Ch. 32 Stress

Stress

• “a nonspecific response of the body to any demand made upon it.”

-can harm the body by raising blood pressure, increasing heart rate, and triggering harmful hormones

-it can lead to serious health issues like heart disease, chronic pain, and autoimmune disorders

Stressor

is an event or stimulus that disrupts the person’s sense of equilibrium

Stress appraisal

is the process by which the person interprets a stressor as either a threat or a challenge

Physiologic

body’s reaction to a threat

psychological

emotional or cognitive reaction involved in the appraisal (assessment) of a threat

sociocultural

stress from societal pressures (racism, poverty, political upheaval)

Sister Callista Roy’s Adaptation Model

• people adapt to stress by meeting their physiologic needs, developing a positive identity, performing social role functions, and balancing dependence and independence

• the nurse’s role is to help patients adapt to illness or develop positive adaptive behaviors

Homeostasis

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

General Adaptation Syndrome (GAS)/ Hans Selye

• The body reacts the same way to any stressor (physical, emotional, pleasant, or unpleasant)

• Stress triggers the autonomic nervous system to create an adaptive response

Distress

harmful, overwhelming stress

Eustress

positive, motivating stress

Three Stages of GAS

• Alarm: the fight-or-flight response is activated

  • Cortisol ⬆, HR and BP ⬆️

• Resistance: Body tries to stabilize and adapt

  • Poor concentration, irritability, frustration

• Exhaustion: Prolonged stress depletes resources; risk of illness

  • depression fatigue

Local Adaptation Syndrome (LAS)

• Localized response of body tissues to stress

• NOT systemic like GAS

• Triggered by physical or emotional stressors in specific areas

Common Responses:

• Inflammation, pain reflex, hypoxia

• LAS is most evident in immune system activity

• Hypoxia can impair wound healing and mental clarity during high anxiety

Allostasis

•The process by which the body regains stability (homeostasis) after stress
•Helps the body adapt to both physical and emotional stress.
•Short-term stress → Adaptive, helpful
•Chronic stress → Harmful
•The wear and tear on the body from prolonged stress.
•Can lead to serious effects like brain changes, illness, and dysfunction.
•Teach patients (and remember for yourself!) that stress responses should shut off after the threat is gone. Help patients learn ways to manage stress and recover to prevent long-term damage.

Stress Appraisal/ the automatic

• Appraisal is the process of evaluating a stressor, often automatically and
unconsciously.
• Happens in two stages:
◦ Primary Appraisal:
- "Is this situation a threat or a challenge?"
- Focuses on the severity, urgency, and ambiguity of the stressor.
◦ Secondary Appraisal:
- "Do I have the resources to cope?"
- Evaluates options for managing the situation.
•Threat = potential harm or loss
•Challenge = opportunity for growth or benefit

Sense of Coherence (SOC)

• A personality trait that helps explain why some people handle stress better

• Three key parts:

  • Comprehensive: Life events make sense and are predictable

  • Manageable: Resources are available to meet demands

  • Meaningful: Life’s challenges are worthy of engagement

Coping Strategies

• Problem focused: Actively changing or removing the stressors (learning new skills, seeking info)

• Emotion-focused: Managing emotional response when the stressor can’t be changed (relaxation, avoidance)

• Defense Mechanisms:

  • Unconscious protective response (denial, suppression)

  • Useful short- term but can be harmful if relied on long-term

Nervous System Response

• Sympathetic Nervous System Activation

• Brain Involvement

• Sensory input (from skin, eyes, ears)

→ Spinothalamic pathway

• Reticular Activating System (RAS) and Thalamus: Keep the brain alert

• Cerebral Cortex:

  • Frontal lobe: Evaluates threat

  • Temporal lobe: Triggers fear response

• Hypothalamus Role

• Systemic Effects

  • ⬆Blood to muscles

• Bronchodilation

• Common Symptoms

  • Palpitations, Nausea, Anxiety, Light Headedness

Sympathetic Nervous System Activation

• Trigger the “fight-or-flight” response

• Increase HR, BP, and RR

• Decreases digestion and skin blood flow

Hypothalamus Role

• Receives Signals

• Releases CRH → Pituitary → ACTH → adrenal response

Bronchodilation

• ⬇GI motility

• ⬆Glucose & fat availability

• Pupil dilation → better vision

Immune Response

• Job: To defend the body against infection and injury

• Identifies what doesn’t belong in the body (viruses, bacteria, foreign proteins)

• First Sign of Immune Response:
  • Pain: signals something is wrong
  • Inflammation: triggered by local immune cells
  • Redness: vasodilation
  • Swelling: increased capillary permeability

• Cellular Response
  •Phagocytes and macrophages: ingest harmful invaders
  •T and B lymphocytes: destroy infected or abnormal cells

• If defense fails: the hypothalamus is alerted and a systemic stress response is triggered (fever, fatigue, etc)

Endocrine Response

Key Hormonal Responses
◦ Hypothalamus → Releases CRH
◦ CRH stimulates pituitary to release:
◦ ACTH → Stimulates adrenal cortex to release corticosteroids & aldosterone
◦ Beta-endorphins → Natural pain relief (analgesic effect)
◦ Adrenal Medulla Activation
◦ Releases epinephrine & norepinephrine
◦ Combined effect: Sympathoadrenal Response
◦ ↑ Heart rate, ↑ blood pressure
◦ ↑ Blood flow to muscles
◦ ↑ Clotting time
◦ ↓ Blood flow to non-vital organs

• Corticosteroid Effects
  •↑Serum glucose
  •↓ Inflammation
  •Helps body adapt to prolonged stress
  •Prolonged use can suppress immune function

• Clinical Implications
  •Stress-induced hyperglycemia:
  • Seen in MI (myocardial infarction), surgery, pregnancy
  • ↑ Infection risk
  • Delayed wound healing

Stress Appraisal

• How a person perceives and assigns meaning to a stressor

• Influences emotional and physical response

Measurement Tools
•Social Readjustment Rating Scale (Holmes & Rahe): ranks major life events
•Everyday Hassles Scale (Lazarus & Folkman): evaluates daily stressors
•Perceived Stress Scale (PSS-14) (Cohen): measures general stress perception

Resilience and coping

Resilience: the ability to adapt and recover from stress

• Traits of resilient individuals: optimism, faith, purpose, flexibility

• Effective coping = using problem-focused + emotion-focused strategies

• Coping success varies by personality, past experience, and support systems

Anxiety

• Response to uncertain threat; different from fear
  •Mild: Enhances focus

  • can be motivating, creativity, and think clearly
    •Moderate:

  • Narrows attention, dulls perception
    •Severe: Impairs decision-making
    •Panic: Extreme dread, physical symptoms (e.g., chest pain, palpitations)

• Anxiety disorders: GAD, OCD, PTSD, social anxiety

• GAD: is characterized by unrealistic levels of worry and tension with or without an identifiable cause.

Anger and Depression

•Anger: Natural response to perceived wrong; must be managed constructively

-may be prepared to attack
•Depression: Often follows loss; may include fatigue, withdrawal, or hopelessness
•Severe cases need psychotherapy and/or medication

Parasympathetic Overactivation

• ⬆GI motility → IBS

• Bronchoconstriction → Asthma

*Stress does not always trigger GI

Immune System Suppression

• ⬇Lymphocyte activity & antibody levels

• ⬇Vaccine response

• Faster HIV → AIDS progression

• Higher viral loads → ⬇ HAART effectiveness

Autoimmune & Viral Reactivation

• Triggers MS (multiple sclerosis) flares

• Reactivates HSV-1/HSV-2 & shingles

Hormonal Imbalance

• ⬆Aldosterone & ADH(antidiuretic hormone) → fluid retention, ⬇K+, NA, & Ca2+

  • Aldosterone secreation increases sodium reabsorption in the kidney

• ⬆Cortisol (measured in saliva, blood, urine)

Reproductive Disruption

• Males: ⬆Testosterone with acute stress

• Females: Stress can delay ovulation and suppress menstruation

Assessment

• Build Trust: Use open-ended questions to explore personal stressors and coping strategies
  •Types of Coping:
  •Problem-Focused: Change/remove the stressor
  •Emotion-Focused: Adjust emotional response

• Cultural Competence:
  •Assess stress in the context of the patient’s cultural beliefs and worldview
  •Use culturally appropriate tools

• Observe Behavior:
  •Verbal cues + nonverbal signs (e.g., agitation, poor eye contact)
  •Incongruent behaviors warrant deeper inquiry

• Identify Caregiver Stress: Especially in the “sandwich generation”, which means they are caring for thier own childdern as well as thier parents

• Assess Physical & Emotional Symptoms:
  •Use tools like the Holmes-Rahe Scale (consider cultural relevance)

Nursing Diagnosis

Coping Skills Overview
Coping strategies protect mental & physical well-being.
Poor coping can lead to maladaptive behaviors:
◦ Denial, substance use, avoidance.
◦ ICNP Nursing Diagnoses for Stress & Coping:
1. Difficulty Coping
◦ Ex: Recently separated, unemployed, crying, anxious at night, low energy.
2. Anxiety
◦ Ex: Change in health status, fatigue, trouble concentrating.
3. Caregiver Stress
◦ Ex: Complex caregiving duties, fatigue, GI upset, weight changes.

Planning

Nursing Diagnoses & Care Planning for Stress
Prioritize nursing diagnoses based on severity; life-threatening first
Sample goals:
◦ Discuss coping strategies with counselor
◦ Improve concentration before discharge
◦ Use respite care regularly for caregivers
Collaborate with healthcare team and specialists
◦ Family, friends, & healthcare providers offer essential support and encouragement
◦ Encouragement helps prevent discouragement during setbacks
Patient involvement in care planning improves outcomes
◦ Nurses play a vital role in reducing stress-related physical and emotional harm

Implementation and Evaluation

• Stress Management Interventions:
  •Reduce stressors & enhance coping skills
  •Nurse and patient collaborate on plan
  •Social & emotional support from family/friends lowers stress
  •Use internal (emotional) & external (social) coping strategies
  •Mobilize general resistance resources:
  •Physical, emotional, social, cultural supports
  •Examples: positive attitude, family, financial help

Relaxation & Mind-Body Therapies

Teach techniques like deep breathing, progressive muscle relaxation, guided imagery, and meditation.

Point out their benefits: lower BP, reduced pain, improved sleep, and enhanced well-being

Anger Management

Discuss healthy ways to express anger (calm communication, exercise, humor) and when professional help might be needed

• forgiving, doing deep- breathing exercises

Nutrition

Stress the importance of balanced nutrition to reduce inflammation and promote healing, collaborating with dietitians as needed

Exercise

Emphasize that even simple daily movement reduces stress hormones and improves mood and physical health

Sleep

Explain how stress affects sleep and share nursing interventions to promote good sleep hygiene (quiet environment, limiting screen time)

Complementary and Alternative Therapies

• Yoga, Biofeedback, Reiki, Therapeutic Touch

• Social Support and Support Groups

• Time Management and Mindfulness

• Address Crisis Intervention

• Emphasize Evaluation and Long-Term Care

Biofeedback therapy

is an alternative medicine approach that teaches you to change the way your body functions. It’s a mind-body therapy that may improve your physical and mental health.

Stress and Nursing

•Nursing Stress Risks:
•Burnout, compassion fatigue, depression
•Causes: low staffing, long shifts, poor teamwork, workplace incivility
•Effects of Burnout:
•Reduced patient safety & care quality
•Increased patient dissatisfaction
•Compassion Fatigue Signs:
•Mood swings, avoidance, poor concentration
•Physical symptoms: headaches, fatigue, muscle tension
•Prevention & Self-Care:
•Mentoring, relaxation spaces, mindfulness, yoga
•Work-life balance & peer support
• Healthy Nurse Initiatives:

ANA’s Healthy Nurse Healthy Nation program
• Resources for emotional, spiritual, physical well-being COVID-19 Impact:

Nurses’ vital role recognized by WHOANA COVID-19 Resource Center for
mental health support
• Professional Support:

Counseling essential for coping with extreme stress