Stress

Stress and Stressors

• Definition of stress: a negative emotional experience.
• Stressors: psychological or physical stimuli that are incompatible with function.
• Real-life nuance: some stressors come from moving toward something positive (e.g., joy, celebration) but are still stressful due to planning, inputs, timelines, and decision-making.
• Personal example: son has worked for Epic for $3 weeks in November and$1$week in December, plus travel perks and per diem; still stressful because of planning, lodging, and logistics, even though it will be a positive break from work.</li> <li>Distress vs eustress:<ul> <li>Eustress: generally positive stressors (moving into a new house, marriage, having a baby) that are typically short-term and can enhance motivation and efficiency when well planned; still stressful.</li> <li>Distress: negative stress, can be short- or long-term.</li></ul></li> <li>Examples of positive and negative stressors (used for study questions): positive can still be stressful (e.g., pregnancy, wedding, promotion) and should not be dismissed when considering patient stress.</li> <li>Physiological responses to stress (overview): adrenal glands release catecholamines and corticosteroids; literature mentions adrenal fatigue from chronic corticosteroid exposure; endorphins may decrease pain sensitivity in acute stress (e.g., post-trauma shock); serotonin usage can increase synthesis; chronic stress may require higher SSRI dosing to maintain serotonin levels; prolonged stress can heighten illness risk.</li> <li>Types of stressors:<ul> <li>Physical: trauma, excessive heat or cold, physical injury.</li> <li>Psychological: divorce, job loss, financial problems, retirement, death of a loved one, marriage, baby, promotion, etc.</li></ul></li> <li>Perception of the stressor: awareness varies; stress is influenced by personal interpretation and context; sometimes therapy helps identify stressors.</li> <li>Coping and support:<ul> <li>Counseling/therapy helps people identify and manage stressors.</li> <li>Support groups (formal and informal) and cultural attitudes toward stress.</li> <li>Spiritual/religious practices (not strictly religious) such as yoga, meditation, and prayer can enhance immune function and well-being.</li> <li>Mental health care emphasizes taking care of the mind as part of overall health.</li></ul></li> <li>Standardized stress assessment tool (Holmes and Rahe SRRS):<ul> <li>Antiquated but still referenced; scales introduced in the late 1960s and revised later; organized as points for positive and negative stressors.</li> <li>Examples of high-scoring items include: death of a spouse or child, divorce, marital separation, imprisonment, death of a close family member, marriage, marriage reconciliation, retirement, etc.; the top ten events include three positive life events, which still contribute to stress scores.</li> <li>The assessment captures acute stress by correlating perceived stress with physiological signs such as heart rate, respiratory rate, and appetite changes.</li></ul></li> <li>Coping strategies and nurse-backed interventions:<ul> <li>Therapeutic communication and active listening.</li> <li>Relaxation techniques and deep breathing.</li> <li>Exercise; mindfulness, meditation, journaling.</li> <li>Cognitive-behavioral approaches (cognitive reframing) to reframe negative thoughts to more positive interpretations (e.g., "my blood counts are better than yesterday" or "this transfusion today may help discharge sooner").</li> <li>Sunshine and fresh air as mood and energy boosters; the presenter notes office layout (a cave-like space) can miss the benefit of sunlight; sun exposure and outdoor time are meaningful for mood.</li> <li>Sunlight and fresh air are simple, free interventions that can reset stress.</li> <li>Limit-setting on device use: encourage patients to disconnect from social media and work emails to improve sleep and rest (e.g., turn off devices from 21:00 to 07:00).</li> <li>Recognize the pressure of modern device usage on sleep; reflect on personal device habits for self-care as a healthcare provider.</li></ul></li> <li>Anger, aggression, and violence: definitions and relationships<ul> <li>Anger: an emotional response to frustration or a perceived threat to needs (emotional/physical) or a challenge.</li> <li>Aggression: the behavior that results in verbal or physical attack.</li> <li>Violence: intentional use of force that results in injury to another person.</li> <li>Predictors of violence may include physical cues (e.g., pacing, tense muscles, red/angry face, rapid breathing, sweating, tachycardia) and verbal/behavioral signs (cussing, shouting, threats).</li> <li>Violence can be observed in patients with cognitive deficits, trauma histories, or underlying psychiatric conditions; some violence is situational (e.g., intoxication).</li> <li>Biological risk factors: genetic predispositions, neurotransmitter imbalances; brain tumors, traumatic brain injury (TBI), Alzheimer’s disease, and some epilepsies can alter personality and aggression.</li> <li>Case illustrations: a celebrity with dementia (Bruce Willis) highlighted as an example of early behavioral changes; TBI-related anger can be misinterpreted as personality change.</li> <li>Psychological risk factors: learned responses, social learning theory (modeling behavior in response to stimuli; e.g., a child who sees aggression rewarded may imitate it).</li> <li>Trauma-informed care: disruptive patients often have trauma histories; self-soothing difficulties are common.</li> <li>Trauma and coping: unresolved trauma complicates current coping strategies; clinicians must acknowledge personal strengths and vulnerabilities to avoid impulsive reactions.</li> <li>Important clinical concept: pause button for self-awareness and emotion regulation; cultivate awareness of personal triggers and implement coping strategies before reacting.</li></ul></li> <li>Violence risk assessment in clinical settings<ul> <li>Observational cues across the unit help identify risk: pacing, irritability, frowning, red faces, somatic signs, and aggression (verbal or physical).</li> <li>New admits with a history of violence or property damage require heightened vigilance; intoxication increases aggression risk; possession of improvised weapons or objects (caps, pens, utensils) can be used as weapons.</li> <li>Environmental risk factors: overcrowded units, chaotic environments, trauma histories, and lack of self-regulation; inexperienced staff and poor limit setting escalate risk; provocative/undermining staff behavior can worsen aggression; arbitrary loss of privileges can escalate anger.</li> <li>Patient behavior patterns: self-isolation, mood swings, drastic changes in attitude, or increased need for control can indicate higher violence risk.</li> <li>Unit dynamics: overcrowded, poorly designed spaces; trauma histories; staff shortages; lack of consistent, therapeutic communication; overly controlling approaches.</li></ul></li> <li>Management of escalating patients: de-escalation and safety planning<ul> <li>Early and calm engagement: hear the patient’s feelings, approach in a calm, controlled, open, non-threatening manner.</li> <li>De-escalation techniques: use a quieter voice, reduce stimuli (lighting, nearby stressors), reposition others to create space; consider moving others out of the area.</li> <li>Offer PRN medications to reduce anxiety or agitation when appropriate and with consent; reassure the patient that you’re there to help, not just medicate.</li> <li>Set explicit expectations for behavior: concrete statements like, "I expect you to stay in control" and specific limits (no more throwing chairs, etc.).</li> <li>Use seclusion, restraints, or medications as a last resort; prep for a code/rapid response with a clear plan and adequate backup.</li> <li>Code-style escalation structure: assign a clearly defined leader for the response and designate staff roles; maintain open communication while ensuring safety of all patients and staff.</li> <li>Environmental and logistical precautions: know the layout, avoid cornering the patient, avoid blocking exits, and keep escape routes clear; remove potential improvised weapons (avoid hardback books; spiked or sharp objects).</li> <li>CPI (crisis prevention/intervention) principles: maintain a supportive stance with open posture; stance should allow quick movement if needed while staying approachable; use one voice during de-escalation to minimize confusion.</li> <li>Documentation and debrief: security/response teams document the incident (time, actions, who responded, patient outcomes); conduct a debrief after the event to review what happened and what could be improved.</li> <li>Post-deescalation communication: once the patient is calm, avoid berating or rehashing the incident; later, discuss strategies (e.g., whether to take a PRN in future episodes) in a calm, concise, non-punitive manner.</li></ul></li> <li>Pharmacology and pharmacotherapy in acute agitation<ul> <li>Common therapeutic categories include:</li> <li>SSRIs for anxiety and depression (continuity of care and dose considerations in chronic stress).</li> <li>Benzodiazepines (e.g., lorazepam, diazepam) for acute agitation; note elderly cautions due to metabolism and renal/hepatic function; diazepam is longer-acting than some alternatives.</li> <li>Antipsychotics (typical and atypical): haloperidol is common historically; second- and third-generation antipsychotics may be used in acute agitation; there is a preference for safer, age-appropriate agents in older adults.</li> <li>Common injectable “rapid tranquilization” regimens (e.g., the B52 cocktail): as used in some settings, typically a combination that may include haloperidol (Haldol), lorazepam (Ativan), and diphenhydramine (Benadryl). In notation:$ ext{B52} = ext{Haldol} + ext{Ativan} + ext{Benadryl}.$$
• Medication choices must consider comorbidities, age, cognitive status, and potential interactions; monitor for oversedation and respiratory depression.