is sometimes called “the royal disease.” Ask students to write a report researching the derivation of this nickname.
Evaluation
Chapter review questions: Circulatory System Conditions.
p. 270

Legend: IR = instructor’s resource; SR = student resource; PPt = PowerPoint.

Objective 5-5

Name two signs or symptoms of deep vein thrombosis.Date:

Lecture Outline

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Figures, Tables, and Features

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Resources and

In-Class Activities

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Outside Assignments

Evaluation

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Instructor’s Notes

Content / Text page / PPt slide
Thrombophlebitis, Deep Vein Thrombosis = Veins have become obstructed with clots
Usually calves, thighs, pelvis
Thrombophlebitis = lesser, greater saphenous veins
DVT = popliteal, femoral, iliac veins
Etiology
Thrombi = stationary clots; can fragment and travel
  • Usually to lung → pulmonary embolism
  • Exception with patent foramen ovale; cross over to arterial side
Virchow triad
  • Injury to endothelium
  • Hypercoagulability
  • Venous stasis
Possible triggers
  • Physical trauma
  • Varicose veins
  • Local infection
  • Reduced circulation
  • Immobility
  • Pregnancy and childbirth
  • Certain types of cancer
  • Surgery
  • High-estrogen birth control pills or hormone replacement therapy
  • Otherfactors: cigarette smoking, hypertension, paralysis, and some genetic conditions
Clot forms; sudden movement or change in position causes debris to break off and travel
Signs and Symptoms
May be obvious with signs of inflammation
Sometimes distal edema
Chronic problem → skin rashes, ulcers
With infection: fever, malaise
DVT more dangerous, higher risk of serious damage
  • May show pitting edema
Diagnosis
Ultrasound: fast, noninvasive, high chance of false positive
Venography: more accurate, slower, more risk of damage
MRI: fast, noninvasive, accurate, expensive, not available everywhere
Treatment
Thrombolytics to break clots; anticoagulants to prevent future ones
Risk of bleeding
Pneumatic compression, support hose for DVT
Superficial thrombophlebitis: hot packs, analgesics, gentle exercise
Vena cava filter
Massage
A client with diagnosed blood clots is not a good candidate for circulatory massage
Signs may be indistinct, misleading / 244-248 / 77-84 / Features
Thrombophlebitis, Deep Vein Thrombosis
p. 245
Case History 5.1 Deep Vein Thrombosis
p. 246
Figures
5.9 Deep vein thrombosis
p. 247 / Resources
Answer to Chapter Objectives (SR)
Answers to Chapter Review Questions (SR)
In-Class Activities
Similar to the way our blood flows through our veins and arteries, a piece of celery uses a process called transpiration. Divide the class into small groups. Provide each group with a clear glass, water, dark food coloring, and a stalk of celery. Have the groups add the food coloring to the water, then place the stalk of celery in the water with the leafy side facing up. Throughout the class, have the students check the progress of the colored water throughout the celery’s “vascular bundle.”
Materials
Freshly cut stalks of celery, glasses half full of water, and dark food coloring. / Outside Assignments
Deep vein thrombosis has been nicknamed “economy class syndrome.” Ask students to research and write a report on this nickname.
Evaluation
Chapter review questions: Circulatory System Conditions.
p.270

Legend: IR = instructor’s resource;SR = student resource;PPt = PowerPoint.

Objective 5-6

Name the tissue that is damaged first in chronic hypertension.Date:

Lecture Outline

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Figures, Tables, and Features

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Resources and

In-Class Activities

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Outside Assignments

Evaluation

/

Instructor’s Notes

Content / Text page / PPt slide
Hypertension = High blood pressure
Persistently above 140/90
Etiology
Blood pressure variables
  • Pressure inside vessels
  • Pressure outside vessels
  • Blood volume
  • Vessel diameter
Types of high blood pressure
Essential: 95%
Secondary (temporary complication)
Malignant hypertension: diastolic rises very quickly—medical emergency
Blood pressure readings
Risk of damage to vessels begins when systolic > 115, diastolic > 75
A measurement is based on two or more readings at different office visits
Signs and Symptoms
Silent killer
Shortness of breath; headache/dizziness; swelling of ankles; sweating, anxiety
Complications
Edema
Atherosclerosis
Stroke
Enlarged heart, heart failure
Aneurysm
Kidney disease
Vision problems
Treatment
Of 65 million with hypertension in US
  • 63.4% know
  • 45.3% treat it at all
  • 29.3% treat it successfully
70% of people with hypertension don’t control it well enough to prevent complications
DASH diet
Exercise
Medication
  • Diuretics, vasodilators, beta-blockers
  • Medication causes side effects; high blood pressure has no symptoms
Massage
Depends on health, resilience of client
Massage can lower blood pressure and stress
  • Get information on kidney, heart problems
  • No deep abdominal work
/ 255-258 / 114-124 / Features
Hypertension
p. 256
Tables
5.1: Blood Pressure Ratings
p. 256
Sidebar 5.4 Heart Disease in the United States: Sobering Statistics
p. 256 / Resources
Animation (SR)
Answer to Chapter Objectives (SR)
Answers to Chapter Review Questions (SR)
In-Class Activities
Salt is a highly absorptive substance. Divide the class into small groups providing each with the materials to conduct an experiment illustrating the absorptive properties of table salt. Each group will need a container of salt, and three different liquids varying in chemical makeup (milk, soda, water). Instruct each group to pour a small amount of each liquid into separate bowls, pouring a mound of salt on top. The groups should document the time differences in the absorption, applying theories explaining why they achieved those results.
Materials
Depending on the size of the class, you will need table salt, soda, water, milk, and bowls for each group of students.
Video: For more information on blood pressure see the animation at thePoint.lww.com/Werner5e / Outside Assignments
Sodium is an environmental factor of hypertension that relieves a lot of attention. Ask students to research how salt consumption can affect a person’s bloodstream.
Evaluation
Chapter review questions: Circulatory System Conditions.
p.270

Legend: IR = instructor’s resource; SR = student resource; PPt = PowerPoint.

Objective 5-7

Name three controllable risk factors for the development of atherosclerosis.Date:

Lecture Outline

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Figures, Tables, and Features

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Resources and

In-Class Activities

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Outside Assignments

Evaluation

/

Instructor’s Notes

Content / Text page / PPt slide
Atherosclerosis = hardening of the arteries from any cause
Subtype of arteriosclerosis
Hardening of arteries due to plaque
  • Damage causes spasm, blood clots
  • Diameter is occluded (Fig. 5-9)
Coronary artery disease (CAD) = atherosclerosis at coronary arteries (Fig. 5-14)
Etiology
Multifactorial process
  • Influenced by gender, age, race, diet, and other factors
Basic progression
  • 1. Endothelial damage
  • Carbon monoxide; high levels of low-density lipoproteins (LDLs) and triglycerides; high iron.
  • Occurs most readily at branches or sharp curves
  • 2. Monocytes arrive, move in, become macrophages
  • 3. Macrophages take up LDL.
  • Become foam cells: beginning of plaque
  • 4. Foam cells infiltrate and damage smooth muscle tissue.
  • Secrete growth factors that cause smooth muscle cells to proliferate
  • Release enzymes that damage arterial walls, promote clotting
  • 5. Platelets arrive
  • Secrete growth factors
  • Form clots
  • Cause vascular spasm
Unchangeable risk factors
Heredity, genetics
Gender
Age
Kidney disorders
Modifiable risk factors
Smoking
High cholesterol levels
High blood pressure
Sedentary lifestyle
Diabetes
Other Risk Factors
C-reactive protein
Homocysteine
Others: BMI, fibrinogen, lipoproteins, stress management, etc.
Signs and Symptoms
None early: 50% occlusion before dysfunction
Angiogenesis, adaptability
Later: poor stamina, shortness of breath, complications
Complications
High blood pressure
Aneurysm
Arrhythmia
Thrombus or embolism, peripheral vascular disease
Angina pectoris
  • Stable angina pectoris
  • Unstable angina pectoris
Heart attack
Diagnosis
Angiogram, CT, blood tests, echocardiogram, ultrasound, ankle-brachial index
Treatment
Diet and exercise
Drugs
  • Lower blood pressure, cholesterol, platelet activity
Surgery
  • Bypass, angioplasty, endarterectomy
Massage
Determined by client’s resilience
Adjust for medications as needed / 250-254 / 98-112 / Features
Artherosclerosis
p. 251
Sidebar 5.2: A Brief Digression on Cholesterol
p. 252
Figures
5.12: Atherosclerosis.
p. 251
5.13: Carotid artery disease. Note the point of stenosis just past the bifurcation
p. 254
5.14: Coronary artery disease
p. 254 / Resources
Animation (SR)
Answer to Chapter Objectives (SR)
Answers to Chapter Review Questions (SR)
Resources
Answer to Chapter Objectives (SR)
Answers to Chapter Review Questions (SR)
In-Class Activities
Pair students in groups of two, asking each group to come up with as many risk factors for arteriolosclerosis as possible. Through discussion, ask the class as a whole to classify each factor as unchangeable or modifiable.
Video: For more information on monocytes see the animation at thePoint.lww.com/Werner5e / Outside Assignments
The terms “arteriosclerosis,” “arteriolosclerosis,” and “atherosclerosis” are very similar, yet distinct, in both spelling and meaning. Ask students to research the differences comparing and contrasting the three.
Evaluation
Chapter review questions: Circulatory System Conditions.
p.270

Legend: IR = instructor’s resource; SR = student resource; PPt = PowerPoint.