Chapter 12: Stress & Adaptation
What Are the Main Points of This Chapter?
-Stress is a disturbance in normal homeostasis caused by internal or external stimuli called stressors. -Adaptive coping techniques are those that offer healthy choices to the person and reduce the negative effects of stress. -Approaches to coping include altering the stressor, adapting to the stressor, and avoiding the stressor. -Whether the outcome of stress is positive (adaptation) or negative (disease) depends on the balance between the strength and duration of the stressors and the effectiveness of the person's coping methods. -The three stages of Selye's general adaptation syndrome (GAS) are alarm, resistance, and exhaustion. Each stage in the GAS produces different physical or psychological responses. -In the alarm stage of the GAS, responses are produced primarily by adrenal hormones, epinephrine, mineralocorticoids, and the sympathetic nervous system. -The exhaustion stage can lead to stress-induced illness, burnout, or death. -The two most common responses of the local adaptation syndrome (LAS) are the reflex pain response and the inflammatory response. -Examples of psychological responses are anxiety, fear, anger, and ego defense mechanisms. -Ego defense mechanisms are unconscious mental mechanisms that help to decrease the inner tension associated with stressors; when overused, they are maladaptive. -Unsuccessful adaptation can lead to crisis, organic disease (e.g., stomach ulcers), somatoform disorders (e.g., hypochondriasis), and psychological disorders (e.g., mental illness). -Crisis exists when (1) an event in a person's life drastically changes his or her routine and is perceived as a threat to self, and (2) the person's usual coping methods are ineffective, resulting in high anxiety and reduced ability to function. -Burnout occurs when nurses or other professionals cannot cope effectively with the demands of the workplace. -You should assess for data about the patient's stressors, risk factors, coping and adaptation, support systems, and psychosocial and physiological responses to stress. -Interventions for stress must be individualized to the patient. They include (1) health promotion activities for preventing and improving the ability to cope with stressors; (2) managing anxiety, fear, and anger; (3) stress management techniques that focus on discharging tension or producing relaxation; (4) techniques to alter perception (i.e., cognitive restructuring and positive self-talk); (5) identifying and using support systems; (6) reducing the stress of hospitalization; (7) providing spiritual support; (8) crisis intervention; (9) stress management in the workplace; and (10) making referrals.
Define crisis, burnout, and post-traumatic stress disorder.
Answer: -A crisis exists when (a) an event in a person's life drastically changes his routine and is perceived as a threat to self, and (b) the person's usual coping methods are ineffective, resulting in high levels of anxiety and inability to function adequately. Such events are often sudden and unexpected (e.g., serious illness or death of a loved one, serious financial losses, an automobile accident, rape, or natural disasters). -Burnout occurs when nurses and other professionals cannot cope effectively with the physical and emotional demands in the workplace. The nurse feels overwhelmed and helpless and suffers low self-esteem and depression. The nurse who burns out may develop a physical illness or a negative attitude or may use maladaptive coping techniques, such as smoking, substance abuse, or distancing from patients—"going through the motions" but not really interacting with patients in a meaningful way. Many nurses in such situations give up and leave nursing. -Post-traumatic stress disorder is a specific response to a violent, traumatizing event (such as an earthquake or other natural disaster), or physical or emotional abuse (such as rape, torture, or war experience). The victim experiences anxiety and flashbacks that may last for months or years. They may also attempt to self-medicate their emotional pain by misusing alcohol or other recreational or prescription drugs.
Name two LAS responses.
Answer: Answers may include any of the following LAS responses: -Blood clotting -Pupil constriction in response to light -Reflex pain -Inflammatory response -Tissue edema -Hyperemia (increase blood flow to tissue)
Name and describe at least three somatoform disorders.
Answer: Answers may include any of the following somatoform disorders: -Hypochondriasis. The person is preoccupied with the idea that he is or will become seriously ill. The person is abnormally concerned with his health and interprets his real or imagined symptoms unrealistically, fearing that they will get worse or become incurable. The person is not "faking it"; anxiety about her health may trigger the physical sensations. -Somatization. In this disorder, anxiety and emotional turmoil are expressed in physical symptoms, loss of physical function, pain that changes location often, and depression. The patient is unable to control the symptoms and behaviors, and complaints are vague or exaggerated. -Somatoform pain disorder. This is emotional pain that manifests physically. Pain is the patient's main focus of the person's life. The level of pain the person states is inconsistent with the physical condition—that is, no physical cause can be found for the pain. The pain does not change location. -Malingering. Malingering is different from the other disorders because it is a conscious effort to escape unpleasant situations. The patient merely pretends to have the symptoms for personal or tangible gain (e.g., calling in sick because the person does not want to go to work).
Name and describe three stress-induced organic and systemic responses to stress.
Answer: Answers may include any of the following stress-induced responses: -Cardiovascular system. Continued secretion of epinephrine may cause cardiovascular disorders, including angina, myocardial infarction, cardiomegaly, and congestive heart failure, all of which lead to decreased cardiac output. As cardiac output decreases, less oxygen circulates to meet cellular metabolic demands, and the body becomes fatigued. Prolonged secretion of epinephrine and renin result in vasoconstriction, causing hypertension. ADH, aldosterone, ACTH, and cortisol create electrolyte imbalance and retention of sodium and water, thus promoting peripheral edema. -Endocrine system. Continuing high levels of blood glucose and insulin can cause diabetes. Metabolic disorders of hyperthyroidism or hypothyroidism can result as persistent demands for thyroid hormone production cause a rebound failure of the gland. Even prenatal stress can cause adaptive changes in fetal endocrine and metabolic processes that impact later adult health (Sullivan, Hawes, Winchester, et al., 2008). -Immune system. Stress reduces the ability of the body's immune cells to differentiate between self and nonself. Thus, the immune cells begin to attack body tissues, producing autoimmune illness. Common autoimmune illnesses include rheumatoid arthritis, lupus, cancer, and allergies. Research has linked stress to suppression of the immune system and even to viral replication in HIV patients (e.g., Davidson, Kabat-Zinn, Schumacher, et al., 2003; McCain, Gray, Elswick, et al., 2008 ). -Gastrointestinal system. The gastrointestinal system may respond to central nervous system stimulation with constipation or diarrhea, gastroesophageal reflux, colitis, or irritable bowel syndrome. Continued secretion of hydrochloric acid produces gastric hyperacidity and erosion of the gastrointestinal tract, especially in the presence of H. pylori. -Musculoskeletal system. Constant readiness for fight or flight produces muscle tension and pain in various body sites. Tension headache and temporomandibular joint pain result from prolonged muscle tension in the head, neck, and spine. -Respiratory system. Epinephrine and circulating hormones dilate the bronchial tubes and increase the rate of respiration. Hyperventilation can produce symptoms of alkalosis, including dizziness, tingling hands and feet, and anxiety. Distress in the respiratory system can exacerbate existing asthma, hay fever, and allergies.
Explain how mild to moderate anxiety can be adaptive.
Answer: Anxiety can be adaptive when it motivates and mobilizes the person to action.
List three questions you could ask to assess Gloria's physiological responses to stress. What observations might you also make?
Answer: Assess physiological responses to stress as follows: Questions. Recall that GAS is nonspecific, so you must obtain data from all body systems. If coping is successful, clinical signs and symptoms may not occur. The following are examples of questions you should ask: What do you do to stay healthy? Tell me about your health habits. How often do you have a health and dental checkup? What are your health concerns? Observations. A check of vital signs for elevations in pulse, respiration, and blood pressure will indicate whether the fight-or-flight response is present. In your general survey, or overview, of the patient you should note hygiene, grooming, facial expression, and ability to make eye contact. Box-12-5 in 12 of Volume 1 (repeated below) summarizes other physiological responses you might see: Dilated pupils Muscle tension Stiff neck Headaches Nail biting Skin pallor Skin lesions (e. g., eczema) Diaphoresis, sweaty palms Dry mouth Nausea Weight or appetite changes Increased blood glucose Increased heart rate Cardiac dysrhythmias Hyperventilation Chest pain Water retention Increased urinary frequency or decreased urinary output Diarrhea or constipation Flatulence
What are ego defense mechanisms?
Answer: Ego defense mechanisms are unconscious mental mechanisms that make a stressful situation more tolerable by decreasing the inner tension associated with stressors. Their purpose is to relieve anxiety.
True or false: The difference between adaptive and maladaptive coping is that maladaptive coping does not relieve stress.
Answer: False Rationale: Maladaptive coping may indeed relieve stress temporarily, but it does not promote adaptation. Although the maladaptive behavior may temporarily relieve the anxiety associated with the stressor, it may have other harmful physical and even pychosocial effects. For example, a woman who smokes to relieve tensions of a stressful work situation may experience an immediate decrease in anxiety. However, she is doing nothing to change or adapt to the stressful situation and over the long term is creating physical stress for herself.
True or false: One difference between anxiety and fear is that the danger in anxiety may be imagined, whereas in fear the danger is real.
Answer: False Rationale: The danger in fear may be real or imagined. The differences regarding the danger are that (a) in anxiety danger is anticipated, in the future, whereas in fear it is imminent or present. (b) Anxiety results from a psychological threat (danger), whereas fear may be in response to either a psychological or physical threat.
Refer to the Meet Your Patients scenario in Volume 1. What are Gloria's stressors? Classify each of them as follows: (1) Are they physiological or psychosocial? (2) Are they developmental or situational?
Answer: Gloria has the following stressors: -Having a spouse who commutes to work—psychosocial and developmental -Running a business from home—psychosocial and developmental -Coping with two teenage boys and coordinating schedules to include all of the boys' activities—psychosocial and developmental -Providing transportation—psychosocial and developmental -Thinking of lessons for Sunday school—psychosocial and developmental -Planning Boy Scout meetings—psychosocial and developmental -Coping with her parents' illnesses—psychosocial and developmental (maybe situational) -Facing the mortality of her parents—psychosocial and developmental -Watching her father deteriorate—psychosocial and developmental -Being "sandwiched" between caring for her children and her parents—psychosocial and developmental -Juggling housekeeping duties for two households—psychosocial and developmental (maybe situational) -Cooking meals for two households—psychosocial and developmental (situational) -Interfacing with her sister for their parents' care—psychosocial and developmental
In the alarm stage of the GAS, what are the effects of the sympathetic nervous system on each of the following: heart, brain, glycogen stores, and skeletal muscle?
Answer: In the GAS alarm stage, the sympathetic nervous system produces a fight-or-flight response that: Increases heart rate and strength of contractions, increasing cardiac output Increases mental alertness Causes the release of glycogen stores and increases in blood glucose levels Increases muscle strength (ability to contract)
What are John's stressors?
Answer: John has the following stressors: -Commuting -Witnessing Gloria's stress -Arranging time to be present for the boys' activities -Assuming more responsibility for Boy Scout meetings and Sunday school classes
In addition to avoiding the stressor, what are two other approaches to coping?
Answer: Other approaches to coping are (1) eliminating or changing the stressor and (2) adapting to the stressor.
You know Gloria's sister is providing some support. How could you find out more about the extent of Gloria and John's support system?
Answer: Recall that support systems such as family, friends, and coworkers can be important to the success of a person's coping strategies. Conversely, these individuals may be affected by the same stressors, or by the client's response to them. For these reasons, you should determine the supports available and their ability to assist the client—that is, do the significant others have the sensitivity and skills to be supportive? For example, you might ask: Tell me about your home. Describe your living environment. Who are the persons that provide the most support for you? In what ways do they support you? What support is available from family, friends, significant others, community agencies, and clergy that you may not have required until now? Do you have or do you seek spiritual support? How has your stress affected the family? (Ask about major life events that have occurred—e.g., birth, death, and divorce—job instability, a recent move, and so on.) What are your financial resources? What are your financial obligations? Do you feel you can adequately meet those obligations?
What is the effect of Selye's resistance stage on the cardiovascular and respiratory systems? On hormone levels?
Answer: Selye's resistance stage has the following effects: Normalizes heart rate, blood pressure, cardiac output, respiratory function, and hormone levels Stimulates insulin secretion, increasing glucose uptake by cells
In general, what is the difference between the alarm stage and the resistance stage of the GAS?
Answer: The GAS alarm and resistance stages differ as follows: In the alarm stage, the body is preparing to "fight" or "take flight." It is reacting physiologically to the stressor. The cerebral cortex sends messages to the hypothalamus and pituitary to increase various hormone levels. The hormones produce increases in heart rate, blood pressure, and respiratory function and shunt blood to the skeletal muscles. In the resistance stage, the body attempts to stabilize by using physiological and psychological coping mechanisms, and the body systems (e.g., heart, lungs, and immune response) return to normal.
What are four characteristics of the local adaptation syndrome (LAS)?
Answer: The LAS has the following characteristics: -It is a localized body response (involves only a specific body part, tissue, or organ). -It is initiated by a stressor; it does not just occur on its own. -It is short term. -It is adaptive in nature; that is, it attempts to restore homeostasis.
What are the classic symptoms of the inflammatory process?
Answer: The following are classic inflammatory symptoms: -Redness -Pain -Heat -Edema -Loss of function
In addition to ego defense mechanisms, name four common emotional responses to stress.
Answer: The following are common emotional responses to stress: Anxiety Fear Anger Depression
Name the gland that releases each of the following hormones in response to stress, and name each hormone's function: corticotropin-releasing hormone (CRH), antidiuretic hormone (ADH), adrenocorticotropic hormone (ACTH), aldosterone, cortisol, epinephrine, and norepinephrine.
Answer: The following glands release the following hormones: -The hypothalamus gland releases corticotropin-releasing hormone (CRH), which stimulates the pituitary to release ACTH and ADH. -The pituitary gland releases adrenocorticotropic hormone (ACTH) and antidiuretic hormone (ADH), which causes water reabsorption/retention (thereby decreasing urine output and increasing blood volume). -The adrenal cortex releases corticosteroids (e.g., cortisol, aldosterone). Cortisol decreases the use of glucose for energy by all cells except the brain and promotes its storage in the liver. It is an anti-inflammatory. Aldosterone causes sodium and water retention, thereby increasing blood volume. -The adrenal medulla releases catecholamines (epinephrine, norepinephrine). These prepare the body for fight or flight; they produce responses similar to those of the sympathetic nervous system, which is also activated during the alarm stage of the GAS. Norepinephrine causes vasoconstriction throughout the body, raising blood pressure. Epinephrine increases heart rate and contraction, dilates bronchioles, decreases peristalsis, stimulates the liver to convert glycogen to glucose, increases the use of fats for energy, and increases the rate of cellular respiration.
Name and discuss at least four aspects of a healthful lifestyle that can help prevent or relieve stress.
Answer: The following health promotion activities can help prevent or relieve stress: Nutrition. Nutrition is important for maintaining physical homeostasis and resisting stress. For example, adequate nutrition is essential to maintain the integrity of the immune system, and proteins are needed for tissue building and healing. In addition, obesity and malnutrition are stressors that may lead to illness. Refer to Chapter 27 in Volume 1 for detailed information about nutrition, but to summarize, you should advise clients to: Maintain a normal body weight Limit the intake of fat (especially animal fat) to no more than 30% of daily calories Limit the intake of sugar and salt Eat more fish and poultry and less red meat Eat smaller, more frequent meals to aid digestion Consume 25 grams of fiber (fruits, vegetables, and whole grains) daily to promote bowel elimination Consume no more than two alcoholic beverages per day Exercise. Regular exercise promotes physical homeostasis by improving muscle tone and controlling weight. It also improves the functioning of the heart and lungs and reduces the risk of cardiovascular disease. Exercise improves emotional homeostasis by promoting relaxation and reducing tension. During exercise, endogenous opioids are released, creating a feeling of well-being. To achieve health benefits, the client needs to exercise for at least 30 minutes at least 5 days a week. Advise clients who are obese, chronically ill, or who have always been sedentary to consult a primary care provider before beginning a new exercise program. Suggest that the client identify a variety of physical activities that he or she enjoys (e.g., swimming, bicycling, walking, sports), and, if possible, schedule regular sessions with one or more exercise "buddies." These strategies help the client adhere to the exercise routine. Sleep and rest. Sleep and rest restore energy levels, allow the body to repair itself, and promote mental relaxation. Most people need 7 or 8 hours of sleep a day, but the amount of sleep varies among individuals. Stress, pain, and illness may interfere with the ability to sleep, so some clients may need help identifying and implementing techniques for relaxing and going to or staying asleep. Refer to Chapter 34 in Volume 1 for more information on sleep. Leisure activities. As compared with exercise, which not everyone enjoys, leisure activities are any activities that provide joy and satisfaction. They may involve physical activity (after all, many people do enjoy exercising), or they may be sedentary activities, such as reading, painting, and even watching television. Leisure activities are a form of rest and, as such, are restorative. Time management. People who manage their time efficiently and organize their life routines feel more in control and therefore less stressed. If clients feel overwhelmed, you can help them to prioritize tasks and make "to do" lists. It is also important they learn to delegate responsibilities and set boundaries on the use of time. A working couple with three children may need to assign each child mealtime tasks, such as setting the table, drying the dishes, and so forth. Or they may need to limit the amount of time they spend cooking, reserving elaborate meals for weekends. They might also consider limiting the number of extracurricular activities and/or sports each child is involved in. Time management also includes saying no. Out of a need to be liked or a strong sense of responsibility to others, people sometimes try to make everyone happy by agreeing to all/most requests for assistance: from spouse, children, parents, friends, church, school, and the community. You can prompt clients to identify how much they can realistically accomplish—what is essential to do, and what would be "nice" to do. Help clients to work out a balance between their responsibilities to self and their responsibilities to others. Avoiding maladaptive behaviors. Some people use maladaptive behaviors as a response to stress. For others, the behaviors themselves become stressors. Advise clients to help avoid the following unhealthy behaviors: Drinking more than two alcoholic beverages per day Consuming excess caffeine (e.g., coffee, tea, colas, energy drinks) Eating large quantities of nutrient-poor food, such as sweets, chips Smoking or chewing tobacco Using illegal street drugs Abusing over-the-counter medications or prescription drugs (for uses other than prescribed) Avoiding social interaction
The outcome of stress (adaptation or disease) depends on the balance between the strength, number, and duration of the stressors and _____________.
Answer: The outcome of stress (adaptation or disease) depends on the balance between the strength, number, and duration of the stressors and the effectiveness of the coping responses (including the person's perception of the stressors).
List three questions you could ask to assess Gloria's emotional and behavioral responses to stress.
Answer: To assess emotional and behavioral responses, ask questions such as the following: Do you use tobacco products? If so, how often? How much alcohol do you drink every day? What do you eat? What is your typical eating pattern? How much fluid do you drink daily? How many hours do you sleep at night? Do you feel rested when you wake up? What prescribed medications, vitamins, over-the-counter medications, or herbs do you take? What regular physical activity do you engage in? How would you rate your personal energy level? How much time is spent at work versus compared to leisure and play? How do you relax? How do you most often express anger? Do you try to be perfect? How do you feel if you do not achieve that? Would you describe yourself as having the stress-filled lifestyle? How often do you find yourself feeling hopeless? Sad? Apathetic? Is your appetite normal for you?
List three questions you could ask to find out how Gloria is coping and adapting to stress.
Answer: To obtain this information, ask questions such as the following: What coping strategies have you used previously? What was successful, and what was not successful? Tell me about previous experiences you have had with stressful situations in your life. What do you usually do to handle stressful situations? (If the client needs prompting, you can ask, "Do you cry, get angry, avoid people, talk to family or friends, do physical exercise, pray? Some people laugh or joke, others meditate, others try to control everything, and others just work hard and look for a solution. What is your usual response?") How well do these methods usually work for you? What have you been doing to cope with the present situation? How well is that working? During the interview, you should also observe for the use of psychological defense mechanisms. If the patient has not exhibited any defense mechanisms, you could ask about the common ones. For example, "Do you ever cope with a situation by denying that it exists or just trying to put it out of your mind?" Go to Chapter 12 , Table 12-1, in Volume 1. Also ask Gloria about physiological changes and diseases caused by ongoing stress. For data that might indicate maladaptation to stress, go to Chapter 12,"Stress-Induced Organic Responses," in Volume 1. Check the client's records for a history of somatoform disorders. Ask the client: What physical illnesses do you have? How long have you had them? What, if any, physical changes have you noticed? Do you have other physical conditions—for example, hypertension, cardiac disease, diabetes, arthritis, joint pains, and cancer?
Describe at least five specific interventions for dealing with an angry person.
Answer: Use the following interventions for dealing with an angry person: -Be aware of how you are responding to angry clients. Are you relieving your own stress, or are you relieving the client's stress? If you respond angrily to relieve your own stress, you may provoke further anger in the client and even escalate the situation to the point of violence. -Keep reminding yourself not to take anger personally; remind family members of this as well. -Recognize the client's right to be angry. Do not discount feelings by saying something like, "Please don't be so angry" or "You shouldn't talk like that." Encourage the client and family to express feelings verbally and appropriately. -Listen instead of defending. If the client yells, "Everything about this place stinks," don't respond with something like, "This hospital is highly rated by the Joint Commission" or "We really are all trying to do the best we can for you." Instead, say something to encourage the person to express his feelings or give you more information: "You seem really angry; what's going on?" or "Maybe I can help. Tell me a little more about what stinks." -Do not take responsibility for the client's anger. It is not your fault, so don't apologize (unless you really do have something to apologize for). In the preceding example, for instance, it is not your fault that "the place stinks" or that the patient feels that way. So do not say, "I'm sorry we haven't been meeting your expectations." -Remain calm; this reassures the person. -Help the client identify what is causing the anger and try to meet those needs. -Be alert to your own and the client's safety needs. If the person seems violent, do not allow him to get between you and the door. Be sure you know how to call for help from staff or security personnel when you think you or someone else is in danger. -Refer to the NIC intervention Anger Control Assistance (Bulechek, Butcher, & Dochterman, 2008, pp. 134-135) for other suggestions.
How might you determine whether stress is affecting Gloria's cognitive functioning?
Answer: You can assess the client's cognitive functioning as you assess other functional areas. Notice whether the person has difficulty focusing and responding to your questions. When you ask the client to describe and rate the intensity of her stressors, you can begin to assess whether she perceives the stressors realistically or in an exaggerated way. Asking the client about her coping strategies will give you an idea of her problem-solving abilities. The following answers are from Box 12-3, in Chapter 12 of Volume 1. They are examples of cognitive responses. Difficulty concentrating Poor judgment Decrease in accuracy (e.g., in counting money) Forgetfulness Decreased problem-solving ability Decreased attention to detail Difficulty learning Narrowing of focus Preoccupation, daydreaming
How might you identify and assess Gloria and John's stressors (Meet Your Patients, in Volume 1)?
Answer: You might identify and assess stressors in the following ways: You might begin gathering this data by having the client complete a stress inventory, such as the Holmes-Rahe scale. See Assessment Guidelines and Tools in Chapter 12 of Volume 2. You might ask the client: What is causing the most stress in your life? On a scale of 1 to 10 (1 is "not much" and 10 is "extreme"), rate the stress you are experiencing in each of these areas: work or school, finances, community responsibilities, your health, health of a family member, family relationships, family responsibilities, and relationships with friends. How long have you been dealing with the stressful situation(s)? Can you track the accumulation of stress in your life? How long have you been under this stress? You should note the client's developmental stage and determine whether he is functioning as expected for his stage. Review Chapter 9, Volume 1, to help you identify developmental milestones), and Refer to Box 12-1 (Chapter of Volume 1) to help you assess for stressors that can be predicted to occur in each stage. You might ask questions such as: What challenges do you face as a result of your life and your age? Have you had recent life changes? Do you anticipate any life changes?