1.

Introduction
Stress is a universal experience. Stress is a part of living alive and is a person
environment interaction. Right from the time of birth till the last breath drawn, an individual is
invariably exposed to various stressful situations. The word stress was originally used by Selye
in 1956 to describe the pressure experienced by a person in response to life demands. These
demands are referred to as stressors. Stress can be positive or negative.
The term stress has been derived from the Latin word “Stringere” which means “To Draw
Tight”. This term was used to refer the hardship, strain, adversity or affliction.
2. Definition
2.1 Stress:
Stress is defined as any process, either in the external environment or within an
individual that demands a response from the individual".
- Engel, 1962
Stress is a condition in which human system responds to changes in its normal balanced
state
- Taylor Lemone, 1989
Stress is a physical or emotional state always present in the person as a result of living. It
is intensified in a non- specific response to an internal and external environmental change or
threat.
- Ruth, Murrey, Bectmen
Stress as the non- specific that is common result of any demand placed upon the body.
- Hans Selye 1956
2.2 Stressor
A stimulus that causes stress is known as stressors. A biological, psychological, social or
chemical factors that causes physical or emotional tension is the stimuli proceeding or
precipitating a change. It may be internal or external. The triggers that promotes the stressful
reaction is called a stressors.
3. Basic Concepts of Stress:
 It is the physical and emotional state always present in the person as a result of living
and it is intensified with internal and external environment threat.
 Stress reaction are purposeful and protective.
  On positive side, helps to maintain equilibrium, to increase the motivation, learning.
Creativity, productivity and satisfaction.
 On negative side, stress is noxious, unpleasant or damaging the stress.
 Complete freedom from stress is death.
4. Types
4.1 Stress:
1. Distress: Stress due to an excess of adaptive demands placed upon us. The demands are
so great that they lead to bodily and mental damage.
Eg. Unexpected death of a loved person.
Distress is unpleasant, objectionable.
2. Eustress: The optimal amount of stress, which helps to promote health and growth.
Eg. Praise from a teacher for a well-written assignment.
Eustress is pleasant and desirable.
3. Neutral stress: The subject neither feels good nor bad about the stress.
Equilibrium or homeostasis is maintained
4.2 Stressors:
External Stressors - Physical Environment, Social Interaction, Organizational, Major Life
Events, Daily Hassles.
i. Physical Environment: Noise, Bright Lights, Heat, Confined Spaces.
ii. Social Interaction: Rudeness, Business, and Aggressiveness of others,
Bullying
iii. Organizational: Rules, Regulations, and Deadlines
iv. Major Life Events: Birth, Death, Lost Job, Promotion, Change of Marital
Status.
v. Daily Hassles: Commuting, misplacement of keys/important papers,
Mechanical Breakdowns
Internal Stressors - Lifestyle Choices, Negative Self-talk, Mind Traps, Personality Traits

i. Lifestyle Choices: Caffeine, Lack of Sleep, Overloaded Schedules

ii. Negative Self-Talk: Pessimistic Thinking, Unnecessary self-criticism, Over
analysing facts
 iii. Mind Traps: Unrealistic Expectations, Taking Things Personally, All or
Nothing Thinking, Exaggeration, Rigid Thinking
iv. Personality Traits: Perfectionists, Workaholics

Acute stressors:
According to Thomas Holmes and, Richard Rahe (1967) change of any kind that required
some adjustment in behaviour or life style could cause stress. Moreover. They believed that
exposure to numerous stressful events with in short period of time could have a direct,
detrimental effect on health.
Chronic stressors:
According to McLean & Link (1994): Chronic stressors are of 5 types.
1. Persistent life difficulties: Long duration, related to life events. Ex.: son leaving
home, disabled family member
2. Role strain: Working, relationship, parenting, and multiple roles.
3. Social groups discrimination: Race, class, gender, disability.
4. Community: Wide strains at ecological level. Ex; living in high-crime area.
5. Daily hassle: Waiting too long in a queue, traffic jam etc All positive/negative
situations that require adjustment can be stressful.
Positive situations: Include Marriage, Pregnancy, Child birth, etc.
Negative situations: Includes Frustrations, Conflicts, and Pressures.
5. Predisposing Factors:
The risk factors that influence both the type and amount of resources the person can handle
stress and are biological, psychological, and socio cultural in nature.
 Biological Factors: Include genetic background, nutritional status, biological
sensitivities, general health, and exposure to toxins
 Psychological Factors: Include intelligence; verbal skills, morale, personality, past
experiences, self-concept, motivation, psychological defense and locus of control or a
sense of control over ones own fate.
 Socio cultural Factors: Include age, gender, education, income, occupation, social
position, cultural background, religious upbringing and beliefs, political affiliation,
socialization experiences and level of integration or relatedness.
6. Precipitating Factors:
 The stimuli that are challenging, threatening or demanding to the individual. They require
excess energy and produce a state of tension and stress. They are biological, psychological or
socio cultural in nature, and they may originate either in the person's internal or external
environment.
7. Sources of Stress:
There are many sources of stress, these are broadly classified as:
1. Internal Stressors: They originate within a person. E.g.: cancer, feeling of depression.
2. External Stressors: It originates outside the individual. E.g.: moving to another city,
death in a family.
3. Developmental Stressors: It occurs at predictable times throughout an individual’s life.
E.g.: child- beginning of school.
4. Situational Stressors: They are unpredictable and occur at any time during life. It may
be positive or negative. E.g.: death of the family members, marriage, divorce.
8. Psychological Adaptation to Stress:
Anxiety and grief have been described as two major primary psychological response
patterns to stress.
8.1 Anxiety
 Anxiety derives from the Greek root word meaning “to press right".
 Anxious is related to the Latin word “Angere”, which means “to strangle" and “to
distress”.
 Anxiety involves one's body, perceptions of self, and relationships with others.
Characteristics of anxiety:
i. Anxiety is an emotion and subjective individual experience.
ii. It is provoked by the unknown and precedes all new experiences such as entering
school, starting a new job, or giving birth to a child.
iii. Anxiety is communicated interpersonally. If a nurse is talking with a patient who is
anxious, within a short time the nurse also will experience feelings of anxiety.
iv. The crux of anxiety self-preservation. Anxiety occurs as a result of a threat to a
person's selfhood, self-esteem, or identity.
v. Culture is related to anxiety because culture can influence the values one considers
most important. Underlying every fear is the anxiety of losing one’s own being.
Levels of anxiety:
Peplau (1963) identified four levels of anxiety and described their effects.
1. Mild anxiety is associated with the tension of day to day living:
During this stage the person is alert and the perceptual held is increased. The
person sees, hears, and grasps more than before.
2. Moderate anxiety in which the person focuses only on immediate concerns, involves
the narrowing of the perceptual field:
The person sees, hears and grasps less. The person blocks selected areas but can
attend to more if directed to do so.
3. Severe anxiety is marked by a significant reduction in the perceptual field:
The person tends to focus on a specific detail and not think about anything else.
4. Panic is associated with awe, dread, and terror, and the person feeling it is unable to
do things even with direction:
Panic involves the disorganization of the personality and can be life threatening.
Increased motor activity, decreased ability to relate to others, distorted perceptions and
loss of rational thoughts.
Behavioural Adaptation Responses to anxiety
A variety of behavioural adaptation responses occur at each level of anxiety
Level of Anxiety Behavioural Adaption Behaviour
Mild Anxiety Following types of coping mechanisms
(Menninger (1963)
 Sleeping
 Eating
 Physical exercise
 Smoking
 Crying
 Pacing
 Drinking
 Laughing
 Nail-biting
Moderate Anxiety Sigmund Freud (1961) identified defense
mechanisms are
 Compensation
 Denial
 Displacement
 Identification
 Intellectualization
 Introjection
 Isolation
 Projection
Severe Anxiety DSM IV TR describes as Neurosis, and there
are
 Anxiety disorders
 Somatoform disorders
 Dissociative disorders
Panic Anxiety APA 2000, describes as Psychosis loss of ego
boundaries.
 Presence of delusions
 Hallucinations
 Impairment of interpersonal
functioning and relationship

Adjustment mechanism of defense mechanisms:

Adjustment is the process by which individual maintains a balance between his needs and
circumstances that influences the satisfaction of needs.
 Defense mechanisms are adjustment mechanisms.
 Defense mechanisms refers to the unconscious process that defends a person against
anxiety.
 When the primitive id drive are in serious conflict with the controls imposed by the ego
or the superego.
 The individual suffers from tension and anxiety.
  This uncomfortable situation is reflected in the individual’s behaviour. The human being
is usually able to relive the conflict by utilizing certain forms of adaption. Which are
called ego defense mechanisms, adjustment mechanisms or mental dynamisms.
Classification:
Defense mechanism can be divided into successful and unsuccessful mechanisms
Successful Unsuccessful
 Repression  Suppression
 Rationalization  Reaction formation
 Intellectualization  Displacement
 Compensation  Denial
 Substitution  Isolation
 Sublimation  Projection
 Regression
 Conversion
 Fixation
 Fantasy

8.2 Grief
Grief is a form of sorrow that follows the perception or anticipation of a loss of one or
more of valued or significant objects. These responses often include helplessness, loneliness,
hopelessness, sadness, guilt and anger. Grief involves thoughts, feelings and behaviours.
Purpose:
o To enable adjustment to a new way of life, which takes time.
o The grieving person will try a variety of strategies in order to cope.
Worden (1991) describes the following tasks of grief that facilitate healthy adjustment to loss.
 Accepting the reality of loss
 Experiencing the pain of grief
 Adjusting to an environment.
 Re- investing emotional energy
Theories of the grieving process:
The concept and theories of grief are only tools that can be used to anticipate the emotional
needs of individuals and families.
1. Engel’s Theory:
Engel (1964) proposed that the grieving process has 3 phases that can be applied to grieving and
dying people.
Phases:
1. Shock and disbelief
2. Developing awareness
3. Reorganization and restitution
1. Shock and disbelief:
During the first phase, the individuals denies the reality of the loss and may
withdraw, sit motionless or wander aimlessly. Physical reactions may include fainting,
nausea, diarrhoea, rapid heart rate, restlessness, insomnia and fatigue.
2. Developing awareness:
In the second phase, the individual begins to feel the loss acutely and may
experience desperation. Suddenly anger, guilt. Frustration, depression and emptiness
occur
3. Reorganization and restitution:
During the third phase, inevitability of the loss is acknowledged. The "loss is clear
to the individual who begins to reorganize life. New self-awareness is also developed.
2. Kubler-Ross Stages of Dying:
The frame work provided by Kubler Ross (1969) is behaviour oriented and includes 5
stages.
1. Denial:
The individual acts as though nothing has happened and may refuse to believe
that a loss has occurred.
2. Anger:
The individual resists the loss and may feel frustrated and angry or may
experience a sense of helplessness and loss of control.
 3. Bargaining:
Postponement of the reality of the loss. The individual may attempt to make a
deal in a subtle or overt way to prevent the loss. The person frequently seeks the opinions
of others during this stage.
4. Depression:
Occurs when the loss is realized and the full impact of its significance is
apparent. This stage may be accompanied by overwhelming loneliness and withdrawal.
5. Acceptance:
Physiological reactions cease, and social interactions resume
3. Martocchio’s Phases :
Martocchio (1985) describes 5 phases of grief that have overlapping boundaries and no
expected order. Intense reactions of grief usually subside within 6 to 12 months and active
mourning may continue for 3 to 5 years.
Phases are;
1) Shock & disbelief,
2) Learning & protest,
3) Anguish, disorganization & despair,
4) Identification in bereavement,
5) Reorganization & restitution.
Complicated Grief:
Some individuals find it more difficult to give than do others. A normal, healthy
movement through their bereavement does not occur.
So indicators of unresolved or complicated grief includes:
 Over activity without a sense of loss.
 Alteration in relationships with friends and family.
 Hostilities against specific people.
 Agitated depression with tension, agitation, insomnia, feelings of worthlessness, extreme
guilt and even suicidal tendencies.
 Inability to discuss the loss without crying.
 False euphoria.
Nursing Care in Grief:
1. Promoting Comfort: Personal hygiene basic needs. pain control sleep, appetite,
mobility & psychological function
2. Maintaining Independence
3. Preventing loneliness and isolation
4. Promoting spiritual comfort
5. Supporting the grieving family - supportive relationship with family.
Grief Resolution:
Although grief resolution of grief may require months or years, most individuals are
under a nurse’s care for only a short period of time. The nurse may become frustrates when, just
as the person or family begins to express grief, the person leaves the health care unit or dies.

9. Concept to stress
 Stress as a Biological Response
 Stress as an Environmental Event
 Stress as a Transaction between the Individual and the Environment
9.1 Stress as a Biological Response:
Hans Selye has revised the definition of stress, calling it "the state manifested by a
specific syndrome which consists of all the non-specifically induced changes within a biologic
system”. This syndrome of symptoms has come to be known as the “Fight or Flight Syndrome”.
Biology the Stress Response:
 Normally, when a person is in a serene (Not agitated; without losing self-possession),
unstimulated state, the “firing" of neurons in the locus ceruleus is minimal.
 A novel stimulus (which could include a perception of danger or an environmental
stressor such as elevated sound levels or over illumination).
 Once perceived, is relayed from the sensory cortex of the brain through the hypothalamus
to the brain stem.
 That route of signalling increases the rate of noradrenergic activity in the locus ceruleus.
 The person becomes alert and attentive to the environment.
 Similarly, an abundance of catecholamine’s at neuroreceptor sites facilitates reliance on
spontaneous or intuitive behaviours often related to combat or escape.
  If a stimulus is perceived as a threat, a more intense and prolonged discharge of the locus
Ceruleus activates the sympathetic division of the autonomic nervous system.
 This activation is associated with specific physiological actions in the system, both
directly and indirectly through the release of epinephrine (adrenaline) and to a lesser
extent norepinephrine from the medulla of the adrenal glands.
 The release is triggered by acetylcholine released from preganglionic sympathetic nerves.
 The other major factor in the acute stress response is the hypothalamic-pituitary-adrenal
axis.
Physiology of the Stress Response:
These catecholamine hormones facilitate immediate physical reactions associated with
a preparation for violent muscular action. These include the following:
 Acceleration of heart and lung action
 Inhibition of stomach and intestinal action
 General effect on the sphincters of the body
 Constriction of blood vessels in many parts of the body
 Liberation of nutrients for muscular action
 Dilation of blood vessels for muscles
 Inhibition of Lacrimal gland (responsible for tear production) and salivation
 Dilation of pupil
 Relaxation of bladder
 Inhibition of erection
 Auditory Exclusion (loss of hearing)
 Tunnel Vision (loss of peripheral vision)
Stress Adaptation Model: (General Adaptation Syndrome (GAS) :
Hans Selye developed a framework to describe how people respond to stress. He said
that the entire body responds to stress in an attempt to maintain or adapt to the circumstances of
the event creating stress. He also recognized the each person has a limited amount of energy to
use in dealing with stress. When stress is continuous, and the adaptive capacity of the body may
be exceeded the disease may result.
 Stage 1 Stage 2 Stage 3

Alarm Resistance Exhaustion

Stressor
Body prepares for Attempts are made to Body can no longer
action, increased cope with stressor. resist stressor;
arousal. psychological
breakdown begins

Three Stage Model of General Adaptation Syndrome

Physiological response occur in three stages:
1. Alarm reaction:
Arousal of CNS. Catecholamine is excreted, heart rate increases, the strength of heart
contraction is increases, the blood glucose level increases this is known as flight or fight
response. Cortisol is released to an increase glucose levels from the stored glucose. If the
stressor remains, the body cannot stay in stage 1 experiencing pathologic changes. Changes
occurs in thymus, spleen and lymph nodes, and gastric ulcer develop. The thymus, spleen and
lymph nodes atrophy in response to the cortisol.
2. Stage of resistance:
Maximum adaptation occurs in this stage. This bodily signs characteristic of the alarm
reaction disappear. Resistance increases to levels above normal; if the stressor is halted in this
state. The body should be able to return to a normal state.

3. Stage of exhaustion:
Occurs when the stressor continues and the body cannot continue to produce hormones as
in stage 1 or when damage has occurred to other organs. In this stage, the body has run out of its
reserve of body energy and immunity. Mental, physical and emotional resources suffer heavily.
The body experiences “adrenal exhaustion". The blood sugar levels decrease as the adrenals
become depleted, leading to decreased stress tolerance, progressive mental and physical
exhaustion, illness and collapse.
9.2 Stress as an Environmental Event:
 A second concept defines stress the “thing" or "event" that triggers the adoptive
physiological and psychological responses in an individual.
 The event creates changes in the individuals, requires significant adjustment in lifecycle,
and taxes available personal resources
 The changes can be either positive or negative, such as being fired the job.
  The emphasis here is on changes from the existing state of the individual’s life pattern.
9.3 Stress as a Transaction between the Individual and the Environment:
This definition of stress emphasizes the relationship between the individual and the
environment. Personal characteristics and the nature of environmental events are considered.

Precipitating Events:
Lazarus and Folkman (1984) define stress as a relationship between the person and the
environment that is appraised by the person as taxing or exceeding his or her resources and
endangering his or her well- beings. It is the stimulus arising from the internal or external
environment and is perceived by the individual in a specific manner.
The cognitive response consists of primary appraisal and secondary appraisal.
Individuals Perception of the event:
 Primary appraisal:
  Lazarus and Folkman (1984) identify three types of primary appraisal; irrelevant, benign-
positive, and stressful.
 An event is judged irrelevant when the Outcome holds no significance of the individual.
 A benign-positive outcome is one that is perceived as a producing pleasure for the
individual.
 Stress appraisals include harm or loss, threat, and challenge. Harm/loss appraisal refers to
the damage or loss already experienced by the individual.
 Appraisals of a threatening nature are perceived as anticipated harms or losses.
 When an event is appraised as challenging, the individual focuses on the potential for
gain or growth, rather than on risk associated with the event.
 Challenges produces stress even through the emotions associated with it are viewed as a
positive, and coping mechanism must be called on to face encounter.
 When stress is produced in response to harm/loss, threat, or challenge, a secondary
appraisal is made by the individual.
 Secondary appraisal
This secondary appraisal is an assessment of skills, resources, or knowledge that the person
possesses to deal with the situation.
The individual evaluates by considering the following.
 What coping strategies are available to me?
 Will the option I choose be effective in the situation?
 Do I have the ability to use that strategy in an effective manner?
The interaction between the primary appraisal of the event that has occurred and the
secondary appraisal of available coping strategies determine the quality of the individual's
adaptations response to stress.
Predisposing Factors:
A variety of elements influences how an individual perceives and responds to stressful
events. These predisposing actors strongly influence whether the response is adaptive or
maladaptive.
Types of predisposing factors includes;
 Genetic influences: are though circumstances of an individual’s life that are acquired
through hereditary. E.g. includes family history of physical and psychological conditions
and temperament.
 Past experiences: that can influence the individual’s adaptation response.
It include the previous exposure to the stressor, learned coping response, and degree of
adaptation to the stressor.
 Existing conditions: incorporate the vulnerabilities that influence the adequacy of the
individual’s physical, psychological, and social resources for dealing adaptive demands.
E.g.; include current health status, motivation developmental maturity, financial and
educational resources, age, and existing coping strategies, and a support system of caring
others.
10. Effect of Stress
10.1 Short Term Effects of Stress
1. Physical Changes:

Physical symptoms are usually triggered by arousal of autonomic nervous system and
includes increase in heart rate and blood pressure

2. Psychological Changes:
 Lack of concentration
 Muscle ache,
 Headache,
 Insomnia.
 Loss of memory,
 Inability to make decision,
 Forgetfulness,
 Confusion
 Faster breathing
3. Emotional Changes:
 Anxiety
 Nervousness
  Frustration
 Anger
 Irritability
4. Behavioural Symptoms:
 Impact of stress also affects the behaviour and present as pacing
 Fidgety movement
 Nail biting
 Smoking
 Drinking
 Throwing things

10.2 Long Term Effects of Stress:

1. Behavioural Changes:

The affected person becomes victim of serious behavioural disorder like,

 Fearfulness
 Obesity
 Alcoholism
 Drugs addiction
2. Physiological Changes:

The affected person become victim of serious Physiological disorder like,

 Hypertension
 Heart diseases
 Skin diseases
 Cancer
3. Emotional Changes:
 Chronic anxiety
 Depression.

The affected person become victim of serious Emotional disorder, like

  Fear and phobia
 Personality changes
 Mental disorder
4. Cognitive Changes:

The affected person become victim of serious Cognitive disorder, like

 Memory problem
 Obsessive thoughts
 Sleep disorder

11. Stress Management:

Stress management involves the use of coping strategies in response to stressful
situations. Coping strategies are adoptive when they protect the individual from the harm
strengthen the individual’s ability to meet challenging situations. Adoptive responses help restore
to the body and impedes the development of diseases of adaptation.
11.1 Models of Stress Management
11.1.1 Transactional Model:
 Richard Lazarus and Susan Folkman suggested in 1984 that stress can be thought of as
resulting from an “imbalance between demands and resources" or as occurring when
“pressure exceeds one's perceived ability to cope”.
 Stress management was developed and premised on the idea that stress is not a direct
response to a stressor but rather one's resources and ability to cope mediate the stress
response.
 In order to develop an effective stress management programme it is first necessary to
identify the factors that are central to a person controlling his/her stress.
 To identify the intervention methods which effectively target these factors.
 His interpretation of stress focuses on the transaction between people and their
external environment (known as the Transactional Model). The model conceptualizes
stress as a result of how a stressor is appraised and how a person appraised his/her
resources to cope with the stressor.
  The model breaks the stressor-stress link by proposing that if stressors are perceived as
positive or challenging rather than a threat. If the stressed person is confident that
he/she possesses adequate rather than deficient coping strategies.
 The model proposes the stress can be reduced by helping stressed people change their
perceptions of stressor, help them to cope and improving their confidence in their
ability to do so.
11.1.2 Health Realization or Innate Health Model:
 The health realization model focuses on the nature of thought, stating that it is ultimately
a person's thought processes that determine the response to potentially stressful external
circumstances.
 In this model, stress results from appraising oneself and one's circumstances through a
mental filter of insecurity and negativity, whereas a feeling of well-being results from
approaching the world with a “quiet mind," “inner wisdom." And “common sense”.
 This model proposes that helping stressed individuals understand the nature of thought-
especially providing them with the ability to recognize when they are in the grip of
insecure thinking. Disengage from it, and access natural positive feelings will reduce
their stress.
11.1.3 Stimulus – Based Model (Holmes and Rahes Model - 1960)
According to this model, stress is defined as a stimulus, a life events, or a set of
circumstances that arouses physiologic and psychological reactions that may increase the
individual’s vulnerability to illness.
Holmes and Rahe developed the social Readjustments Rating Scale (SRRS) consisting of 43
life changes or events which are both positive and negative in nature and considered stressful.
The SRRS provides a general impression of the stressors in a persons life. The more stressors a
person experiences in a short period (1 – 2 year) the more likely that physical illness, mental
disorders or other stress responses will follow.
This theory also explains that many people with high scores on the SRRS do not
subsequently experience serious problems. In addition, low scores do not guarantee a life free of
dangers of stress. One reason is that mediating factors, such as how the individual perceives and
copes with each stressor, plays an important roles in determining the impact of stressors on each
individual.
11.2 Adaptive Coping Strategies:
 Awareness:
o The initial step in managing stress is awareness to become aware of the factors
that creates stress and the feelings associated with a stressful response. Stress can
be controlled only when one recognizes that it is being experienced. As one
become aware of stressors, he or she can omit. avoid, or accept them.
 Relaxation:
o Individuals experience relaxation in different ways, Some individuals relax by
engaging in large motor activities, such as sports, jogging, and physical exercise;
Still others use techniques such as breathing exercises and progressive relaxation
to relive stress.
 Meditation:
o Practiced for 20 minutes once or two daily, meditation has been show to produce
a lasting reduction in blood pressure and other stress related symptoms,
Meditation involves assuming a comfortable position, closing the eyes, casting off
all other thoughts, and concentrating on a single word, sound, or phrase that has
positive meaning to the individual.
o Interpersonal communication with a caring others:
o As previously mentioned, the strength of one’s available support systems in an
existing condition that significantly influences the adaptiveness of coping with
stress. Sometimes just “talking the problem out" with an individual who is
empathetic is sufficient to interrupt escalation of the stress response. Writing
about ones feelings in a journal or dairy can also be therapeutic.

 Problem solving:
o An extremely adaptive coping strategy is to view the situation objectively. After
an objective assessment of the situation can be instituted as follows:
o Assess the facts of the situation.
o Formulate goal for resolution of the stressful situation.
o Study the alternatives for dealing with the situation.
o Determine the risk and benefits of each alternative
 o Select an alternative.
o Implement the alternative selected.
o Evaluate the outcome of the alternative selected, if the first choice is ineffective,
select and implement second option.
 Pets:
o Recently psychological studies have begin to uncover evidence that those who
care the pets, especially dogs and cats, are better able to cope with the stressor of
life.
o The physical act of stroking or petting a dog or cat can be therapeutic.
o It gives animal an intuitive sense of being cared for at the same time gives the
individual the calming feeling of warmth, affection and interdependence with a
reliable trusting being.
 Music:
It is true that music can ‘soothe savage beast’ Creating and listening to music
stimulate motivation, enjoyment and relaxation. Music can reduce depression and bring
about measurable changes in mood and general activity.
 Manage Time:
One of the greatest sources of stress is poor management of time. Most importantly,
do not overwork yourself, schedule time for both work and recreation.
 Monitor Physical Comfort:
Wear comfortable clothing. If the chair is uncomfortable, change it. Don't wait until
the discomfort turns into a real problem.
 Take Care of Body:
Health eating and adequate sleep fuels the mind as well as the body.
 Laugh:
Maintain your sense of humour, including the ability to laugh at yourself.
 Know Limits:
There many circumstances in life beyond your control, consider the fact that we
live in a world. Know your limits, if problem is beyond on control and cannot be changed
at the moment, don’t fight the situation. Learn to accept what is, for now, until such time
when it can change things.
  Think Positively:
Refocus negative to be positive. Make an effort to stop negative thoughts.
 Compromise:
Consider co-operation or compromise rather than confrontation.
 Have a Good Cry:
A cry periods of stress can be bring relief to your anxiety.
 Avoid Self- Medication:
Alcohol and other drugs remove the conditions that cause stress.
11.3 Coping Mechanism
Coping refers to the things peoples to deal with stress and distress. Coping style are the
behaviours that People tends to use more often across situation.
It is divided into 3 categories;
 Problem Focused Coping:
When action is directed at dealing with the stressor. Students as prepare for exam. Instead
of getting frustrated and panicking, setting a time limit for each portion and started preparing for
the examinations.
 Emotion Focusing Coping:
When action is directed at dealing with the distress. E.g. on your first in your ward, one
of the ward supervisors scolds you for an error. Totally upset. You go to the room cry.
 Escape Avoidance:
Coping when the person tries to avoid the stressor by escaping from the situation or
denial. E.g. a student not prepared well for exam. He misses the exam on a pretext of being ill.
11.4 Techniques of Stress Management:
There are several ways of coping with stress. Some techniques of time management may
help a person to control stress.
1. Autogenic Training:
It is a relaxation technique developed by the German psychiatrist Johannes Schultz and
first published in 1932. The technique involves the daily practice of sessions that last around 15
minutes, usually in the morning, at lunch time, and in the evening .During each session, the
practitioner will repeat a set of Visualisations that induce a state of relaxation on. Each session
can be practiced in a position chosen amongst a set of recommended postures (eg. lying down
meditation etc.). It can be used to alleviate many stress induced psychosomatic disorders.
2. Cognitive Therapy:
Seeks to help the client overcome difficulties by identifying and changing dysfunctional
thinking, behaviour, and emotional responses. This Involves helping clients develop skills
modifying beliefs, identifying distorted thinking, relating to others in different ways, and
changing behaviours. Treatment is based on collaboration between client and therapist and on
testing beliefs.
3. Conflict Resolution:
It is a range of processes aimed at alleviating or eliminating sources of conflict. The term
conflict resolution is sometimes used interchangeably with the term dispute resolution or
alternative dispute resolution. Processes of conflict resolution generally include negotiation,
mediation and diplomacy. The processes of arbitration, litigation, and, formal complaint
processes such as ombudsman processes, are usually described with the term dispute resolution,
although some refer to them as conflict resolution. Processes of mediation and arbitration are
often referred to as alternative dispute resolution.
4. Physical Exercise:
 It is any bodily activity that enhances or maintains physical fitness and overall
health. It is performed for many different reasons.
 These include: strengthening muscles and the cardiovascular system, honing
athletic skills, and weight loss or maintenance.
 Frequent and regular physical exercise boosts the immune system, and helps
prevent diseases of affluence such as heart disease, cardiovascular disease, Type 2
diabetes and obesity.
5. Hobbies:
Hobbies are practiced for interest and enjoyment. Rather than financial reward. Examples
include collecting, creative and artistic pursuits, making, tinkering. Sports and adult education.
Engaging in a hobby can lead to acquiring substantial skill, knowledge and experience. However,
personal fulfilment is the aim.
 6. Meditation:
It is a mental discipline by which one attempts to get beyond the conditioned. ‘Thinking’
mind into a deeper state of relaxation or awareness. Meditation often involves turning attention
to a single point of reference. It is recognized as a component of almost all religions and has
been practiced for over 5000 years.
7. Diaphragmatic Breathing/Abdominal Breathing:
It is the act of breathing deep into your lungs by flexing your diaphragm rather than
breathing shallowly by flexing your rib cage. Symptoms of Diaphragmatic Spasms include the
pain in abdominal area as well as dizziness caused by taking air into upper body instead of
giving the lower body the air it needs to allow you to run or do another physical activity.
8. Creativity:
It is a mental and social process involving the generation of new ideas or concepts. or
new associations of the creative mind between existing ideas or concepts. An alternative
conception of creativeness is that it is simply the act of making something new.
9. Time management:
Refers to a range of skill, tools and techniques utilized to accomplish specific tasks:
projects and goals. This set encompasses a wide scope of activities, and these include planning,
setting goals, delegation, analysis of time spent, monitoring, organizing, scheduling, and
prioritizing. Initially time management referred to just business or work activities, but eventually
the term broadened to include personal activities also. A time management system is a designed
combination of processes, tools and techniques
10. Relaxation technique:
It is any method, process, procedure, or activity that helps a person to relax; to attain a
state of increased calmness; or otherwise reduce levels of anxiety. Stress or tension. Relaxation
techniques are often employed as one element of a wider stress management program and can
decrease muscle tension, lower the blood pressure and slow heart and breathe rates, among other
health benefits.
11. Stress Ball
It is a malleable toy, usually not more than 7cm in diameter. It is squeezed in the hand
and manipulated by the fingers, ostensibly to either help relieve stress and muscle tension or to
exercise the muscles of the hand. There are many types of stress balls. Many are a closed-cell
polyurethane foam rubber. This type of stress ball is made by injecting the liquid components of
the foam into a mould. The resulting chemical reaction creates carbon dioxide bubbles as a by-
product, which in turn creates the foam
12. Naturopathic medicine
(Also known as naturopathy or natural medicine) is a complementary and alternative
medicine which emphasizes what it describes as the body's intrinsic ability to heal and maintain
itself. Naturopathy prefer to use natural remedies such as herbs and foods rather than surgery or
synthetic drugs. Naturopathic practice includes many different modalities.
13. Listening to certain types of relaxing music particularly:
New Age music is peaceful music of various styles, which is intended to create
inspiration, relaxation, and positive feelings, often used by listeners for yoga, massage,
inspiration, relaxation, meditation, and reading as a method of stress management or to create a
peaceful atmosphere in their home or other environments often associated with
environmentalism and New Age Spirituality.
Classical music is a broad term that usually refers to mainstream music produced in, or
rooted in the traditions of Western liturgical and secular music, encompassing a broad period
from roughly the 9th century to present times. The central norms of this tradition became
codified between 1550 and 1900, which is known as the common practice period
11.5 Stress Control
 ABC Strategy
 Change thinking
 Change behaviour
 Change lifestyle

I. ABC strategy

A = Awareness

What causes you stress?

How do you react?

B = Balance

There is a thin line between positive / negative stress.

How much can you cope with before it becomes negative?

C = Control

What can you do to help yourself combat the negative effects of stress?

 II. Change thinking

Reframing

 It is a technique to change the way to look at things in order to feel better about them.
 Reframing does not change the external reality, but helps to view things in a different
light and less stressfully.

Positive Thinking

 Focus on strengths, look for opportunities, and seek out the positive make a change.
 Learn from the stress are under.

III. Change Behaviour

Be Assertive

 Express feelings, opinions, and beliefs.

 Say NO when feel so.
 Be yourself don’t act for the benefit of others.
 Set own priorities.

Get Organized

 Organization will help avoid personal and professional chaos.

 Structured approaches offer security against ‘out of the blue’ problems.

Ventilation

 Develop a support network through friends or colleagues to talk with.

Humour

 Applies at home and work.

 Works as a good stress reducer.
 Relieves muscular tension.
 Improves breathing.
Diversion and Distraction

Take time out, reduce stress level, calm down, think logically and get away from things that
bother.

IV. Change Lifestyle

Diet

 Healthy eating habits, salt and caffeine (stimulant).

Quit Smoking and Alcohol

 Stop or at least your consumption to bare minimum.

Exercise

 Uses up excess energy released by the ‘Fight or Flight’ reaction, improves blood
circulation, lowers blood pressure, improves self-image.
 Increases social contacts.

Sleep

 Good stress reducer, plenty of daytime energy, wake refreshed after night’s sleep.

Leisure

 Gives you a break from stress, provides social contact and provides outlet for relief.

Relaxation

 Lowers blood pressure, promotes sleep, reduces pain and eases muscle tension.

Closing Thought

12. Role and Responsibilities of Nurse in Stress Management:

12.1 Assessment:
Assessment of the person:
 Assess for the following characteristics in the individual. Such individuals are at high risk
of developing stress related disorders
 Rigid and self-punishing and moral standards
 High and unrealistic expectations Too much dependence on others for love and affection
and approval
  Inability to master change or learn new ways of dealing with frustration. Easily prone to
extreme emotional responses of fear, anxiety and depression.
 Type personality persons
 In addition, the stressful events like birth, deaths, marriages, divorces, retirement etc. can
predispose to stress related illness.
Assessment of the Family:
 Assess the family perception of the problem, and whether it is supportive of the client's
efforts at coping.
Assessment of the Environment:
 Occupations with a high degree of stress; adverse environmental influences like too much
of lightning, temperature etc.
12.2 Interventions:
 They are directed towards relief of acute or chronic stress. A nurse can help person to
examine the situation, identify possible solutions and accept his feelings without guilt or
fear.
 People suffering from acute stress related illness often needs to change their life styles
and ways of relating to others. The initial work of nurse involves helping the client to
recognize that change is essential in relation to the change.
 Some clients show resistance to necessary changes.
 Increasing the client awareness as an actual or potential health problem exists.
 Helping him realize that the health problem can increase if personal changes do not
occur.
 Identifying all personal resources. To support the client through the process of change
and cooperation with the treatment
 When the client becomes aware of the nature of the health problems and is told of the
change need, he often experiences a feeling of anxiety, depression and anger.
 The client is encouraged to talk about the losses that has resulted from the behaviour
change.
 Family members also need accurate information about nature of the disorder, and how
they can help the client in coping with stress. The client and families also need to be
informed about various alternatives such as meditation, yoga, relaxation training etc.
 these technique have a valuable role to play in helping individuals cope with stressful life
events.
 In all this, the nurse must always bear in mind that they are only facilitators of the change
process, and the clients have rights and responsibilities in relation to change.
14. Nursing Diagnosis for Stress
 Acute response to stress, alarm state related to stressor.
 Acute response to stress resistance.
 Chronic response to stress, diminishing stage related to stressor.
 Anxiety related to interpersonal and environmental situation.

15. Theory Application

Betty Neuman’s Systems Model
Introduction
Betty Neuman developed the Neuman system modal in 1970 to “provide unity, or a focal point,
for student learning” at the school of Nursing. University of California, in Los Angeles
(Neuman, 1995).

Neuman recognized the need for educators and practitioners to have a framework to view
nursing comprehensively within various contexts.

She developed the modal strictly as a teaching aid.

Biographical Information

1924- Born near Lowell, Ohio

1947- Received RN Diploma from Peoples Hospital School of Nursing, Akron, Ohio. Moved to
California and gained experience as a hospital, staff and head nurse school nurse and industrial
Nurse and as a clinical instructor in medical-surgical, critical care and communicable disease
nursing. Attended University of California at Los Angels (UCLA) with double major in
psychology and public health.

1966 - Received Master’s degree in Mental Health, public Health Consultation form UCLA.
Recognized as pioneer in the field of nursing involvement in community mental health. Began
developing her model while lecturing in community mental health at UCLA.

1970 - She developed the Neuman Systems Model.

1972 - Her model was first published as a Model for teaching total person approach to patient
problems in Nursing Research.

1985 - Received doctorate in clinical Psychology from Pacific Western University.

1998 - Received second honorary doctorate- this one from Grand Valley State University,
Michigan.

Overview of the Neuman Systems Model

The philosophic base of the Neuman Systems Model encompasses holism, a wellness
orientation, client perception and motivation, and a dynamic systems perspective of energy and
variable interaction with the environment to mitigate possible harm from internal and external
stressors, while caregivers and clients form a partnership relationship to negotiated desired
outcome goals for optimal health retention, restoration, and maintenance. This philosophic base
pervades all aspects of the model.

- Betty Neuman

Unique Perspectives of the Neuman Systems Model

1. Each individual client or group as a client system is unique; each system is a composite of
common known factors or innate characteristics within a normal, given range of response
contained within a basic structure.
2. The client as a system is in a dynamic, constant energy exchange with the environment.
3. Many known, unknown, and universal environmental stressors exist. Each differs in its
potential for disturbing a client’s usual stability level, or normal line of defense. The particular
interrelationships of client variables—physiological, psychological, sociocultural,
developmental, and spiritual—at any point in time can affect the degree to which a client is
protected by the flexible line of defense against possible reaction to a single stressor or a
combination of stressors.
4. Each individual client–client system has evolved a normal range of response to the
environment that is referred to as a normal line of defense, or usual wellness/ stability state. It
represents change over time through coping with diverse stress encounters. The normal line of
defense can be used as a standard from which to measure health deviation.
5. When the cushioning, accordion-like effect of the flexible line of defense is no longer capable
of protecting the client– client system against an environmental stressor, the stressor breaks
through the normal line of defense. The interrelationships of variables—physiological,
psychological, sociocultural, developmental, and spiritual—determine the nature and degree of
system reaction or possible reaction to the stressor.
6. The client, whether in a state of wellness or illness, is a dynamic composite of the
interrelationships of variables— physiological, psychological, sociocultural, developmental, and
spiritual. Wellness is on a continuum of available energy to support the system in an optimal
state of system stability.
7. Implicit within each client system are internal resistance factors known as lines of resistance,
which function to stabilize and return the client to the usual wellness state (normal line of
defense) or possibly to a higher level of stability following an environmental stressor reaction.
8. Primary prevention relates to general knowledge that is applied in client assessment and
intervention in identification and reduction or mitigation of possible or actual risk factors
associated with environmental stressors to prevent possible reaction. The goal of health
promotion is included in primary prevention.
9. Secondary prevention relates to symptomatology following a reaction to stressors, appropriate
ranking of intervention priorities, and treatment to reduce their noxious effects.
10. Tertiary prevention relates to the adaptive processes taking place as reconstitution begins and
maintenance factors move the client back in a circular manner toward primary prevention.
The Conceptual Model
Neuman’s original diagram of her model is illustrated. The conceptual model was
developed to explain the client–client system as an individual person for the discipline of
nursing. Neuman chose the term “client” to show respect for collaborative relationships that exist
between the client and the caregiver in Neuman’s model, as well as the wellness perspective of
the model. The model can be applied to an individual, a group, a community, or a social issue
and is appropriate for nursing and other health disciplines. The Neuman Systems Model provides
a way of looking at the domain of nursing: humans, environment, health, and nursing.
Client-Client System
 The client-client system consists of the flexible line of defense, the normal line of defense
lines of resistance and the basic structure energy.
  Five client variables: physiological, psychological, sociocultural, developmental, and
spiritual occur and are considered simultaneously in each concentric circle that makes up
the client - client system

Flexible Line of Defense

 Neuman described the Flexible line of

defense as an accordiong like mechanism
that acts like a protective buffer system to
help prevent stressor.
 The flexible line of defense protect the
normal line of defense.
 The client has more protection from
stressors when the flexible line expands
away from the normal line of defense.
 The flexible line of defense can be
rapidly altered over a relatively short
time period.

Normal Line of Defense

 The normal line of defense represent

what the client has become over time or
the usual state of wellness.

Lines of Resistance

 Neuman identified the series of

continuous circles that surround the basic
structure as lines of resistance for the
client.
 When the normal line of defense is penetrated by stressors, a degree of reaction, or signs
and/or symptoms, will occur.
 Line of resistant are activated when following invasion of the normal line of defense by
environmental stressors.
 When the lines of resistance are ineffective, energy depletion and death occur.

Basic Structure

The basic structure or central core consists of factors that are common to the species.
Neuman offered the following examples of basic survival factors: temperature range, genetic
structure, response pattern, organ strength or weakness, ego structure, and known or
commonalities.

Five Client Variables

Neuman identified five variables that are contained in all client systems: physiological,
psychological, sociocultural, developmental, and spiritual. These variables are considered
simultaneously in each client concentric circle. They are present in varying degrees of
development and in a wide range of interactive styles and potential. Neuman offers the following
definitions for each variable;

 Physiological: Refers to bodily structure and function

 Psychological: Refers to mental processes and relationships
 Sociocultural: Refers to combined social and cultural functions
 Developmental: Refers to life-developmental processes
 Spiritual: Refers to spiritual beliefs and influence

Environment

Neuman defined environment broadly as “all internal and external factors or influences
surrounding the identified client or client system”.
Internal Environment- Interpersonal in nature. It consists of all forces or interactive influences
contained within the boundaries of the client-client system.

 Physiological Variable- degree of mobility, range of body function.

 Psychological & Sociocultural Variable- attitudes, values, expectation, behaviour
patterns, coping patterns.
 Developmental Variable- age degree of normalcy, factors related to the present
situation.
 Spiritual Variable- hope, sustaining forces.

External Environment- Inter &extra personal in nature. It consist of all forces or interactive
influences existing outside the client-client system.

Created Environment- Intra, inter, and extra personal in nature. It offers a protective coping
shield that helps the client to function. A major objective of the created environment is to
stimulate the client’s health

Health

Health is the third concept in Neuman’s model. Neuman’s believes that wellness and
illness are on opposite ends of the continuum. Health is the best possible wellness at any given
time. Wellness exists when more energy is built and stored than expended, whereas death occurs
when more energy more energy is needed than is available to support life. Health is seen as
varying levels within a normal range, rising and falling throughout the life span.

Nursing

Nurse’s major concern is to keep the client system stable by.

1. Accurately assessing the effects and possible effects of environmental stresses.

2. Assisting client adjustment required for optical wellness.

3. Nursing actions which she labels as prevention by intervention are initiated to keep the
system stable.

4. Neuman has created a Topography her prevention by intervention nursing actions.

Primary Prevention

It occur before the system reacts to a stressor. On the one hand, it strengthens the person
(primarily the flexible line of defense) to enable him to better deal with stressors, and on the
other hand manipulates the environment to reduce or weaken stressors. Primary prevention
includes health promotion and maintenance of wellness.

Secondary Prevention

It occurs after the system reacts to a stressor and is provided in terms of existing systems.
Secondary prevention focuses on preventing damage to the central core by strengthening the
internal lines of resistance and /or removing the stressor
Tertiary Prevention

It occurs after the system has been treated through secondary prevention strategies.
Tertiary prevention offers support to the client and attempts to add energy to the system or
reduce energy needed in order to facilitate reconstitution.

Clinical Application of Neuman’s Theory

 Asses the stressor and patients response to the stressor.

 Identify nursing diagnosis.
 Plan patient centred care.
 Implement interventions.
 Evaluate the patient’s response.
 Determine if the stressor is resolved
18. Journal Abstract

A Study of Causes of Stress and Stress Management among Youth

Introduction
Stress is a condition of mental pressure for particular individual facing problems from
environmental and social well-being which leads to so many diseases. Young age is the critical
period because at this time youth faces lots of changes in his/her life. They are expected to be the
elites in the society. Thus, they should enhance their stress management abilities so as to live
a healthy life after entering the society. Stress may usually cause psychological, physical, and
behavioural problems. Taking all these factors into account an effort is made to understand the
stress and emotional adjustments of today’s youth. The inference of this study may lead to better
adjustment and academic performance of the students.
Methodology
The tool employed for generating responses was questionnaire based survey of young
candidates who are students or some are working under different organization. The Information
was collected from both primary and secondary data. The questionnaire has main three parts,
first part covers the different symptoms on a seven point scale, second part covers the causes
of stress through 25 statements on five point scale and last section covers the ten coping
strategies.

Result
From the findings, the results clearly show that youth are stressed toward high level. The
symptoms identified are being eating, depression and headaches are more among students. It is
identified that among all factors, the main causes of stress among youth is relationship stress,
financial and psychological stress. They want to maintain the social network and they are
increasing the networking with the use of technology.

Conclusion

It is observed that due to the increase us of social media the young generation become
self-centred and only connect with the technology. It reduces the physical movement of the body
and spending time with relatives and friends. All these create stress which increases the case of
depression and suicide. It is necessary and suggestions to the young people that make objective
planned systematically, use technology within limit and share your emotions with your loved
ones.

16. Summary:
So far I discussed about the stress and its managements which includes Definition of stress
and stressor, Concept of stress, Types of stress and stressor, predisposing factors, Sources of
stress, Psychological adaptation to stress, Stress on biological response, Stress on environmental
event, Stress as a transaction between the individual and the environment, effects of stress, Stress
management, models of stress, adaptive coping strategies, Coping mechanism, Techniques of
stress management, Role of nurse in stress management, nursing care plan in stress.
17. Conclusion:
Here I conclude the topic that the Managing stress can help reduce the stress and make you
feel healthier. We have to remember that we cannot change the view of others but prepare
ourselves to prove our point. No one is perfect so don not underestimate yourself. Always try to
practice out for different relaxation techniques. Always think positively and keep a positive
attitude. 
18. Bibliography:

Book references:

 Mary C. Townsend. Psychiatric Mental Health Nursing: Concepts of Care in Evidence-

Based Practice. 8th Edition. New Delhi: Jaypee Brother Medical Publication. Page No.2 -
9.
 Mary Ann Boyd. Psychiatric Nursing: Contemporary Practice. 3rd Edition: Lippincott
Williams and Willins; 2005. Page Number: 772 – 783.
 D. Elakkuvana Bhaskara Raj. DERBS Mental Health [Psychiatric] Nursing. I st Edition.
Bangalore: EMMESS Medical Publication; 2014. Page No : 82 - 94.
 C.L. Subash Indra Kumar. A Textbook of Psychiatric and Mental Health Nursing. I st
Edition. Bangalore: EMMESS Medical Publication; 2014. Page No :597 - 600.
 Bimlakapoor. Textbook of Psychiatric Nursing. Volume – 2. 7 th Edition. New Delhi:
Kumar Publishing House; 2002. Page Number: 45 – 60.
  R. Sreevani. A Guide To Mental Health And Psychiatric Nursing. 4th Edition. New
Delhi: Jaypee Brothers Medical Publication; 2016. Page No. 322- 326.
 Marilyn Parker. Nursing Theories and Nursing Practice. New York. Page no. 182 – 198.

Journal references:

 Institute of Research Advances- International Journal of Management & Social Sciences;

Vol.11, Issue 03 (June 2018) Pg. no. 108-117.

Net references:
 https://www.slideshare.net/vihangtayde/stress-management-ppt-87194131
 https://www.slideshare.net/parvathysree/stress-and-management-59112336
 https://www.slideshare.net/satya8may/stress-management-63867855
 https://www.slideshare.net/manalihsolanki/stress-management-ppt-17274128