Definition of the TermsStress• 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.
• 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.
• 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 lifes 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”.
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.
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
• 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
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.
Local Adaptation SyndromeDefinition• 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
General Adaptation SyndromeDefinition• Physiological response of the whole body to stress• Involves several body systems, primarily the autonomic nervous system and endocrine systemStages• Alarm Reaction (AR)• Resistance stage (SR)• Exhaustion stage (ES)
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
• 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
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.
• Overuse by the bodys 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
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
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.
• 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
Difference between Stress and Crisis Stress Crisis1. 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
Difference between Stress and Crisis Stress Crisis5. 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, itbecomes stress over time.
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.
Fear: Threat can lead to fear, which againleads to stress.Fear leads to imagined outcomes, which arethe real source of stress.Uncertainty: When we are not certain, we areunable to predict, and hence feel we are notin control, and hence may feel fear or feelthreatened by that which is causing theuncertainty.
• 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).
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
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
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
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
• Technological change• Uncomfortable workplace• Working long hours• Lack of training On-off incidents
Causes of StressThe causes of stress depends on the perception of it. Something thats stressful to one person may not disturb other; he/she may even enjoy it.Common external causes of stressNot all stress is caused by external factors. Stress can also be self-generated:• Major life changes• Work• Relationship difficulties
• Financial problems• Being too busy• Children and familyCommon internal causes of stress• Inability to accept uncertainty• Pessimism• Negative self-talk• Unrealistic expectations• Perfectionism• Lack of assertiveness
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
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
Emotional Symptoms• Moodiness• Irritability or short temper• Agitation, inability to relax• Feeling overwhelmed• Sense of loneliness and isolation• Depression or general unhappiness
Cognitive Symptoms• Memory problems• Inability to concentrate• Poor judgment• Seeing only the negative• Anxious or racing thoughts• Constant worrying
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)
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.
• 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.
• 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).
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.
• 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.
Measures to Reduce StressGeneral 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.
• 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.
• 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).
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
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.
• 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.
• 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.
• Organize life with priorities so that you will accomplish what must be done at the right time.• Develop healthy social relationship.• Practice coping statement
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
• A crisis situation may be dangerous for individual, may harm self or another• Crisis usually lasts one to six weeks.
Types of Crisis• Developmental crisis• Situational crisis• Cultural crisis• Community crisis
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.
• 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
Developmental Stage Developmental CrisisChild 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 becomeOlder adult Decreasing physical abilities and health, changes in residence, retirement and reduced income, death of spouse and friends etc.
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.
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
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
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
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
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
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
Factors Affecting Outcome of Crisis1. 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.
• 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.
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.
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.
• 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.
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.
• 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.
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.
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.
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.
Crisis InterventionGoals of crisis intervention are• To reduce the impact of stressful events• To help those affected with present problemsThere are 4 phases of crisis intervention techniques which are similar to nursing process
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
• 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.
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
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.
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
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.
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.
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.
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.