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Medical-Surgical Nursing

CONCEPTS OF STRESS AND ILLNESS

CLIENTS RESPONSE TO ILLNESS

INDIVIDUAL FACTORS

Genetics and Biologic Factors

Heredity and biologic factors are not undervoluntary control. We cannot change these factors.

Research has identified genetic links to several

disorders. Genetic makeup tremendously influences a

persons response to illness and perhaps even to

treatment. Hence, family history and background are

essential parts of the nursing assessment.

Physical Health and Health Practices

Physical Health can also affect how a person

responds to illness or stress. The healthier a person is,

the better he or she is able to cope with stress or illness.

Poor nutritional status or lack of sleep may impair a

persons ability to cope. Unlike genetic factors, how a

person lives and takes care of him or herself can alter

many of these factors.

Response to Drugs biologic differences canalter a clients response to treatment. Ethnic

groups differ in the metabolism and efficacy of

different compounds. When evaluating the

efficacy of medications, the nurse must be alert

to side effects and serum drug levels in clients

from different ethnic backgrounds. Self-Efficacy Self-efficacy is a belief that

personal abilities and efforts affect the events

in our lives. A person who believes that his or

her behavior makes a difference is more likely

to take action. People with self-efficacy set

personal goals, are self-motivated, cope

effectively with stress and request support from

others when needed.

Hardiness hardiness is the ability to resistillness when under stress. Hardiness has three

components:o Commitment or active involvement in

life activities

o Control or the ability to makeappropriate changes in life activities

o Challenge or the ability to perceivechange as beneficial rather than just

stressful.

Hardiness has been found to have a moderating

or buffering effect on people experiencing stress.

Personal hardiness is often described as a pattern of

attitude and actions that helps the person turn stressful

circumstances into opportunities for growth.

Resilience and Resourcefulness resilienceand resourcefulness help people to cope with

stress and to minimize the effects of illness.

Resilience is defined as having healthy

responses to stressful circumstances or risky

situations. Resourcefulness involves using

problem-solving abilities and believing that

one can cope with adverse or novel situations.

People develop resourcefulness through

interactions with others, that is, through

successful coping with life experiences.

Spirituality spirituality involves the essenceof a persons being and his or her purpose for

living. It may include belief in God or a higher

power, the practice of Religion, Cultural beliefs

and practices and a relationship with the

environment. Because spiritual and religious

beliefs and practices help many clients to copewith stress and illness, the nurse must be

particularly sensitive to and accepting of such

beliefs and practices. Incorporating these

practices into the care of the clients can help

them cope with illness and help them find

meaning and purpose in the situation.

Interpersonal Factors

Sense of Belongingness sense ofbelongingness is the connectedness with or the

involvement in a social system or environment

of which a person feels an integral part. A sense

of belongingness was found to promote health,

whereas a lack of belongingness impaired

health. Persons with a sense of belongingness

are less alienated and isolated, have a sense of

purpose, believe they are needed by others and

feel productive socially.

Social Networks and Social Support Socialnetworks are groups of people whom one

knows and with whom one feels connected.

Social support is the emotional sustenance thatcomes from friends, family members and even

health care providers who help a person when a

problem arises. Two key components are

necessary for a support system to be effective:

o The clients perception of the supportsystem, and

o The responsiveness of the supportsystem.

Family Support family as a source of socialsupport can be a key factor in the recovery of

clients with illnesses. Although family membersare not always a positive resource in health,

they are the most often important part of

recovery. Health care professionals cannot

totally replace family members. The nurse must

encourage the family members to support the

client even while he or she is in the hospital and

should identify family strengths, such as love,

and caring, as a resource for the client.

HOMEOSTASIS, STRESS AND ADAPTATION

When the body is threatened or suffers an

injury, its response may involve functional and

structural changes; these changes may be adaptive

(having a positive effect) or maladaptive (having a

negative effect). These defense mechanisms that the

body exhibits determine the difference between

adaptation and maladaptation.

Dynamic Balance: The Steady State

Physiologic mechanisms must be understood in

the context of the body as a whole. The person, as a

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living system, had both an internal and an external

environment, between which information and matter

are continuously exchanged. Within the internal

environment of each organ, tissue and cell is also a

system or subsystem of the whole. The goal of

interaction of the bodys subsystems is to produce a

dynamic balance or Steady State so that all subsystems

are in harmony with each other.

Stress and Adapatation

Stress is a state produced by a change in the

environment, which is perceived as challenging,

threatening or damaging to the persons dynamic

balance or equilibrium. The nature of the stressor is

variable, an event or change that will produce stress in

one person may be neutral for another, and an event

that produces stress at one time and place for another

person may not do so for the same person at another

time or place.

The desired goal in stress is Adaptation, or

adjustment to the change so that the person is again in

equilibrium and has the energy and the ability to meet

demands.

Stressors: Threats to the Steady State

Types of Stressors

Stressors may exist in many forms and

categories. They may be described as physical,

physiologic and psychosocial. Stressors can also occur as

normal life transitions that require some adjustment

such as going from childhood to puberty, gettingmarried or giving birth. Stressors have also been

classified as:

Day-to-day frustrations or hassles includessuch common occurrences as getting caught in

a traffic jam, experiencing computer downtime,

and having an argument with a spouse or a

roommate.

The second group of stressors influences largegroups of people, including possibly entire

nations. These include events of history such as

terrorism and war, which are threateningsituations when experienced either directly, in

the war zone, or indirectly, as through live news

coverage.

The third group of stressors has been studiedmost extensively and concerns relatively

infrequent situations that directly affect the

individual. This category includes the influence

of life events such as death, birth, marriage,

divorce and retirement.

A stressor can also be categorized according to

duration. It may be:

An acute, time-limited stressor, such asstudying for final examinations

A stressor sequence a series of stressfulevents that result from an initial event such

as job loss or divorce

A chronic, intermittent stressor, such asdaily hassles; and

A chronic enduring stressor that persistsover time, such as a chronic illness, a

disability or poverty.

Psychological Responses to Stress

After the recognition of a stressor, an individual

consciously reacts to manage the situation. This is called

the Mediating Process. A theory developed by Lazarus

(1991) emphasizes the cognitive appraisal and coping asimportant mediators of stress. Appraisal and coping are

influenced by the antecedent variables that include the

internal and external resources of the person.

Appraisal of the Stressful Event

Cognitive Appraisal is a process by which an

event is evaluated with respect to what is at stake

(primary appraisal) and what might and can be done

(secondary appraisal).What individuals see as being at

stake is influenced by their personal goals,

commitments and motivation. Important factors

include:

How important or relevant the event is to them Whether the event conflicts with what they

want or desire; and

Whether the situation threatens their ownsense of strength and ego identity

As an outcome of Primary Appraisal, the situation is

identified as either stressful or non-stressful. IfNon-

stressful, the situation is irrelevant or benign (positive).

A Stressful situation may be one of three kinds:

One in which harm or loss has occurred One that is threatening, in that harm or loss is

anticipated

One that is challenging, in that someopportunity or gain is anticipated.

Secondary Appraisal is an evaluation of what

might and can be done about the situation. Actions

include:

Assigning blame to those responsible for afuture event

Thinking about whether one can dosomething about the situation (coping

potential); and

Determining future expectancy, or whetherthings are likely to change for the better or

worse.

Reappraisal, a change of information based on

new information, also occurs. The appraisal process is

not necessary sequential; primary and Secondary

Appraisal may occur simultaneously. Information

learned from an adaptation encounter can be stored, sothat when a similar situation is encountered again, the

whole process need not be repeated.

Coping with the Stressful Event

Coping according to Lazarus, consists of the

cognitive and behavioral efforts made to manage the

specific external or internal demands that tax a persons

resources and may be emotion-focused or problem-

focused.

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Coping that is emotion-focused seeks to make

the person feel better by lessening the emotional

distress felt

Problem-focused coping aims to make direct

changes in the environment so that the situation can be

managed more effectively.

Physiologic Response to Stress

The physiologic response to a stressor, whetherit is a physical or a psychological stressor, is a protective

and adaptive mechanism to maintain the homeostatic

balance of the body.

THE GENERAL ADAPTATION SYNDROME

Phases of the General Adaptation Syndrome

The General Adaptation Syndrome has three

phases: Alarm, Resistance and Exhaustion.

During the Alarm Phase, the Sympathetic

Fight-or-flight response is activated with the release

ofCatecholamines and the onset ofAdenocorticotropic

Hormones. The alarm reaction is defensive and anti-

inflammatory but self-limited. Because living in a

continuous state of alarm would result in death, the

person moves into the second stage, Resistance. During

this stage, adaptation to noxious stress occurs and

cortisol activity is still increased.

If exposure to the stressor is prolonged,

Exhaustion sets in and endocrine activity increases. This

produces deleterious effects on the bodys systems

(especially the circulatory, digestive and immunesystems) that can lead to death.

Selye emphasized that stress is the nonspecific

response common to all stressors, regardless of

whether they are physiologic, psychological or social.

Interpretation of Stressful Stimuli by the Brain

Physiologic responses to stress are mediated by

the brain through a complex network of chemical and

electrical messages. In the stress response, afferent

impulses 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.

Neural and Neuroendocrine pathways under

the control of the hypothalamus are also activated in

the stress response. First, there is a sympathetic-

nervous discharge, followed by a sympathetic-adrenal-

medullary discharge. If the stress persists, the

hypothalamic-pituitary system is activated.

Sympathetic-Nervous System Response

The Sympathetic-Nervous system response is

rapid and short-lived. Norepinephrine is released at

nerve endings that are in direct contact with their

respective end organs to cause an increase in function

of the vital organs and a state of general body arousal.

The heart rate is increased and peripheralvasoconstriction occurs, raising the blood

pressure.

Blood is also shunted away from abdominalorgans. The purpose of these activities is to

provide better perfusion of vital organs

(brain, heart and skeletal muscles).

Blood Glucose is increased, applying morereadily available energy. The pupils aredilated, and mental activity is increased; a

greater sense of awareness exists.

Typically, the person appears tense, withthe muscles of the neck, upper back and

shoulders tightened; respirations may be

rapid and shallow, with the diaphragm

tense.

Sympathetic-Adrenal Medullary Response

The sympathetic nervous system also stimulates

the medulla of the Adrenal Gland to release thehormones Epinephrine and Norepinephrine. The action

of these hormones is similar to that of the sympathetic

nervous system and has the effect of sustaining and

prolonging its actions. Epinephrine and Norepinephrine

are catecholamines that stimulate the nervous system

and produce metabolic effects that increase the blood

glucose level and increase the metabolic rate.

Hypothalamic-Pituitary Response

The longest-acting phase of the physiologic

response, which is more likely to occur in persistent

stress, involves the Hypothalamic-Pituitary pathway.

The hypothalamus secretes corticotropin-releasing factor; which

Stimulates the Anterior Pituitary to produceACTH

ACTH in turn stimulates the Adrenal Cortex toproduce Glucocorticoids, primarily Cortisol.

Cortisol stimulates protein catabolism, releasingamino acids; stimulates liver uptake of Amino

Acids and their conversion to glucose

(gluconeogenesis) and inhibits glucose uptake

(anti-insulin action) by many body cells but notthose of the brain and heart.

Maladaptive Response to Stress

When the responses to stress are ineffective,

they are referred to as Maladaptive. Maladaptive

responses are chronic, recurrent responses of patterns

of response over time that do not promote the goals of

adaptation. The goals of adaptation are somatic or

physical health (optimal wellness), psychological health

or having a sense of well-being (happiness, satisfaction

with life, morale) and enhanced social functioning,which includes work, social life and family (positive

relationships). Maladaptive responses that threaten

these goals include faulty appraisals and inappropriate

coping.

The frequency, intensity, and duration of

stressful situations contribute to the development of

negative emotions and subsequent patterns of

neurochemical discharge. Coping processes that include

the use of alcohol or drugs to reduce stress increase the

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risk of illness. Other forms of inappropriate coping

include denial, avoidance and distancing. The intent of

denial is to control the threat, but it may also endanger

life.

Stress at the Cellular Level

Pathologic processes may occur at all levels of

the biologic organism. The cell exists on continuum of

function and structure, ranging from the normal cell tothe adapted cell, to the injured or diseased cell, to the

dead cell. Changes from one state to another may occur

rapidly and may not be readily detectable, because each

state does not have discrete boundaries and disease

represents an extension and distortion of normal

processes.

Other determinants of cellular level response

are the type or nature of the stimulus, its duration and

its severity.

Control of the Steady State

The concept of the cell as existing on a

continuum of function and structure includes the

relationship of the cell to compensatory mechanisms,

which occur continuously in the body to maintain the

steady state.

Negative Feedback

Negative Feedback mechanisms throughout the

body monitor the internal environment and restore

homeostasis when conditions shift out of range. These

mechanisms work by sensing deviations from a pre-

determined set point or range of adaptability andtriggering a response aimed at offsetting the deviation.

The net result of the activities of the feedback

loops is homeostasis. A steady state is achieved by the

continuous, variable actions of the organs involved in

making the adjustments and by the continuous, small

exchanges of chemical substances among the cells,

interstitial fluid and blood.

Positive Feedback

Positive Feedback perpetuates the chain of

events set in motion by the original disturbance insteadof compensating for it. As the system becomes more

unbalanced, disorder and disintegration occur. There

are some exceptions to this; blood clotting in humans,

for example, is an important positive feedback

mechanism.

Cellular Adaptation

Cells are complex units that dynamically

respond to the changing demands and stresses of daily

life. Cells can adapt to environmental stress through

structural and functional changes. Some of these

adaptations are:

Hypertrophy Compensatory hypertrophy isthe result of an enlarged muscle mass and

commonly occurs in skeletal and cardiac

muscle that experiences a prolonged, increased

workload. One example is the bulging muscles

of an athlete who engages in body building.

Atrophy atrophy can be the consequence of adisease of decreased use, decreased blood

supply, loss of nerve supply, or inadequate

nutrition. Disuse of a body part is often

associated with the aging process. Cell size and

organ size decrease, structures principally

affected are the skeletal muscles, the

secondary sex organs, the heart and the brain.

Hyperplasia is an increase in the number ofnew cells in an organ or tissue. As cells multiply

and are subjected to increased stimulation, the

tissue mass enlarges. It is a mitotic responsebut it is reversible when the stimulus is

removed. This distinguishes it from neoplasia

or malignant growth, which continues after the

stimulus is removed.

Dysplasisa - is the change in the appearance ofthe cells after they have been subjected to

chronic irritation. Dysplastic cells have a

tendency to become malignant; dysplasia is

seen commonly in epithelial cells in the bronchi

of smokers.

Metaplasia metaplasia is a celltransformation in which a highly specialized cell

changes to a less specialized cell. This serves as

a protective function, because the less

specialized cell is more resistant to the stress

that stimulated the change.

These adaptations allow the survival of the

organism. They also reflect the changes in the normal

cell in response to stress. If the stress is unrelenting, the

function of the adapted cell may succumb, and cell

injury will occur.

Cellular Injury

Injury is defined as a disorder in steady-state

regulation. Any stressor that alters the ability of the cell

or system to maintain optimal balance of its adjustment

processes will lead to injury. Structural and functional

damage then occurs, which may be reversible, or

irreversible. Causes of disorder and injury in the system

may arise from the external and internal environment

and include hypoxia, nutritional imbalance, physical

agents, chemical agents,, infectious agents, immune

mechanisms, genetic defects and psychogenic factors.These agents act at the cellular level by damaging or

destroying:

The integrity of the cell membrane, necessaryfor ionic balance

The ability of the cell to transform energy(aerobic respiration, production of adenosine

triphosphate)

The ability of the cell to synthesize enzymes andother necessary proteins.

The ability of the cell to grow and reproduce(genetic integrity)

CELLULAR RESPONSES TO INJURY: INFLAMMATION

Cells or tissues in the bod may be injured or

killed by any of the agents described earlier. When this

happens, an inflammatory response naturally occurs in

the healthy tissues adjacent to the site of injury.

Inflammation is a defensive reaction intended to:

Neutralize

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Control Eliminate the offending agent Prepare the site for repair

It is a non-specific response that is meant to

serve a protective function. Regardless of the cause, a

general sequence of events occurs in the local

inflammatory response. This sequence involves changes

in the microcirculation, including vasodilation, increasedvascular permeability, and leukocytic cellular

infiltration. As these changes take place, five cardinal

signs of inflammation are produced.

The transient vasoconstriction that occursimmediately after injury is followed by

vasodilation and an increased blood flow

through the microcirculation

Local heat and redness result. Vascular permeability increases and plasma

fluids leak into the inflamed tissues, producing

swelling. Pain produced is attributed to the pressure of

the fluids or swelling on nerve endings and to

the irritation of nerve endings by chemical

mediators released at the site. (Bradykinin,

Prostaglandin)

As blood flow increases and fluid leaks into thesurrounding tissues, the formed elements

remain in the blood, causing it to become more

viscous.

Leukocytes collect in the vessels, exit andmigrate to the site of injury to engulf offending

microorganisms and to remove cellular debris

(Phagocytosis )

Fibrinogen in the leaked plasma fluidcoagulates, forming fibrin for clot formation.

Teaching Relaxation Techniques

Relaxation techniques are a major method used

to relieve stress. Commonly used techniques include

progressive muscle relaxation, the Benson Relaxation

Response and relaxation with Guided Imagery. The goal

of relaxation training is to produce a response thatcounters the stress response. The different relaxation

techniques share four similar elements:

A quiet environment A comfortable position A passive attitude A mental device (something on which to focus

the attention, such as word, phrase or sound)

Progressive Muscle Relaxation

Progressive muscle relaxation involves tensing

and releasing the muscles of the body in sequence andsensing the difference in feeling.

It is best if the person lies in a soft cushion onthe floor in a quiet room, breathing easily

Someone usually reads the instructions in a lowtone with a slow and relaxed manner.

The person tenses the muscle in the wholebody (one muscle group at a time) holds,

senses the tension and then relaxes.

As each muscle group is tensed, the personkeeps the rest of the body relaxed. Each time

the focus is on feeling

When the exercise is completed, the wholebody should be relaxed.

Bensons Relaxation Response

Pick a brief phrase or word that reflects yourbasic belief system

Choose a comfortable position Close your eyes Relax your muscles Become aware of your breathing, and start

using your selected focus word

Maintain a passive attitude Continue for a set period of time Practice the technique twice dailyThis response combines meditation with relaxation.

Along with the repeated word or phrase, a passiveattitude is essential. If other thoughts or distractions

occur, Benson recommends not fighting the distraction

but simply continuing to repeat the focus phrase. The

time of day is not important, but the exercise works

best on an empty stomach.

Relaxation with Guided Imagery

Simple Guided Imageryis the purposeful use

of imagination to achieve relaxation or direct attention

away from undesirable sensation. The nurse helps the

person select a pleasant scene or experience, such as

watching the ocean or dabbling the feet in a cool

stream. This image serves as the mental device in the

technique. As the person sits comfortably and quietly,

the nurse guides the individual to review the scene,

trying to feel and relive the imagery with all of the

senses.

Stages of Illness

Edward Schuman (1965) devised an orderly

approach for studying illness behavior with his

elaboration of the five key stages of illness experience: Symptom Experience Assumption of the sick role Medical care contact Dependent patient role Recovery and rehabilitation

Stage 1: Symptom Experience

The illness experience is initiated when an

individual first senses that something is wrong a

perception of pain, discomfort, general unease or some

disruption in bodily functioning. Suchman states thatthere are three distinct processes that occur at this

time:

The physical pain or discomfort Cognitive recognition that physical symptoms

of an illness are present; and,

An emotional response of concern about thesocial implications of the illness, including a

possible disruption in the ability to function

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Stage 2: Assumption of the Sick role; illness as

deviance

If the individual accepts that the symptoms are

a sign of illness and are sufficiently worrisome, then the

transition is made to the sick role, at which time the

individual begins to relinquish some or all normal social

roles.

The Sick Role, one of the most fundamentalconcepts in medical sociology, was first introduced by

Talcott Parsons. Parsons emphasized that illness is not

simply a biological or psychological condition, and it is

not simply an unstructured state free of social norms

and regulation. The sick role is also a social role,

characterized by certain exemptions, rights, and

obligations shaped by society, groups and cultural

tradition to which the sick person belongs.

Within the context of the social control

responsibilities of medicine, society allows two explicit

behavioral exemptions for the sick person but also

imposes two explicit behavioral requirements. The

exemptions are:

The sick person is temporarily excused fromnormal social roles. Depending on the nature

and the severity of the illness, a physician can

legitimize the sick role status and permit the

patient to forgo normal responsibilities.

The sick person is not held responsible for theillness. Society accepts that cure will require

more than the best efforts of the patient ad

permits the patient to be taken care of byhealth care professionals and others.

In order to be granted these role exemptions,

however, the patient must be willing to accept the

following obligations:

The sick person must want to get well.The person must not get so accustomed

to the sick role or enjoy the lifting of

responsibilities that motivation to get

well is surrendered.

The sick person is expected to seekmedical advice and cooperate with themedical experts. This requirement

introduces another means of social

control. The patient who refuses to see a

health care professional creates a

suspicion that the illness is not legitimate.

Such a refusal inevitably reduces the

patience and sympathy of society and

those surrounding the patient.

Stage 3: Medical Care Contact / Self-care

The third stage was labeled as medical care

contract and described as the point in which an

individual sought professional medical care. Today,

medical sociologists are much more aware of the

variety of options available to persons who have

entered the sick role, the increasingly common practice

of self-care and the importance of the individuals social

and cultural environment in shaping the action taken.

Concentrating on the more individual level,

three factors have been specified that influence the

decision to seek care:

The background of the patient. The patients perception of the illness. Zola

(1973) identified five social triggers that

influence the judgment that the symptoms

need professional health care.

o Perceived interference with vocationalor physical activity, especially work-related activity

o Perceived interference with social orpersonal relations

o An interpersonal crisiso A temporalizing of symptomso Pressure from family or friends

The social situationStage 4: Dependent Patient Role

With the onset of the dependent-patient role,

the patient is expected to make every effort to get well.

The severity of the illness, the individuals coping ability

and the nature and extent of social support coalesce to

determine the impact of the illness on the dependent

patient. The following list determines the major

concerns people have during stage 4:

Impairments of personal cognitive functioning Loss of personal independence Changes in body image Withdrawal from social key roles The future

Stage 5: Recovery and rehabilitation

The final stage of Suchmans schema varies

depending on the type of illness. For acute patients, the

process is one of relinquishing the sick role and moving

back to normal role obligations. For chronic patients,

the extent to which prior role obligations may be

resumed ranges from those who forsake the sick role to

those who will never be able to leave it.