3. STRESS
• A stressor is any agent or stimulus that poses a real or
potential threat to homeostasis.
• Stress is the internal state of the person as he or she
responds to the stressor.
• Stress is how we feel when we are worried
• A successful response to the stressor is termed as
adaptation.
Synonyms(anther names) of stress:-
– Pressure
– Tension
– Anxiety
– Worry
– Distress
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4. Origins of Stressors
• Stressors are found in all aspects of life.
• They may originate
Internally (psychological or physical in nature)
Externally (environmental, social)
• They all have in common is their potential to disturb
homeostasis.
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5. Cont’d
• The situation itself is not the stress but rather, our
reaction to the situation causes the stress
• Situation/Events which cause us stress are referred to
as stressors
• What may cause one stress may be excitement to
another
• “People are disturbed not by the things that happen to
them but by their interpretation of those things.”
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6. Cont’d
• Two people may experience the same thing but their
reactions to it will be different. The intensity of stress
depends on:
»the event involved
»our reaction to the event
»the importance of the event to us.
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7. Cont’d
The physiology of stress:-
• Fight or flight response:- the body’s mechanism for
marshalling energy in case of emergency.
• During emergencies:-
Blood pressure goes up
Breathing goes up.
Heart rate pulse goes up.
Sweating increases.
Blood rushes to parts that need it most (face,
arms, legs etc).
Adrenaline is secreted into the blood.
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8. Cont’d
What causes stress ?
• This differs from person to person, but anything that
makes us worry and tense up is a stressor
• An event will be more stressful if it:
is unpredictable
involves a lot of pressure
speeding pace of work/activity
meeting deadlines
working at maximum capacity for a long time (hrs)
unfamiliar.
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9. Cont’d
Work related stressor
• Degree of Participation in:
• decision-making process
• consultations on issues affecting the
organisation
• establishing rules of behaviour at work
• Role Problems:
• role overload
• role insufficiency
• role ambiguity
• role conflict
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10. Cont’d
Type A vs Type B Personalities
Type A personality
• Philosophy- There is a lot to do but very little time to do it.
Hard-driving individuals: pushing themselves above human
limits.
• Always in a hurry. Eat pretty fast; often standing.
• Very competitive; set themselves very unrealistic goals.
• Hostile, irritable and impatient.
Type B personality
Less competitive
Easy going
Less hurried
More friendly
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11. Cont’d
Stress and Health
About 50% of cases reported at hospitals are stress
related.
Hypertension
Ulcers - stomach and mouth.
Asthma and other lung problems
Migraine headaches
Stroke
Heart diseases
Diseases of the arteries
Insomnia
Pre- mature gray hair
Pre- mature hair loss
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12. The General Adaptation Syndrome
• Hans Selye developed a theory of adaptation that
profoundly influenced the scientific study of stress
• Experimenting with animals, first described a syndrome
consisting of.
• Enlargement of the adrenal cortex
• Shrinkage of the thymus, spleen, lymph nodes, and other
lymphatic structures
• Deep bleeding ulcers in the stomach and duodenum
• He identified this as a nonspecific response to diverse,
noxious stimuli
• From this beginning, he developed a theory of
adaptation to biologic stress that he named the general
adaptation syndrome
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13. Phases of the general adaptation syndrome
• The general adaptation syndrome has three phases:
– Alarm
– Resistance and
– Exhaustion
• During the alarm phase:-
• The sympathetic “fight-or-flight” response is activated
with release of catecholamines and
• The onset of adrenocorticotropic hormone (ACTH)
induces adrenal cortical response
• The alarm reaction is defensive and anti-inflammatory
but self-limited
• Because living in a continuous state of alarm ,would result in
death, the person moves into the second stage ” resistance”
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14. Cont’d
• During the resistance stage.
• Adaptation to the noxious stressor occurs, and cortisol
activity is still increased
• If exposure to the stressor is prolonged, exhaustion sets in
and endocrine activity increases.
• During exhaustion
• The increased endocrine activity produces deleterious
effects on the body systems (especially the circulatory,
digestive, and immune systems) that can lead to death
• Stages one and two of this syndrome are repeated, in
different degrees, throughout life as the person encounters
stressors
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15. Coping Stress
Lazarus & Folkman (1984)
• Propose that the interpretation of stressful events is
more important than the events themselves
• It is neither the environmental event nor the person’s
response that defines stress, but it is the individual’s
perception of the psychological situation that
defines stress
• Stress is a function of the person’s feeling of threat,
vulnerability, and ability to cope rather than a
function of the stressor
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16. Cont’d
• Problem solving
• Social support
• Vacations
• Meditation
• Mental relaxation
• Physical exercise & relaxation
• Time management
• Relationship management
• Sleep well
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17. Cont’d
Social support: there is a saying that: “a friend in need is
a friend in deed” Good friends becomes highly
supportive during the time of stress crisis
• Sharing fears, frustrations and joys with trusted friends
makes life richer and contribute to the well-being of
the body and mind
• Have a network of people at home, at work and in the
community on whom you can rely for emotional
support
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18. Cont’d
Plan in your life in advance
• Accept unexpected difficulties in life. It is better to
project events in life and plan to confront them when
they occur
• Many times people creates situation which induce
stress because they either didn’t plan or they did bad
job of planning
• If you plan ahead and properly utilized the resource
on given time the chance of getting stress is less
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19. Cont’d
Physiological fitness
• There is evidence to suggest that individual who
exercise, so strengthen their endurance and
cardiovascular system are much less likely to suffer
from certain types of stress related illness.
• There is a correlation between physical fitness and
stress
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20. Cont’d
Meditation
• Meditation involves concentration of mind away from
stress producing area
• The place of meditation should be such that, the
mediator is not disturbed from any outside forces
such as telephone, children, or visitors
• The basic idea is to block extraneous and distracting
thoughts from one’s mind
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21. Human Sexuality
• Human sexuality is characterized by physical, social,
psychological and spiritual attributes that are
associated with one's gender.
• Sexuality is expressed in terms of physical structure,
physiologic functioning, attitudes and values,
knowledge and behavior that results from inherited
characteristics and social learning.
• The relationship among these factors comprises the
status of an individual's sexual health.
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23. The Sexual Response Cycle
The sexual response cycle has four phases:
– Excitement
– Plateau
– orgasm
– and resolution.
• although both men and women experience these
phases, the timing usually is different.
• For example, it is unlikely that both partners will reach
orgasm at the same time. In addition, the intensity of
the response and the time spent in each phase varies
from person to person
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24. The Sexual Response Cycle
Phase 1: Excitement
General characteristics include:-
• Muscle tension increases.
• Heart rate quickens and breathing is
accelerated.
• Skin may become flushed
• Nipples become hardened or erect.
• Blood flow to the genitals increases,
resulting in swelling of the woman's
clitoris and labia minora, and erection
of the man's penis.
• Vaginal lubrication begins.
• vaginal walls begin to swell.
• The man's testicles swell, his scrotum
tightens, and he begins secreting a
lubricating liquid.
Phase 2: Plateau
General characteristics include:
• The phase 1 are intensified.
• The vagina continues to swell from
increased blood flow, and the vaginal
walls turn a dark purple.
• The woman's clitoris becomes highly
sensitive (may even be painful to
touch)
• The man's testicles tighten.
• Breathing, heart rate, and blood
pressure continue to increase.
• Muscle spasms may begin in the feet,
face, and hands.
• Muscle tension increases.
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25. The Sexual Response Cycle…
Phase 3: Orgasm
The orgasm is the climax of the sexual
response cycle and the shortest.
General characteristics include:
• Involuntary muscle contractions
• Blood pressure, heart rate, and
breathing are at their highest rates,
with a rapid intake of oxygen.
• There is a sudden, forceful release of
sexual tension.
• In women, the muscles of the vagina
contract.
• The uterus also undergoes rhythmic
contractions.
• In men, rhythmic contractions of the
muscles at the base of the penis result
in the ejaculation of semen.
Phase 4: Resolution
• During resolution, the body slowly
returns to its normal level of
functioning, and swelled and erect
body parts return to their previous
size and color.
• Some women are capable of a
rapid return to the orgasm phase
with further sexual stimulation and
may experience multiple orgasms.
• Men need recovery time after
orgasm, called a refractory period,
during which they cannot reach
orgasm again.
• The duration of the refractory
period varies among men and
usually lengthens with elder
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26. Sexual health includes:
• One's freedom from physical and psychological
impairment,
• The awareness of open and positive attitudes toward
sexual functioning
• Accurate knowledge of sexuality and
• Congruency among gender identity and role
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27. Human Sexual Disorders
Sexual Desire Disorders
– Hypoactive sexual desire disorder
– Paraphilia
– Sexual aversion disorder
Sexual Arousal Disorders
– Female sexual arousal disorder
– Male erectile disorder
Orgasmic Disorders
– Female/male orgasmic disorder
– Premature ejaculation
Sexual Pain Disorders
– Dyspareunia, vaginismus 27
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28. Paraphilia
• A disorder Characterized by recurrent, intense sexual
urges, behaviors, or sexually arousing fantasies
involving the following:
– Exhibitionism = exposure of one’s genitals to an
unsuspecting stranger
– Fetishism = use of nonliving objects
– Frotteurism = touching and rubbing against a
nonconsenting person
– Pedophilia = sexual activity with a prepubescent
child.
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29. Possible Causes
• Relationship difficulties
• Medical illness or treatments
• Major life stressors
• Hormonal changes
• Health problems
• Anxiety or depression
• FGM
• Psychosocial factors
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30. PAIN
• Pain is an unpleasant sensory and emotional
experience
• associated with actual or potential tissue damage, or
described in terms of such damage
• Pain is a subjective experience.
• The experience varies from person to person and
from time to time
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31. pain…
• Pain is the most feared complication of illness
• Often under-diagnosed and under-treated
• Has Effect on mood and functional status
• Fifth vital sign
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32. Physiology of Pain
• Noxious stimuli activate nociceptors (receptive
neurons for painful sensations) that, together with the
axons of neurons convey information to the spinal
cord where reflexes are activated.
• The information is simultaneously transmitted to the
brain supraspinally.
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34. Characterizations of pain
•Pain can be described by its:
– Duration – acute or chronic
– Mechanism – nociceptive or neuropathic
– Origin – somatic or visceral etc
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35. Duration:(acute vs.chronic pain)
Acute pain
• Presentation: characterized by help-seeking behavior
such as crying
• Cause: definite injury or illness
• Signs/symptoms:
• Definite onset with limited and predictable duration
• Clinical signs of sympathetic over-activity: tachycardia,
pallor, hypertension, sweating,, crying, anxious,
pupillary dilation
• Example: trauma, surgery, or inflammation
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36. Duration(acute vs. chronic pain)…
Chronic pain
• Presentation: Patients may not show signs of stress seen
in acute pain
• Cause: chronic pathological process
– Under-treatment of acute pain can lead to changes in
the central nervous system that result in chronic pain
• Signs/symptoms:
– Gradual or vague onset
– Continues and may become progressively more severe
– Patient may appear depressed and withdrawn
– Usually no signs of sympathetic over-activity
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37. Mechanism(nociceptive vs neurophatic pain)
NOCICEPTIVE PAIN
•caused when nerve receptors called nociceptors are irritated.
•Nociceptors exist both internally (visceral) and externally
(somatic)
i) Somatic pain:
•stimulation of nociceptors in the skin, soft tissues, muscle, or
bone
•Pain usually is in a particular location
• Aching, throbbing, or persistent pain
• Causes: bone or soft tissue infiltration
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38. Mechanism:
nociceptive vs neurophatic pain…
ii) Visceral Pain:
•stimulation of nociceptors in internal organs and hollow
viscera organs
• Pain is often not in a single location
• Described as pressure, cramping, or squeezing pain
• It may caused by: blockage, swelling, stretching, or
inflammation of the organs from any cause
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39. Mechanism:
nociceptive vs neurophatic pain…
NEUROPATHIC PAIN:
• Caused by damage to nerve pathways
• Described as burning, prickling, stinging, pins and
needles, insects crawling under skin, numbness,
hypersensitivity, shooting, or electric shock
Possible causes
• infiltration by cancer,
• HIV infection,
• herpes zoster,
• drug-related peripheral neuropathy,
• central nervous system injury, or
• surgery B: Amanuel.O 39
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40. Numeric pain rating scale
• Pain levels from 0-10 can be explained verbally to the
patient using a scale in which 0 is no pain and 10 is the
worst possible pain imaginable
• Patients are asked to rate their pain from 0 to 10
• Record the pain level to make treatment decisions,
follow-up, and compare between examinations
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0 1 2 3 4 5 6 7 8 9 10
No pain Mildpain Moderatepain Severepain Veryseverepain Worstpossiblepain
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41. Pain management
Non pharmacological
• reassurance, cold or hot compress etc
Pharmacologic pain management
– analgesics
– Maintain therapeutic serum levels
– Choose appropriate route for administration
– Use nonsteroidal anti-inflammatory drugs (NSAIDs)
to reduce some risk.
(continued)
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42. Pain managment…
Other drugs possibly for treatment of neuropathic
pain
• Tricycle antidepressants
• Anticonvulsants
• Corticosteroids
• Antispasmodics
• Opoids/ narcotic analgesia
(continued)
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43. World Health Organization Step Ladder
1) Begin with non-opiate, nonsteroidal antiinflammatory
agents (NSAIDS)
2) Add a “weak” opiate, such as codeine or hydrocodne
(with or without an adjuvant)
3) Move to a stronger opiate, such as oxycodone, morphine
(with or without an adjuvant)
4) Complementary, non-pharmacologic strategies
5) Interventional strategies
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45. STEP 1: NON OPIATES
NSAIDs
No Classification ,NSAIDS Example of Drug
1 Salycylates ASA
2 Propionic acid Ibuprofen
3 Acetic acid Indometacine, ketrolac,
Diclofenac
4 Enolic acid Meloxicam,piroxicam
5 Fenamenic acid Mefenamine
6 Selective cox 2 & 3 Celecoxib , paracetamol
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46. Step 1: Non Opiates...
• NSAIDS
– Avoid if renal insufficiency
– Useful with throbbing, aching pain
– Administer with food to reduce gastric irritation
– Salsalate and tolmetin produce less inhibition of
platelet aggregation than other NSAIDS
– Maximum dose of aspirin is 10g/day
– Use with caution in persons with asthma
– Indomethacin is available in suppository form
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47. NSAIDS side effects
• Prolonged bleeding after an injury or surgery
• GI: ulcer, nausea ,vomiting, diarrhea, constipation,
appetite loss,
• Hyper-sensitivity: Skin rash
• Dizziness, headache and drowsiness.
• fluid retention, leading to oedema.
• The most serious side effects are renal failure, liver
failure
• If one non-opiate is ineffective, switch to a different one.
• If one NSAID is ineffective, switch to a different class
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48. Step 1: Non Opiates(cont.)
Acetaminophen ( paracetamol
• No effect of platelet function
• Avoid in cases of hepatic insufficiency
• Maximum of 4g/day
• analgesic and antipyretic
• Inactive at some sites:
– kidney → no renal impairment
– Platelet → no antiplatelet effect
– gut → no peptic ulcer risk
– inflammation → not anti-inflammatory
• Toxicity occurs in large doses (≈ 10 time therapeutic
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49. Step 2: Non opiate + Weak Opiate( With or
Without Adjutants )
– NSAIDS: provide additive analgesia when
given to supplement the opiate, often lengthen
the duration of opiates
– Corticosteroids: treats both the cause and
resulting pain of aphthous ulcers; also relieves
cerebral edema
– Corticosterioids caution: can cause gastric
bleeding, caution with low platelet counts
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50. Step 2: Non opiate + Weak Opiate (With or
Without Adjuvant ....)
• Types of Adjuvants
– Antidepressants (amitriptyline, desipramine, etc):
used for neuropathic pain and post-herpetic
neuralgia and additive analgesia with opiates
Antidepressants caution: can cause dry mouth,
urinary retention and “hangover effect
– Antihistamines (hydroxyzine): provides additive
analgesia as well as antiemetic and anxiolytic
effect
Antihistamine Caution: Can cause dry mouth and
drowsiness
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51. Step 2: Non opiate + Weak Opiate(With or
Without Adjuvants ...)
• Types of adjuvants cont.
– Anticonvulsants: gabapentin is the most useful with the
fewest side effects and is used to treat neuropathic pain
Anticonvulsant Caution: carbamazepine can cause
neutropenia
– Caffeine: drinking a cup of strong coffee along with
opiate will increase its effect
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52. Step 3: Opiates With/Without Adjuvants
• Dosing schedule and titration
– Titrate to pain relief – doses are individualized: the
right dose is whatever it takes to relieve the pain
with the least amount of side effects/toxicity
– Long-acting opiates should be used for long-term
pain
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54. Side Effects of Morphine
Constipation -always
Drowsiness – common /excessive doses
Twitching – rare/excessive doses
Urinary retention-catheter in/out
Vomiting over first few days,
Respiratory Depression – pain is a physiological
antagonist to this/rare
Dependence/addiction-rare in pain management
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55. NURSE’S ROLE IN PAIN MANAGEMENT
The nurse’s role in pain management is:
• The nurse helps relieve pain by administering pain-
relieving interventions (including both pharmacologic and
non-pharmacologic approaches),
• Assessing the effectiveness of those interventions,
• Monitoring for adverse effects,
• Serving as an advocate for the patient when the prescribed
intervention is ineffective in relieving pain.
• Serves as an educator to the patient and family to enable
them to manage the prescribed intervention themselves
when appropriate
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56. Response to loss, death and dying
• Elisabeth Kübler-Ross discovered that most people pass through
five stages in response to death and dying.
• Although some individuals experience the stages in a different
order and others revisit some stages, knowledge of these stages can
help the nurse evaluate—and deal with—a patient’s responses to
death and dying.
Stages of death and dying
1. Denial and isolation: the initial response characterized by shock
and disbelief
2. Anger: expressions of rage and resentment
3. Bargaining: attempts to strike a bargain, typically with God, in
exchange for prolonged life
4. Depression: feelings of loss, grief, and intense sadness
5. Acceptance: a quiet stage characterized by a gradual, peaceful
withdrawal from life
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