Concept of Health & Illness

Definitions
A.World Health Organization
HEALTH purposeful, adaptive response
physically, mentally, emotionally and socially, to
the external stimuli in order to maintain stability
and comfort
B.Health-illness continuum (dynamic, changes with
time) it includes states of high level wellness,
health, precursors for illness, illness and severe
illness
- an individual may experience any of these
states across the lifespan and its movement may
be dynamic in lesser direction as individual
adapt to optimum level of health.

Wellness Model
Premature
Death

High-level
Wellness
Disabilty Symptoms Signs Awareness Education Growth

Treatment Model

Neutral
Point

C.Concept of high-level wellness including holism

an integrated method of functioning that is
oriented toward maximizing the potential of
which the individual is capable within the
environment where he or she is functioning.
D.National Goals (Healthy People 2010, US Dept
HHS):
1. Increase quality and years of healthy life
Life expectancies in years: 73.6 male; 79.4
female
2. Eliminate health disparities
Factors Affecting Health Status (can they be modified?)
A. Genetic makeup (predisposition to specific
illnesses: genome project)
B. Cognitive abilities and education (response to
health teaching)
C. Race, ethnicity, cultural background
D. Age, gender, developmental level
E. Life style, environment
F. Socio-economic status
G. Geographic area
Health and the Nursing Process
A. Assessment of clients health status and
identifiable health risks related to factors
affecting health status
Risk refers to alikelihood that a health problem
might occur.

Types of Risk:
1. Inherited Risk refer to those determined by
biological characteristics of age, family history
or genetic endowment that have predictable
consequence for illness.
2. Environmental Risk includes physical, social
and economic stressors
3. Behavioral Risk refers to those related to
health habit, low values for health practice or
self examination and health appraisals
B. Interventions include client teaching regarding
status and preventative actions
Example: overweight 35-year-old woman with a
strong family history of diabetes type II changes
to low fat diet and adds 3 thirty-minute walks
per week
C. Evaluation: improvement of leading indicators
Healthy People 2010
Concept of Illness
A. Differentiation from disease
Illness is defined as the maladaptation to
internal and external environments.
Disease or health problems are more objective
description of illness
- failure of a persons adaptive mechanisms to
adequately counteract stimuli and stresses,
resulting in functional and structural
disturbances

Determinants of Health and Illness

1. Heredity includes the non modifiable
factors of age, sex, racegenetic endowment and
family history as a foundation of health
2. Lifestyle includes factors modifiable by
choice
Health and Illness Behavior
Health Behavior refers to an activity an
individual engages in to maintain health,
prevent disease, or treat health problems
Illness Behavior are responses to abnormal
body signals. Responses may include:
1. monitoring body signals
2. taking action to deal with signals
3. using health care facilities
Illness behaviors measured in stages
Progression through stages halts if reverts to
healthy state
5 Stages of SICK ROLE in client:
1. Experiencing symptoms
2. Assuming the sick role
3. Seeking medical care
4. Assuming dependent role
5. Achieving recovery and rehabilitation
Types of Illness:
Acute illness: characteristics: rapid onset, selflimiting
Chronic illness: characteristics: requires long
period of care, includes permanent disability
1. 3-fold increase in incidence in future

2. Clients adaptation to illness

3. Effect on family members and
developmental tasks
4. Nursing interventions focus on education to
promote client independence, improved
quality of life, rehabilitation
Stages of Illness
1. Incubation Period the time elapsed from
the entrance of the microorganism in to the
body to the appeareance of clinical signs
and symptoms
2. Period of Illness
Types:
a. Fulminating when the course of
the disease is usually rapid and the
manifestations are usually severe and
uncontrollable
b. Prodromal Period the individual
has early manifestations of the impending
illness but does not have the specific signs
and symptoms
3. Period of Convalescence during this
period the individual may completety
recover, develop complication, recover from
illness with permanent disability or death
may result.
Nurses Role in Health Promotion
A. Clients achievable high-level wellness
B. Prevention of illness 3 Levels of Prevention

1. Primary prevention key concept: healthy

living to prevent disease
Example: Dietary intake: 5-9 servings of
fruits and vegetables daily
2. Secondary prevention key concepts: early
diagnosis, treatment of disease
Example: Blood pressure screening
3. Tertiary prevention key concepts:
prevention of complications; rehabilitation
Example: Exercise program post hip
fracture
Adult Client Health Status and Risks: Divided
according to age
A. Young adult (age 18 to 40)
1. Peak physiologic development to age 25
2. Specific age health risks: accidents, sexually
transmitted diseases, substance abuse,
physical and psychosocial stressors
B. Middle adult (age 40 to 65)
1. Physical changes
2. Specific age health risks: obesity,
cardiovascular disease, cancer, substance
abuse (nicotine, alcohol, prescribed drugs),
psychosocial stressors
C. Older adult (over age 65)
1. Population increasing at faster rate than
any other
2. Physical changes
3. Specific age health risks:

a. Chronic illness (includes arthritis,

hypertension, hearing impairments,
cardiovascular diseases, cataracts),
obesity, cardiovascular disease, cancer
b. Injuries mainly falls, fires, motor
vehicle accidents
c. Pharmacologic effects due to
predisposition to drug toxicity
d. Physical and psychosocial stressors
Chapter 6
Homeostasis, Stress, and Adaptation
Steady State - a stable condition that does not change
over time, or when change in one direction is balanced
by change in an opposite direction
Each person, as a living system, has both an internal
and an external environment, between which
information and matter are continuously exchanged.
Pathophysiologic processes result when cellular injury
occurs at such a rapid rate that the body's
compensatory mechanisms can no longer make the
adaptive changes necessary to remain healthy.
Claude Bernard, a 19th-century French physiologist,
developed the biologic principle that for life there must
be a constancy or fixity of the internal milieu despite
changes

Internal constancy

Walter Cannon used the term homeostasis to describe

the stability of the internal environment, which, he said,
was coordinated by homeostatic or compensatory
processes that responded to changes in the internal
environment
Homeostasis - a steady state within the body
Rene Jules Dubos (1965) provided further insight into
the dynamic nature of the internal environment with his
theory that two complementary concepts, homeostasis
and adaptation, were necessary for balance.
Stress - a disruptive condition that occurs in
response to adverse influences from the internal or
external environments
- perceived as challenging, threatening, or
damaging to a person's dynamic balance or
equilibrium.

Adaptation - a change or alteration designed to

assist in adapting to a new situation or environment
- the desired goal or adjustment to the
change so that the person is again in equilibrium and
has the energy and ability to meet new demands.

Stress is a threat to the steady state

Types of Stressors

Physical

Examples: cold, heat, and chemical agents

Physiologic

Examples: pain and fatigue

Psychosocial

Examples: developmental tasks/changes, anxietyproducing events such as losing job

Stressors have also been classified as

(1) day-to-day frustrations or hassles;
(2) major complex occurrences involving large groups,
even entire nations; and
(3) stressors that occur less frequently and involve fewer
people.
Duration may also be used to categorize stressors, as in
the following list:
An acute, time-limited stressor, such as studying
for final examinations
A stressor sequencea series of stressful events
that result from an initial event such as job loss or
divorce
A chronic intermittent stressor, such as daily
hassles
A chronic enduring stressor that persists over time,
such as chronic illness, a disability, or poverty
Stress as a Stimulus for Disease

Links between stress and illness

- people under constant stress have a high incidence of
psychosomatic disease.

Life event scales

Holmes and Rahe (1967) - developed life events

scales that assign numerical values, called life-change
units, to typical life events.

Recent Life Changes Questionnaire (1982) - 118

items such as death, birth, marriage, divorce,
promotions, serious arguments, and vacations. The
items include both desirable and undesirable events.

Each persons appraisal and response to an event

or stressor will vary.

Primary appraisal results in the situation being

identified as either nonstressful or stressful. A
nonstressful situation is irrelevant or benign (positive).
A stressful situation
may be one of three kinds:
(1) one in which harm or loss has occurred;
(2) one that is threatening, in that harm or loss is
anticipated; and
(3) one that is challenging, in that some opportunity or
gain is anticipated.
Secondary appraisal is an evaluation of what might and
can be done about the situation.
Reappraisal

When a person endures prolonged or unrelenting

suffering, the outcome is frequently the development of
a stress-related illness. Nurses possess the skills to assist
people to alter their distressing circumstances and
manage their responses to stress.

After recognizing a stressor, a person consciously or

unconsciously reacts to manage the situation. This is
termed the mediating process.
Physiologic Response to Stress
The physiologic response to a stressor, whether it is
physical or psychological, is a protective and adaptive
mechanism to maintain the homeostatic balance of the
body. When a stress response occurs, it triggers a series
of neurologic and hormonal processes to be activated
within the brain and body systems. The duration and
intensity of the stress can cause both short-term and
long-term effects. A stressor can disrupt homeostasis to
the point where adaptation to the stressor fails, and a
disease process results.
Selyes General Adaptation Syndrome

Theory of adaptation to biologic stress. A syndrome

consisting of enlargement of the adrenal cortex;
shrinkage of the thymus, spleen, lymph nodes, and
other lymphatic structures; and the appearance of deep,
bleeding ulcers in the stomach and duodenum. He
identified this as a nonspecific response to diverse,
noxious stimuli.
Three phases: (General Adaptation Syndrome)
3 Stages of Response
1. Stage of Alarm: SNS fight-or-flight response;
catecholamines released, onset of ACTH response, selflimiting

It occurs when a threat have been perceived and

the nervous system and the endocrine systems have
been notified of the emergency
2. Stage of Resistance: adaptation occurs to the stressor;
cortisol activity is still increased
Nerves and glands are aiding the body tissues in
resisting the stress
3. Stage of Exhaustion: endocrine activity continues and
the body will fail if exposure to the stressor is
prolonged. Has negative effect on the body system.
Occurs when the tissues surrender to stress
Local Adaptation Syndrome

A local response to an injury.

Includes the inflammatory and tissue repair

process.

If the injury is severe enough, General Adaptation

Syndrome will also be activated.

TABLE 6-1 SympatheticAdrenalMedullary Response

to Stress
Effect
Purpose
Mechanism
Increased
Better
Increased cardiac output
heart rate and perfusion of
due to increased
blood pressure vital organs
myocardial contractility
and heart rate; increased
venous return
(peripheral
vasoconstriction)
Increased
Increased
Increased liver and
blood glucose available
muscle glycogen
level
energy
breakdown; increased
breakdown of adipose
tissue triglycerides
Mental acuity Alert state
Increase in amount of
blood shunted to the
brain from the
abdominal viscera and
skin
Dilated pupils Increased
Contraction of radial
awareness
muscle of iris
Increased
Preparedness Excitation of muscles;
tension of
for activity,
increase in amount of
skeletal
decreased
blood shunted to the
muscles
fatigue
muscles from the
abdominal viscera and
skin

Increased
Provision of
ventilation
oxygen for
(may be rapid energy
and shallow)
Increased
Prevention of
coagulability ofhemorrhage in
blood
event of
trauma

Stimulation of
respiratory center in
medulla;
bronchodilation
Vasoconstriction of
surface

Maladaptive Response to Stress

- are chronic, recurrent responses or patterns of
response over time that do not promote the
goals of adaptation.
- include faulty appraisals and inappropriate
coping
Selye (1976) proposed a list of disorders that he called
diseases of maladaptation: high blood pressure, diseases
of the heart and blood vessels, diseases of the kidney,
hypertension of pregnancy, rheumatic and rheumatoid
arthritis, inflammatory diseases of the skin and eyes,
infections, allergic and hypersensitivity diseases,
nervous and mental diseases, sexual dysfunction,
digestive diseases, metabolic diseases, and cancer.

Indicators of Stress
Chart 6-1: Assessing for Stress
Be on the alert for the following signs and symptoms:
Restlessness
Depression
Dry mouth
Overpowering urge to act out
Fatigue
Loss of interest in life activities
Intense periods of anxiety
Strong startle response
Hyperactivity
Gastrointestinal distress
Diarrhea
Nausea or vomiting
Changes in menstrual cycle
Change in appetite
Injury-prone
Palpitations
Impulsive behaviors
Emotional lability
Concentration difficulties
Feeling weak or dizzy
Increased body tension
Tremors
Nervous habits
Nervous laughter
Bruxism (grinding of teeth)
Difficulty sleeping

Excessive perspiration
Urinary frequency
Headaches
Pain in back, neck, or other parts of the body
Increased use of tobacco
Substance use or abuse

Nursing Implications
- realize that the optimal point of intervention
to promote health is during the stage when a
person's own compensatory processes are still
functioning effectively.
- early identification of both physiologic and
psychological stressors.
- relate the presenting signs and symptoms of
distress to the physiology they represent and
identify a person's position on the continuum
of function, from health and compensation to
pathophysiology and disease.
Stress at the Cellular Level
TABLE 6-2 Cellular Adaptation to Stressors
Adaptation
Stimulus
Example
Hypertrophy
Increased
Leg muscles of
increase in cell size workload
runner
leading to increase
Arm muscles in
in organ size
tennis player
Cardiac muscle in
person with
hypertension

Atrophy
Decrease in:
shrinkage in size of Use
cell, leading to
Blood supply
decrease in organ
Nutrition
size
Hormonal
stimulation
Innervation
Hyperplasia
Hormonal
increase in number influence
of new cells
(increase in
mitosis)

Dysplasiachange
in the appearance
of cells after they
have been
subjected to
chronic irritation
Metaplasia
transformation of
one adult cell type
to another
(reversible)

Secondary sex
organs in aging
person
Extremity
immobilized in cast

Breast changes of a
girl in puberty or
of a pregnant
woman
Regeneration of
liver cells
New red blood cells
in blood loss
Reproduction of Alterations in
cells with
epithelial cells of
resulting
the skin or the
alteration of
cervix, producing
their size and irregular tissue
shape
changes that could
be the precursors
of a malignancy
Stress applied to Changes in
highly
epithelial cells
specialized cell lining bronchi in
response to smoke
irritation (cells
become less
specialized)

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 leads to injury.
Hypoxia
Inadequate cellular oxygenation (hypoxia) interferes
with the cell's ability to transform energy. Hypoxia may
be caused by:
A decrease in blood supply to an area
A decrease in the oxygen-carrying capacity of the
blood (decreased hemoglobin)
A ventilation/perfusion or respiratory problem that
reduces the amount of oxygen available in the
blood
A problem in the cell's enzyme system that makes it
unable to use the oxygen delivered to it
Nutritional Imbalance
Nutritional imbalance refers to a relative or absolute
deficiency or excess of one or more essential nutrients.
Physical Agents
1. Temperature
2. Radiation and Electrical Shock
3. Mechanical Trauma
Chemical Agents

Chemical injuries are caused by poisons, such as lye,

which have a corrosive action on epithelial tissue, or by
heavy metals, such as mercury, arsenic, and lead, each
of which has its own specific destructive action.
Infectious Agents
Biologic agents known to cause disease in humans are
viruses, bacteria, rickettsiae, mycoplasmas, fungi,
protozoa, and nematodes.
Disordered Immune Responses
The immune system is an exceedingly complex system,
the purpose of which is to defend the body from
invasion by any foreign object or foreign cell type, such
as cancerous cells.
Genetic Disorders
Cellular Response to Injury: Inflammation
Inflammation is a defensive reaction intended to
neutralize, control, or eliminate the offending agent
and to prepare the site for repair.
It is a pathophysiological response that serves to
defend the tissues against microorganisms and to
prepare the tissue for repair.

Types of Inflammation
1. Acute inflammation is characterized by the
local vascular and exudative changes
described earlier and usually lasts less than 2
weeks
2. Chronic inflammation develops if the
injurious agent persists and the acute response

is perpetuated. Symptoms are present for

many months or years
3. Subacute inflammation falls between acute
and chronic inflammation.
Types of Inflammatory Reactions
1. Local Inflammatory Response
1. Increased vascular permeability
2. Infiltration of Leukocytic cells
3. Cell Repair
2. Systemic Inflammatory Response occurs
when bacterial invaders cannot be successfully
localized and destroyed. Fever and leukocytosis
herald the onset of a systemic inflammatory
response
Cellular Healing
Regeneration
The ability of cells to regenerate depends on whether
they are labile, permanent, or stable.
Replacement
Depending on the extent of damage, tissue healing may
occur by primary intention or by secondary intention.
Nursing Implications
- Use of Nursing Process

Assessment
both objective signs and subjective symptoms are the
primary indicators of existing physiologic processes.
The following questions are addressed:
Are the heart rate, respiratory rate, and
temperature normal?
What emotional distress may be contributing to the
patient's health problems?
Are there other indicators of steady-state
deviation?
What are the patient's blood pressure, height, and
weight?
Are there any problems in movement or sensation?
Are there any problems with affect, behavior,
speech, cognitive ability, orientation, or memory?
Are there obvious impairments, lesions, or
deformities?

Assessment

Subjective symptoms

Objective symptoms

Include indicators of stress response such as

anxiety, increased pulse, and increased respirations.

Also consider potential indicators for stress such as

life events, developmental tasks, and health risk
appraisal. See Chart 6-2.
Chart 6-2: Information Addressed in Health Risk
Questionnaires

Demographic data: age, gender, race, ethnic

background
Personal and family history of diseases and health
problems
Lifestyle choices
Eating, sleeping, exercise, smoking, drinking,
sexual activity, and driving habits
Stressors at home and on the job
Role relationships and associated stressors
Physical measurements
Blood pressure
Height, weight, body mass index (BMI)
Laboratory analyses of blood and urine
Participation in high-risk behaviors
Nursing Diagnosis

Anxiety

Impaired adjustment

Ineffective coping

Social isolation

Risk for powerlessness

Risk for spiritual distress

Decisional conflict

Situational low self-esteem

Interventions

Stress management interventions: is directed

toward reducing and controlling stress and improving
coping.

The five predominant ways of coping with illness

identified in a review of 57 nursing research studies
were as follows (Jalowiec, 1993):
Trying to be optimistic about the outcome
Using social support
Using spiritual resources
Trying to maintain control either over the situation
or over feelings
Trying to accept the situation
Chart 6-3: Coping Enhancement: Nursing Interventions
Definition
Assisting a patient to adapt to perceived stressors,
changes, or threats that interfere with meeting life
demands and roles
Activities
Appraise a patient's adjustment to changes in body
image as indicated.
Appraise the impact of the patient's life situation
on roles and relationships.
Encourage the patient to identify a realistic
description of change in role.
Appraise the patient's understanding of the disease
process.
Appraise and discuss alternative responses to the
situation.
Use a calm, reassuring approach.

Provide an atmosphere of acceptance.

Assist the patient in developing an objective
appraisal of the event.
Help the patient to identify the information that he
or she is most interested in obtaining.
Provide factual information concerning diagnosis,
treatment, and prognosis.
Provide the patient with realistic choices about
certain aspects of care.
Encourage an attitude of realistic hope as a way of
dealing with feelings of helplessness.
Evaluate the patient's decision-making ability.
Seek to understand the patient's perspective of a
stressful situation.
Discourage decision making when the patient is
under severe stress.
Encourage gradual mastery of the situation.
Encourage patience in developing relationships.
Encourage relationships with persons who have
common interests and goals.
Encourage social and community activities.
Encourage the acceptance of limitations in others.
Acknowledge the patient's spiritual/cultural
background.
Encourage the use of spiritual resources if desired.
Explore the patient's previous achievements.
Explore the patient's reasons for self-criticism.
Confront the patient's ambivalent (angry or
depressed) feelings.
Foster constructive outlets for anger and hostility.

Arrange situations that encourage the patient's

autonomy.
Assist the patient in identifying positive responses
from others.
Encourage the identification of specific life values.
Explore with the patient previous methods of
dealing with life problems.
Introduce the patient to persons (or groups) who
have successfully undergone the same experience.
Support the use of appropriate defense
mechanisms.
Encourage verbalization of feelings, perceptions,
and fears.
Discuss the consequences of not dealing with guilt
and shame.
Encourage the patient to identify his or her own
strengths and abilities.
Assist the patient in identifying appropriate shortand long-term goals.
Assist the patient in breaking down complex goals
into small, manageable steps.
Assist the patient in examining available resources
to meet the goals.
Reduce stimuli in the environment that could be
misinterpreted as threatening.
Appraise the patient's needs and desires for social
support.
Assist the patient to identify available support
systems.
Determine the risk of the patient's inflicting selfharm.

Encourage family involvement as appropriate.

Encourage the family to verbalize their feelings
about the ill family member.
Provide appropriate social skills training.
Assist the patient to identify positive strategies to
deal with limitations and manage needed lifestyle
or role changes.
Assist the patient to solve problems in a
constructive manner.
Instruct the patient in the use of relaxation
techniques as needed.
Assist the patient to grieve and to work through the
losses of chronic illness and/or disability if
appropriate.
Assist the patient to clarify misconceptions.
Encourage the patient to evaluate his or her own
behavior.

Relaxation techniques
(1) a quiet environment,
(2) a comfortable position,
(3) a passive attitude, and
(4) a mental device (something on which to focus one's
attention, such as a word, phrase, or sound).
Progressive muscle relaxation involves tensing and
releasing the Pr muscles of the body in sequence and
sensing the difference in feeling. It is best if the person lies
on a soft cushion, in a quiet room, breathing easily.

Benson's Relaxation Response

Benson (1993) describes the following steps of the
Benson Relaxation Response:
Pick a brief phrase or word that reflects your basic
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 demeanor.
Continue for a set period of time.
Practice the technique twice daily.
Guided imagery
Simple guided imagery is the mindful use of a word,
phrase, or visual image for the purpose of distracting
oneself from distressing situations or consciously taking
time to relax or reenergize. A nurse can help a person
select a pleasant scene or experience, such as watching the
ocean or dabbling the feet in a cool stream.

Assist and support coping and adjustment

Coping enhancement; see Chart 6-3
Enhance social support; support and therapy groups

Promote a healthy lifestyle A health-promoting lifestyle

provides internal resources that aid in coping, and it
buffers or cushions the impact of stressors.