1. STRESS AND CRISIS

2. Definition of the Terms
Stress
• Stress is a physical and emotional state always
present in the person, one influenced by
various environmental, psychological and
social factors but uniquely perceived by the
person and intensified in response when
environmental change or threat occurs
internally or externally and the person must
respond.

3. • The manifestations of the stress are overt and
covert, purposeful, initially protective,
maintaining equilibrium, productivity and
satisfaction to the extent possible
• According to Hans Selye, stress is nonspecific
response of the body to any demand made
upon it, whether is caused by the results of
pleasant and unpleasant situation.

4. • In small doses, stress can be a good thing. It
can give you the push you need, motivating
you to do your best
• But when the stress gets too tough and life's
demands exceed your ability to cope, stress
becomes a threat to both your physical and
emotional well-being
• According to old concept “To be alive is to be
under stress”.

5. Stressor
• A stressor is any event or stimulus that causes
an individual to experience stress.
• For example
Internal stressor originates inside the body
such as fever, pregnancy, menopause,
emotion etc.
External stressor originates outside the
individual for example physical stressors,
biological stressors, social stressors etc.

6. Crisis
• Crisis is a situation that can not be resolved by
usual method of coping mechanism; as a
result a person becomes unable to function
normally and requires intervention to regain
equilibrium.
• Crisis occurs when coping and defensive
mechanism that has been used to solve
problems and adapt to change is no longer
effective

7. • A crisis is an acute, time-limited state of
disequilibrium resulting from situational,
developmental or social sources of stress. A
person in crisis is temporarily unable to cope
with or adapt to the stressor by using methods
of problem solving. People in crisis generally
have a distorted perception of the event and do
not have adequate situational support or coping
mechanisms.
• Crises always involve change and loss

8. Coping
• According to Folkman and Lazarus (1991),
coping is “the cognitive and behavioral effort
to manage specific external and/or internal
demands that are appraised (estimated) as
taxing or exceeding the resources of the
person”.
• A coping strategy (coping mechanism) is a
natural or learned way of responding to a
changing environment or specific problem or
situation.

9. Local Adaptation Syndrome
Definition
• Response of the body tissue, an organ, or part
of the body to the stress of trauma, illness, or
other physiological change
• is the method used to wall off and control
effects of physical stressors locally
• Examples
– Reflex pain response: localized response of
CNS to stimulus of pain (remove hand from
hot surface)
– Inflammatory response

10. General Adaptation Syndrome
Definition
• Physiological response of the whole body to
stress
• Involves several body systems, primarily the
autonomic nervous system and endocrine system
Stages
• Alarm Reaction (AR)
• Resistance stage (SR)
• Exhaustion stage (ES)

11. Alarm stage

12. Alarm Reaction (AR)
• In the first stage of GAS
• During the alarm phase, a stressor disturbs
homeostasis
• The brain subconsciously perceives the
stressor and prepares the body either to fight
or to run away, a response sometimes called
the fight or flight response
• Body releases adrenaline and a variety of
other psychological mechanisms to combat
the stress and to stay in control

13. • Rising hormone levels results in increased blood
volume, blood glucose levels, epinephrine and
nor-epinephrine amount, heart rate, blood flow
to muscles, oxygen intake and mental alertness.
• In addition , the pupils of the eye dilate to
produce greater visual field
• May last from 1 minute to many hours
• Once the cause of the stress is removed, the
body will go back to normal.
• If not resolved………. person enters into
resistance or adaptation stage

14. Resistance stage

15. Resistance stage (SR)
• In this phase, the body has reacted to the
stressor and adjusted in a way that begins to
allow the body to return to homeostasis
• This is the body’s response to long term
protection.
• It secretes further hormones that increase
blood sugar levels to sustain energy and raise
blood pressure. The adrenal cortex (outer
covering) produces hormones called
corticosteroids for this resistance reaction.

16. • Overuse by the body's defense mechanism in
this phase eventually leads to disease
• If this adaptation phase continues for a
prolonged period of time without periods of
relaxation and rest to counterbalance the
stress response, sufferers become prone to
fatigue, concentration lapses, irritability and
lethargy as the effort to sustain arousal slides
into negative stress.
• If stressor remains for prolonged period and
person unable to adapt…. Person enters into
Exhaustion Stage

17. Exhaustion stage

18. Exhaustion Stage (ES)
• In this stage, the body has run out of its
reserve of body energy and immunity.
• Mental, physical and emotional resources
suffer heavily.
• The body experiences "adrenal exhaustion".
• The blood sugar levels decrease as the
adrenals become depleted, leading to
decreased stress tolerance, progressive
mental and physical exhaustion, illness and
collapse.
• If stress continues, death may result

20. References
• http://www.angelfire.com/la2/stress/general.
html
• http://helpguide.org/mental/stress_signs.htm
• Kozier, B. & Erb, G. (2000). Fundamentals of
Nursing: Concept and Practice (6th ed.) USA:
Prentice Hall.
• Perry, A.G. & Potter, P.A. (2005). Clinical
Nursing Skills and Techniques. St. Louis:
Mosby.

21. • Murray, R.B. & Zentner, J. P.(2000). Health
Promotion Strategies Through the Life Span.
(7th ed.)
• Taylor, C.,Lillis, C., & LeMone, P.(2006).
Fundamentals of Nursing(5th ed.). Wolters
Kluwer Health (India) Pvt. Ltd., New Delhi.
• http://www.holisticonline.com/stress/stress_g
as.
• htmhelpguide.org/.../burnout_signs_symptom
s.htm

22. Difference between Stress and Crisis
Stress Crisis
1. Stress comes frequently in 1. It comes rarely or can’t be
our daily life. come.
1. Stress can be overcome 2. Crisis can’t be overcome
easily by coping mechanism. easily and it takes long time to
be in previous normal state.
3. It doesn’t harm an individual 3. There is no alternative incase
if he/she faces it positively of crisis. When it occurs it
because stress is normally changes the whole pattern of
present in living animals. living style of an individual
which is very miserable
(unhappy) and terrible.
4. Stress is a chronic condition 4. Crisis is the acute condition
in which the perceived danger which causes potential
persists over a long period of eminent danger that needs
time without resolving it. immediate attention

23. Difference between Stress and Crisis
Stress Crisis
5. Stress makes a person 5. It makes a person shock
tempered and irritated. including helpless, anxiety,
confusion, depression, anger,
withdraw, psychosomatic
symptoms, insufficiency and
hopeless. Suicidal and
homicidal thoughts may be
present.
6. Various ways of tension relief 6. Less ways of tension relief.
The difference is that if crisis is not dealt with or resolved, it
becomes stress over time.

24. Causes of Stress
• General Causes
Threat: A perceived threat will lead a person
to feel stressed.
• This can include physical threats, social
threats, financial threat, and so on.
• In particular it will be worse when the person
feels they have no response that can reduce
the threat, as this affects the need for a sense
of control.

25. Fear: Threat can lead to fear, which again
leads to stress.
Fear leads to imagined outcomes, which are
the real source of stress.
Uncertainty: When we are not certain, we are
unable to predict, and hence feel we are not
in control, and hence may feel fear or feel
threatened by that which is causing the
uncertainty.

26. • Cognitive Dissonance: When there is a gap
between doing and thinking, then experience
of cognitive dissonance occurs, which is felt as
stress. Thus, if a person think he is a nice
person then does something that hurts
someone else, he will experience dissonance
and stress.
• Dissonance also occurs when person cannot
meet his/her commitments due to certain
circumstances (ie a social threat).

27. Life Causes
• Death: of spouse, family, friend
• Health: injury, illness, pregnancy
• Crime: Sexual molestation, mugging, burglary,
pick-pocketed
• Self-abuse: drug abuse, alcoholism, self-harm
• Family change: separation, divorce, new baby,
marriage
• Sexual problems: getting partner, with partner
• Argument: with spouse, family, friends, co-
workers, boss

28. Life Causes
• Physical changes: lack of sleep, new work
hours
• New location: vacation, moving house
• Money: lack of it, owing it, investing it
• Environment change: in school, job, house,
town, jail
• Responsibility increase: new dependent, new
job

29. Stress at work
• The demands of the job
• The control over staff how they do their work
• The support they receive from colleagues and
superiors
• Their relationships with colleagues
• Whether they understand their roles and
responsibilities
• How far the company consults staff over
workplace changes

30. Other stress indicators at work
• Poor communication between teams
• Sickness absence
• Lack of feedback on performance
• High staff turnover
• Lack of clarity of roles and responsibilities
• Bullying (harassment/maltreatment)
• Dissatisfaction with non-monetary benefits
• Value and contribution
• Boring and mundane work

31. • Technological change
• Uncomfortable workplace
• Working long hours
• Lack of training On-off incidents

32. Causes of Stress
The causes of stress depends on the perception
of it. Something that's stressful to one person
may not disturb other; he/she may even enjoy
it.
Common external causes of stress
Not all stress is caused by external factors. Stress
can also be self-generated:
• Major life changes
• Work
• Relationship difficulties

33. • Financial problems
• Being too busy
• Children and family
Common internal causes of stress
• Inability to accept uncertainty
• Pessimism
• Negative self-talk
• Unrealistic expectations
• Perfectionism
• Lack of assertiveness

34. Top Ten Stressful Life Events
• Spouse’s death
• Divorce
• Marriage separation
• Jail term (imprison)
• Death of a close relative
• Injury or illness
• Marriage
• Fired from job
• Marriage reconciliation
• Retirement

35. Effects of Stress
Physical Effects
• GI system: Stomachache, nausea, dry mouth,
constipation, diarrhea, hungry
• Circulatory System: Palpitation, flushing, high
BP, feeling cold, dizziness, hot flushing
• Respiratory: Breathlessness, restlessness,
holding breath, etc.
• Reproductive system: decreased sexual drive
• Urinary system: Frequency of micturation

36. Emotional Symptoms
• Moodiness
• Irritability or short temper
• Agitation, inability to relax
• Feeling overwhelmed
• Sense of loneliness and isolation
• Depression or general unhappiness

37. Cognitive Symptoms
• Memory problems
• Inability to concentrate
• Poor judgment
• Seeing only the negative
• Anxious or racing thoughts
• Constant worrying

38. Behavioral Symptoms
• Eating more or less
• Sleeping too much or too little
• Isolating yourself from others
• Procrastinating or neglecting responsibilities
• Using alcohol, cigarettes, or drugs to relax
• Nervous habits (e.g. nail biting, pacing)

39. Health Problems Linked to Stress
• Stroke: People who are prone to stress face
the risk of hypertension and clogged arteries.
This increases the chances of stroke if they
experience prolonged periods of stress.
• Diabetes: Studies have shown that chronic
stress is associated with deficient production
of insulin in the body.

40. • Eating problems: Stress is often linked to
weight gain and obesity. When people are
stressed they develop a craving towards salt
and sugar and end up eating fatty and starchy
foods to combat stress. Stressed people may
also suffer a loss of appetite and loss of
weight. In rare cases, chronic stress triggers
hyperactivity of thyroid gland, and this causes
the body to burn up calories at a rapid rate.

41. • Ulcers: Chronic stress is commonly linked with
peptic ulcers. Peptic ulcers are caused by
bacteria or by the excessive intake of some
medicines (such as aspirin, ibuprofen). Some
studies indicate that stress does increase the
susceptibility to ulcers or prolongs the cure of
an existing ulcer. A chronic stress condition
also ends up irritating the large intestine
(Irritable bowel syndrome).

42. Sexual Problems
• Stress can lead to loss of libido, or even
temporary impotence in men. In women it can
lead to inability to achieve orgasm, reduced
fertility, and higher chances of miscarriage,
reduced estrogen levels, or even
discontinuation of menstruation.
Memory loss
• Acute stress can cause impaired memory and
lack of concentration, thus inhibiting learning
ability and work efficiency.

43. • Infections; As stress weakens the immune
system, people who are stressed face an
increased risk of infections. Many studies have
shown that people with chronic stress have a
reduced white blood cell count and are
vulnerable to common diseases such as cold,
cough, etc.
• Insomnia
• Substance abuse
• Depression
• Obesity and Heart attack
• Hypertension etc.

44. Measures to Reduce Stress
General guidelines for helping the clients who
are stressed and feeling anxious are as below:
• Listen attentively; try to understand the
client’s perspective on the situation.
• Provide an atmosphere of warmth and trust;
convey a sense of caning and empathy.
• Determine if it is appropriate to encourage
clients’ participation in the plan of care; give
them choices about some aspects of care but
do not overwhelm them with choices.

45. • Stay with clients as needed to promote safety
and feelings of security and to reduce fear.
• Control the environment to minimize
additional stressors such as reducing noise,
limiting the number of persons in the room,
and providing care by the same nurse as much
as possible.
• Implement suicide precautions if indicated.
• Communicate in short, clear sentence.

46. • Help clients to
Determine situations that precipitate anxiety
and identify signs of anxiety.
Verbalize feelings, perceptions, and fears as
appropriate. Some cultures discourage the
expression of feelings.
Identify personal strengths.
Recognize usual coping patterns and
differentiate positive from negative coping
mechanisms.
Identify new strategies for managing stress (e.g.
exercise, massage, progressive relaxation).

47. Identify available support systems
• Teach clients about
The importance of adequate exercise, a
balanced diet, and rest and sleep to energize
the body and enhance coping abilities.
Educational programs available such as time
management, assertiveness training, and
meditation groups

48. Coping with Stress by the Nurse
• Identify the possible cause of stress
• Develop good rapport with others
• Do one thing at a time
• Balance the life activities with work and play,
family and friends and time for herself.
• Exercise body everyday or at least four times a
week (sports, yoga, dancing or walking)
• Meditate to promote relaxation.

49. • Relax body regularly through a systematic
method of tensing and relaxing all muscles.
• Understand and accept what you can and
what you can not do or be.
• Assume a more positive attitude toward
irritating and frustrating situations or events.
• Determine to enjoy selected stressors as a
challenge e.g. examination
• Accept loved support from others, their
encouragement, and suggestion, be willing to
receive help.

50. • Set a time for relaxation each day e.g.
meditation, yoga, seek source of joy and
rumors.
• Talk about your feelings with friends and
counselors
• Accept the things that one can not change.
• Try to correct the aspects of your life that
causes stress.
• Don not push yourself beyond your limit of
achievement and expectation but be satisfied
with less while you do your best.

51. • Organize life with priorities so that you will
accomplish what must be done at the right
time.
• Develop healthy social relationship.
• Practice coping statement

52. Characteristics of Crisis
• Crisis occurs in everybody’s life at one time or
another
• Crisis is personal in nature. Any situation
which is stress for one individual may not be
so far for another.
• Crisis is acute and will be solved one way or
another within a brief period
• A crisis situation contains the potential for
psychological growth or deterioration

53. • A crisis situation may be dangerous for
individual, may harm self or another
• Crisis usually lasts one to six weeks.

54. Types of Crisis
• Developmental crisis
• Situational crisis
• Cultural crisis
• Community crisis

55. Developmental Crisis
• It is a transient period which everybody
experiences in the process of bio-psychosocial
growth and development which is
accompanied by chance in thought, feelings
and abilities of individual who is not able to
cope with the crisis
• Examples: entry into school, puberty,
marriage, pregnancy, child birth, menopause,
old age, leaving home, retirement, facing
death of others and of the self etc.

56. • Onset of development crisis is gradual and
move from one stage to another and stage
does last for whole life.
• Reasons for developmental crisis: The main
reason for this type of crisis is persons’
inability to make role changes as per their
needs

57. Developmental Stage Developmental Crisis
Child Beginning school, establishing peer
relationships, peer competition.
Adolescent Changing physique, relationships involving
sexual attraction, exploring independence,
choosing career.
Young Adult Marriage, leaving home, managing a home,
getting started in an occupation, continuing
one’s education and children.
Middle Adult Physical changes of aging, maintaining
social status and standard of living, helping
teenage children to become
Older adult Decreasing physical abilities and health,
changes in residence, retirement and reduced
income, death of spouse and friends etc.

58. Reasons for persons not being able to
make role changes
• Person’s inability to picture himself in a new
role
• Lack of resources, inadequate communication
skills, inability to realize alteration to his
present life style as well as achievement of
central goal
• Refusal by others in social system to see the
person in a different role.

59. Community crisis or Social Crisis
• A crisis which affects whole community is
known as community crisis or social crisis or
adventitious.
• Example of community crisis are natural
disaster, armed conflicts

60. Situational crisis
• Any external events or situation which occurs
often suddenly, unexpectedly and
unfortunately which is not a part of normal
living.
• Examples are natural disaster, accidents,
suicide, death of loved one, illness or
hospitalization
• Both situational and developmental crisis may
occur at the same time e.g. suicidal attempt
followed by unwanted marriage

61. Cultural crisis
• Cultural crisis is a situation where a person
experienced cultural shock in the process of
adjustment or adaptation to new culture or
returning to one’s culture after being
assimilated into another

62. Phases of crisis
Initial impact or shock: In this phase person
experiences shock and depersonalization
Realization: In this phase, collapse of self
structure occurs.
• The person experiences high level of anxiety,
panic and helplessness.
• The person can not plan, reason and
understand the situation

63. Defensive retreat: There is an attempt to
establish previous identity, avoidance of
reality or denial.
• Wishful thinking may ensure to relieve the
anxiety.
Recoil or acknowledgement ( ‘yes’ stage): The
individual experiences depression without
intervention.
• The person may become more disorganized,
depressed and have more suicidal tendency.
• In this stage person realizes events

64. Resolution or adaptation: If help is adequate,
changes occur and new identity appears along
with hope.
• The person struggles to solve the situation
and may involve other people to help them

65. Factors Affecting Outcome of Crisis
1. Individual’s Perception of the Events
• If the event (or the implications or
consequences of it) threatens the self-
concept; conflicts with the value system, self-
expectations, or wishes for the future;
contributes to a sense of shame or guilt; or is
demoralizing or damaging to self, family, or
personal objects, the situation is defined as
hazardous.

66. • The perception of the event is reality for the
person of family, regardless of how others
might define reality.
• How the event is perceived depends in large
measure on past experience.

67. 2. Individual’s physical and emotional status
• This includes level of health, amount of energy
present, age, genetic endowment, and
biological rhythms of the person or family, or
the general well-being of the community.
• Working through crisis takes considerable
energy.

68. 3. Coping mechanism and level of maturity
• If adaptive capacities are already strained, or if
the stress is overwhelming, the person will
cling to old habits or existing defenses, and
behavior will very likely be inappropriate to
the task at hand.
• The person or family who has met
developmental tasks all along and who
perceives self as able to cope will adapt more
easily in any crisis.

69. • The group or community that has
mechanisms, policies, or procedures defined
and in operation to cope with the unexpected
event or disaster can better meet the crisis.

70. 4. Previous Experiences with Similar Situation
• The person, family, or group needs to learn to
cope with stress, change, and loss.
• If past crises were handled by distorting reality
or by withdrawing, when similar crises arise,
burdens of the prior failure will be added to the
problem of coping with the new situation.
• Unresolved crises are cumulative in effect.
• The most recent crisis revives the denial,
depression, anger, or mal-adaption that was left
unsettled from past crises.

71. • If the person, family, or group successfully
deals with crises, self-confidence and self-
esteem will thereby be increased, and future
crises will be handled more effectively.

72. 5. Cultural Influences
• How the person is trained and socialized in the
home to solve problems and meet crisis
situations; the use of religious, cultural, or
legal ceremonies or rituals to handle
separation or loss and facilitate mourning;
expectations of how the social group will
support the person or family during crisis; and
the method established by the community to
provide help-all influence present behavior.

73. 6. Support of Family, Friends or Other
Resources
• The less available the environmental or
emotional support systems are to decrease
stress or buttress (support) the coping
response, the more hazardous the event will
be.
• The family system, by its influence on
development of self-concept and maturity,
can increase or decrease the person’s
vulnerability to crisis.

74. 7. Realistic Aspect of the Current Situation
• These include personal, material, or economic
losses, the extent to which group ties or
community services are interrupted, and
changes in living pattern or family life
necessitated by the loss.
8. Degree of Perceived Dependency on a Lost
Object
• This is always crucial; the greater the
dependency, the more difficult the resolution
of loss.

75. Crisis Intervention
Goals of crisis intervention are
• To reduce the impact of stressful events
• To help those affected with present problems
There are 4 phases of crisis intervention
techniques which are similar to nursing
process

76. Assessment
• In this phase, nurses gather information
regarding the precipitating stressors and the
resulting crisis
• Nurses assess the followings;
Determine the events or situation that
precipitated the crisis and what caused the
individual to seek help.
Assess the person’s coping style and strength
Assess the support available to the person

77. • In addition determine whether or not the
crisis situation has produced feeling of severe
despair or anger, self destructive or suicidal.
• If nurses find such types of feeling on patients,
nursing actions to prevent self harm should be
instituted immediately.

78. Planning
• After assessment, nurses make nursing
diagnosis for each problem identified during
assessment. Nursing diagnosis (NANDA, 2000)
that is common in person’s undergoing crisis
• Diagnosis may be made as follows
• Fear related to the precipitating
factors/events.
• Hopelessness related to the sense of inability
to recover from the crisis

79. Planning Contd.
• After making nursing diagnosis, nurses select
the appropriate nursing actions for identified
nursing diagnosis.
• Then the nurse will establish short term as
well as long term goals of care.

80. Intervention
• Establish trust with the client, ensure
confidentiality and develop a good
understanding of patients or client’s
experiences and feelings.
• Let the client verbalize his/her feelings
• Encourage honest disclosure and does not
attempt to avoid emotional reactions like
anger/crying

81. Intervention contd.
• If necessary, change environment; it may
serve to alleviate stress or feeling of comfort
and safety.
• Support the client in the use of defense
mechanism that supports him/her.
• Never criticize clients coping mechanism at a
time of crisis but may gently suggest ways.

82. Intervention contd.
• Identify support systems and new social
networks from which the individual may seek
assistance at a time of crisis.
• Always remain with the clients experiencing
panic anxiety.
• Discourage lengthy explanation of the situation;
provide an atmosphere for verbalization of true
feeling.
• Set limits on aggressive and destructive
behaviors.

83. Evaluation
• At last, nurses assess the outcomes of the
crisis.
• The nurse and client together can determine
whether it was a successful resolution of the
crisis.

84. Evaluation Continue
– Does the client feel he/she can return to a
normal life?
– Does he/she have the skills and confidence to
return to the work?
– Have positive behavioral changes occurred?
– If the client wishes to pursue continue
therapy, group support and development
after resolution of crisis, the nurses should
refer the client to available resources.