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● Homeostasis, Stress,
and Adaptation

On completion of the chapter, the learner will be able to:
1. Relate the principles of internal constancy, homeostasis, stress,
and adaptation to the concept of steady state.
2. Identify the significance of the body’s compensatory mechanisms
in promoting adaptation and maintaining the steady state.
3. Identify physiologic and psychosocial stressors.
4. Compare the sympathetic-adrenal-medullary response to stress to
the hypothalamic-pituitary response to stress.
5. Describe the general adaptation syndrome as a theory of adapta-
tion to biologic stress.
6. Describe the relationship of the process of negative feedback to
the maintenance of the steady state.
7. Compare the adaptive processes of hypertrophy, atrophy, hyper-
plasia, dysplasia, and metaplasia.
8. Describe the inflammatory and reparative processes.
9. Assess the health patterns of an individual and determine their
effects on maintenance of the steady state.
10. Identify ways in which maladaptive responses to stress can
increase the risk of illness and cause disease.
11. Identify measures that are useful in reducing stress.
12. Specify the functions of social networks and support groups in
reducing stress.


such as cortisol. as a living system. inflammation: a localized. each exchanging information and matter (Fig. Stress. vessel . drate sources such as amino acids and the stances are synthesized cretion of cortisone and other hormones glycerol portion of fats metaplasia: a cell transformation in which a by the adrenal cortex guided imagery: use of the imagination to highly specialized cell changes to a less antidiuretic hormone (ADH): a hormone achieve relaxation or direct attention away specialized cell secreted by the posterior lobe of the pitu. Society as a whole Stress and Function Humans Physiology is the study of the functional activities of the living or- ganism and its parts. and Adaptation 81 W hen the body is threatened or suffers an injury. Dynamic Balance: The Steady State The goal of the interaction of the body’s subsystems is to pro- duce a dynamic balance or steady state (even in the presence of Physiologic mechanisms must be understood in the context of the change). heat. protective reac. The defense mechanisms that the body exhibits Group determine the difference between adaptation and maladaptation— Community health and disease. redness. or new cells steady state: a stable condition that does not dopamine) that serve as neurotransmitters hypoxia: inadequate supply of oxygen to change over time. each with its own internal and external en- vironment. between which information enhance the nurse’s understanding of steady state. stress: a disruptive condition that occurs in dysplasia: a change in the appearance of a fungi. body as a whole. and adaptation— ternal and an external environment. they are involved in tion. so that all subsystems are in harmony with each other. pathophysiologic mechanisms give rise to signs that are observed by the patient. These smallest system. that are produced tion of tissue to injury. These mecha- nisms are compensatory in nature and work to restore balance in the body. to assist in adapting to a new situation or carbohydrate. In this figure the cell is the increasing venous pressure. manifested by pain. or symptoms that are reported by the patient. vasoconstriction: the narrowing of a blood mones. plus a sound knowledge of physiologic and pathophysiologic processes. norepinephrine. ergy for bodily processes and other sub- the pituitary gland that stimulates the se. Each different body system performs spe- cific functions to sustain optimal life for the organism. that response to adverse influences from the cell after exposure to chronic irritation cause disease in people internal or external environments glucocorticoids: the group of steroid hor. Four concepts—constancy. Glossary adaptation: a change or alteration designed by the adrenal cortex. nurse. Chapter 6 Homeostasis. substances are broken down to yield en- hormone produced by the anterior lobe of especially by the liver from noncarbohy. such as posite direction person’s resources viruses. which worsens the condition. the cell direction is balanced by change in an op- gies used to manage the stressors that tax a infectious agents: biologic agents. and fat metabolism swelling. Pathophysiology is the study of disordered Organ system function of the body. and nematodes. system of the whole. can as. mycoplasmas. these changes may External environment: be adaptive (having a positive effect) or maladaptive (having a Family negative effect). An example of a pathophysiologic change is the development of FIGURE 6-1 Constellation of systems. protozoa. being a subsystem of all other systems. protein. bacteria. tissue. the output of a system elevates blood pressure. or other health care provider. and matter are continuously exchanged. Each system is a subsystem of the heart failure: the body reacts by retaining sodium and water and larger system (suprasystem) of which it is a part. These observations. has both an in. homeostasis. The person. or when change in one coping: the cognitive and behavioral strate. irritation. and reduces the excretion of urine the stability of the internal environment positive feedback: feedback that increases catecholamines: any of the group of amines hyperplasia: an increase in the number of the output of a system (such as epinephrine. Within the internal sist in determining the existence of a problem and can guide the environment each organ. stress. 6-1). from uncomfortable sensations or situations negative feedback: feedback that decreases itary gland that constricts blood vessels. Mecha- nisms for adjusting internal conditions promote the normal steady Organ state of the organism and ultimately its survival. homeostasis: a steady state within the body. and sometimes loss of function environment and have anti-inflammatory properties metabolic rate: the speed at which some adrenocorticotropic hormone (ACTH): a gluconeogenesis: the formation of glucose. rickettsiae. Pathophysiologic processes result when cellular injury occurs Cell at such a rapid rate that the body’s compensatory mechanisms can no longer make the adaptive changes necessary to remain healthy. its response may involve functional and structural changes. and cell is also a system or sub- nurse in planning the appropriate course of action. or infec. An example of this restorative effort is the development Tissue of rapid breathing (hyperpnea) after intense exercise in an at- tempt to compensate for an oxygen deficit and excess lactic acid accumulated in the muscle tissue.

Examples of psychosocial stressors are to disease and may be active during disease. and the various challenges or only of the change itself. was co. than it might at another time. Stressors can also the steady state. or therefore limits the person’s freedom of action. and chemical agents. or adjustment to the change so that the person is again in pressure. The demographic. the day-to-day perceived as challenging. sors include cold. were necessary for balance. els of a system. havioral scientists. When a change or stress occurs that causes a body function to de- viate from its stable range. for example. a traffic jam. getting married. gree of “fit” between the skills and capacities of the person. or behavioral changes in an individual. The person is. this ability to cope and adapt can change. a compensatory The second group of stressors influences larger groups of peo- process with physiologic and psychological components.” Homeostasis and adap- external event or situation that creates the potential for physio- tation were both necessary for survival in a changing world. The change or argument with a spouse or roommate. which is a threat to fear of failing an examination and losing a job. The nature of the effect. palpitations. These biologic processes sought physio. subcellular components or with subsystems of the total body. Stressors. The desired goal is adapta. Adaptation occurs throughout the life span as the the biologic principle that for life there must be a constancy or individual encounters many developmental and situational chal- “fixity of the internal milieu” despite changes in the external en. stressors. however. even entire nations. giving birth. and societies. experiencing computer downtime. meet the requirements of the social and physical environment in logic and chemical balance and were under involuntary control. and reproduction. or indirectly. but also of the speed with which the stressors being confronted. These less dramatic. economic. The pathophysiologic processes can lead include pain and fatigue. adaptation is an individual change occurs. phasized that acceptable ranges of response to stimuli existed and it contributes to growth and enhances life. It disrupts function and such as going from childhood into puberty. mulative effect they have over time. Walter Cannon used the term homeostasis to describe lar. cognitive. Any change and adaptation in individuals. a 19th-century French physiologist. refers to a steady state within the body. groups. can that these responses varied for different individuals: “Absolute upset this equilibrium. which they exist. threatening. Stressors have also been classified as: (1) day-to-day frustra- STRESS AND ADAPTATION tions or hassles. heat. frustrating. Physical stres- is threatened. thereby providing the individual with a wide range of Claude Bernard. Adaptive processes resulted Each person operates at a certain level of adaptation and regularly in structural or functional changes over time. physiologic and biochemical processes. possibly even entire nations. processes are initiated to restore and TYPES OF STRESSORS maintain the dynamic balance. The first group. study stress sponded to changes in the internal environment. Biologists are concerned mainly with the stability of the internal environment. Homeostasis. They may be de- or compensatory mechanisms are not adequate. A stressor may be defined as an internal or constancy is only a concept of the ideal. tissue. The outcome depends on the de. These include events of history. then. he said. 1993). rapidly making the adjustments necessary to Stressors: Threats to the Steady State maintain the internal environment. function becomes disordered. encounters is to promote adaptation. A person appraises greater health impact than major life events because of the cu- and copes with changing situations. un. equilibrium and has the energy and ability to meet new demands. ongoing process that requires a change such as terrorism and war. The desired goals of adaptation for namic nature of the internal environment with his theory that any system are survival. Disease is an abnormal variation in the structure occur as normal life transitions that require some adjustment. or behavior so that the person is better experienced either directly. or function of any part of the body. the steady state scribed as physical. as suited to the environment. They can lead to high blood tion. and pathophysio. or damaging to the per. When these adjustment processes Stressors exist in many forms and categories. and (3) stressors that occur less fre- Stress is a state produced by a change in the environment that is quently and involve fewer people. (2) major complex occurrences involving large groups. or psychosocial. in the war zone. The internal milieu was the fluid that bathed the cells. ple. Adaptation is a constant. growth. especially related to health and illness. or feels. includes such common occurrences as getting caught in son’s dynamic balance or equilibrium. or other physiologic problems ( Jalowiec. As such. . This is the process of coping with the stress. function. which are threatening situations when in structure. including many nurse researchers. the The tension produced by any stressor is sometimes a result not type of social support available. OF THE STEADY STATE As new challenges are met. encountering a rainstorm while one is vaca- stressor is variable. homeostasis and adaptation. These experiences vary in stimulus that evokes this state is the stressor. logic. and an event that pro. developed adaptive ability. this goal is realized by optimal wellness. lenges. Dubos also em- encounters a certain amount of change. Such change is expected. it involves an interaction between the through live news coverage. Adaptation is a continuous process of seeking Rene Jules Dubos (1965) provided further insight into the dy. physiologic. and person and the environment. emotional. Be- ordinated by homeostatic or compensatory processes that re. two complementary concepts. an event or change that will produce stress in tioning at the beach will most likely evoke a more negative response one person may be neutral for another. The goal of these vironment. duces stress at one time and place for one person may not do so and irritating events—daily hassles—have been shown to have a for the same person at another time and place. His principle implied a Because both stress and adaptation may exist at different lev- static process. Homeostatic processes occurred quickly in response to stress. and having an able to meet the demands of the new situation. physiologic stressors logic mechanisms occur. which. In situations of health and and the constancy was the balanced internal state maintained by illness.82 Unit 2 BIOPHYSICAL AND PSYCHOSOCIAL CONCEPTS IN NURSING PRACTICE HISTORICAL THEORIES process: each individual has varying abilities to cope or respond. technological changes occurring in society also serve as stressors. harmony in an environment. and organ levels. families. it is possible to study these reactions at the cellu- Later. they within the internal environment initiated a “righting” response focus on how a group’s organizational features are modified to to minimize the change.

1991a. marriage. cognition. effective coping. It enced by their personal goals. ondary appraisal). and coping into a more complex model relating emotion problems. Coping that is emotion focused seeks ating process. People typically experi. such as daily hassles relevant or benign (positive). ence distress related to alterations in their physical and emotional They might feel fear. pro. the situation is identified from an initial event such as job loss or divorce as either nonstressful or stressful. time-limited stressor. one can theoretically predict the likelihood of illness whole process does not need to be repeated. birth. and Adaptation 83 The third group of stressors has been studied most extensively cognitive appraisal and coping as important mediators of stress. sign numerical values. and a lack of necessary coping skills is often a physiology. • A stressor sequence—a series of stressful events that result As an outcome of primary appraisal. and vacations. and concerns relatively infrequent situations that directly affect Appraisal and coping are influenced by antecedent variables that the individual. and whether the situation threatens their own sense of examinations strength and ego identity. 1993). Holmes and Rahe (1967) developed life events scales that as. pri- events. A stressful situation may be one of • A chronic enduring stressor that persists over time. demands that tax a person’s resources and may be emotion- consciously reacts to manage the situation. Bryla. (2) one that chronic illness. This is called the medi. motions. anger. emotion is an integrative. Fears of im. each emotion also includes a tendency Sources of stress for patients have been well researched (Bal. More enduring chronic stressors have also been placed in this category and may Cognitive appraisal (Lazarus. Chapter 6 Homeostasis. and manage their responses to stress. whether the event conflicts with what they want or de- • An acute. to typical life also occurs. in that harm or loss is anticipated. Coping With the Stressful Event PSYCHOLOGICAL RESPONSES Coping. A theory other conditions or overwhelming demands are likely to cause in. Because the items in the scales reflect events that require mary and secondary appraisal and reappraisal may occur simulta- a change in a person’s life pattern. in that some opportunity or gain is anticipated. commitments. consists of the cognitive and be- TO STRESS havioral efforts made to manage the specific external or internal After the recognition of a stressor. organismic concept dures prolonged or unrelenting suffering. and stress is defined as an ac. loneliness. changes in their level of daily functioning. STRESS AS A STIMULUS FOR DISEASE Secondary appraisal is an evaluation of what might and can be Relating life events to illness (the theoretical approach that de. nies a particular emotion. who in the 1930s one can do something about the situation (coping potential). neously. 1991c). and positive emotions accompany challenge. the situation is ir- • A chronic intermittent stressor. and sociology: “More than any other arena of psy- source of additional distress for an individual. The appraisal process is not necessarily sequential. isolation. sensory changes. Jalowiec. and death or disability increase a person’s anxiety level. called life-change units. an unexpected quiz in the lard. a change of opinion based on new information. the outcome is fre. 1984) include such things as having a permanent functional disability is a process by which an event is evaluated with respect to what is or coping with the difficulties of providing long-term care to a at stake (primary appraisal) and what might and can be done (sec- frail elderly parent. chological thought. or motivations. Information learned from an adaptational encounter can cumulation of changes in one’s life that require psychological be stored. such as death. these emotions outwardly with hostile behavior or comments. 1981. serious arguments. such as studying for final sire. classroom might be judged as threatening by unprepared students. so that when a similar situation is encountered again the adaptation. The events listed In addition to the subjective component or feeling that accompa- include both desirable and undesirable circumstances. or poverty is threatening. to act in a certain way. Reappraisal. financial praisal. divorce. harm/loss appraisals. Nurses possess unites motivation. marriage. and (3) one that is challenging. such as three kinds: (1) one in which harm or loss has occurred. risk–benefit analysis) determines the degree of stress. divorce. Any of these identified variables plus a myriad of on negotiation with a physical and social world” (p. and observed in “life charts” of his patients a linkage between illnesses determining future expectancy. If nonstressful. may be Important factors include how important or relevant the event is to them. ap- mobilization. This can be traced to Adolph Meyer. 13). focused or problem-focused. and de. The Recent Life Changes Questionnaire (Tausig. Lazarus (1991a) expanded his former ideas about stress. and retirement. This category includes the influence of life events include the internal and external resources of the person. according to Lazarus. by checking off the number of recent events and deriving a total The appraisal process contributes to the development of an score. 1982) emotion. 40).” with the term relational “standing for a focus discomfort. to adaptation. or whether things are likely to and critical life events. and adaptation in a complex con- the skills to assist people to alter their distressing circumstances figuration” (p. done about this situation Actions include assigning blame to fines stress as a stimulus) has been a major focus of psychosocial those responsible for a frustrating event. of emotion was proposed as the bridge to connect psychology. For example. A theory developed by Lazarus (1991a) emphasizes to make the person feel better by lessening the emotional distress . birth. creased social support or the loss of significant others. What individuals see as being at stake is influ- A stressor can also be categorized according to duration. A compari- under constant stress have a high incidence of psychosomatic son of what is at stake and what can be done about it (a type of disease. When a person en. an individual consciously or un. 1996. Stress. 1991a. Negative emotions such as fear and anger accompany contains 118 items such as death. that subsumes psychological stress and coping within itself and quently the development of a stress-related illness. a disability. Lazarus & Folkman. He called this model a “cognitive-motivational- Loss of one’s role or perceived purpose in life can cause intense relational theory. thinking about whether studies. and resentment and might express health status. Subsequent research revealed that people change for better or worse (Lazarus. It also in- cludes the psychosocial crises described by Erikson as occurring Appraisal of the Stressful Event in the life cycle stages of the human experience.

lieves the emotion it generated. docrine activity increases. control. lymph nodes.. problem. hippocampus. The limbic system has connections with both the cere- bral hemispheres and the brain stem. In addition. The local sonality characteristic composed of control. up of a number of nuclei. tic response (Watkins. He iden. resis. along with other structures. Hardy people perceive stressors as something they can contact dermatitis. drinking. and exhaustion. commitment. noxious stimuli. 1997). and other lymphatic structures.84 Unit 2 BIOPHYSICAL AND PSYCHOSOCIAL CONCEPTS IN NURSING PRACTICE felt. temperature control. the child is vulnerable. mon to all stressors. regardless of whether they are physiologic. eral adaptation syndrome is activated as well. a stressor is an event that challenges homeostasis. and cortisol activity is still increased. Stages one and two of this syn- and to ward off any threats. tive support has been found for hardiness as a significant variable psychological. topical injuries. change and new situations Selye emphasized that stress is the nonspecific response com- are viewed as challenging opportunities for growth. spleen. Together with the limbic sys- The General Adaptation Syndrome tem. the person encounters solving skills. exhaustion sets in and en- Even if the situation is viewed as challenging or beneficial. or social. defense. Selye. The alarm reaction is defen. personal belief systems. The characteristics that have been a number of life’s stressful events and develops a resistance or adap- studied most often in nursing research are health-promoting tation. nose. shrinkage of the thymus. throughout life as the successful coping reduces or eliminates the source of stress and re. which is located in the cen- process of adaptation to the stress” (McEwen & Mendelson. and immune lenge—that is. and social skills. mastery. is a protective and adaptive by the Brain mechanism to maintain the homeostatic balance of the body. The cerebral hemispheres are con- From this beginning. During childhood. experi. account for differences in the tolerance of different people for stress: some people may develop diseases of adaptation. varied. resistance. The body . skin) and internal sensors (barorecep- sive and anti-inflammatory but self-limited. According to Selye’s theory. tively. During the alarm phase. such as hypertension and migraine headaches. in different degrees. pair processes that occur at the local site of tissue injury. memory. In many circumstances. Problem-focused coping aims to make direct changes in the into the second stage. and eventually death occurs. amines and the onset of the adrenocorticotropic hormone In the stress response. Selye compared the general adaptation syndrome with the life Appraisal and coping are affected by internal characteristics process. A health-promoting lifestyle buffers the and the wear and tear on the organism again deplete the person’s effect of stressors. and the appearance Literature supports the concept that each of these structures of deep. chemoreceptors) to nerve centers in the brain. cerned with cognitive functions: thought processes. digestive. In harmful or threatening situations. The stress response is a “cascade of neural and hormonal events that Physiologic responses to stress are mediated by the brain through have short. this out. communication system. eating. and life goals. drome are repeated. 2000. bleeding ulcers in the stomach and duodenum. The hypothalamus integrates autonomic nervous system mechanisms that maintain the chemical constancy of the internal environment of the body. whether it is a physical Interpretation of Stressful Stimuli stressor or a psychological stressor. Because living in a tors. surrounded by the limbic system and the cerebral 1993. potentially stressful situ. the reticular ac- PHASES OF THE GENERAL ADAPTATION SYNDROME tivating system. commitments or stress to promote the development of adaptive functioning. PHYSIOLOGIC RESPONSE TO STRESS The physiologic response to a stressor. hemispheres. This produces deleterious effects on the ing efforts may be required to develop and sustain the chal. The many conditioning factors in each that positively influences rehabilitation and overall improvement person’s environment account for why different demands are in- after an onset of an acute or chronic illness (Felton. Some posi. In 1936. 101). sory organs (eye. The hypothalamus is made menting with animals. the person moves to the perception of stress is integrated in the hypothalamus. with neural and hormonal actions that maintain homeostatic balance a disease outcome being looked upon as a failure of the normal are integrated by the hypothalamus. ear. The response continuous state of alarm would result in death. and each has its own characteris- tified this as a nonspecific response to diverse. promoting a LOCAL ADAPTATION SYNDROME healthy lifestyle is more achievable than altering the stressors. To them. the gen- change and therefore control. From a nursing practice standpoint. . he developed a theory of adaptation to bio. waking state of the body. and septal nuclei. the limbic system contains the amyg- largement of the adrenal cortex. and rewarding experiences. If exposure to the stressor is prolonged. During adulthood. During this stage. Both types of coping usually occur in a stressful situation. influenced the scientific study of stress. responds differently to stimuli. p. aggression). ability to adapt. dala. This network controls the alert or “fight-or-flight” response is activated with release of catechol.and long-lasting consequences for both brain and a complex network of chemical and electrical messages. such as challenge. come—buffering the effect of stressors—supports nursing’s goal of promoting health. body systems (especially the circulatory. the sympathetic midbrain and limbic system. person encounters stressors. it also regulates emotions and many visceral behaviors nec- Hans Selye developed a theory of adaptation that profoundly essary for survival (eg. ations are interesting and meaningful. and logic stress that he named the general adaptation syndrome. a local adaptation syndrome also oc- Hardiness is the name given to a general quality that comes curs. Conditioning factors also Williams. while others are unaffected. afferent impulses are carried from sen- (ACTH)–adrenal cortical response. ter of the brain. During the later years. first described a syndrome consisting of en. and adaptation syndrome occurs in small. the noxious stressor occurs. If the local injury is severe enough. It is a per. knowledge. which is a network of cells that forms a two-way The general adaptation syndrome has three phases: alarm. cop. . This syndrome includes the inflammatory response and re- from having rich. the accumulation of life’s stressors lifestyles and hardiness. . to maintain the positive benefits of the challenge systems) that can lead to death. learning. self-esteem. 2000). terpreted by different people as stressors. resistance falls. there are too few encounters with such as health. extends from the brain stem into the tance. energy. adaptation to environment so that the situation can be managed more effec. reproduction.

the diaphragm tense. Norepinephrine is released at nerve endings that are in di. Epinephrine and norepineph- abdominal organs. V. and mental activity is increased. In addition to its direct effect on major end organs. stimula- tion. chills. the sympa- lived. sels of the skin limits bleeding in the event of trauma. The pupils are dilated. Blood glucose is increased. with the hypothalamic-pituitary system is activated (Fig. Stress. The responses are mutually reinforcing. Constriction of the blood ves- responses. adrenocorticotropic hormone. SYMPATHETIC NERVOUS SYSTEM RESPONSE SYMPATHETIC-ADRENAL-MEDULLARY RESPONSE The sympathetic nervous system response is rapid and short. into the bloodstream. upper back.. raising the blood pressure. supplying more readily available en- static balance. produce metabolic effects that increase the blood glucose level Physiology/Pathophysiology FIGURE 6-2 Integrated responses to stress me- diated by the sympathetic nervous system and the hypothalamic–pituitary–adrenocortical axis. First. Blood is also shunted away from taining and prolonging its actions. thetic nervous system also stimulates the medulla of the adrenal rect contact with their respective end organs to cause an increase gland to release the hormones epinephrine and norepinephrine in function of the vital organs and a state of general body arousal. and a knot in the stomach. Colored arrows. N. 6-2). shoulders tightened. The degree and duration of the response varies. If the stress persists. inhibition. Louis: C. The purpose of these activities is to provide rine are catecholamines that stimulate the nervous system and better perfusion of vital organs (brain. ACTH. the hypothalamus are also activated in the stress response. corticotropin- releasing hormone. The per- Neural and neuroendocrine pathways under the control of son is likely to experience cold feet. M. clammy skin and hands. and sympathetic-adrenal-medullary discharge. a major stress evokes both sympathetic and pituitary adrenal greater sense of awareness exists. and Adaptation 85 which coordinates the adjustments necessary to return to homeo. Negative feedback by cor- tisol also can limit an overresponse that might be harmful to the individual. ergy. & Levy. that of the sympathetic nervous system and have the effect of sus- curs. St. respirations may be rapid and shallow. Reproduced with permission from Berne. open arrows. skeletal muscles). Mosby. M. heart. with the muscles of the neck. . the per- there is a sympathetic nervous system discharge. palpitations. R. (1993). Physiology. The action of these hormones is similar to The heart rate is increased and peripheral vasoconstriction oc. Chapter 6 Homeostasis. followed by a son appears tense. CRH. at both the cen- tral and peripheral levels. Typically.

Because one’s response to stress. 1997). impaired hormone and glucagon stimulates the uptake of amino acids by immune response to immunizations. Neuro- hibits glucose uptake (anti-insulin action) by many body cells but endocrine hormones released by the central nervous system and not those of the brain and heart. an event activates the stress response system. but their adaptive function is less clear. enhance. stimulates liver uptake of amino ber of different neuropeptides that can have a direct effect on acids and their conversion to glucose (gluconeogenesis). This effect has some important im. as coping in new and threatening situations. which and adrenal-medullary responses is summarized in Table 6-1. which stimulates the anterior pituitary to produce Research findings show that the immune system is connected to ACTH. They may also affect mood and have been implicated in the so-called “high” that long- HYPOTHALAMIC-PITUITARY RESPONSE distance runners experience. needs more insulin than nomic and neuroendocrine responses can interact to initiate. The bolic effects provide the body with a ready source of energy wide variety of stressors people experience may result in different during a stressful situation. surgery. Excitation of muscles. ideas. the central and autonomic nervous systems. Cortisol stimulates protein richly supplied by autonomic nerves capable of releasing a num- catabolism. Any patient who is under stress (caused. by weaken. primarily cortisol. hormone and neuropeptide synthesis. or terminate an immune response (Watkins. endocrine tissues can inhibit or stimulate leukocyte function. The secretion of other hormones is The longest-acting phase of the physiologic response. bronchodilation Increased coagulability of Prevention of hemorrhage in Vasoconstriction of surface blood event of trauma vessels . involves the hypothalamic- pituitary pathway. usual. leukocyte regulation and the inflammatory response. and thoughts can have profound neurochemical and hemorrhage or loss of fluids through excessive perspiration. in- creased venous return (peripheral vasoconstriction) Increased blood glucose level Increased available energy Increased liver and muscle glycogen breakdown. Endorphins. All of these possible auto- such as that caused by an infection. increase during stress and enhance the This effect is called the “fight-or-flight” reaction. ADH immunologic consequences. and diminished cytotoxic- Table 6-1 • Sympathetic–Adrenal–Medullary Response to Stress EFFECT PURPOSE MECHANISM Increased heart rate and blood Better perfusion of vital organs Increased cardiac output due pressure to increased myocardial con- tractility and heart rate. For example. Multiple studies have demonstrated has also been shown to influence learning and may thus facilitate alteration of immune function in people who are under stress. perception of events and coping styles determine whether. Lymphoid tissue is glucocorticoids. alterations in autonomic activity and subtle variations in neuro- plications. Other hormones released are antidiuretic hor. IMMUNOLOGIC RESPONSE releasing factor. helping to mobilize energy resources. trauma or prolonged psychological stress) catab. and to mone (ADH) from the posterior pituitary and aldosterone from what extent. olizes body protein and needs supplements. mune system and the effects of these relationships on overall nephrine) and cortisol are the most important in the general health outcomes is called psychoneuroimmunology. one’s percep- water retention. releasing amino acids. illness. ACTH in turn stimulates the adrenal cortex to produce the neuroendocrine and autonomic systems. are endogenous opiates. a person with diabetes who is under stress. for example. The effect of the sympathetic cells. Children subjected The study of the relationships among the neuroendocrine sys- to severe stress have retarded growth. increased breakdown of adipose tissue triglycerides Mental acuity Alert state Increase in 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 Preparedness for activity. and in. and the im- The actions of the catecholamines (epinephrine and norepi. and be- the adrenal cortex. more likely to occur in persistent stress. tem. which is an adaptive mechanism in the event of tions. These cortisol-induced meta.86 Unit 2 BIOPHYSICAL AND PSYCHOSOCIAL CONCEPTS IN NURSING PRACTICE and increase the metabolic rate. increase muscles decreased fatigue in amount of blood shunted to the muscles from the ab- dominal viscera and skin Increased ventilation (may be Provision of oxygen for energy Stimulation of respiratory rapid and shallow) center in medulla. threshold for tolerance of painful stimuli. which is also affected. ADH and aldosterone promote sodium and cause the stress response affects immune activity. Secretion of growth evidenced by a decrease in the number of leukocytes. The hypothalamus secretes corticotropin.

based on Selye’s theory. Goodkin behavior patterns of withdrawal and depression are seen. In ad- et al. and infections and tu- Taylor. has been retained from our evolu. They are cisive point in a ball game. tion to threatening situations. sive. Other inappropriate cop- ing patterns may increase the risk of illness less directly.. Type A be- haviors increase the output of catecholamines. and distancing. 1998. social life. it is possible to anticipate and defuse some of these situations. Denial may be illustrated by the woman who feels a lump in her breast but downplays its seriousness and delays seeking medical attention. the goals of adaptation. Sergerstrom. psychological health or hav- ing a sense of well-being (happiness. competitiveness. specific immune measures (Chalfont & Bennett. sexual derangements. blood pressure. Chapter 6 Homeostasis. This same mobilization comes into play in re. intensity. inflammatory diseases of the MALADAPTIVE RESPONSES TO STRESS skin and eyes. recurrent characteristic pattern of behavior during stress that is a warning responses or patterns of response over time that do not promote that the system is out of balance. (whether from genetic traits. For example. this new field of study will mors may develop. avoid- ance. satisfaction with life. If the production of the ACTH is prolonged or excessive. which includes work. diseases of the heart and blood vessels. Over time. 1998). Rabin. physiologic. health. haviors and thought processes. vous and mental diseases. which. they are referred coping behaviors. Kemeny. Pike sympathetic adrenal-medullary response is prolonged or exces- et al. and cancer. By appraising sit- uations more adequately and coping more appropriately. or age). The frequency. & Stone. Fahey. 1999. Maladaptive re- sponses that threaten these goals include faulty appraisals and in- appropriate coping (Lazarus. as indicated earlier facilitates adapta. and duration of stressful situations contribute to the development of negative emotions and sub- sequent patterns of neurochemical discharge. suggests that any stressor elicits a state of disturbed phys- iologic equilibrium. the immune response is decreased. As research continues. Indicators of stress and the stress response include both subjec- sponse to emotional stimuli unrelated to danger. but it may also endanger life. as having positive effects on health or ease. 1991a). that may be observed directly or reported by the person. allergic and hypersensitivity diseases. Kennedy. For example. diseases of the kidney. Constantino. morale). and family (positive relationships). with their attendant effects on the body. or when excited about attending a psychological. The intent of denial is to con- trol the threat. a tive and objective measures. leads to illness. it will increase the susceptibility of the person to illness. arteriosclerotic changes. frequent potentially stressful encounters (eg. The goals of adaptation are somatic or physical health (optimal wellness). 2000. For ex- ample. of maladaptation: high blood pressure. metabolic diseases. 2000. is an anticipatory response that mobilized the bodily resources of our ancestors to deal with predators and other harsh factors in their INDICATORS OF STRESS environment. Stress. hypertension of pregnancy. and enhanced social functioning. and achievement orienta- tion and have an underlying hostile approach to life are more prone than others to develop stress-related illnesses. Chart 6-1 lists signs and symptoms person may get an “adrenaline rush” when competing over a de. for example. such as op. and Adaptation 87 ity of natural killer cells (Andersen et al. 1996.. Coping processes that include the use of alcohol or drugs to reduce stress increase the risk of illness.. infections. & dition. This susceptibility. Robinson. or a pattern of procrastination (eg. Other forms of inappropriate coping include denial. Models of illness frequently cite stress and maladaptation as precursors to disease. Some of these reactions may be When the responses to stress are ineffective. 1997. or behavioral and reflect social be- party. 1997. digestive diseases. rheumatic and rheumatoid arthritis. 2000). marital discord) might be avoided with better communication and prob- lem solving. Glaser & Kiecolt-Glaser. Maladaptive responses are chronic. each person tends to develop a to as maladaptive. ner- The stress response. and cardiovascular dis- timism and active coping. delaying work on tasks) could be corrected to reduce stress when deadlines approach. continue to uncover to what extent and by what mechanisms Selye (1976) proposed a list of disorders that he called diseases people can consciously influence their immunity. the adrenal- medullary hormones. a state of chronic arousal develops that may lead to high Other studies have identified certain personality traits. coupled with a predisposition in the person . If the ula. tionary past. A general model of illness. The “fight-or-flight” response. Sec. If this state is prolonged or the response is ex- cessive. Matthews. & Witek-Janusek. people who demonstrate “type A” personality behaviors such as impatience.

The nurse would also encourage weight loss and discuss the woman’s in. For example. body temperature. to the dead cell (Fig. with the ultimate goal and structure includes the relationship of the cell to compen- being to create a healthy lifestyle and prevent hypertension and satory mechanisms. maintain the steady state. because each state does not have discrete boundaries. Hilton. It is important for the nurse to realize that the optimal point of sunburn and injury occur. Changes monograph developed by Barnfather and Lyon (1993). researchers have devel. the nurse would counsel her small amounts of a barbiturate. morphologic response to expo- sure to the rays of the sun. Miller and Smith (1993) provided a stress audit and disease represents an extension and distortion of normal and a stress profile measurement tool that is available in the pop. and fluid and electrolyte balance are or diseased cell. and its physiologic state are determinants of in research journals. and activity. in other instances. Many of these are discussed in the research FIGURE 6-3 The cell on a continuum of function and structure. blood glucose ranging from the normal cell. The patient and the nurse would CONTROL OF THE STEADY STATE identify both individual and environmental stressors and discuss The concept of the cell as existing on a continuum of function strategies to decrease the lifestyle stress. The nurse should be able to relate the pre- the response. respiratory depression and death. . For example. Norlander. Starzonski & tectable. mechanisms. lationships between physical and emotional health can be found its ability to adapt. The earliest changes occur at the molecular or subcel- lular level and are not perceptible until steady-state functions or ular lay literature. adaptability and triggering a response aimed at offsetting the The cell exists on a continuum of function and structure. with control achieved through negative feedback. ACTH. Langius. Some examples of the research instruments that nurses com- monly use to measure levels of client distress and client func- tioning can be found in a variety of research reports (Cronquist. blood pressure of 130/85 mm Hg. The cell involved. Blood pressure. and some cells may die. acid–base balance. as evidenced intervention to promote health is during the stage when the in- by desquamation (“peeling”). 2000. The point at which was based on a synthesis conference held by nurse scientists on compensation subsides and pathophysiology begins is not clearly defined. deviation. 2000). Immunoglobulin assays may be determined. if an anxious middle-aged woman pre- of the stimulus. Reliable HEALTH DISEASE measures of stress include blood levels of catecholamines. some changes may be re- versible. with a rons that control respiration can develop a tolerance to regular. which occur continuously in the body to its sequelae. the state of the science in stress and coping nursing research. dividual’s own compensatory processes are still functioning. Pathologic processes may occur at all levels of the biologic or- ganism. Wredding. Early Different cells and tissues respond to stimuli with different identification of both physiologic and psychological stressors re- patterns and rates of response. and Negative feedback mechanisms throughout the body monitor so forth). cardiac muscle cells respond to hy- senting signs and symptoms of distress to the physiology they rep- poxia (inadequate oxygenation) more quickly than smooth mus- resent and identify the individual’s position on the continuum of cle cells do. For example. which in the cell are not as easily discerned as the diagram depicts. Changes from one examples of functions regulated through such compensatory state to another may occur rapidly and may not be readily de. and coping strategies. function. Cell remains intact Loss of cell integrity oped questionnaires to identify and assess stressors. Among the measures. Indeed. Compensatory processes are regulated primarily by the autonomic nervous system and the endocrine Stress at the Cellular Level system. stress. In addition to using laboratory tests. structures are altered. These mechanisms work by logic processes are often described by scientists at the subcellular sensing deviations from a predetermined set point or range of or molecular level. The serum creatine/creatinine ratio and elevations of cholesterol and free fatty acids can also be Normal Adapted Injured or Dead cell cell diseased cell cell measured. to the adapted cell. For example. however. Increases in blood pressure and heart rate can also be measured. With greater attention to neuroimmunology. If the cell is considered the smallest unit or subsystem Negative Feedback (tissues being aggregates of cells. and its severity. to the injured level. corti- coids. take of salt (which affects fluid balance) and caffeine (which pro- vides a stimulant effect). the processes of health and disease or adaptation and the internal environment and restore homeostasis when condi- maladaptation can all occur at the cellular level. Physiology/Pathophysiology blood and urine analyses can be used to demonstrate changes in hormonal levels and hormonal breakdown products. stress management. organs aggregates of tissues. Pathophysiologic mechanisms. improved laboratory measures are likely to follow. some cells are more vulnerable to mains a major role of the nurse. patho. neu- sented for a checkup and was found to be overweight. from health and compensation to pathophysiology and Other determinants of cellular response are the type or nature disease. If the exposure is continued. 6-3). processes. the injuries are lethal. and eosinophils. & Bjorvell. its duration. With cell injury. tions shift out of the normal range. Compensatory mechanisms. but one large dose may result in with respect to diet. and information on the interre- one type of stimulus or stressor than others. NURSING IMPLICATIONS tanning of the skin is an adaptive.88 Unit 2 BIOPHYSICAL AND PSYCHOSOCIAL CONCEPTS IN NURSING PRACTICE Laboratory measurements of indicators of stress have helped in understanding this complex process.

carbon dioxide is exhaled. however. gastrointestinal tract. increased workload. leading to decrease in Use person organ size Blood supply Extremity immobilized in plas- Nutrition ter cast Hormonal stimulation Innervation Hyperplasia—increase in Hormonal influence Breast changes of a girl in pu- number of new cells (increase berty or of a pregnant in mitosis) woman Regeneration of liver cells New red blood cells in blood loss Dysplasia—change in the ap. A steady state is achieved by the continuous. Another type of feedback. local responses consisting of small feedback loops in a group of cells or tissues are possible. liver. the hydrogen ion concentration returns Atrophy can be the consequence of a disease or of decreased to normal. Changes in epithelial cells lin- one adult cell type to another cialized cell ing bronchi in response to (reversible) smoke irritation (cells be- come less specialized) . There are some exceptions to When stimulated. an increase in the carbon Cells can adapt to environmental stress through structural and dioxide concentration of the extracellular fluid leads to increased functional changes. The maintenance function in an exercised muscle stimulates dilation of blood vessels in the refers to the activities that the cell must perform with respect to area to increase blood flow and improve the delivery of oxygen itself. which increases the rate of respiration.” In addition to the responses controlled by the nervous and en. these organs alter their rate of activity or the this. they have itive feedback mechanism. blood clotting in humans. loss of nerve supply. As the number of dead cells increases. lungs. CELLULAR ADAPTATION docrine systems. dysplasia. For example. Compensatory hy- tive receptors in the respiratory control center of the medulla of pertrophy is the result of an enlarged muscle mass and commonly the brain. Reproduction of cells with re. The cells detect a Cells are complex units that dynamically respond to the chang- change in their immediate environment and initiate an action to ing demands and stresses of daily life. in. pro- have been subjected to and shape ducing irregular tissue chronic irritation changes that could be the precursors of a malignancy Metaplasia—transformation of Stress applied to highly spe. ized functions of the tissues are altered and the individual’s health tinuous small exchanges of chemical substances among cells. and skin. is threatened. been called the “organs of homeostasis or adjustment. positive feedback. the accumulation of lactic acid function and a specialized function. decreased blood supply. Chapter 6 Homeostasis. They possess a maintenance counteract its effect. lation to the tissues and organs of which it is a part. One example is the bulging muscles tercostal muscles. increased carbon dioxide raises the hydrogen Hypertrophy and atrophy lead to changes in the size of cells ion concentration of the blood. The major organs affected of compensating for it. Some of these adaptations are hypertrophy. Because of this. and blood. and metaplasia (Table 6-2). specialized functions are those that the cell performs in re- and removal of waste products. variable action ism. This is detected by chemosensi. For example. disorder and disintegration occur. Individual The net result of the activities of feedback loops is homeosta. and the chemically sensitive neurons are no longer use. terstitial fluid. for example. is an important pos- amount of secretions they produce. the special- of the organs involved in making the adjustments and by the con. Alterations in epithelial cells of pearance of cells after they sulting alteration of their size the skin or the cervix. and hence the size of the organs they form. On a cellular level. atrophy. or inadequate stimulated. hyperplasia. are the heart. kidneys. and Adaptation 89 Most of the human body’s control systems are integrated by Positive Feedback the brain and influenced by the nervous and endocrine systems. Stress. which decreases the carbon dioxide level. Control activities involve detecting deviations from the predeter. Disuse of a body part is often associated with the aging Table 6-2 • Cellular Adaptation to Stressors ADAPTATION STIMULUS EXAMPLE Hypertrophy—increase in cell Increased workload Leg muscles of runner size leading to increase in Arm muscles in tennis player organ size Cardiac muscle in person with hypertension Atrophy—shrinkage in size of Decrease in: Secondary sex organs in aging cell. pulmonary ventilation. longed. Excess of the athlete who engages in body building. The chemoreceptors stimulate an increase in the rate occurs in skeletal and cardiac muscle that experiences a pro- of discharge of the neurons that innervate the diaphragm and in. cells may cease to function without posing a threat to the organ- sis. As the system becomes more unbalanced. nutrition. perpetuates the mined reference point and stimulating compensatory responses chain of events set in motion by the original disturbance instead in the muscles and glands of the body.

This may be mani- the system more susceptible to another injury. leading to hypoxia is slow and progressive. creased hemoglobin) cumb. examples. or there may be faulty regulation of function. and the brain. Ischemia stressor that alters the ability of the cell or system to maintain op. but it is reversible when the Processing stimulus is removed. With injury. which continues after the stimulus is removed. The length of time different tissues can sur- pensation occurs and a steady state is achieved. An example is the in- crease in the size of the thyroid gland caused by thyroid-stimulating hormone (secreted from the pituitary gland) when a deficit in thy. They • A decrease in blood supply to an area also reflect changes in the normal cell in response to stress. For example. loss of Inadequate cellular oxygenation (hypoxia) interferes with the the cilia and protective mucus. FIGURE 6-4 Influences leading to disorder may arise from the internal Metaplasia is a cell transformation in which a highly special. steady-state regulation is lost. Thrombi and emboli are common causes of cerebrovascular changes within the body’s systems. Excesses or deficits ized cell changes to a less specialized cell. infectious agents. nutritional imbalance. The squamous cells can survive. and Nutritional imbalance refers to a relative or absolute deficiency infectious agents. Any The usual cause is ischemia. although it may vive without oxygen varies. and in 3 to 6 minutes. With adaptive changes. production of adenosine triphosphate) ciencies and avitaminosis (deficiency of vitamins) are typical • The ability of the cell to synthesize enzymes and other nec. the tissue mass enlarges. or deficient blood supply. may develop. Dysplasia is the change in the appearance of cells after they have been subjected to chronic irritation. structures principally External affected are the skeletal muscles. Protein defi- tion. cient or when there is an imbalance of nutrients. If the • A decrease in the oxygen-carrying capacity of the blood (de- stress is unrelenting. chemical agents. however. can have damaging cell’s ability to transform energy. may also prevent glucose from entering the cell from the . This serves a protective of information and matter may occur. Nutritional Imbalance nisms. An energy deficit leading to cell injury can occur if essary proteins there is insufficient glucose. ance Specific deficiencies arise when an essential nutrient is defi- • The ability of the cell to transform energy (aerobic respira. Hyperplasia is an increase in the number of new cells in an Internal organ or tissue. is commonly seen in myocardial cell injury in which arterial timal balance of its adjustment processes will lead to injury. accidents (strokes). Cell size and organ size decrease. These agents act at the cellular level point of obesity overloads cells in the body with lipids. which may be re. In addition. com. These adaptations allow the survival of the organism. It is a mitotic response (a change occurring with mitosis). Caloric excess to the tem vulnerable to infection. blood flow is decreased because of atherosclerotic narrowing Structural and functional damage then occurs. If the condition changes in functioning ensue. tissue. in. A lack of insulin. organ. (Fig. 6-4) and include hypoxia. depending on the situation. the function of the adapted cell may suc. For example.90 Unit 2 BIOPHYSICAL AND PSYCHOSOCIAL CONCEPTS IN NURSING PRACTICE process. Dysplastic cells have a Environment tendency to become malignant. As cells multiply and are subjected to increased stimulation. the ciliated columnar epithelium lining the bronchi of smokers is replaced Hypoxia by squamous epithelium. obesity places a strain on the body and has been associated with the development • The integrity of the cell membrane. the presence of one injury makes or excess of one or more essential nutrients. or the inability to use tegrity) insulin. and cell injury will occur. Hypoxia may be caused by: consequences. of disease. environment and the external environment of the system. the glucose into energy. calories) or overnutrition (caloric excess). chemical injury. or insufficient oxygen to transform • The ability of the cell to grow and reproduce (genetic in. genetic defects. brain cells may succumb be at new levels. especially pulmonary and cardiovascular disease. The most com- mon causes are hypoxia (oxygen deficiency). this mechanism is not highly reliable. and matter Hyperplasia may be hormonally induced. of information lignant growth. Environment roid hormone is detected. the secondary sex organs. immune mecha. This distinguishes it from neoplasia or ma. Homeostatic adjustments are concerned with the small ply. of blood vessels. and psychogenic factors. necessary for ionic bal. whereby blood is supplied by other blood vessels body) may arise from the external or internal environment in the area. the heart. because the less specialized cell is more resistant to processing. the stress that stimulated the change. dysplasia is seen commonly in epithelial cells in the bronchi of smokers. fested as undernutrition (inadequate consumption of food or adequate oxygenation and nutritional deficiencies make the sys. Ischemia also results from intravascular clots versible (permitting recovery) or irreversible (leading to disability (thrombi or emboli) that may form and interfere with blood sup- or death). • A ventilation/perfusion or respiratory problem that reduces the amount of oxygen available in the blood • A problem in the cell’s enzyme system that makes it unable CELLULAR INJURY to use the oxygen delivered to it Injury is defined as a disorder in steady-state regulation. However. physical agents. By re- by damaging or destroying quiring more energy to maintain the extra tissue. collateral circulation Causes of disorder and injury in the system (cell. For example.

Disordered liver normal when the fever abates. but like other adjustment processes it can become tion. fungi. main to support healing. immunodeficiency diseases occur. Eventually. which has a structure are of intense research interest. are killed. heart rate. when it is hy- Mechanical trauma can result in wounds that disrupt the cells and peractive. As a result of the certain people. Many of these defects corrosive action on epithelial tissue. thermostat may be reset at a higher temperature. produce exotoxins that circulate and create cell damage. large amounts can lead to nutritional deficiency. then invade severe. This physiologic condition occurs in Biologic agents known to cause disease in humans are viruses. the high temperature causes bacteria. and cell injury will occur. and basal metabolic rate cohol is broken down into acetaldehyde. al- curs and the respiratory rate. With fever induced by infections. of glucose can cause osmotic shifts. rickettsiae. mechanism. produce endotoxins when they classified as partial-thickness burns if epithelializing elements re. Many other chemicals are toxic in specific amounts. If the injury is a complex mechanism. in the extreme. responses of the body to the presence of infection. arsenic. A disorder of the im- tissues of the body. With still lower temperatures. Body temperatures greater than 41°C (106°F) suggest hyperthermia. The duration of exposure and the intensity ary dosages. others contribute to more obvious congen- action. It an antigen (foreign substance) into the body evokes the production may also abnormally stimulate nerves. The immune response de- the cell. the hypothalamic effect on liver cells that leads to a variety of liver abnormalities. The immune system is an exceedingly complex system. and in distinctive tissues. because the Infectious Agents physiologic function of the thermoregulatory center breaks down and the temperature soars. ice Disordered Immune Responses crystals may form. elec. such as lack mercury. creating a favorable environment for opportunistic in. The severity of the wound. is coagulated. Genetic Disorders Chemical Agents Genetic defects as causes of disease and their effects on genetic Chemical injuries are caused by poisons. In the body. Others. Drugs. This occurs in diabetes mellitus. foreign cell type. and the The local response to thermal or burn injury is similar. ber of microorganisms entering the body. the smallest living organisms. The tubercle bacillus induces an immune reaction. and too much insulin can cause subnormal levels Physical Agents of glucose in the blood (hypoglycemia) and can lead to coma. protein Some bacteria. people with heat stroke. then return to including cirrhosis in susceptible individuals. leading to ischemic damage in the involved tissues. When a person’s temperature is elevated. is an increase in metabolic activity. enzyme systems are destroyed. as heat increases. When MECHANICAL TRAUMA it is hypoactive. such as those that cause tetanus and diphtheria. or cold. in the outcome. radiation. the entire body system becomes involved. Alcohol (ethanol) is also a chemical irritant. can cause injury to the cells than others and manifest toxic reactions at the usual or custom- or to the entire body. of the stressor determine the severity of damage. This is a steady-state ing forms of radiation may cause injury by their destructive ac. each with its own specific destructive of a single enzyme. such as produce mutations that have no recognizable effect. Through volved determines the prognosis for the patient. age. its pur- RADIATION AND ELECTRICAL SHOCK pose is to defend the body from invasion by any foreign object or Radiation is used for diagnosis and treatment of diseases. and. Polypharmacy (taking many medications at one time) also occurs frequently in the aging population and is a problem because of the EXTREMES OF HIGH TEMPERATURE unpredictable effects of the resulting medication interactions. affecting the fluid and elec- trolyte balance. and Adaptation 91 blood. an in- EXTREMES OF LOW TEMPERATURE flammatory response and immune reaction are the physiologic Extremes of low temperature. The amount of body surface in. Burns of the epithelium are such as the gram-negative bacteria. Aging tends to decrease tolerance to medications. hypersensitivity disorders arise. Ioniz. Excessive secretion of Human Genome Project. and the extent of nerve damage are significant factors Such disorders are labeled autoimmune diseases (see Unit 11). such as cancerous cells. The entrance of generated when electrical current travels through the body. health. The severity of the infectious disease depends on the num- cooled rapidly to prevent brain damage. patients can be genetically assessed for . immune defenses). can also cause chem- Physical agents. The body must be todes. charring or carbonization occurs. Some individuals are less tolerant of medications trical shock. tects foreign bodies by distinguishing non-self substances from fections. Radiation decreases the protective inflammatory response of disordered. and mechanical trauma. and the cells may burst. to of antibodies that attack and destroy the antigen (antigen–antibody fibrillation of the heart. in ital abnormalities. Chapter 6 Homeostasis. and lead. and hyper. cause vasoconstriction. such as lye. they replicate within the cells. their virulence. including temperature extremes. a metabolic disorder that hydrochloric acid can damage the stomach lining. and the cells die. An immune response is metabolism develops as a pathophysiologic response. protozoa. for example. other cells and continue to replicate. Blood flow becomes sluggish and clots form. Typically. Stress. ical poisoning. The increase in body temperature cell function leads to complications in other organs of the body. including prescribed medications. There host’s defenses (eg. is achieved through physiologic mechanisms. the living cells they invade. survive as parasites of and must be grafted for healing. and nema- coagulation of cell proteins. leading. Full-thickness burns lack such elements Viruses. The immune system can be hypoactive or hyperactive. reaction). Electrical shock produces burns as a result of the heat self substances and destroying the non-self entities. which has a direct toxic all increase. or by heavy metals. and. mycoplasmas. Viruses infect specific cells. and the cells har- boring the viruses can be injured in the process. mounted by the body to eliminate the viruses. blood loss. such as Down syndrome. the amount of mune system itself can result in damage to the body’s own tissues. hypermetabolism oc.

loss of appetite. Systemic Response to Inflammation ing swelling. Inflam. These sub- tissues. For example. Leukocytosis. meability. white blood cells. During this process. or is only one of several agents that may trigger an inflammatory re. increased vascu. including vasodilation. An infection exists when the infectious agent is living. is present in many tissues of the body but is concentrated in the lar permeability. and to remove cellular debris in a process called phagocytosis. which controls body and platelets) remain in the blood. Regardless of the cause. Bradykinin is only local signs and symptoms. for clot formation. Plasma fluids. stances reset the hypothalamic thermostat. phenylke. and loss of function. The availability of genetic information and technology enables health care providers to per- form screening. a general sequence of events occurs in the local inflammatory response. infectious) described earlier. may and migrate to the site of injury to engulf offending organisms occur to provide the body with greater ability to fight infection. exit. another group of injury is followed by vasodilation and an increased rate of blood chemical substances. cystic fibrosis. Physiology/Pathophysiology tonuria. testing. or chronic. eliminate the offending agent and to prepare the site for repair. and counseling for patients with genetic Migration of leukocytes Cellular injury concerns. forming fibrin cluding malaise. which serves to wall off the injured area and prevent the spread of infection. and proteins occur. Foremost changes described earlier and usually lasts less than 2 weeks. When this happens. Loss of also occur. An infectious agent FIGURE 6-5 Inflammatory response. general. It chemical is a nonspecific response (not dependent on a particular cause) that mediators is meant to serve a protective function. aching. they also The transient vasoconstriction that occurs immediately after attract neutrophils to the area. obesity. to inflamed area to engulf foreign material ect has also created opportunities for assessing a person’s genetic profile and preventing or treating disease. and weakness. and Alzheimer’s disease. It may be acute. As mast cells.92 Unit 2 BIOPHYSICAL AND PSYCHOSOCIAL CONCEPTS IN NURSING PRACTICE conditions such as sickle cell disease. hemophilia A and B. synthesis and release of neutrophils from bone marrow. and plasma fluids (includ- ing proteins and solutes) leak into the inflamed tissues. Acute Injury initiates the inflammatory response. physical. Types of Inflammation Inflammation is categorized primarily by its duration and the type Chemical Mediators of exudate produced. control. Prostaglandins. inflamma. However. mation is a defensive reaction intended to neutralize. and produce fever. in a sore throat. (internal substances that cause fever) released from neutrophils As blood flow increases and fluid leaks into the surrounding and macrophages (specialized forms of leukocytes). causing endings by chemical mediators released at the site. infectious. are also suspected of causing increased per- flow through the microcirculation. and multiplying in the tissues and is able to overcome Fibrinogen and plasma coagulate to prevent spread of infection. heat. This sequence involves changes in the microcirculation. mediators. Diagnostic genetics and gene therapy have the potential to identify and modify a gene before it begins to express traits that would lead to disease or disability. pain. It is released when injury occurs and is responsible these changes take place. Fever is the most common sign of a systemic response function is most likely related to the pain and swelling. Next. Knowledge obtained from the Human Genome Proj. five cardinal signs of inflammation are for the early changes in vasodilation and vascular permeability. an increase in the cous. Inflammation also occurs in permeability of microcirculation cell injury events. and leukocytic cellular infiltration (Fig. cardiovascular disease. temperature. swelling. The pain produced is attributed to the pressure of fluids or swelling on nerve endings. Local heat and redness result. leukocytes. CELLULAR RESPONSE TO INJURY: INFLAMMATION Cells or tissues of the body may be injured or killed by any of the agents (physical. and to the irritation of nerve The inflammatory response is often confined to the site. Leukocytes remove cellular debris. other factors cause cellular injury. produc. such as strokes and myocardial infarctions. leak into Vasodilation and inflamed area tion may be observed at the site of a bee sting. Kinins increase vasodilation and vascular permeability. in- Fibrinogen in the leaked plasma fluid coagulates. an inflammatory response (or inflammation) naturally occurs in the healthy tissues adjacent to the site of injury. produced: redness. inflammation is characterized by the local vascular and exudative stances released at the site induce the vascular changes. the body’s normal defenses. Chemical. and it is most likely caused by endogenous pyrogens exact mechanism is not completely known. Inflammation is not the same as infection. and at a burn site. nonspecific symptoms develop. systemic responses can one of the chemical mediators suspected of causing pain. Leukocytes (white blood cells) collect in the vessels. breast cancer. vascular permeability increases. growing. Vasodilation and release of chemical- sponse. but chemical sub. but the to injury. subacute. causing it to become more vis. Histamine acute inflammatory response is immediate and serves a protective . or leukocytes. 6-5). chemical. An among these chemicals are histamine and the kinins. the formed elements (red blood cells. in increased vascular a surgical incision.

Permanent cells include neurons—the nerve cell bodies. followed by water. all of which indicate and results in more scar formation. As the inflammation becomes chronic. poor adaptive responses. in which cells of another type. with loss of specialized func. Under normal physiologic processes. The following Subacute inflammation falls between acute and chronic in. Labile cells multiply constantly to re. re- normal structure and function. as are the sources of stress. Management of specific biologic disorders is dis- bile. or deformities? occurs by proliferation of cells of the same type as those de. and the nature an accurate diagnosis allows interventions and goals to be more and severity of the injury affect the processes of inflammation and specific and leads to improved outcomes. it is every- generate. muscles no longer contract. . the nurse must relate the symp- toms or complaints expressed by the patient to the physical signs The ability of cells to regenerate depends on whether they are la. or memory? may occur by regeneration. arriving at The condition of the host. such as computed tomography (CT). cognitive ability. which leads to edema. the nurse can assist any place cells worn out by normal physiologic processes. the environment. but if they are damaged or de. and temperature normal? phase. with repair In the assessment of the person who seeks health care. customary activities of daily living may be disrupted. As the cells rupture. ward with granulation tissue. Situational low cause the electrical signal cannot be conducted through the con. The term subacute inflammation is not widely used. Anxiety. tion healing. of the cell. The chronic response zymes that destroy tissues escape. or powerlessness are emotions stroyed. ifested as ineffective coping patterns. Spiritual distress. the nursing diagnoses of Impaired adjustment. Further signs of change are indicated in diagnostic studies stroyed. uneasy feeling. ings of inadequacy. Healing pro. as in a surgical wound. blood glucose. many months or years. defined as a vague. they are able to regenerate. Essentially. eating and activity patterns may be altered. After the injurious agent is removed. but axons may regenerate. • Does the person demonstrate any problems with affect. which is tion healing. One nursing diagnosis related to stress is Anxiety. among others. speech. dence can also be obtained from laboratory data. These include functional cells often associated with stress. these patient to respond to stress-inducing biologic or psychological include epithelial cells of the skin and those lining the gastroin. and Powerlessness. Chronic inflammation may also begin in. Stress or the potential for stress is ubiquitous. not their axons. Objective evi- formation. liver. orientation. Risk for impaired parenting. self-esteem. In secondary inten. and feel- and do not need replacement. tissue healing may occur by Many nursing diagnoses are possible for patients suffering from primary intention or by secondary intention. or stable. Ineffective coping. The process of repair takes longer Defensive coping. Sodium and calcium enter Chronic inflammation develops if the injurious agent persists the cell. If normal activity is to return. frustration. questions are addressed during the assessment: flammation. and Adaptation 93 function. anger. tis. usu. Stress Management: Nursing Interventions sue regeneration must occur in a functional pattern. occur. for Social isolation. in which gradual repair of the defect • Are there obvious impairments. Nerve impulses are no longer transmitted. The wound fills from the bottom up. and fibrosis begins. example. sulting in a nonrestricted flow of ions. as in the chronic • Are the heart rate. and urinalysis. and energy and the acute response is perpetuated. Other possible nursing diagnoses include tion. blood urea nitrogen (BUN). lysosomal en- sidiously and never have an acute phase. fill in the tissue defect and result in scar (MRI). Readiness for family coping. permanent. lesions. both ob- and breakdown occurring simultaneously. necrosis. and pancreas. the wound is clean and dry and the edges are ap. of the physiologic processes that are occurring. height. have abnormal electrocardiographic (ECG) tracings be. nonspecific or not known to the person. that are present. and weight? The reparative process begins at approximately the same time as • Are there any problems in movement or sensation? the injury and is interwoven with inflammation. In the presence of these emotions. disorders with stress-management interventions. it is debilitating and can produce long-lasting effects. the wound or defect is larger and gaping and has or disrupted relationships. People who have recovered from myocardial infarction. Considerable scarring jective signs and subjective symptoms are the primary indicators may occur. cussed in subsequent chapters. for example. be- ceeds after the inflammatory debris has been removed. Any of the injuries previously discussed can lead to death subsides and healing takes place with the return of normal or near. and cell death and necrosis does not serve a beneficial and protective function. Chapter 6 Homeostasis. impaired thought processes. resulting in permanent tissue damage. It includes elements of the active exudative phase of the acute response as well as elements of repair. Stable cells have a latent ability to re. and positron emission tomography (PET). Depending on the extent of damage. that is. • What emotional distress may be contributing to the pa- tient’s health problems? • Are there other indicators of steady-state deviation? CELLULAR HEALING • What is the person’s blood pressure. Stress. respiratory rate. Because human re- nective tissue that has replaced the infarcted area. the source of which may be proximated. A cycle NURSING IMPLICATIONS of cellular infiltration. sponses to stress are varied. magnetic resonance imaging ally connective tissue. In primary inten. or by replacement. Stress may also be man- and the wound is usually healed in a week. the cell membrane becomes impaired. especially in the growth of several axons. including elec- trolytes. trary. Decisional conflict. the of the kidney. they are not shed where and anywhere at once. Destruction of a neuron is a permanent loss. Healing havior. helplessness. and Ineffective denial. however. Little scar formation occurs. the inflammation repair. Symptoms are present for transformation ceases. changes occur at the site of in- jury and the nature of the exudate becomes proliferative. and family processes or role performance may be Healing by Replacement disrupted. Healing by Regeneration In making a nursing diagnosis. These human responses are reflected in necrotic or dead material. on the con. a sleep disturbance may be present. testinal tract. stress.

It is best if the person lies on a soft cushion on the floor. Participation in high-risk behaviors quiet room.94 Unit 2 BIOPHYSICAL AND PSYCHOSOCIAL CONCEPTS IN NURSING PRACTICE Stress management is directed toward reducing and control. tified in the health appraisal. as iden- ling stress and improving coping. the person’s risks and major health hazards are in the whole body (one muscle group at a time). achieved. or threats that 3. Height. Someone usually reads the instruc- The personal information is compared with average popula. or habits that contribute to the risk of illness can be identified through a health risk appraisal. senses the identified. Lifestyles abilities. have periodic screening exami. and driving habits focus the attention. and psychological stress is reduced. nurse can build on the patient’s existing coping strategies. ation. changes. Benson (1993) describes the following steps of the Benson Re- laxation Response: ENHANCING COPING STRATEGIES 1. the action of the hypothalamus adjusts and decreases nations) to improve their health. holds. Benson’s Relaxation Response ing health is level of education (Mickler. 1993): reduction methods and coping enhancements can derive from either internal or external sources. The sequence of physiologic effects and their signs and symptoms are interrupted. tension. sex. It is hoped guided imagery. Questionnaires typically address the activity of the sympathetic and parasympathetic nervous sys- the following information: tems. PROMOTING A HEALTHY LIFESTYLE and using self-talk for encouragement. sexual ac. Further comparisons with population data can esti. Health risk questionnaires estimate the likelihood that a per. a review of 57 nursing research studies were as follows (Jalowiec. of the instructions may be played. Physical measurements Progressive Muscle Relaxation a. & Stark. Laboratory analyses of blood and urine ing. breathing easily. Blood pressure Progressive muscle relaxation involves tensing and releasing the b. tions in a low tone and with a slow and relaxed manner. Personal and family history of diseases and health problems The different relaxation techniques share four similar ele- 3. need to prevent illness. An individual’s personal resources that aid in coping include The nurse can implement the coping enhancement interven- health and energy. However. Demographic data: age. the per- mate how many years will be added to the person’s life span if the son keeps the rest of the body relaxed. • Using spiritual resources work is an external resource that helps reduce stress. phrase. adopting healthy • Trying to be optimistic about the outcome eating habits and practicing relaxation techniques are internal re. • Using social support sources that help to reduce stress. 1997). system. When this goal is their activities (eg. improve the quality of life. exercise. Nurses might use these meth. Role relationships and associated stressors 4. and decrease The five predominant ways of coping with illness identified in the cost of health care makes efforts to promote health essential. stop smoking. 1996). and stress control is a significant health-promotion goal. . As each muscle group is tensed. The 4. tant factor for determining health status is social class. smoking. repriori- because their sense of vulnerability to threat is decreased. Relax your muscles. race. Lifestyle choices ments: (1) a quiet environment. they will alter response that counters the stress response. 1993. b. the whole body should be relaxed (Benson. or teach new strategies for coping if ods not only with their patients but also in their own lives. The single most impor. pleted. Commonly used techniques include progressive muscle relax- fied. ment” as a nursing intervention and defined it as “assisting a pa. Pick a brief phrase or word that reflects your basic belief McCloskey and Bulechek (1999) identified “coping enhance. The person tenses the muscles From this analysis. and relaxation with son with a given set of characteristics will become ill. (3) a a. lowering expectations. and it is much easier for individuals with adequate • Trying to accept the situation financial resources to cope with constraints in the environment. and the risk factors are identified and weighted. The goal of relaxation training is to produce a that if people are provided with this information. When the exercise is com- demonstrated that providing people with such information en. interfere with meeting life demands and roles” (Chart 6-2). comparing oneself to others. The necessary. developing a broad social net. planning activities to conserve energy. drinking. For example. ethnic background This is a learned response and requires practice to achieve. in a 5. weight muscles of the body in sequence and sensing the difference in feel- c. Stressors at home and on the job c. making compro- mises. Benson sures that they will change their habits. Goods and • Trying to maintain control either over the situation or over feelings services that can be purchased are also external resources for stress management. research so far has not feeling the tension and relaxation. or sound). such as a word. 2. or a tape tion risk data. 2. Other ways of coping included seeking information. Eating. habits and recommending changes when a health risk is identi. Each time the focus is on suggested changes are made. Close your eyes. 1. listening to one’s body. and (4) a mental device (something on which to tivity. sleeping. A health-promoting lifestyle provides these re. TEACHING RELAXATION TECHNIQUES A health risk appraisal is an assessment method that is de- signed to promote health by examining an individual’s personal Relaxation techniques are a major method used to relieve stress. (2) a comfortable position. tions and explore methods for improving the patient’s coping sources and buffers or cushions the impact of stressors. passive attitude. the Benson Relaxation Response. taking things one step at a time. Choose a comfortable position. tient to adapt to perceived stressors. Stress. tizing needs and roles. and within a social class the research suggests that the major factor influenc. and then relaxes.

the nurse guides the individual to review the ing patients information also reduces the emotional response so . Reiki. scene. a review of achieve relaxation or direct attention away from undesirable sen. preoperative teaching)—have the goal of reducing stress and improving the patient’s coping ability. harmful or a threat will now be perceived more positively. trying to feel and relive the imagery with all of the senses. biofeedback. or 6. p. breathing techniques. Chapter 6 Homeostasis. This image serves tionship such that something that might have been viewed as as the mental device in this technique. music therapy. such as watching tion. the pain of an ailment) occur. and Adaptation 95 5. EDUCATING ply continuing to repeat the focus phrase. Practice the technique twice daily. commercial tape recordings for guided imagery and relaxation 7. These techniques may alter the person–environment rela- the ocean or dabbling the feet in a cool stream. Other relaxation techniques include meditation. lected focus word. and start using your se. Maintain a passive attitude. Become aware of your breathing. providing sensory information and providing procedural infor- mation (eg. and the This response combines meditation with relaxation. massage. Benson recommends not fighting the distraction but sim. such as a les- Simple guided imagery is the “purposeful use of imagination to son in childbirth preparation to expectant parents. Along use of humor. Stress. 506). a passive attitude is essential. This prepara- Relaxation With Guided Imagery tory education includes giving structured content. cardiovascular anatomy to the cardiac patient. 8. If other thoughts or distractions (noises. or a description of sations” (McCloskey & Bulechek. can be used. 1999. The nurse helps sensations the patient will experience during cardiac catheteriza- the person select a pleasant scene or experience. A tape recording may be made of the description of the image. but the exercise works best on an empty stomach. Continue for a set period of time. The time of day is not Two commonly prescribed nursing educational interventions— important. with the repeated word or phrase. Giv- fortably and quietly. As the person sits com.

Nurses can provide this support. or who withdraw in times of stress have a high risk of cop. Millo & Sullivan. and victims of child (Calvin & Lane. Think about a patient who has survived a major motor vehicle crash and is hospitalized for severe burns. These factors are directly related to the health patterns of most often in a relationship between two people in which mutual the individual. but the necessary support comes only when there is a deep level of in- volvement and concern. The second type of information leads peo. people with ostomies. found to provide the individual with several different types of As previously noted. the nurse is obligated. abuse. internal and external sources of stress management. Describe the manner in which home- viding the individual with ostasis has been maintained or disrupted and the compen- • A positive social identity satory mechanisms that are evident. health. the father AND THERAPY GROUPS has coronary artery disease. The family has ample resources for making changes in leukemia. The third type anisms and perspectives on health and disease. agreement of the patient. The nurse has a significant role and responsibility trust and attachment are expressed by helping one another meet in identifying the health patterns of the person receiving care. Wineman. patient that demonstrate that the woman uses problem- egy to manage it. Peo. this use of others helps the person to focused coping and emotion-focused coping? maintain mastery of a situation and to retain self-esteem. mastectomy patients. the sons are somewhat over- Support groups exist especially for people in similar stressful sit. on the nature of the social support. and the maternal grandfather explore with the nurse RECOMMENDING SUPPORT their health promotion needs. 3. social support has been demonstrated problems or goals has a releasing effect on a person that promotes to be an effective moderator of life stress. coping style of the woman. Groups have been formed by parents of children with ure. to seek ways to promote balance. exists requires a total assessment of the person. and religious support groups are active in many communities. Identify in a spiraling fashion if relief is not provided. system and encourage its use. chronic ill. the way that one of information leads people to believe that they belong to a net. with the assistance and effective when there is recognition that demonstrates the indi. after sustaining a rib fracture. 1988. There are groups for single parents. The 1. Emotional support from family and significant others pro- ? Critical Thinking Exercises vides a person with love and a sense of sharing the burden. a frac- emotions that accompany stress are unpleasant and often increase tured hip. Determine nursing strategies to reduce or alleviate these however. copes with stress. Select a patient to whom you are assigned who has an Thus. A 50-year-old woman is diagnosed with osteoporosis ing failure. This emotional support appears comes. and disabilities.96 Unit 2 BIOPHYSICAL AND PSYCHOSOCIAL CONCEPTS IN NURSING PRACTICE that they can concentrate and solve problems more effectively stance abusers and their family members. gain mastery of the situation. How does the patient’s • Emotional support medical treatment support the compensatory mechanisms? • Material aid and tangible services How do you determine the nursing interventions that are • Access to information appropriate for promoting the healing process? • Access to new social contacts and new social roles 4. Being a member of a group with similar been studied extensively. sub- . A family composed of two parents. and ple to believe that they are esteemed and valued. and with someone and express feelings openly may help the person to psychosocial stressors evident from this person’s trauma. and the grandfather has mild congestive heart fail- uations. What interventions would the nurse initiate with other kinds of cancer or other serious diseases. To network share information and make goods and services available evaluate a patient’s health patterns and to intervene if a problem to the members on demand. and their nursing management are addressed in greater depth in this depends. 1999. a person’s psychological and biologic emotional information (Heitzman & Kaplan. This is most social balance. who are iso- lated. 2. psychological. Social support has been freedom of expression and exchange of ideas. not when people merely touch the sur- face of each other’s lives. The critical qualities within a social network are the exchange of intimate communications and the presence of solidarity and trust. weight. The family’s health history reveals that the mother has adult-onset diabetes. People who are loners. physiological. Professional. If their emotional needs. other chapters. two adolescent male sons. and consciousness-raising groups ENHANCING SOCIAL SUPPORT to help people modify their usual behaviors in their transactions The nature of social support and its influence on coping have with their environment. 2000). Again. Being able to talk the actual and potential physical. The first type of information leads people to believe that relationships with the environment are predictors of health out- they are cared for and loved. What indications would the formation. Specific problems Social support also facilitates an individual’s coping behaviors. the way one relates to others. and 1990). it is important to identify the person’s social support stressors. and multiple lacerations and abrasions. Members of this goals held are also interwoven into those physiologic patterns. and those their lifestyle. as- sertiveness training programs. civic. There are also encounter groups. however. to promote a healthier lifestyle for this family? nesses. vidual’s favorable position in the group. and the values and work of communication and mutual obligation. ple can have extensive relationships and interact frequently. acute illness or injury. those patterns are not achieving physiologic. it helps to seek information and advice from others nurse note in her interactions and follow-up care for this who can assist with analyzing the threat and developing a strat. It elevates the person’s Although this chapter has presented some physiologic mech- sense of self-worth and is called esteem support. The nurse is evaluating the Because anxiety can also distort a person’s ability to process in. social networks assist with management of stress by pro.

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