Patho-inflammatory Response

GENERAL CONCEPTS in Medical-Surgical Nursing

Andrew D. Beluso,RN

Erikson’s Psychosocial Development and Havighurst’s Developmental Tasks • Adolescence (12-20) – Identity vs Role Confusion

– Achieving new and more mature relations with age-mates of both sexes – Achieving a masculine or feminine social role – Accepting physique and using body effectively – Achieving emotional independence from parents and other adults

Erikson’s Psychosocial Development and Havighurst’s Developmental Tasks – Preparing for marriage and family life – Preparing for an economic career – Acquiring set of values and ethical system as guide to behavior; developing ideology – Desiring and achieving socially responsible behavior

Erikson’s Psychosocial Development and Havighurst’s Developmental Tasks

• Early Adulthood (21-39) – Intimacy vs Isolation

– Selecting a mate – Learning to live with marriage partner – Starting a family rearing children – Managing a home – Getting started in an occupation – Taking on civic responsibility

Erikson’s Psychosocial Development and Havighurst’s Developmental Tasks • Middle Age (40-60) – Generativituy vs Stagnation

– Assisting teenage children to become responsible and happy adults – Achieving adult social and civic responsibility – Reaching and maintaining satisfactory performance in one’s occupational career – Developing adult leisure-time activities

Erikson’s Psychosocial Development and Havighurst’s Developmental Tasks – Relating oneself to one’s spouse as a person – Accepting and adjusting to the physiologic changes of middle age – Adjusting to aging parents

Erikson’s Psychosocial Development and Havighurst’s Developmental Tasks • Later Maturity (>65) – Ego Integrity vs Despair

– Adjusting to decreasing physical strength and health – Adjusting to retirement and reduced income – Adjusting to death of spouse

Erikson’s Psychosocial Development and Havighurst’s Developmental Tasks – Establishing an explicit affiliation with one’s age-group – Adopting and adapting social roles in a flexible way – Establishing satisfactory physical living arrangements

Terminologies • Health – (WHO) a state of complete physical, mental and social well being and not merely the absence of disease or infirmity – Absence or presence of symptoms of illness or their ability to carry out their normal activities

Terminologies • Disease – Presence of pathologic change in the structure or function of the body or mind

• Illness – Abnormal process in which the person’s level of functioning is changed compared with a previous level

Selye’s Types of Stress Responses • Localized Adaptation Syndrome (LAS) – Short-lived stressor, signs and symptoms seen in a certain part of the body

• Generalized Adaptation Syndrome (GAS) – Stressor present for a long period; signs and symptoms manifested by the entire body – Eg. Anorexia, body malaise, fever

Steps in the Inflammatory Response • •

Cell and tissue injury Vascular response • Vasoconstriction – produces chemical mediators (histamine, bradykinin, serotonin, prostaglandins); produces blanching of skin • Vasodilation – causes stasis of blood and margination of leukocytes; produces redness of skin • Fibrin clot formation – histamine, kinins, prostaglandins causes opening of venules

Steps in the Inflammatory Response • Fluid exudation - histamine, kinins, protaglansdins causes opening of venules

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Serous – clear and watery; protein or albumin portion of the blood and from serous membrane Sanguinous – large number of red blood cells and looks like blood

Steps in the Inflammatory Response • Purulent – white blood cells, liquified dead tissue debris and live or dead bacteria; thick and foul smelling • Edema – swelling of tissue from fluid in the interstitial space

Steps in the Inflammatory Response • Cellular Exudation • Leukocyte exudation – leukocytes passes from blood to site of injury and accumulates there • Attack and engulfment of foreign materials – removal and digestion of bacteria, foreign particles and damaged tissues

Steps in the Inflammatory Response • Healing

• Fibroblasts produce collagen fibers leading to resolution of inflammation • Regeneration – proliferation with same type of cell; • Labile cells – multiply constantly like the gastrointestinal tract • Permanent cells – neurons • Stable cells – latent regeneration: kidney, liver

Cardinal Symptoms of Inflammation • Rubor (redness)

• caused by hyperemia

• Calor (heat)

• caused by vasodilation

• Tumor (swelling)

• caused by fluid exudation

• Dolor (pain)

• caused by pressure of fluid exudates and chemical irritation of nerve endings

• Loss of function

• caused by swelling and pain

Systemic Reactions in Inflammation • Fever

• release of endogenous pyrogens, prostaglandins, endotoxins and leukotrienes; defense mechanism and helps increase production of antimicrobial agents like interferon

• Leukocytosis

• Increase number of leukocytes released from bone marrow and lymph nodes into blood

Systemic Reactions in Inflammation • Increased Erythrocyte Sedimentation Rate • Increase in fibrinogen; indicates that the body’s defense mechanisms for the repair of damaged tissues are operating

Classification of Inflammation • According to characteristic type of exudates:

• Serous – clear; easily reabsorbed without damage • Fibrinous – filled with large amount of fibrinogen • Sanguinous or hemorrhagic – large amount of blood from vascular damage

Classification of Inflammation • Purulent or suppurative – results from bacterial infection • Catarrhal – mucinous secretion and results from viral infection of respiratory tract

Classification of Inflammation • According to position that inflamed area occupies within involved tissue:

• Abscess – localized collection of pus caused by suppuration in tissue, organ and confined space • Sinus – infection forming abscess develops suppurating channel and ruptures onto the surface or into a body cavity

Classification of Inflammation • Fistula – infection forms a tube-like passage from an epithelium-lined organ or normal body cavity to the surface of another organ or cavity • Cellulitis – inflammatory process poorly defined and diffused with tendency to spread; involves cellular or connective tissue • Ulcer – superficial defect on surface of organ or tissue caused by sloughing of necrotic tissues

Classification of Inflammation • According to location (with suffix itis – depends upon organ affected)

Classification of Inflammation • According to duration or length of time • Acute • Lasts less than 2 weeks; response is immediate;

healing takes place with return of normal structure and function

Classification of Inflammation • Chronic • Lasts from several weeks to years; debilitating and produces long lasting effect; proliferative cell multiplication, cellular filtration, necrosis, fibrosis or scarring; with periods of • Remission – disease is present but the person does not experience symptoms • Exacerbation – acute phase, signs and symptoms are back

Objectives and Principles of Care • Conserving energy • Enhancing inflammatory process • Increasing fluid intake • Diminishing effects of inflammation • Isolating patient

Physiologic Responses to Stress • Neuroendocrine responses • SAMR – Sympatho Adrenal Medullary Response • Fight or flight response • Epinephrine

Physiologic Responses to Increased Epinephrine • Increased heart rate and blood pressure • Better perfusion of vital organs

• Increased cardiac output and cardiac rate • Increased myocardial contractility

• Increased venous return

• Peripheral vasoconstriction

• Increased blood glucose • Increased energy

Physiologic Responses to Increased Epinephrine • Glycogenolysis or carboydrate breakdown • Increased mental activity • alertness, dilated pupils

• Increased tension of skeletal muscles • Preparedness for activity, decreased fatigue

• Increased ventilation • Provision of O2 for energy

Physiologic Responses to Increased Epinephrine • Increased coagulability of blood • Prevents hemorrhage

• Increased perspiration • Dissipation of heat

• Decreased urinary output • Decreased gastrointestinal tract activity; decreased urinary output; decreased salivation

Physiologic Responses to Stress • Adreno-cortical response • Glucocorticoids • cortisol

• Mineralocorticoids • aldosterone

Physiologic Effects of Glucocorticoids • • • • • • •

Maintains blood glucose Increases gluconeogenesis Decreases glucose uptake by cells Protein and fat catabolism Depresses immune response Inhibits inflammatory process Destroys lymphocytes and decreases antibody production

Physiologic Effects of Glucocorticoids • Augments effects of other hormones and • • • • •

catecholamines Maintains cardiac output and blood pressure Promotes Na and H2O water retention and K excretion Maintains emotional stability Increases RBC and platelet formation Inhibits defensive acts (anti-inflammatory)

Physiologic Effects of Mineralicorticoids • Stimulate defensive acts (pro-

inflammatory) • Acts on distal tubule of kidneys • Reabsorption of Na and water • Excretion of K and H ions • Maintains vascular volume and BP

Physiologic Responses to Stress • Neurohypophyseal response • Vasopressin or ADH • Promote Na and water retention • Adaptive mechanism in bleeding

Physiologic Responses to Stress • Antigen-antibody reaction • Antigen/immunogens • Substances which when introduced into an animal causes formation of antibodies or sensitized cell

• Antibody/immunoglobulins • Produced when exposed to antigen; produced in lymphoid tissues

Antibody Types • IgG – immunoglobulin G

• Crosses placental barrier • Predominant class (75-85%); major antibody in primary and secondary immune responses • Present in blood plasma • Plays major role in blood borne and tissue infection • Activates compliment system and enhances phagocytosis

Antibody Types • IgA – immunoglobulin A • •

Present in all body fluids like tears, saliva, [ Protects against respiratory, gastrointestinal and genitourinary infection • Prevents absorption of antigens from food • Passed on breast milk to protect neonates

Antibody Types • IgM – immunoglobulin M • Confines in intravascular fluids; attached to Bcells • First produced in response to bacterial or viral infection • Mainstay or primary immune system • Responsible for transfusion reactions in ABO blood typing system

Antibody Types • IgE – immunoglobulin E • Produced by plasma cells in mucous membranes and tonsils • Mediate serum and hypersensitivity reaction • Defense against parasitism

Antibody Types • IgD – immunoglobulin D • • •

Attached to B cells Unknown biologic function Activation of and suppression of lymphocyte function

Antigen-antibody Reactions • Agglutination

• Agglutinins; clump

• Precipitation

• Precipitins; clusters

• Opsonization

• Opsosins; coats

• Lysis

• Lysozyme; dissolves or liquifies

• Neutralization

• Antitoxin; neutralizes

Physiologic Responses to Stress • Immune Response • Developed when the body recognized the invading organism that cannot be identified as part of itself • Immunity – state of being resistant to injury or disease

Functions of Immune System • Defense – resisting infection • Homeostasis – removing”worn out” self component • Surveillance – identification and destruction of mutant cells

Types of Immunity • Active • Antibodies are synthesized by the body in response to antigenic stimulation • Natural • Contact with antigen eg. chickenpox, measles • Artificial • Immunization with antigen (live or killed vaccine or toxoid immunization)

Types of Immunity • Passive

• Antibodies produced in one individual transferred to another • Natural • Transplacental colostrum transfer from mom to child

• Artificial • Injection of serum from immune human or animal • e.g. human globulin, hyperimmune sera

Interactive Divisions of the Immune System • Humoral (antigen antibody reaction) • Provides immunity against: • Bacteria that produce acute infection • Bacterial exotoxins (diphtheria, tetanus) • Viruses that must enter the bloodstream to reach their target tissues • Organisms that enter the body from mucosal tissues

Interactive Divisions of the Immune System • Cellular (cell mediated; lymphocytes) • Offers protection from: • Chronic bacterial infection (syphilis, leprosy, TB) • Many viral infections (measles, herpes, chickenpox) • Fungal infections (candidiasis) • Parasitic infections (pneumocystis carinii) • Transplanted or transformed cells

Comparison of Humoral and Cellular Immunity Cells Products Reaction e.g.

HUMORAL B-lymphocytes Antibodies

CELLULAR T-lymphocytes Sensitized T-cells

Immediate Delayed Anaphylactic TB, contact shock, transfusion dermatitis, AIDS reaction

TH ANK Y OU!