Stress and Coping

Therapeutic procedrues

COGNITIVE BEHAVIORAL THERAPY: -anxiety decreased by changing behaviors -cognitive reframing to help identify negative thoughts that produce anxiety) -behavioral therapy (teach ways to decrease anxiety or avoidant behavior and opportunity to practice: relaxation modeling: see a demonstration of appropriate behavior (help them learn to immitate behavior) --think about the great amount of assitance when recieving examples systemic desnsitization: mastering of relaxation while exposed to increasing levels of anxiety-producing stimulus flooding: exposing to undesirable stimulus in attmpt to turn off anxiety (helpful for phobia) response prevention: focuses on preventing from forming cumpulsive behavior (THINK ABOUT HOW AUTOMATIC OVERTHINKING MODE-HELPING THEM STOP THESE COMPULSIONS) thought stopping: say stop when negative thoughts or behaviors arise (makes sense)

Chronic stress

Can lead to moderate anxiety -nervous or agitated -muscle stiffness -uneasy, can still ufnction but change in ptich, easily shaken or sensitive

Risk factors for anxiety

-Family h/x of anxiety -shyness/ worrying as a child -poor coping mechanisms during times of stress (becomes chronic) -childhood adversity (think about children who are born with parents who are addicts) -lack of social connection (psychological theory) -traumatic events PREVENTION: EARLY RECOGNITION OF SIGNS OF ANXIETY/ INCREASED LEVEL OF STRESS AND T/X BEFORE IT BECOME CHRONIC OR SYMPTOMS WORSEN -education on the risks for drug abus/ self-medicating (can worsen anxiety which potentiates the dual-diagnosis conflict)

Adaptation

-ability to progress and find new solutions during a newly presented confict -how individual handles demands in the environment general adaptation syndrome (stress syndrome) that describes the stress reaction in three stages: 1. ALARM (body function are heightened to respond to stressors) -think about how the body is uncertain which produces the fight or flight response -epinephrine, norepinephrine and cortisone respond=increase in blood pressure, increase in heart rate, heightened alertness (think about how norepinephrine is a stimulant), heightned mental awareness, decrease metabolism for non vital organs, decreased urinary output, increased blood flow to muscles (preparing to run) 2. resistance stage (think about how the ego interferes after evaluating the stress) -body attempts to cope with the stressor and return to homeostasis (stable bp, hr and hormones) 3. Exhaustion: rest and digest -body functions are no longer able to maintain response to stressor (results in recovery or death***

Risk factors for crisis

-accumulation of unresolved losses (think about how theres no way to rationalize what happned/ intellectualize -current life stressors (think about how if there is an extensive amount of strain and adding to the strain can result in a crisis) -mental and physical health issues (think about if you were disabled in some way, it would be very frustrating) -excessive fatigue or pain -age and developmental stage (think about how those in their 20s have increased risk especially since they are beginning many new persuits) PROTECTIVE FACTORS: SUPPORT SYSTEM, PRIOR EXPERIENCE WITH STRESS/ CRISIS (understand the abrupt change and know what to expect)

Beta blockers

-can also produce anti-anxiety effects (think about how its preventing cascade of stress response) -watch bp before admin (under 90, contraindicated) -assess for orthostatic, confusion, fatigue or drowsiness -should not give if hr is less than 60 -may cause hyper or hypoglycemia ANYONE WITH DM SHOULD BE MONITORED -block cardiac and bronchial beta receptors (think about how the symapthetic nervous system naturally increases hr, cardiac contractility and bp when stressed

Stress and defense mechanisms

-can behelpful in coping with stressors but can become maladaptive when they interfere with functioning ALTRUISM AND SUBLIMATION ARE DEFENSE MECHANSIMS THAT ARE ALWAYS HEALTHY*** OTHER CAN BE USED HEALTHILY BUT CAN PREDISPOSE TO MALADAPTIVE ALTRUISM: dealing with anxiety by reaching out to others (think I need the truth yal) -adaptive: nurse who lost family member in a fire and volunteers as a firefighter (reaching out and helping others, controls their own anxiety) SUBLIMATION: deeling wiht unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression (think substituting the negative emotion with I am going to be happy more) adaptive: feelings of anger and hostility toward work supervisor and sublimates by working out vigorously at the gym during gym or woman angrly with bf and goes to a shooting range Suppression: denying unpleasant throughts and feelings adaptive: student puts of thinking about a fight they had with a friend to focus on a test maladaptive: neglects their feelings (lost job and states they will worry about it next week) THINK ABOUT PEOPLE WITH ANXIETY DISORDERS HOW THEY TEND TO IGNORE IMPORTANT DECISIONS REPRESSION: unconsciously putting unacceptable ideas, thoughts and emotions (think its on repeat so intrinsic rather than conscious) -adaptive: person preparing to give speech unconsciously forgets about past when kids laughed at them on stage mal: has fear of dentist and forgets to go to the dentist regression:

Situational role changes

-caused by situations other than physical growth and development (marriage, job changes, divorce, parenthood) -illness or hospitilization that disrupts roles -with resolution can contribute to healing in physical, mental and spiritual ways (learning how to adapt and accept change) temporary role changes: resume the role when illness resolves permanent: illness has altered level of clients health to a point that previous roles are no longer available (injury that doesnt allow working).

FAMILY SYSTEMS AND DYNAMIC

-client and consists of the individual structures and roles -two or more people whos relationship creates a bond, mutual development, support, goals and resources FIVE REALMS OF PROCESSES: 1. interactive: think about how always present and communicating with one another 2. developmental (continues to strengthen or progress as people age/ reach certain milestones) 3. coping (HOW WELL THEY ALL HANDLE STRESS) 4. integrity (think about how families that keep up with each other have stronger bonds) 5. health current issues involving families: increased need for caregivers (due to increased elderly population), increased unemployment, family violence (think about how substance abuse can strongly impact this=more trauma in children--especially females), any acute or chronic illness, homelessness (lack of stable environment, financial issues, indadequate access to health care) LACK OF AFFORDABLE HOUSING**

Clinical therapes for crises

-cognitive behavioral therapy -clear guidance/ eye contact -crisis intervention -inpatient hospitlization and counseling -couple therapy, family or group therapy -

examples of type of coping

-cognitive: emotional focused coping (defensive): oh its not that bad -behavioral:

Adherence

-commitement to something (such as following a t/x) -commitment increases adherence (think about how routine helps create consistancy within the brain--consistency is a calming thing0 -complicated regimen intereres with adherence (think about how over researching proper dietary measures for weight loss or for exercise can demotivate an individual) -NEED SIMPLE GOALS AND SIMPLE INSTRUCTION** (LIKE FOR DRUG USERS, CAN GET OVERWHELMED) -involvement of client and significant support people in the planning stage=increases adherence (THINK ABOUT HOW THEY ARENT FEELING ALONE AND WILL HELP THEM AVOID TRIGGERS) -adverse effects of medicaiton diminish adherence (think about jasmine and how anti depressants side effects have detered her from taking them) -negative coping mechanisms (denial, rationalization) -increased resources

PATIENT CENTERED CARE FOR CRISES:

-designed to provide rapid assistance for individuals or groups who have an urgent need (care is resolution of the immediate problem** think about how the person won't think about anything else0 -its like maslows, wherever is creating the crisis is where they are on the pyramid -INITIAL TASK IS TO PROMOTE SAFETY FOR CLIENT BY ASSESSING RISK FOR SUICIDE OR HOMICIDE (THINK ABOUT HOW THIS IS THE CASE FOR THOSE WITH SUBSTANCE ABUSE AS WELL--SAFETY IS PRIORITY) diagnosis: risk for injury***** -assist with admission to an inpatient facility as needed for those with suicidal or homicidal thoughts -prioritize interventions that adress physical needs first - Initial interventions: 1. identify current problem and directing interventions for resolution (think about how they are attempting to fix the cause of the crisis but it isnt working=the increased distress, withdrawal or depression depending on the phase -phase 2 if they are experiencing extreme anxiety, disorientaiton, trial and error attempts 3 if they are failing and they are starting to withdraw or trying to escape the situation (flight) -take an active, directive role wiht the client (encourage active participation in solutions and goal setting--think about how they are losing a sense of direction and feeling powerless, giving instruciton while giving them autonomy helps boost their confidence leels) -help set realistic goals USE STRATEGIES TO DECREASE ANXIETY -therapeutic nurse client relationship -remain with client -listen and observe -eye contact -questions r/t feelings and event -demonstrate genuineness and caring -communicate clearly and with clear directives (think about how they are overwhelmed by how they will handle this event and require someone outside who can show some control -avoid false reassurance -teach relaxation techniques Teach coping skills: assertivness training, parenting skills, boundary setting assist with action plan: short term, focused on the crisis******, realistic and manageable, self assessment by nurse, debriefing for staff (think about how this could be distressing for them) CRITICAL INCIDENT STRESS DEBRIEFING: GROUP APPROACH THAT CAN BE USED WITH A GROUP OF PEOPLE EXPOSED TO CRISIS (ADVENTITIOUS TYPE OF CRISIS)

Diagnosis; powerlessness

-determine if they are depressed, hopeless or feeling apathy -determine patien's power needs -distinguish locus of control (extent to which people associate responsibility to themselves vs other forces) -think about how this could be projecting or displacement more external (seeing things beyond their control) have more feelings of powerlesness -evaluate decision making competence (think about how during crisis, it is often disoriented) -encourage patient to identify strengths and to verbalize feelings -discuss t/x and have them apart of plan of care -help them reexamine negative perceptions -eliminate unpredicability of events by preparing them for procedures -give control over their environment -render positive feedback

nonbenzodiazepines buspirone (think about how this is the exception and can be used to t/x anxiety)

-dopamine agonist in brain and inhibit serotonin reuptake (increaed circulating srotonin) -assess for nausea, headaches and dizziness -use with caution with liver or kidney function -advise pt daily admin for several weeks seide effects: chest pain, s.o.b, light headedness -headache, dizziness, insomnia, nausea, feeling nervous or excited (think about how too many emotions can be overwhelming)

Anxiety acrossed the lifespan

-for adolescents and children anxiety is common and the first time of treatment is usally psychotherapy (think about felicity and how she was placed in exposure therapy) WHY? helps build constructive responses to stress ANXIETY IN CHILDREN: -more prevalent in girls and children from low socioeconomic backgrounds (makes sense because they are dealing with many levels of anxiety) -family dynamics are altered (creating some stressors of role confusion or role conflict) -common among children is Separation anxiety (especially from 18 months to 3yrs of age--think about how toddlers can be caudled which can result in this) -SYMPTOMS THAT SHOW THEY HAVE SAD INCLUDE: fear of separation, obvious impairment of daily life and persists for 4 months or greater -can continue from 7-9 years of age -FIRST LINE OF TREATMENT/ MOST EFFECTIVE WITH CHILDREN ARE SSRIS AND cognitive behavioral therapy (help them change their reactivity to certain fears/ stimuli that induces anxiety) MAY WORRY EXCESSIVELY ABOUT BEING AWAY FROM PARENTS, HAVE REPEATED NIGHTMARES ABOUT SEPARATION, WANT TO SLEEP WITH THEIR PARENTS, REFUSE TO GO TO SCHOOK, COMPLAINTS OF MUSCLE ACHES distinct from stranger anxiety (normal between 7-11) think 711 has a lot of sketchy strangers -social anxiety 11 and 15 (think about how this is when they are going into middle school) SYMPTOMS IN CHILDREN: frequent missing school or social acitivites (think about how felicity would often miss school when her anxiety was bad and how she would refuse to stay at grandmas because she wanted to be with her mom) -tiredness/ exauastion/ fatigue (think about how they usually have a hard time sleeping) -declining grades at school (think about how teaching isnt effective when anxiety is at its worst) -restlessness -trouble concentrating (think about how felicity and i struggle with that) -irritability -extreme homesickness when away -shyness -frequent crying

DIFFERENCES BETWEEN SOMEONE WITH REGULAR ANXIETY AND ANXIETY DISORDER

-free-floating anxiety: rather than anxiety related to a specific life stressor -it is considered free floating which means excssively worrying which makes it hard to control and whose focus may shift from moment to moment (think about how I am always worrying about something) MILD: -some distress, increase in sensory perception and arousal, increase in alrtness, sleeplessness, increase in motivation and restlesness (think about how this is a functional level of anxiety--aware of surroundings and lack of sleep is the body's response to pay attention to the immediate environment) MODERATE: -narrowing of perceptual field and attention span (selective attention--think about how the reason why i have poor memory is because my brain is selective on what is within my periphery) -reduction in alertness and awareness of surroundings (think about my poor sense of direction) -feeling of discomfort or irritability with others -increased restlesness -self-absorption -increase in resp, hr, and muscle tension (think about how when my anxiety gets worse, its usualy chest tension) -increase in respiration -rapid speech, louder tone and higher pitch SEVERE ANXIETY: -perceptual field greatly reduceed -difficulty following directions (think about how when you are under stress its hard to pay attention) -feelings of dread, horror -need to relieve anxiety -headache -dizziness -nausea, trembling and insomnia -palpitations, tachycardia, hyperventilating and diarrhea (think about how this is a bad day) -FEEL SENSE OF DOOM (WHICH IS THE FEELINGS OF HORROR AND NEED TO GET AWAY)** ALSO IMPORTANT TO RULE OUT SUBSTANCE INDUCED ANXIETY (THINK about how people go through withdrawal which can excite the neurons and result in increased anxiety)

Risk factors:

-genetics (more likely in females--think about how women tend to multitask especially in thinking) OCD affects more females than males (think about how females tend to be more organized) -can experience anxiety due to hyperthyroidism or pulmonary embolism--think about how phsyiological stress can cause onset of fear r/t breathing) ASSESS MANIFESTATIONS OF ANXIETY IN A MEDICAL FACILITY TO RULE OUT PHYSICAL CAUSE (THINK ABOUT HOW MENTAL DISORDERS CAN HAVE PHYSIOLOGICAL ASSOCIATEIONS)

COPING

-how an individual deals with problems and issues (behavior and cognitive efforts of an individual to manage stress)**** THINK ABOUT HOW IN BEHAVIOR (WORKOUT, EATING HEALTHY) AND MENTAL (FOCUSING ON THE POSITIVE) FACTORS INFLUENCING: NUMBER, DURATION AND INTENSITY OF STRESSORS, PAST EXPERIENCES, CURRENT SUPPORT SYSTEM AND AVAILABLE RESOURCES (think about it, when I am coping the least it is usually when there are multiple stressors going on, I feel I am losing connection in my relationships and past experiences have caused some insecurity) -ego defense mechanisms: assist during stressfrul situation (think very basic mechanism to survive)

ASSESSMENT OF CRISES

-length of time (usually lasts about 4-6 weeks) -is usually personal and varies -fast onset giving no time for adaptation or proper coping -defined individually -presence of suicidal or homicidal ideation (think ABOUT HOW THEY MAY HAVE LOST A FAMILY MEMBER, LOST A LOVED ONE AND THEY AREN'T ABLE TO COPE WITH THIS NEW EXPERIENCE) -cultural or religious needs of the client -the client's perception of the precipitating event -support system -present coping skills -physical assessment -disorganization (think about how it occurs abrubtly which gives them no time to prepare and results in disorganization) -overwhelm and anxiety -inadequate problem solving (think of this similar to severe anxiety where they are disoriented or during times of panic) -possible anger or aggression

PATHOPHYSIOLOGY OF ANXIETY ETIOLOGY AND VARIOUS THEORIES

-neurotransmitters: most closely involve anxiety response are GABA, norepinephrine and serotonin Neurobiological: differences in the brain's limbic response -the amygdala is the "emotional brain" and responds to the stimuli -can produce increase of respirations through the brainstem, hippocampus memory formation (creating more of an intrinsic reaction to certain stimuli) Neurochemical: can be caused by structural differences in the neurons itself, over-excitatory causes, misfiring of neurotransmitors, sensitivity (makes sense for anxiety, very hypersensitive to various stimuli) BELIEVE THERE IS A DECREASE IN GABA NEUROTRANSMITTORS WHICH CAUSES MORE EXCITEMENT OF THE NEURON AND INCREASED PRODUCTION OF NEUROPENIPHERINE WHICH RESULTS IN MORE ANXIETY -ADDITIONALLY SEROTONIN IS DECREASED (DECREASED SENSE OF WELL BEING WHICH CONTRIBUTES TO ANXIETY) PSYCHOSOCIAL: ability to express inner emotions (if unable, results in inner termoil and increased anxiety levels behavioral: poor adaption to stress during developmental periods which could result in anxiety genetic: heritability is 30-60% humanistic: encompases the whole individual (sees there are genetic predispositions/ neurochemical-biological imbalances and upringing that impact prodcution of anxiety)

Interventions for personal roles

-provide teaching to further clarify roles -educate on stressors (physical demands and social isolation)--think about how families of addicts tend to isolate themselves from the community to avoid any judgment -provide short-term care to provide relief -provide encouragement during times of stress -seek congruence -prepare client for situational crisis -anticipate role conflict or overload, improve relationships, help improve their self worth -provide counseling -make refarrals to community services -make referrals to social servies

Symptoms common in adolescence (anxiety)

-restlessness -social anxiety (appears during 11 and 15) -withdrawal from social activities -poor grades -continual nervousness -dependency -easily startle -urinary frequency -engage in substance abuse -impulsive sexual behavior (think about how i was and how jennifer was) -have depression or an eating disorder -suicidal ideations (think about how i self harmed) -changes in eating habits -self-injury -trembling -HIGH AMONG TEENAGERS (MORE THAN TWICE AS LIKELY IN FEMALES) DUE TO INCREASED VALUE IN BODY IMAGE AND REPUTATION INTERVENTIONS FOR ADOLESCENTS: -must identify anxiety (very common to be undiagnosed to due difficulty assessing symptoms of gad -can lead to risky behavior: suicide, self-harm, drug abuse and impulsive sexual behavior SSRIS CAN ALSO POTENTIATE DEPRESSION/ SUICIDAL IDEATION (important to notify parents and adolescent of the risks prior to t/x)

THERAPEUTIC COMMUNICATION FOR SOMEONE IN A CRISIS

-use open ended questions -ask about the causes behind their crisis and their emotions surrounding the crisis -provide clear cut direction and allow patient autonmy/ include the patient in planning -frequent, simple and directive communication (THINK ABOUT HOW THEY ARE CURRENTLY DISORIENTED AND OVERWHELMED, WILL NOT UNDERSTAND COMPLEX INFORMATION) -MUST** CONTINUALLY ASSESS WHAT THEY HAVE HEARD AND CLARIFY -observe interactions between the family (understand areas of support which aids in stress management and may need to correct communication, tone, inflection and mannerisms) -incorporate nonverbal communication (think about how it would be difficult for them to understand words with that level of anxiety) -maintain eye contact -have a non-demanding posture (open body language, at eye level) -maintain congruence between nonverbal and verbal -paraphrase adn repeat the patient's statements to validate the nurse's understand -avoid making comments that invades or judges the experience -silence is also effective and respect their privacy and willingness to share -know the timing when to communicate (during the initial part of the crisis, will not want to listen--want to help resolve any immediate problems) -speak at a slow pace, plan for time to communicate and give time to respond especially if depressed or confused CHILDREN: simple straightforward language, use nonverbal, be at the childs eye level, incorporate play ADOLESCENT: determine how they perceive their situation -minimize distractions, provide privacy

assessment for personal roles

1. current roles and opinions on the role (are they experiencing role conflict where they are balancing two responsibilities at once, role strain where they dont feel adequate, role confusion where they arent sure of how they should take on the role 2. have they experienced a great life change? opinions? 3. identify roles as percieved as owning and by significant others -five realms of family (interactive, integrity, coping, health processes, developmental) -validate any discrepencies (think about providing teaching if there is role confusion or ambiguity) -identify the effet that the loss or addition of a role is having on the client -determine who is taking on the new role -findings of a caregiver burden or role strain (difficulty sleeping, and illness)

The homes-fahe life stress inventory

1. death of a spouse 2. divorce 3. marital separation from mate 4. detention in jail 5. death of a family member 6. loss of a job 7. marriage 6. major personal injury or illness 7. being fired 8. marital reconciliation 9. retirement -major change in health, pregnnacy, new parenthood, education, major disability, sexual difficulties, gaining a new family member, business readjustment, change in financial state, death of close friend, change in number of arguments, in-law troubles (think about intermittent stressors), outstanding personal achievment, ceasing or begining schooling, revision of personal habits, trouble with boss, body image changes? change in new school, change in church activity/ spirituality, change in social activities, loans, sleeping habits, eating changes, cavation 150 or less is low life change and low susceptibility to stress 150-300: 50% chance of major health breakdown in next 2 yrs 300 or more: about 80% chance

crisis connection

1. establish a therapeutic relationship with the patient -determine most immediate needs and help address those needs 2. assess immediate safety needs (think about risk for suicide/ injury or physiologic endangerment) 3. determine thought processes (are they feeling powerless, depressed, frustrated--may be upset about losing independence) 4. scan for physical distress 5. listen intently, supporting emotional reactions 6. explore perceptions of the crisis 7. identify coping strengths (helps build patient self-esteem) 8. develop a plan and follow-up plan (prioritizing which is first, simple and repeated instructions and identifying patient's comprehension of instruction)

Nursing transactional model

1. focus on the person, make eye contact as appropriate and minimize distractions (think about how people with anxiety will be triggered and easily distracted by the environment) 2. take a nonthreatening stance (open posture, eye level-se open ended questions and allow them to communicate feelings -encourage deep breathing exercises and relaxation techniques (15 min every day) -validate patient's feelings "i know you are very uncomfortable; we will do everything we can to help you feel better" -determine and adress immediate concenrs "what can i do to help you" -think about how this adresses maslows hierarchy of needs -adress patient by name and avoid terms of endearment NEVER USE FIRST NAME FOR THOSE OVER 18 W/O PERMISSION

RISK FOR INJURY NURSING IMPLICATIONS

1. guide the pt to their surroundings -put call light within reach and teach to call for assistance 2. have medical alarm systems (alert if patient is experiencing physiological changes) 3. have close patient supervision by sustaining observation or awareness of pt at all times (near nurse's station) -weapons and pills should be removed -present opportunities for patient to express thoughts -create verbal or written contract stating patient will not act on impulse to do self harm -stay with patient more often -arrange for patient to stay with family or firiends (hospitilization considered if no one is available) -edu on appropriate use of medications

Medications for crisis management

ADMINISTER ANTI-ANXIETY (ALRPAZOLAM, DIAZEPAM OR OAZEPAM) -THINK ABOUT HOW THIS WOULD BE FOR SHORT-TERM USE SINCE A CRISIS TYPICALLY IS 4-6 WEEKS -WANT TO MAKE SURE THEY DO NOT DRINK ALCOHOL WITH BENZOS -MONITOR RESP RATE, HEPATIC FUNCTION/ RENAL, AND LEVEL OF SEDATION -antidepressent (paroxetine, bupropion, fluoxetine--think about how these are more long term, discontinue MOI drugs 12 weeks behind) -careful with pregnancy** -WATCH FOR SEROTONIN SYNDROME (WHERE THEY FEEL DIZZY, MAY HAVE HYPONATREMIA AND LOW BP) -CHECK CBC -CANNOT TAKE WITH ALCOHOL

Stress and anxiety nursing care management

ASSESSMENT: -assess the amount/ extent of stressors in their life (how does their day-to-day stressors impact them) -what is the extent, duration, frequency and amount of stressors in the person's current life -what coping strategies/ ego defense mechanisms are they demonstrating What is their current stress levels: mild displays of anxiety: increased sensory stimulation, may be unable to sit still or fine tremors moderate: still able to function, higher pitched tone, less reasoning/ logic, uncomfortable, shaken and senistive (think about how if you were to provide feedback, with moderate anxiety it is so much harder) -SELECTIVE CONCENTRATION SEVERE: DIFFICULTY CONCENTRAITON, BELIEVE THERE IS A THREAT (THIS IS DURING THE SECONDARY AND PRIMARY APPRAISAL STAGES -have taken the stressor and rather than viewing it as a positive-benign stressor, they view it as a threat which engages the fight-or-lfight response) -very agitated, confused and indadequate -range of perception reduced (prolonged sense of gloom and doom) -will feel threatened or be avoidant -may have increased resp, dizziness, tingling sensations, headache CAN DEVELOP INTO GENERALIZED ANXIETY WHEN PERSISTENT (USUAL ONSET IS EARLY 20S, MAKES SENSE SINCE THE GROWTH AND DEVELOPMENT IN ADOLESCENCE MAY NOT BE RESOLVED=ANXIETY0 IDENTIFY CAUSES: may be genetic (it may be changes r/t decreased dopamine and serotonin) Biochemical neuranatomic: brain atrophy, underdeveloped frontal and temporal lobes, amygdala abnormalities (may be over reactive which impairs memory formation) Nursing assessment: assess level of anxiety, familial and physiological factors (want to make sure the upringing isnt because of a pulmonary condition or other anxiety-inducing condition) -assess awareness and ability to recognize and express feelings -assess for substance abuse (since this can further exacerbate or be the primary cause of anxiety) interventions: -assist to identify feelings (establish therapeutic relationship) -clarify meaning of feelings -promote wellness (help them identify ways to manage their fears--think about this as a form of identification) -the stop method (saying it aloud which allows the person to stop ruminating thoughts) -provide a quiet/ minimally-stimulating environment/ controlled

Crises along the lifespan

Adolescence and children: -children require more nonverbal support/ communication -speaking to them at eye level, therapeutic play, having parents present, bright colored room Should let the child know they are safe, encourage them to express their emotions, encourage parents to stay with their child (observe their interactions), keep them informed about the event LIMIT THEM FROM WATCHING TV ABOUT THE EVENT AND MONITOR DEVELOPMENTAL LEVEL Educate the parents on identifying signs of poor coping (very similar to anxiety): insomnia, bed-wetting, behavioral outbursts at school, irritability, inconsolability, fear of abandonment, strong attachment/ need for parent to be present, reports of headaches/ stomach aches (think about how when I over-think and have a lot of anxiousness, i have stomach aches and headaches) ADOLESCENTS: SUICIDE WATCH******* -have close adolescent supervision, limit access to medications or other dangerous objects (weapons and pills should be removed), encourage to express feelings, stay with them more often, arrange hospitilization or other cares if needed PREGNANT WOMEN: want to address the most immediate problem/ root-cause for feelings of distress/ crisis many pregnant women experience these stressors: lack of support from their husband, teen pregnancy (will present difficulties with their educaiton or may have disapproval from family), trauma from rape, feelings of inadequacy for parenthood, finding out their child will be disabled in some way nursing interventions: assisitng in immediate concern disability: providing education on how to care for a child who is disabled rape: helping them find resources to identify the person Teen: helping them connect with family or provide them with other means of support for their pregnancy physiological: provide education on how to maintain wellness and importance of abstaining from substance abuse/ alcohol abuse r/t increased risk for low birth weight, resp abnormalities, cognitive abnormalities, sad, genetic predispositions, etc. OLDER ADULTS: -nurses priority is to determine current level of understanding/ orientation to the present moment (person, place, time and event) -if they are oriented, providing cares for emotional and physiological needs -obtaining list of medications (THINK ABOUT HOW THEIR BODILY SYSTEM IS DEPENDENT ON CERTAIN MEDICATIONS) -AND obtaining familial support

Pharmacological therapy

Antidepressants (SSRIs--usually given to children, adolescents, pregnancy and older adults) -can cause suicidal ideation CITALOPRAM (think sit down pram, your anxiety is driving me crazy) ESCITALOPRAM (think finally excited) FLUOXETINE (do not give this to pregnant women---can cause birth defects/ complications) PAROXETINE (same for this one with pregnancy) SERTRALINE (think searching for happiness--can be given in pregnancy and in adolescents usually) -inhibit reuptake of serotonin which results in increased circulation of serotonin HELPS WITH INCREASED WELLNESS AND EFFECTIVE WITH ANXIETY, OCD AND PANIC DISORDER NURSING CONSIDERATIONS: monitor for suicidal ideation or worsening of symptoms (THINK ABOUT INCREASED RISK FOR ADOLESCENTS AND ADULTS--WHEN THEY START TO HAVE ISOLATING AND SOMETIMES DEPRESSIVE SYMPTOMS) -watch for dizziness or drowsiness (think too much excitement and happiness, turned in circles which caused dizziness and drowsiness) -counsel to avoid alcohol in combination with ssris (cns overload and confusion--blackouts, sedation) -obtain cbc with differential, serum electrolyte and liver an dkidney function studies MAKES SENSE BECAUSE CAN CAUSE SEROTONIN SYNDROME: AGITATION, HALLUCINATIONS, FEVER, SWEATING, SHIVERING, FAST HEART RATE, MUSCLE STIFFNESS, TWITCHING, LOSS OF COORDINATION, N/V (THINK ABOUT HOW THEY ARE LOSING ELECTROLYTES) -approved for 6yr olds to t/x ocd NOT depression side effects: anxiety, panic attacks, trouble sleeping, hyperactivity, thoughts of suicide =CALL DOCTOR IF: UNUSUAL BLEEDING, SEIZURE, VISION CHANGES, LOW BLOOD SODIUM (HEADACHE, CONFUSION, PROBLEMS W/ MEMORY, FEELING UNSTEADY) makes sense NORMALLY PLATELETS RELEASE SEROTONIN IN RESPONSE TO VASCULAR INJURY WHICH TRIGGERS VASOCONSTRICTION AND PLATELET AGGREGATION (think about how body is happy and wants to heal) -do not take ssris within 14 days of discontinuing maoi (also powerful anti-depressants--think about how it takes a couple weeks before it kicks in)

Panic disorder vs general anxiety disorder

Anxiety disorder;: more persistent than temporary worry -come from nowhere and have no apparent cause or trigger CAN BECOME AN ANXIETY DISORDER IF STRESS BECOMES LONG-TERM (NEUROTRANSMITTORS WILL BECOME STRONGER=GO-TO THOUGHTS DURING LOW MENTAL STIMULATION) Panic disorders:sudden onset of at least four of a dozen symptoms: heart palpitations, sweating, chest pains, trembling, s.o.b, nausea, chills, numbness, dizziness, fear of losing control, fear of detachment, fear of impending death THINK ABOUT HOW PANIC DISORDER IS MORE PHYSIOLOGICAL AN DABRUPT -when at least one of the attacks has been followed by 1 month of persistent concern about having more attacks, worry about the implications of attack or significant change in behavior r/t attack (think about how it is viewed as a life impediment) -INABILITY TO FOCUS, PERCEPTION DISTORTED, TERROR, FEELINGS OF DOOM, BIZARRE BEHAVIOR (REMEMBER MY PANIC ATTACK AND I SCREAMED LOUDER THAN WHAT IS NORMAL), TRMBLEING, MUSCULAR INCOORDINATION, PALPITATIONS, IMMOBILITY -can experince flushed or chilled hands -tingle or become numb, nausea, chest pain and sense of breathlesness (remember how on bad anxiety days i feel thses emotions) TERROR OF LOSING CONTROL fear of these symptoms (remember how felicity would always fear having a panic attack when she would have sleep overs) -BELIEVE THEY ARE DYING OR LOSING THEIR MIND -LOSE ALL SENSE OF LOGIC BASICALLY -LASTS ONLY AROUND 10 MINUTES -TWICE AS COMMON IN WOMEN THAN MEN (THINK about how a lot of women face anxiety disorders) full-fledged panic disorder: incapacited by condition (think about how often it would occur and how much time they would spend worrying it would happen again) -require treatment and may start to avoid situations where attacks occur 1/3 of people with panic disorders become housebound (think about it, its a biological defense mechanism to avoid danger. makes sense why it is such a high statistic) ANXIETY IS VERY DIFFERENT FROM THIS (USUALLY NOT AVOIDANT LIKE IN PANIC DISORDERS, ITS MAINLY RESTLESS WHICH CAN PROGRESS INTO COMPLETE RIGIDITY BUT USUALLY DOESNT RESULT INTO ISOLATION (THINK ABOUT HOW PEOPLE WITH PHOBIAS ISOLATE--THESE PHOBIAS CAUSE THE PANIC ATTACK USUALLY)

Nursing process for coping

Assessment: assess the duration, intensity and frequency of stressors (how long has it been impacting the individual) -what is the individual's support system: are they financially supported, have family connections, spiritually supported (feeling a great sense of purpose and can find placement with the world) -assess for cultural beliefs, norms and values (coping behavior based on cultural perceptions of normal and abnormal coping) -observe for causes of ineffective coping (poor self-concept, grief--think about how bereavment and divorce is an environmental stressor that can impact multiple people, lack of problem solving (impaired mechanism during the secondary appraisal stage of a stressor) -assess for intergenrational family problems (think about how many adolescents are at risk for substance abuse when their parents poorly cope with other stressors in their life) -identify specific stressors (is it acute where the problem should only exist shortly, is it cumulative or sequential, is it intermittent--where they have a role burden or is it permanent like disability) -observe for strengths or help them acknowledge strengths (for example during critical injuries, emphasizing what they can do and help them focus on those strenghts) -determine understanding of the stressful situation IS IT AVOIDANCE COPING:

Pharmacologic t/x of crises

Benzodiazepines (diazepam, olazaepam)--usually short-term anti-anxiety medications as indicated or t/x of antibiotics (think about how immune system is supressed during fight or flight response -pain management (especially for physiological trauma) REMEMBER HOW WITH CRISES, THE NURSE'S PRIORITY IS T/X AND IDENTIFYING THE CAUSE OF THE CRISIS -THREAT OF INFECTION (PROPHYLACTIC T/X), ANXIETY OR DEPRESSION MEDICATIONS

Crisis counseling crisis intervention

Crisis counseling: requires assessment of their current level, physiological needs that are present, and planning various t/x to help them navigate through the crisis Crisis intervetion: is focused on minimizing the stress of the event by providing meotional support and improving coping strategies in the here and now THINK ABOUT HOW IT STATES INTERVENTION, NO ASSESSMENT AT THE MOMENT -can incorporate family members to aid in crisis support OUTREACH ORIENTED COUNSELING: REACH OUT TO TRAUMA SURVIVORS RATHER THAN WAITING FOR THEM TO REACH OUT ABCS OF CRISIS COUNSELING: achieve rapport: establish a therapeutic relationship with the patient (uses therapeutic communication: simple and direct instruction, open ended questions, empathy and patience) -helps clarify feelings and perceptions of the even first -will help them vent out their initial emotions (think about how once that is released, more logic can be brought in) -intellectualization*** -additional goals: ASSESSING IMMEDIATE NEEDS (ENSURING PHYSICAL AND EMOTIONAL SAFETY) -THINK ABOUT HOW DURING MASLOWS ITS MAINLY SURVIVAL AND SAFETY FIRST BOIL DOWN THE PROBLEM: -identify their thoughts on the circumastances, life contributors and what type of crisis (is it maturational? did they miss a developmental stage which ismaking it harder for them to cope? is it situational? was there a divorce of natural disaster or physical illness? -IDENTIFY, VALIDATE AND INTERVENE -COMMUNICATION INVOLVES: identifying the problem, assesshing how they are thinking and feeling about the problem and evaluating functionality (what stage in the crisis are they at? are they withdrawn? are the scrambling to try new solutions? are they in shock?) =goals: helping identify most pressing problems, encouragting to talk about the present and assessing and addressing ongoing safety (RISK FOR SUICIDE, ABUSE AND SUBSTANCE ABUSE) MANY ARE LOSING HOPE/ GETTING A SENSE OF POWERLESSNESS (ASK THEM SIMPLE QUESTIONS LIKE IF THEY WOULD WANT TO MAKE A PHONE CALL) WHICH HELPS BUILD CONFIDENCE Cope with the problem: resolution and referral -determines what is necessary to help patient cope with problem -use maslows to help adress and prioritize interventions for patient (physiologic, safety, love) SOME REQUIRE TEMPORARY RELOCATION (THINK ABOUT OW IF THEY ARE HOMELESS, WILL NOT FEEL SAFE--RELOCATION ALLOWS THEM THE OPPORTUNITY TO HAVE SHELTER AND SAFETY)

Coping

Desrcribes how they deal with problems (illness and stress) Factors: family dynamics (think about how if there is an unstable home, a lot harder to recieve support), adherence to t/x (think about how they are unwhilling to accept the need to change/ adapt) and role an individual plays in relationships

Crisis Etiology Clinical manifestation clinical therapies

Etiology: -can either be internal (such as mental health strain) -external (divorce, death/ bereavement) -or maturational: newfound parenthood, progression through life cycle -THINK ABOUT HOW ERIKSON THEORIZES THAT WHEN AN INDIVIDUAL MISSES A STAGE OF DEVELOPMENT IT GETS INCREASINGLY MORE DIFFICULT WHEN THEY ARE OLDER -occurs abruptly Situational: rape/ trauma/ natural disaster/ divorce/ loss of a relationship emotional trauma (psychologic and verbal abuse) Exposure to violence, illness or health-related alterations -exposes to acts of terrorism -financial stressors -legal stressors (divorce, child custody disputes and identity theft) CLINICAL MANIFESTATIONS: -stage 1: initial shock fight or flight response (fast heart rate, fast respiratory rate), -stage 2: fighting mechanisms fail and begin to attempt trial and error -stage 3: attempts are failing, begin to descend into withdrawal -stage 4: hopelessness, depression, suicidal ideation difficulty problem solving, disorganized thought processes, disorientation, vulnerability, increased tension and helplessness, fearfulness and sense of being overwhelmed, intense emotional reactions, increased sensory input and bobardment, hypervigilance, intense physical reactions depicted by fight or flight response -usually resolves within 4-6 weeks

Stress

Exposure to environmental influences that can influence the body in a good or bad way ex: chronic disease or job change -stress can be developmental (think about how milestones can be missed which results in increased struggles as they progress) -can be caused by sociocultural (explains why drug users often get into drugs--less education, not married by 30, not educated, living ina poor community) PRESENCE OF STRESS DELAYS HEALING OF A WOUND (THINK ABOUT HOW FIGHT OR FLIGHT STOPS THE IMMUNE RESPONSE/ INFLAMMATORY RESPONSE

Communicating painful information

Greet individuals with warmth, a kind smile and an introduction -inform you will assist during this difficult time -provide privacy -inquire about what they know and answer questions (think about how its the nursing process and must assess baseline before proceeding) -appriase them of current circumstances -respond to their feelings and offer support -ask what they need and what has helped in the past with coping (think about how during times of crisis people will use what worked in the past) -incorporate cultural and religious practices to provide comfortt -focus on immediate reaction -write down contact numbers and instructino -check back with them as neeeed EXPRESSES OF EMOTION IN CULURE: -some see expression of emotions as a weakness and need to respect privacy/ refusal to express emotions -some are relationship focused which measn they will feel guilt and blame themselves for certain actions (INCREASED RISK FOR SUICIDE) AND OTHERS CAN VALUE MORE INDEPENDENCE AND INDIV IDUALITY WHICH TENDS TO DISPLAY AGRESSION AND ANGER (think about older folks and how they can be agressive with their new situation)

Assessment/ diagnostic of anxiety-related disorders

Hamilton rating scale for anxiety fear questionaire panic disorder seveirty scale would want to gather a complete health h/x (think about how you would want to determine if this is r/t substance abuse, physiological disorders like hyperthyroidism or a pulmonary embolism) -would want to know how often this occurs (incessant worrying of more than 6 months is a strong indicator) -panic attacks that occur for a duration of 15-30 minutes (usually 10 minutes) -laboratory tests (usually to rule out physical illness) -provide a structured interview to keep client focused on the present (THINK ABOUT HOW THEY HAVE A VERY SELECTIVE ATTENTION SPAN AND REQUIRE NARROW SURROUNDINGS) -ASSESS FOR COMORBID CONDITIONS -PROVIDE SAFETY AND COMFORT DURING THESE DISORDERS (think about how would want to know certain triggers especially for severe-to-panic level anxiety) -remain with the client during the worst of anxiety to provide reassurance (think about same for substance abuse, cannot leave them until know they are safe) MILEIU THERAPY (think about how this is the malibu-safe environment for people) 1. structured envirionment for physical safety and predictability 2. Monitor for self harm or suicide*** THINK ABOUT PRIORITY CONCERN, SAFETY ONCE AGAIN FOR MENTAL DISORDERS 3. daily activities to encourage 4. therapeutic communicaiton (open-ended questions to help express feelings) 5. relaxation techniques (deep breathing, reassurane) -instill hope for positive outcomes/ w/o false reassurance -enhance self-esteem (remember how a lot of my anxiety stems from insecurity which requires some reassurance) -postpone teaching until panic attack and severe anxiety subside -identify counseling, group therapy

Older adults and anxiety

High risk for those who are unmarried (limited support-which makes sense since they are entering a stage of potential dependency on adl assistance), financial stressors(retirement limitations), health disorders NEED TO BE CAUTIOUS WITH MEDICATIONS (need to start them at a low dose first and titrate up as needed) -think about polypharmacy and how there will be drug-drug interactions BENZODIAZEPINES SHOULD NOT BE GIVEN (seems like benzos are usually last resort and more for short term periods of anxiety) -this is harder on their body(makes sense since it can cause respiratory depression and many medications are not recommended for ages above 65)

table 31-1 DAILY HASSLES INTERNAL STRESSORS ENVIRONMENTAL CLASSIFICATION: ACUTE AND TIME LIMITED SEQUENTAL CHORNIC INTERMITTENT CHRONIC PERMANENT

IMPORTANT TO CONSIDER THESE DAILY HASSLES/ ELEMENTS OF SPIRITUAL, PHYSICAL AND MENTAL HEALTH IN ORDER TO UNDERSTAND RISK FACTORS FOR INEFFECTIVE COPING (THINK ABOUT HOW THE STUDIES IN RESILIENCE ALL MENTION THE REASON FOR BURNOUT STEMS FROM PERSONAL LIFE AT HOME) Daily hassles: roles of living, caring for children (think about how this can result in role conflicts--dealing with being a student and a parent, role confusion--if they are unsure how to be a parent, role strain-not feeling competent or role overload (when there is so much to do as a parent) -pets -work responsibility -paying bills -traffic -neighbors (think about how all of these are common in everyone) INTERNAL STRESSORS: -cognition (thoughts), spirutality and emotions (think about how this is the response to all of these stressors) ENVIORNMENTAL: natural disasters, war, floods, hurricanes -major changes affecting one or a few people (divorce or bereavement--loss of someone) STRESS CLASSIFICATIONS: ACUTE AND TIME LIMITED: ankle sprain and nursing licensure exam Sequential events: losing a job and subsequently filing for bankrupcy (think all pertanent to loss of financial security) Chronic intermittent: strained relationship with in laws or caregiving an elderly chronic permanent: parlysis and disability

COPING

Internal stressors: can occur when there are insecurities, mental health issues, and depends on basic human needs (think about maslows how people want to feel safe, loved, high self esteem and self actualization -HELPS DETERMINE WHAT PRIORITIES ARE NEEDED-MEET HIGHER ORDER OF NEEDS BY PROVIDING -think first helping with physiological (providing pain management), then safety (having a quiet place for them), love and actualization--providinga community -think about how 12-step program focuses on this as well (eventually leading to spirituality) SPRIRITUALITY: WHO WE ARE AND HOW WE RELATED TO THE WORLD/ FIT INTO THE WORLD (THINK ABOUT HOW THOSE WHO ARE ADDICTS STRUGGLE WITH THIS CONCEPT BECAUSE THEY FEEL ALONE AND FIND NO SENSE OF PURPOSE)--FEEL USELESS IN SOCIETY ESPECIALLY SINCE MANY JOBS DO NOT ALLOW ADDICTS) EXTERNAL: natural disazters, socioeconomicsan event is a stressor when it casues change in the persons life or individual's circumstances STRESSOR THREATENS EQUILIBRIUM (THINK ABOUT IT, WE ARE ALWAYS SEEKING BALANCE AS A SPECIES) -HAVING A ROUTINE IS A SENSE OF BALANCE AND ANYTHING THAT DISRUPTS CAN RESULT IN INITIAL SHOCK AND TRYING TO SORT OUT NEW HOMEOSTASIS)

ANXIETY IN PREGNANT WOMEN AND ELDERLY

PREGNANT WOMEN: -usually insomnia/ sleep difficulty and fatigue are not reliable indicators of anxiety (MAINLY BECAUSE THEY WILL EXPERIENCE THIS AS GENERALIZED SYMPTOMS OF PREGNANCY) -RELIABLE INDICATORS: **muscle aches and panic attacks--remember how panic attacks last about 10 minutes (15-30 sometimes) and appear suddenly (s.o.b, feelings of impending doom) -important to recognize these symptoms because anxiety can cause premature labor, low birth weight, DIFFICULTY ADAPTING TO LIFE OUTSIDE WOMB (POSTPARUM DEPRESSION, IMPAIRED ATTACHMENT TO THE BABY AND SUBSTANCE ABUSE) ssris have teratogenic effects on baby (sertraline is less impactful) -pregnant women should not abruptly stop ssri medicaiton (instead plan ahead and slowly taper prior to getting pregnant) PRIMARY T/X: relaxation techniques AND CBT ARE HIGH PRIORITY -severe: may decide to continue meds which should have them discuss risks with provider (THINK ABOUT HOW ALL PRECAUTIONARY MEASURES EMPHASIZE TALKING WITH PROVIDER PRIOR TO TAKING ANY MEDICATIONS -highest risk: increased insecurity in relationships (me), h/x of infertility, and lack of psychosocial resources fluoxetine and paroxetine (think **** Pregnancy) -increased risk of pulmonary htn in newborn (think about how pulm htn can cause anxiety--the irony)

Phases of a crisis

Phase 1: escalating anxiety from a threat activates increased defense responses (think about how its the initial fight or flight) -the primary appraisal begins to act and process phase 2: anxiety continues escalating as defense responses fail, functioning becomes disorganized and resorts to trial and error attempts to resolve anxiety -think about how during the primary appraisal, the person's subconscious decides it is a threat which in the secondary it increases/ aggravates the stress (for severe anxiety this also occurs which results in disorganization and uncertainty on how to react--think the planning/ evaluaiton has never done this before so it is trial and error--THIS DETERMINES IF THE PERSON WILL LEARN FROM THE EXPERIENCE OR IF THEY WILL FAIL AND FURTHER DECLINE Phase 3: trial and error methods of resolution: clients anxiety escalates to severe or panic levels, leading to flight or withdrawal behaviors (think about how a crisis lasts 4-6 weeks and the clients ability to adapt is dysfunctional which results in these failures to cope Phase 4: overwhelming anxiety that can lead to anguish and apprehension (feelings of powerlessness and being overwhelmed) =depersonalization, detachment from reality, depression, confusion or violence against others or self THINK ABOUT A LARGE ANXIETY (IMAGINE IF MANY MEMBERS IN YOUR LIFE BEGIN TO GET UPSET WITH YOU FOR BEING SELF-INVOLVED. tHIS CREATES A CRISIS WITH THE EXTENT OT PEOPLE BEING UPSET. uNCERTAIN ABOUT HOW TO REACT, ATTEMPTS TO AMMEND RELATIONSHIPS BUT FAILS BECAUSE PERSONALLY BURNT OUT=FAILURE TO DO SO RESULTS IN FLIGHT (FIGHTING IS NOT WORKING=FLIGHT OR WITHDRAWAL) -CONTINUAL WITHDRAWAL/ ISOLATION RESULTS IN DEPRESSION AND FEELINGS OF POWERLESNESS

ASSESSMENT FOR STRESS/ COPING

QUESTIONS TO ASK: 1. current familial dynamic (current relationship/ outside support) 2. socioeconomic status (race/ cultural influencers, current education persuits, work-life, financial status, living circumstances) 3. current coping mechanisms (behaviors and current mentality) 4. previous h/x of coping or coping influencers in family 5. adherence to healthy behaviors and/or t/x regimen 6. sleep pattern (think about how adequate sleep negates some stress and helps the body reset) 7. altered elimination, change in appetite and weight loss or gain (coping mechanism and effects of fight or flight response) -current stage of coping: a. are they in the fight or flight response? are they in the resistance stage (body attempting to achieve homeostasis--normalization of bp, hr, and other systems) or are they resting (nearing death or unable to physiologically keep up anymore) 8. appearance (eye contact, verbal, motor, cognitive status) 9. vs (elevated bp? hr? resp rate?) 10. observe for irritability, anxiety and tension (will be resistant of any teaching, want to help reassure them unless they are undergoing stress form pcp or very violent)

REAPRAISAL ADAPTATION OF COPING

REAPRAISAL: when they evaluate if the coping mechanisms used were effective adaptation: is finally finding a balance/ a new way flowing around the stressor adaptation: how they eventually handle the demands general adaptation syndrome: stress response syndrome begin with: 1. alarm stage: where the body goes into shock and then countershock which is evidenced with fight or fligth 2. resistance: body treis to normalize while responding (returns to homeostasis) 3. exuastion: no longer able to maintain (may be recovery or death) ADHERENCE: -ability of cient to follow t/x regimen -commitment increases adherence -need to have relevant and simple/ attainable goals (too much at first is overwhelmeing) -comlicated regimen interferes w/ adherence -INVOLVEMENT OF SUPPORT PEOPLE (DURING THE PLANNING STAGE, THINK ABOUT HOW PEOPLE CAN SERVE AS A POOR INFLUENCE IN REGARDS TO REACTIVITY TO STRESSORS) -adverse effects of medications (think about how jasmine doesnt want to take ssris because of adverse effects0 -denial can cause nonadherence (refsal to acknowledge reality or consequences of truth)

TYPES OF ROLE PROBLEMS: ROLE CONFLICT SICK ROLE ROLE AMBIGUITY ROLE STRAIN ROLE OVERLOAD

ROLE CONFLICT: when a person must assume apposing roles w/ incompatible expectations ex: when parents expect adolescents to participate in sports and perform household tasks) or interole (when mother wants to stay at home with baby but is required to work) THINK ABOUT HOW THEY STILL HAVE THEROLE BUT ITS TWO DUELING ROLES THAT COMPETE WITH REQUIRED RESPONSIBILITIES SICK ROLE: -expectations of others and society on how one should behave when sick (caring for self while sick and contnuing to provide childcare to grandchildren) THINK ABOUT HOW AS A MOTHER, ITS HARD TO ABANDON BEING A MOTHER WHEN ILL ROLE AMBIGUITY: uncertainty about what is expected when assuming a role; creates confusion (think about a new parent or about a child with a parent who isnt participatory) role strain: when you feel inadequate for assuming a role (caring for a parent with dementia) SEEMS SIMILAR TO ROLE CONFLICT (BUT CONFLICT IS BETWEEN TWO ROLES WHEREAS STRAIN IS MORE THE ONE RESPONSIBILITY) -ROLE OVERLOAD: more responsibility and roles than manageable (role of a student, employee and parent)

TYPES OF ANXIETY DISORDERS: SEPARATION ANXIETY PHOBIAS SOCIAL ANXIETY AGORAPHOBIA PANIC DISORDER GENERALIZED ANXIETY DISORDER

SEPARATION ANXIETY: excessive fear or anxiety when separated from an individual (think of felicity and kate) phobias: irrational fear agoraphobia: think im aghast about thinking of leavin gmy house -fear of certain places social anxiety -excessive levels of anxiety and concern when separated from someone -think about how kate cant do anything on her own physiological symptoms: HEADACHES, NAUSEA/ VOMITING AND SLEEP DISTURBANCES panic disorder: recurrent panic attacks generalized anxiety: uncontrollable, excessive worry for at least 6 months -restlessness, muscle tension, avoidance of stressful acitivities, increased time and effort required to prepare for stressful activities, procrastination in decision making, sleeping disturbance PANIC DISORDER lasts about 15-30 minutes -usually about 10 minutes -considered one panic attack within a month with accompanying symptoms of worrying about the next panic attack -feel like they are losing sense of control over their emotions -palpitations, s.o.b, nausea, chest pain, choking, fear of dying, chills or hot flashes

MEDICATIONS FOR ANXIETY

SSRI anatidepressants FIRST LINT OF T/X FOR ANXIETY AND OBSESSIVE COMPULSIVE sertraline (remember searching for happiness) -think about how they are serotonin reuptake which helps increase sense of well-being paroxetine (think me and my med rock as a pair) Antianxiety medications: -benzodiazepine: short-term use (think about more for withdrawal or sedation prior to surgery to help with anxiety) Buspirone: managing anxiety and can be taken long-term (thing this bus can take you to happiness long term) beta blockers and antihistamines (think about how reduction in hr and bp can help prevent cascade of physiological anxiety) -same for antihistamines anticonvulsants: mood stabilizers

Types of crises situational/external maturational/ internal adventitious

Situational: unanticipated loss or change experienced in everyday, often unanticipated, life events (divorce or job change--think about how others are seeing this happen and other elements to ones life) MATURAITONAL: achieving new developmental stages, which requires learning additional coping mechanisms (getting married or retiring) -think of maturaiton: maturing and doing something that is strengthening persona ADVENTITIOUS: natural disasters, crimes, people in communities with large-scale psychological trauma caused by natural disaster

Theoretical models of stress: stimulus state of body eustress distress biogenic stressors

State of the body during stress: ALARM STAGE: -WHEN THE BODY RELEASES stress hormones which results in -dialation of the goes through ALLOSTASIS (THINK, ALLOW ME TO DETERMINE WHAT IS HOMEOSTASIS) -THIS IS A DEVIATION FROM HOMEOSTASIS AND MAINTENANCE OF FUNCTION THAT IS BENEFICIAL TO THE PERSON AT TIMES OF STRESS (should not be prolonged) Begins within shock phase (think about how when I am frightened everything freezes) which causes reversal: hypotension, decreased temperature, decreased resp Countershock: is when the body counters with a realization of the stressor which causes release of epinephrine and nonepinephrine (causes bronchodilation for optimization of air circulation, high bp, tachycardia) -pupillary dilation (allows more intake for light--think about how my eyes are always dilated which may be because I am stressed) -enhanced awareness (alertness in response to severe threats) -increase release of glucocorticoids and increased gluconeogenisis which increases serum glucose (makes sense since body needs supply of atp to workout)--think about how weight gain could be elicited if not exercising urinary: increased sodium and water retention (decreased urine output and increased blood volume--explains high bp) -increased muscle tension (thinking preparing to hit something) -other disorders: cancer, decreased immune response -diaphoresis and skin pallor r/t blood flow changes -increased resp, increased heart rate and decreased peristalsis=constipation (think about how its not in the rest and digest stage) might be a little impatient, might have some fine tremors

Assessment procedures for stress repsone

Stress can be good or bad (depending on the ability to cope with the situation) Mild stress: usually aware of the current distress, aware of surroundings, intensely focused, increased sensory stimulation (THINK ABOUT HOW IN A NORMALLY FUNCTIONING PERSON, STRESS OCCUR BRIEFLY AND SURVIVAL RESPONSE IS TO BE AWARE OF SURROUNDINGS) -MAY MOTIVATE TO TRY NEW THINGS (think about how the animal attempting to survive is more aware and motivated to try new things) -more aware of environment and motivated to deal with existing problems usually starts with an alarm stage (tachycardia, increases bp, increased blood flow to muscles, increased respirations) -then the resitance stage where the body maintains homeostasis (proper thermoregulation, proper fluid and electrolyte levels) Eustress: is good stress where there is a sense of victory and accomplishment (think eus or yeus! I did it) Distress: sense of inadequacy, insecurity and loss

Interventions: stress

Stress: -encourage health promotion strategies (exercise, optimal nutrition, adequate sleep and rest) -time management tasks (writing a list and helping them prioritize--similar to what dad and I did) -encourage relaxation techniques (meditation, deep breathing, massage, imagery--brain is more responsive to imagery than words) -listen attentively (encourages them to speak) -control enviornment to reduce stressors (think about how this is done for those undergoing withdrawal, reducing environmental stimuli) -identify support (help motivate them) -educate on training (journal writing, assertiveness, mindfulness) OPTIMAL TIME TO TEACH IS AFTER COPING WITH CRISIS SUCCESSFULLY*** (THINK ABOUT HOW WHEN THEY ARE EXPERIENCING THE INITIAL FEARS OF A NEW CONFLICT/ OBSTACLE THE INDIVIDUAL IS FOCUSED ON THE UNSAFE ASPECT OF MASLOWS) COPING: -empathetic in communication and encourage to verbalize feelings -identify clients and familys strengths (think about how when Im not coping its usually when my confidence is low) -encourage autonomy (think about how addicts respond well when encouraged to improve their own addiciton) -discuss clients and familys abilities to deal ADHERENCE: -proper education on importance of compliance to t/x -put instrucitons in writing (helps them remember) -make sure t/x is accessible and affordable -simplify t/x regimens (too complex is too overwhelming)

Nursing implications for denial in: substance abuse

Substance abuse: determine how they want to be adressed -encourage family members to seek help regardless if the abuser does (think about how the true relief will be when the addict admits they are struggling; however, the family shouldnt have to endure waiting) -convey an accepting attitude when separating the individual from inappropriate behavior (promotes dignity) -help them accept accountability such as developing alternatives to drug longing and use (think about how milieu therapy and 12-step programs help organize an environment for addicts to accept responsibility and initiate ways to improve their life) -confront and investigate denial (denial is primary definsive measure) -make sure they regularly attend recovery support and therapy groups (helps assist with denial--will hear others say I will fix it later which affirms they are in denial) other diseases: -encourage to express their fears and difficulties (especially in admitting they have a disease) -help clarify any need for further knowledge regarding t/x (especially if there are fears involving t/x) -allow for emotional outbursts

biogenic stressors vs psychosocial stressors

biogenic: think about how we do not consciously regulate this (it is all manipulated by a substance) ex: caffiene (causes stress we are not aware of), amphetamines (think about how this causes increase in energy levels which if given too much, causes an increased amount of stress), extreme temperatures (remember how when there are droughts and increased temp, people have a tendency to be more violent)

Types of coping cognitive: emotion-focused problem focused avoidance approach meaning behavioral: emotion-focused problem focused avoidance approach meaning affective: emotion-focused problem focused avoidance approach meaning

cognitive: emotion-focused: think about how emotion focused is the emotions involved with the experience "minimizing the event by stating its not that bad" problem focused: what are my odds of surviving? think about how this is more logical (math problems are more logical) avoidance: denial of what just occured approach: confronting the situation or ignorign meaning: important to see how they approach all of these elements (determines if there is a positive outcome, for ex: increased family bonding or if it is a negative outcome) BEHAVIORAL -emotion-focused coping: performing a physical activity to avoid thinking about a stressful situation (think about how its expelling negative emotions) problem-focused: adhereing to health care plan (think about the problem focused care maps)

Ego defense mechanisms compensation denial displacement identification intellectualization introjection minimization projection rationalization reaction formation regression repression sublimation sibstitution undoing

compensation: covering up weaknesses by emphasizing a more desirable trait or by overachievment in a more comfortable area (think of the phrase, are you compensating for something) ex: high school student too small to be a football player so compensate by being the star in track and field USE/ PURPOSE: FINDS A WAY TO NAVIGATE A WEAKNESS denial: unwilling to admit there is a problem ex: refuisng to admit they are addicted USE: TEMPORARIRLY ISOLATES FROM FULL IMPACT OF TRAUMATIC SITUATION (THINK ABOUT IF THERE WERE OTHER IMMEDIATE ISSUES, DENIAL WOULD ASSIST) displacement: transferring or discharging emotional reactions from one object or person to another object or person ex: husband and wife fighting, and husband hits door instead of his wife -student gets a c on the paper and yells at family Use: can be helpful in preventing any harm on someone CAN BE HARMFUL BY HURTING SOMEONE WHO IS INNOCENT IN THE SITUATION identification: attempting to manage anxiety by imitating the behavior of someon feared or respected -student nurse imitates nurturing behavior observed in instructor when interacting with patients (think, identifying with a situation or example and using it in own practice) Intellectuaization: evading emotional response that normally accompanies an uncomfortable situation by using rational explanations that remove incident any personal sifnificance and feelings -think intellectuals are logical and remove emotions ex: pain over parents dudden death is reduced by sayin g'he wouldnt have wanted to live disabled" introjection: id that allows for accaptance of others norms and values into oneself when identification: intellectualization: is when someone uses logic rather than emotional-decision making ex: by justifying why they chose to end their life (he wouldnt have wanted to live disabled) use: helps sort out emotions Minimization: acknowledge the significance of ones behavior ex:i wasnt so drunk I couldnt drive" -allows individual to decrease responsibility for behavior (can be bad because it can manipulate people in thinking its not as bad as it really is) projection: blaming others for things you are responsible for ex: mother told her child must repeat garade in school and blames this on the teacher's poor instruction when really its a troubled child Rationalization: justifying certain behavior by faulty logic and ascription of motives that are socially acceptable -ex: mother spanks her toddler too hard but states its okay because the diaper was well padded DIFFEENT THAN INTELLECTUALIZATION BECAUSE INTELLECTUALIZATION SORTS OUT EMOTIONS AND THINKS ABOUT THINGS MORE LOGICALLY/ IN ANOTHER PERSPECTIVE reaciton formation: a mechanism that causes people to act exactl opposite to the way they feel ex: an executive resents his bosses for calling in a consulting firm to make recommendations for change but verbalizes complete support (think I'm forming a reaction, something that is not intrinsically there, to best suit the situation) Regression: resorting to an earler more cmfortable level of functioning that is characteristically less demanding and responsible ex:an adult throws a temper tantrum when they don't get their own way (an old level, a child funcitons at which is more comfortable to them and requires less self work) repression: unconscious mechanism by which threatening thoughts, feelings, and desires are kept from becoming conscious (think suppress is more conscious but repress--the brain doesnt want to repeat old mistakes and doesnt trust the owner so does it itself) Sublimation: displacing energy associated with more primitive sexual or agressive drives into socially acceptable activities ex: invest psychic energy into spiritual drives rather than sexual energy think substituting what he really wants to do with his limb by getting into a religious ervie substitution: replacing a highly valued unacceptable or unvailble object with a less valuable, accetable or available object ex; woman wants to find a man like her father (emotionally) but settles for someone looking like him undoing: performing an action or using words designed to cancel some disapproved throughts, impulses or acts in which the person relieves guilt by making reparation ex: father spanks his child and undoes the situation by getting him a present -a teacher makes a test too hard and in return, grades on a curve to ammend the situation

emotion vs problem focused coping

emtion: efforts to reduce impact of emotional stressors "feeling reactions" wuch as fear, anger, sadness or shame -may feel numb or spaced out --think about how efforts to reduce arent necessarily trying to solve it, just manage it (like deep breathing, exercise, or meditation) problem focused: effots to sovle the underlying cause of stress (this is actually doing something about it) -this is making goals and adhering to the goals if there is no way to solve, usually its just emotional management -emotion coping is flexible (tools to change emotional response and reactivity to things) -people with low emotional intelligence may struggle being aware of these forms of reactivity (think about how often they just neglect it, where as feelers tend to notice these chanes) problem solving: solves underlying causes of stress, positive effect on mood -doesnt always reduce intensity (think about how sometimes I can be overly sensitive and want to solve everything where really the best course of action would be to manage my emotions) avoidance: refusing to get a mamogram when a h/x of brest cancer runs in the family (think about how its the action whereas the cognitive is just within the thoughts) affective: hoping for a miracle problem focused: keeping feelings from interfering avoidance: daling with feelings late approach: using feelings to motivate change -regulating emotional response to stress

Coping: COPING PROCESS

how they react to a stressor whether if it is positive or negative -can depend on duration, intensity and number of stressors (think if their daily life stressors: job, family life, finances, traffic; spiritual and environmental are relatively stable, they usually are able to cope much better with other stressors -EGO DEFENSE MECHANISMS CAN ASSIST IN A STRESSFUL SITUATION OR CRISIS (THINK ABOUT HOW W/O THE EGO, WOULDN'T CARE ABOUT IMPROVING SELF-IMAGE) COGNITIVE APPRIASAL: is how the person reacts/ identifies with the stressor during the primary apraisal: the person identifies with the stressor initially (this is the beginning response, and makes sense for mindfulness practice how its important to not identify too strongly with stimuli) -the person begins to process the stimuli and determine if it is irrelevant (no need to stress about that--think about how when its related to fashion or something materialistic I often get disgusted when i begin to see that as a stressor), determine it as benign positive (think about how when i start school again, my body reacts initially by getting very stressed but see how this is a positive stressor0 or stressful (will be harmful which triggers cascade of further stress) secondary: is the coping reaction, attempt to predict, impact, intensity and duration (think about how this is the evaluation) -and begins to assign coping responses

Assessment for stress: stimulation-based stress model

identifies life factors that can predispose a person to poor coping/ reactivity to stress -assesses loss of a spouse (think about environmental factors) -assesses job status/ loss of a job, financial insecurity, home insecurity -role conflicts as a parent -these all are a wear an tear towards a person Response-based stress models: -determines local response or systemic/ global response global: usually the whole fight or flight and causes changes throughout the whole body system local: usually inflammation of a particular organ (think about a staff infection), or inflammation of the liver either way, can cause the alarm reaction: initial is shock where the sympathetic is supressed -then eventually the body responds in the counter shock which is sympathetic stimulation: increased fat mobilization, bornhcial dilation, increased cardial activity -can occur from 1 min to 24hrs (think about 1 days worth is enogh) resistance; attempting to reach homeostasis or move towards restoraion while responding to stressor -can have an outward appearance of relaxation (mainly denial) with physiological facotrs that continue to predispose to gastric ulcers, htn and otehr illnesses exhuastion: think about after 1 day, usually the body is worn out (explains shock or death) or may resolve

Crisis management

is an acute, time-limited (lasts 4-6 weeks) event during which a client experiences an emotional response that cannot be managed with the client's normal coping mechanism -think about how a midlife crisis (relize they cannot do things as they used to physiologically or mentally) DURING CRISIS, ASSUMED THE CLIENT WAS WELL-FUNCTIONING AND MENTALLY HEALTHY -crisis is NOT pathological but represents a struggle for equilibrium and adaptation -are personal in nature (think again about midlife-crisis, it is personal) -OPINIONS ON WHAT IS AND WHAT ISNT A CRISIS VARIES BETWEEN INDIVIDUALS CHARACTERISTICS OF A CRISIS: -sudden event with little or no time to prepare (think about how this occurs in people who havent fully understood what it means to turn 40) -perception of the event as overwhelming or life-threatening (like a panic attack) -loss or decrease in communicaiton with significant others -sense of displacement from the familiar -actual or perceived loss

Anxiety disorders

normal anxiety is a healthy response to stress that is essential for survival -when elevated or persistent, behavioral changes and impairment can occur (think about how the neurons will strengthen which will create the neurological disorder) Mild: reslessness, increased motivation and irritability Moderate: agitation and muscle tightness (think about how agitation in withdrawal signs is more of a moderate withdrawal) Severe: inability to function, ritualistic behavior and unresponsive or panic (distorted perception, loss of rational thought and immobility) THINK ABOUT HOW PANIC IS LIKE A DEER UNDER HEADLIGHT (CANNOT FUNCTION PROPERLY)

Psychotherapeutic interventions:

primary care: collaborate with client to id potential problems instruct on coping mechanisms and assist in lifestly THIS IS WITH PRIMARY CARE PROVIDER (LESS EXTENSIVE) secondary: COLLABORATE TO ID INTERVENTION IN AN ACUTE CRISIS THAT PROMOTES SAFETY (THIS IS A CLINIC THAT HELPS--SPECIALIZING IN THAT AREA) TERTIARY: PROVID SUPPORT THAT INCLUDES OUTPATIENT, REHAB OR CRISIS STABILIZATION

VARIOUS FAMILY STRUCTURES ASSESSMENT;

rigid structure: many rules and dictorial open strucutre: few or no boundaries, consistent behavior or consequences -either one impacts communication, problem solving abilities and available resources (think about how open could make adolescents more comfortable to speak up?) -is the family dynamic dictorial or open? -current or h/x of abuse -job status of parents -number of kids if an adult (perceptions of parenthood) -assess all clients -assessment as a system and according to the context NURSING CARE: ASSIST IN STRENGTHENING: COMMUNICATION, ADAPTABILITY, ADAPTABLITIY, CRISIS AS GROWTH ELEMENT, PARENTING SKILLS AND RESILIENCY -SET REALISTIC GOALS -provide info about support networks: child and adult day care, caregiver support groups -promote family unity -ensure safety at risk for violence (provide supportive care for kids who are suspected of having been abused) -encourage conflict resolution -evaluate goals -PROTECT CLIENTS EXPERIENCING CRISIS FROM SELF-HARM AND INITIATE REFERRAL TO MENTAL HEALTH SERVICES (REMEMBER HOW YOU CANT LEAVE A CLIENT ALONE IF THEY ARE AT RISK FOR INJURING THEMSELVES AND MUST ASSESS FOR SUICIDE RISK ESPECIALLY IF THEY AREN'T RECIEVING FAMILIAL SUPPORT)

denial nursing diagnosis

s/x: refusing to discuss the issue behavioral based denial (avoiding doing the action, doesn't want to get a ecg done to see if they have a heart abnormality) cognitive: by saying that's not true -blaming other individuals, continuing to engage despite unfavorable outcomes (sign of addiction), promises to deal with the issue in the future (why it is improtant to first have an addict admit that they have a problem before helping them manage it), trying to avoid worrying about the situation projection: blames someon else rather than blaming themselves minimization: think about the cognitive denial "oh its not that bad" or its not important impacts: can be harmful, result in resistance to change, result in poor coping mechanisms, result in further decline in health, may experience some shock UNDERSTANDING THE CAUSE OF DENIAL IS FIRST STEP TOWARDS UNDERSTANDING HOW TO DEAL WITH IT REASONS BEHIND DENIAL/ RISK FACTORS: 1. ANOSOGNOSIA: unable to recognize what is going on with them (think about those who are trying to emotionally cope and are unable to recognize emtions) 2. fears: fear of stigma or t/x (think about how they understand the risks of t/x, they understand how they would be labeled or how it would change any dynamic) Nursing implications: -psychotherapy and support groups may be beneficial -help them come to terms with the truth (such as understanding that they are addicted to a substance, understanding a loved one is dying, understanding that they are undergoing a terminal illness) SUCCESSFUL METHODS IN DEALING: consider why he is afraid to confront the situation (think about the underlying cuase--can be effective in problem-focused coping), considering the reprcussions, talking to a close friend or relative, working on detecting any erroneous thoughts S/X OF INEFFECTIVE: -not adhering to t/x, not aderhing to careplan, defensive during teaching, denail of health care, misinterpretation or minimizing risky situations, self-medication, projecting, refusal to acknowledge lifestyle, disinterest in traumatic events