NUR325 Stress and Coping

sympathetic nervous system response to stress

increased heart rate, blood Zpressure, cardiac output, blood perfusion to skeletal muscles, bronchial dilation, pupil dilation, and blood glucose, increased water and sodium retention, increased protein synthesis, inflammatory response, immunosuppresion

what are consequences of chronic stress

leads to heightened responses, exhaustion of resources leads to loss of homeostasis

TCM

"Life in balance" Health promotion Yin and yang are opposing, complementary forces that exist in dynamic equilibrium Methods for evaluation of patient's condition Observing Hearing/smelling Asking/interviewing Touching/palpating. Therapeutic modalities TCM is a whole system of medicine that began approximately 3600 years ago. Chinese medicine views health as "life in balance," which manifests as lustrous hair, a radiant complexion, engaged interactions, a body that functions without limitations, and emotional balance. Health promotion encourages healthy diet, moderate regular exercise, regular meditation/introspection, healthy family and social relationships, and avoidance of environmental toxins such as cigarette smoke. Yin represents shade, cold, and inhibition; whereas yang represents fire, light, and excitement. Yin also represents the inner part of the body, specifically the viscera, liver, heart, spleen, lung, and kidney; whereas yang represents the outer part, specifically the bowels, stomach, and bladder. Harmony and balance in every aspect of life are the keys to health, including yin-yang balance. [Review Table 33-2, Three Causes of Disease According to Traditional Chinese Medicine, with students.] Imbalance ultimately leads to disruption of vital energy, qi, which then compromises the body-mind-spirit of the person, causing "disease." Disruptions in qi along the meridians can be systematically evaluated and treated by TCM practitioners. TCM practitioners use four methods to evaluate a patient's condition: observing, hearing/smelling, asking/interviewing, and touching/palpating. Therapeutic modalities include acupuncture, Chinese herbs, tui na massage, moxibustion (burning moxa, a cone or stick of dried herbs that have healing properties on or near the skin) cupping (placing a heated cup on the skin to create a slight suction), tai chi (originally a martial art that is now viewed as a moving meditation in which patients move their bodies slowly, gently, and with awareness while breathing deeply), qi gong (originally a martial art, now viewed as a series of carefully choreographed movements or gestures that are designed to promote and manipulate the flow of qi within the body), lifestyle modifications, and dietary changes. Evidence about its effectiveness is limited. Some evidence shows that TCM is helpful in treating fibromyalgia and in addressing symptoms associated with menopause. There is some concern about the safety of Chinese herbal treatments that are used in teas, remedies, and supplements. Recent reports about these products suggest that many Chinese herbs are contaminated with drugs, toxins, or heavy metals or that many ingredients may not be clearly listed or labeled. Further, these herbs can be very powerful, interacting with drugs and causing serious complications. When assessing a person using TCM, you need to ask your patient about the therapies he or she receives, including the types of herbs that the patient is using. Some patients consider these as teas or dietary additives, powders, or supplements and not as over-the-counter medications.

Biofeedback

A mind-body technique that uses instruments to teach self-regulation and voluntary self-control over specific physiological responses. Instruments measure, process, and provide information about neuromuscular and autonomic nervous system activity. Immediate feedback is provided in physical, physiological, auditory, and/or visual signals. Electronic or electromechanical instruments give information to patients about their muscle tension, cardiac activity, respiratory rates, brain-wave patterns, and autonomic nervous system activity. Feedback increases a person's awareness of internal processes that are linked to illness and distress. Biofeedback therapies are used to change thinking, emotions, and behaviors, which in turn support beneficial physiological changes, resulting in improved health and well-being. Biofeedback is an effective addition to more traditional relaxation programs because it immediately demonstrates to patients their ability to control some physiological responses and the relationships among thoughts, feelings, and physiological responses. Biofeedback provides immediate feedback about which stress relaxation behaviors work most effectively. Biofeedback is helpful in stroke recovery, smoking cessation, attention-deficit/hyperactivity disorder (ADHD), epilepsy, headache disorders, and a variety of gastrointestinal (GI) Patients who are compliant have more positive results. Several precautions have been put forth, particularly for those with psychological or neurological conditions. During biofeedback sessions, repressed emotions or feelings for which coping is difficult sometimes surface. Thus practitioners need to be trained in more traditional psychological methods or have qualified professionals available for referral. Long-term use of biofeedback sometimes lowers blood pressure, heart rate, and other physiological parameters. As with other biobehavioral interventions, monitor patients closely to determine the need for medication adjustments

imagery

A mind-body therapy that uses the conscious mind to create mental images to stimulate physical changes in the body, improve perceived well-being, and/or enhance self-awareness Clinical applications Pain control Limitations Relatively few side effects Frequently imagery, combined with some form of relaxation training, facilitates the effect of the relaxation technique. Imagery may be self-directed, in which individuals create their mental images, or guided, during which a practitioner leads an individual through a particular scenario. [Guide the class through an imagery exercise. When guiding an imagery exercise, direct the patient to begin slow abdominal breathing while focusing on the rhythm of breathing. Then direct the patient to visualize a specific image such as ocean waves coming to shore with each inspiration and receding with each exhalation. Next instruct the patient to take notice of the smells, sounds, and temperatures that he or she is experiencing. As the imagery session progresses, instruct the patient to visualize warmth entering the body during inspiration and tension leaving the body during exhalation. Individualize imagery scenarios for each patient to ensure that the image does not evoke negative memories or feelings.] Imagery often evokes powerful psychophysiological responses such as alterations in gastric secretions, body chemistry, internal and superficial blood flow, wound healing, and heart rate/heart rate variability. Although most imagery techniques involve visual images, they also include the auditory, proprioceptive, gustatory, and olfactory senses. Creative visualization is self-directed imagery based on the principle of mind-body connectivity. [Review Box 33-2, Patient Teaching: Creative Visualization, with students.] Imagery helps control or relieve pain, decrease nightmares, and improve sleep. It also aids in the treatment of chronic conditions such as asthma, cancer, sickle cell anemia, migraines, autoimmune disorders, atrial fibrillation, functional urinary disorders, menstrual and premenstrual syndromes, gastrointestinal disorders such as irritable bowel syndrome and ulcerative colitis, and rheumatoid arthritis. Imagery has relatively few side effects. Yet increased anxiety and fear sometimes occur when imagery is used to treat posttraumatic stress disorders and social anxiety disorders. Some patients with chronic obstructive pulmonary disease (COPD) and asthma experience increased airway constriction when using guided imagery. Thus you need to closely monitor patients when beginning this therapy.

natural products and herbal therapies

A natural product is a chemical compound or substance produced by a living organism. Herbal medicines are not approved for use as drugs and are not regulated by the FDA. Although many herbs are safe and effective, "natural" does not equal "safe." Some interact with prescription and over-the-counter medications. Look for U.S. Pharmacopeia (USP)-verified dietary supplement mark. As the oldest form of medicine, archeological evidence suggests that herbal remedies have been used for more than 60,000 years. Herbal medicines are a prominent part of health care among indigenous populations worldwide. Nonvitamin, nonmineral natural products are used by almost 20% of the U.S. population to prevent disease and illness and to promote health and well-being. Natural products include herbal medicines (also known as botanicals), dietary supplements, vitamins, minerals, mycotherapies (fungi-based products), essential oils (aromatherapy), and probiotics. [Ask students: Are you familiar with any natural products, herbs, or supplements? Discuss.] The most frequently used products are garlic, cranberry, Echinacea, saw palmetto, ginkgo biloba, soy, ginseng, black cohosh, St. John's wort, glucosamine, peppermint, fish oil/omega 3, soy, and milk thistle. Many are sold as foods or food supplements. The Dietary Supplement Health and Education Act (1994) allows companies to sell herbs as dietary supplements as long as no health claims are written on their labels. A number of herbs are safe and effective for a variety of conditions. [Review Table 33-3, Select Herbs and Corresponding Effects, with students.] Simply because a product is "natural" does not make it "safe." Because they are not regulated, concentrations of the active ingredients vary considerably. Contamination with other herbs or chemicals, including pesticides and heavy metals, is also problematic. Not all companies follow strict quality control and manufacturing guidelines that set standards for acceptable levels of pesticides, residual solvents, bacterial levels, and heavy metals. Teach patients to purchase herbal medicines only from reputable manufacturers. Labels on herbal products need to contain the scientific name of the botanical, the name and address of the actual manufacturer, a batch or lot number, the date of manufacture, and the expiration date. Using natural products that have been verified by the U.S. Pharmacopeia (USP) is another way to ensure product safety, quality, and purity. Some herbs also contain toxic products that have been linked to cancer. [Review Table 33-4, Unsafe Herbs, with students.] As with any other medication, examine herbs for interaction and compatibility with other prescribed or over-the-counter substances that are being used simultaneously.

evaluation

A patient recovering from acute stress often spontaneously reports feeling better when the stressor is gone. Observe patient behaviors and talk with the patient and family if appropriate. Ask the patient about sleep patterns, appetite, and ability to concentrate. Ask about coping strategies that the patient uses and determine their effectiveness. Ask patients to compare current feelings and behaviors with feelings and behaviors 6 months ago. If desired outcomes have been met, the patient reports feeling better now than 6 months ago. Actively involving patients and families in the processes of problem identification (assessment), prioritizing, goal setting, and evaluation. Engaging the patient as a partner in health care creates open communication. If he or she reports continued acute stress, assess for safety by asking about whether or not there have been any recent accidents at home, in the car, or at work. Ask about coping strategies to determine if the patient is using unsafe, maladaptive strategies. Ask about coping mechanisms used. An essential part of the evaluation process is collaborating with patients to determine if their own expectations from nursing have been met. Any revision in the plan of care includes steps to address patient expectations.

immune system

Acute and chronic stress can cause immunosuppression Decreasing number and function of natural killer cells Decreasing lymphocyte proliferation Altering production of cytokines Decreasing phagocytosis

effects of stress on health

Acute stress is your "alarm system" — it puts you on high alert. When a person sustains chronic, unrelieved stress, the body's defenses can no longer keep up with the demands. Over time, stress takes its toll. Your body was not meant to be on high alert all of the time. Therefore, stress plays a role in the development or progression in the diseases of adaptation or stress-related illnesses (Table 6-2). Stress is linked to leading causes of death, including cancer, accidents, and suicides. Stress can have effects on cognitive function, including poor concentration, memory problems, distressing dreams, sleep disturbances, and impaired decision making. Stress can also cause a wide variety of changes in behavior. These include people withdrawing from others, becoming quiet or unusually talkative, changing eating habits, drinking alcohol excessively, or becoming irritable.

therapuetic touch

Affects energy fields with conscious intent to help or heal Five phases: centering, assessing, unruffling, treating, and evaluating Therapeutic touch (TT) is a natural human potential that consists of placing the practitioner's hands on or close to the body of a person. A nurse developed this therapy. The practitioner attempts to redirect energy to bring the person back into an energy balance similar to that of the practitioner. Phases Centering: To begin the practitioner centers physically and psychologically, becoming fully present in the moment and quieting outside distractions. Assessing: Then the practitioner scans the body of the patient with the palms (roughly 2 to 6 inches [5 to 15 cm] from the body) from head to toe. Unruffling: While assessing the energetic biofield of the patient, the practitioner focuses on the quality of the qi and areas of energy obstructions, redirecting the energy to harmonize and move. Treating: Using long downward strokes over the energy fields of the body, the practitioner touches the body or maintains the hands in a position a few inches away from the body. Evaluating: Ensuring that energy is flowing freely, and determining additional outcomes and responses to the treatment. Evidence supporting the effectiveness of TT is inconclusive, although it may be effective in treating pain in adults and children, dementia, trauma, and anxiety during acute and chronic illnesses. [Review Box 33-3, Focus on Older Adults: The Importance of Touch, with students.] [Shown is Figure 33-3: During a Therapeutic Touch session, the practitioner intentionally directs energy to facilitate the patient's healing process.] Although the use of TT causes very few complications or side effects, it is contraindicated in certain patient populations, especially those who are sensitive to human interaction and touch.

pharmacological therapy

Anxiolytics Hypnotics Antidepressants Psychotherapeutics Muscle relaxants Antimigraine agents Selective serotonin reuptake inhibitors (SSRIs)

stress

Appraisal is how a person interprets the impact of the stressor, it is also a personal evaluation of the meaning of the event on what is happening and a consideration of the resources on hand to help manage the stressor. Stress is a physical, emotional, or psychological demand that can lead to personal growth or overwhelm a person and lead to illness or worsening of existing acute or chronic illnesses. When stress overwhelms existing coping mechanisms, patients lose emotional balance, and a crisis results. If symptoms of stress persist beyond the duration of the stressor, a person has experienced a trauma.

coping responses

Cognitive assessment Primary appraisal Initial assessment of stressor to determine if stressor is a threat Secondary appraisal Evaluation of resources to Overcome the stressor Eliminate the stressor Reduce the stressor Engagement

coping

Cognitive means and behavioral actions to manage internal or external situations perceived as difficult and/or beyond the individual's current resources (Lazarus and Folkman) Being action oriented toward a goal of changing a situation (Ray)

complementary medicine vs alternative vs whole medical systems and integrative health

Complementary—therapies used in addition to conventional treatment (aka integrative therapies) Alternative—therapies that replace allopathic medical care Whole medical systems—based on different philosophies and life systems Integrative health care emphasizes the importance of the relationship between practitioner and patient; focuses on the whole person; is informed by evidence; and makes use of appropriate therapeutic approaches, health care professionals, and disciplines to achieve optimal health

mediation

Concentrated focus on A sound Object Visualization The breath Movement The purpose of meditation is to increase awareness, reduce stress, promote relaxation, and enhance personal and spiritual growth. Best to practice medication in a quiet place, free of distractions, although it can be performed anywhere.

counseling

Consists of individual or group therapy and includes multiple techniques including: Cognitive behavioral therapy Meditation Relaxation techniques and massage Time management Health education

shortcomings of allopathic medicine

Despite the success of allopathic medicine (conventional Western medicine), many conditions such as chronic back and neck pain, arthritis, gastrointestinal problems, allergies, headache, and anxiety are sometimes difficult to treat. Researchers estimate that up to 75% of patients seek care from their primary care practitioners for stress, pain, and health conditions for which no causes or cures are known. Allopathic medicine is less effective in preventing disease, decreasing stress-induced illnesses, managing chronic disease, and addressing the emotional and spiritual needs of individuals, and improving quality of life and general well-being. 56230-0

music

Diversion from a stressful situation Music decreases anxiety and pain while eliciting the relaxation response About 60-80 beats/min is considered soothing Diversion from a stressful situation Music decreases anxiety and pain while eliciting the relaxation response About 60-80 beats/min is considered soothing

collaborative care

Education Developing an action plan Accessing resources Cognitive restructuring

Implementation

Effective stress management enhances an individual sense of control, confidence, self-reliance, and limits the emotional response to stressful circumstances. This helps prevent the harmful effects of a stress response. As a nurse, you are in an ideal situation to integrate stress management in clinical practice. You are also well equipped to develop and test the effectiveness of new approaches to manage stress and promote positive health outcomes. However, it is very important to recognize when the patient or caregiver needs to be referred to a professional with advanced training in counseling.

emotion focused coping

Emotion-focused coping: Managing emotions that one feels when a stressful event occurs Purpose: To help decrease negative emotions and help create a feeling of well-being Examples of emotion-focused coping: discussion of feelings with a friend or taking a hot bath.

implementation

First step in managing stress is awareness of its presence Stressful feelings will be expressed Facilitate and enhance coping strategies Interventions depend on severity of stress experience Implement stress management strategies for yourself. It will benefit you personally and enhance your own health and wellness. Share them with patients and caregivers. Table 6-11 provides ideas for incorporating stress management strategies into nursing practice: Relaxation breathing Imagery Music Exercise Massage Meditation Art therapy Journaling

PRAYER

Form of meditation Spiritual communication with God or an object of worship Many people find deep comfort in their faith. Religious services, conversations with clergy, individual worship and prayer - all may help to alleviate a person's stress and give one a greater perspective, strength, and inspiration.

imagery

Generates images that have a calming effect on the body Involves a focused mind and incorporates all senses to create physiologic and emotional changes Guided imagery: Images are suggested by another person Imagery can be used in many clinical settings for stress reduction and pain relief. Benefits of imagery include anxiety reduction, decreased muscle tension, improved comfort during medical procedures, immune system improvement, decreased recovery time following surgery, and reduction in sleeping problems. Nurses may use imagery in their own lives or may use guided imagery with their patients. One of the purposes of imagery is to create a special place for a mental retreat. This technique can be found in Table 6-8. When imagery is performed, It is best to find a comfortable position Take slow deep breaths Focus involving all senses (sight, hearing, touch, and smell). Imagery can also be used to enhance performance or process stressful or difficult tasks. For example, it can be used to help an athlete or anyone achieve greater success. Imagery allows one an opportunity to mentally rehearse the difficult or challenging situation. It can be used to help a fearful nurse start an IV or perform a difficult procedure. It can also be used with a patient who is afraid to have a stressful or painful procedure performed (e.g., bone marrow biopsy).

elements of assessment

Goal: Determine individual's appraisal stage and coping strategies History Perception of threat Past coping patterns Medical history Social history Examination Observation of behavior Mental health assessment

integrative medicine

Grounded in six principles, integrative nursing is defined as "a way of being-knowing-doing that advances the health and well-being of persons, families, and communities through caring-healing relationships. Integrative nurses use evidence to inform traditional and emerging interventions that support whole-person/whole-systems healing." Although the body of evidence about CAM is growing, limited data make it difficult to establish the specific benefits of complementary therapies. Weigh the risk and benefits of each intervention and consider the following when recommending complementary therapies: (1) the history of each therapy (many have been used by cultures for thousands of years to support health and reduce suffering); (2) nursing's history and experience with a particular therapy; (3) outcomes and safety data, including case study and qualitative research; and (4) the cultural influences and context for certain patient populations.

Four months later you see J.R. in the E.D. with complaints of dyspnea, palpitations, and chest pain. He looks like he has gained weight. Lab tests, ECG, and chest x-ray are normal. MI and pulmonary embolism are both ruled out. What might be happening to J.R.?

He may not be managing his diabetes well. Additional weight may be contributing to his difficulties. Stressors may be mounting. Assess what other situational or environmental stressors he may be/have been experiencing. Find out what else might be keeping his body on "high alert." Assess any cognitive, behavioral, work-related, or sleep changes that are occurring. Evaluate if he is depressed or suicidal. Assess for any secondary infections. Talk to his wife/family if possible to obtain their perspectives.

nursing process implementation

Health promotion Decrease stress-producing situations Increase resistance to stress Learn skill that reduce physiological response to stress Regular exercise and rest

J.R.'s wife enters his room and begins to cry. She sits down and begins to tell you about the car accident she narrowly escaped on the way to the hospital. What are some of the physiologic responses her body experienced at the time of the event?

Heart rate increases. Peripheral blood vessels constrict. Blood is diverted to vital organs. Systolic BP increases. Breathing becomes more shallow. Respiratory rate increases. The adrenal gland produces more adrenaline and norepinephrine. There is a prolonged SNS response. The liver makes more glucose available. The GI system produces less secretions, less peristalsis, and less digestion occurs.

maladaptive coping

Inability to accurately assess stressor Denial or avoidance Actual or perceived lack of control Actual or perceived lack of support No experience or poor past experiences in managing stressful situations

Stress Response

Increases Cardiac output Blood glucose levels Oxygen consumption Metabolic rate

key characteristics

Individuals who possess a high degree of resilience are not as likely to perceive an event as stressful. Hardiness is a combination of three characteristics that together help people "turn things around" from potential calamities into opportunities for personal growth. Commitment Control Openness to change People with positive attitudes view situations differently from those with a negative attitude and can impact wellness and longevity. Being optimistic can help you to cope more effectively with stress. Reduce a person's chances of developing stress-related illnesses. Tend to recover more quickly from an illness than pessimists. Pessimists Likely to deny the problem, distance themselves from the stressful event, focus on stressful feelings, or allow the stressor to interfere with achieving a goal. Tend to report poorer health compared with those with an optimistic attitude.

what factors effect ones ability to cope with stress

Internal influences Age, health status, personality, previous experience with stress External influences Cultural and ethnic influences, socioeconomic status, social support, timing of stressors

massage

Involving touch and movement, massage is typically delivered with the hands. It reduces muscle tension and positively affects mental and emotional states. Massage is a form of caring, communication, and comfort. Your role related to massage differs from that of the registered massage therapist. Whereas massage therapists can provide more comprehensive massage therapies, as a nurse, you can use specific massage techniques as part of nursing care. For example, you can give a back massage to help promote sleep. For a bedridden patient, gentle massage can stimulate circulation and help prevent skin breakdown. A simple hand massage can be used to have a calming and relaxing effect, especially for patients who are anxious or agitated. During end-of-life care, hospice nurses may incorporate massage into their nursing care as the massaging touch can lessen pain and restlessness. When you identify that massage may be useful, first assess the patient's preference regarding touch and massage. Consider cultural and social beliefs, and discuss potential benefits with the patient. Family members can be taught to perform massage on their loved one, providing a way for family members to participate in patient care. This can be therapeutic for both the patient and family, even when the loved one is cognitively impaired or unresponsive.

Buffers

Key personal characteristics Resilience Hardiness Attitude Being optimistic

effects of stress on health

Long-term exposure to catecholamines from excessive activation of the SNS Increases risk of CV diseases Decreases control of metabolic conditions Makes us more susceptible to infection Excessive activation of sympathetic nervous system may also cause or worsen Migraine headaches Irritable bowel syndrome Peptic ulcers Control of metabolic disorders. Control of metabolic conditions, such as diabetes mellitus, is also affected by stress. Behavioral interventions aimed at stress reduction and relaxation in conjunction with standard medical therapy have been successful in helping to manage these diseases. In a landmark study, healthy volunteers were inoculated intranasally with low doses of upper respiratory tract viruses. The subjects underwent psychologic testing to determine the occurrence of stressful events in their lives and their reactions to such stresses. The results showed that the rates of both viral infection and clinical colds increased with the degree of psychologic stress. In this study, social support buffered the harmful effects of stress. At the cellular level, stress may promote earlier onset of age-related diseases Link between stress and telomere length Chronic stress is a major contributor to chronic illness, which in turn is a major driver of escalating health care costs. It is critical that the entire health care community recognize the role of stress and unhealthy behaviors in causing and exacerbating chronic health conditions.

meditation and breathing

Meditation includes a wide range of practices that involve relaxing the body and stilling the mind. Four components of meditation are (1) a quiet space, (2) a comfortable position, (3) a receptive attitude, and (4) a focus of attention. Meditation differs from relaxation; the purpose of meditation is to become "mindful," increasing our ability to live freely and escape destructive patterns of negativity. Most meditation techniques involve slow, relaxed, deep abdominal breathing that evokes a restful state, lowers oxygen consumption, reduces respiratory and heart rates, and reduces anxiety. Meditation reduces overall systolic and diastolic blood pressures and significantly reduces hypertensive risk. It also successfully reduces relapses in alcohol treatment programs. Patients with cancer who use mindfulness-based cognitive therapies often experience less depression, anxiety, and distress, and report an improved quality of life. Patients suffering from posttraumatic stress disorder and chronic pain also benefit from mindfulness meditation. Meditation increases productivity, improves mood, increases sense of identity, and lowers irritability. Considerations for the appropriateness of meditation include the person's degree of self-discipline; meditation requires ongoing practice to achieve lasting results. Most meditation activities are easy to learn and do not require memorization or particular procedures. Meditation is contraindicated for some people. A person who has a strong fear of losing control will possibly perceive it as a form of mind control and thus will be resistant to learning the technique. Some individuals become hypertensive during meditation and require a much shorter session than the average 15- to 20-minute session. Meditation may enhance the effects of certain drugs. Therefore, monitor individuals learning meditation closely for physiological changes with respect to their medications. Prolonged practice of meditation techniques sometimes reduces the need for antihypertensive, thyroid-regulating, and psychotropic medications (e.g., antidepressants, antianxiety agents). In these cases, adjustment of the medication is necessary. Meditation Any activity that limits stimulus input by directing attention to a single unchanging or repetitive stimulus, person becomes more aware of self Clinical application Lowers oxygen consumption, reduces respiratory and heart rates, and reduces anxiety, lowers BP Limitations May become hypertensive May enhance effects of certain drugs

the integrative nursing role

Need to encourage dialogue about the use of CAM Responsibility to understand the benefits of therapies that encourage active patient participation Multiple practitioner approach: integrative Holistic in nature Follow Nurse Practice Act scope of practice. Work closely with patient Most people using and seeking information about CAM are well educated and have a strong desire to actively participate in decision making about their health care. Allopathic physicians have increasing concerns that current conventional medicine is not meeting the needs of their patients. Mainstream physicians who have increasing concerns that current conventional medicine is not meeting the needs of their patients. All providers, including nurses, need to encourage open, honest dialogue about the use of CAM by patients and better understanding of the benefits of therapies that encourage active participation by patients in preventing or managing illness rather than relying solely on surgery or drugs. Integrative health care involves interprofessional group practices in which a patient seeks care simultaneously from more than one type of practitioner. An interprofessional group practice represents a truly integrated system where all practitioners work side-by-side to improve the well-being of their patients. This integrative approach is consistent with nursing's patient-centered legacy, focused on whole-person well-being and health. Nurses should be essential participants in this type of health care delivery system as many already practice the use of touch, relaxation techniques, imagery, and breathwork using the principles of integrative nursing. Know which patient is most likely to benefit from each therapy, which complications might occur, and which precautions are needed when using these therapies. Familiarize yourself with the evidence in each modality that you incorporate into your practice. Know which patient is most likely to benefit from each therapy, when to employ the various therapies, which complications might occur, and which precautions are needed when using these therapies. You need enough knowledge to discuss the full range of possible therapeutic options, both biomedical and complementary, so that you can help patients make informed health care decisions. Always ask patients directly about their use of complementary therapies, including self-care activities such as yoga, meditation, or dietary supplements. Be aware of the safety precautions for each complementary therapy and incorporate these in your teaching plans. Understand your state Nurse Practice Act with regard to complementary therapies and practice only within the scope of these laws.

holistic medicine

Nurses have historically practiced in an integrative fashion; a review of nursing theory reveals the values of holism, relational care, and informed practice. Until recently, nursing identified its practice as holistic rather than integrated. Holistic nursing treats the mind-body-spirit of the patient, using interventions such as relaxation therapy, music therapy, touch therapies, and guided imagery. The American Holistic Nurses Association maintains Standards of Holistic Nursing Practice, which defines and establishes the scope of holistic practice and describes the level of care expected from a holistic nurse.

J.R. is 46 years old. His doctor just left the room before you walk in. At first he is quiet. After a few minutes he tells you that his doctor just told him that he has type 2 diabetes and will require treatment and changes in his lifestyle. What can you say?

Obtain more information that helps you understand his perception of the diagnosis. Ask about his understanding of the diagnosis how he feels about this new information what this means for him and his lifestyle how his family might react what impact this might have on his family what he would like to know or do at this point.

weapon against stress

Our mind Helps us conquer stress Gives us the power to choose how we respond to a crisis or difficult time

problem focused coping

Problem-focused coping: Finding solutions to resolve problems causing stress Purpose: Allows one to look at a challenge objectively and take action to address the problem and reduce the stress When a situation is unchangeable or uncontrollable, emotion-focused coping may predominate. When a problem can be changed or controlled, problem-focused coping is the most helpful coping strategy.

acupuncture

Regulates or realigns vital energy (qi), which flows through channels in the form of a system of pathways called meridians Effective for pain Also used to treat other disorders with varying effectiveness As a key component of TCM, acupuncture is one of the oldest practices in the world. When applied outside the whole system practice of TCM, acupuncture is viewed as a mind-body therapy and is called medical acupuncture. In the United States, medical acupuncture is often provided as an individual treatment by conventionally trained health care providers. Acupuncture regulates or realigns the vital energy (qi), which flows like a river through the body in channels that form a system of 20 pathways called meridians. An obstruction in these channels blocks energy flow in other parts of the body. Acupuncturists insert needles in specific areas along the channels called acupoints, through which the qi can be influenced and flow reestablished. Current evidence shows that acupuncture modifies the body's response to pain and how pain is processed by central neural pathways and cerebral function. Acupuncture is effective for a variety of health problems, such as low back pain, myofascial pain, hot flashes, simple and migraine headaches, osteoarthritis, plantar heel pain, and chronic shoulder pain. Acupuncture is a safe therapy when the practitioner has the appropriate training and uses sterilized needles. Although needle complications occur (e.g., infection, fainting), they are rare if the practitioner takes appropriate steps to ensure the safety of the equipment and the patient. In addition, you need to exercise caution when using acupuncture with pregnant patients and those who have a history of seizures, are carriers of hepatitis, or are immune compromised. Treatment is contraindicated in persons who have bleeding disorders and skin infections.

relaxation strategies

Relaxation strategies can be used to cope with stressful circumstances and elicit the relaxation response. The decrease in SNS activity leads to decreased heart and respiratory rates, decreased BP, decreased muscle tension, decreased brain activity, and increased skin temperature. The relaxation response can be elicited through a variety of relaxation strategies. Regular elicitation of the relaxation response has proved to be an effective treatment for a wide range of stress-related disorders, including chronic pain, insomnia, and hypertension. Individuals who regularly engage in relaxation strategies are able to deal better with their stressors, increase their sense of control over stressors, and reduce their tension. Relaxation strategies can include Relaxation breathing Meditation Prayer Imagery Music Massage

signs and symptoms

Signs and symptoms of stress response Physical Increased HR and BP, hyperventilation, or headache Behavioral Anxiety, irritability, or impaired speech Cognitive Self-reports of forgetfulness or indecision Patients and caregivers face many potential stressors that can have health consequences. Assess stress in patients and caregivers Assist in identifying high-risk periods for stress Implement stress management strategies Assess number of stressors, duration of stressors and previous experience with similar demands. Assess the personal meaning attached to the situation. Be specific with questions. Illness is a source of stress. Identify what aspects are most distressing - physical needs, job responsibilities, finances, children. Helps you understand the patient's perspective. Assist you in identifying potential and actual sources of stress and their effect on the patient and caregiver.

examples of physiologic vs emotional stressors

Skin burn Chronic pain Hypothermia Infectious disease Excessive noise Starvation Running a marathon Birth of a baby Diagnosis of cancer Marital problems Failing an examination Inadequate financial resources to meet needs Grieving the loss of a family member Caring for a disabled child Winning or losing an athletic event Winning the lottery

relaxation therapy

Some CAM therapies are general in nature and use natural processes to help patients with acute or chronic conditions. They are easily learned by health care professionals. The relaxation response is the state of generalized decreased cognitive, physiological, and/or behavioral arousal. The process of relaxation elongates the muscle fibers, reduces the neural impulses sent to the brain, and decreases the activity of the brain, as well as other body systems. Decreased heart and respiratory rates, blood pressure, and oxygen consumption and increased alpha brain activity and peripheral skin temperature characterize the relaxation response. Relaxation helps individuals develop cognitive skills to reduce the negative ways in which they respond to situations within their environment. Cognitive skills include the following: Focusing (the ability to identify, differentiate, maintain attention on, and return attention to simple stimuli for an extended period). Passivity (the ability to stop unnecessary goal-directed and analytic activity). Receptivity (the ability to tolerate and accept experiences that are uncertain, unfamiliar, or paradoxical). Progressive relaxation training teaches an individual how to effectively rest and reduce tension in the body. The person learns to detect subtle localized muscle tension sequentially, one muscle group at a time. One active progressive relaxation technique involves the use of slow, deep abdominal breathing while tightening and relaxing an ordered succession of muscle groups, focusing on the associated bodily sensations while letting go of extraneous thoughts. The goal of passive relaxation is to still the mind and body intentionally without the need to tighten and relax any particular body part. One effective passive relaxation technique incorporates slow, abdominal breathing exercises while imagining warmth and relaxation flowing through specific body parts such as the lungs or hands. Passive relaxation is useful for persons for whom the effort and energy expenditure of active muscle contracting leads to discomfort or exhaustion. Be aware that on occasion some relaxation techniques result in continued intensification of symptoms or the development of altogether new symptoms. An important consideration when choosing a relaxation technique is the physiological and psychological status of the individual. Progressive relaxation requires energy and is not recommended for weak patients.

immune system

Stress has an impact on the immune system. Because it is now known that the brain is connected to the immune system by neuroanatomic and neuroendocrine pathways, stressors have the potential to lead to alterations in immune function.

primary prevention of stress

Stress management and reduction techniques Counseling Maintenance of positive relationships Family, friends, social networks, and others Maintenance of optimal health Wellness programs Health education

stress

Stress refers to an internal or external event or demand of life experienced by the individual that is perceived and appraised for scope and meaning on a continuum to determine whether resources and abilities for management are available, exceeded, or exhausted.

implementation

Support systems Time management Guided imagery and visualization Progressive muscle relaxation therapies Assertiveness training Journal writing Mindfulness-based stress reduction (MBSR) Stress management in the workplace

fight or flight

The fight-or-flight response is a very important and necessary adaptive mechanism of the body to acute stress. This response is activated in response to stressors regardless of whether they are physiologic (e.g., acute pain) or emotional/psychologic (e.g., death of a child, loss of a home through fire, fear). Acute stress leads to physiologic changes that are important to a person's survival. This "alarm system" puts a person on high alert. The acute stress response is a state of physiologic and psychologic arousal characterized by increased SNS activity that leads to increased heart and respiratory rate, increased BP, increased muscle tension, increased brain activity, and decreased skin temperature.

general adaption syndrome

The general adaptation syndrome (GAS) describes how the body responds physiologically to stressors through stages of: alarm, resistance and exhaustion. The GAS is triggered either directly by a physical event or indirectly by a psychological event. It involves several body systems, especially the neuroendocrine feedback, and responds immediately to stress. When the body encounters a physical demand such as an injury, the pituitary gland initiates the GAS. A fundamental concept underlying this reaction is that the body will attempt to return to a state of balance, a process referred to as allostasis. During the alarm stage the central nervous system is aroused and the body's defenses are mobilized; this is the flight-or-fight reaction. Rising hormone levels result in increased blood volume, blood glucose levels, epinephrine and norepinephrine amounts, heart rate, blood flow to muscles, oxygen intake, and mental alertness. If the stressor poses an extreme threat to life or remains for a long time, the person progresses to the second stage, resistance. The resistance stage also contributes to the flight-or-fight response and the body stabilizes and responds in an attempt to compensate for the changes induced by the alarm stage. Hormone levels, heart rate, blood pressure, and cardiac output should return to normal, and the body tries to repair any damage that occurred. These compensation attempts consume energy and other bodily resources. The exhaustion stage is where continuous stress causes progressive breakdown of compensatory mechanisms. This occurs when the body is no longer able to resist the effects of the stressor and has depleted the energy necessary to maintain adaptation. The physiological response has intensified, but the person's ability to adapt to the stressor diminishes. Even in the face of chronic demands, an ongoing state of chronic activation can occur. This chronic arousal with the presence of powerful hormones causes excessive wear and tear on bodily organs and is called allostatic load. A persistent allopathic load can cause long-term physiological problems such as chronic hypertension, depression, sleep deprivation, chronic fatigue syndrome, and autoimmune disorders

stress

The inability to cope with perceived demands or threats to one's mental, emotional, and spiritual well-being it is important to remember that each person perceives

mind body spirit

The mind-body-spirit connection demonstrates the relationship and interconnectedness among the various parts that a person is made of: mind, body, and spirit. All three parts are important in your life and determining who you are. What goes on in your mind influences every part of the body. Your body and your mind are affected by how connected you feel to your spirit (soul). Your spirit is the life force within you that gives life, energy, and power. You are not just a person with a body. You are a spiritual being with a mind that affects every aspect of your body. Stress has a powerful effect on mind, body, and spirit.

crisis

When stress overwhelms a person's usual coping mechanisms and demands mobilization of all available resources, it becomes a crisis. A crisis creates a turning point in a person's life because it changes the direction of his or her life in some way. The precipitating event usually occurs approximately 1 to 2 weeks before the individual seeks help, but sometimes it has occurred within the past 24 hours. Crisis intervention is a specific type of brief psychotherapy and has two specific goals. First, patient safety. Use external controls to protect the patient and others if the person is suicidal or homicidal. Second, is anxiety reduction using techniques so that a patient's inner resources are put into effect. Help the patient make the mental connection between the stressful event and his or her reaction to it. This is crucial because he or she is sometimes unable to see the whole situation clearly. Help the patient explore coping mechanisms, perhaps identifying new methods of coping. A person who has experienced a crisis has changed, and the effects often last for years or for the rest of the person's life. The final stage of adapting to a crisis is acknowledgment of the long-term implications of the crisis. If a person has successfully coped with a crisis and its consequences, he or she becomes more mature and healthy.

Planning

The nurse often selects interventions for stress and improved coping, such as coping enhancement and crisis intervention, in addition to individualized interventions, after considering the nursing diagnosis, the resources available to the patient, and the goals identified by the patient and the nurse. Nursing interventions are designed within the framework of primary, secondary, and tertiary prevention. At the primary level of prevention you direct nursing activities to identifying individuals and populations who are possibly at risk for stress. Nursing interventions at the secondary level include actions directed at symptoms such as protecting the patient from self-harm. Tertiary-level interventions assist the patient in readapting and can include relaxation training and time-management training. The nurse and the patient assess the level and source of the existing stress and determine the appropriate points for intervention to reduce it. Use a concept map to identify multiple nursing diagnoses from the assessment database and show how they are related. Interventions focus on a partnership with the patient and support system, usually the family. Consider the patient's perspective and responses to assessment questions when setting priorities for care. As in all areas of nursing, safety of the patient and others is the first priority. When you have completed immediate assessment and ensured safety, begin the problem-solving process. To effectively plan individualized care, collaborate with occupational therapists, dietitians, pastoral care professionals, and health care professionals from other clinical specialties, depending on the patient's situation. Recognize the need for collaboration and consultation; inform the patient about potential resources; and make arrangements for interventions such as consultations, group sessions, or therapy as needed.

relaxation breathing

The way one breathes affects every aspect of life Simplest and most effective way to stop the stress response is to breathe deeply and slowly Relaxation (abdominal) breathing Performed while sitting, standing, or lying down Involves primary use of the diaphragm and less use of the upper chest and shoulders Abdomen gently moves in and out

Training-Specific Therapies

Training-specific therapies are CAM treatments that nurses (or other health care providers) administer only after completing a specific course of study and training. These therapies require postgraduate certificates or degrees indicating completion of additional education and training, national certification, or additional licensure beyond the registered nurse (RN) to practice and administer them. Several training-specific therapies (e.g., biofeedback, acupuncture) are very effective and are often recommended by Western health care practitioners. However, others (e.g., homeopathy, naturopathy) have not been adequately studied, and their effectiveness in many conditions has been questioned. Although many of these complementary therapies elicit positive effects, all therapies carry some risk, particularly when used in conjunction with conventional medical therapies. Therefore you need advanced knowledge to effectively talk about them with patients and to provide education about their safe use. Biofeedback therapeutic touch acupuncture chiropractic therapy natural products and herbal therapies

what types of stress are there

acute episodic and chronic

CAM

an array of health care approaches with a history of use or origins outside of mainstream medicine

individual risk factors of stress

impaired cognition, chronic health conditions including mental health issues, multiple significant life changes, socioeconomic status, caregiver, individual in a foreign country

types of stress

could be emotional, physiological, positive or negative it all depends on how the person perceives it perception is the most important aspect of it all because it determines if a person becomes stressed or not and if it will have a negative or positive effect on the person

what are sources of stress

physiological and psychological/emotional

coping strategies

positive and negative Positive: Activities such as exercise and use of social support - helps us handle stressors so they don't overwhelm us. Negative: May include substance abuse and denial - may temporarily relieve stress, but in the long run they actually increase it.