Case Study, Porth
Chapter 9, Stress and Adaptation
Maria is a 21-year-old single mother. On the way to work, she drops off her 3-year-old daughter at a community day care center, and she picks her up on the way home. Because her income is low, Maria works at a second job from home in the evening and rarely gets out for social interactions. For the past several days, her daughter has been sick with influenza, so Maria has stayed awake throughout the night to care for her. One morning, while preparing her daughter’s breakfast, Maria realized they had run out of milk and bread again. Maria sat down on the floor and began to cry. (Learning Objectives 3, 4, 5, 7, 9, 10, 11, 12, 13, 14)
1.One of the effects of chronic stress is an impaired immune response. Outline the physiologic mechanisms that will make Maria particularly prone to contracting her daughter’s illness.
2.Assuming the stressors are the same, how is it that someone might react differently from Maria? From what you know of her history, what are some factors affecting Maria’s ability to cope both physically and psychologically?
3.Identify the signs and symptoms that would distinguish a person with post-traumatic stress disorder from an individual like Maria.
Suggested Answers for Case Study, Porth
Chapter 9, Stress and Adaptation
1.Psychological stress is a contributing factor to the development of physical illness. Although the exact mechanisms aren’t known, immune suppression is a result of a series of endocrine-immunologic interactions that include the following:
- Hormone receptors on lymphocytes: suppression of lymphocyte activity occurs under the influence of a variety of CNS-controlled hormones.
- Catecholamine release: the SNS innervates lymph nodes, thymus, and spleen. A synergistic relationship between epinephrine, CRF, and cortisol acts to suppress the function of lymphatic structures.
- Alteration of T-cell production: stress hormones stimulate the proliferation of particular subtypes of T-lymphocyte helper cells. This creates a physiologically altered immune response.
2.Conditioning factors contribute to an individual’s response to a stressor. Factors affecting Maria’s ability to cope might include the following:
- Time: students might identify the illness of her daughter, loss of sleep, and lack of food within a short length of time to be a factor in Maria’s adaptive abilities.
- Age: it may be indicated by some students that she is a young mother and therefore less able to cope with daily stressors.
- Nutrition: there is indication that food security has been a problem in the household.
- Sleep-wake cycles: decreased sleep disrupts both immunologic and psychological functioning.
- Hardiness: while not addressed specifically in the case study, some students may suggest Maria’s sense of control of her life is limited by her circumstances.
- Psychosocial factors: social support mechanisms and personal relationships are limited in this situation.
3.The individual with post-traumatic stress disorder presents with the following triad:
- Intrusion: there are flashbacks and nightmares recounting the traumatic event
- Avoidance: emotional numbing and withdrawal from relationships. There are also feelings of guilt and depression following the event.
- Hyperarousal: there is increased emotional irritability, anxiety, decreased concentration, hypervigilance, and strong concern for safety. The patient will also demonstrate sleeping difficulties and an increased startle reflex.
Case Study, Porth
Chapter 10, Alterations in Temperature Regulation
Anna is a small, frail 89-year-old woman. She resides in a nursing home and receives regular nursing care. One afternoon, Anna did not go to the lunch room for a mid-afternoon tea and cookie break. When a nurse noticed this, he went to Anna’s room to see how she was feeling. Anna was lying down and told him she was felt tired and very weak. The nurse asked her some more questions about her health, and Anna seemed confused when trying to answer him. He decided to take Anna’s temperature and discovered it was 1.6˚C above her baseline temperature of 36.3˚C. He took her pulse and noted her heart rate was elevated. He offered Anna some cool water and went to contact the physician. (Learning Objectives 4, 5, 7, 10)
1.Why would Anna’s temperature of 37.9˚C be of particular concern to the nurse? How is the physiologic mechanism for the production of a fever in the elderly different from that of adults?
2.What acid-base imbalance will Anna be at risk for developing? Explain your answer using your understanding of the fever response.
3.Why is it harmful to cool a patient with pyrexia too quickly?
Suggest Answers for Case Study, Porth
Chapter 10, Alterations in Temperature Regulation
- There are a number of reasons why a slight increase in temperature in the elderly is clinically significant:
- Basal temperature is often lower in the elderly.
- The febrile response can often be blunted or absent. Any increase in temperature is therefore clinically remarkable and may indicate serious illness.
Physiologically, the thermoregulatory center in the hypothalamus is less effective at set-point regulation in the elderly. There are also alterations in the release of endogenous pyrogens. Finally, neurologic responses in eliciting heat generation in the body can be diminished or absent.
2.Anna is at risk for metabolic acidosis. Anorexia is common finding with fever. There is also a significant increase in metabolic rate with protein catabolism and lipolysis for energy production. With prolonged fever, these findings collectively lead to a state of metabolic acidosis.
3.Rapid cooling causes superficial vasoconstriction, which impedes heat loss. It may also generate shivering and thereby promote increased heat production.
Case Study, Porth
Chapter 11, Activity Tolerance and Fatigue
Brianna is 47 years old and has not been able to work for more than a year. She finds the simplest daily tasks difficult to do because of her extreme fatigue. Despite her fatigue, her sleep is disturbed and never refreshing for her. She also suffers from joint pain, muscle soreness, low-grade fever, and frequent sore throat. Her doctor examined her thoroughly and, after careful consideration, concluded Brianna had chronic fatigue syndrome. (Learning Objectives 2, 6, 7, 8, 9, 10, 11, 12, 13, 14)
1.There are other functional disorders that share similar features to chronic fatigue syndrome, making a definitive diagnosis of CSF difficult. What are some examples?
2.Her doctor told Brianna that, despite how difficult it may seem, regular gentle exercise would be beneficial for her, particularly for her immune system. Why did he emphasize that the exercise should be moderate and not strenuous?
3.Brianna told her doctor that what she preferred to do was to go to bed and stay there until her muscle and joint discomfort went away. Why would her doctor dissuade her from this decision?
Suggested Answers for Case Study, Porth
Chapter 11, Activity Tolerance and Fatigue
1.Symptoms of CSF closely mimic those of fibromyalgia, multiple chemical sensitivities, depression, and irritable bowel syndrome.
2.Some students may note that in CSF, muscular activity can create postexertional malaise that lasts longer than 24 hours. In terms of immunity, strenuous activity can have a negative effect on immune system integrity. Moderate exercise, however, increases the number of circulating leukocytes and increases NK cell activity.
3.Bed rest is detrimental to the musculoskeletal system because it:
- Promotes muscular disuse atrophy
- Decreases force-generating capacity and increases fatigability in muscles
- Encourages muscle shortening
- Causes contractures leading to a decreased range of motion in joints
- Promotes anatomic changes in articular cartilage, tendons, and ligaments
- Results in altered bone metabolism and the development of osteoporosis