The document outlines the concept of stress, its various forms, sources, and impacts on individuals, including physical, emotional, social, and spiritual consequences. It discusses coping strategies and mechanisms to handle stress, differentiating between problem-focused and emotion-focused coping, as well as adaptive and maladaptive coping styles. Additionally, the document emphasizes the importance of recognizing stress indicators and provides nursing interventions for managing anxiety.

1. Objectives:
 At the end of this unit, Learner will be able to:
1. Define stress and the different forms people can
experience
2. Describe common risks factors causing stress
3. Learn about techniques to reduce the stress
4. Describe what coping is, what coping strategies are, and
coping styles
5. Understand how individuals become resilient (Adapt)
Concept of Stress & Coping

2. Stress and coping
Introduction :
Stress is universal phenomenon .
All people experience it.
 Parents refer to the stress of raising children ,
 Working people talk about the stress of their job, at students at all
levels talk of the stress of school .
stress can result from both positive and negative
experience.
For example :
A bride preparing for her wedding ,
A graduate preparing to start new job.

3. The concept of stress is important because it provides a way
of understanding the person as a being who respond in
totality ( Mind , body , and spirit ) to a variety of changes
that take place in daily life .
Concept of stress :
Stress is a condition In which the person experience changes
in normal balanced state .
Stressor is any event or stimulus that caused as individual to
experience stress .
Coping
When a person face stressors , responses are referred to as
coping strategies ,coping responses , or coping mechanisms .

4. Sources of Stress :
There are many sources of stress such as
Internal stressors : internal stressors originate within person, e.g.
infection or feelings of depression.
External stressors : External stressors originate outside the
individual , e.g. a move to another city , a death in the family or
pressure from peers .
Developmental stressors : Developmental stressors occur at
predictable times throughout an individual’s life .
Situational stressors : Situational stressors are unpredictable and
may occur any time during life. e.g.
Death of a family member .
Marriage or divorce.
Births of a child.
New job.
Illness.

5. Internal stressors Death in the family
Alcohol
& job
stress

6. Effect of stress
Stress can have Physical, Emotional ,Intellectual , Social and spiritual
consequences
 Physically stress can threaten a person’s physiological
homeostasis .
Emotionally stress can produce negative or no constructive
feelings about the self.
Intellectually stress can influence a person’s perceptual
and problem solving abilities.
Socially stress can alter a person’s relationship with others.
Spiritually stress can challenge one’s beliefs and values.

7. Models of Stress
 Models of stress
assist nurses to
predict stressors in a
 Particular situation
and to understand
the individual’s
responses
 Three main models
of stress
1. Stimulus based
2. Response based
3. Transaction based
1-Stimulus based model
 Stress is define as a stimulus a life event,
or a set of circumstances that arouses
physiologically and/or psychologically
reactions that may increase the
individual’s vulnerability to illness.
 Such as a divorce, pregnancy and retirement.
In this view both positive and negative event
are considered stressful.
 For example, a divorce may be highly
traumatic to one person and cause relatively
little anxiety to another. In addition many
scales have not been tested for age,
socioeconomic status or cultural sensitivity.

8. 2-RESPONSE BASED MODELS
Stress may also be considered as a response .
This definition was developed and described by selye (1956, 1976)
as “the nonspecific response of the body to any kind of demand
made upon it”
Selye’s stress response is characterized by a chain or pattern of
physiological event called the general adaptation syndrome(GAS) or
stress syndrome .
To differentiate the cause of stress from the response to stress,
Selye (1976) used the term stressor to denote any factor that produce
stress and disturbs the body’s equilibrium.
Stress can be observed only by the changes it produce in the body .
The response of the body , the stress syndrome or GAS , occurs with
the release of certain adaptive hormones and subsequent changes
in the structure and chemical composition of the body .

9. Gastrointestinal tract .
Adrenalin gland .
Lymphatic structures .
Deep ulcers appear in the lining of stomach .
Adrenal gland enlarge considerably .
Lymphatic structure such as the ( thymus ,spleen , and
lymph node) .
In the addition to adaption globally , the body can also
react locally ; that is , one organ or a part of the body
reacts alone . This is referred to as the Local adaptation
syndrome (LAS) . E.g. Inflammation .
Effected point :

11.  The stress may be perceived consciously or
unconsciously by the person.
 Stressor stimulate the sympathetic nervous system,
which in turn stimulate the hypothalamus .
 The hypothalamus releasing corticotrophin releasing
hormone , which stimulate anterior pituitary gland to
release adrenocorticotrophic hormone .
 During the time of stress the adrenaline medulla secrets
epinephrine and nor epinephrine in response to
sympathetic stimulation .
 Significant body response to epinephrine include the
following .
1. Shock phase

12.  Increase myocardial contractility, which increase the
cardiac output in blood flow to the active muscle .
 Bronchial dilation which always increase the oxygen
intake.
 Increase the blood clotting .
 Increase the cellular metabolism .
 The principal effect of nor epinephrine is decrease blood
to the kidneys in increasing secretion renin . Renin is an
enzyme that hydrolyze one of the blood proteins to
produce angiotensin .
 Angiotensin tends to increase the blood pressure by
constricting arterioles . The person is then ready for “
flight or fight”

13. 2 . Counter shock phase
The second part of the alarm reaction is called counter
shock . during this time , the changes produce in the
body during the shock phase are reverse . Thus , a
person is best mobilize they react during the shock phase
of the alarm reaction.
Stage of resistance :
The second stage in the GAS and LAS syndromes the
stage of resistance, in when the bodies adaptation take
place . In other word ,the body attempts cope with the
stressor and to limit the stressor to the smallest area of
the body that can deal with it .

15.  During the third stage , the stage of exhaustion, the
adaptation that the body made during the second stage
cannot be maintain .
This means that the ways used to cope with the stressor
have been exhaustion .
If adaptation has not overcome the stressor , the stress
may spread to the entire body .
It the end of this stage , the body may either rest and
return to the normal , or death may be ultimate
consequence .
3. Stage of exhaustion :

17. 3-Transaction Based Model
 Transactional stress theory encompasses a set of
cognitive, effective , and adaptive coping response that
arise out of the person environment transaction .
The person and the environment are inseparable; each
effects and is effected the other .
Stress “ refers to any event in which environmental demand
, internal demand , or both tax are exceed the adaptive
resources of an individual , social system , or tissue system”
The individual responds to perceived environmental
changes by adaptive or coping responses.

18. Indicator of stress
Indicators of an individual’s stress may be physiological
psychological , or cognitive .
Responses to stress vary
depending on the individual’s
perception of events. The
physiologic signs and
symptoms of stress result from
activation of the sympathetic
and neuroendocrine systems
of the body.
Box 42.1 lists physiologic
indicators of stress.

19. Psychological indicator:
Psychological manifestations
of stress include
 Anxiety,
 Fear,
 Anger,
 Depression
 Unconscious ego defense
mechanisms .
Some of the coping patterns are
helpful ; others are a hindrance ,
depending on the situation and
the length of time they are used
or experienced .
Anxiety
Anxiety :
A state of mental uneasiness ,
apprehension,dread,or a feeling
of helplessness related to an
Impending or anticipated
unidentified threat to self or
significant relationships .
Anxiety may be manifested
on four levels .
1) Mild anxiety
2) Moderate anxiety
3) Severe anxiety
4) Panic

20. 1. Mild anxiety: produces
a slight arousal that
enhances perception ,
learning ,and productive
abilities
2.Moderate anxiety:
increases the arousal to a
point where the person
expresses feelings of
tension , nervousness , or
concern .
3. Severe anxiety : consumes most of the persons
energies and requires intervention . Perception is further
decreased . The person , unable to focus on what is really
happening , focuses on only one specific detail of the
situation generating the anxiety .
4.Panic : panic is an overpowering , frightening level of
anxiety causing the person to lose control .

24. Anxiety and fear differ in four ways:
The source of anxiety may not be identifiable ; the source
of fear is identifiable .
Anxiety is related to the future that is to an anticipated
event . Fear is related to the past ,present and future .
Anxiety is vague , whereas fear is definite .
Anxiety is the result of psychological or emotional conflict
; fear is the result of specific of physical or psychological
entity.
Fear : Fear is an emotion or feeling of apprehension
aroused by impending or seeming danger , pain or another
perceived threat .

25. Anger:
Anger is an emotional state consisting of a subjective
feeling of animosity or strong displeasure .
Anger differs from hostility , aggression , and violence ,
but at can lead to destructiveness and violence if the anger
persists unabated.
Depression:
Depression is a common reaction to events that seem
overwhelming or negative .
Depression an extreme feeling of sadness,despair,dejection
lack of worth,or emptiness,affects millions of Americans a
year .
Differentiation between Anger &depression :

26. Signs and symptoms
Emotional
symptoms :
Feeling of tiredness
.
Sadness .
Emptiness or
numbness .
Behavioral signs :
Irritability .
Inability to
concentrate .
Crying .
Ego defense mechanisms are unconscious
psychological adaptive mechanisms or
according to Anna Freud (1967), mental
mechanisms that develop as the personality
attempts to defend itself , establish ,
compromises among conflicting impulses ,
and calm inner tensions .
Defense mechanisms are the unconscious
mind working to protect the person from
anxiety .
They can be considered precursors to
conscious cognitive coping mechanisms that
will ultimately solve the problem . Like
some verbal and motor responses , defense
mechanisms release tension .
Ego Defense mechanisms :

29. Cognitive indicators :
cognitive indictors of stress
are thinking response that
include
problem solving .
structuring .
self-control or self-
discipline.
Suppression.
fantasy .
1-Cognitive problem :
cognitive problem involves thinking
through the threatening situation , using
specific step to arrive at a solution . The
person assesses the situation or problem ,
analyzes or defines it , chooses alternative ,
carries out the selected alternative ,and
evaluates weather the solution was
successful .
2-Structuring :
structuring is the arrangement or manipulation of a situation so that
threatening events do not occur .
For example,
 A nurse can structure or control an interview with a client by asking only
direct, structuring can be productive in certain situations .
 A person who schedules a dental examination semiannually to prevent
severe dental disease is using productive structuring.

30. 3-Self control (discipline)
 Self control (discipline) is assuming a manner and facial expression that
convey a sense of being in control or in charge.
 When self control prevents panic and harmful or nonproductive action in
a threatening situation , it is a helpful response that conveys strength.
4-Suppression
 Suppression is consciously and willfully putting a thought or feeling out of mind .
 I wont deal with that today . I will do it tomorrow .
 This response relieves stress temporarily but does not solve the problem .
 A ma who keeps ignoring a toothache, pushing it out of his mind because he fears the pain
of having a filling , will not obtain relief of his symptoms.
5-Fantasy or daydreaming
Fantasy or daydreaming is linked to make believe
Unfulfilled wishes and desires are imagined ass fulfilled ,or a threatening experience
is reworked or replayed so that it ends differently from reality
For example : a client who is waiting the results of a breast biopsy result might say
to herself ,Even if the doctor says , you have cancer , as long as he also says it can be
treated . I can accept that . Fantasies can be destructive and nonproductive if a person
uses them to excess and retreats from reality.

31. Coping may be described as dealing with change
successfully or unsuccessfully .
A coping strategy (coping mechanism) is a natural or
learned way of responding to a changing environment or
specific problem or situation.
According to Folkman and Lazarus (1991) coping is “the
cognitive and behavioral effort to manage specific
external and/or internal demands that are appraised as
taxing or exceeding the resources of the person.
Coping

32. 1)Problem focused coping
Problem focused coping refers to efforts to improve a
situation by making changes or taking some action.
2)Emotion focused Coping
Emotion focused coping includes thoughts and action that
relieve emotional distress.
Emotion focused coping does not improve the situation but
the person often feels better.
Both types of strategies usually occur together
(Lazarus2006).
Coping strategies

33. Coping strategies may be involves :
1-Long term coping strategies
Long term coping strategies can be constructive and practical.
For example:
 In certain situation talking with others and trying to find out more about
the situation are long term strategies.
 Others long term strategies include a change in lifestyle pattern such
as eating a healthy diet , exercising regularly ,balancing leisure time
with working , or using problem solving in decision making instead of
anger or other non constructive responses.
2) Short term coping strategies
Short term coping strategies can reduce stress a tolerable limit temporarily
but are ineffective ways permanently deal with reality . they may even have
a destructive detrimental effect on the person.
Example of short term strategies are using alcoholic beverages or drugs
daydreaming and fantasizing ,relying on the belief that everything will
work out, and giving in to others to avoid anger.

34. Coping can be
A .Adaptive coping :
Adaptive coping helps the person
to deal effective with stressful
events and minimizes distress
associated with them.
B .Maladaptive coping :
Maladaptive coping can result in
unnecessary distress for the
person and others associative
with the person or stressful event .
 Effective coping :
is results in adaptation ;
Ineffective coping :
is result in maladaptation.
Although the coping behavior
may not always seem appropriate ,
the nurse needs to remember that
coping is always purposeful .
The effectiveness of an individual’s
coping is influenced by a number of
factors , including :
The number , duration , and
intensity of the stressor
Past experiences of the individual .
Support systems available to the
individual .
Personal qualities of the person .

35. Caregiver Burden
 If the duration of the stressor is extended beyond the
coping powers of the individual , that person becomes
exhausted and may develop increased susceptibility to health
problem.
 Reaction to long –term stress is seen in family members
who undertake the care of a person in home for a long period .
 This stress is called caregiver burden and produces
responses such as chronic fatigue , sleeping difficulties and
high blood pressure .
 Prolonged stress can also result in mental illness . A coping
strategies or defense mechanisms become ineffective , the
individual may have interpersonal problem , work difficulties
,and a significant decrease in the ability to meet basic human
need.

38. Interventions Rationales
Recognize awareness of the patient’s
anxiety.
Since a cause of anxiety cannot always be identified, the patient
may feel as though the feelings being experienced are
counterfeit. Acknowledgment of the patient’s feelings validates
the feelings and communicates acceptance of those feelings.
Use presence, touch (with
permission), verbalization, and
demeanor to remind patients that they
are not alone and to encourage
expression or clarification of needs,
concerns, unknowns, and questions.
Being supportive and approachable promotes communication.
Familiarize patient with the
environment and new experiences or
people as needed.
Awareness of the environment promotes comfort and may
decrease anxiety experienced by the patient. Anxiety may
intensify to a panic level if patient feels threatened and unable to
control environmental stimuli.
Interact with patient in a peaceful
manner.
The nurse or health care provider can transmit his or her own
anxiety to the hypersensitive patient. The patient’s feeling of
stability increases in a calm and non-threatening environment.
Nursing Interventions for Anxiety
Nursing interventions for Anxiety can apply to any individual with anxiety, regardless of etiologic and
contributing factors. Here are the common nursing interventions for the Anxiety nursing diagnosis:

39. Recommend patient to keep a log of episodes
of anxiety. Instruct the patient to describe
what is experienced and the events leading up
to and surrounding the event. The patient
should note how the anxiety dissipates.
Recognition and exploration of factors leading to or reducing anxious
feelings are important steps in developing alternative responses. The patient
may be unaware of the relationship between emotional concerns and
anxiety. If the patient is comfortable with the idea, the log may be shared
with the health care provider, who may help the patient develop more
effective coping strategies. Symptoms often provide the health care
provider with information regarding the degree of anxiety being
experienced.
Encourage the patient to consider positive self-
talk like “Anxiety won’t kill me,” “I can do
this one step at a time,” “Right now I need to
breathe and stretch,” “I don’t have to be
perfect.”
Cognitive therapies focus on changing behaviors and feelings by changing
thoughts. Replacing negative self-statements with positive self-statements
aids to reduce anxiety.
Consider the patient’s use of coping strategies
that the patient has found effective in the past.
This enhances the patient’s sense of personal mastery and confidence.
Avoid unnecessary reassurance; this may
increase undue worry.
Reassurance is not helpful for the anxious individual.
Assist the patient in developing new anxiety-
reducing skills (e.g., relaxation, deep
breathing, positive visualization, and
reassuring self-statements).
Discovering new coping methods provides the patient with a variety of
ways to manage anxiety.
Explain all activities, procedures, and issues
that involve the patient; use nonmedical terms
and calm, slow speech. Do this in advance of
procedures when possible, and validate
patient’s understanding.
With preadmission patient education, patients experience less anxiety and
emotional distress and have increased coping skills because they know
what to expect. Uncertainty and lack of predictability contribute to anxiety.

40. Intervene when possible to eliminate
sources of anxiety.
Anxiety is a normal response to actual or perceived danger; if the
threat is eliminated, the response will stop.
Accept patient’s defenses; do not dare,
argue, or debate.
If defenses are not threatened, the patient may feel secure
and protected enough to look at behavior.
Converse using a simple language and
brief statements.
When experiencing moderate to severe anxiety, patients
may be unable to understand anything more than simple,
clear, and brief instruction.
Reinforce patient’s personal reaction to
or expression of pain, discomfort, or
threats to well-being (e.g., talking,
crying, walking, other physical or
nonverbal expressions).
Talking or otherwise expressing feelings sometimes
reduces anxiety.
Lessen sensory stimuli by keeping a
quiet and peaceful environment; keep
“threatening” equipment out of sight.
Anxiety may intensify to a panic state with excessive
conversation, noise, and equipment around the patient.
increasing anxiety may become frightening to the patient
and others.
Help patient determine precipitants of
anxiety that may indicate interventions.
Obtaining insight allows the patient to reevaluate the threat
or identify new ways to deal with it.

41. Allow patient to talk about anxious
feelings and examine anxiety-
provoking situations if they are
identifiable.
Talking about anxiety-producing situations and anxious
feeling can help the patient perceive the situation
realistically and recognize factors leading to the anxious
feelings.
Instruct the patient in the appropriate use of
antianxiety medications.
Short-term use of antianxiety medications can enhance patient
coping and reduce physiological manifestations of anxiety.
Benzodiazepines
Drugs in this group work through enhancing the action of the
inhibitory neurotransmitter gamma-aminobutyric acid (GABA).
These drugs are recommended for short-term use, not to exceed 3
to 4 months. Physical dependence and tolerance are problems
associated with prolonged use of these drugs.
Buspirone HCl (BuSpar)
This drug has fewer side effects and less risk for dependence than
the benzodiazepines. The drug has a slower onset of action and may
take 1 to 2 weeks to produce a noticeable therapeutic effect.
Selective serotonin reuptake inhibitors
(SSRIs)
Several drugs in this group have been approved by the Food
and Drug Administration (FDA) for use in the management
of panic disorder Their use in treatment of other types of anxiety is
being investigated.
Nonselective beta-blockers and alpha-2-
receptor agonists
Beta-blockers are effective in managing the physical symptoms of
anxiety that occur with the social phobias (e.g., stage fright). The
alpha-2 agonists are used to manage anxiety associated with
withdrawal from nicotine and opioids.

42. Tell the patient to limit use of central
nervous system stimulants.
Stimulants (e.g., caffeine, nicotine, theophylline, terbutaline sulfate,
amphetamines, and cocaine) can increase physical symptoms of anxiety.
Provide massage and backrubs for patient to
reduce anxiety.
This aids in reduction in anxiety.
Provide patients with a means to listen to
music of their choice.
Music is a simple, inexpensive, esthetically pleasing means of alleviating
anxiety.
Rule out withdrawal from alcohol, sedatives,
or smoking as the cause of anxiety.
Withdrawal from these substances is characterized by anxiety.
Educate patient and family about the
symptoms of anxiety.
If patient and family can identify anxious responses, they can intervene
earlier than otherwise.
Teach patient to visualize or fantasize about
the absence of anxiety or pain, successful
experience of the situation, resolution of
conflict, or outcome of procedure.
Use of guided imagery has been useful for reducing anxiety.
Teach use of appropriate community
resources in emergency situations (e.g.,
suicidal thoughts), such as hotlines,
emergency rooms, law enforcement, and
judicial systems.
The method of suicide prevention found to be most effective is a
systematic, direct-screening procedure that has a high potential for
institutionalization.

43. Assessment Diagnosis planning Implementin
g
Rational Evalution
.
Nursing Diagnosis Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an
autonomic response (the source often nonspecific or unknown to the individual); a feeling of
apprehension caused by anticipation of danger. It is an alerting signal that warns of
impending danger and enables the individual to take measures to deal with the threat.

44. Assessment Diagnosis planning Implementin
g
Rational Evalution
.