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NURSING FUNDAMENTALS FOCUS IV

Stress Adaptation Process

• 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

• Discuss the effects of prolonged exposure to stress

• List some of the ways to reduce or manage stress

OBJECTIVES

STRESS STRESS

DISORDERS CAUSED BY STRESS

(From Health and Wellness: A Holistic Approach, 9th ed. (p. 46), by G. Edlinand E. Golanty, 2007, Boston: Jones & Bartlett. Adapted with permission.)

Stress?

Stressor?

STRESS AND STRESSORS

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Coping Strategies

Coping Responses

Coping Mechanisms

RESPONSES TO STRESSFactors influencing response to stress:

• Psychological• coping, control, emotions, beliefs

• Physiological• injuries, illness, infection, substances

• Social• support, status, education

• Environmental• pollution, hazards, extremes in temperatures

RELATIONSHIP BETWEEN STRESS AND STRESSORS

• Internal• Infection

• Depression• External

• A move, a death, pressure from peers• Developmental

• Predictable • Situational

• Unpredictable - may be positive or negative

SOURCES OF STRESS

• Affects the Whole Person• Physically

• Threatens homeostasis• Emotionally

• Negative feelings toward self• Intellectually

• Perceptual and Problem-solving abilities• Socially

• Relationships can be affected• Spiritually

• Challenges beliefs and values

EFFECTS OF STRESS

• Stimulus-based models• Response-based models• Transaction-based models

CONCEPTS REGARDING STRESS

• Stress defined as a stimulus, a life event, or set of circumstances that arouses physiologic/psychologicreaction

• This stress may increase vulnerability to illness

• Both positive and negative events considered stressful

• Original work �– Holmes and Rahe - 1967

STIMULUS-BASED MODELS

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• Stress may be considered a response• Selye (1956, 1976) defined as nonspecific

response of body to any kind of demand made upon it

RESPONSE BASED MODELS• Based on work of Lazarus (1966)• Set of cognitive, affective, and adaptive (coping)

responses • arise out of person-environment transactions

• Person and environment are inseparable• 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

TRANSACTION BASED MODELS

• Dr. Hans Selye - 1907-1982• Endocrinologist

• Director of Medicine and Surgery @University of Montreal until 1976

• Founded the Institute of Stress 1977

• General Adaptation Syndrome Theory

• Based on experimentation with rats

• Chain or pattern of physiologic events

GENERAL ADAPTATION SYNDROME THEORY

• Differentiates cause of stress from the response of stress

• Stressor• Produces stress• Disturbs body�’s equilibrium

• Stress is state of the body• Observed by changes produced in body• Hormones released• Body changes in structure and chemical composition• GI tract, Adrenal glands, lymphatic structures

GENERAL ADAPTATION SYNDROME (GAS)

• Body can also react locally• One organ or part of body• Inflammation

• 3 stages of GAS and LAS

LOCAL ADAPTATION SYNDROME (LAS)

• Generalized Adaptation Syndrome

• Alarm Reaction

• short term, acute, response

• Resistance

• intermediate hormonal response

• Exhaustion

• prolonged worry/fatigue/breakdown

PHYSIOLOGIC RESPONSE TO STRESS

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SELYE�’S GENERAL ADAPTATION SYNDROME

• Body defenses alerted• Shock phase

• Counter shock phase

ALARM REACTION ALARM 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.)

Resistance!

Attempts to Adapt

STAGE 2

Exhaustion!

Resources gone!!!

STAGE 3

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SELYE DIAGRAM

Pupils dilateSweat production increasesHeart rate and cardiac

output increaseSkin is pallidSodium and water retainedRate and depth of

respiration increase

Urinary output decreasesMouth may be dryPeristalsis of the intestines

decrease for serious threats

Mental alertness improvesBlood sugar increases

PHYSIOLOGIC INDICATORS

• Anxiety• Fear• Anger• Depression• Unconscious ego defense

mechanisms

PSYCHOLOGIC RESPONSE TO STRESS

• Problem solving• Structuring• Self-control or self-discipline• Suppression• Fantasy

COGNITIVE INDICATORSLAS Characteristics:

Localized response does not involve body systemsThe response is adaptive, stress is needed to stimulate

itThe response is short term.

The response is restorative LAS is in business of assisting in homeostasis to the body region or part.

PHYSIOLOGIC RESPONSE TO STRESS

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• Dr. Robert Ader coined the concept in 1975

• Director of the Behavioral and Psychosocial Medicineat New York University of Rochester.

• Dr Ader believes there is a link between our state of mind, our health and our ability to heal ourselves.

• He carried out his primary experimentation on mice with saccharin.

PSYCHONEUROIMMUNOLOGY (PNI)

• Concerned with the interrelationshipbetween the brain, behavior andthe immune system.

• Neuro-psychological, neuro-anatomicand psychosocial studies have

demonstrated their role inaccentuating or diminishing

immune/allergic responses

PSYCHONEUROIMMUNOLOGY

Negative States Physiologic Reaction

Bereavement Decreased lymphocyte proliferation

Pessimistic states Decreased lymphocyte reactivity; decreased T-cell effectiveness

Academic stress Decreased NK cell activity; decreased T-cells; decrease in certain immune chemicals; increased susceptibility to herpes virus; decreased immunoglobulin A; increased blood levels of Epstein-Barr virus.

Depression Decreased T-cells; decreased number and function of lymphocytes; decreased NK cells.

Loneliness Decreased NK (Natural Killer Cell) activity

Chronic stress Decreased T-cells; decreased NK cells; decreased B-cells; increased blood levels of Epstein-Barr virus

Divorce/separation/poor marital quality

Decreased lymphocyte function; increased blood levels of Epstein-Barr virus; decreased T-cell effectiveness.

Expressed need for power and control

Decreased NK activity; decreased lymphocytes

PSYCHONEUROIMMUNOLOGY PSYCHONEUROIMMUNOLOGYPositive

Satisfying personal relationships and social support

Increased lymphocyte function; increased NK activity; increased immunity by mitogen tests; increased immune response to hepatitis B vaccine

Personal sharing and disclosure of traumatic experiences

Increased lymphocyte response

Humor and laughter Increased Immunoglobulin A; increased lymphocyte count and activity

Hypnosis and relaxation techniques

Increased T-cell effectiveness; increased NK cell activity; decreased blood levels of stress hormones; decreased blood levels of herpes virus

Physical exertion and aerobic exercise

Increased number of white blood cells; increase in endorphins; increase in certain immune chemicals; increased NK cell number and activity; increased T-cells; decreased T-cell effectiveness; decreased lymphocyte function

Group intervention and support

Increased NK cell number and activity; increased number of lymphocytes; decrease in T-helper cells

ANXIETY

MildModerateSeverePanic

Nursing approaches

http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH6e/Constructor/index.cfm?plan=4

PSYCHOLOGICAL RESPONSE TO STRESS

• Mild Anxiety• State of slight arousal

• increases perception, learning, productive abilities

• seeking information and asking questions

STAGES OF ANXIETY

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• Increased state of arousal• Feelings of tension, nervousness, concern• Focuses on a particular aspect of a situation• Slight increased RR and HR• Mild gastric symptoms

MODERATE ANXIETY

• Communication that is difficult to understand

• Increased motor activity

• Inability to relax• Fearful facial

expression• Inability to focus or

concentrate

• Easily distracted• Severely impaired

learning• Tachycardia• Hyperventilation• Headache• Dizziness• Nausea

SEVERE ANXIETY

• Communication not understandable

• Increased motor activity• Agitation• Unpredictable responses• Trembling• Poor motor coordination• Overpowering, Frightening• Person loses control • Can distort events

• Perception distorted or exaggerated

• Inability to learn or function• Dyspnea, palpitations,

choking• Chest pain/pressure• Feeling of impending doom• Paresthesia, sweating

PANICPhysiological effect

hypertension cardiovascular disorders

migraine and tension headaches cancer arthritis

respiratory disease ulcers colitis

muscle tension problems

PROLONGED EXPOSURE TO STRESS

• Psychological effect• anxiety

• panic attack

• depression

• adjustment disorders

• Behavioral effects• conduct disorders • eating disorders • alcoholism • hypochondria

PROLONGED EXPOSURE TO STRESS Physical data

Increased heart rateIncreased BPPalpitationsHeadaches

Muscle tensionGI disturbances

Sleep disturbanceUnusual fatigue

Restlessness

Psychosocial data

Anger, loss of temperHelplessness

PowerlessnessResistance to treatment regimen

and or testingOveruse of drugs

WithdrawnNervousness

IrritabilityComplaints of anxiety

Over excited

ASSESSMENT

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Ineffective copinghttp://www1.us.elsevierhealth.com/Evolve/Ackley/NDH6e/Constructor/index.cfm?plan=14

Ineffective denialIneffective family coping

Fear http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH6e/Constructor/index.cfm?plan=19

Isolation Physical dependency

Loss of controlStress related to hospitalization

Sleep pattern disturbance http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH6e/Constructor/index.cfm?plan=44

NURSING DIAGNOSIS

Physiological Evidence of Anxiety

Stressor itselfHospitalization

SurgeryDiagnosis

Fiscal responsibilities

RELATED FACTORS �…

Measurable short term and long term goalis set to measure a change in behavior.

Behavior + change + timeframe

GOAL SETTING

• Nursing History • Client-perceived stressors or stressful incidents

• Manifestations of stress

• Past and present coping strategies

• Developmental transitions

ASSESSING STRESS AND COPING PATTERNS

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• Assessment interview• Scale to rate specific stressors• Duration of stressful situation• Usual strategy for handling stressful

situations• Effectiveness of these strategies

ASSESSING STRESS AND COPING PATTERNS

• Physical Examination• Verbal

• Motor

• Cognitive

• Other physical manifestations of stress

ASSESSING STRESS AND COPING PATTERNS

• Interventions to increase coping skills• Enhance social supports

• Protecting vulnerable self

• Practicing adaptive thinking

• Gaining control through knowledge

• Interventions to aid in effectively manage stressors

• Stress management skills

INTERVENTIONS

• Education

• Provide accurate information

• Positive attitude• Reducing stress• Relaxation• Exercise• Diet

• Eliminate negative beliefs & emotions• fear, rage, anger, guilt

• Forgiveness• Problem solving

• creating positive future goals

• Positive visual imagery• + commands and

instructions to the body

FACTORS INVOLVED WITH HEALING

• Other methods include:

• Listen attentively• Provide atmosphere of warmth and trust• Convey sense of caring and empathy• Include client in plan of care• Promote feeling of safety and security• Minimize additional stressors• Help with recognition of stressors and coping mechanisms

REDUCING CLIENT STRESS• Audio Glossary• American Institute of Stress

• Understanding the role of stress in health and illness• Georgia Reproductive Specialists

• Stress management, definition, and coping with stress• Mind Tool

• Stress management techniques• Health Education

• Web book containing medical information on stress, depression, and anxiety• National Center for Post-Traumatic Stress

• 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

RESOURCES

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• International Society for Traumatic Stress Studies• Home page for the International Society for Traumatic Stress Studies (ISTSS), the world's

premier trauma organization dedicated to trauma treatment, education, research, and prevention.

• What You Need To Know About• Articles, chats, and tips for overcoming stress

• Center for Anxiety & Stress Treatment• Tips for relieving stress

• Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health• Information on causes of stress at work and ways to prevent stress

• Internet Mental Health• Diagnostic and treatment articles on stress

RESOURCES BIBLIOGRAPHY

Berman, A., Snyder, S., Kozier, B, & Erb, G. (2008), Kozier & Erb’sFundamentals of Nursing: Concepts, Process, and Practice. (8th ed). New Jersey. Prentice Hall Publishing. Harkreader H.& Hogan.M. (2004) The Fundamentals of Nursing Caring and Clinical Judgment (2nd ed.) St. Louis MO:SaundersIgnatavicius D., Workman M, et al (1995) Medical Surgical Nursing: a Nursing Process Approach (2nd ed.) Philadelphia PA : SaundersReference: Kiecolt-Glaser, J.K., Garner, W., Speicher, C.E., Penn, G., and Vlaser, R. "Psychosocial Modifiers of Immunocompetence in Medical Students." Psychosomatic Medicine 46 (1984