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
persons 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 timechronic illness, disability, poverty.
Psychological Response to Stress (LAZARUS)

 Appraisal of the Stressful Event

o 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 Event
o 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
Selyes Theory of Adaptation
o General Adaptation Syndrome
Alarm- is defensive and anti-inflammatory but selflimiting
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
Increased
rate
and
pressure

Purpose

Mechanism

heart Better perfusion of Increased

cardiac
blood vital organs
output
due
to
increased
myocardial
contractility
and
heart rate; increased
venous return.

Increased
blood Increased
glucose level
energy

available Increased liver and

muscle
glycogen

breakdown;
increased
breakdown
adipose
triglycerides

of
tissue

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 Preparedness

for Excitation of muscle;
of
skeletal activity, decreased increase in amount
muscles
fatigue
of blood shunted to
the muscle from the
abdominal
viscera
and skin.
Increased
ventilation

Increased
coagulability
blood

Provision of oxygen Stimulation

of
for energy
respiratory center in
the
medulla;
bronchodilation.
Prevention
of Vasoconstriction
of hemorrhage in event surface vessels
of trauma

of

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
function
o Can adapt to environmental stress through structural
and functional changes
o Examples of adaptation
Hypertrophy,
atrophy,
hyperplasia,
dysplasia,
metaplasia

 Reflect changes in the normal cells in response to

stress
Maintenance function
o Activities that the cell must perform with respect to
itself
Specialized function
o The cell performs in relation to the tissues and organs
of which it is a part
Hypertrophy and atrophy
o Lead to the changes in the size of cells
Compensatory hypertrophy
o Result of an enlarged muscle mass
o Commonly occurs in skeletal and cardiac muscle that
experiences a prolonged, increased workload
Hypertrophy
o Increase in the size leading to the increase in organ size
o Stimulus: increase workload
o Example
Leg muscles of runner
Arm muscles in tennis player
Cardiac muscle in person with hypertension
Atrophy
o Can be the consequence of:
a. Disease
b. Decreased use
c. Decreased blood supply
d. Loss of nerve supply
e. Inadequate nutrition
o Cell size and organ size decreased
o Structure principally affected:
a. Skeletal muscle
b. Secondary sex organs
c. Heart
d. Brain
o Shrinkage in size of cells leading to decrease in organ
size
o Stimulus: decrease in
a. Use
b. Blood supply
c. Nutrition

d. Hormonal stimulation
e. Innervation
o Example
Secondary sex organs in aging person
Extremity immobilized in cast
Disuse of a body parts
o Often associated
immobilization

with

the

aging

process

and

Hyperplasia
o 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
Neoplasia
o Malignant growth
o 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
Metaplasia
o 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
Injury
o Disorder in steady state regulation
o 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 lost
o Changes in function ensure
Cause of disorder and injury in the system
o May arise from the internal and external environment
o Hypoxia, nutritional imbalance, physical, chemical and
infectious agents, immune mechanisms, genetic
defects, psychogenic factor

 Most common cause

a. Hypoxia
b. Chemical injury
c. 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 energy
c. The ability of the cell to synthesize enzymes and other
necessary proteins.
d. The ability of the cell to grow and reproduce.
Homeostatic adjustments
o Concerned with the small changes within the bodys
systems
Adaptive changes
o Compensation occurs
o Steady state is achieved (may be a new level)
Hypoxia
o Inadequate cellular oxygenation
o 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 cells enzyme system that makes it
unable to use the oxygen delivered to it.
Common cause: ischemia.
Nutritional Imbalance
o It refers to a relative or absolute deficiency or excess of
one or more essential nutrients.
Physical Agents
o Temperature
o Radiation and electrical shock
o Mechanical trauma
Chemical Agents
o Poison, drugs, alcohol.
Infectious Agents
o 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 Inflammation
o 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 Regeneration
o 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
Bensons 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 Pain
o 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 Management
o 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 Analgesic
o Preventive Approach
o PCA/Patient controlled analgesia
Non pharmacologic Management
o Massage/ cutaneous stimulation
o Thermal therapies

o
o
o
o
o
o

Distractions
Relaxation
Guided imagery
Hypnosis
Music therapy
Acupuncture

*Intractable pain
*Neurosurgery
Rhozotomy- destruction of sensory nerve roots
Cordoctomy- cutting of spinal pathways in the spinal
cord.

Pathophysiology
(Stress, Inflammation, Pain, CHF, Angina Pectoris, Myocardial
Infarction)

Stress
Stress
o Changes in Environment

o Perceive as challenging, threatening, danger

o Any event, any stimulus, circumstances
Autonomic Nervous
System

Sympathetic Nervous
System
Adrenergic-E/N
Fight or Flight- user of
energy
Aggressive or Avoidance
Increased Activity

Parasympathetic Nervous
System
Repose, vegetation
Cholinergic-Ach
Decreased activity-source
of energy

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

Pathophysiology:
STRESS
STIMULATION OF THE ANS
Stimulation of the hypothalamus
SNS

PPG

APG
SAMR
Adrenal Medulla
Adrenal Cortex

release of ADH

Increased ADH
N/E

Glucocorticoid

Increased Blood Volume

Renin

Mineralocorticoid

ACTH

StimulatiIncreased
on of the
adrenerg
Release of
angiotensinogen ic
receptor
Tachycardia
in the
Convert to
angiotensin
I
ConvertInflammation
to
vasoconstriction
angiotensin
II
Inflammation

BP and Increased P
cortosol

Release of
aldosterone
Reabsorption

catabolism
of Na+
CHO

CHO
N
Bld. Vol.

Water
reabsorption

Fats

Increased Bld.
vol

Glucose

BP

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 Selyes Theory of Adaptation
o 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
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
(Calor)

Redness

(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
-acute
Nociceptors - - - - - - - - - - - - a-delta

C-fiber

-chronic
-slow
unmyelinate
d

-fast
Myelinate
d

Secondary Neuron
Spinal Cord
Afferent neuron

Anterior and lateral spinothalamic tract

Cerebral cortex (fast)
Reticular Formation
Efferent neuron

Thalamus (slow)

Response
CV D/O
CAD
o CHF
o MI
o Angina Pectoris
Etiology: Atherosclerosis- hardening and narrowing of
the BV
Risk Factors:
Non-modifiable
(predisposing
factors)
Gender
Age
heredity

Modifiable
(precipitating
factors)
Environment
Diet
Condition

Aggravating
Stress
Lifestyle
Obesity

o CHF
o Decreased supply and increased demand of bld.
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
O2
Tissue hypoxia
hypertrophy

preload
atrial dilatation
atrial

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 CVP
JVD
CNS Depression
Increased ICP
Hepatomegaly
Slpeenomegaly
Anorexia
N/V
Ascites
Portal
hypertension
edema

Increased central venous

pressure
Backflow to organs
right congestive heart failure

Management:
Short acting- nitroglycerine
Long 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
Pain
metabolism

cardiac hypoxia

platelet aggregation

anaerobic

Lactic acid accumulation

Acidosis

MI
Sudden occultation/obstruction of coronary artery leading to
necrosis
Pathophysiology:
Atheroma
Blockage/ obstruction
No O2 supply
Necrosis
Intense pain
S/Sx:
1. Intense pain
2. Hypotension
3. Tachycardia
4. Tachypnea
5. Fever
6. Indigestion

increased isoenzymes
Lactic
Increased:
Myoglobin
Dehydrogenase
Troponin
CPK-MB
(creatine
phospokinase

7. Increased ESR
8. Anxiety
Management:
Morphine SO4 for pain