Stress

STRESS

Personal definition
What is Stress?

Stress and Adaptation
STRESS
A condition in which the person responds to changes in the normal balanced state
Selye: non specific response of the body to any kind of demand made upon it
Any event – environmental / internal demands or both tax or exceed the adaptive resources of an individual, social system or tissue systems

STRESSOR
Any event or stimulus that causes an individual to experience stress
They may neither positive or negative , but they have positive or negative effects
Internal Stressor (illness, hormonal change, fear)
External Stressor (loud noise, cold temperature)
Developmental Stressor
Situational Stressor

COPING- a problem solving process that the person uses to manage the stresses or events with which he/she is presented.

ADAPTATION- the process by which human system modifies itself to conform to the environment. It is a change that results from response to stress.

SOURCES OF STRESS
Internal
External
Developmental
Situational

Stress Characteristics
It is a universal phenomenon.
It is an individual experience.
It provides stimulus for growth and change.
It affects all dimension of life.
It is not a nervous energy.

Effects of Stress on the Body
Physical - affects physiologic homeostasis
Emotional - affects feeling towards self
Intellectual - influences perception and problem solving abilities
Social – can alter relationships with others
Spiritual - affects one’s beliefs and values

Effects of Stress on the Body
Metabolic Disorders
Hyper/hypothyroidism
Diabetes
Cancer
Accident proneness
Skin disorders
Eczema
Pruritus
Urticaria
Psoriasis
Respiratory disorders
Asthma
Hay fever
Tuberculosis
CVD
Coronary artery disease
Essential hypertension
CHF
GIT disorders
Constipation
Diarrhea
Duodenal ulcer
Anorexia nervosa
Obesity
Ulcerative colitis
Menstrual irregularities
Musculoskeletal disorders
RA
LBP
Migraine Headache
Muscle tension

GENERAL THEORETICAL FRAMEWORKS FOR UNDERSTANDING STRESS
Stress can be defined differently by the three models
STIMULUS
RESPONSE
TRANSACTION

Models of Stress
STIMULUS based models
RESPONSE based models
TRANSACTION based models

Stress as a Stimulus
Holmes and Rahe 1967: They studied the relationship between specific life changes such as divorce or death, and the subsequent onset of illness.
Focus: disturbing events within the environment

Stress as a Transaction
The transactional stress theory includes cognitive, affective, and adaptive responses from person and environment interaction. The person responds to perceived environmental changes by coping mechanisms.
Transactional theory of stress emphasizes that people & groups differ in their sensitivity & vulnerability to certain types of events, as well as in their interpretations & reactions

Stress As a Response
Disruptions caused by harmful stimulus or stressors
Specifies particular response or pattern of responses that may indicate a stressor
Selye (1976): developed models of stress, that defines stress as a non-specific response of the body to any demand made on it

Focus: reactions of the BODY
Selye used the term “stressor’ as the stimulus or agents that evokes a stress response in the person .
A stressor may be anything that places a demand on the person for change or adaptation.

Hans Selye (1976) “ non-specific response of the body to any kind of demand made upon it
He called it “non-specific” because the body goes through a number of biochemical changes and re-adjustments without regard to the nature of the stress producing agents.
Any type of stressor may produce the same responses in the human body

Advantage : response to stress is purely physiologic; determines physiological response to stress
Disadvantage: does not consider individual differences in response pattern

Stress as a response
SELYE proposed two Stress adaptation responses
General Adaptation Syndrome
Local Adaptation Syndrome

Physiologic responses of the whole body to stressors
Involves the Autonomic Nervous System, and Endocrine System
Occurs with the release of adaptive hormones and subsequent changes in the WHOLE body

General Adaptation Syndrome Stressor Alarm reaction Shock phase Epinephrine Cortisone Stages of resistance Stages of exhaustion Three stages adaptation to stress for both GAS/LAS: Counter-shock Phase Rest Death Normal state

I. ALARM REACTION
Initial reaction of the body; “ fight OR flight” responses
Mobilizing of the defense mechanisms of the body and mind to cope with stressors.
SHOCK PHASE- the autonomic nervous system reacts; release of Epinephrine and Cortisol
COUNTERSHOCK PHASE- reversal of the changes produced in the shock phase

II. STAGE OF RESISTANCE:
The BODY stabilizes, hormonal levels return to normal, heart rate, blood pressure and cardiac output return to normal
2 things may occur:
Either the person successfully adapts to the stressors and returns to normal, thus resolving and repairing body damage; or
The stressor remains present, and adaptation fails (ex. Long-term terminal illness, mental illness, and continuous blood loss)

III. STAGE OF EXHAUSTION:
Occurs when the body can no longer resist stress and body energy is depleted.
The body’s energy level is compromised and adaptation diminishes.
Body may not be able to defend self that may end to death.

A-R-E
ALARM: sympathetic system is mobilized!
RESISTANCE: adaptation takes place
EXHAUSTION : adaptation cannot be maintained

GAS
Hypothalamus
Anterior Pituitary Gland
Adrenal Gland
Adrenal Cortex Adrenal medulla

Adrenal gland

Adrenal Gland

Hormonal Changes
Adrenal Cortex
MINERALOCORTICOIDS
Aldosterone
Na+ retention
WATER retention
Protein anabolism
GLUCOCORTICOIDS
Cortisol
(Anti-inflammatory)
Protein catabolism
Gluconeogenesis
Adrenal Medulla
NOREPINEPHRINE
Peripheral vasoconstriction
Decreased blood to kidney
Increased renin (angiotensin)
EPINEPHRINE
Tachycardia
Increased myocardial activity
Increased Bronchial dilatation
Increased Blood clotting
Increased Metabolism
Increased Fat Metabolism

Localized responses to stress
Ex. Wound healing, blood clotting, vision, response to pressure
Adaptive: a stressor is necessary to stimulate it
Short- term
Restorative: assist in homeostasis

Reflex Pain response:
Localized response of the CNS to pain
Adaptive response and protects tissue from further damage
Involves a sensory receptor, a sensory serve to the spinal cord, a connector neuron, motor nerve, effector’s muscles. Example: unconscious removal of hand from a hot surface, sneezing, etc.
Inflammatory Response:
Stimulated by trauma or infection, thus preventing it to spread; also promotes healing
Pain, heat, redness, swelling

FACTORS INFLUENCING RESPONSE TO STRESS
Age, Sex
Nature of Stressors
Physiological functioning
Personality
Behavioral Characteristics
Level of personal control
Availability of support system
Feelings of competence
Cognitive appraisal, Economic Status

The MANIFESTATIONS OF STRESS
INDICATORS OF STRESS
Physiologic
Psychological
Cognitive
Verbal-Motor

Physiological Indicators
Dilated pupils
Diaphoresis
Tachycardia, tachypnea, HYPERTENSION, increased blood flow to the muscles
Increased blood clotting
Bronchodilation
Skin pallor
Water retention, Sodium retention
Oliguria
Dry mouth, decrease peristalsis
Hyperglycemia

Remember these Physiologic Manifestations of Stress
Pupils dilate to increase visual perception when serious threats to the body arise
Sweat production (diaphoresis) increases to control elevated body heat due to increased metabolism

Heart rate or pulse rate increases to transport nutrients & byproducts of metabolism more effectively
Skin becomes pale (Pallor) because of constriction of peripheral blood vessels to shunt blood to the vital organs.

BP increases due to vasoconstriction of vessels in blood reservoir (skin, kidneys, lungs), due to secretion of renin, Angiotensin I and II
Increased rate/depth of respiration with dilation of bronchioles, promoting hyperventilation and increased oxygen uptake

Mouth may become dry, urine output may decrease. The peristalsis of the intestines decreases leading to constipation
For serious threats, there is improved mental alertness

Increased muscle tension to prepare for rapid motor activity/defense
Increased blood sugar (glucocorticoids & gluconeogenesis) to supply energy source to the body.

Psychological indicators
This includes anxiety, fear, anger, depression and unconscious ego defense mechanisms

Anxiety
A state of mental uneasiness, apprehension, or helplessness, related to anticipated unidentified stress
Occurs in the Conscious, subconscious, or unconscious levels

Levels of Anxiety
4 Levels of Anxiety:
Mild
Moderate
Severe
Panic

Levels of Anxiety
Mild- increased alertness, motivation and attentiveness
Moderate- perception narrowed, selective inattention and physical discomfort

Levels of Anxiety
Severe- behaviors become automatic, details are not seen, senses are drastically reduced, very narrow focus on specific details, impaired learning ability.
Panic- overwhelmed, unable to function or to communicate, with possible bodily harm to self and others, loss of strong displeasure

Anxiety

ANXIETY Palpitation, choking, chest pain Tachycardia, Hyperventilation Slight Increase NONE VS changes Trembling unpredictable response Difficult to understand Easily distracted Voice tremors Focus on particular object Increased questioning Communication Distorted perception Inability to focus Narrowed focus Increased arousal Perception and attention PANIC SEVERE MODERATE MILD CATEGORY

Fear
It is a mild to severe feeling of apprehension about some perceived threat.
The Object of fear may or may not be based on reality.

Anxiety versus fear Result of discrete physical or psychological entity, definite and concrete events Result of psychological or emotional conflict Definite Vague Related to the present Related to the future Source is identifiable Source may not be identifiable Emotion of apprehension State of mental uneasiness FEAR ANXIETY

Anger
Subjective feeling of strong displeasure
It is an emotional state consisting of subjective feeling of animosity or strong displeasure

Depression
Emotional Symptoms:
Tiredness
emptiness
numbness
Physical signs
loss of appetite
weight loss
constipation
headache
dizziness
Behavioral signs:
irritability
inability to concentrate
difficulty making decision
loss of sexual desire
crying
sleep disturbance
social withdrawal

Unconscious Ego defense mechanism
These are PSYCHOLOGIC adaptive mechanisms
Mental mechanisms that develop as the personality attempts to DEFEND itself, establishes compromises among conflicting impulses and allays inner tensions

Unconscious Ego defense mechanism
The unconscious mind working to protect the person from anxiety
Releases tension

COGNITIVE MANIFESTATIONS
Thinking responses that include problem solving, prayer, structuring, self control, suppression and fantasy
Thinking responses of the individual toward stress

PROBLEM SOLVING: Use of specific steps to arrive at a solution
STRUCTURING: manipulation of a situation so that threatening events do not occur

SELF CONTROL / DISCIPLINE: assuming a sense of being in control or in charge of whatever situation
SUPPRESSION: willfully putting a thought / feeling out of one’s mind

FANTASY / DAYDREAMING: “ make believe” or imagination of unfulfilled wishes as fulfilled
PRAYER: identification, description of the problem, suggestion of solution, then reaching out for help or support to the supreme being

VERBAL / MOTOR MANIFESTATIONS
First hand responses to stress

CRYING: feelings of pain, joy, sadness are released
VERBAL ABUSE: release mechanism toward non living objects, and stress producing events
LAUGHING: anxiety reducing response that leads to constructive problem solving

SCREAMING: response to fear or intense frustration and anger
HITTING AND KICKING: spontaneous response to physical threats or frustrations
HOLDING AND TOUCHING: responses to joyful, painful or sad events

Coping

COPING
A problem solving process or strategy that the person uses to manage the out-of-ordinary events or situations with which he/she is presented.
Successfully dealing with problems

Coping related terms
Adaptive coping- helps person deal effectively with stress
Maladaptive coping- results in unnecessary distress for the person and stressful events

MODES OF ADAPTATION
1. Physiologic mode (biologic adaptation)
Occurs in response to increased or altered demands placed on the body & results in compensatory physical changes.
2. Psychological Mode
Involves a change in attitude & behavior toward emotionally stressful situations. (Ex. Stopping smoking)
3. Socio-cultural Mode
Changing persons behavior in accordance with the norms, conversions, & beliefs of various groups (leaving in new country)

CHARACTERISTICS OF ADAPTIVE RESPONSES
All attempts to maintain homeostasis
Whole body or total organism response
Have limits (Physiologic, Psychologic/Social)
Requires time
Varies from person to person
Maybe inadequate or excessive (infection/allergy

MANIFESTATIONS OF ALTERED COPING
Addictive behaviors
Physical illness
Anxiety and depression
Violent behaviors

Applying the Nursing Process
A
D
P
I
E

Assessment
1. Utilize the Nursing History
Subjective data- such as the functional pattern, risk pattern and dysfunctional pattern.
2. Physical Examination – centered on the changes in the ANS and NES. Objective data- Physical assessment, Diagnostic tests and procedures
3. Laboratory Examination

Diagnoses
Utilize those accepted by NANDA
Anxiety 7. Fear
Caregiver role strain 8. Impaired adjustment
Compromised family coping 9. Ineffective coping
Decisional conflict 10. Ineffective Denial
Defensive coping 11. Post-trauma Syn
Disabled Family coping 12. Relocation Stress Syn

Planning
There are four important guidelines to be followed in choosing nursing goals. The nurse must choose goals geared :
To eliminate as many stressors as possible
To teach about the effects of stress to the body
To teach how to cope with stress
To teach on how to adjust to stress

Planning
Examples of Patient outcome criteria are:
After 3 hours/ 4days:
1. The patient will identify sources of stress in his/her life
2. The patient will identify usual personal coping strategies for stressful situations
3. The patient will define the effect of stress and coping strategies on activities of daily living

Implementation
There are essentially three ways to manage Stress:
Eliminate the causes/sources of stress
Produce a relaxation response in the body
Suggest a change in lifestyle, if possible

Implementation
Stress reduction techniques:
Proper nutrition
Regular exercise, physical activity & recreation
Meditation, Breathing exercises, creative imagery, YOGA
Communication, time management, expression of feeling, talking it out, organizing time
Biofeedback
Therapeutic touch
Relaxation response , Problem Solving Techniques

Implementation
Minimize anxiety
Support the client and the family
Orient the client to the hospital
Give the client in a hospital some way of maintaining identity.
Provide information when the client has insufficient information.

Implementation
Massage
These include effleurage (stroking), friction, pressure, petrissage (kneading or large, quick pinches of the skin, subcutaneous tissue and muscle), vibration and percussion.
Purposes
- enhances or induces relaxation before sleep
-stimulates skin circulation
Duration: 5-20 minutes

Implementation
Progressive Relaxation
Jacobson (1930), the originator of the Progressive relaxation technique

Implementation
Guided Imagery
Imagery is "the formation of a mental representation of an object that is usually only perceived through the senses" (Sodergren 1985) . Example:
Visual -A valley scene with its many greens
Auditory -Ocean waves breaking rhythmically
Olfactory -Freshly baked bread
Gustatory -A Juicy hamburger
Tactile-proprioceptive -Stroking a soft, furry cat

Implementation
Biofeedback is a technique that brings under conscious control bodily processes normally thought to be beyond voluntary command. muscle tension, heartbeat, blood flow, peristalsis, & skin temperature – can be voluntarily controlled
feedback provided through:
a. temperature meters (that indicate temp. changes)
b. EMG (electromyogram) that shows electric potential created by contraction the muscles

Implementation
Therapeutic Touch
“ a healing meditation, because the primary act of the nurse (healer) is to "center" the self and to maintain that center (mental concentration and focusing) throughout the process.

Implementation
CRISIS INTERVENTION
A technique of helping the person go through the crisis
To mobilize his resources
To help him deal with the here and now
A five step problem solving technique designed to promote a more adaptive outcome including improved abilities to cope with future crises

Evaluation
The evaluation of the plan of care is based on the mutually established expected outcomes.
It is important to observe BOTH verbal and non-verbal cues when evaluating the usefulness of the plan.

Stress Management for Nurses
Plan daily relaxation program
Establish a regular pattern of exercise
Study assertive techniques. Learn to say “no”
Learn to accept failures
Accept what cannot be changed
Develop collegial support
Participate in professional organization
Seek counseling

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Stress

by Nurse ReviewDotOrg on Oct 19, 2007

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