Stress and Coping - Chapter 42 - Module G

Models of Stress

assist nurses to predict stressors in a particular situation and to understand the individual's responses. Nurses can use these models to assist clients in strengthening health coping responses and in adjusting unhealthy, unproductive responses.

Long-Term Coping

can be constructive and practical.

Short-Term Coping

can reduce stress to a tolerable limit temporarily but are ineffective ways to permanently deal with reality

Severe Anxiety

consumes most of the person's energies and requires intervention. Perception is further decreased. The person, unable to focus on what is really happening, focuses on only one detail of the situation generating the anxiety.

When a person faces stressors, responses are referred to as

coping strategies, coping responses, or coping mechanisms.

Anxiety may be manifested on four levels

mild moderate severe panic

Effective Planning for Crisis Intervention

must be based on careful assessment and developed in active collaboration with the person in crisis and the significant people in that person's life. Implementation involves crisis counseling and home crisis visits. Their goal is to plan steps to provide immediate relief and then long-term follow-up if necessary.

Mild Anxiety

produces a slight arousal that enhances perception, learning, and productive abilities.

Problem-Focused Coping

refers to efforts to improve a situation by making changes or taking action

Three main models of stress are

stimulus-based, response-based, and transaction based.

Stimulus Based Models

stress is defined as a stimulus, a life event, or a set of circumstances that arouses physiological and/or psychological reactions that may increase the individual's vulnerability to illness. Similar scales have since been developed, but all scales should be used with caution because the degree of stress an event presents is highly individual. In addition, many scales have not been tested for sensitivity to age, socioeconomic status, or culture

Anger is a

subjective feeling

Although coping behavior may not always seem appropriate,

the nurse needs to remember that coping is always purposeful

The traditional steps of the nursing process correspond to

the steps of crisis intervention

Safety Alert: Anger

A nurse who is concerned for his or her own safety while working with an angry client should withdraw from the situation or obtain support from another individual.

Nursing Diagnosis: Compromised Family Coping

A usually supportive primary person (family member or close friend) provides insufficient, ineffective, or compromised support, comfort, assistance, or encouragement that may be needed by the client to manage or master adaptive tasks related to his or her health challenge

Selye proposed that both the GAS and the LAS have three stages:

Alarm Reaction Stage or Resistance Stage of Exhaustion

Burnout

Although most nurses cope effectively with the physical and emotional demands of nursing, in some situations nurses become overwhelmed and develop burnout, a complex syndrome of behaviors that can be likened to the exhaustion stage of the general adaptation syndrome.

Implementing

Although stress is part of daily life, it is also highly individual: a situation that to one person is a major stressor may not affect another. Some methods to help reduce stress will be effective for one person; other methods will be appropriate for a different person.

Nursing Diagnosis: Disabled Family Coping

Behavior of significant individual (family member or other primary person) that disables his or her capacities and the client's capacities to effectively address tasks essential to either person's adaption to the health challenge.

Syle's (1976) local adaptation syndrome (LAS)

Besides adapting globally, the body can also react locally; that is, one organ or a part of the body reacts alone. This is referred to as the local adaptation syndrome (LAS). One example of the LAS is inflammation. Selye (1976) proposed that both the GAS and the LAS have three stages; alarm reaction, resistance, and exhaustion.

Lifespan Considerations of Stress and Coping: Infants and Children

Children's perceptions of and responses to stress depend on their developmental stage.

Cognitive Indicators

Cognitive indicators of stress are thinking responses that include problem solving, structuring, self-control, or self-discipline, suppression, and fantasy.

Nursing Diagnosis: Caregiver Role Strain

Difficulty in performing the family caregiver role.

Mediating Anger

Delaune (2013) recommends the following strategies for dealing with clients' anger: • Remember that there is a difference between anger (a subjective feeling) and aggression (a harmful behavior). • Approach each client with a calm, reassuring manner. This will help the client feel less threatened and more secure. • Involve clients in their own care as much as possible. This will increase their sense of control, which helps decrease anger. • When a client's aggression is escalating, you must protect the safety of that client, other clients, yourself, and other staff. • Call for help immediately if your interventions have not deescalated the client's aggressive behavior

Depression

Depression is a common reaction to events that seem overwhelming or negative. Depression, an extreme feeling of sadness, despair, dejection, lack of worth, or emptiness, affects millions of Americans a year. Prolonged depression is a cause for concern and may require treatment.

Planning for Home Care

Determining how much and what type of planning and home care follow-up is needed is based in great part on the nurse's knowledge of how the client and family have coped with previous stressors and the nature of the present stressor.

Shock Phase

During the shock phase, the stressor may be perceived consciously or unconsciously by the person. Stressors stimulate the sympathetic nervous system, which stimulates the hypothalamus. All of these adrenal hormonal effects permits the person to perform far more strenuous physical activity than would otherwise be possible. The person is then ready for "fight or flight".

Stage of Exhaustion

During the third stage, the stage of exhaustion, the adaptation that the body made during the second stage cannot be maintained. This means that the ways used to cope with the stressor have been exhausted. If adaptation has not overcome the stressor, the stress effects may spread to the entire body. The end of this stage depends largely on the adaptive energy resources of the individual, the severity of the stressor, and the external adaptive resources that are provided.

Ego Defense Mechanisms

Ego defense mechanisms are unconscious psychological adaptive mechanisms or, according to Anna Freud (1967), mental mechanisms that develop as the personality attempts to defend itself, establish compromises among conflicting impulses, and calm inner tensions. Defense mechanisms are the unconscious mind working to protect the person from anxiety.

Evaluating

If outcomes are not achieved, the nurse, client, and support people, if appropriate, need to explore the reasons before modifying the care plan.

Caregiver Burden

If the duration of the stressors is extended beyond the coping powers of the individual, that person becomes exhausted and may develop increased susceptibility to health problems. Reaction to long-term stress is seen in family members who undertake the care of a person in the home for a long period. This stress is called caregiver burden and produces responses such as chronic fatigue, sleeping difficulties, and high blood pressure.

Clinical Alert: Comfort Foods

Many individuals have "comfort foods" - foods they like to eat that make them feel better emotionally. These should be allowed whenever they are not contraindicated by the person's health condition.

Nursing Diagnosis: Ineffective Coping

Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use resources.

Sources of Stress

Internal Stressors External Stressors Developmental Stressors Situational Stressors The degree to which any of these events has positive or negative effects depends to some extent on an individual's developmental stage.

Using Relaxation Techniques

Several relaxation techniques can be used to quiet the mind, release tension, and counteract the fight-or-flight responses of GAS discussed earlier in this chapter. Specific relaxation techniques include: • Breathing exercises • Massage • Progressive relaxation • Imagery • Biofeedback • Yoga • Meditation • Therapeutic touch • Music therapy • Humor and laughter

Lifespan Considerations of Stress and Coping: Middle-Aged Adults

Middle-aged adults are often called the "sandwich generation." They care for children and grandchildren and often caring for aging parents at the same time. When these activities become time and energy consuming, there is often not enough time left for attention to self. Nurses need to be aware of this and assist in suggesting resources and effective planning to ease the strain.

Self Care Alert

Mild or moderate anxiety motivates goal-directed behavior. In this sense, anxiety is an effective coping strategy. For example, mild anxiety motivates students to study. Excessive anxiety. However, often has destructive effects.

Stress Management for Nurses

Nurses can prevent burnout by using the techniques to manage stress discussed for clients. Suggestions include: • Plan a daily relaxation program with meaningful quiet time to reduce tension (e.g., read, listen to music, soak in a tub, or meditate). • Establish a regular exercise program to direct energy outward. • Study assertiveness techniques to overcome feelings of powerlessness in relationships with others. Learn to say no. • Learn to accept failures - you own and others - and make it a constructive learning experience. Recognize that most people do the best they can. • Accept what cannot be changed. • Develop collegial support groups to deal with feelings and anxieties generated in the work setting. • Participate in professional organizations to address workplace issues. • Seek counseling if indicated to help clarify and cope with concerns.

Lifespan Considerations of Stress and Coping: Older Adults

Older adults experience many losses and changes in their lives. Changes in health, decreased functional ability and independence, need for relocation, loss of family and friends, and becoming a caregiver for a spouse or friend are a few of the stresses often experienced by older adults.

Situational Stressors

are unpredictable and may occur at any time during life. Situational stress may be positive or negative. Examples of situational stress include: •Death of a family member •Marriage or divorce •Birth of a child •New job •Illness.

Time Management

People who manage their time effectively usually experience less stress because they feel more in control of their circumstances. Controlling the demands of others is also an important aspect of effective time management because requests made by others cannot always be met.

Nursing Diagnosis: Relocation Stress Syndrome

Physiological and/or psychosocial disturbance following transfer from one environment to another.

Psychological Indicators

Psychological manifestations of stress include anxiety, fear, anger, depression, and unconscious ego defense mechanisms. Anxiety Fear Anger Depression Unconscious Ego Defense Mechanisms

Physical Exercise

Regular exercise promotes both physical and emotional health. Psychological benefits include relief of tension, a feeling of well-being, and relaxation.

Nursing Diagnosis: Defensive Coping

Repeated projection of falsely positive self-evaluation based on a self-protective pattern that defends against underlying perceived threats to positive self-regard.

Style's (1956, 1957) general adaptation syndrome (GAS) or stress syndrome

Selye's stress response is characterized by a chain or pattern of physiological events called the general adaptation syndrome (GAS) or stress syndrome. To differentiate the cause of stress from the response to stress, Selye (1976) used the term stressor to denote any factor that produces stress and disturbs the body's equilibrium. Stress can be observed only by the changes it produces in the body. This response of the body, the stress syndrome or GAS, occurs with the release of certain adaptive hormones and subsequent changes in the structure and chemical composition of the body.

Encouraging Health Promotion Strategies

Several health promotion strategies are often appropriate as interventions for clients with stress-related nursing diagnoses. Among these are physical exercise, optimal nutrition, adequate rest and sleep, and time management.

Adequate Rest/Sleep

Sleep restores the body's energy levels and is an essential aspect of stress management.

Effects of Stress

Stress can have physical, emotional, intellectual, social, and spiritual consequences. Many health conditions have been linked to stress.

Concept of Stress

Stress is a condition in which an individual experiences changes in the normal balanced state

Response-Based Models

Stress may also be considered as a response. This is described as "the nonspecific response of the body to any kind of demand made upon it."

Nursing Diagnosis: Anxiety

Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual): a feeling of apprehension caused by the anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with a threat.

Nursing Diagnosis: Post-Trauma Syndrome

Sustained maladaptive response to a traumatic, overwhelming event.

Alarm Reaction

The initial reaction of the body is the alarm reaction, which alerts the body's defenses. includes shock phase and fight or flight counter shock phase

Planning

The nurse and client set goals to change the existing client responses to the stressor or stressors.

Physiological Indicators

The physiological signs and symptoms of stress result from activation of the sympathetic and neuroendocrine systems of the body.

Counter-Shock Phase

The second part of the alarm reaction is called the counter-shock phase. During this time, the changes produced in the body during the shock phase are reversed. A person is best mobilized to react during the shock phase of the alarm reaction.

Stage of Resistance

The second stage in the GAS and LAS syndromes, the stage of resistance, is when the body's adaptation takes place. In other words, the body attempts to cope with the stressor and to limit the stressor to the smallest area of the body that can deal with it

Fight or Flight

This primary response is short lived, lasting from 1 minute to 24 hours.

Optimal Nutrition

To minimize the negative effects of stress (e.g., irritability, hyperactivity, anxiety), people need to avoid excesses of caffeine, salt, sugar, and fat, and deficiencies in vitamins and minerals.

Transaction Based Models

Transactional theories of stress are based on the work of Lazarus (1966), who stated that the stimulus theory and the response theory do not consider individual differences. In contrast to Selye, who focuses on physiological responses, Lazarus includes mental and psychological components or responses as part of his concept of stress. Lazarus's transactional stress theory encompasses a set of cognitive, affective, and adaptive (coping) responses that arise out of person-environment transactions. The person and the environment are inseparable: each affects and is affected by the other.

Types of Coping Strategies

Two types of coping strategies have been described: problem focused and emotion focused. Problem-focused coping and Emotion-focused coping

Aggression is

a harmful behavior

Anxiety

a state of mental uneasiness, apprehension, dread, or foreboding or a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationships.

Help Clients to:

a) Determine situations that precipitate anxiety and identify signs of anxiety. b) Verbalize feelings, perceptions, and fears as appropriate. Some cultures discourage the expression of feelings. c) Identify personal strengths. d) Recognize usual coping patterns and differentiate positive from negative coping mechanisms. e) Identify new strategies for managing stress (e.g., exercise, massage, progressive relaxation). f) Identify available support systems

Teach Clients about:

a) The importance of adequate exercise, a balanced diet, and rest and sleep to energize the body and enhance coping abilities. b) Support groups available such as Alcoholics Anonymous, Weight Watchers or Overeaters Anonymous, and parenting and child abuse support groups. c) Educational programs available such as time management, assertiveness training, and meditation groups

Three approaches to coping with stress are to

alter the stressor, adapt to the stressor, or avoid the stressor.

Emotion-Focused Coping

includes thoughts and actions that relieve emotional distress. Emotion-focused coping does not improve the situation, but the person often feels better.

Moderate Anxiety

increases the arousal to a point where the person expresses feelings of tension, nervousness, or concern. Perceptual abilities are narrowed.

Problem Solving

involves thinking through the threatening situation, using specific steps to arrive at a solution.

Coping Strategy (coping mechanism)

is a natural or learned way of responding to a changing environment or specific problem or situation. According to Folkman and Lazarus (1991), coping is "the cognitive and behavioral effort to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person".

Crisis Intervention

is a short-term helping process of assisting clients to (a) work through a crisis to its resolution and (b) restore their pre-crisis level of functioning.

Crisis

is an acute, time-limited state of disequilibrium resulting from situational, developmental, or societal sources of stress.

Fear

is an emotion or feeling of apprehension aroused by impending or seeming danger, pain, or another perceived threat. The object of fear may or may not be based in reality.

Anger

is an emotional state consisting of a subjective feeling of animosity or strong displeasure.

Panic

is an overpowering, frightening level of anxiety causing the person to lose control.

Stressor

is any event or stimulus that causes an individual to experience stress.

Self-Control (Discipline)

is assuming a manner and facial expression that convey a sense of being in control or in charge.

Suppression

is consciously and willfully putting a thought or feeling out of mind: "I won't deal with it today. I'll do it tomorrow". This response relieves stress temporarily but does not solve the problem.

Fantasy or Daydreaming

is likened to make-believe. Unfulfilled wishes and desires are imagined as fulfilled, or a threatening experience is reworked or replayed so it ends differently from reality.

Structuring

is the arrangement or manipulation of a situation so threatening events do not occur.

Coping

may be described as dealing with change-successfully or unsuccessfully

Indicators of stress

may be physiological, psychological, or cognitive.

Developmental Stressors

occur at predictable times throughout an individual's life.

Assessing

of a client's stress and coping patterns includes (a) nursing history and (b) physical examination of the client for indicators of stress (e.g., nail biting, nervousness, weight changes) or stress-related health problems (hypertension, dyspnea).

External Stressors

originate outside the individual, for example, a move to another city, a death in the family, or pressure from peers.

Internal Stressors

originate within a person, for example, infection or feelings of depression.

A clearly expressed verbal communication of anger,

when the angry person tells the other person about the anger and carefully identifies the source, is constructive. This clarity of communication gets the anger out into the open so the other person can deal with it and help to alleviate it. The angry person "gets it off the chest" and prevents an emotional buildup.

Common Characteristics of Crisis

• All crises are experienced as sudden. The person is usually not aware of a warning signal, even if others could "see it coming." The individual or family members may feel that they had little or no preparation for the event or trauma. • The crisis is often experienced as life threatening, whether this perception is realistic or not. • Communication with significant others is often decreased or cut off. • There may be perceived or real displacement from familiar surroundings or loved ones. **All crises have an aspect of loss, whether actual or perceived. The losses can include an object, a person, a hope, a dream, or any significant factor for that individual.**

The overall client goals for individuals experiencing stress-related responses are to

• Decrease or resolve anxiety. • Increase ability to manage or cope with stressful events or circumstances. • Improve role performance.

Minimizing Anxiety

• Listen attentively; try to understand the client's perspective on the situation. • Provide an atmosphere of warmth and trust; convey a sense of caring/empathy. • Determine if it is appropriate to encourage clients' participation in the plan of care; give them choices about some aspects of care but do not overwhelm them with choices. • Stay with clients as needed to promote safety and feelings of security and to reduce fear. • Control the environment to minimize additional stressors such as reducing noise, limiting the number of individuals in the room, and providing care by the same nurse as much as possible. • Implement suicide precautions if indicated. • Communicate in short, clear sentences.

The effectiveness of an individual's coping is influenced by

• The number, duration, and intensity of the stressors • Past experiences of the individual • Support systems available to the individual • Personal qualities of the person.

Anxiety and Fear Differ in Four Ways

• The source of anxiety may not be identifiable; the source of fear is identifiable. • Anxiety is related to the future, that is, to an anticipated event. Fear is related to the past, present, and future. • Anxiety is vague, whereas fear is definite. • Anxiety results from psychological or emotional conflict; fear results from a specific physical or psychological entity.

Clinical Manifestations of Stress

•Pupils dilate to increase visual perception •Sweat production (diaphoresis) increase to control elevated body heat due to increased metabolism. •Heart rate and cardiac output increases to transport nutrients and by-products of metabolism more efficiently. •Skin is pallid because of constriction of peripheral blood vessels, an effect of norepinephrine. •Sodium and water retention increases due to release of mineralocorticoids, which increases blood volume. •Rate of depths of respirations increase because of dilation of the bronchioles promoting hyperventilation. •Urinary output decreases *Mouth may be dry. •Peristalsis of the intestines decreases, resulting in possible constipation and flatus. •For serious threats, mental alertness improves. •Muscle tension increases to prepare for rapid motor activity or defense. •Blood sugar increases because of release of glucocorticoids and gluconeogenesis.