1. 9/15/2010
NURSING FUNDAMENTALS OBJECTIVES
FOCUS IV
• Explain the relationship between stress and stressors
• Identify the physiological behaviors (responses) to stress
and the endocrine actions responsible for the behavior
• Describe the psychological responses to stress
Stress Adaptation Process • Discuss the effects of prolonged exposure to stress
• List some of the ways to reduce or manage stress
STRESS STRESS
DISORDERS CAUSED BY STRESS STRESS AND STRESSORS
Stress?
Stressor?
(From Health and Wellness: A Holistic
Approach, 9th ed. (p. 46), by G. Edlin
and E. Golanty, 2007, Boston: Jones &
Bartlett. Adapted with permission.)
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2. 9/15/2010
RELATIONSHIP BETWEEN STRESS
AND STRESSORS
RESPONSES TO STRESS
Factors influencing response to stress:
Psychological
Coping Strategies •
• coping, control, emotions, beliefs
• Physiological
Coping Responses • injuries, illness, infection, substances
• Social
• support, status, education
Coping Mechanisms
• Environmental
• pollution, hazards, extremes in temperatures
SOURCES OF STRESS
EFFECTS OF STRESS
• Affects the Whole Person
• Internal • Physically
• Infection • Threatens homeostasis
• Depression • Emotionally
• External • Negative feelings toward self
• Intellectually
• A move, a death, pressure from peers
• Perceptual and Problem-solving abilities
• Developmental
• Socially
• Predictable • Relationships can be affected
• Situational • Spiritually
• Unpredictable - may be positive or negative • Challenges beliefs and values
CONCEPTS REGARDING
STRESS
STIMULUS-BASED MODELS
• Stimulus-based models • Stress defined as a stimulus, a life event, or set of
circumstances that arouses physiologic/psychologic
• Response-based models reaction
• Transaction-based models • This stress may increase vulnerability to illness
• Both positive and negative events considered stressful
• Original work –– Holmes and Rahe - 1967
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3. 9/15/2010
TRANSACTION BASED MODELS
RESPONSE BASED MODELS
• Based on work of Lazarus (1966)
• Stress may be considered a response • Set of cognitive, affective, and adaptive (coping)
responses
• Selye (1956, 1976) defined as nonspecific
• arise out of person-environment transactions
response of body to any kind of demand
• Person and environment are inseparable
made upon it
• each affects and affected by the other
• Stress
• any event in which environmental and/or internal demands
tax adaptive resources of individual, social system, or tissue
system
GENERAL ADAPTATION SYNDROME
GENERAL ADAPTATION SYNDROME (GAS)
THEORY
• Dr. Hans Selye - 1907-1982 • Differentiates cause of stress from the response
of stress
• Endocrinologist
• Stressor
• Director of Medicine and Surgery @
University of Montreal until 1976
• Produces stress
• Disturbs body’’s equilibrium
• Founded the Institute of Stress 1977
• Stress is state of the body
• General Adaptation Syndrome Theory • Observed by changes produced in body
• Based on experimentation with rats • Hormones released
• Chain or pattern of physiologic events • Body changes in structure and chemical composition
• GI tract, Adrenal glands, lymphatic structures
LOCAL ADAPTATION SYNDROME PHYSIOLOGIC RESPONSE TO
(LAS) STRESS
• Generalized Adaptation Syndrome
• Body can also react locally
• Alarm Reaction
• One organ or part of body • short term, acute, response
• Inflammation • Resistance
• intermediate hormonal response
• Exhaustion
• 3 stages of GAS and LAS • prolonged worry/fatigue/breakdown
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4. 9/15/2010
SELYE’’S GENERAL ADAPTATION
SYNDROME
ALARM REACTION ALARM PHASE
• Body defenses alerted
• Shock phase
• Counter shock phase
(From Wellness: Concepts and Application, 6th ed. (p. 298), by D. J. Anspaugh, M. Hamrick, and F. D. Rosato, 2005, New York: McGraw-Hill. Reprinted with
permission.)
STAGE 2
STAGE 3
Resistance! Exhaustion!
Attempts to Adapt
Resources gone!!!
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5. 9/15/2010
SELYE DIAGRAM
PHYSIOLOGIC INDICATORS
Pupils dilate Urinary output decreases
Sweat production increases Mouth may be dry
Heart rate and cardiac Peristalsis of the intestines
output increase decrease for serious
Skin is pallid threats
Sodium and water retained Mental alertness improves
Rate and depth of Blood sugar increases
respiration increase
PSYCHOLOGIC RESPONSE TO STRESS
• Anxiety
• Fear
• Anger
• Depression
• Unconscious ego defense
mechanisms
PHYSIOLOGIC RESPONSE TO STRESS
COGNITIVE INDICATORS
LAS Characteristics:
• Problem solving Localized response does not involve body systems
• Structuring The response is adaptive, stress is needed to stimulate
• Self-control or self-discipline it
The response is short term.
• Suppression
The response is restorative LAS is in business of
• Fantasy assisting in homeostasis to the body region or part.
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6. 9/15/2010
PSYCHONEUROIMMUNOLOGY PSYCHONEUROIMMUNOLOGY
(PNI)
• Concerned with the interrelationship
• Dr. Robert Ader coined the concept in 1975
between the brain, behavior and
the immune system.
• Director of the Behavioral and Psychosocial Medicine
• Neuro-psychological, neuro-anatomic
at New York University of Rochester.
and psychosocial studies have
demonstrated their role in
• Dr Ader believes there is a link between our state of mind,
accentuating or diminishing
our health and our ability to heal ourselves.
immune/allergic responses
• He carried out his primary experimentation on mice with saccharin.
PSYCHONEUROIMMUNOLOGY PSYCHONEUROIMMUNOLOGY
Negative States Physiologic Reaction Positive
Bereavement Decreased lymphocyte proliferation Satisfying personal Increased lymphocyte function; increased NK activity;
relationships and social increased immunity by mitogen tests; increased immune
Pessimistic states Decreased lymphocyte reactivity; decreased T-cell effectiveness
support response to hepatitis B vaccine
Academic stress Decreased NK cell activity; decreased T-cells; decrease in certain Personal sharing and Increased lymphocyte response
immune chemicals; increased susceptibility to herpes virus; disclosure of traumatic
decreased immunoglobulin A; increased blood levels of Epstein- experiences
Barr virus.
Humor and laughter Increased Immunoglobulin A; increased lymphocyte count
Depression Decreased T-cells; decreased number and function of and activity
lymphocytes; decreased NK cells. Hypnosis and relaxation Increased T-cell effectiveness; increased NK cell activity;
Loneliness Decreased NK (Natural Killer Cell) activity techniques decreased blood levels of stress hormones; decreased blood
levels of herpes virus
Chronic stress Decreased T-cells; decreased NK cells; decreased B-cells;
increased blood levels of Epstein-Barr virus Physical exertion and Increased number of white blood cells; increase in
aerobic exercise endorphins; increase in certain immune chemicals; increased
Divorce/separation/ Decreased lymphocyte function; increased blood levels of NK cell number and activity; increased T-cells; decreased T-
poor marital quality Epstein-Barr virus; decreased T-cell effectiveness. cell effectiveness; decreased lymphocyte function
Expressed need for Decreased NK activity; decreased lymphocytes Group intervention and Increased NK cell number and activity; increased number of
power and control support lymphocytes; decrease in T-helper cells
PSYCHOLOGICAL RESPONSE TO STRESS
STAGES OF ANXIETY
ANXIETY
• Mild Anxiety
Mild • State of slight arousal
Moderate • increases perception, learning, productive abilities
Severe • seeking information and asking questions
Panic
Nursing approaches
http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH6e/Constructor/index.cfm?plan=4
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MODERATE ANXIETY
SEVERE ANXIETY
• Increased state of arousal • Communication that is • Easily distracted
• Feelings of tension, nervousness, concern difficult to understand • Severely impaired
• Increased motor learning
• Focuses on a particular aspect of a situation activity • Tachycardia
• Slight increased RR and HR • Inability to relax
• Hyperventilation
• Mild gastric symptoms • Fearful facial
• Headache
expression
• Inability to focus or • Dizziness
concentrate • Nausea
PROLONGED EXPOSURE TO STRESS
PANIC
Physiological effect
• Communication not • Perception distorted or
hypertension
understandable exaggerated
• Increased motor activity cardiovascular disorders
• Inability to learn or function
• Agitation migraine and tension headaches
• Dyspnea, palpitations,
• Unpredictable responses choking cancer
• Trembling arthritis
• Chest pain/pressure
• Poor motor coordination respiratory disease
• Overpowering, Frightening • Feeling of impending doom
• Paresthesia, sweating ulcers
• Person loses control
• Can distort events colitis
muscle tension problems
ASSESSMENT
PROLONGED EXPOSURE TO STRESS Physical data Psychosocial data
Increased heart rate Anger, loss of temper
Increased BP Helplessness
• Psychological effect • Behavioral effects Palpitations Powerlessness
• anxiety
• conduct disorders Headaches Resistance to treatment regimen
• panic attack Muscle tension and or testing
• depression • eating disorders GI disturbances Overuse of drugs
Withdrawn
• adjustment disorders • alcoholism Sleep disturbance
Unusual fatigue Nervousness
• hypochondria Restlessness Irritability
Complaints of anxiety
Over excited
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8. 9/15/2010
NURSING DIAGNOSIS
Ineffective coping
http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH6e/Constructor/index.cfm?plan=14
Ineffective denial
Ineffective family coping
Fear
http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH6e/Constructor/index.cfm?plan=19
Isolation
Physical dependency
Loss of control
Stress related to hospitalization
Sleep pattern disturbance
http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH6e/Constructor/index.cfm?plan=44
Physiological Evidence of Anxiety
RELATED FACTORS ……
Stressor itself
Hospitalization
Surgery
Diagnosis
Fiscal responsibilities
GOAL SETTING ASSESSING STRESS AND COPING
PATTERNS
Measurable short term and long term goal • Nursing History
is set to measure a change in behavior. • Client-perceived stressors or stressful incidents
• Manifestations of stress
• Past and present coping strategies
Behavior + change + timeframe
• Developmental transitions
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9. 9/15/2010
ASSESSING STRESS AND COPING ASSESSING STRESS AND COPING
PATTERNS PATTERNS
• Assessment interview • Physical Examination
• Scale to rate specific stressors • Verbal
• Duration of stressful situation • Motor
• Cognitive
• Usual strategy for handling stressful
• Other physical manifestations of stress
situations
• Effectiveness of these strategies
INTERVENTIONS
FACTORS INVOLVED WITH HEALING
• Interventions to increase coping skills • Education • Eliminate negative beliefs &
• Enhance social supports emotions
• Provide accurate
information • fear, rage, anger, guilt
• Protecting vulnerable self
• Positive attitude • Forgiveness
• Practicing adaptive thinking
• Problem solving
• Reducing stress
• Gaining control through knowledge • creating positive future
• Relaxation
• Interventions to aid in effectively manage stressors goals
• Exercise • Positive visual imagery
• Stress management skills
• Diet • + commands and
instructions to the body
RESOURCES
REDUCING CLIENT STRESS
• Audio Glossary
• Other methods include: • American Institute of Stress
• Understanding the role of stress in health and illness
• Listen attentively
• Georgia Reproductive Specialists
• Provide atmosphere of warmth and trust • Stress management, definition, and coping with stress
• Convey sense of caring and empathy • Mind Tool
• Include client in plan of care • Stress management techniques
• Health Education
• Promote feeling of safety and security
• Web book containing medical information on stress, depression, and anxiety
• Minimize additional stressors • National Center for Post-Traumatic Stress
• Help with recognition of stressors and coping mechanisms • Site to advance the clinical care and social welfare of America's veterans through
research, education, and training in the science, diagnosis, and treatment of PTSD
and stress-related disorders
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RESOURCES BIBLIOGRAPHY
• International Society for Traumatic Stress Studies Berman, A., Snyder, S., Kozier, B, & Erb, G. (2008), Kozier & Erb’s
• Home page for the International Society for Traumatic Stress Studies (ISTSS), the world's Fundamentals of Nursing: Concepts, Process, and Practice. (8th ed). New
premier trauma organization dedicated to trauma treatment, education, research, and Jersey. Prentice Hall Publishing.
prevention.
Harkreader H.& Hogan.M. (2004) The Fundamentals of Nursing Caring and
• What You Need To Know About Clinical Judgment (2nd ed.) St. Louis MO:Saunders
• Articles, chats, and tips for overcoming stress Ignatavicius D., Workman M, et al (1995) Medical Surgical Nursing: a Nursing
• Center for Anxiety & Stress Treatment Process Approach (2nd ed.)
Philadelphia PA : Saunders
• Tips for relieving stress
Reference: Kiecolt-Glaser, J.K., Garner, W., Speicher, C.E., Penn, G., and Vlaser, R.
• Centers for Disease Control and Prevention, National Institute for "Psychosocial Modifiers of Immunocompetence in Medical Students." Psychosomatic
Occupational Safety and Health Medicine 46 (1984
• Information on causes of stress at work and ways to prevent stress
• Internet Mental Health
• Diagnostic and treatment articles on stress
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