Stress and Adaptation

A. Consequences of stress
I. stress has numerous consequences
a. physiologically
i. can threaten a person's physiologic homeostasis
b. emotionally
i. can produce negative or unconstructive feelings about the self
c. intellectually
i. can influence a person's perceptual and problem-solving abilities
d. socially
i. can alter a person's relationships with others
e. spiritually
i. can challenge one's beliefs and values
II. many illnesses have been linked to stress, e.g.:
a. skin disorders, e.g.:
i. excema
ii. urticaria
iii. psoriasis
b. metabolic disorders, e.g.:
i. hyperthyroidism
ii. hypothyroidism
iii. diabetes
c. respiratory disorders, e.g.:
i. asthma
ii. hay fever
iii. tuberculosis
d. cardiovascular disorders, e.g.:
i. coronary artery disease
ii. essential hypertension
iii. congestive heart failure
e. gastrointestinal disorders, e.g.:
i. constipation
ii. diarrhea
iii. duodenal ulcer
iv. anorexia nervosa
v. obesity
vi. ulcerative colitis
f. menstrual irregularities
g. musculoskeletal disorders, e.g.:
i. rheumatoid arthritis
ii. low back pain
iii. migraine headache
iv. muscle tension
h. cancer
i. accident proneness
B. Stress as a stimulus
I. definition of stress as a stimulus
a. a life event, life change, and/or set of circumstances causing a disrupted response that increases the individual's vulnerability to illness
b. focuses on events rather than reactions or individual differences
II. stress as a stimulus was developed by Holmes and Rahe (1967)
a. concepts important to Holmes and Rahe's view of stress as a stimulus
i. life-change
a. a form of stress related to the development of illness
ii. life-change is measured on the Social Readjustment Rating Scale (SRRS)
iii. the SRRS is a tool that rank-orders life-changes and pre-determined life-change units for each of these life-changes, allowing for no individual
perceptions
iv. an individual indicates on the SRRS which life-changes, and the corresponding life-change units, he/she has experienced within the last year
v. after an individual indicates on the SRRS which life-changes, and corresponding life-change units, he/she has experienced within the last year, a
cumulative score is determined for him/her
vi. interpretation of the individual's cumulative score on the SRRS is as follows:
a. 150-199; mild stress
b. 200-299; moderate stress
c. 300 or over; severe stress
C. Stress as a response
I. definition of stress as a response
a. stress is the non-specific response of the body to any kind of demand made upon it
b. focuses on reactions rather than events or individual differences
II. stress as a response was developed by Hans Selye (1956, 1976)
a. Seyle's view of the non-specific response
i. a response to any demand made on the body, also known as a stressor
ii. occurs regardless of the cause, situation, or psychological interpretation of the stressor
iii. characterized by the same predictable chain or pattern of physiologic events
iv. called the General Adaptation Syndrome (GAS), or stress response
 v. the GAS results in the release of certain adaptive hormones and subsequent changes in the structure and chemical composition of the body
D. Stress as a transaction
I. definition of stress as a transaction
a. stress is a transaction between the person and an event within a certain environment
b. focuses on individual differences, rather than events or reactions
II. stress as a transaction view developed by Lazarus (1966)
a. concepts important to Lazarus' view of stress as a transaction
i. demands
a. an event within the internal and external environment confronting an individual
ii. primary (cognitive) appraisal of demands
a. is the interpretation of a demand by an individual
b. individual factors which can influence an individual's primary (cognitive) appraisal of a demand
i. his/her depth of feeling about the event
ii. his/her beliefs about the event
iii. his/her control over the event
c. event factors which can influence an individual's primary (cognitive) appraisal of a demand
i. unpredictability of the event
ii. uncertainty of the event
iii. timing of the event
iv. duration of the event
v. ambiguity of the event
iii. secondary appraisal of demands
a. assessment by an individual of coping mechanisms available for utilization in adapting to a demand
iv. reappraisal of demands
a. reevaluation by an individual of the efficacy of coping mechanisms utilized to adapt to a demand
b. stress as a transaction view attempts to answer the following:
i. which factors lead some persons, and not others, to respond effectively to events within a certain environment
ii. why some persons differ in their sensitivity and vulnerability to certain types of events in a certain environment
iii. why some persons are able to adapt over longer periods than others to events within a certain environment
E. Physiologic manifestations of stress
I. GAS
a. Stage one (alarm reaction [AR])
i. initial response of the body to a stressor
ii. divided into parts (two parts)
a. shock phase
i. stressor is perceived by the person either consciously or unconsciously
ii. autonomic nervous system (ANS) reacts
a. readies the person for "fight or flight"
iii. lasts from one minute to 24 hours
b. countershock phase
c. reversal of bodily changes produced in the shock phase
b. Stage two (stage of resistance [SR])
i. body attempts to adapt to the stressor
a. there is complete reversal of bodily changes produced in Stage one
b. there is institution of coping and adaptive mechanisms
c. there is confinement of stress to the smallest area possible
i. local adaptation syndrome (LAS)
a. e.g., inflammation
c. Stage three (stage of exhaustion [SE])
i. coping and adaptive mechanisms are exhausted
a. two possibilities
i. body may rest and mobilize its defenses to return to normal
ii. body may reach total exhaustion and die
F. Psychologic manifestations of stress
I. anxiety
a. vague sense of impending doom or apprehension that appears to have no reason
b. experienced to some degree by all people
c. not always bad
i. needed to accomplish developmental tasks
ii. needed to motivate goal-directed behavior
d. levels of anxiety
i. mild
a. present in day-to-day living; increases alertness and perceptual fields and motivates learning and growth
b. although mild anxiety may interfere with sleep, it also facilitates problem-solving
ii. moderate
a. narrows the person's perceptual fields so that the focus is on immediate concerns, with inattention to other communications and details
iii. severe
a. creates a very narrow focus on specific detail; causes all behavior to be geared toward getting relief
b. the person has impaired learning ability and is easily distractible
iv. panic
a. causes the person to lose control and experience dread and terror
b. the resulting disorganized state in characterized by increased physical activity, distorted perceptions and relations, and loss of rational thought
c. the person is unable to learn, concentrates only on the present situation, and often experiences feelings of impending doom
d. can lead to exhaustion and death
II. fear
a. a mild to severe feeling of apprehension about some perceived threat
b. difference between anxiety and fear
 i. source of stress
a. anxiety = unknown
b. fear = known
ii. timing
a. anxiety = related to the future
b. fear = related to the present
iii. explicitness
a. anxiety = vague
b. fear = definite
iv. cause
a. anxiety = result of psychologic or emotional conflict
b. fear = result of a discrete physical or psychologic entity
III. coping mechanisms
a. in mild level of anxiety
i. crying, laughing, sleeping, and cursing
ii. physical activity and exercise
iii. smoking and drinking
iv. lack of eye contact and withdrawal
v. limiting relationships to those with similar values and interests
b. in moderate, severe, and panic levels of anxiety
i. task-oriented reactions
a. attack behavior
i. occurs when a person attempts to overcome obstacles to attack a problem; may be constructive, with assertive problem-solving, or
destructive, with feelings and actions of aggressive anger or hostility
b. withdrawal behavior
i. involves physical withdrawal from the threat, or emotional reactions such as admitting defeat, becoming apathetic, or feeling guilty and
isolated
c. compromise behavior
i. usually constructive; involves the substitution of goals or negotiation to fulfill one's needs partially
IV. unconscious ego defense mechanisms
a. mental mechanisms which develop as the personality attempts to defend itself, establish compromises among conflicting impulses, and allay inner tensions
b. descriptions of unconscious ego defense mechanisms
i. compensation
a. occurs when a person attempts to overcome a perceived weakness by strengthening other areas
b. example
i. a short man shows aggressive, dominating traits to suggest strength and authority that his short stature does not convey (the Napoleon
complex)
ii. a boy who cannot participate in athletics studies hard and attains high grades
ii. denial
a. occurs when a person refuses to acknowledge the presence of a condition that is disturbing
b. example
i. a man does not acknowledge that he has cancer even though the physician has told him the results of the biopsy
ii. a child insists that his mother is not dead, but just out of town for a few days
iii. displacement
a. occurs when a person can satisfy a need, blocked by one type of behavior, by using another type of behavior
b. example
i. a child directs hostility toward a parent to a teacher
ii. a woman who has had an unpleasant experience with a man with red hair reacts strongly against all men with red hair
iv. introjection
a. occurs when a person internalizes some part of the external world and keeps it intact in the psyche
b. example
i. after the death of a loved one, a person may internalize the deceased person or some attribute of the deceased person
v. projection
a. occurs when a person's undesirable impulses are attributed to another person or object
b. example
i. a woman criticizes her neighbor for being a terrible gossip when in fact the woman gossips herself
ii. a wife with illicit sexual desires claims that all husbands are unfaithful and not to be trusted
vi. rationalization
a. occurs when a person gives questionable behavior a logical or socially acceptable explanation
b. example
i. a student rationalizes not turning in a paper on time because the computer "ate his/her file"
ii. a patient whose work is interrupted by illness prematurely gives up the work and says he wouldn't have been successful in that field
anyway
vii. reaction formation
a. occurs when a person gives a reason for behavior that is opposite from its true cause
b. example
i. a parent of an unwanted child overindulges his/her child
ii. a man strongly criticizes pornographic material when he has a desire to read it
viii. regression
a. occurs when a person returns to an earlier method of behaving
b. example
i. a child, who is toilet-trained and drinking from a cup, begins soiling his/her diaper and drinking from a bottle when ill
ii. a hospitalized elderly woman becomes more dependent on the nurse than is physically warranted
ix. repression
a. occurs when a person exclude an anxiety-producing event from the conscious awareness
b. example
i. a woman forgets a repugnant work assignment
 ii. a person forgets the unpleasantness of the past relationship with a deceased sibling and remembers only the good times
x. sublimation
a. occurs when a person expresses an unacceptable or impossible impulse or feeling in more acceptable way
b. example
i. a woman who has chosen to be celibate and forgo motherhood may sublimate her maternal drives by working with children, breeding
pets, or nurturing plants
ii. a person channels, to some degree, a sex drive into athletic activity, work, poetry, or music
xi. suppression
a. occurs when a person consciously turns attention away from a perceived threat
b. example
i. a person chooses to ignore a headache because he/she will never be able to accomplish what he/she must do that day
ii. Scarlet O'Hara says, "Tomorrow is another day"
xii. conversion
a. occurs when a person transfers a mental conflict into a physical symptom
b. example
i. before taking a math exam, a student develops a headache
ii. a woman develops a "lump in her throat" at a sad event
V. cognitive manifestations
a. types of cognitive manifestations:
i. problem-solving
a. thinking through the threatening situation, using specific steps similar to those of the nursing process, to arrive a solution
ii. structuring
a. arrangement or manipulation of a situation so that threatening events do or occur
iii. self-control (discipline)
a. assuming a manner and facial expression that convey a sense of being in control or in charge, no matter what the situation is
iv. suppression
a. consciously and willfully putting a thought or feeling out of mind
v. fantasy or daydreaming
a. using make-believe scenarios in which unfulfilled wishes and desires are imagined as fulfilled, or a threatening experience is reworked or
replayed so that is ends differently from reality
vi. prayer
G. Effects of stress
I. in health, may promote health and prevent illness, e.g.,
a. fear of developing lung cancer may motivate a person to quit smoking
b. anxiety about baby care may motivate prospective parents to attend prenatal classes and read child care books
c. facilitates normal growth and development
II. in illness, usually negative
a. demands new coping skills at a time when homeostasis is challenged
III. on family, effects a person's family members or significant others
H. Factors affecting stress and adaptation
I. the source of the stress
a. developmental crisis that occurs as a person progresses through the normal stages of growth and development from birth to old age
b. situational stress that occurs at anytime
II. the type of stressor
a. physiologic, e.g.:
i. chemical agents, e.g.:
a. drugs, poisons, toxins
ii. physical agents, e.g.:
a. heat, cold, radiation, electric shock, trauma
iii. infectious agents, e.g.:
a. viruses, bacteria, fungi
iv. faulty immune system
v. genetic disorders
vi. nutrition imbalance
vii. hypoxia
b. psychosocial, e.g.:
i. accidents and their survivors
ii. experiences of family members and friends
iii. horrors of history
iv. fear of aggression or mutilation from others
v. events of history that are brought into our homes through television
vi. developmental life crises
vii. rapid changes in our world and the way we live
III. the nature of the stressor
IV. the perception of the stressor
V. the number of stressors
VI. the duration of exposure to the stressor
VII. the previous experience with the stressor
VIII. age
IX. support people
X. personality type
a. type A personality
i. hurried speech
ii. constant, rapid movement/eating
iii. inability to delegate authority
iv. preoccupation with deadlines
v. chronic sense of time urgency
 vi. impatience with the rate at which things occur and the way others operate
vii. career orientation, lack of hobbies
viii. little satisfaction with accomplishments
ix. restlessness and feelings of guilt during periods of relaxation
x. tendency to think and perform several things at once
xi. obsession with money and numbers
xii. tendency to dominate conversation, determine topics
xiii. preoccupation with own thoughts when others are talking
xiv. over concern with getting things worth having, less concern with becoming things worth being
xv. facade of self-assurance and confidence to hide insecurity about status
xvi. tendency to measure self-worth by number of achievements
xvii. nervous gestures: tics:, clenched fist or jaw, tooth grinding
b. type B personality
i. freedom from all type A traits
ii. no sense of time urgency
iii. ability to relax without guilt
iv. ability to work without agitation
v. belief that the purpose of play is fun and relaxation, not to demonstrate superiority
vi. tendency to discuss achievements and accomplishments only when situation demands it
c. research on type A and B personality types and heart disease
i. conflicting results
a. some studies suggest that people with type A personalities experience more cardiovascular disease than people with type B personalities
b. other studies suggest that there is no relationship between a person’s personality type and incidence of cardiovascular disease
ii. research led to the identification of the type C personality type
d. type C personality
i. "coping personality"
ii. share some of the characteristics of type A and B personalities
iii. proactive versus reactive
iv. demonstrate three particular personality characteristics as coping strategies:
a. challenge
i. view life change as an opportunity to grow
b. commitment
i. strong sense of inner purpose and confidence
c. control
i. recognition that people have control over their own lives and attitudes
I. Nurse as role model
i. follow the recommendation of the food guide pyramid for proper nutrition
ii. participate in regular exercise
iii. evaluate own use of drugs, nicotine, alcohol, and food as coping mechanisms
iv. practice relaxation techniques regularly
v. set aside time for activities that are fun
vi. emphasize his/her own strengths and abilities
vii. learn to say no without feeling guilty or offering an excuse
J. The nursing process and stress and adaptation
I. assessing
a. nursing history
i. stress and coping pattern history
a. rating of stress the patient is experiencing in potential stressful areas on a scale of 1 - 10
b. determining how long the patient has been dealing with the above stressors
c. determining how the patient usually handles stressful situations
d. determining how the patient's usual coping strategy works
b. physical assessment
i. physiologic manifestations of stress
ii. psychologic manifestations of stress
iii. cognitive manifestations of stress
II. diagnosing
a. nursing diagnoses relating specifically to clients experiencing stress:
i. anxiety
ii. ineffective individual coping
b. alternative nursing diagnoses in which responses to stressful situations may be an etiology:
i. fear
ii. defensive coping
iii. family coping: potential for growth
iv. ineffective family coping: compromised
v. ineffective family coping: disabling
vi. decisional conflict
III. planning
a. develop a plan with the following:
i. patient, depending on his/her:
a. state of health
b. level of anxiety
c. support resources
d. coping mechanisms
e. sociocultural and religious affiliation
ii. patient's significant support persons
iii. clinical nurse specialist
iv. experienced nurse
 b. overall goals
i. decrease anxiety and fear
ii. increase the ability to manage or cope with stressful event or set of circumstances
c. suggested outcome criteria
i. verbalizes a reduced level of anxiety
ii. develops realistic goals
iii. expresses feelings in a positive way
iv. verbalizes feelings to another
v. develops effective coping mechanisms in managing stress
vi. identifies alternative strategies for coping with stress
vii. selects appropriate strategies
viii. receives adequate support for coping
ix. expresses ability to cope with multiple life changes
IV. implementing
a. teach healthy activities of daily living
i. exercise
ii. rest and sleep
iii. nutrition
b. encourage use of support systems
c. encourage use of stress management techniques, e.g.:
i. massage
ii. progressive relaxation
a. a process in which a person experiences progressive contraction and relaxation of muscle throughout the body
iii. meditation
a. a process in which a person gains control over his/her attention, clearing the mind and blocking out the stressor(s) responsible for the
increased tension
iv. anticipatory guidance
a. a process in which a person focuses on psychologically preparing him/herself for an unfamiliar or painful event
v. guided imagery
a. a process in which self-chosen or instructor-suggested positive images are used to achieve specific health-related goals in a person
b. imagery can include one or more of the following senses:
i. visual; e.g., a beach
ii. auditory; e.g., ocean waves
iii. olfactory; e.g., gingerbread
iv. gustatory; e.g., a juicy hamburger
v. tactile-proprioceptive; e.g., stroking a soft, furry cat
c. imagery can focus the mind in two ways:
i. away from the body to remove self from the stressful situation
ii. to the body to improve the stressful situation
a. e.g., to improve the effects of chemotherapy
vi. biofeedback
a. a process in which a person learns to reliably influence physiologic responses of two kinds:
i. responses which are not ordinarily under voluntary control
ii. responses that ordinarily are easily regulated but for which regulation has broken down as a result of trauma or disease
vii. therapeutic touch (TT)
a. a process by which energy is transmitted or transferred from one person to another with the intent of potentiating the healing process of one
who is ill or injured
V. Evaluating
a. nurse collects data in accordance to outcome criteria established earlier
b. evaluation activities may include the following:
i. observations of the patient for absence or reduction of fear and/or anxiety
ii. measuring the patient's blood pressure and heart rate
iii. listening to the patient's reports of increased physiologic or psychologic comfort, decreased emotional responsiveness, or verbalization of fears and
concerns
iv. asking the patient about personal strengths or coping resources identified
v. questioning the patient about effective and ineffective coping responses and consequences
vi. discussing with the patient situations in which he/she has used specific adaptive coping methods and his/her perception of their effectiveness
vii. asking the patient about specific resources used, including support persons

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