Nursing and Adaptive Response

Introduction
Adaptive response refers to how the human body protects itself from injury or infection. It is the third line of defense after inflammatory response and innate immunity (Huether & McCance, 2017). Advanced practice nurses should understand patient’s adaptive responses to alterations caused by disease processes. This paper explains the pathophysiology of tonsillitis, irritant contact dermatitis (ICD), and stress responses as determined from scenario 1, 2 and 3 (see Appendix A). In addition, it presents the mind map of tonsillitis that shows epidemiology, pathophysiology, risk factors, clinical presentation, diagnosis, and adaptive responses.
Scenario 1: Acute Tonsillitis
The conclusion from scenario 1 (see Appendix A) is a 2-years-old female patient suffering from on and off fever, sore throat, and swallowing pain for three days. Physical examination shows the patient’s throat is red with 4 tonsils, diffuse exudates, and palpable tender anterior cervical nodes. Patient's vital signs reveal a heart rate of 128 beats per minute, respiratory rate of 24 beats per minute, and temperature of 102.30F. These symptoms and signs are clinical presentations of acute tonsillitis.
Tonsillitis is the inflammation of the palatine tonsil (part of the waldeyer ring) by viral or bacterial infections (Skovbjerg et al., 2015). The waldeyer ring consists of a few lymph nodes that produce lymphocytes and antibodies. So, it acts as a defensive wall that attacks pathogens in food, drink, or air respiration. Common viruses that cause tonsillitis include Epstein-Barr virus (EBV), rhinovirus, adenovirus, coronavirus, and influenza. The most common bacterial cause of tonsillitis is Group A Streptococcus. In reality, distinguishing between viral and bacterial acute tonsillitis is difficult (Skovbjerg et al., 2015).
Acute tonsillitis begins with the infiltration of Group A Streptococcus to the epithelial layer of palatine tonsils. Once the invasion has occurred, the mast cells are triggered and inflammatory mediators (cytokines) are released. Cytokines then recruit polymorphonuclear leukocytes and its infiltration causes sore throat, fever, and tonsillitis. This process can be clinically seen as the tonsils are red with enlarged diffuse exudates (Skovbjerg et al., 2015). Other symptoms of acute tonsillitis include dysphagia (difficulty in swallowing), odynophagia (pain when swallowing), and tender cervical nodes.
The inflammation of the tonsils demonstrates the actions of the inflammatory response, the second line of defense in the human body (Huether & McCance, 2017). Inflammation is an adaptive response that promotes healing by protecting the body from further injury and preventing infection of the injured tissue. Other adaptive responses include tender cervical nodes, enlarge tonsils with exudates, and fever.
Scenario 2: Irritant contact dermatitis (ICD)
In scenario 2 (See Appendix A), Jack, a 27-year-old male, is a maintenance engineer and often works with abrasive solvents and chemicals. He has noticed that both his hands are red and flaky after exposure to cleaning fluids. These symptoms are clinical presentations of irritant contact dermatitis (ICD). ICD is an “inflammatory response of the skin due to various external stimuli” (Lee, Stieger, Yawalkar, & Kakeda, 2013). It occurs when a chemical agent causes direct injury to the skin leading to skin barrier disruption, cellular changes, and release of various proin?ammatory mediators (Eberting, 2014).
The pathogenesis of ICD is multifactorial (Hammer & McPhee, 2019). If chemical irritants such as acetone come into contact with the skin, it damages the epidermal cells by extracting lipids from the stratum corneum (the outermost layer of the skin). Chemical irritants can also damage protein structures such as, involucrin, keratin, proflaggrin and loricrin, thereby exposing new water binding sites and causing transepidermal water loss (TEWL) and disorganization of the lipid bilayers (Lee et al., 2013). The end result of this damage to the epidermal skin barrier is the activation of the innate immunity and production of proin?ammatory cytokines such as interleukin (IL) 1 alpha (IL-1?), chemokines such as IL-1 beta, IL-6, and tumor necrosis factor alpha (TNF- ?), and adhesion molecules such as intercellular adhesion molecule-1 (ICAM-1). This process can be clinically seen as the skin is red and itchy (Lee et al., 2013).
The primary cytokines that are released following the disruption of skin barrier are IL-1? and TNF- ?. These two cytokines are involved in the activation of dendritic cells and T-cells, production of secondary cytokines/chemokines such as IL-6 by dermal and epidermal cells, and upregulation of adhesion molecules such as ICAM-1 on fibroblasts and endothelial, which can all lead to skin inflammation. Given that all these inflammatory mediators are involved in ICD demonstrates the complexity of skin response to irritants.
Scenario 3: Stress Response
The conclusion from scenario 3 (see Appendix A) is a 65-year-old female patient who retired recently from her job and is suffering from insomnia, palpitations, and anorexia. The patient also spends a lot of time taking care of her 87-year-old mother, who lost her mobility and independence after a hip fracture. These symptoms are clinical manifestations of stress response.
Stress refers to “perceived or anticipated threat that disrupts a person’s well-being” (Huether & McCance, 2017). Stressors can either be external or internal. External stressors include significant life changes, relationship difficulties, financial problems, time constraints, and family problems. Internal stressors include pessimism, chronic worry, unrealistic expectations, and negative self-talk
Emotional responses to various stressors activate the sympathetic nervous system and hypothalamus-pituitary-adrenal cortex (HPA) axis, which prepares the body for “fight and flight” or stress response (Huether & McCance, 2017). Any type of stress (mental, physical, or metabolic) stimulates the hypothalamus leading to the secretion of corticotropin-releasing factor (CRF). The CRF activates the pituitary gland to release adrenocorticotrophic hormone (ACTH), which stimulates the adrenal cortex to release cortisol. Cortisol causes signs and symptoms of chronic stress, which include increased heart rate, breathing rate, blood sugar, and blood pressure. Cortisol also suppresses inflammatory responses (Hammer & McPhee, 2019). Overall, stress response depends on one's perception of the stressor and their coping mechanism.
Hans Seyle, a well-known physiologist, studied how the human body responds to stress. He concluded that there are three distinct phases to stress response: alarm, resistance, and exhaustion (Tan & Yip, 2018). In stage one of the stress response (alarm stage), the sympathetic nervous system (SNS) releases catecholamines and the adrenal glands releases cortisol. These hormones help the body to deal with stress. In stage two (resistance), cortisol is still being released for arousal. The third and final stage is exhaustion. In this stage, continuous stress causes the breakdown of compensatory mechanisms.
Conclusion
Clinical presentations of disease processes and patient factors can lead to a diagnosis. So, advanced practice nurses should understand the pathophysiology of diseases process in order to make accurate diagnosis.
Tonsillitis
Clinical Presentation
Fever
Sore Throat
4 Tonsil Swelling
Dysphagia
Odynophagia
Tender Cervical nodes
Epidemiology
Pathophysiology
Risk Factors
Adaptive Responses
Diagnosis
ENT Examination with cultures
Most Common in children
GABS Bacteria (Strep Throat) responsible for 15%-30% of cases
Medical Hx Review
Young Age
Frequent Exposure to Germs
Tonsil's immune system function declines after puberty
Sometimes occurs in young adults
CBC to determine if viral or bacterial
Fever
Swollen Tonsils with Exudate
Swelling of Cervical Lymph nodes
Promoted by overcrowded conditions and malnourishment
Common Viruses:
· Herpes simplex virus
· Epstein-Barr virus (EBV)
· Cytomegalovirus
· Other herpes viruses
· Adenovirus
· Measles virus
Inflammation of palatine Tonsils
Pathogens invade epithelial layer of palatine tonsils
Group A Streptococcus common in Winter and Spring
Tonsillitis Mind Map
References
Eberting, C. L. (2014). Irritant Contact Dermatitis: Mechanisms to Repair. Journal of Clinical & Experimental Dermatology Research, 5(6). doi:10.4172/2155-9554.1000246
Hammer, G. D., & McPhee, S. J. (2019). Pathophysiology of Disease: An Introduction to Clinical Medicine (8th ed.). New York, NY: McGraw-Hill Education / Medical.
Huether, S. E., & McCance, K. L. (2017). Understanding Pathophysiology (6th ed.). Maryland Heights, MO: Mosby.
Lee, H. Y., Stieger, M., Yawalkar, N., & Kakeda, M. (2013). Cytokines and Chemokines in Irritant Contact Dermatitis. Mediators of Inflammation, 2013, 1-7. doi:10.1155/2013/916497
Skovbjerg, S., Roos, K., Olofsson, S., Lindh, M., Ljung, A., Hynsjö, L., … Wold, A. E. (2015). High Cytokine Levels in Tonsillitis Secretions Regardless of Presence of Beta-Hemolytic Streptococci. Journal of Interferon & Cytokine Research, 35(9), 682-689. doi:10.1089/jir.2014.0123
Tan, S., & Yip, A. (2018). Hans Selye (1907–1982): Founder of the stress theory. Singapore Medical Journal, 59(4), 170-171. doi:10.11622/smedj.2018043
Appendix A
Scenario 1:
Jennifer is a 2-year-old female who presents with her mother. Mom is concerned because Jennifer has been “running a temperature” for the last 3 days. Mom says that Jennifer is usually healthy and has no significant medical history. She was in her usual state of good health until 3 days ago when she started to get fussy, would not eat her breakfast, and would not sit still for her favorite television cartoon. Since then she has had a fever off and on, anywhere between 101oF and today’s high of 103.2oF. Mom has been giving her ibuprofen, but when the fever went up to 103.2oF today, she felt that she should come in for evaluation. A physical examination reveals a height and weight appropriate 2-year-old female who appears acutely unwell. Her skin is hot and dry. The tympanic membranes are slightly reddened on the periphery, but otherwise normal in appearance. The throat is erythematous with 4 tonsils and diffuse exudates. Anterior cervical nodes are readily palpable and clearly tender to touch on the left side. The child indicates that her throat hurts “a lot” and it is painful to swallow. Vital signs reveal a temperature of 102.8oF, a pulse of 128 beats per minute, and a respiratory rate of 24 beats per minute.
Scenario 2:
Jack is a 27-year-old male who presents with redness and irritation of his hands. He reports that he has never had a problem like this before, but about 2 weeks ago he noticed that both his hands seemed to be really red and flaky. He denies any discomfort, stating that sometimes they feel “a little bit hot,” but otherwise they feel fine. He does not understand why they are so red. His wife told him that he might have an allergy and he should get some steroid cream. Jack has no known allergies and no significant medical history except for recurrent ear infections as a child. He denies any traumatic injury or known exposure to irritants. He is a maintenance engineer in a newspaper building and admits that he often works with abrasive solvents and chemicals. Normally he wears protective gloves, but lately they seem to be in short supply so sometimes he does not use them. He has exposed his hands to some of these cleaning fluids, but says that it never hurt and he always washed his hands when he was finished.
Scenario 3:
Martha is a 65-year-old woman who recently retired from her job as an administrative assistant at a local hospital. Her medical history is significant for hypertension, which has been controlled for years with hydrochlorothiazide. She reports that lately she is having a lot of trouble sleeping, she occasionally feels like she has a “racing heartbeat,” and she is losing her appetite. She emphasizes that she is not hungry like she used to be. The only significant change that has occurred lately in her life is that her 87-year-old mother moved into her home a few years ago. Mom had always been healthy, but she fell down a flight of stairs and broke her hip. Her recovery was a difficult one, as she has lost a lot of mobility and independence and needs to rely on her daughter for assistance with activities of daily living. Martha says it is not the retirement she dreamed about, but she is an only child and is happy to care for her mother. Mom wakes up early in the morning, likes to bathe every day, and has always eaten 5 small meals daily. Martha has to put a lot of time into caring for her mother, so it is almost a “blessing” that Martha is sleeping and eating less. She is worried about her own health though and wants to know why, at her age, she suddenly needs less sleep.