Homeostasis, Stress, & Adaptation

COMPENSATORY MECHANISM OF BODY SYSTEMS

o Mechanisms for adjusting internal conditions promote steady state and survival of organism.
o Mechanisms are compensatory in nature and work to restore balance in our body.
o Example: rapid breathing (hyperpnea) after intense exercise in an attempt to compensate for oxygen
deficit and excess lactic acid accumulated in muscle tissue
PATHOPHYSIOLOGIC PROCESS
o Cellular injury occurs when compensatory mechanism cannot adapt to change
o Example: development of heart failure; body retains Na & H20, venous pressure which worsens
condition.
STEADY STATE
o Stable condition that doesnt change over time, when change in one direction is balanced by change in
the opposite direction.
o Within internal environment, each organ, tissue, and cell is a Subsystem or Subsystem of a whole and
each has own internal & external environment exchanging information and matter.
Constellation of Systems
Internal Environment
Cell
(Smallest Subsystem or Subsystem of All Systems)
Tissue
Organ
Organ System
Living Organism (Human)
External Environment
Family
Group
Community
Society
Goal of the Interaction of Body Systems
o Dynamic balance or steady state even in the presence of change
4 Concepts to Understand Steady State
1. Constancy
2. Homeostasis
3. Stress
4. Adaptation

EACH SYSTEM is a
SUBSYSTEM of a LARGER
SYSTEM or SUPRASYSTEM

CLAUDE BERNARD (19th Century French Phsyiologist)

o Biologic principle: For life there must be constancy OR fixity of internal milieu despite
changes in external environment
CONSTANCY balanced internal state maintained by physiologic & biochemical processes
INTERNAL MILIEU fluid that bathes the cells
HOMEOSTASIS
o Steady State within the body or Stability of Internal Environment
o Bodys ability to maintain stable internal condition and respond appropriately to stimulus
DISEASE
o Abnormal variation in the structure or function of any body part
o Disrupts body function thus limits freedom of action
STRESS
o State produced by a change in the environment thats perceived as challenging, threatening, or
damaging to a persons dynamic balance
o disruptive condition in response to adverse influences from internal or external environment
STRESSOR
o Change or stimulus that evokes stress; its nature is variable (any event thats stressful for one
person may not be stressful to another or event that causes stress at one time & place may not
do so at other time & place)
ADAPTATION
o Compensatory process of coping with stress that has physiologic & psychological component
and occurs throughout life as a person encounters challenges to health and illness.
o Change or alteration to assist in adapting to a new situation or environment.
DURATION OF STRESSORS
Acute Stressor or Time Limited Stressor
Stressor Sequence
(series of events resulting from initial event)
Chronic Intermittent Stressor
Chronic Enduring Stressors that persists over time
TYPE OF STRESSORS
Physical

Physiologic
Psychosocial
Normal Life Transitions

EXAMPLES
Studying for an exam
Job loss that leads to a divorce
Daily hassles
Chronic illness, Disability, Poverty

EXAMPLES
Extreme Cold (can lead to hypothermia)
Extreme Heat (can lead to heat stroke)
Chemical Agents (acids)
Pain (acute or chronic)
Fatigue (ex. lack of sleep)
Fear (failing an exam, losing a job, diagnostic result)
Childhood to Puberty
Getting Married
Giving birth

CLASSSIFICATION OF STRESSORS
Day to day frustrations or hassles
Greater health impact due to its cumulative
effects such as hypertension, palpitations and
other physiologic problems; vary in effect
Major complex occurrences involving
large groups or nation

Occurs less frequently & involves few people

Infrequent situations that directly affect
people; most extensive

EXAMPLES
Caught in a traffic jam
Argument with a spouse or roommate
Computer downtime
War (direct at the war zone or news)
Terrorism
Changes in Society
(demographic, economic, technologic)
Birth, Marriage, Divorce, Retirement,
Death, Psychosocial Crises (permanent
disability, long term care of frail elderly)

STRESS AS STIMULUS FOR DISEASE

o
o

Definition of stress according to theoretical approach: Relating life events to illness

People under constant stress have higher incidence of Psychosomatic Disease.

HOLMES & RAHE (1967)

o Developed Life Changing Units (life events scales that assign numerical values wherein items
reflect events that require change in a persons life)
o Stress: Accumulation of changes in ones life that require Psychological Adaptation
o The Recent Life Questionnaire (118 items about death, birth, marriage, divorce, promotions,
arguments, vacations; includes both desirable and undesirable items)

SOURCES OF STRESS
o
o
o
o
o

Alterations in physical & emotional status

Changes of daily level of function
Decreased social support
Loss of significant others
Fears of immobilization

o
o
o
o
o

Isolation and loneliness

Sensory changes
Financial problems
Death or disability
Loss of role

PSYCHOLOGICAL RESPONSE TO STRESS (LAZARUS)

Mediating Process
o After recognizing a stressor, person is consciously or unconsciously reacts to manage situation.
Important Mediators of Stress
1. Cognitive Appraisal
2. Coping
Cognitive Appraisal
o Evaluation or assessment of an event or situation; may occur simultaneously
a. Primary Appraisal - what is at stake; non-stressful or stressful situations
b. Secondary Appraisal - what might and what can be done
c. Reappraisal change of opinion based on new information

Cognitive Appraisal develops Emotions

a. Negative Emotions fear and anger accompany harm and loss.
b. Positive Emotions accompany challenge
Note: Each emotion includes us to act in a certain way (unprepared students may view unexpected
quiz as threatening and may express thru hostile behaviour comments)
Cognitive Motivational Relational Theory (Lazarus)
o Relates emotion to behaviour
o Relational - Standing for a focus on negotiation with physical or social world
Coping
o Consists of cognitive & behavioural efforts to manage specific external or internal
demands that taxs a persons resources
a. Emotion Based Coping makes person feel better by lessening emotional distress.
b. Problem Focused Coping direct changes in environment so situation can be managed
more effectively
o Both occur in a stressful situation even if viewed as challenging or beneficial. Coping efforts may
be required to develop & sustain challenge, to maintain positive benefits of challenge and ward
off threats. Successful coping or eliminates source of stress.

INTERNAL FACTORS THAT AFFECTS APPRAISAL AND COPING

o
o
o
o

Health
Energy
Personal belief systems
Commitment or life goal

o
o
o

Knowledge
Problem Solving skills
Social skills

Hardiness
o Having rich, varied, and rewarding experiences
o Hardy people perceive stressors as challenging opportunities for growth

PHYSIOLOGIC RESPONSES TO STRESS (HANS SELYE)

o
o

Protective and Adaptive Mechanism to maintain homeostasis

Activates Neurologic and Hormonal Process within the brain and body systems

Theory of Adaptation
o Influenced the Scientific Study of Stress
o Described a Syndrome: Nonspecific response to diverse, noxious stimuli
Enlargement of adrenal cortex
Shrinkage of spleen, lymph nodes, & other lymphatic structures
Appearance of deep bleeding ulcers in stomach and duodenum

General Adaptation Syndrome (GAS)

1. Alarm
o SNS is stimulated by emergency, emotion, exercise, and embarassment
o SNS Fight or Flight Response & releases Catecholamines and Adrenocorticotropic
Hormone (ACTH)
o Defensive and anti- inflammatory but self- limited (because it can lead to death)
Catecholamines
o any group of amines (amino acid based hormones such as epinephrine, norepinephrine,
dopamine) that acts as neurotransmitter
Adrenocorticotropic Hormone (ACTH)
o released by Anterior Pituitary Gland to stimulate Adrenal Cortex to release Cortisol
(Glucocortecosteroid)
2. Resistance
o Adaptation to noxious stressor
o Cortisol is still if prolonged exposure to stressor occurs
3. Exhaustion
o Increased Endocrine activity that causes negative effects on systems especially Immune,
Circulatory, and Digestive that can lead to death.
Comparison of GAS to Life Process
a. Childhood few encounters stress to promote development of adaptive functioning
b. Adulthood stressful event occurs and people develop resistance or adaptation.
c. Later Years accumulation of lifes stressors and wear and tear of organism that decreases
ability to adapt, resistance falls, and eventually death occur
Local Adaptation Syndrome (LAS)
o Inflammatory response and repair process at the local site of tissue injury which usually occurs
as a small topical (surface) injury (ex. contact dermatitis).
o If local injury is severe, GAS is activated
o Stress is a nonspecific response common to all stressors
o There are differences in the tolerance of people for stress. Some develop diseases of adaptation
while others are unaffected.

INTERPRETATION OF STRESSFUL STIMULI IN CNS (BRAIN)

1. Hypothalamus
o Located at the center of the brain (part of diencephalon) and surrounded by Limbic
System and Cerebral Hemispheres.
o Integrates Neural and Hormonal actions to maintain Homeostasis
o Integrates Autonomic Nervous System that maintains chemical constancy of bodys
internal environment
o Together with Limbic System, along with other structures, hypothalamus regulates
emotions & visceral behaviour for survival such as:
Eating
Reproduction
Drinking
Defense
Regulation of Body Temperature
Aggression (violence)

2. Cerebrum or Cerebral Hemispheres (Right and Left)

o Superior or uppermost portion of the Brain.
o Integrates cognitive functions such as thought process, learning, and memory.
o 4 Lobes
a. Frontal (speech; brocas area)
c. Occipital (visual)
b. Parietal (taste; wernickes area)
d. Temporal (auditory)
3. Limbic System
o Emotional Visceral Area or Pleasure or Satisfaction Center
o Has connections between Cerebral Hemispheres and Brain Stem
4. Reticular Activating System (RAS)
o 2 way communication system that extends from brain stem midbrain limbic
system
o Controls alert or waking state of body / sleep and wake cycle

3 Stimulus that activate Endocrine Gland

Endocrine Glands are ductless glands that produce hormones which they release into blood.
1. Hormonal Stimuli
o Endocrine organs are prodded into action by other hormones
Ex. Hypothalamic Hormones stimulates Anterior Pituitary Gland to secrete hormones and
Anterior Pituitary Hormones stimulate other endocrine glands to release their hormones.
2. Neural Stimuli
o Nerve fibers stimulate hormone release
Ex. SNS stimulation of Adrenal Medulla release epinephrine & norephinephrine during stress
3. Humoral Stimuli
o Changing blood levels of certain ions and nutrients may stimulate hormone release.
Ex. Insulin produced by Pancreas Islets of Langerhans
Parathyroid Hormone by Parathyroid Gland
Calcitonin by Thyroid Gland
Pituitary Gland
Located at the Hypothalamus of the Brain
1.

Anterior Pituitary Gland

o Regulated by Hormonal Stimuli
o Hormones released produced by Hypothalamus:
Adrenocorticotropic Hormone (regulates endocrine activity of Adrenal Cortex)
Growth Hormone
Thyroid Stimulating Hormone (TSH)
Prolactin

 Gonadotropic Hormone Sex Hormones

Follicle Stimulating Hormone (FSH)
Luteinizing Hormone (LH)
2.

Posterior Pituitary Gland

o storage area for hormones by Hypothalamic Neurons
o 2 Hormones released
a. Anti Diuretic Hormone (ADH) water & salt retention, reabsorption (incase of
dehydration, loss of fluids, hemmorhage)
b. Oxytocin
Adrenal Glands
o Located at the top of kidney

1.
2.

Adrenal Medulla
o Releases Epinephrine and Norepinephrine
Adrenal Cortex
o Produces corticosteroids to resist long term stressor by Blood Glucose and has antiinflammatory actions
a. Cortisol breakdown of fat and protein and reduces inflammation
b. Aldosterone regulates mineral content of blood (Na & K) and water balance
o Renin produced by kidneys when BP is low and releases aldosterone to BP
o Atrial Netruiretic Peptideprevents release of Aldosterone when BP is high; BP
c. Sex Hormones Estrogen and Androgen

DURING STRESS RESPONSE

Stressful Stimuli
Detected
Sensory Organs (hearing, vision, smell, taste, touch)
Internal Sensory Receptors
(Detects stimulus inside and out the body)
(baroreceptors to pressure in blood vessels, chemoreceptors to chemicals, , thermoreceptors to hot cold
temp, nociceptors to pain, osmoceptors to osmolarity in fluids, etc)
Transmits
Afferent Impulses to CNS
(Sensory /Affarent Division of PNS carries impulses to CNS from skin, skeletal muscles, joints, & visceral organs)

Nerve Centers in the Brain (CNS)

Hypothalamus (CNS)
(Integration: response to perception of stress is integrated to make adjustments and to return to Homeostasis)

If Major Stress evoke

Stimulates
SNS Responses & Pituitary Adrenal Responses

SNS discharge of hormones (Norepinephrine and Epinephrine)

Sympathetic Adrenal Medullary discharge of hormones (Norepinephrine and Epinephrine)

IF STRESS PERSISTS
Activates
Hypothalamic Pituitary discharges of hormones (Glucocorticoids Primarily Cortisol)
And
Neural & Neuroendocrine Pathways under the control of Hypothalamus
Remember:
Epinephrine & Norepinephrine & Cortisol is the most important in general response to stress

SYMPATHETIC NERVOUS SYSTEM RESPONSE TO STRESS

o
o

Release Norepinephrine & Epinephrine that is directly in contact with their major end organs
that the function of vital organs and state of general body arousal.
Response is rapid and short lived

1. HR & Peripheral Vasoconstriction (Venous Return), BP, and blood is shunted away from
abdominal organs to provide better perfusion of vital organs (brain, heart, skeletal muscles)
2. Blood Glucose to supply readily available energy
3. Dilated Pupils, Mental Activity, Sense of Awareness
4. Constriction of blood vessels of skin limits bleeding and prevents hemmorhage during trauma
5. Cold Feet, clammy skin, hands, chills, palpitations, and knots in stomach
6. Muscles Appears tense (muscles of neck, upper back, shoulders tightened)

7. Respirations may be rapid and shallow and diaphragm is tense

SYMPATHETIC ADRENAL MEDULLARY RESPONSE TO STRESS

o
o
o

Releases Epinephrine & Norepinephrine (Catecholamines) that stimulate nervous system and
produce metabolic effects which blood glucose and metabolic rate
Effect is called Fight and Flight Reaction
Similar to SNS response & has effect of sustaining & prolonging its actions.

Effect
Heart Rate
Blood Pressure
Blood Glucose

Mental Acuity
Dilated Pupils
Skeletal
Muscle Tension
Respirations or
Ventilation

Blood Coagulation
(Blood Clotting)

Purpose
Mechanism
Better perfusion of vital Cardiac output b/c myocardial contractility &
organs
heart rate
Venous return (peripheral vasoconstriction)
Increased available
Liver and muscle glycogen breakdown
energy
Adipose tissue triglycerides breakdown
Amount of blood
Alert state
blood shunted to brain from abdominal viscera & skin
Increased Awareness
Contraction of radial muscle of iris
Preparedness for
Excitation of muscles
Activity; fatigue
blood shunted to muscles of abdominal viscera & skin
Provide oxygen for
Stimulation of Respiratory Center in Medulla Oblongata
energy
Medulla Oblongata part of brain stem that controls
respirations, heart rate, blood pressure, and swallowing.
Brain Stem connects brain and spinal cord
Prevent hemmorhage Vasoconstriction of surface vessels
during trauma
Normal Clotting time of 3 5 secs

HYPOTHALAMIC PITUITARY RESPONSE TO STRESS

o Involves Hypothalamic Pituitary Pathway.
o Longest physiologic response that occurs during PERSISTENT STRESS
o Response is prolonged
Hypothalamus
Releases Hypothalamic Hormone
Corticotrophin Releasing Factor (CRF)
Stimulates
Anterior Pituitary Gland
Releases
Adrenocorticotropic Hormone (ACTH)
Stimulates
Adrenal Cortex
Releases
GLUCOCORTOCOIDS (HYPERGLYCEMIC HORMONES) --- CORTISOL
Stimulates
Protein Catabolism
Releases
Amino Acids
Stimulates
Liver uptake of Amino Acids and their conversion to glucose
GLUCONEOGENESIS

Inhibits Glucose Uptake (Anti Insulin Action) by the cells except heart and brain cells

Cortisol Metabolic Effect:

Provide body with source of energy during stressful situation
Nursing Implications:
1. Diabetics who are under stress caused by infection needs insulin
2. Diabetics who are under stress caused by illness, surgery, trauma, & psychological stress catabolises
protein and needs supplements.

Other Hormones
Anti-diuretic Hormone (P. Pituitary)
Aldosterone (Adrenal Cortex)
Growth Hormone (A. Pituitary)
Glucagon (Islets of Langerhans of
Pancreas)
Endorphins (Endogenous Opioids)

o
o
o

Action
Sodium and water retention & Reabsorption
Adaptive mechanism during hemmorhage and loss of body fluids
Stimulates uptake of amino acids to mobilize energy resources

o
o
o

Increases during stress

Enhance affect mood and threshold of painful stimuli
so called high that runners experience

IMMUNOLOGIC RESPONSE
Immune system is connected to Neuroendocrine and Autonomic Nervous System. Stressors may
result in alterations in autonomic activity and slight variations in neurohormone and neuropeptide
synthesis thus, can initiate, weaken, enhance, or terminate immune response.
Neuropeptides
o Released by Lymphoid Tissue (Bone Marrow)
o Functions: Regulates Leukocytes (WBCs) and Inflammatory Response
Neuroendocrine Hormones
o Released by CNS and Endocrine tissues
o Function: Stimulate or inhibit Leukocyte function.
Psychoneuroimmunology
o Study of relationships between Neuroendocrine, CNS, ANS & Immune System and effects of
these relationships on overall health outcomes.

MALADAPTIVE RESPONSES TO STRESS

Goals of Adaptation
1. Somatic / Physical Health (Optimal Wellness)
2. Psychological Health / Sense of well being (happiness, satisfaction with life, morals)
3. Enhanced Social functioning of work, social life, and family (positive relationship)
Maladaptive Responses to stress are ineffective
Maladaptive Responses
o Chronic, recurrent, or pattern of responses that doesnt promote goals of adaptation.
1.

Faulty Appraisals
o Frequency, intensity, and duration of stressful situations contribute to the development
of emotions and neurochemical discharge. By appraising and coping appropriately its
possible to anticipate and resolve some of these situations.
o Marital discords (disagreements) might be avoided with better communication
o Pattern of procrastination (delaying work on tasks) can be corrected to reduce stress

2.

Ineffective Coping
a. Use of alcohol or drugs to reduce stress risk of illness
b. Type A behaviours
o impatience, competitiveness, and achievement orientation
o prone to develop stress related illness which increases catecholamines and adrenal
medullary hormones
c. Denial, Avoidance, Distancing
Denials intent is to control threat but may endanger life (Ex: Woman who feels a lump in
her breast doesnt take it seriously & delays to seek medical attention)

3.

Models of Illnesses: Stress and Maladaptation as PRECURSOR to DISEASE

o Selye: any stressor elicits state of disturbed physiologic equilibrium. If prolonged or
excessive, it susceptibility to illness.
a. Sympathetic Adrenal Medullary Response (Nore and Epi)
o Arousal, Hypertension, arteriosclerotic changes, and cardiovascular diseases.
b. Adrenocorticotropic Hormone (ACTH)
o Withdrawal, Depression
c. Immune Response
o Infections, Tumors
Diseases of Maladaptation by Selye (1976)
1. Cancer
2. High Blood Pressure (including Hypertension of Pregnancy)
3. Heart and Blood Vessels Diseases
4. Kidney Diseases
5. Digestive and Metabolic Diseases
6. Nervous and Mental Diseases
7. Rheumatic and Rheumatoid arthritis
8. Inflammatory diseases of skin and eyes
9. Sexual Dysfunctio

INDICATORS OF STRESS
1. Subjective and Objective (Signs and Symptoms of Stress)
o Physiologic, psychological & behavioural reflect social behaviour and thought process
o
o
o
o
o
o
o
o
o
o
o

Restlessness (agitation)
Depression
Fatigue
Intense periods of anxiety
Loss of interest in activities
Nausea and vomiting
Dry mouth
Overpowering to act out
Strong startle response
Hyperacitivity
GIT distress, Diarrhea

o
o
o
o
o
o
o
o
o
o
o

Changes in Menstrual cycle

Change in Appetite
Injury prone
Palpitations
Impulsive
Emotional liability
Difficulty of concentrating
Feeling weak or dizzy
Increased Body Tension
Tremors
Nervous habits

o
o
o
o
o
o
o
o
o
o

Nervous laughter
Bruxism (grinding of teeth)
Difficulty of sleeping
Excessive Perspiration
Urinary frequency
Headaches
Pain in back, neck, etc
Increased use of tobacco
Substance abuse or use
Unintentional weigh lossgain

2. Laboratory Measurements
a. Blood and Urine Analysis
o Changes in hormonal levels and breakdown of products
o Blood levels of catecholamines, glucocorticosteroids, ACTH, and eosinophils
b. Serum Cholesterol and Free Fatty Acids Level
o Changes in Adrenal Cortex Hormones (Cortisol and Aldosterone). As their levels ,
theres simultaneous of additional cholesterol into general circulation.
o Physical and Psychological distress cholesterol levels
c. Immunoglobin Assay
o Increases when exposed to variety of stressors, infections, & immunodeficiency
diseases.
3. Questionnaires developed by Researchers: The Work of Rice compilation of info from
research on stress, coping, & health.

NURSING IMPLICATIONS
o

Optimal point of intervention to promote health is when compensatory processes are still
functioning effectively

Major Role of Nurses

1. Early identification of physiologic and psychological stressors
2. Relate presenting s/s of distress to the physiology they represent
3. Identify clients position on continuum of function, from health, compensation,
pathophysiology and disease.
Example: anxious middle aged woman presented for check up was found to be overweight with BP of 150/85mmHg. The
nurse would counsel about diet, stress management, and activity; and encourage weight loss and discuss intake of salt
(affects fluid balance) and caffeine (stimulant to effect). Patient and nurse would identify both individual and
environmental stressors and discuss strategies to decrease lifestyle stress, with ultimate goal being to create a healthy
lifestyle and prevent hypertension

STRESS AT THE CELLULAR LEVEL

o

Pathologic process may occur at all levels of an organism. If cell is the smallest unit, the
process of health and disease or adaptation and maladaptation can occur at CELLULAR LEVEL /
SUBCELLULAR / MOLECULAR LEVEL

Cell exists on a continuum of function and structure, ranging from: Normal Cell Adapted Cell
Injured Cell or Diseased Cell Dead Cell. Changes from one state to another may occur
rapidly but not readily detectable, because each state doesnt have discrete boundaries &
disease represents disruption of normal processes.

Earliest changes that occur at molecular level are not perceived until steady state functions or
structures are altered. With cell injury, changes may be reversible or lethal.
Ex. Tanning of skin is an adaptive, morphologic response to sun exposure. if exposure is
continued, sunburn or injury occurs, some cells may die, as evidenced by Desquamation.

Different cells & tissues respond to stimuli with different patterns and rates. Some cells are
more vulnerable to one type of stimulus than others
Ex: Cardiac muscle cells respond to hypoxia more quickly than smooth muscles cells.

Cells respond to different type of nature, stimulus, duration, and severity

Ex. neurons that control respiration can develop tolerance to small amounts of barbiturate, but
one large dose may result in respiratory depression and death

CONTROL OF STEADY STATE

o

Relationship of cell to compensatory mechanism occurs continuously to maintain steady state.

Compensatory processes are regulated by ANS & Endocrine System & achieved through
negative feedback

NEGATIVE FEEDBACK
o
o

Decreases the output of a system (reduce or stop initial stimulus)

Monitors internal environment and restore homeostasis when conditions shift out the normal
range by sensing deviations & give responses at offsetting the deviation.

Functions Regulated
1. Blood Pressure
2. Fluid and Electrolyte Balance
3. Acid based balance

4. Blood Glucose Level

5. Body Temperature

Organs of Homeostasis or Organs of Adjustment

o When stimulated, they alter their rate of activity or amount of secretions produced.
1. Lungs
4. GIT
2. Heart
5. Liver
3. Kidneys
6. Skin
o

Cells detect change in their immediate environment & initiates action to counteract its effect
(ex. accumulation of lactic acid in an exercised muscle stimulates vasodilation to blood flow
and improve delivery of oxygen and removal of waste products.

Steady state is achieved thru continuous small exchanges of chemical substances among cells,
interstitial fluid, and blood.

POSITIVE FEEDBACK
o
o
o

Increases the output of a system

Increases the changes from stimulus
Instead of compensating, system becomes more unbalanced, disorder, & disintegrated
Ex. Blood clotting, Birth of Baby, Loss of Blood
Ex. Accident BP due to blood loss (detected by receptor) needed to BP to Heart
Rate (POSITIVE FEEDBACK CONSTANTLY BP)

CELLULAR ADAPTATION
Functions of Cell
1. Maintenance Functions activities that cell must perform with respect to itself
2. Specialized Functions cells perform in relation to tissues & organs to which its a part.
Adaptation
Hypertrophy

Compensatory
Hypertrophy
Atrophy

Definition
Increase in cell size leading to
increase in organ size.

Stimulus
Prolonged; workload

Enlarged muscle mass; Occurs in

skeletal & cardiac muscle

Prolonged; workload

Decrease in cell size leading to

decrease in organ size

Diseased; Decreased use,

blood supply, loss of nerve
supply, hormonal
stimulation, innervations.
Disuse of body part is
associated with aging.

Occurs in skeletal muscle,

secondary sex organs, heart, brain
Hyperplasia

Increase in no. of new cells in

organ or tissue ( in mitosis) but
reversible when stimulus is
removed.

Examples
Leg muscles of runner
Arm muscles of tennis player
Cardiac muscle of person w/ HPN
Bulging muscles of Body Builders

Hormonal influence

Secondary sex organs in elders

Extremity immobilized cast

size of thyroid gland caused by

TSH hormone secreted by
Pituitary Gland
Breast changes in puberty or of a
pregnant woman.
Regeneration of liver cells

Dysplasia

Metaplasia

Change in appearance (size and

shape_ of cells after chronic
irritation

Reproduction of cells with

resulting alteration of
their size and shape

Cell transformation of one mature

adult cell type to another
(reversible); protective function

Stress applied to highly

specialized cell

New RBCs in blood loss

Alterations of epithelial cells of
skin or cervix, producing irregular
tissue changes that could be
precursors of malignancy
Changes in epithelial cells lining
bronchi in response to smoke
irritation (cells become less
specialized)

CELLULAR INJURY
o
o
o

Disorder in steady state regulation

Structural and functional damage occurs that may be reversible (permitting recovery) or
irreversible (leading to disability or death)
Presence of one injury makes system more susceptible to another injury
(Ex. inadequate o2 & nutritional deficiencies make system vulnerable to infection)

Most common causes

1.
hypoxia
2.
chemical injury
3.
infectious agents
These agents act at the cellular level by damaging or destroying the ff
a. Integrity of cell membrane for ionic balance
b. Ability of cell to transform energy (aerobic respiration, production of ATP)
c. Ability of cell to synthesize enzymes and other proteins
d. Ability of cell to grow and reproduce (genetic integrity)
e. Hypoxia
Hypoxia
o Inadequate cellular oxygenation that interfere cells ability to transform energy
a. blood supply to an area
b. oxygen carrying capacity of blood ( Hemoglobin)
c. Ventilation or perfusion or respiratory problem that amt of oxygen in blood
d. Problem in cells enzyme that makes it unable to use the oxygen delivered to it.
e. Ischemia usual cause
Ischemia
o Deficient blood supply
o Causes:
a. Myocardial cell injury
o Arterial blood flow due to atherosclerotic narrowing of blood vessels.
b. Intravascular clots (Thrombi or Emboli)
o Interfere with blood supply
o common cause of Cerebrovascular Accident or CVA (strokes)
Note: The length of time different tissues can survive w/o oxygen varies (ex. brain cells may give in
for 3 6 minutes, depending on situation)
Nutritional Imbalance
o Absolute deficiency or excess of one or more essential nutrients
a. Undernutrition
o Inadequate consumption of food or calories
o Specific Nutritional deficiencies (Ex. Protein Energy Malnutrition, Avitaminosis)
o Energy deficit leads to cell injury if theres insufficient glucose or oxygen to transform
glucose into energy.
o Lack of insulin or inability to use insulin may prevent glucose to enter the cell from the
blood (example: Diabetes Mellitus)
b. Overnutrition
o Excessive caloric intake to the point of obesity
o Requires more energy to maintain extra tissue
o obesity strains the body
o associated with Pulmonary and Cardiovascular Disease

4 PHYSICAL AGENTS
1. Temperature extremes
2. Radiation
3. Electrical Shock
4. Mechanical Trauma
Extremes of Low Temperature or Cold
o Causes vasoconstriction (narrowing of blood vessels)
o Blood flow becomes sluggish and clots form, leading to ISCHEMIC DAMAGE.
o With still lower temp, ice crystals may form, and cell may burst.
Extremes of High Temperature
o

Hypermetabolism, RR, HR, BMR occurs

With fever induced by infections, hypothalamic thermostat may be reset at higher

temperature, then return to normal when fever decreases

Increase in body temp is achieved through physiologic mechanisms. Body temp > 41C
suggests Hyperthermia, because physiologic function of thermoregulatory center breaks down
and temperature soars which occurs in coagulation of cell proteins, and cells die. Body must be
cooled rapidly to prevent brain damage.

Local response to thermal or burn injury is similar. Theres metabolic activity, protein is
coagulated, enzyme are destroyed, and in the extreme, charring of carbonization occurs.
Burns of epithelium are classified as the ff:
a. Partial thickness burns epitheliazing elements remain to support healing.
b. Full thickness burns lack epitheliazing elements & must be grafted for healing

Radiation
o Used for diagnosis and treatment of diseases.
o Inflammatory response of cell, creating favourable environment for opportunistic
infections.
Electric Shock
o Produces burns as a result of heat generated when electrical current travels thru body.
o May abnormally stimulate nerves (ex. fibrillation of the heart)
Mechanical Trauma
o Can result in wounds that disrupt cells and tissues of body.
o Ex. Gunshot
Chemical Agents
o Poisons
lye has corrosive effect on epithelial tissues
heavy metals - mercury, arsenic, lead
o Hydrochloric Acid can damage stomach lining (ex. Bleeding Ulcer)
o Glucose causes Hyperglycemia and affects fluid and electrolyte balance
o Insulin can cause Hypoglycemia and can lead to coma
o Drugs may cause chemical poisoning b/c some are less tolerant and manifest toxic
reactions.(Ex. aging tends to decrease tolerance to medications)

o
o

Polypharmacy (taking many medications at one time)

Alcohol (ethanol) has direct toxic effect on liver cells that may lead to liver abnormalities such
as cirrhosis.

Infectious Agents
o Biologic agents that cause disease in humans (virus, bacteria, fungi, protozoa, ricketssiae,
mycoplasmas, nematodes
o Severity of infectious disease depends on no. of microbes that enters body, virulence, and
hosts defences (ex. health, age, immune defences).
o Bacteria that cause tetanus and diphtheria produce exotoxins that create cell damage.
o Gram (-) bacteria produce endotoxins when they are killed.
o Tubercle Bacilli
o Inflammatory response & immune reaction are physiologic responses of body to infection.
Disordered Immune Responses
o Immune system defend body from invasion of foreign object or cell (ex. cancer cells)
o Immune response detects foreign bodies by distinguishing non-self substances from selfsubstances and destroying non self-entities.
o Entrance of antigen (foreign substance) produces antibodies to destroy antigen
(Antigen antibody reaction
o Immune system can be hypoactive or hyperactive.
1.
Hypoactive immunodeficiency diseases occur.
2.
Hyperactive hyperactive disorders occur
o Autoimmune Diseases (disorder of immune system itself can result in damage to own tissues)
Genetic Disorders
o Produce mutations that have no recognizable effect, such as lack of a single enzyme
o Contribute to congenital abnormalities such as Down syndrome.
Human Genome Project
o Created opportunities to assess genetic profile of a person to prevent or treat possible disease.
a. Sickle cell disease
b. cystic fibrosis
c. haemophilia (A&B)
d. breast cancer
e. obesity
f. cardio disease
g. phenylketonuria
h. Alzheimers.

CELLULAR RESPONSE TO INJURY:

INFLAMMATION OR INFLAMMATORY RESPONSE
Second Line of Defense / Non-Specific Defense / Cellular and Chemical Defense

o
o

Triggered when the cells and tissues of our body are injured.
Normally occurs in healthy tissues adjacent (near) to injured site.

Functions
1. Prevent spread of all foreign agents to protect our body
2. Neutralize (toxins), control, and eliminate foreign agents
3. Promote tissue repair
Note
1. Inflammation is not the same with infection
2. Infectious agent is one of the agents that may trigger inflammatory response.
3. Infection happens when infectious agents living, growing, and multiplying in tissues & able to
overcome.
4 General Sequence of events in local inflammatory response
1.
Changes in microcirculation
2.
Vasodilation
3.
Increased vascular permeability (capillary permeability)
4.
Leukocytic cellular infiltration
5 Cardinal signs of local inflammation
1. Heat / Warmth / Calor
2. Redness / Erythema / Rubor
3. Swelling / Edema / Tumor
4. Pain / Dolor
5. Loss of function

LOCAL INFLAMMATORY EVENTS

Injury

Immediate Transient Vasoconstriction

Vasodilation and
Blood Flow thru Microcirculation

Heat & Redness

Vascular (Capillary) Permeability & Plasma Fluids

Proteins and Solutes leaned into inflamed tissues
(Plasma Proteins: Albumin, Fibrinogen, Globulins)

Swelling or Edema d/t accumulated fluids

Pain due to pressure on fluids or swelling on

nerve endings and irritation of nerve endings
due to the RELEASE OF CHEMICAL MEDIATORS
(Histamine, Bradykinin, Prostaglandins, Serotonin
Loss of function may occur related to pain and swelling

Blood flow increases and leaks into surrounding tissues

Formed elements (RBCs, WBCs, and Platelets) remain in the blood causing it to become more viscous (thick)

LEUKOCYTE CELLULAR INFILTRATION

Leukocytes (monocyte and granulocyte) Collect in blood vessels, exit & migrate to site of injury to engulf foreign
organisms PATHOGENESIS
Neutrophils become active phagocytes for acute infection
Monocytes becomes macrophages for chronic infections

Fibrinogen (clotting factor) in leaked plasma fluid coagulates

Formation of Fibrin for clot formation

To wall off injured area and prevent spread of infection.

Chemical Mediators (Chemical Defenses)

o Chemical substances released at the injured site to induce vascular changes
1. Histamine
o present in many body tissues but is concentrated in mast cells
o responsible for early changes in vasodilation and vascular permeability
2. Kinins /Bradykinins vasodilation & vascular permeability; attract neutrophils to the area
3. Prostaglandins vascular permeability; causes pain
4. Serotonin
5. Acetylcholine

Special Characteristics of WBCS

1. Diapedesis can slip in and out of blood vessels if theres injury
2. Positive Chemotaxis can locate areas of damage and infection
3. Ameboid Motion can move into tissue spaces
WBCs (Leukocytes)
1. Granulocytes
Neutrophils active phagocytes for acute infections; most abundant
Eosinophils allergy attacks; parasitic worms
Basophils releases Histamin and Heparin (blood clotting)
2. Agranulocytes
Lymphocytes B and T Lymphocytes
Monocytes becomes macrophages during chronic infections
Systemic Response to Inflammation
1. Fever
o Most common sign of systemic response to injury
o Pyrogens (internal substances that cause fever) released from Neutrophils & Macrophages
and reset Hypothalamic Thermostat, which controls body temperature and produce fever.
2. Leukocytosis
o synthesis & release of neutrophils from bone marrow (lymphoid tissue) to provide body
to fight infection.
3. General, Nonspecific symptoms
o malaise or weakness
o loss of appetite; anorexia
o aching
o sepsis (state of infection)
TYPES OF INFLAMMATION
1. Acute Inflammation
o Local vascular and exudative changes and lasts < 2 weeks
o Immediate and serves as protection
o After causative agent is removed, inflammation subsides and healing takes place with the
return of normal or near normal structure and function.
2. Chronic Inflammation
o Develops if injurious agent persists and acute response is perpetuated.
o Symptoms are present for months or years and may begin insidiously and never have an
acute phase.
o Changes at the site of injury and nature of the exudates become proliferative. A cycle of
cellular infiltration, necrosis, and fibrosis begins, with repair and breakdown occurring
simultaneously. Considerable scarring may occur, resulting in permanent tissue damage.
3. Subacute Inflammation
o Falls between acute and chronic inflammation.
o Includes exudative phase of acute response and elements of repair in chronic phase.

CELLULAR HEALING
o
o

Reparative process begins at the same time as the injury and is connected with inflammation.
Healing proceeds after inflammatory debris has been removed and may occur by:

Regeneration
o Gradual repair occurs by proliferation of cells of the same type as those destroyed
a. Labile cells
o Multiply constantly to replace cells worn out by normal physiologic processes
o Ex. epithelial cells of skin and those lining the GIT
b. Permanent cells
o Destruction of neuron is a permanent loss, but axons may regenerate.
c. Stable cells
o Have latent ability to regenerate.
o Includes functional cells of kidney, liver and pancreas.
Replacement
o Cells of another type (usually connective tissue) fill in the tissue defect and result in scar
formation.
a. Primary intention healing
wound is clean and dry and edges are approximated
Little scar formation occurs and wound is usually healed in a week.
b. Secondary intention healing
o Wound is larger and gaping has necrotic or dead material
o Wound fills with granulation tissue.
o The process of repair takes longer and results in more scar formation, with loss of
specialized function.

NURSING IMPLICATIONS
The following questions are addressed during the assessment
1. Are the heart rate, respiratory rate, and temperature normal?
2. What emotional distress may be contributing to the patients health problems?
3. Are there other indicators of steady-state deviation
4. What are the persons blood pressure, height, and weight?
5. Are there any problems in movement or sensation?
6. Does the person demonstrate problems with affect, behavior, speech, cognitive ability,
orientation, or memory?
7. Are there obvious impairments, lesions, or deformities?
Further signs of change are indicated in diagnostic studies
1. Computed tomography (CT)
2. Magnetic resonance imaging(MRI)
3. Positron emission tomography (PET).
4. Blood urea nitrogen (BUN)
5. Blood glucose
6. Urinalysis

Nursing Interventions: Stress Management

o
o

Anxiety, frustration, anger, and feelings of inadequacy, helplessness, or powerlessness are

emotions often associated with stress and activities of daily living may be disrupted
Ex. sleep disturbance, eating and activity patterns altered and family processes or role
performance may be disrupted

Nursing diagnoses
1. Anxiety vague, uneasy feeling; source may be nonspecific or not known to the person.
2. Ineffective coping patterns
3. Impaired thought processes
4. Impaired adjustments
5. Disrupted relationships
Poor adaptive process
6. Defensive coping
7. Ineffective denial
Other possible nursing diagnoses include
1. Social isolation
2. Risk for impaired parenting
3. Spiritual distress

4. Decisional conflict
5. Situational low self-esteem
6. Powerlessness

Stress Management
o Directed toward reducing and controlling stress and improving coping.
o Stress control is a significant health-promotion goal
Stress reduction methods and coping enhancements
1. Internal Sources
adopting healthy eating habits; practicing relaxation techniques
2. External Sources
Developing a broad social network ; Goods and services that can be purchased

PROMOTING A HEALTHY LIFESTYLE

1. Health-promoting lifestyle
o Buffers or cushions the impact of stressors
2. Health risk appraisal
o Lifestyle or habits that contribute to the risk of illness can be identified through a health
risk appraisal.
o Assessment method that is designed to promote health by examining an individuals
personal habits and recommending changes when a health risk is identified.
3. Health risk questionnaires
o Estimate the likelihood that a person with a given set of characteristics will become ill.
Questionnaires typically address the following information
o Demographic data: age, sex, race, ethnic background
o Personal and family history of diseases and health problems
o Lifestyle choice: eating, sleeping, exercise, smoking, drinking, sexual activity, and driving
habits.
o Physical measurements (BP, Height, Weight, Lab analysis of blood and urine)
o Participation in high-risk behaviours

The single most important factor for determining health status is social class, and within a social
class research suggests that the major factor influencing health is level of education
ENHANCING COPING STRATEGIES
assisting a patient to adapt to perceived stressors, changes, or threats that interfere with
meeting life demands and roles
Five ways of coping with illness
Try to be optimistic about the outcome
Use social support
Use spiritual resources

Maintain control over situation or feelings

Try to accept the situation

Other ways of coping included

seek information
reprioritize needs and roles
lower expectations
make compromises
compare oneself to others

plan activities to conserve energy

take things one step at a time
listen to ones body
Use self-talks for encouragement.

TEACHING RELAXATION TECHNIQUES

Goal of relaxation: produce a response that counters the stress response. When this goal is
achieved, the action of the hypothalamus adjusts and activity of SNS and PNS. The sequence of
physiologic effects is interrupted, and psychological stress is reduced.
The different relaxation techniques share four similar elements:
(1) Quiet environment
(2) Comfortable position
(3) Passive attitude
(4) Mental device (something on which to focus the attention, such as a word, phrase, or sound).
1.

Progressive muscle relaxation

o Tensing and releasing muscles of the body in sequence and sensing difference in feeling.
o Person lies on a soft cushion on the floor, in a quiet room, breathing easily. Someone
usually reads the instructions in a low tone and with a slow and relaxed manner, or a tape
of the instructions may be played

2.

Bensons Relaxation Response (Meditation with Relaxation)

o Pick a brief phrase or word that reflects your basic belief system.
o If distractions (noises, pain of an ailment) occur continue to repeat focus phrase
o Time of day is not important, but the exercise works best on an empty stomach.

3.

Guided Imagery
o use of imagination or direct attention away from undesirable sensation
o Nurse helps the person select a pleasant scene or experience (ex. watching the ocean)
o Image serves as mental device in this technique.
Meditation
8.
Music therapy
Breathing techniques
9.
Biofeedback
Massage
10.
Use of humor.
Reiki

4.
5.
6.
7.

CLIENT EDUCATION
1. Providing sensory information (ex. lesson in childbirth for expectant parents, sensations the
patient will experience during cardiac catheterization)
2. Providing procedural information (eg, preoperative teaching)
ENHANCE SOCIAL SUPPORT
provide individual with different types of emotional information
1. Leads people to believe that they are cared for and loved.
Most often in a relationship between two people in which mutual trust and attachment are
expressed by helping one another meet their emotional needs.
2. Leads people to believe that they are esteemed and valued.
Most effective when theres recognition that demonstrates individuals favourable position in
the group.
Elevates persons sense of self-worth and is called esteem support.
3. Leads people to believe that they belong to a network of communication & mutual obligation.
Members of this network share information and make goods and services available to the
members on demand. The critical qualities within a social network are the exchange of intimate
communications and the presence of solidarity and trust.
Emotional support from family and significant others provides a person with love and a sense of
sharing the burden. The emotions that accompany stress are unpleasant. Being able to talk
with someone and express feelings openly may help the person to gain mastery of the situation.
Nurses can provide this support; however, it is important to identify the persons social support
system and encourage its use. People who are loners, who are isolated, or who withdraw in times of
stress have a high risk of coping failure. Because anxiety can also distort a persons ability to process
information, it helps to seek information and advice from others who can assist with analyzing the
threat and developing a strategy to manage it. Again, this use of others helps the person to maintain
mastery of a situation and to retain self-esteem.
Social networks assist with management of stress by providing the individual the ff
A positive social identity
Emotional support
Access to information
Access to new social contacts and new social roles
RECOMMENDING SUPPORT AND THERAPY GROUPS
Support groups exist especially for people in similar stressful situations.
parents of children with leukemia
people with ostomies
mastectomy patients
cancer or other serious diseases, chronic illnesses, and disabilities
groups for single parents
substance abusers and their family members
Victims of child abuse.
Professional, civic, and religious support groups are active in many communities.
Being a member of a group with similar problems or goals has a releasing effect on a person that
promotes freedom of expression and exchange of ideas.