FUNDAMENTAL CONCEPTS
environment that is perceived as challenging,
 Each body system performs specific functions to
sustain optimal life for an organism.
 Compensatory mechanisms for adjusting
internal conditions promote the steady state of
the organism, ensure its survival, and restore
balance in the body.
 Pathophysiologic processes result when cellular
injury occurs at such a rapid rate that the body’s
compensatory mechanisms cannot make the
adaptive changes necessary to remain healthy.
 The goal of the interaction of the body’s
subsystems is to produce a steady state (even in
the presence of change) so that all subsystems
are in harmony with each other.
 Four concepts—constancy, homeostasis, stress,
and adaptation—are key to the understanding of
steady state.
CONSTANCY AND HOMEOSTASIS
HOMEOSTASIS
 Refers to a steady state within the body.
 When a change or stress occurs, processes are
initiated to restore and maintain balance.
 When adjustment processes or compensatory
mechanisms are not adequate, steady state is
threatened, function becomes disordered, and
dysfunctional responses occur.
 Dysfunctional responses can lead to disease (an
abnormal variation in the structure or function of
any part of the body).
STRESS AND ADAPTATION
 Stress is a state produced by a change in the
threatening, or damaging to a person’s dynamic
balance or equilibrium.
 The change or stimulus that evokes this state is
the stressor.
 The desired goal is adaptation or adjustment to
the change so that the person is again in
equilibrium and has the energy and ability to
meet new demands.
 This is the process of coping with the stress, a
compensatory process that has physiologic and
psychological components.
OVERVIEW OF STRESS
 Each person operates at a certain level of
adaptation and regularly encounters a certain
amount of change.
 Such change is expected; it contributes to
growth and enhances life.
 A stressor can upset this equilibrium.
 A stressor may be defined as an internal or
external event or situation that creates the
potential for physiologic, emotional, cognitive,
or behavioral changes.
TYPES OF STRESSORS
 They may be described as physical,
physiologic, or psychosocial.
 Physical stressors include cold, heat, and
chemical agents.
 Physiologic stressors include pain and fatigue.
 An example of a psychosocial stressor is fear
(e.g., fear of failing an examination, losing a job,
waiting for a diagnostic test result).
TYPES OF STRESSORS
 Duration may also be used to categorize
stressors, as in the following:
1. An acute, time-limited stressor, such as studying
for final examinations
2. A stressor sequence—a series of stressful
events that result from an initial event such as
job loss or divorce
3. A chronic intermittent stressor, such as daily
hassles
4. A chronic enduring stressor that persists over
time, such as chronic illness, a disability, or
poverty
STRESS AS STIMULUS FOR DISEASE  Coping consists of the cognitive and behavioral
efforts made to manage the specific external or
 Research suggests that people under constant
internal demands.
stress have a high incidence of disease (Gallo,
 Emotion-focused coping seeks to make the
Roesch, Fortmann, et al., 2014; Greenberg,
person feel better by lessening the emotional
Tanev, Marin, et al., 2014).
distress.
 People typically experience distress related to
 Problem-focused coping aims to make direct
alterations in their physical and emotional
changes in the environment so that the situation
health status, changes in their level of daily
can be managed more effectively.
functioning, and decreased social support or the
 In harmful or threatening situations, successful
loss of significant others.
coping reduces or eliminates the source of stress
 When a person endures prolonged or unrelenting
and relieves the emotion generated.
suffering, the outcome is frequently the
 Appraisal and coping are affected by internal
development of a stress-related illness.
characteristics such as health, energy, personal
 Nurses have the skills to assist people to alter
belief systems, commitments, or life goals, self-
their distressing circumstances and manage their
esteem, control, mastery, knowledge, problem-
responses to stress.
solving skills, and social skills.
PSYCHOLOGICAL RESPONSES TO STRESS
PHYSIOLOGIC RESPONSE TO STRESS
 After recognizing a stressor, a person
 The physiologic response to a stressor, whether
consciously or unconsciously reacts to manage
it is physical, psychological, or psychosocial, is
the situation. This is termed the mediating
a protective and adaptive mechanism to maintain
process.
the body’s homeostatic balance.
 A theory developed by Lazarus (1991)
 When a stress response occurs, it activates a
emphasizes cognitive appraisal and coping as
series of neurologic and hormonal processes
important mediators of stress.
within the brain and body systems.
 Appraisal and coping are influenced by
 The duration and intensity of the stress can
antecedent variables, including the internal and
cause both short- and long-term effects.
external resources of the individual person.
GENERAL ADAPTATION SYNDROME (SELYE,
APPRAISAL OF THE STRESSFUL EVENT
1976)
 Cognitive appraisal is a process by which an
 Has three phases: alarm, resistance, and
event is evaluated with respect to what is at
exhaustion.
stake (primary appraisal) and what might and
can be done (secondary appraisal). 1. During the alarm phase, the sympathetic fight-
 What a person sees as being at stake is or-flight response is activated with release of
influenced by their personal goals, catecholamines and the onset of the ACTH–
commitments, or motivations. adrenal cortical response.
 Primary appraisal results in the situation being
2. During the resistance stage, adaptation to the
identified as either non-stressful or stressful.
noxious stressor occurs, and cortiso activity is
 Secondary appraisal is an evaluation of what
still increased. If exposure to the stressor is
might and can be done about the situation.
prolonged, the third stage—exhaustion—occurs.
 Reappraisal—a change of opinion based on
new information—may occur. 3. During the exhaustion stage, endocrine activity
 The appraisal process contributes to the increases, which has negative effects on the
development of an emotion. body systems (especially the circulatory,
 Negative emotions such as fear and anger digestive, and immune systems) that can lead to
accompany harm/loss appraisals, and positive death.
emotions accompany challenge.
LOCAL ADAPTATION SYNDROME (SELYE, 1976)
COPING WITH THE STRESSFUL EVENT
  Includes the inflammatory response and repair
processes that occur at the local site of tissue
injury.
 If the local injury is severe enough, the GAS is
activated as well.
INTERPRETATION OF STRESSFUL STIMULI BY
THE BRAIN
 The neural and hormonal actions that maintain
homeostatic balance are integrated by the
hypothalamus.
 In the stress response, afferent impulses are
carried from sensory organs (eye, ear, nose,
skin) and internal sensors (baroreceptors,
chemoreceptors) to nerve centers in the brain.
 The response to the perception of stress is
integrated in the hypothalamus, which
coordinates the adjustments necessary to return
to homeostatic balance.
 The hypothalamus integrates autonomic
nervous system mechanisms that maintain the
chemical constancy of the internal environment
of the body.
SYMPATHETIC NERVOUS SYSTEM RESPONSE
 Rapid and short lived.
 Norepinephrine is released to cause an increase
in function of the vital organs and a state of
general body arousal.
SYMPATHETIC–ADRENAL–MEDULLARY
RESPONSE
 The sympathetic nervous system stimulates the
adrenal medulla to release the hormones
epinephrine and norepinephrine into the
bloodstream.
 These hormones are catecholamines, they
stimulate the nervous system and produce
metabolic effects that increase the blood
glucose level and metabolic rate.
 This effect is called the fight-or-flight
response.
HYPOTHALAMIC–PITUITARY RESPONSE
 The longest-acting phase of the physiologic
response. More likely to occur in persistent
stress.
 ADH and aldosterone promote sodium and
water retention, which is an adaptive mechanism
in the event of hemorrhage or loss of fluids.
 Secretion of growth hormone and glucagon
stimulates the uptake of amino acids by cells,
helping to mobilize energy resources.
 Endorphins increase during stress and enhance
the threshold for tolerance of painful stimuli.
IMMUNOLOGIC RESPONSE
  The immune system is connected to the INDICATORS OF STRESS
neuroendocrine and autonomic systems.
 Indicators of stress and the stress response
 Lymphoid tissue is richly supplied by
include both subjective and objective measures.
autonomic nerves.
 Neuroendocrine hormones can inhibit or  Blood levels of catecholamines, glucocorticoids,
stimulate leukocyte function. ACTH, and eosinophils are reliable measures of
 All of possible autonomic and stress.
neuroendocrine responses can interact to
initiate, weaken, enhance, or terminate an  Serum cholesterol and free fatty acid levels can
immune response. be used to measure stress.
 Psychoneuroimmunology - the study of the  The results of immunoglobulin assays are
relationships among the neuroendocrine increased when a person is exposed to various
system, the central and autonomic nervous stressors, especially infections and
systems, and the immune system and the immunodeficiency conditions.
effects of these relationships on overall
health outcomes. STRESS AT THE CELLULAR LEVEL
 Studies have demonstrated altered immune
function in people who are under stress
(Jain & Chandel, 2013; Polloni, 2015;
Schwitalla, 2014).
MALADAPTIVE RESPONSES TO STRESS
 When responses to stress are ineffective, they
are referred to as maladaptive.
 Maladaptive responses are chronic, recurrent
responses or patterns of response that do not
promote the goals of adaptation.
 Coping processes that include the use of alcohol
or drugs to reduce stress increase the risk of
illness.

CONTROL OF THE STEADY STATE

1.
 If the sympathetic–adrenal–medullary response
is prolonged or excessive, a state of chronic
arousal develops that may lead to high blood
pressure, arteriosclerotic changes, and
cardiovascular disease.
Negative Feedback
 Negative feedback mechanisms throughout the
body monitor the internal environment and
restore homeostasis when conditions shift out of
the normal range.
 These include blood pressure, acid–base
balance, blood glucose level, body
temperature, and fluid and electrolyte
balance.

 If the production of ACTH is prolonged or  The major organs affected are the heart, lungs,
excessive, behavior patterns of withdrawal and kidneys, liver, gastrointestinal tract, and skin.
depression are seen.
 In addition, the immune response is decreased
and infections and tumors may develop.

2. Positive Feedback
 Perpetuates the chain of events set in motion by
the original disturbance instead of compensating
for it.
 As the system becomes more unbalanced,
disorder and disintegration occur.
CELLULAR ADAPTATION
 Cells possess a maintenance function and a
specialized function.
 The maintenance function refers to the
activities that the cell performs with respect to
itself.
 The specialized functions are those that the cell
performs in relation to the tissues and organs of
which it is a part.
 Cells can adapt to environmental stress through
structural and functional changes.
 Some of these adaptations include cellular
hypertrophy, atrophy, hyperplasia, dysplasia,
and metaplasia.
 Hyperplasia is an increase in the number of
new cells in an organ or tissue.
 Dysplasia is bizarre cell growth resulting in
cells that differ in size, shape, or arrangement
from other cells of the same tissue type.
 Metaplasia is a cell transformation in which one
type of mature cell is converted into another
type of cell.
CELLULAR INJURY
 Injury is a disorder in steady-state regulation.
 Structural and functional damage then occurs,
which may be reversible (permitting recovery)
or irreversible (leading to disability or death).
1. Hypoxia - inadequate cellular oxygenation.
 Interferes with the cell’s ability to transform
energy.
 The usual cause of hypoxia is ischemia or
deficient blood supply.
2. Nutritional Imbalance - a relative or absolute
deficiency or excess of one or more essential
nutrients.
 This may be manifested as undernutrition or
overnutrition.
 Physical Agents - temperature extremes,
radiation, electrical shock, and mechanical
trauma.
 Chemical Agents - caused by poisons, heavy
metals, drugs or alcohol.
 Infectious Agents - viruses, bacteria, rickettsiae,
mycoplasmas, fungi, protozoa, and nematodes.
 Disordered Immune Responses - the immune
system may function normally, or it may be
hypoactive or hyperactive.
 Genetic Disorders - genetic defects as causes of
disease and modifiers of genetic structure.
CELLULAR RESPONSE TO INJURY:
INFLAMMATION
 Inflammation is a localized reaction intended to
neutralize, control, or eliminate the offending
agent to prepare the site for repair.
 It is a nonspecific response that is meant to
serve a protective function.

CELLULAR HEALING
CHEMICAL MEDIATORS OF INFLAMMATION
 Injury initiates the inflammatory response;
however, chemical substances released at the
site induce vascular changes.
 Histamine - released when injury occurs and is
responsible for the early changes in vasodilation
and vascular permeability.
 Kinins - cause vasodilation and increased
vascular permeability, and they attract
neutrophils to the area.
2.
 Prostaglandins - also suspected of causing
increased vascular permeability.
SYSTEMIC RESPONSE TO INFLAMMATION
 Fever - the most common sign of a systemic
response to injury, and it is most likely caused
by endogenous pyrogens.
 Leukocytosis - an increase in the synthesis and
release of neutrophils from bone marrow. This
enhances the body’s ability to fight infection.
NURSING MANAGEMENT
TYPES OF INFLAMMATION
1. Acute inflammation - usually lasts less than 2
weeks.
 Immediate and serves a protective function.
2. Chronic inflammation - symptoms are present
for many months or years.
 May also begin insidiously and never have an
acute phase.
 Does not serve a beneficial and protective
function.
 Considerable scarring may occur, resulting in
permanent tissue damage.
 The reparative process begins at approximately
the same time as the injury.
 Healing proceeds after the inflammatory debris
has been removed.
 Healing may occur by regeneration or
replacement.
1. Regeneration
 Labile cells - multiply constantly to replace
cells worn out by normal physiologic processes
(epithelial cells of the skin, lining the
gastrointestinal tract).
 Permanent cells - the nerve cell bodies, not
their axons (neurons).
 Stable cells - have a latent ability to regenerate
(functional cells of the kidney, liver, and
pancreas).
Replacement
 First-intention healing - wound edges are
approximated, little scar formation occurs, and
the wound healing occurs without granulation.
 Second-intention healing - the edges are not
approximated and the wound fills with
granulation tissue.
 Third-intention healing - the wound edges are
not approximated and healing is delayed.
 A major role of nurses is the early
identification of both physiologic and
psychological stressors.
 The following questions are addressed:
 Stress management is directed toward reducing
and controlling stress and improving coping.
 Stress reduction methods and coping
enhancements can derive from either internal or
external sources.
1. Promoting a Healthy Lifestyle
2. Enhancing Coping Strategies
3. Relaxation Techniques
4. Educating About Stress Management
5. Promoting Family Health
6. Enhancing Social Support
7. Recommending Support and Therapy Groups