Stress Handout

SCHOOL OF NURSING
RN-BSN PROGRAM

COLLEGE
OF
HEALTH
AND URBAN AFFAIRS

COURSE
DESCRIPTION

GENERAL INFO REQUIREMENTS

SCHEDULE
DUE DATES

RN-BSN MAIN PAGE

Transition to Professional Nursing
STRESS/COPING

To e-mail the instructor phillips@fiu.edu

CLASS HANDOUT

DEFINITION OF STRESS

A universal phenomenon experienced by the person as a unified being who responds in totality
(mind and body) to change.
The effects of stress encompass the person's physical, emotional, intellectual, social and spiritual
dimensions.
Stress may be a stimulus, a response, and/or a transaction.

STRESS AS A STIMULUS

A life event, or a set of circumstances causing a disrupted response that increases an individual's
vulnerability to illness.
A stressor.

STRESS AS A RESPONSE

A reaction to a noxious stimulus or stressor.
Produces effects on the body--general and/or local adaptation (stress syndrome).
General Adaptation Syndrome (GAS)--the body's general response is characterized by a predictable
chain or pattern of physiological events.
Local Adaptation Syndrome (LAS)--the body's local response, such as inflammation.
Stages of GAS and LAS:
- Alarm reaction
- Resistance
- Exhaustion

STRESS AS A TRANSACTION
Lazarus's Model

Emphasizes the individuality of reactions to potential and actual stressors.
Stress is defined as a particular relationship between the person and environment that is appraised by the
person as taxing or exceeding the person's resources and endangering well-being.
Includes cognitive appraisal and mental and psychological responses as well as physiological responses.
The individual responds to perceived environmental changes by adaptation or coping responses.

Nuernberger's Model

Stress is a state of internal imbalance reflecting the unrelieved dominance of either the sympathetic NS
(fight or flight) or inhibition by the parasympathetic NS (possum response).
The primary source of stress is a person's internal state of mind--emotional, perceptual factors, thought
patterns that form a person's basic personality.
Stress occurs when arousal is not balanced by relaxation (inhibition) or not balanced by activity.
Prolonged parasympathetic imbalances are associated with diseases such as depression.
Prolonged sympathetic imbalances are associated with diseases such as cardiovascular disease.

MANIFESTATIONS OF STRESS

Stress manifestations are considered coping mechanisms (strategies).
Coping is the immediate response to a changing or threatening situation.
Adaptation is the final response or change that occurs.
Effective coping results in adaptation; ineffective coping results in maladaptation.
Coping strategies can be long-term or short-term. Short-term strategies can reduce stress temporarily,
but may be detrimental in the long-term.

TYPES OF STRESS MANIFESTATIONS
Physiological manifestations
Changes in heart rate, BP, muscle tension, mental alertness, diaphoresis.

Psychological manifestations
Include anxiety, anger, cognitive behaviors, verbal and motor responses, unconscious ego defense
mechanisms.

Anxiety

Anxiety is manifested as mild, moderate, severe or panic.
Anxiety differs from fear in that:
- Its source is not identifiable.
- It is related to the future.
- It is vague.
- It is the result of psychological/emotional conflict.

SIGNS OF MILD, MODERATE AND SEVERE ANXIETY

SIGN	MILD ANXIETY	MODERATE ANXIETY	SEVERE ANXIETY
Verbal	Expresses concern. Increased information-seeking.	Expresses apprehension. Nervousness. Voice tremors and pitch changes. Increased rate of verbalization.	Expresses dread, helplessness. Absence of verbalization. Inappropriate verbalization (laughing).
Motor	Mild restlessness.	Pacing. Hand tremor. Increased muscle tension.	Immobilization. Purposeless activity. Rigid posture.
Perception Attention	Increased awareness. Increased attending.	Narrow focus of attention. Ability to focus on what is happening.	Fixed or scattered focus. Intent or fearful watching of all activity. Inability to focus on reality—denial. Intellectualizing.
Physiological	Nil	Rapid pulse Increased respiratory rate Diaphoresis. Irritability. Sleep or eating disturbances.	Tachycardia./Palpitations. Hyperventilation. Dilated pupils Clammy hands and skin. Dry mouth

Anger

Communicated through verbal and overt actions.
Can be manifested as hostility, aggression or violence.
Constructive expressions of anger includes:
- Alerting--engaging another's attention.
- Describing--delineating source of angry person's feelings.
- Identifying--seeking response and support from others.

Verbal/Motor responses

Examples are crying, verbal abuse, screaming, hitting/kicking, holding/touching.
Releases tension; beneficial if not harmful to others and followed by problem-solving.

Cognitive behaviors
Includes problem-solving, structuring, self-discipline, suppression, fantasy, or prayer.

Problem-solving--assessing, analyzing, choosing alternatives, carrying out chosen alternative(s), evaluating.
Structuring--manipulation of a situation so threatening event(s) do not occur.
Self-discipline—assuming a manner that conveys a sense of being in control/charge, no matter what the situation.
Suppression--consciously and willfully putting a thought or feeling out of the mind.
Fantasy--unfulfilled wishes and desires are imaged as fulfilled.
Prayer--usually involves identifying the problem, suggesting solutions, reaching out for support and help.

Unconscious Ego Defense mechanisms

Working of the unconscious mind to protect the person from anxiety.
Are considered precursors to conscious cognitive coping mechanisms that ultimately solve the problem.

EXAMPLES OF UNCONSCIOUS EGO DEFENSE MECHANISMS

MECHANISM	DESCRIPTION	ADAPTIVE USE	MALADAPTIVE USE
Denial	Reality is disregarded or transformed so it is no longer threatening.	A man does not immediately acknowledge he has cancer even though told.	A man who has cancer does not follow prescribed treatment.
Compensation	Substituting an activity for one the person cannot do.	A student who can’t participate in athletics attains high grades.	A woman abuse alcohol to make up for feelings of inadequacy.
Repression	Excluding from consciousness, those things that conflict with the self-image.	A woman forgets a repugnant work assignment.	A man develops amnesia.
Conversion	Transforming a mental conflict into a physical conflict.	Before taking a math exam, a student develops a headache.	A girl develops an inability to speak in the context of protecting a sexually abusive father.

NURSES AND BURNOUT
Etiology

Constant and intense interaction with people you are trying to help.
Two many contacts—overload.
High level of difficult patients.
Monotony—no variety in job.
Lack of recognition.
Constant competition.
Crowded, noisy working conditions.
Lack on control.
Lack of training.
High ideals and expectations.
Meaningless work.

Symptoms

Distancing from peers.
Negative attitudes toward people.
Dehumanization of patients.
Easy loss of temper.
Feelings of hopelessness, entrapment.
Pessimistic about life and work.
Increased reliability on crutches (alcohol, drugs, caffeine).
Chronic exhaustion.
Susceptible to illness, colds.
Overreaction to annoyances.
Easily distracted.
Psychosomatic symptoms.
Suicidal thoughts.

Treatment

Talk about it.
Lower level of aspirations, accept limitations.
Exercise. Eat nutritiously.
Engage in relaxation strategies on a routine basis.
Take vacations.
Vary work patterns, or if possible, the work environment.
Separate work from rest of life. “Leave it at work.”
Take steps to improve the working conditions.
Join support groups.

FACTORS INFLUENCING THE MANIFESTATIONS OF STRESS

Nature of the stressor.
Perception of the stressor.
Number of stressors.
Duration of exposure to the stressor.
Experience with comparable stressors.
Age of individual.
Assistance from support people.
Hardiness of individual.
Personality type of individual:
- Personality A--feels constant pressure, hurried, impatient; prone to cardiovascular dz.
- Personality B--relaxed, enjoy work and play.
- Personality C--sustains considerable stress, but has learned to cope with it.

COPING
Homeostasis
Tendency of body to maintain equilibrium or balance.

Physiological homeostasis
Mechanisms are:

Self-regulating.
Compensatory (counterbalancing) which counteract abnormal conditions.
Regulated by negative feedback mechanisms (inhibiting change to bring system back to stability).
May require several feedback mechanisms to correct on imbalance.

Psychological homeostasis
Requires a:

Stable physical environment.
Stable psychological environment.
Social environment with healthy role models.
Life experience that includes satisfactions.

ADAPTATION
Modes of adaptation

Physiological
Psychological
Sociocultural
Developmental

Characteristics of adaptation responses

All responses attempt to maintain homeostasis.
Responses involve the whole body.
Adaptation responses have limits.
Adaptation requires time.
Adaptability varies from person to person.
Adaptive responses may be inadequate or excessive.
Adaptive responses are egocentric and tiring.

THE NURSING PROCESS RELATED TO STRESS/COPING

ASSESSMENT
Assess for patterns:

Number and type of stressors.
Length of time in dealing with stressors.
Coping strategies.
Coping strategies that have worked.

SAMPLE NURSING DIAGNOSES

Ineffective coping (individual, family)
Altered family processes
Impaired adjustment
Anxiety
Spiritual distress
Knowledge deficit
Impaired verbal communication
Post-trauma response
Altered role performance
Risk for violence (self, others)
Self-care deficit
Hopelessness
Fatigue
Fear
Low self-esteem
Rape trauma syndrome
Decisional conflict

PLANNING
Overall goals

Minimizing anxiety or mediating anger.
Identifying coping mechanisms most useful to the client.
Identifying meaningful support persons who can help.
Planning stress reduction measures.

Example: The client (Example: will demonstrate decreased anxiety) as evidenced by:

Verbalizing awareness of feelings of anxiety.
Experiencing a reduction in the manifestations of anxiety (specify).
Using adaptive coping mechanisms to reduce anxiety (specify), etc.

INTERVENTIONS
Minimizing anxiety

Convey caring/understanding.
Orient to surroundings.
Maintain client's identity.
Provide sufficient information.
Repeat information.
Encourage client's participation.
Allow time for verbal expression.
Ensure that expectations are within capabilities.
Be sensitive to situations that increase anxiety.
Assist in client making correct appraisal.
Provide for independent functioning.
Reinforce positive environmental factors.
Arrange for other clients with similar conditions to visit.
Provide smooth transition to community support.
Communicate competence and empathy.

Mediating anger

Focus on feeling words of client.
Note general content of message.
Restate the feeling and content of client's communication.
Observe the client's body language.
Place yourself in client's position.

Use of stress management techniques (mind-body therapies)

Humor
Progressive Relaxation
Guided Imagery
Aromatherapy
Biofeedback
Meditation
Yoga
Prayer
Hypnosis
Music Therapy
Exercise