medical surgical nursing; pathophysiology
TRANSCRIPT
Medical-Surgical Nursing
(Stress, Inflammation and Pain)
Dynamic Balance: Steady Balance
Claude Bernard: “Fixity of internal milieu” Walter Cannon: “ Homeostasis” Rene Jules Dubos: “Homeostasis and Adaptation”
o Homeostasis- stead state within the body.
Stress and Adaptation
Stress
A disruptive condition that occurs in response to adverse influences from the internal or external environments.
It is a state produced by a change in the environment that is perceived as challenging, threatening, or damaging to a person’s dynamic balance or equilibrium.
Adaptation
It is a constant, ongoing process that requires change in structure, function, or behavior so that a person is better suited to the environment.
A change or alteration designed to assist in adapting to a new situation or environment.
Types of Stressors
Physical Stressors- cold, heat, chemical agents. Biological/ Physiological- pain and fatigue. Psychosocial- fear of failing exams, loss of job and waiting for the result of
a diagnostic exam. Day to day frustration/hassles- caught in traffic jam, experiencing
computer down time, having argument with a roommate/spouse. Major complex occurrence involving large group- terrorism, war Stressors that occur less frequently and involving fewer people- death,
birth, marriage, divorce and retirement. Acute, time-limited stressors- studying foe final exam. Stressor sequence- series of stressful events Chronic intermittent stressors- daily hassles. Chronic enduring stressors that persistent over time- chronic illness,
disability, poverty.
Psychological Response to Stress (LAZARUS)
Appraisal of the Stressful Evento Cognitive appraisal- is a process by which an event is evaluated with
respect to what is at stake (primary appraisal) and what might and can be done (secondary appraisal).
o Primary Appraisal- results in the situation being identified as either nonstressful or stressful.
o Secondary Appraisal- is an evaluation of what might and can be done about the situation.
o Reappraisal- a change of opinion based on new information, also occurs.
Coping With the Stressful Evento Emotion Focus Coping- seeks t make the person fell better by
lessening the emotional distress.o Problem-focus coping- aims to make direct changes in the
environment so that the situation can be managed more effectively.
Physiologic Response to Stress
Selye’s Theory of Adaptation
o General Adaptation Syndrome Alarm- is defensive and anti-inflammatory but self-limiting Resistance- adaptation to the noxious stressor occurs, and
cortisol activity is still increased. Exhaustion- endocrine activity increases and this has negative
effects on the body systems that can lead to death.
o Local Adaptation Syndrome Inflammatory Response and repair.
Sympathetic-Adrenal-Medullary Response to Stress
Effects Purpose Mechanism
Increased heart rate and blood pressure
Better perfusion of vital organs
Increased cardiac output due to increased myocardial contractility and heart rate; increased venous return.
Increased blood glucose level
Increased available energy
Increased liver and muscle glycogen breakdown; increased breakdown of adipose
tissue triglycerides
Mental Acuity Alert state Increased amount of blood shunted to the brain from the abdominal viscera and skin.
Dilated pupils Increased awareness Contraction of radial muscle of iris
Increased tension of skeletal muscles
Preparedness for activity, decreased fatigue
Excitation of muscle; increase in amount of blood shunted to the muscle from the abdominal viscera and skin.
Increased ventilation Provision of oxygen for energy
Stimulation of respiratory center in the medulla; bronchodilation.
Increased coagulability of blood
Prevention of hemorrhage in event of trauma
Vasoconstriction of surface vessels
Maladaptive Response to Stress
o Maladaptive- ineffective response to stress.
Cellular adaptation
Cells
o Complex units that dynamically respond to the changing demand and stress of daily life
o Possess a maintenance function and a specialized functiono Can adapt to environmental stress through structural and functional
changeso Examples of adaptation
Hypertrophy, atrophy, hyperplasia, dysplasia, metaplasia Reflect changes in the normal cells in response to stress
Maintenance functiono Activities that the cell must perform with respect to itself
Specialized functiono The cell performs in relation to the tissues and organs of which it is a
part
Hypertrophy and atrophyo Lead to the changes in the size of cells
Compensatory hypertrophyo Result of an enlarged muscle mass o Commonly occurs in skeletal and cardiac muscle that experiences a
prolonged, increased workload
Hypertrophyo Increase in the size leading to the increase in organ sizeo Stimulus: increase workloado Example
Leg muscles of runner Arm muscles in tennis player Cardiac muscle in person with hypertension
Atrophyo Can be the consequence of:
a. Diseaseb. Decreased usec. Decreased blood supplyd. Loss of nerve supplye. Inadequate nutrition
o Cell size and organ size decreased
o Structure principally affected:a. Skeletal muscleb. Secondary sex organsc. Heartd. Brain
o Shrinkage in size of cells leading to decrease in organ size
o Stimulus: decrease ina. Useb. Blood supply c. Nutrition
d. Hormonal stimulatione. Innervation
o Example Secondary sex organs in aging person Extremity immobilized in cast
Disuse of a body partso Often associated with the aging process and immobilization
Hyperplasiao Increase in the number of new cells in an organ or tissue
o Tissue mass enlarges Cells multiply Subjected to increased stimulation Reversible when stimulus is removed
o May be hormonally induced Increased size of the thyroid gland caused by thyroid – stimulating
hormone
o Increase in number of new cells
o Increase in mitosis
o Stimulus: hormonal influence
o Example Breast changes of girl in puberty or of a pregnant woman Regeneration of liver cells
New blood cells in blood loss
Neoplasiao Malignant growtho Continues growing of cells even though stimulus is removed
Dysplasia o The change in the appearance of cells after they have been subjected
to chronic irritation
o Dysplastic cells Have the tendency to become malignant
o Seen commonly in epithelial cells in the bronchi of smokers
o Stimulus: reproduction of cells with resulting alteration of their size and shape
o Example Alterations ins epithelial cells of the skin or cervix, producing
irregular tissue changes that could be the precursors of malignancy
Metaplasiao Cell transformation in which highly specialized cells change to less
specialized cells
o Serves as a protective function
o Less specialized cells More resistant to stress that stimulated the change
o Example Ciliated columnar epithelium lining the bronchi of smokers is
replaced by squamous epithelium (can survive)
o Transformation of one adult cell type to another
o Stimulus: stress applied to highly specialized cells o Example
Changes in the epithelial cells lining bronchi in response to smoke irritation
Cellular injury
Injuryo Disorder in steady state regulationo Can be caused by stressor that alters the ability of the cells or system
to maintain optimal balance of its adjustment processes o Structural or functional changes occur (reversible: permits recovery;
irreversible: leading to disability or death)o Steady state regulation is losto Changes in function ensure
Cause of disorder and injury in the system
o May arise from the internal and external environmento Hypoxia, nutritional imbalance, physical, chemical and infectious
agents, immune mechanisms, genetic defects, psychogenic factor
Most common causea. Hypoxia b. Chemical injuryc. Infectious agents
Agents act at the cellular level by damaging or destroying:a. Integrity of the cell membrane (necessary for ionic balance)b. The ability of the cell to transform energyc. The ability of the cell to synthesize enzymes and other necessary
proteins.d. The ability of the cell to grow and reproduce.
Homeostatic adjustmentso Concerned with the small changes within the body’s systems
Adaptive changes o Compensation occurso Steady state is achieved (may be a new level)
Hypoxiao Inadequate cellular oxygenationo Causes:
Decrease in blood supply in the area Decrease blood carrying capacity of the blood Ventilation/perfusion or respiratory problem that reduces the
amount of oxygen available in the blood. Problem in the cell’s enzyme system that makes it unable to
use the oxygen delivered to it. Common cause: ischemia.
Nutritional Imbalanceo It refers to a relative or absolute deficiency or excess of one or more
essential nutrients.
Physical Agentso Temperatureo Radiation and electrical shocko Mechanical trauma
Chemical Agents
o Poison, drugs, alcohol.
Infectious Agentso Viruses, bacteria, fungi, protozoan.
Disordered Immune Response
Genetic Disorder
Inflammation
Inflammation- is a defensive reaction intended to neutralize, control, or eliminate the offending agent and to prepare the site for repair.
Types of Inflammationo Acute Inflammation- is characterized by local vascular and exudative
changes and usually lasts less than 2 weeks.o Chronic Inflammation- develops if the injurious agent persists and
the acute response is perpetuated.o Subacute Inflammation- falls between acute and chronic
inflammation. Cellular Healing
o Regenerationo Replacement
Primary Intension Healing- wound is clean and dry and the edges are approximated.
Secondary Intension Healing- the wound or defect is larger and gaping and has necrotic or dead material.
Nursing Management (STRESS)
Promoting a Healthy Lifestyle Enhancing Coping Strategies Teaching Relaxation Techniques Progressive Muscle Relaxation Benson’s Relaxation Response Relaxation with Guided Imagery
Pain
Pain- is whatever patient says it is and whenever the patient says it does.
o It is an unpleasant sensory and emotional experience resulting from actual or potential tissue damage.
Types of Paino Acute Pain-usually recent onset and commonly associated with a
specific injury. Usually last for seconds to 6 months
o Chronic Pain- is constant or intermittent pain that persists beyond the expected healing time and that can seldom be attributed to a specific cause of injury.
Last for 6 months of longer. Cancer-Related Pain- can be acute or chronic.
Pain Assessment and Management
Characteristics: Intensity- Pain scale: Mild 1-2; moderate 3-5; severe 7-9 Timing- threshold-amount of force for patient to feel pain;
tolerance- amount of pain the patient can bear. Onset and Duration- e.g. sudden, intermittent, gradual. Quality- e.g. burning, aching, throbbing, stabbing. Location- local, referred, radiating, projecting. Personal Meaning Aggravating and Alleviating Factors Non verbal behavior
Role of Nurse Identify Goals Establishing Nurse-patient relationship Provide physical care Managing anxiety r/t pain
Pharmacological Managemento Balance Analgesia
S/E: Respiratory Depression, Sedation, N/V Constipation, inadequate pain relief, pruritus, tolerance, dependence, addiction
NSAID Opiod/Narcotics (Smeltzer, Bare, Hinkle, & Cheever, 2008) Local Anesthetics
Topical EMLA cream Lidocaine 5% patch
S/E: irritation
Spinal anesthesia S/E: Hemorrhage, infection
o Pro-Re-Nata/PRN Analgesico Preventive Approacho PCA/Patient controlled analgesia
Non pharmacologic Managemento Massage/ cutaneous stimulationo Thermal therapieso Distractions o Relaxationo Guided imageryo Hypnosiso Music therapyo Acupuncture
*Intractable pain*Neurosurgery
Rhozotomy- destruction of sensory nerve rootsCordoctomy- cutting of spinal pathways in the spinal cord.
Pathophysiology
(Stress, Inflammation, Pain, CHF, Angina Pectoris, Myocardial Infarction)
Stress
Stresso Changes in Environmento Perceive as challenging, threatening, dangero Any event, any stimulus, circumstances
Organs SNS PNS
Blood Vessels Constriction Dilation
Vital Signs Increased Decreased
Pupil Dilate Constrict
Airways Dilate Constrict
Blood vessels: GI & GU Constrict Dilate
Salivation Decreased Increased
Sphincters Contract Relax
Blood Glucose increased No effect
Autonomic Nervous System
Sympathetic Nervous System
Adrenergic-E/NFight or Flight- user of energyAggressive or AvoidanceIncreased Activity
Parasympathetic Nervous System
Repose, vegetationCholinergic-AchDecreased activity-source of energy
Pathophysiology:STRESS
STIMULATION OF THE ANS
Stimulation of the hypothalamus
SNS PPG APG SAMRAdrenal Medulla release of ADH Adrenal Cortex
Increased ADHN/E E
Increased Blood VolumeRenin ACTH
Increased BP and Increased P cortosol
catabolismTachycardia
Inflammation
Inflammation Nonspecific defense of the body Nonspecific stimulus of a body that makes body
adaptive Neutralizes the effect of the injury Prepares body for repair Eliminate source of injury
o Selye’s Theory of Adaptationo GAS
Neuroedocrine response SNS response
Alarm- increased V/S, decreased resistance Resistance- normal V/S, increased resistance Exhaustion-R-est; R-ecover; R-IP.
o LAS Nonspecific
Stimulation of the adrenergic receptor in the heart
Release of angiotensinogen
Convert to angiotensin I
Glucocorticoid Mineralocorticoid
Release of aldosterone
Reabsorption of Na+
Water reabsorptionCHON CHO
Fats Increased Bld. vol
BP
Glucose
Convert to angiotensin II vasoconstriction Bld. Vol.
Inflammation Pain
Pathophysiology:Inflammants
(physical, chemical, biological)
Injury
Vasoconstriction
Release of chemical mediators (PGE, H, serotonin, bradykinin, leukotrienes)
Vasodilatation
Increased capillary permeability
Fluid/ plasma exudation hyperemia
Swelling (Tumor) Warmness Redness (Calor) (Rubor)
Pain (Dolor)
Loss of Function (function laissa)
Systemic manifestation: Fever Leukocytosis Increased erythrocyte sedimentation Headache Fatigue Malaise Anorexia
Pain
Pain- is what every person or experiencing person say it existing whenever the person say it does.
IASP- Pain is the 5th vital sign Set of sensory and emotional response to actual or potential tissue
damage.
Pathophysiology:Stimulus
Nociceptors - - - - - - - - - - - - a-delta
C-fiber
Secondary Neuron
Spinal Cord
Afferent neuron
Anterior and lateral spinothalamic tract
Cerebral cortex (fast) Thalamus (slow)
Reticular Formation
Efferent neuron
Response
CV D/O
CADo CHFo MIo Angina Pectoris
Etiology: Atherosclerosis- hardening and narrowing of the BV
Risk Factors:
Non-modifiable(predisposing factors)
Modifiable(precipitating factors)
Aggravating
GenderAgeheredity
EnvironmentDietCondition
StressLifestyleObesity
o CHFo Decreased supply and increased demand of bld.
-acute-fast-Myelinated-sharp-chronic
-slow-unmyelinated-dull
o Decreased bld. Vol.
o Compensatory mechanism Tachycardia Ventricular dilatation Ventricular hypertrophy
o S/Sx DOB Rales Cough Sputum Tympanic
Pathophysiology:Increased residual vol.
CO preload
O2 atrial dilatation
Tissue hypoxia atrial hypertrophy
Increased atrial pressure
Backward flow of bld. Towards lungs
Pulmonary congestion
Left sided heart failure
Increased pulmonary pressure
Backward flow of bld. Towards right ventricle
Increased pressure in the right ventricle
Right ventricular hypertrophy
Right ventricular dilatation
Increased pressure in the Right atrium
Right atrial dilatation
Right atrial hypertrophy
S/Sx of RCHF
Increased CVPJVDCNS DepressionIncreased ICPHepatomegalySlpeenomegalyAnorexiaN/VAscitesPortal hypertensionedema
Increased central venous pressure
Backflow to organs
right congestive heart failure
Management:
Short acting- nitroglycerineLong acting- Isosorbide Dinitrate
Nsg. Mngt when giving patches:
Non hairy part
Angina Pectoris
Pain in the chest wall Myocardial ischemia- due to decreased o2
Pathophysiology:Atheroma
Platelet aggregation narrowing
PGE O2 hypoxemia
Vasospasm cardiac hypoxia
Pain platelet aggregation anaerobic metabolism
Lactic acid accumulation
Acidosis
MI
Sudden occultation/obstruction of coronary artery leading to necrosis
Pathophysiology:
Atheroma
Blockage/ obstruction
No O2 supply
Necrosis
Intense pain increased isoenzymes
S/Sx:1. Intense pain2. Hypotension3. Tachycardia4. Tachypnea5. Fever6. Indigestion7. Increased ESR8. Anxiety
Management:Morphine SO4 for pain
LacticIncreased: Myoglobin Dehydrogenase Troponin CPK-MB(creatine phospokinase MB)