Stress, coping and self-concept

Stress

Process starting with a factor that includes tension in mind or body

Stressor

Physical, psychological, or social stimuli that can produce stress

Appraisal

How a person interprets the impact of a stressor. Personal evaluation of the meaning of the event to what is happening and a consideration of the resources on hand to help manage the stressor

General adaption syndrome

Triggered directly by a physical event or indirectly by a psychological event. Body attempts to return to a state of balance through allostasis.

1. Alarm reaction

2. Resistance stage

3. Exhaustion stage

Alarm stage (1st stage)

Fight or flight

Body changes- increases in:

• blood volume

• glucose levels (less that 200 mg/dL for random, nondiabetic pt)

• Epinephrine and norepinephrine

• Heart rate and blood pressure

• Pupil dilation

• Blood flow to muscles

• Oxygen intake

• Mental alertness

Scientific Foundation

Fight or flight response: physiologic response to stress by activation of the autonomic nervous system

Allostasis: the body’s regulation of systems to maintain a steady state

Resistance stage (2nd stage)

Responds in attempt to compensate. Body stabilizes. Body tries to repair damage. Energy is consumed.

Bodily changes- return to normal:

• Hormone levels drop

• Heart rate

• Blood pressure

• Cardiac output

Exhaustion stage (3rd stage)

• Constant stress causes breakdown of compensatory mechanism

• No longer resist effect of stressor

• Energy needed to adapt is depleted

• Allostatic load

• Chronic HTN

• Depression

• Sleep deprivation

• Chronic fatigue syndrome

• Autoimmune disorders

Immune response

Stress can impair immune function

Increases risk for:

• infection

• high blood pressure

• diabetes

• cancers

Stress responses

Primary appraisal:

• evaluating event in terms of personal meaning for pt

• ongoing process

• if seen as threat- stress occurs

Secondary appraisal:

• consideration of possible coping strategies/resources

• if demands by event exceed coping ability- stress occurs

Coping

• efforts to manage stressor

• both cognitive and behavioral efforts used to manage stressor

• coping influenced by age and background

• no one size fits all

• usually use a combo of strategies

Coping and ego-defense mechanisms

Coping mechanisms include psychological adaptive behaviors

Often task oriented involving use of direct problem-solving techniques to cope w/ threats

Ego-defense mechanisms regulate emotional distress- protection from anxiety and stress, unconsciously use

Compensation

making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset

Denial

Avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain

Displacement

Transferring emotions, ideas, and wishes from a stressful situation to a less anxiety-producing substitute

Conversion

Unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms

Identification

patterning behavior after that of another person and assuming that person’s qualities, characteristics, and actions

Dissociation

Experiencing a subjective sense of numbing and a reduced awareness of one’s surroundings

Regression

Coping with a stressor through actions and behaviors associated with an earlier developmental period (commonly heard about in children)

Stress

Chronic- occurs in stable condition and results from stressful roles

Acute- time limited events that threaten a person for a relatively brief period provoke acute stress

Post-traumatic stress disorder (PTSD)

• when a person experiences, witnesses or is confronted with a trauma

• responds with intense fear or helplessness

• anxiety is sometimes manifested by nightmares and emotional detachment

• flashbacks

• depression is common with PTSD

• secondary traumatic stress

Crisis

Developmental/maturational- as person moves through stages of life

Situational- job change, vehicle crash

Adventitious/Disaster- natural disasters, crime of violence

Situational factors

• arises from personal changes

• work related stressors: burnout, transfers, promotions

• chronic illnesses: diabetes, cancer, cardiac disease, depression

Maturational factors

• vary with life stages

• children

• adolescents

• adults

• older adults

Sociocultural factors

• environmental and social stressors can lead to developmental problems

• poverty

• physical disability

• isolation

• culture

Stress and nursing

Demands of workplace can lead to:

• compassion fatigue

• burnout

• decreased job satisfaction

To care most effectively for others, nurses must first take time to care for themselves. Healthy coping strategies: exercise, balanced nutrition, and mindfulness therapy

Assessment

Patient’s perspective:

• trusting relationship

• perception

• meaning of event

Questions:

• open-ended

Subjective findings:

• use communication skills

• non-threatening environment

Objective findings:

• appearance

• non-verbal behavior observations and the environment

Nursing Diagnosis

• Anxiety

• stress overload

• difficulty coping

• risk for post trauma response

• despair

Planning

Desirable goals and outcomes: goals-effective coping, caregiver emotional health

Nursing interventions: primary prevention, secondary prevention, tertiary prevention (these are to help pt achieve goals)

Planning expected outcomes examples

• Patient will discuss possible coping strategies during weekly office visits

• patient will report increased ability to concentrate on care instructions prior to discharge

• caregiver will use respite for his loved one once a week for the next month

• patient will attend a support group on a weekly basis

• patient will discuss strategies for coping with family violence with a social worker within 24 hours

Implementation

Three main methods of intervention:

• decrease stress-producing situations

• increase resistance to stress

• learn skills that decrease physiological response to stress

Implementation health promotion:

• regular exercise and rest

• support systems

• time management

• guided imagery and visualization

• progressive muscle

• relaxation

• assertiveness training

• journal writing

• mindfulness- based stress reduction

• stress management in the workplace

• burnout

• social isolation and loneliness prevention

Implementation acute care and restorative/continuing care

Acute care:

crises intervention- specific type of brief psychotherapy. Has two specific goals- patient safety and anxiety reduction

Restorative/continuing care:

person recovers when stressor is removed or coping strategies are successful. Experiencing a crisis has lasting effects. Introduce stress-management skills

Evaluation

Patient’s perceptions, compare actual to expected outcomes, and continually reassess

Complementary

Therapy used in addition to or together with conventional treatment

Alternative

Sometimes include same interventions or complementary therapy

Integrative

Complementary therapies used for or prescribed by licensed healthcare providers

Complementary and alternative therapies

Nursing-accessible therapies

• relaxation

• meditation

• imagery

Training-specific therapies

• biofeedback

• traditional Chinese medicine

• acupuncture

• therapeutic touch

• Pilates

• chiropractic therapy

Relaxation therapy

Benefits:

• decrease bp and hr

• decrease muscle tension

• improve well being

• reduce symptom distress

• can decrease pain and anxiety

• exert control

• reduce depression

• reduce breathlessness in chronic respiratory illnesses

Limitations:

• increased sensitivity in awareness of muscle tension

• can result in continued intensification of symptoms

• progressive relaxation requires moderate energy expenditure

• not appropriate for pts with advanced disease or decrease energy reserves

Meditation

Application:

• limits stimuli

• direct attention to a single stimulus

• Benefits: decrease bp, decreased relapse in alcohol addiction, decrease in depression in cancer pts

• Improves: productivity and lowers irritability

Limitations:

contraindicated for:

• pt in fear of loosing control

• some become hypertensive

• sometimes increases effects of certain medications

Imagery

Application:

• uses mind to create images to stimulate physical changes

• can be guided or self-directed

• Benefits: control/relieve pain and treatment of chronic conditions

Limitations:

• relatively few side effects

• can have increased anxiety and fear

• COPD/asthma pts can have airway construction

Biofeedback

• mind-body technique that teaches self-regulation and voluntary self-control over specific physiological responses

• uses electronic or electromechanical instruments

• can change thinking, emotions, and behaviors

• used in numerous situations: stoke recovery, smoking cessation, ADHD, lower bp

• use with precautions in pts with psychological or neurological conditions

Acupuncture

• regulates/realigns vital energy

• needles inserted into the skin in specific areas along channels in the body

• modifies response of the body to pain and how processed

• used for: low back pain, TMJ, migraines, depression, and addiction

Limitations:

• immunocompromised, needle injury, pregnant, have seizures

Therapeutic touch

• affects energy fields (positively)

• practitioner places open palms either on or close to the body of the pt

• five phases: centering, assessing, unruffling, treating, evaluating

• may be effective in treating pain, dementia, trauma, and anxiety during illness

• contraindicated: history of trauma/abuse, pregnancy, neonates, actively dying

Herbal therapies

• because it is natural does not mean it is safe

• herbal meds are not approved for use of drugs and not regulated by the FDA

• verification by US pharmacopeia (USP label)

• Safe: cranberry, ginger, gingko, garlic, chamomile, saw palmetto, valerian, aloe vera

• Unsafe: calamus, chaparral, coltsfoot, comfey, ephedra, life root, pokeweed

Self-concept

How an individual thinks about oneself

• subjective

• complex mixture of unconscious and subconscious thoughts, attitudes, and perceptions

Self-concept provides a frame of reference that affects the management of all situations and relationships with others

Development of self-concept

• development and maintenance of self-concept begins and continues throughout the life span: early childhood (think highly of themselves), adolescence (self image), adulthood (successful), older adulthood (loose function)

• ethnic and cultural influences on self-concept continue to develop throughout life span

Situations affecting self-concept

• loosing body function

• decline in activity tolerance

• managing a chronic illness

• decrease self esteem

An individuals view of themselves, and their own health is closely related

Identity stressors

• job loss

• change in marital status

• abuse or neglect

• dependency on others

• repeated failures

• societal attitudes

• conflict with others

Body image stressors

• stroke

• colostomy

• anorexia

• incontinence

• obesity

• amputation

• scarring

• mastectomy

Most of the time it is things that others cannot see

Role performance stressors

• inability to balance career and family

• transition from school to work

• changing work environment

• responsibility for aging parent

Role conflict

assuming two or more roles that are inconsistent

Role ambiguity

unclear expectations on what to do/ how to do it

Role strain

role conflict and ambiguity. feeling inadequate for both roles

Self esteem stressors

• harsh criticism

• perceived inability to meet parental expectations

• poor health

• loss of spouse

• decline in achievement experiences following retirement

18-29 have the highest rate of depression

Components of self-concept

• identity

• body image

• role performance

• self-esteem

Identity

a conscious sense of individuality and uniqueness that is continually evolving throughout life

Body image

Body image involves attitudes related to the body:

• physical appearance

• structure

• function

Influences on body image:

• personal view of body

• cultural and societal changes

• developmental changes

Role performance

how people perceive their ability to carry out significant roles

• child: am I making parents proud

• friend: am I being a good friend

• employee: am I doing enough work

• wife/husband: am I making them proud

• mother/father

each role involves certain expectations which leads to an enhanced sense of self

difficulty in meeting the role expectations lead to low self-esteem

Self-esteem

an individual’s overall feeling of worth or the emotional appraisal of self-concept

cycles of self-esteem:

• childhood: harsh criticism

• adolescence: sibling rivalry

• adulthood: work, unsuccessful relationships

• elderly: health

each stage involves factors that are important to the development of a healthy, positive self-concept

Nurse impact on self-concept

• a nurse’s acceptance of a pts altered self-concept promotes positive change

• nurses need to remain aware of their own feelings, ideas, values, expectations, and judgments

• understand the appropriate developmental stages related to self-concept