introduction to stress and sleep and how they influence one another.

1. SELF-CARE AND
STRESS

2. TODAY WE WILL:
To reflect on personal health status and explore self-
caring behaviours
To explore conceptualizations of stress, homeostasis
and adaptation
To develop an awareness of stressors that can influence
the health of individuals
To explain the 5 stages of sleep and the functions of
sleep
To demonstrate an awareness of sleep hygiene and
identify factors that promote and/or disrupt sleep
To integrate the meaning of family and relationships,
focusing on later life transitions and intimacy
To identify factors influencing mental health and
wellness in later life
To identify risk and resiliency factors specific to older
adults and identify interventions to promote health and

3. STRESS

4. SCIENTIFIC KNOWLEDGE
BASE
Fight-or-flight response
Neurophysiological responses
Medulla oblongata
Reticular formation
Pituitary gland

5. PHYSIOLOGICAL
CONCEPTUALIZATIONS OF
STRESS
Walter Cannon (1915) first termed the
phrase, fight or flight response.
He utilized this to describe an animal`s
response to threats through the
activation of the sympathetic-adrenal-
medullary (SAM) system.

6. FIGHT OR FLIGHT RESPONSE

7. GENERAL ADAPTATION
SYNDROME
Hans Selye (1974), focused on maladaptation and the
pathology of stress.
Developed the General Adaptation Syndrome
Occurs in 3 stages – in response to serious stressors
 Stage 1 – Alarm Reaction
 Complex physiology changes assist the organism to
mobilize energy and react to the stressor
 Fight or flight response is initiated. If organism enters
fight mode, they proceed to stage 2.

8. G.A.S. CONT’D
 Stage 2 – Resistance Stage
 The organism maintains arousal while the body works
to defend against and adapt to the stressor and
maintain homeostasis.
 If the stressor continues for an extended period of
time, organisms either utilize their ability to adapt or
enter the third stage
 Stage 3 – Exhaustion Stage
 Organisms demonstrate health consequences to
stressors, which may eventually result in death.

10. PSYCHOLOGICAL
CONCEPTUALIZATIONS
Lazarus (1999) stated that an individual only
experiences stress if they assess an event or
circumstance as personally significant.
 Appraisal – of an event or circumstance is an ongoing
process
 Primary appraisal – concerns evaluating a
circumstance for its personal meaning
 If an event is deemed as possibly harmful,
threatening or challenging, the person experiences
stress

11. LAZARUS CONT’D
 Secondary appraisal –is entered if stress is present, it
focuses upon possible coping strategies.
 Coping – the active process of managing circumstances
viewed as stressful, expending one`s effort to solve
personal and interpersonal problems, and seeking to
master, minimize, reduce, or tolerate stress or conflict.

12. COPING MECHANISMS
Problem-focused coping
Emotion-focused coping
Appraisal-focused coping (Ego-defense
mechanisms)

13. CRISIS
If coping is not effective, a crisis may occur.
A crisis results in the person facing a turning
point in life, which requires change.
Developmental – vary with life stage
Situational – arise from personal circumstance

14. TYPES OF STRESS
There are 2 types of stress
 Eustress – stress that protects health
 Includes motivating energy, such as happiness,
hopefulness, and purposeful movement.
 Is a positive stress
 Distress – damaging stress
 Includes many subcategories such as work stressors,
family stressors, chronic stressors, acute stressors,
daily hassles, traumas, and crisis.

15. STRESS-RELATED
DISORDERS
Acute Stress Disorder – a limited reaction to experience,
witnessing, or being confronted with a traumatic event
 Includes a reaction of intense fear, helplessness, or
horror
 Clients may exhibit – flashbacks, avoidance of
pertinent stimuli, hyper arousal, symptoms begin
between 2 days and 4 weeks following event
 For example – witnessing a horrific accident, a fall, a
death

16. STRESS-RELATED
DISORDERS CONT’D
Post-Traumatic Stress Disorder (PTSD)
 Continually persistent, are endured for at least a
month`s time
 Symptoms may emerged immediately following a
traumatic event, or may be delayed
 For example: war veterans from Vietnam began the
utilization of this diagnosis, due to their traumatic
experiences.

17. HEALTH PROMOTION AND
COPING
3 primary modes of intervention for stress:
-Decrease stress-producing situations
-Increase resistance to stress
-Learn skills that reduce the physiological
response to stress

18. HOW TO MAKE STRESS YOUR
FRIEND
http://www.youtube.com/watch?v=RcGyVTAoXEU

19. SLEEP

20. 20
PHYSIOLOGY OF SLEEP
Circadian rhythms
Cyclical rhythms
Biological clock
Sleep regulation
Regulated by a sequence of
physiological states integrated
by central nervous system
activity
Reticular activation system
(RAS)
Stages of sleep
Stages 1, 2, 3, 4, and rapid
eye movement (REM)
(Box 40-2)
Sleep cycle
Presleep period + four to five
complete sleep cycles (NREM
+ one REM) per night

21. 21
NORMAL SLEEP REQUIREMENTS
AND PATTERNS
Neonates
16 hours per day
Infants
10 to 12 hours at night, plus naps,
for a total of 12 to 14 hours per day
Toddlers
12 to 14 hours per day, including
naps
Preschoolers
13 hours per night
School-aged children
9 to 10 hours per night
Adolescents
Varies (shorter during school
week); “sleep debt”
Young adults
6 to 8½ hours per night
Middle and older adults
Decline in total number of hours

22. PHYSICAL ILLNESS
Illness and disease can affect sleep.
 Respiratory
 Cardiovascular
 Musculoskeletal (pain)
 Nocturia

23. SLEEP DISORDERS
Hypersomnolence
Insomnia
Sleep apnea
Narcolepsy
Parasomnias
Shift work
Sleep deprivation

24. QUICK QUIZ!
1. During rounds on the night shift, the nurse notes that
a patient stops breathing for 1 to 2 minutes several
times during the shift. What is this condition called?
A. Cataplexy
B. Insomnia
C. Narcolepsy
D. Sleep apnea

25. 25
FACTORS AFFECTING SLEEP
Drugs and substances
Hypnotics, diuretics, antidepressants, alcohol, caffeine, narcotics,
-blockers, anticonvulsants, anti-parkinsonians
Lifestyle
Work schedule, social activities,
routines
Usual sleep pattern
May be disrupted by social
activity or work schedule
Emotional stress
Worries, physical health, death,
losses
Environment
Noise, routines
Exercise and fatigue
Restful sleep caused by
moderate exercise and fatigue
Food and caloric intake
Time of day, caffeine, nicotine,
alcohol

26. HEALTH PROMOTION
Environmental controls
 Temperature
 Noise
 Light
Promoting bedtime routines
Promoting safety
Promoting comfort
Establishing periods of rest and sleep
Stress reduction
Bedtime snacks
Pharmacological approaches

27. SLEEP
http://www.youtube.com/watch?v=LWULB9Aoopc

28. STRESS AND THE
AGING ADULT

29. STRESS AND THE AGING
ADULT
Consider the wide variety of late life transitions
and stressors that older adults in particular
may face. What are the conditions that may
impact the older adults’ response to these
situations?

30. 2
FAMILIES
The idea of family is whatever an individual believes
it to be
Family members, however they are defined, form the
nucleus of relationships for the majority of older
adults and the support system if they become
dependent.
Roles and relationships change over time

31. 6
OLDER PEOPLE AND
THEIR ADULT CHILDREN
Relationships may become strained because younger
adults are more concerned with their own spouses,
partners, and children.
By and large, older adults and their children have
relationships that are reciprocal in nature and
characterized by affection and mutual support.
These relationships are both the most important and
potentially the most conflicted.

32. 7
GRANDPARENTING
As the term implies, the “grands” are a step beyond
parents in their concerns, exposure, and
responsibility.
Younger grandparents typically live closer to their
grandchildren and are more involved in child care
and recreational activities.
Overall, the grandparent role and identity tends to be
associated with embeddedness in the family, along
with life satisfaction, and psychological well-being.

33. 8
SIBLINGS
As individuals age, they often have more contact
with siblings than they did in the years when family
and work demands were more pressing.
Siblings become particularly important when they are
part of the support system, especially among single
or widowed older adults who are living alone.

34. 10
LATE-LIFE TRANSITIONS
A process of convoluted passage during which
people redefine their sense of self and develop self-
agency in response to disruptive life events.
May occur predictably or by unanticipated events.
The speed and intensity of a major change may make
the difference between a transitional crisis and a
gradual and comfortable adaptation.

35. 11
#1: RETIREMENT
A developmental stage that may occupy 30 years of one’s life
and involve many stages
The transitions are blurring because numerous pursuits and
opportunities may occur after one has “retired.”
The numerous patterns and styles of retiring have produced
more varied experiences in retirement.
Decisions to retire are often based on
 Financial resources
 Attitude toward work
 Chronological age
 Health
 Self-perceptions of ability to adjust to retirement
“Three-Legged Stool”
 Social Security pensions
 Savings
 Investments

36. PHASES OF RETIREMENT
Remote: Future anticipation with little real planning
Near: Preparation and fantasizing regarding
retirement
Honeymoon: Euphoria and testing of the fantasies
Disenchantment: Letdown, boredom, sometimes
depression
Reorientation: Developing a realistic and satisfactory
lifestyle
Stability: Personal investment in meaningful activities
Termination: Loss of retirement role resulting from
illness or return to work
15

37. 16
#2: WIDOWS AND WIDOWERS
One of the most difficult transitions one can face
Involves grief, the psychological and physical reactions to the
loss, as well as the process of grieving and coping with the loss.
Three core features of grief:
 Depression
 Anxiety
 Loneliness
Grieving involves two kinds of coping:
 Coping or dealing with the loss of the partner
 Adjusting to secondary losses, such as tasks the deceased partner
previously did

38. 19
#3: DIVORCE AND THE ELDERLY
Older couples are becoming less likely to stay in an
unsatisfactory marriage.
Health care workers must be concerned with
supporting a patient’s decision to seek a divorce and
with assisting him or her in seeking counselling
during the transition.

39. 20
#4: CAREGIVING
In 2007, 2.7 million Canadians (1 in 5 of those older than 45)
provided unpaid care to an older adult with a health or physical
limitation.
Caregivers frequently experience depression and physical and
emotional exhaustion.
 Caregiving for Parents
 Spousal Caregiving
 Aging Parents Caring for Developmentally Disabled Children
 Grandparents Raising Grandchildren
 Long-Distance Caregiving

40. SUGGESTED NURSING INTERVENTIONS WITH
GRANDPARENT CAREGIVERS
Early identification of at-risk grandparents
Comprehensive assessment of physical,
psychosocial, and environmental factors affecting
those in the caregiving role for grandchildren
Anticipatory guidance and counselling about child
growth and development and other child-raising
issues
Referral to resources for support and counselling
Advocacy for policies supportive of grandparents
who have assumed a caregiving role for
grandchildren
26

41. 21
CAREGIVER NEEDS

42. 28
ROLE OF NONFAMILY CAREGIVER
May include friends and hired or volunteer caregivers
from a church or agency
Caregivers not only provide substantial physical care,
but also are involved with older adults, when
possible, in social activities such as dining, concerts,
and faith-related events.

43. 31
#5: INTIMACY
Five major relational components:
 Commitment
 Affective intimacy
 Cognitive intimacy
 Physical intimacy
 Interdependence

44. 32
SEXUALITY
A central aspect of being human throughout life
Encompasses sex, gender identities and roles, sexual
orientation, eroticism, pleasure, intimacy, and
reproduction
A basic human need
Psychological
 Person’s attitudes, feelings toward self and
others, and learning from experiences

45. 33
INTERRELATIONSHIP OF
DIMENSIONS OF SEXUALITY
Source: Ebersole, P., Touhy, T., Hess, P., Jett, K., & Luggen, A. S. [2008]. Toward healthy aging:
Human needs and nursing response (7th ed., p. 464, Fig. 19-2). St. Louis, MO: Mosby

46. 35
BIOLOGICAL CHANGES WITH AGE
The more sexually active the person is, the fewer
changes he or she is likely to experience in the
pattern of sexual response.
Illnesses and medications affect sexual response.
Changes in the appearance of the body may affect
the older adult’s feelings of attractiveness.
Physical changes are the main influence on the act of
intercourse.

47. 40
INTIMACY AND SEXUALITY
IN LONG-TERM CARE FACILITIES
Intimacy and sexuality among nursing home
residents
 Coitus
 Hugging
 Kissing
 Hand holding
 Masturbation
Should be addressed with the same priority as
nutrition, hydration, and other well-accepted
physiologic needs (think Maslow’s hierarchy…)

48. 44
IMPLICATIONS FOR GERONTOLOGICAL
NURSING AND HEALTHY AGING
The nurse has the responsibility to help maintain the
sexuality of older people by offering the opportunity
for discussion.
Nurses need to open the door to discussions of
sexual concerns in a nonjudgemental manner,
helping those who want to continue to be sexually
active, and making it clear that stopping sex is an
acceptable option for others.

49. IMPLICATIONS FOR GERONTOLOGICAL
NURSING AND HEALTHY AGING
Assessment
 To assist and support older people in their sexual
needs, nurses should
 Be aware of their own feelings about sexuality and
their attitudes toward intimacy and sexuality in older
people
 Be an educator and provide information and
guidance to older people who need it
 Anticipation of problems in older individuals’ sexual
experiences can ward off anxiety, misconceptions, and
an arbitrary cessation of sexual pleasure
45

50. MENTAL HEALTH IN OLDER
ADULTHOOD
According to the World Health Organization
(WHO, 2007), mental health is “a state of well-
being in which every individual realizes his or
her own potential, can cope with the normal
stresses of life, can work productively and
fruitfully, and is able to make a contribution to
her or his community.”

51. 4
MENTAL HEALTH CARE
One in five Canadians experiences mental illness at
some time in their lives.
The most prevalent mental health problems are
 Anxiety
 Severe cognitive impairment
 Mood disorders
 Alcohol abuse and dependence

52. ASSESSMENT AND MENTAL ILLNESS
Observation of appearance
Behaviour and examination of cognitive function
Functional abilities
Anxiety
Adjustment
Reactions
Depression
Substance abuse
Suicidal risk
6

53. MENTAL ILLNESS IN THE
ELDERLY
Anxiety Disorders
Obsessive-Compulsive Disorder
Post-Traumatic Stress Disorder
Psychosis
Paranoia
Delusions
Hallucinations
Schizophrenia
Bipolar Disorder and Mania
Suicide

54. 54
COGNITIVE DISORDERS
Delirium Acute state of confusion; sudden
onset
Dementia Generalized impairment of
intellectual functioning
Depression A mood disturbance characterized
by feelings of sadness and despair

55. DELIRIUM
Delirium is sudden severe confusion and rapid
changes in brain function that occur with
physical or mental illness
Two most common causes are UTIs and
pneumonia
Reversible

56. DEMENTIA
Dementia is a general term for a decline in
mental ability severe enough to interfere with
daily life.
Alzheimer's is the most common type of
dementia
Progressive, debilitating, chronic disease

57. 21
DEPRESSION
Not a normal part of aging
Depression is the most common mental health
problem in later life and remains underdiagnosed
and undertreated.
Factors of health, gender, developmental needs,
socioeconomics, environment, personality, losses,
and functional decline are all significant to
development of depression in later life.
Causes are biological, such as neurotransmitter
imbalances or dysregulation of endocrine function.
Older people who are depressed report more somatic
complaints - physical symptoms such as insomnia,
loss of appetite and weight loss, memory problems,
or persistent pain.

58. 23
IMPLICATIONS FOR GERONTOLOGICAL
NURSING AND HEALTHY AGING
Assessment
 A systematic and thorough evaluation using a depression
screening instrument
 Interview
 History and physical
 Functional assessment
 Cognitive assessment
 Laboratory tests
 Medication review
 Determination of iatrogenic or medical causes
 Family interview

59. AS A LARGE GROUP…
Identify strategies that might be used to
promote mental health and wellness in late life.

60. NEXT WEEK….
Application of the Nursing Process
Documentation
QUESTIONS?