Theories From the Biomedical Sciences

Tine Orbase

Biomedical Theories - basis for research efforts physiologists, physicians, laboratory based scientists for many years. Nurses also been involved in this research type....

WHAT IS DISEASE?
Refers to any condition that disturbs the normal functioning of an organism, whether it affects one organ, or several system.

Also defined as failure of an organism to respond or adapt to an environment.

Ancient Times ......

-Disease was frequently viewed as divine intervention or punishment.

- Early Human Beings attributed diseases to the influence of demons or spirits, and magic was a large part of treatment and prevention.

As Time Passed By....

Interventions, Treatments such as use of plants and extracts were used.

As human formed into societies and distinct cultural groups. Two trends or approaches to medicine evolved. Sorcerers and Priests embraced a MagicoReligious Approach. Early Physicians and Scientists developed Empirico- Rational Approach.

17th Century

William Harvey - an English Physician and Anatomist. He demonstrated the dynamics of blood circulation. (Kalish and Kalisch, 2004)

"De Motu Cordis" (otherwise known as "On the Motion of the Heart and Blood")

19th Century... Scientist Began to unravel the basic causes of infectious disease. Modern Medicine began with the advent of Pasteurs Germ theory, which posited that a specific microorganism was capable of causing an infectious disease.

Today.... Pre dominant general model of disease causation is multicausal, involving invasive agents, immune responses, genetics, environment and behaviour.

Louis Pasteur
He was best known to the general public for inventing a method to stop milk and wine from causing sickness, a process that came to be called pasteurization. He is regarded as one of the three main founders of microbiology, together with Ferdinand Cohn and Robert Koch.

He was a French Chemist and microbiologist,born in Dole. He is remembered for his remarkable breakthroughs in the causes and preventions of diseases. His discoveries reduced mortality from pueperal fever, and he created the first vaccine for rabies and anthrax. His experiments supported the germ theory of disease.

Germ Theory proposed by Louis Pasteur in 1858

Beginning of the 21st Century Theory of Infection, most often applied to prevent infection or to describe the process that sees to identify, understand and manage, infectious disease. Example: Practicing strict hand washing, cleansing a scrape and applying antibiotic ointment, or prophylactically treating a surgery client with antibiotics.

The said process initiates the search for the causative agent of an infection and method of transmission.
Example: AIDS

AIDS
Acquired Immunodeficiency Syndrome

Syndrome was identified by the centers for disease control and prevention in Sept. of 1982, but months passed before, It was determined that the causative agent was a retrovirus, later termed HIV ( Human Immunodeficiency Virus) Early in the process, even before the virus was isolated, methods of transmission were recognized and interventions for prevention proposed. Example: Sexual, transplacental, via blood products

Bovine Spongiform Encephalopathy or Mad Cow Disease, and it relationship with Creutzfeldt Jakob disease. It is hypothesized that the causative agent of Mad Cow disease is a prion, which is not truly a germ, but a protein transmitted through ingestion of contaminated meat.

In Application to Nursing, Research Studies use the Germ theory to identify the causes or agents of infection. For an infection to occur, the host must be susceptible to the invasive organism. This susceptibility may be termed risk. Example: A person who has experienced severe burns is at higher risk of infection because one of the first lines of defense, the skin, is damaged. Research conducted by Nurses on prevention of infection includes a study by Curchoe, Powers, and El- Daher (2002) undertaken to identify factors contributing to an increase of primary bloodstream infections in an intensive care unit. The findings showed that prolonging the interval between changing dressings and switching from alcohol swab sticks to pads was associated with an increase in primary infections.

The Epidemiologic Triangle

Epidemiological Triangle is often used to illustrate the interrelationships among the threes essential components of host, agent and environment with regard to disease causation. A change in any of the three components can result in the disease process.

Host, Agent, and Environmental Factors that affect health can also influence progression of disease process. Host Factors include age, gender, race/ethnicity, marital status, economic status, state of immunity, and lifestyle factors ( diet, exercise patterns, hygiene, occupation, sexual health). Agent Factors include presence or absence of biologic organisms ( bacteria, fungi, viruses), exposure to physical factors ( radiation, extremes of temperature, noise), and exposure to chemical agents ( poisons, allergens, gases) Environmental Factors include such things as physical elements or properties ( climate, seasons, geology), biological entities ( animals, insects, food, drugs), or social/economic considerations ( family, public policy, occupation, culture) McEwen, 2002)

THE WEB OF CAUSATION MacMahon and Pugh (1970) developed the concept of Chain of Causation to explain disease and disability caused by multiple factors. It may be applied to many health- related threats and conditions. Example: The problem of teenage pregnancy it is attributable to a complex interaction among a number of causative and contributing factors including lack of knowledge about sexuality and pregnancy prevention, lack of easily accessible contraception, peer pressure, low self esteem, social patterns in which teen mothers are more likely to be children of teen mothers, use of alcohol or other drugs, and so on.

Web of Causation to the development of Coronary Heart Disease. Adapted with permission from Friedman, G.D (1994)

Nurses developed interventions and proposed strategies to address complex health problems with multifactorial etiologies.
For example, Di Napoli ( 2003) described the multiple risk factors that may contribute to violent behaviors in girls. These factors include social influences such as media exposure, behaviors of peers relative to use alcohol, cigarettes and other substances, parental communication, race/ethnicity, and personal health. In another study, Jones, Marcantonio, and Rabinowitz (2003) identified risk factors for development of depression among nursing home residents. Risk factors for depression in this group were: younger age, female, having been married, white, high cognitive functioning, heart disease and prolonged stay ( 1-2 yrs). In other works, Sowan and Stember (2000) used the web causation as the theoretical framework for their examination of risk factors for infant obesity. Bradley-Springer (1999) discussed the multiple factors need to be addressed to change behaviors to prevent HIV infection.

HISTORY OF NATURAL DISEASE The Natural History of a Disease refers to the progress of a disease process in an individual over time. Leavell and Clark (1965) described two periods in the natural history of disease. Prepathogenesis and Pathogenesis Prepathogenesis Stage > Occur prior to interaction of the disease agent and human host when individual is susceptible.

Example: Adult male smokes, a teenage girl considers becoming sexually active, a preschool attends party also attended by a sick child.
Pathogenesis Stage > After exposure or interaction, ( alterations in lung tissue, pregnancy, chickenpox) and on through the disease course to the resolution either death, disability, or recovery ( lung cancer, teen motherhood, immunity to chicken pox.

Levell and Clark (1965) outlined Three Levels of Prevention Primary Prevention Stage interventions focus on general health promotion activities ( encouraging a healthy diet and promoting regular exercise) and efforts to prevent specific health problems ( vaccination, encouraging use of seatbelts and car seats , promoting oral hygiene). Secondary Prevention Stage concerned with early detection and would include any screening activity ( mammography, cholesterol screening) and subsequent efforts to limit disease progression for those identified with a health condition ( taking statins medications, lumpectomy with radiation/ chemotheraphy). Tertiary Prevention Stage involves efforts to enhance rehabilitation and convalescence following advanced disease.

Level s of Prevention Primary Prevention activities that are directed at preventing a problem before it occurs. This includes altering susceptibility or reducing exposure for susceptible individuals in the period of prepathogensis. It consist of two categories: general health promotion ( good nutrition, adequate shelter) Specific Protection (immunization, water purification).

Secondary Prevention early detection and prompt intervention of a disease or health threat during the period of early pathogenesis. Screening for disease and prompt referral and treatment are secondary prevention.
Tertiary Prevention consists of limitation of disability and rehabilitation during the period of advanced disease and convalescence, where the disease has occurred and resulted in the degree of damage.

Theories and Principles Related to Physiology and Physical Functioning

These include Principles or Theories of Homeostasis, Stress and Adaptation, Immunity and Immune Function, Genetics, Cancer and Pain.

Homeostasis
Claude Bernard A physiologist in the 20th century, first conceived the Idea of Homeostasis. He hypothesized that an organism must have the capacity to maintain its internal environment to live. Walter Canon

A physician in the 20th century, developed the concept of feedback mechanism to further explain Bernards principles of regulation. He coined the term Homeostasis referring to the dynamic equilibrium an flexible ongoing process that maintain certain biological factors within a range (Lipsitz, 2000)

The principles of homeostasis state that all healthy cells, tissues and organs maintain static conditions in their internal environment.

Dr. Eugene Yates introduced the related concept of Homeodynamics to show that here is continuous change in physiologic processes ( heart rate, blood pressure, nerve activity, hormonal secretion), based on changes within or external to the organism.

Homeostasis or Homeodynamics includes physiologic principles often described in terms of organ-based systems (cardiovascular, respiratory, endocrine, immune, and neurologic systems).

Davis, Parker, and Montgomery (2004) used the principles of homeostasis to describe the physiology and function of sleep in health infants and young children. Koo and Warren, (2003) described the benefit in maintaining calcium homeostasis to promote bone health in infants. Yucha and Guthrie, (2003) also examined calcium homeostasis in describing the physiologic process used by the human body in regulating calcium. In research, the concept of homeostasis served as a theoretical framework in a study to determine the effect of soothing music on neonatal behavioral states in the hospital newborn nursery. It was hypothesized that because the newborn nursery is noisy, the sounds might interfere with the neonates effort to achieve physiologic and behavioral homeostasis

Hershey, Valenciano, and Bookbinder (1997) compared three methods of reducing hypothermia among clients in a postanesthesia care unit. Researchers recognized that interventions to decrease the duration and severity of postoperative hypothermia are important to enhance comfort and to decrease postoperative complications because the body must expend energy to react to cold temperature.

Stress and Adaptation : General Adaptation Syndrome

Walter Canon > Developed the concept of fight and flight to explain the bodys reaction emergencies. This fight or flight response prepares the body for muscular activity ( running, self defense) when reacting to a perceived or actual threat.

The Fight or Flight Response is a series of chemical reactions that are initiated by adrenal medulla, which produces epinephrine ( adrenaline) and norepinephrine. This reaction increases the heart rate, respiratory rate, blood pressure, and blood glucose levels. Blood is shunted to the muscles of the legs, heart and lungs from the intestines; this prepares the body for quick response to danger (Black & Matassarin_- Jacobs, 1997)

1960 and 1970s, Hans Selye built on Canons Work by developing a framework to describe how body responds to stress. Selye derived his theories of stress from he observations he made while caring for people who were ill. The clinical manifestations he noted were loss of appetite, weight loss, feeling and looking ill, and generalized muscle aching and pains. He called this response General Adaptation Syndrome (GAS) it involved generalized changes that affect the body.

Selye Stages Of Stress

Stage 1 Alarm phase

Characteristic Begins with flight and fight response. Physiologic changes are coordinated by central nervous system and symphatetic nervous system which stimulates adrenal medulla to secrete norephinephrine and epinephrine; the adrenal cortex is stimulated by the pituitary glands release of ACTH. If stress continous, body begins to experience detrimental changes (e.g shrinkage of the thymus, spleen, lymph nodes and other lymphatic structures) other physical manifestations, such as gastric and duodenal ulcer can occur. Physical Response CNS involuntary response include secretion of specific hormones and metabolism and fluid regulation. SNS response include increased Heart rate, contraction of spleen, release of glucose, increase In respiratory rate, decrease in clotting time, dilatation of pupils, Increased perspiration and piloerection ( hairs standing on end)

Stage 2 Resistance Phase

Occurs when body starts to react and return to homeostasis. If stressor ends, body should be able to return to normal. Characteristics body recognizes a continued threat and physiologic forces adapt to maintain increased resistance to stressors; begins with a decrease in ACTH, and the body concentrates on organs that are most involved in the specific stress. Physical Response Adaptation implies return or improvement in physical health. Ineffective resistance leads to a state of maladaption where there is a deterioration in the level of physical functioning. Chronic resistance eventually causes damage to involved systems.

Stage 3 Exhaustion Phase Occurs when the stressor persists and the body cannot continue to produce hormones, or when damage has occurred to organs Characteristics Body enters exhaustion when all energy adaptation has been used; ACTH secretion increases and the organ system show evidence of deterioration. Physical Response Symptoms include hypertrophy of the adrenal glands, ulceration in the gastrointestinal tract, and atrophy of the thymus gland.

Selye thought that the bodys response to stress is non specific; that is, the body reacts as a whole organism. Health conditions thought to be related to stress include cancer, hypertension, heart disease, cerebrovascular accident, peripheral vascular disease, asthma, tuberculosis, emphysema, irritable bowel syndrome, sexual dysfunction, obesity, anorexia, bulimia, connective tissue disease, ulcerative colitis, Crohns disease, infections, and allergic and hypersensitivity diseases.

In Application to Nursing Motzer and Hertig (2004) described potential gender differences in response to stress. (Koloanowski & Garr, 1999) used the SRRS as one measure to examine factors that predict aggressive physical behavior in institutionalized elders with dementia. Fallon, Gould, and Wainwright (1997) used the GAS to examine the effects of a renal transplant on stress and quality of life. It explored client perceptions of stress and quality of life at different stages after a renal transplant. Topf, Bookman, and Arand (1986) examined the effects of critical care unit noise as a source of stress in a controlled laboratory setting. Concluded that sound levels found in CCU are potential stressors and were detrimental to sleep.

Theories of Immunity and Immune Function Immune System comprised of complex, coordinated group of systems that produces physiologic responses to injury or infection. Purpose: To neutralize, eliminate, or destroy microorganisms that invade the body. Immunity involves specific recognition of what is designated as an antigen, memory for a particular antigens, and responsiveness on re-exposure. It is also related to other system that is involved in inflammation and healing.

Each system involved has two characteristics: 1. Recognition of a stimulating structure by specific receptors. 2. Response by one or more effector elements that aims to alter or eliminate the stimulating structure. Immune system contains a large variety of cells, called leukocytes, that protect the body against foreign invasion. The Five Classes of leukocytes are neutrophils, eosinophils, basophils, monocytes, and lymphocytes.

Monocytes mature into macrophages in tissue and defend against tumor cells. They secrete monokines that assist in immune and inflammatory responses. Lymphocytes originate from stem cells in the bone marrow and mature into either B or T cells. The T cells differentiate in the thymus gland, and the B cells mature in the bone marrow.
Both T and B lymphocytes recirculate between blood, lymph, and lymph nodes. The surface of B lymphocytes is coated with immunoglobulin, and when the appropriately matched antigen is detected by a B cell, the surface immunoglobulin will bind it. The T lymphocytes play a role in cell-mediated immunity.

The complement system consist of 24 interacting molecules found in serum and on cells. Complement System participates in inflammation by coordinating elements of the inflammatory response to microorganism and tissue injury through generation of peptides that initiate effects such as leukocyte activation , chemotaxis, and mast cell degranulation. The system facilitates phagocytic function by coating the target particle with biologically active peptides and fragments of molecules activating the system. Series of pro enzymes and other molecules initiate attack on cell membranes of microorganism ( Winchester, 2002)

Antibody Mediated Immunity involves antigen-antibody actions to neutralize, eliminate or destroy foreign proteins. B lymphocytes are the one who produce antibodies for these. B Lymphocytes become sensitized to a specific foreign protein ( antigen) and synthesize an antibody directed specifically against that protein. The antibody participates in action to neutralize, eliminate or destroy the antigen. Cell mediated immunity involves many leukocyte actions, reactions, and interactions. Lymphocyte stem cells and lymphoid tissues regulate activities and inflammation by producing and releasing cytokines. T lymphocyte can be natural killer cells or helper cells.

In Application to Nursing Principles of immune function can be used as a theoretical framework for research.

Constantino, Sekula, Rabin, and Stone (2000) indicated a correlation between physical and emotional abuse in women and lowered T-cell function, thus indicating lowered immune status in that group. (Dowling, Hockenberry, & gregory, 2003; Mac Donald, 2004) noted the positive effect of humor on immune function.
Dekeyser, Wainstock, Rose and Converse (1998) conducted study to investigate distress and immune function during diagnostic phase in women suspected to have breast cancer.

Genetic Principles And Theories Human Genome Project is an organized effort initiated in 1990 and completed in 2001 to create a biologically and medically useful database of the genome structure and sequence in humans. Human Genome refers to entire complement of genetic material contained on the 46 chromosomes. Information gained from Human Genome Project will increase understanding of inherited conditions, both single gene and complex disease as well as responses to treatment. ( Biesecker, Biesecker, & Collins, 2000; Lea & Tinley, 1998)

Gene fundamental and functional unit of heredity. It is composed of a double strand of DNA, and each of the strands has thousand to millions of bases. The order of bases codes information that directs the manufacture of a specific protein ( Lea & Tinley, 1998). Gene Mutation is an alteration in the coding of the DNA that results in a change in the protein product. Mutations in some genes cause clinical disease because of the absence of the normal protein. Example: sickle cell anemia, results when one base is substituted with another. Gene discoveries have provided information on genetic disorders that cause symptoms in large proportion of persons who have abnormal genotypes. Successes include the isolation of genes for cystic fibrosis, neurofibromatosis, muscular dystrophy, Hunningtons disease, and some types of breast cancer ( Biesecker et al., 2000)

Application to Nursing Genetics greatly affect the way health care is practiced in the future, and nurses will need to incorporate genetic technology and discovery into practice and research at the individual, family, and community levels. Nurses who are able to think genetically can ask appropriate questions of patients to assess genetic risk factors, communicate with patients and their families about inherited risks, make referrals to genetic counselors, reinforce counseling, and administer gene therapy or genetically specific drugs (Lashley, 2000)

A NURSING MODEL FOR GENETICS IN HEALTH CARE

Nursing Science
Individual Caring behavior and support role Care across the life span

Genetic Education
Predictive Genetic Testing Gene discoveries for diseases

Ecogenetic Nursing
Educating patients on genetic testing Assisting patients to determine need for testing