Stress, Coping, Burns, Pain, Lymphedema, Oncology, Wounds, Bariatrics, Behavior Change, Touch, Psychiatric Illness, Rheumatology

Flashcards based off the provided Lecture Notes

What is stress?

A physical or psychological stimuli which disrupts homeostasis & generates stress response

What is a stress response?

Complex interactions between the nervous, endocrine, & immune systems

What is anxiety?

Apprehensive anticipation of future danger or misfortune accompanied by feelings of tension, irritability & agitation

What is processed in the dorsolateral pre- frontal cortex?

Attention, motivation, working memory, judgment/insight

What is processed in the orbitofrontal pre- frontal cortex?

Stimulus interpretation, reward/consequence behavior, emotional, social, motivational behavior

What is processed in the ventromedial pre -frontal cortex?

Planning, emotional control, judgment, personality

Where does the pre-frontal cortex receive input from?

Dorsolateral thalamus (spatial learning & memory), olfactory bulb (smell), temporal lobe (auditory info & memory), amygdala (fear & anxiety)

Where does the pre-frontal cortex send output to?

Amygdala (fear & anxiety), hypothalamus (thermoregulation, appetite, weight, ANS, endocrine control, reproduction, circadian rhythm), hippocampus (learning & memory), cingulate cortex (emotional processing & behavior regulation), temporal lobe (auditory info)

What is the limbic system?

Limbic lobe & hippocampal formation

What is the limbic lobe responsible for?

Feeding, sexual fxn/reproduction, fight or flight, learning & memory

What is an important feature of the hippocampal formation?

Connects to cortical association areas via papez circuit, convergence of cortical activity w/ emotional experience & expression, direct connections w/ amygdala

What are some key features of the amygdala?

Establishes associations between sensory inputs & emotional responses (ex: fear), connections w/ sensory association cortex (orbitofrontal cortex), direct connections to hippocampus, connections w/ hypothalamus

What is the stress response?

Sensory info → prefrontal cortex → limbic system & amygdala to determine if threat; threat detected → acute stress response activated & modulated at sub-cortical level

What are the two types of responses related to an acute stress response?

Primary Response (fast acting, sympathetic response, physiological response) and Secondary Response (slow acting, norendocrine response, metabolic response)

What happens during a primary, fast acting, sympathetic response?

Fight or flight, epinephrine & norepinephrine release, ↑ HR, BP, RR, vasoconstriction, sweat stimulation, pupillary dilation, proinflammatory

Where does the primary, fast acting, sympathetic response occur?

Sympathetic adrenal medullary axis

What is the negative feedback loop of the sympathetic adrenal medullary axis to create physiological effects?

Stress signal → brain stem (locus coeruleus) → adrenal medulla → norepinephrine & epinephrine released to inhibit locus coeruleus

Where does the secondary, slow acting, neuroendocrine response occur?

Hypothalamic pituitary adrenal axis

What is the negative feedback loop of the hypothalamic pituitary adrenal axis to create metabolic effects?

Hypothalamus →CRH release→ anterior pituitary → ACTH release → adrenal cortex → cortisol release

T/F the sympathetic adrenal medullary axis (SAM) is activated before the hypothalamic pituitary adrenal axis (HPA)

False

What will happen once the stressor is removed?

Norepinephrine & epinephrine will dissipate

How long will cortisol levels rise post onset of stressor?

Cortisol rises ~15-30 mins post stressor and can remain elevated for hours

What other hormones are released during an acute stress response?

Glucagon, endogenous opioids, vasopressin

What hormones are inhibited during an acute stress response because they are non-essential?

Estrogen, progesterone, testosterone

What can cause a chronic stress response?

Repeated exposure; learned behavior (info processing, learning, memory, behavior) to create a conditioned response; reacting rather than processing

What is the Hebbian Theory?

Neurons that fire together, wire together

Chronic exposure to stressors may cause what?

Catastrophizing response; prolonged cortisol secretion causing cortisol dysfunction

What is the mechanism of cortisol dysfunction?

Depletion of cortisol available for use; glucocorticoid receptor downregulation; impaired inhibition of CRH; hypersensitivity of the negative feedback loop within the HPA

What occurs due to cortisol dysfunction?

Unregulated inflammatory response; chronic inflammation → oxidative stress → tissue damage

How does cortisol dysfunction affect the central nervous system?

Widens gap in blood brain barrier; cellular waste, toxins, and pathogens pass through BBB; ↑ inflammation of neurologic tissue; ↑ pain, depression, ↓cognitive fxn

What health conditions are associated with chronic stress?

Cardiovascular disease, metabolic disease, GI disease, infectious disease, autoimmune disease

What are some cardiovascular considerations associated with chronic stress?

Prolonged sympathetic drive; ↑ risk cardiovascular disease

What are some metabolic considerations of chronic stress?

↑ sympathetic drive; ↓ parasympathetic drive; ↑ risk type II DM

What are some GI issues that can occur due to chronic stress?

Hyper/hypo-phagia (over/under eating); GI inflammation, ↓ nutrient absorption; ↓ small intestine motility; ↑ large intestine motility

What can cause a GI ulcer?

H pylori (↑ bacterial load); stress; secondary risk factors; ↑ stomach acid, ↓ GI lining from chronic inflammation

What happens to the immune system in relation to acute and chronic stress?

Acute stress response ↑ immune system function and chronic stress response ↓ immune system function

What happens to the immune system after 30 mins of chronic stress?

Immunosuppression (via glucocorticoids); ↓ lymphocytes (WBCs); ↓ development of antibodies in response to foreign bodies; inhibition of immune system & suppression of inflammation

How does chronic stress affect cognitive function?

Reaction stage, resistance stage, exhaustion stage

What are psychosocial adaptations that occur due to chronic stress?

Shock, anxiety, denial, depression, internalized anger, externalize hostility, acknowledgement, adjustment

What is shock?

Onset of trauma/stressor; general adaptation syndrome; delayed emotional response; depersonalization; catatonia

What is anxiety?

Apprehensive anticipation of future danger or misfortune accompanied by feelings of tension & agitation; cognitive flooding

What is denial?

Defense mechanism to alleviate anxiety/stress; prevents confrontation/maladaptive management of a stressor; gradual assimilation of altered reality

What are the 7 types of denial?

Denial of threatening info, denial of vulnerability, denial of urgency, denial of affect, denial of affect relevance, denial of personal relevance, denial of all info

What is depression?

Feelings of despair and hopelessness, negative shifts in perception, ↓ interest; depression & stress share overlapping neuronal networks & metabolic cascade

What is externalized hostility?

Anger towards objects or people; aggression; hypercriticism; antagonistic behavior; false blame; abusive accusation

What is internalized anger?

Reaction to anxiety, misperception, feelings of helplessness/hopelessness, & perceived loss of control

What is acknowledgement?

First step to acceptance; awareness leads to reassessment and adjustment

What is adjustment?

Takes action to initiate change; requires acknowledgement/awareness; stage is not achieved by all & may be stuck in earlier stages

How long does acute stress disorder symptoms range from?

2 days - 4 weeks

How long do acute & chronic PTSD symptoms last?

Acute is less than 3 months and chronic is more than 3 months

What is PTSD?

Vulnerabilities associated w/ development; triple vulnerability model; event perceived as unpredictable & outside of individual’s control

What are the 3 types of coping strategies?

Active Coping, Passive Coping, Avoidant Coping

What is Benefit Finding?

Positive growth from adversity

What are two types of coping strategies when focusing on tasks?

Problem Focused Coping and Emotion Focused Coping

What are examples of defense mechanisms?

Acting Out, Altruism, Autistic Fantasy, Denial, Devaluation, Displacement, Dissociation, Help-rejecting, Humor, Idealization, Intellectualization, Isolation of affect, Omnipotence, Projection, Rationalization, Repression, Splitting, Sublimation, Suppression, Undoing

How can we assist patients with coping?

Acknowledgement and acceptance of stressor - confrontation; recognize actions that are within their control - effective coping

What is cognitive restructuring?

Cognitive Behavioral Therapy; ↓ stress & anxiety by changing maladaptive thought processes & modifying unhealthy behaviors

What are 2 examples of stress management strategies?

Physiologic and Psychologic

What is a physiologic stress management strategy?

↓ hypersensitivity of stress response; calm the nervous system

What is a psychologic stress management strategy?

Psychological flexibility, expression & management of feelings (emotion based coping), identification & management of stressor (problem based coping), identify stress conditions & behavioral progression

What is the function of the skin?

Protection, thermoregulation, immunoglobulin function, fluid & electrolyte balance (excretion), metabolism, neurosensation

What are the 3 layers of skin?

Epidermis, dermis, subcutaneous layer

What is the epidermis?

Avascular, purpose is protection, waterproofing, regeneration and contains hair follicles, sebaceous glands, apocrine & eccrine sweat glands, free nerve endings

What is the dermis?

Dense fibroelastic connective tissue made of collagen, elastic fibers & interfibrillar gel substance, vascular, contains lymphatic system and sensory receptors

What is the subcutaneous layer?

Adipose tissue attached to dermis & overlays muscle fascia, contains subcutaneous nerves, blood vessels, lymphatics

How are burns classified?

Superficial = epidermis, partial thickness = epidermis & parts of dermis, full thickness = epidermis & all dermis, deep full thickness = epidermis, dermis, & subcutaneous tissue

What is a superficial burn?

Epidermis only, presents red, dry & blanchable, mild edema, heals spontaneously w/ time, no residual scarring

What is a superficial partial thickness burn?

Epidermis & ⅓ dermis, bright pink, blanchable, fluid filled blisters, painful , heals spontaneously w/ time, no residual scarring

What is a deep partial thickness burn?

Epidermis & >⅓ dermis; edematous, mottled, bright red or whitened, thin layers eschar, ↓ capillary refill (not blanchable); requires skin grafting; ↑ risk of hypertrophic scarring

What is a full thickness burn?

Epidermis & all of dermis; dry & leathery, thromboses vessels w/ no capillary refill, cherry red, white, charred, insensate (not painful); requires intervention/skin graft for healing; ↑ risk hypertrophic scarring

What are the burn injury zones?

Zone of Coagulation, Zone of Stasis, Zone of Hyperemia

What are 5 types of burn injuries?

Thermal (flame, scald, contact), electrical (entrance/exit wounds), radiation (sunburn), chemical, other (friction, frostbite)

What is burn shock?

Fluid, electrolyte, & protein loss from damaged tissues; >20% TBSA - hypermetabolic state & capillary leak; full body edema formation

What is an inhalation injury?

Injury to airway due to inhaled air >150 F; edema of airway tissue; carbon monoxide poisoning

What are the severities of carbon monoxide poisoning?

Mild = 5-10% (asymptomatic), moderate = 15-40% (confused or lethargic), major = >40% (obtunded)

What is an escharotomy?

Full thickness burns results in eschar (thick, inelastic, nonviable tissue); escharotomy - surgical incision through eschar to prevent vascular compromise & allow for tissue mobility

What is a fasciotomy?

Fasciotomies may be performed to account for burn induced swelling & reduce risk of compartment syndrome

What are the goals for medical management of a burn patient?

Survival, stabilize patient & asses secondary complications, reduce risk of infection, wound closure & healing vital for survival

What are the medical management stages?

Emergent (initial 72 hrs), acute (72 hrs - wound closure), rehabilitative (wound closure - scar formation)

What medical management is done in the emergent stage?

treat burn shock and assess severity of burn (depth/TBSA)

How is TBSA determined in the Emergent Stage?

Rule of Nines and Palmar Hand Estimation

What medical management is done in the acute stage?

Wound closure depends on establishing viable wound bed (dressing, surgical intervention/grafting)

What medical management is done in the acute stage?

Dressings protect wound from damage/infection, absorb exudate, maintain moist environment, nontoxic & non-adherent

What medical intervention/management is done in the acute stage regarding dressings?

Protects wound from damage/infection, absorbs exudate, maintains moist environment

What two medical interventions/management components are done in the acute stage?

Surgical Intervention/Excision, Grafting

Which grafts are used in medical management of the acute stage?

Homograft, xenograft, integra, goal - establish viable wound bed for autograft

What is a split thickness skin graft (STSG)?

Grafting of epidermis & part of dermis; sheet or mesh; graft can contract/shrink after application; sensory regeneration = 4-5 wks

What is a full thickness skin graft (FTSG)?

Epidermis & entire dermis and has nerve endings

What medical management is done in the rehabilitative stage?

Prevent contracture/skin breakdown, maintain ROM, restore OOB tolerance

What can be done to minimize contractures?

Positioning, splinting, ROM

What is optimal positioning for a burn patient?

↓ edema, prevent tissue breakdown, prevent nerve compression, maintain wound in elongated state

What are the 3 stages of healing that are considered when determining treatment interventions?

Inflammatory phase, proliferative phase, maturations phase

What is the treatment emphasis in the inflammatory stage (days 3-5)?

Edema reduction, wound care, early ROM, static positioning & splinting, functional mobility as tolerated

What can be done to prevent contractures in the inflammatory/acute stage, especially in the hand?

Hand splinting in the intrinsic plus position (dorsal hand burn)

What is the treatment emphasis in the proliferative phase (days 5-21)?

Continue tx performed in inflammatory phase; stretching; strengthening; dynamic positioning/splinting for short time periods; promote ↑ functional mobility

What are some examples of positioning devices?

Multi-podus boot/PRAFO, neck conforming orthosis, microstomia & external traction hook, clavicle strap, elbow/knee conformers & hip abduction brace

What are some considerations for positioning devices?

Contact w/ device & straps, tolerance & fit to device, pt. ’s ability to self position & self range, cost benefit of use

What is the treatment emphasis in the maturation phase (day 21 - 18 months)?

Continue tx proliferative phase; conditioning programs (↑ cardiovascular endurance); dynamic splints as needed; scar tissue mobilization

What is hypertrophic scarring?

Scar maturation that occurs 6-18 months post burn; hypertrophic scarring can be minimized by tx in inflammatory & proliferative phases

What is compression therapy & how can it help w/ hypertrophic scarring?

Ace wraps, silicon gel sleeves or inserts, elastic garments; worn for 23 hrs/day (up to 1 yr)