Anne’s Note!

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Unit I- Homeostasis, Stress & Adaptation 3. Homeostasis- refers to the steady state with in the body; the stability of the internal environment Stress- a state produced by a change in the environment that is perceived as challenging, threatening or damaging to the person’s dynamic balance or equilibrium; caused by a Stressor Adaptation- refers to the adjustment to the change so that the person is again in equilibrium i.e. physical and psychological health, and enhanced social functioning. Coping – the process of adaptation; a compensatory process with physiologic and psychological components

Day to day frustrations- arguments, having caught in traffic jams, car aircon not working great health impact due to cumulative effect Events that involve a large group of people- economic and technological changes, war Infrequent situations that directly affect an individual – death of a loved one, divorce, marriage, acquiring permanent functional disability

Types of Stressor According to Duration:

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Acute- time limited Sequence- occurs in series resulting from an initial event Chronic intermittent Chronic enduring

Models of Stress: - assist the nurse to identify the stressor and to predict the individual’s responses 1. Stimulus Based Model - stress is defined as a stimulus, a life event or circumstances that arouses physiologic and/or physiologic responses that may increase an individual’s risk for illness

Stress

Homeostasis

Adaptation

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Physiology- study of functional processes of the living organism and its parts Pathophysiology- study of disordered function of the body

Response Based Model - stress is defined as the non-specific response of the body to any kind of demand made upon it (Selye) - Response is characterized by a chain or pattern of physiologic events called the General Adaptation syndrome (GAS) and Local AS - Stress is viewed as a state of the body and can only be observed through the changes it cause on the body Transaction Based Model This model states that people and group differ in their vulnerability and sensitivity to stress as well as their interpretations and reactions Encompasses a set of cognitive, affective and adaptive responses that arise out of the person-environment transaction Stress refers to any event in which environmental demands, internal demands or both overwhelm the adaptive resources of an individual, a social system or a tissue system.

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Historical Theories of the Steady State: Claude Bernard- developed the principle that for life there must be a constancy or “fixity of the internal milieu” despite changes in the external environment Walter Cannon- used the term homeostasis to describe the stability of the Internal environment as a result of compensatory processes Rene Jules Dubos- proposed that Homeostasis and adaptation were necessary for balance Homeostatic process- occurs quickly in response to stress to maintain internal environment Adaptive process – results in structural and functional changes over time Stressor - Internal or external event or situation that creates a potential for physiologic, emotional, cognitive or behavioral changes in an individual Forms of Stressor: 1. Physical- heat, cold, chemicals 2. Psychosocial- fear of failing 3. Physiologic- pain and fatigue Types of Stressor according to impact and degree of involvement:

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Responses to Stress: I. Physiologic II. Psychological I. Physiologic Response to Stress - a protective and adaptive mechanism to maintain the homeostatic balance of the body in response to a physical or psychological stressor - a cascade of neural and hormonal events that have short and long lasting consequences for both the brain and the body - Hans Selye developed the theory of adaptation:

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General Adaptation Syndrome (GAS) - a non-specific response to diverse noxious stimuli - characterized by adrenal cortex enlargement, shrinkage of thymus, spleen LN, and other lymphatic structures and appearance of GI ulcers

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Phases: a. Alarm- “fight or flight”, defensive and anti-inflammatory but self limited b. Resistance- adaptation to noxious stimuli c. Exhaustion- depletion of energy in prolonged stress, may lead to death 2. Local Adaptation Syndrome (LAS) Anti-inflammatory response and repair process that occur at local site of injury

3. Determining future expectancy or whether things are likely to change for better or worse. Reappraisal- a change in opinion based on new information - the appraisal process contributes to the development of a negative or a positive emotion b. Coping with stressful event - aims to maintain the positive benefit of the challenge and to ward-off any threats - consist of cognitive and behavioral efforts made to mange the stressor and may be problem or emotion-focused. 1. 2. Emotion Focused- seeks to make the person feel better by decreasing the emotional distress felt Problem Focused – aims to make direct changes in the environment to manage the situation more effectively. Appraisal and coping are affected by the ff. internal characteristics: health, energy, personal belief system, commitments or life goals, self-esteem, control, mastery, knowledge, problem solving skill and social kills In Nursing, Health promoting lifestyle and hardiness are the 2 most studied characteristics

Interpretation of the Stressful Stimuli by the Brain: • Physiologic Response to stress is mediated by the brain through a complex network of chemical and electrical messages • Hypothalamus integrates the neural and hormonal actions that maintain homeostatic balance • Initial responses include sympathetic nervous system discharge followed by symphatetic-adrenal-medullary discharge • If stress persist, hypothalamic-pituitary system is activated 1. Sympathetic Nervous system Response: rapid and short-lived involves release of Norepinephrine from peripheral nerves Results in: - vasoconstriction, tachycardia and increase BP - Increased glucose, dilated pupils, increased mental activity - Tachypnea, tensed skeletal muscles 2. Symphatetic-Adrenal-Medullary Response - involves release of epinephrine and NE from the adrenals - sustained and prolonged action 3. Hypohalamic-Pituitary Response - longest acting phase of the physiologic response - occur in persistent stress 4. Immunologic Response - studies have shown that people under stress have decreased WBC, impaired immune response to vaccination and diminished activity of NK cells

1. Health Promoting lifestyle - buffers the effect of stressor rather than altering the stressors 2. Hardiness – is the quality that comes from having rich, varied, and rewarding experience to deal with stressors Indicators of Stress psychological, physiologic or behavioral irritability, depression, change in menstrual cycle, loss or increased appetite, grinding of teeth, insomnia, diarrhea, vomiting etc. Psychological Indicators of Stress: a. Anxiety an emotional state characterized by feeling of apprehension, restlessness, discomfort or worry. Occur as a result of challenging or threatening life events, fear of unknown, impairment in bodily functions, changes in family roles, etc. Usually manifests in behavior and emotion, and physiologically

(*discuss the pathway) II. Psychological Response to Stress a. Appraisal of the Stressful Event (Cognitive Appraisal) - 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).

Primary appraisal identifies the event as stressful or non-stressful - Stressful situation can be one of 3 kinds: 1. Harm or loss has occurred 2. threatening i.e. harm or loss is anticipated 3. Challenging i.e. some opportunity or gain is anticipated

Levels of Anxiety 1. Mild Anxiety - produces slight arousal that enhances perception, learning and productive abilities - experienced by most healthy people - may be manifested as mild restlessness and sleeplessness - usually no physiologic manifestations 2. Moderate Anxiety - increases arousal to a point where the person expresses concerns - Perceptual abilities are narrowed and the person is more focused on a particular aspect of a situation - may have tremors and shakiness - Learning is slightly impaired - slight elevation of RR and CR

Secondary Appraisal includes: 1. Assigning blame to those responsible for a frustrating event 2. Thinking about whether one can do something about the situation

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3. Severe Anxiety - Perception is further decreased making the person unable to focus on the event but focuses only on a specific detail - increased motor activity, unable to relax and easily distracted - learning is severely impaired - tachycardia, hyperventilation - consumes most of the person’s energies and requires intervention 4. Panic - Overpowering, frightening level of anxiety causing the person to lose control - increased motor activity and agitation, trembling and poor motor coordination - unable to learn or function - feeling of impending doom - dyspnea, palpitation, chest pains b. Fear - an emotion or feeling of apprehension aroused by impending or seeming danger, pain or perceived threat - it could be something that has happened, current or will happen Differences of Fear and Anxiety: 1. source of aniety may not be identifiable, source of fear is identifiable 2. Anxiety is related to future, fear to present 3. Anxiety is vague, fear is clear 4. Anxiety is a result of psychological or emotional conflict, fear is a result of discrete physical or psychologic entity. c. Anger - an emotional state consisting of a subjective feeling of animosity or strong displeasure - can be expressed verbally or non-verbally Hostility- marked by overt antagonism and harmful or destructive behavior Aggression- an unprovoked attack or a hostile, injurious or destructive action or outlook Violence- the exertion of physical force to injure or abuse d. Depression - Subjective feeling of extreme sadness, despair, lack of worth or emptiness - a common reaction to events that are overwhelming or negative - Anorexia, weight loss, loss of sexual desire, irritability, social withdrawal, sadness, fatigue etc. e. Unconscious Ego Defense Mechanisms - Mechanisms that develop as the personality attempts to defend itself, establish compromises among conflicting impulses and allay inner tensions - Unconscious mind working to protect the person from anxiety 1. Compensation - covering up weakness by emphasizing a more desirable trait or overachievement in a more comfortable area 2. Denial - an attempt to screen or ignore unacceptable realities by refusing to acknowledge them 3. Displacement - transferring or discharging of emotional reaction from one object or person to another 4. Identification

- an attempt to manage anxiety by imitating the behavior of someone feared or respected 5. Intellectualization - emotional response that normally accompany an uncomfortable or painful incident is evaded by the use of rational explanations that remove any personal significance 6. Introjection - a form of identification that allows for the acceptance of others’ norms and values into oneself even when contrary to one’s previous assumption 7. Minimization - not acknowledging the significance of one’s behavior 8. Projection - blame is attached to others for unacceptable shortcomings 9. Rationalization - justification of certain behavior by faulty logic 10. Reaction Formation - causes people to act exactly opposite the way they feel 11. Regression - resorting to a previous more comfortable level of functioning that is less demanding and responsible 12. Repression - unconscious mechanism where threatening thoughts, feelings and desires are kept from becoming conscious 13. Sublimation - displacement of energy associated with more primitive sexual or aggressive drives into socially acceptable activities 14. Substitution - replacement of a highly valued, unacceptable or unavailable object by a less valuable, acceptable or available objects 15. Undoing - actions or words design to cancel some disapproved thoughts, impulses or acts in which the person relieves guilt by making reparation Maladaptive Response to Stress

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when the response to stress is ineffective it is referred to as Maladaptive usually results from impaired appraisal and inappropriate coping models of stress frequently site stress and maladaptation as precursors to disease Selye proposed a list of disorders he called diseases of maladaptation: HTN, Heart dse., kidney dse., etc.

Inappropriate Coping Patterns: 1. Use of alcohol or drugs 2. Type A personality 3. Denial, avoidance and distancing Stress as a Stimulus for Disease: - Critical life events have been linked to occurrence of illnesses - Constant stress may lead to ineffective coping causing additional distress that can lead to Stress-Related Illness Stress at the Cellular Level • cell exist in a continuum of function and structure ranging from normal, to adapted, to injured, and to dead cells • pathological processes often start at the cellular level Control of the Steady State: 1. Negative feedback • changes from a predetermined set-point triggers compensatory mechanism to restore homeostasis

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integrated by the brain and influenced by the nervous and endocrine system Ex. Accumulation of Lactic acid causes vasodilation Organs of homeostasis include: Heart, lungs, liver, GI and skin

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goal of relaxation training is to produce a response that counters the stress response this decreases the sympathetic and parasympathetic response interrupting Physiologic effects and reducing psychological stress 1. Progressive Muscle Relaxation - involves tensing and releasing the muscles of the body in sequence and sensing the difference in feeling - person lies flat on a soft cushion on the floor in a quiet room breathing easily - someone reads the instructions 2. Benson’s Relaxation Response - combines meditation with relaxation Steps: 1. Pick a brief phrase or word that reflect your basic belief system 2. Choose a comfortable position 3. Close your eyes and relax your muscles 4. become aware of your breathing and start using your selected focus word 5. Maintain a passive attitude 6. Continue for a set period of time 7. Practice the technique twice a day 3. Relaxation with Guided Imagery - the purposeful use of imagination to achieve relaxation or direct attention away from undesirable sensation - assist patient in selecting a pleasant scene or experience - guide patient to review the scene, trying to feel and relive the imagery with all the senses Other relaxation technique: - meditation, breathing technique, massage, music therapy, use of humor

Positive Feedback • perpetuates the initial event set in motion by the original disturbance • Ex. Clotting

Cellular Adaptation: 2 Functions of Cells: a. Maintainace b. Specialized 1. 2. 3. 4. 5. Hypertrophy Atrophy Hyperplasia Dysplasia Metaplasia disorder in steady state regulation

Cell Injury: *(further discussion on Unit II – Illness and Inflammatory Process) Stress Management: directed toward reducing and controlling stress and improving coping aims to prevent illness, improve quality of life and decrease the cost of health care

Possible Nursing Diagnoses: 1. 2. 3. 4. 5. Anxiety Ineffective coping process Impaired thought process Social Isolation Risk for impaired Parenting D.

Nursing Interventions: A. Promoting Healthy Lifestyle - provides resources and buffers the impact of stressors - lifestyles and habits that contribute to the risk of illness are identified and recommendations are done - Ex. Smoking, sedentary lifestyle Enhancing Coping Strategies - assisting a patient to adapt to perceived stressor, changes or threat that interferes with meeting life demands and roles

Educating about Stress Management - includes providing sensory information and procedural information to reduce stress and improving patient’s coping ability - Ex. Giving lessons in childbirth preparation, discussing the anatomy of the heart in patient’s undergoing cardiac procedure - The objective is to reduce emotional response so the patient can concentrate and solve problems more effectively

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Ways of Coping: 1. Trying to be optimistic about the outcome 2. Using social support 3. Using spiritual Resources 4. Trying to maintain control over the situation or over feelings 5. Trying to accept the Situation - seeking information, reprioritizing needs and roles, lowering expectations, comparing self to others , taking things one step at a time, self talk for encouragement C. Teaching Relaxation Technique

E. Enhancing Social Support - Social support makes people feel that they are cared for and loved, respected and valued, and that they belong to a network of communication and mutual obligation - facilitates individual coping behavior - Critical qualities within a social network is the exchange of intimate communication and the presence of solidarity and trust - it’s being able to talk with someone and express feelings openly - Nurses can help patients identify their social support system and encourage them to use it F. Support Groups - usually formed by people with similar stressful situation - being a member of a group with similar problems or goals has a releasing effect on a person that promotes freedom of expression and exchange of ideas twj-md08

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