MS-1 stress

8/3/2019 MS-1 stress

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HEALTHHEALTH

HEALTHHEALTH --Is a state of completeIs a state of completephysical, mental, and social wellphysical, mental, and social well--being and not just the absence ofbeing and not just the absence of

disease of infirmity.disease of infirmity.

This definition implies that there isThis definition implies that there is

1. interaction between the self and1. interaction between the self andenvironmentenvironment

2. Preservation of structure and function2. Preservation of structure and function

3. maintenance of adaptive potential3. maintenance of adaptive potential


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BASIC CONCEPTSBASIC CONCEPTS

A. Health: a dynamic state that is continuallyA. Health: a dynamic state that is continuallychangingchanging

1. Moves on a continuum between optimal wellness1. Moves on a continuum between optimal wellness(where potential is maximized and used with(where potential is maximized and used withpurpose) and death, rather than an absolute state.purpose) and death, rather than an absolute state.

2. Change may be gradual or abrupt2. Change may be gradual or abrupt

3. Level attainable depends on adaptive capacity,3. Level attainable depends on adaptive capacity,

genetic and environmental factors and lifestyle.genetic and environmental factors and lifestyle.


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4. Ability to adapt4. Ability to adaptb. Level of adaptationb. Level of adaptationc. Cultures view of healthc. Cultures view of health

d. Ability to carry out social, family and jobd. Ability to carry out social, family and jobresponsibilities.responsibilities.e. Risk factorse. Risk factors

B. Stresses affect physical, emotional and social healthB. Stresses affect physical, emotional and social health

1. maybe internal or external1. maybe internal or external2. Can be beneficial or detrimental to health2. Can be beneficial or detrimental to health

a. Tension is essential to lifea. Tension is essential to life

b. Stress of life causes wear and tearb. Stress of life causes wear and tear


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8. Stress can alter how a person meets basic8. Stress can alter how a person meets basichuman needshuman needs

9. That which causes stress9. That which causes stress which can upsetwhich can upsetequilibriumequilibrium is called theis called the stressor.stressor.

Internal or external event or situation thatInternal or external event or situation that

creates the potential for physiologic, emotional,creates the potential for physiologic, emotional,cognitive or behavioral changes.cognitive or behavioral changes.


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Types of stressorsTypes of stressors

1.1. Physical (includes heat, cold andPhysical (includes heat, cold andchemical changes)chemical changes)

2.2. Physiologic ( pain and fatigue)Physiologic ( pain and fatigue)

3.3. Psychosocial (fear and anxiety)Psychosocial (fear and anxiety)


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Stress and adaptationStress and adaptation

Stress is a universal phenomenaStress is a universal phenomena

Stress as a stimulus, sometimes called a life event,Stress as a stimulus, sometimes called a life event,

or set of circumstances causing a disrupted responseor set of circumstances causing a disrupted responsethat increases the individuals vulnerability to illness.that increases the individuals vulnerability to illness.

Stress as a response is a disruptions caused by aStress as a response is a disruptions caused by anoxious stimulus or stressor.noxious stimulus or stressor.

Reactions rather than events are the focus.Reactions rather than events are the focus.


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Physiologic Responses toPhysiologic Responses toStressorsStressors


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Stress is a nonStress is a non--specific response of thespecific response of thebody to any kind of demand madebody to any kind of demand madeupon itupon it--

Hans SelyeHans Selye


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General Adaptation SyndromeGeneral Adaptation Syndrome

A general arousal response of theA general arousal response of thebody to a stressor that is characterizedbody to a stressor that is characterizedby certain physiologic events and thatby certain physiologic events and that

is dominated by the sympatheticis dominated by the sympathetic

nervous system.nervous system.


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Local Adaptation syndromeLocal Adaptation syndrome

The reaction of one organ orThe reaction of one organ orbody parts to stressbody parts to stress


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THREE STAGESTHREE STAGES

Alarm reactionAlarm reaction-- alert bodys defenses against thealert bodys defenses against thestressor.stressor.

a.a. Shock phaseShock phase--

autonomic nervous system reactsautonomic nervous system reacts large amount of epinephrine and cortisone arelarge amount of epinephrine and cortisone are

releasedreleased

fight or flightshort lived (1 minute to 24 hours)fight or flightshort lived (1 minute to 24 hours)

b.b. Countershock phaseCountershock phaseBody changes produced during the shock phase isBody changes produced during the shock phase is

reversed.reversed.


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2.2. Stage of resistanceStage of resistance-- bodys adaptationbodys adaptationtakes placetakes place

Body attempts to cope with the stressorBody attempts to cope with the stressor

3.3. Stage of exhaustionStage of exhaustion-- adaptation thatadaptation thatthe body made during the 2nd stagethe body made during the 2nd stagecannot be maintainedcannot be maintained

If adaptation has not overcome theIf adaptation has not overcome thestressor, the effects may spread into thestressor, the effects may spread into theentire bodyentire body


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MANIFESTATIONS OF STRESSMANIFESTATIONS OF STRESS

COPINGCOPING-- cognitive and behavioral effortcognitive and behavioral effortto manage specific external and/orto manage specific external and/or

internal demands that are appraised asinternal demands that are appraised astaxing or exceeding the resources of thetaxing or exceeding the resources of theperson.person.

Can be adaptive or maladaptiveCan be adaptive or maladaptive

Coping mechanismCoping mechanism-- coping strategycoping strategy


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Sympathetic nervous systemSympathetic nervous system

responseresponse Rapid and short livedRapid and short lived Norepinephrine is releasedNorepinephrine is released

HR is increased and RR maybe rapid andHR is increased and RR maybe rapid andshallowshallow

Peripheral vasoconstrictionPeripheral vasoconstriction

Blood is shunted away from the abdominalBlood is shunted away from the abdominalorgansorgans

Blood glucose is increasedBlood glucose is increased

Dilated pupils, Mental activity is increasedDilated pupils, Mental activity is increased

Constriction of blood vesselsConstriction of blood vessels


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SympatheticSympathetic--AdrenalAdrenal--MedullaryMedullary

responseresponse Release of epinephrine andRelease of epinephrine and

norepinephrine (cathecolaminesnorepinephrine (cathecolamineswhich stimulates nervous system) bywhich stimulates nervous system) bythe medulla of the adrenal cortexthe medulla of the adrenal cortexinto the blood stream, and producesinto the blood stream, and produces

metabolic effects that increasesmetabolic effects that increasesblood glucose level and increaseblood glucose level and increasemetabolic rate.metabolic rate.


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HypothalamicHypothalamic-- pituitary responsespituitary responses

LongestLongest--acting phaseacting phase

Hypothalamus secretes corticoprinHypothalamus secretes corticoprin--releasing factorreleasing factoranterior pituitaryanterior pituitaryACTHACTHadrenal cortex to produceadrenal cortex to produceglucocorticoids, primarily cortisolglucocorticoids, primarily cortisolCHONCHONcatabolism, relaeasing amino acids andcatabolism, relaeasing amino acids andconversion to glucoseconversion to glucose(gluconeogenesis)(gluconeogenesis)inhibition of glucoseinhibition of glucose

uptake (antiuptake (anti--insulin action)insulin action)


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Cathecolamines (epinephrine,Cathecolamines (epinephrine,

norepinephrine)norepinephrine)

ADHADH-- released from posteriorreleased from posteriorpituitarypituitary

AldosteroneAldosterone-- released from thereleased from theadrenal cortexadrenal cortex


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Immunologic responsesImmunologic responses

Neuropeptide have direct effect on LeukocytesNeuropeptide have direct effect on Leukocytesregulation and inflammatory responseregulation and inflammatory response

Neuroendocrine hormones released by the CNSNeuroendocrine hormones released by the CNSand endocrine tissues can inhibit or stimulateand endocrine tissues can inhibit or stimulate

leukocyte function.leukocyte function.

This can result to initiation, weakening orThis can result to initiation, weakening orterminating an immune response.terminating an immune response.


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Stress at cellular levelStress at cellular level

Negative feedbackNegative feedback--

mechanisms throughout the body monitor themechanisms throughout the body monitor theinternal environment and restore homeostasis wheninternal environment and restore homeostasis whenconditions shift out of the normal range.conditions shift out of the normal range.

Regulated through compensatory mechanismRegulated through compensatory mechanismthrough the different organsthrough the different organs

Controlled by the endocrine and the nervous systemControlled by the endocrine and the nervous system


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Positive feedbackPositive feedback

perpetuates the chain of events setperpetuates the chain of events set

in motion by the original disturbancein motion by the original disturbanceinstead of compensating for it.instead of compensating for it.

As the system becomes moreAs the system becomes more

unbalanced, disorder andunbalanced, disorder anddisintegration occurdisintegration occur


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Cellular adaptationCellular adaptation

1.1. HypertrophyHypertrophy-- in cell sizein cell size2.2. AtrophyAtrophy-- in cell sizein cell size

3.3. HyperplasiaHyperplasia-- in number of new cellin number of new cell4.4. DysplasiaDysplasia-- change in appearance of cellchange in appearance of cell

after they have been subjected to chronicafter they have been subjected to chronic

irritationirritation5.5. MetaplasiaMetaplasia-- transformation of one adulttransformation of one adult

cell type to another (reversible)cell type to another (reversible)


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Cell injuryCell injury

CausesCauses::

HypoxiaHypoxia

Nutritional imbalanceNutritional imbalance

Physical, Chemical and infectious agentsPhysical, Chemical and infectious agents

Immune mecahnismsImmune mecahnisms

Genetic defectsGenetic defects

Psychogenic factorsPsychogenic factors


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Results to damaging orResults to damaging or

destroying:destroying:

Integrity of the cell membrane, necessary for ionicIntegrity of the cell membrane, necessary for ionicbalancebalance

The ability of the cell to transform energy (aerobicThe ability of the cell to transform energy (aerobicrespiration, production of adenosine triphosphate)respiration, production of adenosine triphosphate)

The ability of the cell to synthesize enzymes andThe ability of the cell to synthesize enzymes andother necessary proteinsother necessary proteins

The ability of the cell to grow and reproduceThe ability of the cell to grow and reproduce

(genetic integrity0(genetic integrity0


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Cellular Response to InjuryCellular Response to Injury

InflammationInflammationDefensive reaction intended toDefensive reaction intended to

neutralize, control or eliminateneutralize, control or eliminatethe offending agent and tothe offending agent and toprepare the site for repair.prepare the site for repair.


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1.1. Disruption of tissue integrityDisruption of tissue integrity Injury, ischemic damage, immune reactionInjury, ischemic damage, immune reaction

2.2. Inflammatory responseInflammatory response Vascular Changes:Vascular Changes:a.a. vasodilationvasodilationb.b. capillary permeabilitycapillary permeabilityc.c. blood flowblood flowd.d. Local tissue congestionLocal tissue congestion

Cellular changes:Cellular changes:a.a. phagocytosisphagocytosisb.b. leukocytes (granulocytes and monocytes)leukocytes (granulocytes and monocytes)c.c. Release of chemical mediators (mast cells and macrophagesRelease of chemical mediators (mast cells and macrophages

3.3. Body responsesBody responses1.1. Local effects:Local effects:

Erythema, warmth, edema, pain, impaired functioningErythema, warmth, edema, pain, impaired functioning

2.2. Systemic effectSystemic effect

Fever, leukocytosis, malaise, anorexia, sepsisFever, leukocytosis, malaise, anorexia, sepsis


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Types of inflammation:Types of inflammation:

Acute: lovcal vascular and exudativeAcute: lovcal vascular and exudativechanges, lasts than 2 weekschanges, lasts than 2 weeks

ChronicChronic-- persistent and lasts to months topersistent and lasts to months toyearsyears

Sub acute inflammationSub acute inflammation--includes elementsincludes elementsof the active exudative phase of the acuteof the active exudative phase of the acuteand elements of repair of the chronicand elements of repair of the chronic

phasephase


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Cellular healingCellular healing

RegenerationRegeneration-- ability of the cell to regenerateability of the cell to regeneratedepends on wether they are:depends on wether they are:

LabileLabile-- multiply constantly to repair cells worn outmultiply constantly to repair cells worn outby normal physiological processes. (epithelialby normal physiological processes. (epitheliallining of the skin and the GI tract)lining of the skin and the GI tract)

PermanentPermanent-- includes the neuron, not the axonsincludes the neuron, not the axons

StableStable-- latent ability to regenerate.latent ability to regenerate.


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ReplacementReplacement

Primary intention healingPrimary intention healing-- wound is cleanwound is cleanand dry and the edges are approximatedand dry and the edges are approximated

Secondary intention healingSecondary intention healing-- wound iswound islarger and gaping and has a necrotic orlarger and gaping and has a necrotic or

dead material. Repair takes longer anddead material. Repair takes longer andresults in more scar formation.results in more scar formation.


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Psychologic manifestationsPsychologic manifestations

anxietyanxiety--state of uneasinessstate of uneasiness

fearfear-- mild o severe feeling ofmild o severe feeling ofapprehensionapprehension angeranger

depressiondepression


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Physiologic Manifestation of StressPhysiologic Manifestation of Stress

Pupils dilate to increase visual perception whenPupils dilate to increase visual perception when

serious threat to the body arise.serious threat to the body arise.

Sweat production (diaphoresis) increase to controlSweat production (diaphoresis) increase to control

elevate body heat due to increased metabolismelevate body heat due to increased metabolism

The heart rate increases, which leads to an increasedThe heart rate increases, which leads to an increasedpulse rate to transport nutrients and bypulse rate to transport nutrients and by--products ofproducts of

metabolism more efficientlymetabolism more efficiently

Skin is pallid because of constriction of peripheralSkin is pallid because of constriction of peripheral

blood vessels and effect of norepinephrineblood vessels and effect of norepinephrine


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BP increase because ofBP increase because of

Constriction of vessels in blood reservoir such as the skin,Constriction of vessels in blood reservoir such as the skin,kidney and most large interior organkidney and most large interior organ

Increased secretion of renin and effect of norepinephrineIncreased secretion of renin and effect of norepinephrine

Increased sodium and water retention due to release ofIncreased sodium and water retention due to release ofmineralcorticoids which results in increase blood volumemineralcorticoids which results in increase blood volume

Increased cardiac outputIncreased cardiac output


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The rate and depth of RR increase because ofThe rate and depth of RR increase because of

dilation of bronchioles promotingdilation of bronchioles promotinghyperventilationhyperventilation

Urinary output decreasesUrinary output decreases

The mouth may be dryThe mouth may be dry

Peristalsis of the intestines decreasesPeristalsis of the intestines decreases

For serious threats, mental alertness improvesFor serious threats, mental alertness improves


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Muscle tension increases to prepare for rapid motorMuscle tension increases to prepare for rapid motor

activity or defenseactivity or defense

Blood sugar increases because of release ofBlood sugar increases because of release ofglucocorticoid and gluconeogenesisglucocorticoid and gluconeogenesis

Lethargy, mental lassitude, inactivity (parasymphateticLethargy, mental lassitude, inactivity (parasymphateticdominance) may ensuedominance) may ensue

There may be decreased physiologic functioning andThere may be decreased physiologic functioning andloss of skeletal muscle tone (parasymphateticloss of skeletal muscle tone (parasymphateticdominance)dominance)


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STRESSSTRESS

SYMPHATETIC NERVOUS SYSTEMSYMPHATETIC NERVOUS SYSTEM

HYPOTHALAMUSHYPOTHALAMUS

---------------- _________________PITUITARY_____________________________PITUITARY____________

ADRENAL CORTEXADRENAL CORTEX ADRENA MEDULLAADRENA MEDULLA

MINERALCORTICOIDSMINERALCORTICOIDS NOREPHINEPHRINENOREPHINEPHRINE

((propro--inflammatory) Na+ retentioninflammatory) Na+ retention peripheral vasoconstrictionperipheral vasoconstrictionprotein anabolismprotein anabolism blood in the kidney, Reninblood in the kidney, Renin

GLUCOCORTICOSTEROIDSGLUCOCORTICOSTEROIDS EPINEPHRINEEPINEPHRINE--TACHYCARDIATACHYCARDIA

(antiinflammatory), CHON catabolism(antiinflammatory), CHON catabolism myocardial contractility, bronchialmyocardial contractility, bronchialGluconeogenesisGluconeogenesis dilatation, blood clotting metabolism, fat dilatation, blood clotting metabolism, fat

mobilizationmobilization________________________________________________________________________________

GENERAL ADAPTATION SYNDROMEGENERAL ADAPTATION SYNDROME


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STAGE 1: ALARM REACTIONSTAGE 1: ALARM REACTION

enlargement of adrenal cortexenlargement of adrenal cortex

enlargement of lymphatic systemenlargement of lymphatic systemincrease in hormone levelincrease in hormone level

STAGE 2: RESISTANCESTAGE 2: RESISTANCE

shrinkage of adrenal cortexshrinkage of adrenal cortexlymph nodes closer to normal sizelymph nodes closer to normal size

hormone level sustainedhormone level sustained

STAGE 3: EXHAUSTIONSTAGE 3: EXHAUSTION

enlargement/ dysfunction of lymphatic structureenlargement/ dysfunction of lymphatic structure

increase in hormone levelincrease in hormone level

depletion of adaptive hormonesdepletion of adaptive hormones


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AdaptationAdaptation

Results when the individual is able to effect a seriesResults when the individual is able to effect a seriesof behaviors and mental processes to neutralize theof behaviors and mental processes to neutralize thestress experience and reestablish integrity ofstress experience and reestablish integrity of

function.function.

Modes of adaptationModes of adaptation

physiologic mode or biologic modephysiologic mode or biologic mode-- results nresults ncompensatory physical changescompensatory physical changes

psychologic and sociocultural modes or psychologicpsychologic and sociocultural modes or psychologicadaptationadaptation

sociocultural adaptationsociocultural adaptation


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PAINPAIN

An unpleasant sensory and emotional experience withAn unpleasant sensory and emotional experience withactual and potential tissue damageactual and potential tissue damage

The most common reason for seeking health careThe most common reason for seeking health care

The fifth vital sign The fifth vital sign

pain is assessed in all patients and that patients pain is assessed in all patients and that patients

have the right to appropriate assessment andhave the right to appropriate assessment andmanagement of painmanagement of pain

Pain is an early warning system: its presence triggersPain is an early warning system: its presence triggers

awareness that is something with the bodyawareness that is something with the body


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Management and nursingManagement and nursing

interventionsinterventions Promoting healthy lifestylePromoting healthy lifestyle Enhancing coping strategiesEnhancing coping strategies

Teaching relaxation techniquesTeaching relaxation techniques Guided imageryGuided imagery

Progressive muscle relaxationProgressive muscle relaxation

Enhancing social supportEnhancing social support Positive social identityPositive social identity

Emotional supportEmotional support

Recommending support and therapy groupRecommending support and therapy group


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PAIN MANAGEMENTPAIN MANAGEMENT


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Types of PainTypes of PainAcute painAcute pain short predictable duration (lastingshort predictable duration (lasting

less than six (6) months)less than six (6) months)

Immediate onsetImmediate onset

Reversible or controllable treatmentReversible or controllable treatment

Example: Postoperative pain that disappears asExample: Postoperative pain that disappears as

surgical wound healssurgical wound heals


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Chronic painChronic pain last more than 6 months:last more than 6 months:continual or persistent and recurrentcontinual or persistent and recurrent

Example: malignancy (cancer) or arthritisExample: malignancy (cancer) or arthritis

Cutaneous painCutaneous pain client can identify specificclient can identify specificarea of pain which may string or burn; mayarea of pain which may string or burn; may

occur along dorsal sensory nerve rootoccur along dorsal sensory nerve rootExampleExample abrasions on skin, herpes zosterabrasions on skin, herpes zoster


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VisceralVisceral painpain affects any of the large bodyaffects any of the large bodycavities (abdominal viscera); characterized ascavities (abdominal viscera); characterized asdiffuse, poorly localized, vague and dulldiffuse, poorly localized, vague and dull

Example: acute pancreatitis, peptic ulcer disease,Example: acute pancreatitis, peptic ulcer disease,cholecystitischolecystitis

SomaticSomatic painpain pain affecting skeletal muscles,pain affecting skeletal muscles,joints and ligaments generally diffuse and lessjoints and ligaments generally diffuse and lesslocalized than cutaneous painlocalized than cutaneous pain

Example: rheumatoid arthritis, osteomyelitisExample: rheumatoid arthritis, osteomyelitis


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Referred painReferred pain -- pain that does not occurs at thepain that does not occurs at thepoint of injurypoint of injury

Example: myocardial ischemia felt in the arm orExample: myocardial ischemia felt in the arm orshoulder; shoulder pain with cholecystitisshoulder; shoulder pain with cholecystitis


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Effects of painEffects of pain

1.1. Sleep deprivationSleep deprivation

2.2. Acute painAcute pain

Can affect respiratory, cardiovascular, endocrineCan affect respiratory, cardiovascular, endocrineand immune systemand immune system

Stress response increases metabolic rate andStress response increases metabolic rate and

cardiac output and increases risk for physiologiccardiac output and increases risk for physiologicdisordersdisorders


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Chronic painChronic pain

DepressionDepression

Increase disabilityIncrease disability

Suppression of immune functionSuppression of immune function


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Factors that Influence Pain ResponseFactors that Influence Pain Response

Past experiencePast experienceAnxietyAnxiety

DepressionDepression

CultureCulture GenderGender

G

eneticsG

enetics Gerontologic considerationGerontologic consideration ExpectationsExpectations


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The Placebo EffectThe Placebo Effect

A physiologic response that results fromA physiologic response that results froman expectation that a treatment will workan expectation that a treatment will work

Placebos should not be used to assess orPlacebos should not be used to assess ormanage painmanage pain


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Assessment of PainAssessment of Pain

Assessment: the patients pain goal or expectation ofAssessment: the patients pain goal or expectation ofcomfort and pain reliefcomfort and pain relief

Meaning of pain for the patientMeaning of pain for the patient

Behavior associated with the painBehavior associated with the pain

Physiologic response to the painPhysiologic response to the pain

Characteristics: intensity, timing, location & qualityCharacteristics: intensity, timing, location & quality

Aggravating or alleviating factorsAggravating or alleviating factors


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Mnemonic to Evaluate PainMnemonic to Evaluate Pain

P: provoking or palliative factorsP: provoking or palliative factors

Q: qualityQ: quality R: regionR: region

S: severityS: severity T: timingT: timing


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Physiologic Basis for Pain ReliefPhysiologic Basis for Pain Relief

Pharmacologic InterventionsPharmacologic Interventions

Opioid analgesics act on the CNS to inhibitOpioid analgesics act on the CNS to inhibitactivity of ascending nocioceptive pathwaysactivity of ascending nocioceptive pathways

NSAIDs decrease pain by inhibiting cycloNSAIDs decrease pain by inhibiting cyclo--oxygenase, which is the enzyme involved inoxygenase, which is the enzyme involved in

the production of prostaglandinsthe production of prostaglandins Local anesthetics block nerve conductionLocal anesthetics block nerve conduction

when applied to the nerve fiberswhen applied to the nerve fibers


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Nonpharmacologic InterventionsNonpharmacologic Interventions

Cutaneous stimulation, massage, and useCutaneous stimulation, massage, and useof hot or cold may be explained by theof hot or cold may be explained by thegateway theorygateway theory

Use of heat and cold changes blood flowUse of heat and cold changes blood flowto the areas and promote healingto the areas and promote healing

Use of distractive and relaxation andUse of distractive and relaxation and

guided imagery may redirect attention,guided imagery may redirect attention,promote muscle relaxation, and affectpromote muscle relaxation, and affectperception and reception of pain stimulusperception and reception of pain stimulusin the brainin the brain


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Gerontologic ConsiderationsGerontologic Considerations

More likely to have adverse drug effectsMore likely to have adverse drug effectsand drug interactionand drug interaction

Increased likelihood of chronic illnessIncreased likelihood of chronic illness

May need to have more time betweenMay need to have more time between

doses of medication due to decreasedoses of medication due to decreaseexcretion and metabolism relating to agingexcretion and metabolism relating to agingchangeschanges


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Pain Relief InterventionsPain Relief Interventions PharmacologicPharmacologic

Balanced anesthesiaBalanced anesthesiaPRN medicationsPRN medications

Routine administrative: round the clockRoutine administrative: round the clock(ATC) or preventive approach(ATC) or preventive approach PCA: Patient controlled analgesiaPCA: Patient controlled analgesia

Local anestheticsLocal anesthetics Topicals and patchesTopicals and patches Intraspinal administrationIntraspinal administration


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Adverse Effects of Analgesic AgentsAdverse Effects of Analgesic Agents

Respiratory depressionRespiratory depression

SedationSedation Nausea and vomitingNausea and vomiting ConstipationConstipation

PruritusPruritus

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