1. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Chapter 37 Stress and Coping

2. 2Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Scientific Knowledge Base  Fight-or-flight response  Neurophysiological responses:  Medulla oblongata  Reticular formation  Pituitary gland

3. 3Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. General Adaptation Syndrome (GAS)  An immediate physiological response of the whole body to stress; involves several body systems, especially the autonomic nervous and endocrine systems, and includes immunological changes  A three-stage reaction to stress:  Alarm reaction  Resistance stage  Exhaustion stage

4. 4Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Quick Quiz! 1. You are a nurse working in the college student health center. You receive a call that an athlete has just fallen and has been injured. You know that according to the general adaptation syndrome, the athlete will be exhibiting A. An increased appetite. B. An increased heart rate. C. A decrease in perspiration. D. A decrease in respiratory rate.

5. 5Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. General Adaptation Syndrome  Psychological stress  Primary appraisal  Secondary appraisal  Coping  Personal characteristics that influence response to a stressor:  Level of personal control  Presence of a social support system  Feelings of competence

6. 6Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. General Adaptation Syndrome (cont’d)  Primary appraisal: evaluating an event for its personal meaning  Secondary appraisal: focuses on possible coping strategies  Coping: the person’s effort to manage psychological stress  Ego-defense mechanisms: regulate emotional distress and give a person protection from anxiety and stress

7. 7Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study  Rachael Bennett, a 32-year-old married mother of three children, works as the nurse manager in a medical intensive care unit.  Recently, patient and staff satisfaction has been declining, and Rachael feels pressured to improve the satisfaction scores. In addition, within the past year Rachael’s husband has had several hospitalizations related to heart disease, and he is unable to work.

8. 8Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Types of Stress  Chronic  Chronic stress occurs in stable conditions and results from stressful roles.  Acute  Time-limited events that threaten a person for a relatively brief period provoke acute stress.

9. 9Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Until recently, Rachael has felt very happy with her job. For the past 6 weeks, she has been feeling defeated and hopeless; she has no energy; and she has difficulty organizing her thoughts.  When her supervisor noticed Rachael’s frequent severe headaches, reported lack of sleep, and use of wine at night to relax, she referred her to the hospital’s employee health office to help her cope with her stress.

10. 10Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Types of Stress  Posttraumatic stress disorder:  An acute stress disorder that begins when a person experiences, witnesses, or is confronted with a traumatic event  May include flashbacks = Recurrent and intrusive recollections of the event

11. 11Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Types of Crises  Developmental  Developmental crises occur as a person moves through the stages of life.  Situational  External sources such as a job change, motor vehicle crash, death, or severe illness provoke situational crises.  Adventitious  A major natural or man-made disaster or a crime of violence can create an adventitious crisis.

12. 12Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Quick Quiz! 2. A patient comes into the emergency department complaining of chest pain. When discussing possible reasons why the chest pain has occurred, the nurse learns that the patient is depressed because of the loss of a job. This type of crisis can be classified as A. Maturational. B. Situational. C. Sociocultural. D. Posttraumatic. 31 - 12

13. 13Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Knowledge Base: Nursing Theory and Role of Stress  Neuman systems model:  Based on the concepts of stress and reaction to stress  Nurses develop interventions to prevent or reduce stress on patients or to help them cope.

14. 14Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Knowledge Base: Nursing Theory and Role of Stress (cont’d)  Neuman systems model  Primary prevention promotes patient wellness by stress prevention and reduction of risk factors.  Secondary prevention occurs after symptoms appear.  Tertiary prevention begins when the patient’s system becomes more stable and recovers.

15. 15Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Knowledge Base: Factors Influencing Stress and Coping  Situational factors  Arise from job changes, illness, caregiver stress  Maturational factors  Vary with life stages  Sociocultural factors  Environmental, social, and cultural stressors perceived by children, adolescents, and adults

16. 16Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Critical Thinking  Keep in mind the neurophysiological changes the patient may be experiencing.  Use clear communication principles.  Be confident.  Utilize the Standards of Care for Psychiatric Mental Health Nursing Practice (ANA).

17. 17Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process  Assessment  Nursing diagnosis  Planning  Implementation  Evaluation

18. 18Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Assessment  See through the patient’s eyes:  Gather information (including patient’s perception).  Synthesize the information.  Apply critical thinking.  Subjective findings  Objective findings

19. 19Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Becky Howard, a nurse practitioner in the employee health office, does preliminary screening and crisis intervention with staff members experiencing stress and potential substance abuse problems.  Becky wants to be thorough in assessing the responses and symptoms Rachael has been experiencing.

20. 20Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Nursing Diagnosis  Nursing diagnoses for stress:  Coping  Ineffective coping  Multiple diagnoses

21. 21Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  During her assessment, Becky observes that Rachael fidgets, uses poor eye contact, and bursts into tears and expresses feelings of being overwhelmed.  Rachael’s vital signs show changes in response to stress.  She has lost weight and has trouble sleeping.  She expresses shame at not coping better and admits to drinking at night to “unwind.”

22. 22Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Planning  Goals and outcomes  Desirable outcomes frequently include Effective coping, family coping, caregiver emotional health, and psychosocial adjustment: life change  Setting priorities  Teamwork and collaboration

23. 23Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Becky’s goal is that Rachael will manage the stressors that have been taxing her individual resources.

24. 24Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Implementation  Health promotion  Regular exercise  Support systems  Time management  Guided imagery and visualization  Progressive muscle relaxation  Assertiveness training  Journal writing  Stress management in the workplace

25. 25Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Implementation (cont’d)  Crisis: When stress overwhelms a person’s usual coping mechanisms and demands mobilization of all available resources, the situation becomes a crisis.  Acute care  Crisis intervention  Restorative and continuing care

26. 26Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d) GoalExpected Outcomes (NOC) Coping Rachael will differentiate effective and ineffective coping patterns. Rachael will verbalize a decrease in stress. Rachael will modify her lifestyle to reduce stress. Rachael will use her personal support system. Rachael will verbalize the need for assistance.

27. 27Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Evaluation  Through the patient’s eyes:  Has stress been reduced?

28. 28Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Case Study (cont’d)  Rachael has taken steps to manage her stress:  She appears less anxious.  She is eating healthy foods and is no longer drinking to reduce her stress.  During the past week, she began to sleep through the night.  She has resumed a friendship with a neighbor.  She now asks for assistance from her husband at home and her coworkers at work.

29. 29Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. Nursing Process: Evaluation  Patient outcomes:  Measure outcomes for each diagnosis.  Maintain communication.  Continually assess needs for additional support.