Anne’s Note! 1.

Day to day frustrations- arguments, having caught in

2.
Unit I- Homeostasis, Stress & Adaptation
3.
Homeostasis- refers to the steady state with in the body; the
stability of the internal environment
traffic jams, car aircon not working
- great health impact due to cumulative effect
Events that involve a large group of people- economic
and technological changes, war
Infrequent situations that directly affect an individual –
death of a loved one, divorce, marriage, acquiring
permanent functional disability

Stress- a state produced by a change in the environment that is Types of Stressor According to Duration:
perceived as challenging, threatening or damaging to the person’s
dynamic balance or equilibrium; caused by a Stressor 1. Acute- time limited
2. Sequence- occurs in series resulting from an initial event
Adaptation- refers to the adjustment to the change so that the
person is again in equilibrium i.e. physical and psychological 3. Chronic intermittent
health, and enhanced social functioning. 4. Chronic enduring

Coping – the process of adaptation; a compensatory process with Models of Stress:

physiologic and psychological components - assist the nurse to identify the stressor and to predict the
individual’s responses

1. Stimulus Based Model

Stress Homeostasis Adaptation
Physiology- study of functional processes of the living organism
and its parts
Pathophysiology- study of disordered function of the body
Historical Theories of the Steady State:
Claude Bernard- developed the principle that for life there must
be a constancy or “fixity of the internal milieu” despite changes in
the external environment
Walter Cannon- used the term homeostasis to describe the
stability of the Internal environment as a result of compensatory
processes
Rene Jules Dubos- proposed that Homeostasis and adaptation
were necessary for balance
Homeostatic process- occurs quickly in response to
stress to maintain internal environment
Adaptive process – results in structural and functional
changes over time
Stressor
- Internal or external event or situation that creates a potential for
physiologic, emotional, cognitive or behavioral changes in an
individual
- stress is defined as a stimulus, a life event or circumstances
that arouses physiologic and/or physiologic responses that may
increase an individual’s risk for illness
2. Response Based Model
- stress is defined as the non-specific response of the body to
any kind of demand made upon it (Selye)
- Response is characterized by a chain or pattern of
physiologic events called the General Adaptation syndrome
(GAS) and Local AS
- Stress is viewed as a state of the body and can only
be observed through the changes it cause on the body
3. Transaction Based Model
- This model states that people and group differ in their
vulnerability and sensitivity to stress as well as their
interpretations and reactions
- Encompasses a set of cognitive, affective and adaptive
responses that arise out of the person-environment
transaction
- Stress refers to any event in which environmental demands,
internal demands or both overwhelm the adaptive resources
of an individual, a social system or a tissue system.
Responses to Stress:
I. Physiologic
II. Psychological
I. Physiologic Response to Stress
- a protective and adaptive mechanism to maintain the
homeostatic balance of the body in response to a physical or
psychological stressor
- a cascade of neural and hormonal events that have short
and long lasting consequences for both the brain and the
body
- Hans Selye developed the theory of adaptation:

Forms of Stressor: 1. General Adaptation Syndrome (GAS)

1. Physical- heat, cold, chemicals - a non-specific response to diverse noxious stimuli
2. Psychosocial- fear of failing - characterized by adrenal cortex enlargement, shrinkage of
3. Physiologic- pain and fatigue thymus, spleen LN, and other lymphatic structures and
appearance of GI ulcers
Types of Stressor according to impact and degree of
involvement:

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Phases:
a. Alarm- “fight or flight”, defensive and anti-inflammatory but
self limited
b. Resistance- adaptation to noxious stimuli
c. Exhaustion- depletion of energy in prolonged stress, may lead
to death
2. Local Adaptation Syndrome (LAS)
- Anti-inflammatory response and repair process
that occur at local site of injury
Interpretation of the Stressful Stimuli by the Brain:
• Physiologic Response to stress is mediated by the brain
through a complex network of chemical and electrical
messages
• Hypothalamus integrates the neural and hormonal
actions that maintain homeostatic balance
• Initial responses include sympathetic nervous system
discharge followed by symphatetic-adrenal-medullary
discharge
• If stress persist, hypothalamic-pituitary system is
activated
- mastery, knowledge, problem solving skill and
1. Sympathetic Nervous system Response:
- rapid and short-lived
- involves release of Norepinephrine from
peripheral nerves
Results in:
- vasoconstriction, tachycardia and increase BP
- Increased glucose, dilated pupils, increased mental
activity
- Tachypnea, tensed skeletal muscles
2. Symphatetic-Adrenal-Medullary Response
- involves release of epinephrine and NE from the
adrenals
- sustained and prolonged action
3. Hypohalamic-Pituitary Response
- longest acting phase of the physiologic response
- occur in persistent stress
4. Immunologic Response
- studies have shown that people under stress have
decreased WBC, impaired immune response to
vaccination and diminished activity of NK cells
(*discuss the pathway)
II. Psychological Response to Stress
a. Appraisal of the Stressful Event (Cognitive Appraisal)
- a process by which an event is evaluated with respect to
what is at stake (primary appraisal) and what might and can
be done (secondary appraisal).
Primary appraisal identifies the event as stressful or non-stressful
- Stressful situation can be one of 3 kinds:
1. Harm or loss has occurred
2. threatening i.e. harm or loss is anticipated
3. Challenging i.e. some opportunity or gain is anticipated
Secondary Appraisal includes:
1. Assigning blame to those responsible for a frustrating event
2. Thinking about whether one can do something about the
situation
3. Determining future expectancy or whether things are likely to
change for
better or worse.
Reappraisal- a change in opinion based on new information
- the appraisal process contributes to the development of a
negative or a positive emotion
b. Coping with stressful event
- aims to maintain the positive benefit of the challenge and to
ward-off any threats
- consist of cognitive and behavioral efforts made to mange
the stressor and may be problem or emotion-focused.
1. Emotion Focused- seeks to make the person feel better
by decreasing the emotional distress felt
2. Problem Focused – aims to make direct changes in the
environment to manage the situation more effectively.
• Appraisal and coping are affected by the ff. internal
characteristics:
- health, energy, personal belief system,
commitments or life goals, self-esteem, control,
social kills
• In Nursing, Health promoting lifestyle and hardiness are
the 2 most studied characteristics
1. Health Promoting lifestyle - buffers the effect of stressor
rather than altering the stressors
2. Hardiness – is the quality that comes from having rich,
varied, and rewarding experience to deal with stressors
Indicators of Stress
- psychological, physiologic or behavioral
- irritability, depression, change in menstrual
cycle, loss or increased appetite, grinding of
teeth, insomnia, diarrhea, vomiting etc.
Psychological Indicators of Stress:
a. Anxiety
- an emotional state characterized by feeling of
apprehension, restlessness, discomfort or worry.
- Occur as a result of challenging or threatening
life events, fear of unknown, impairment in
bodily functions, changes in family roles, etc.
- Usually manifests in behavior and emotion, and
physiologically
Levels of Anxiety
1. Mild Anxiety
- produces slight arousal that enhances perception, learning and
productive abilities
- experienced by most healthy people
- may be manifested as mild restlessness and sleeplessness
- usually no physiologic manifestations
2. Moderate Anxiety
- increases arousal to a point where the person expresses
concerns
- Perceptual abilities are narrowed and the person is more
focused on a particular
aspect of a situation
- may have tremors and shakiness
- Learning is slightly impaired
- slight elevation of RR and CR
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 - an attempt to manage anxiety by imitating the behavior of
3. Severe Anxiety someone feared or respected
- Perception is further decreased making the person unable to 5. Intellectualization
focus on the event - emotional response that normally accompany an uncomfortable
but focuses only on a specific detail or painful incident is evaded by the use of rational explanations
- increased motor activity, unable to relax and easily distracted that remove any personal significance
- learning is severely impaired 6. Introjection
- tachycardia, hyperventilation - a form of identification that allows for the acceptance of others’
- consumes most of the person’s energies and requires norms and values into oneself even when contrary to one’s
intervention previous assumption
7. Minimization
4. Panic - not acknowledging the significance of one’s behavior
- Overpowering, frightening level of anxiety causing the person 8. Projection
to lose control - blame is attached to others for unacceptable shortcomings
- increased motor activity and agitation, trembling and poor 9. Rationalization
motor coordination - justification of certain behavior by faulty logic
- unable to learn or function 10. Reaction Formation
- feeling of impending doom - causes people to act exactly opposite the way they feel
- dyspnea, palpitation, chest pains 11. Regression
- resorting to a previous more comfortable level of functioning that
b. Fear is less demanding and responsible
- an emotion or feeling of apprehension aroused by impending or 12. Repression
seeming danger, pain or perceived threat - unconscious mechanism where threatening thoughts, feelings
- it could be something that has happened, current or will happen and desires are kept from becoming conscious
13. Sublimation
Differences of Fear and Anxiety: - displacement of energy associated with more primitive sexual or
1. source of aniety may not be identifiable, source of fear is aggressive drives into socially acceptable activities
identifiable 14. Substitution
2. Anxiety is related to future, fear to present - replacement of a highly valued, unacceptable or unavailable
3. Anxiety is vague, fear is clear object by a less valuable, acceptable or available objects
4. Anxiety is a result of psychological or emotional conflict, 15. Undoing
fear is a result of discrete physical or psychologic entity. - actions or words design to cancel some disapproved thoughts,
impulses or acts in which the person relieves guilt by making
c. Anger reparation
- an emotional state consisting of a subjective feeling of animosity
or strong displeasure Maladaptive Response to Stress
- can be expressed verbally or non-verbally
- when the response to stress is ineffective it is referred to
Hostility- marked by overt antagonism and harmful or destructive as Maladaptive
behavior
Aggression- an unprovoked attack or a hostile, injurious or - usually results from impaired appraisal and
destructive action or outlook inappropriate coping
Violence- the exertion of physical force to injure or abuse - models of stress frequently site stress and maladaptation
as precursors to disease
d. Depression - Selye proposed a list of disorders he called diseases of
- Subjective feeling of extreme sadness, despair, lack of worth or maladaptation: HTN, Heart dse., kidney dse., etc.
emptiness
- a common reaction to events that are overwhelming or negative Inappropriate Coping Patterns:
- Anorexia, weight loss, loss of sexual desire, irritability, social 1. Use of alcohol or drugs
withdrawal, sadness, 2. Type A personality
fatigue etc. 3. Denial, avoidance and distancing

e. Unconscious Ego Defense Mechanisms Stress as a Stimulus for Disease:

- Mechanisms that develop as the personality attempts to defend - Critical life events have been linked to occurrence of
itself, establish illnesses
compromises among conflicting impulses and allay inner tensions - Constant stress may lead to ineffective coping causing
- Unconscious mind working to protect the person from anxiety additional distress that can lead to Stress-Related Illness

1. Compensation
- covering up weakness by emphasizing a more desirable trait or Stress at the Cellular Level
overachievement in a more comfortable area • cell exist in a continuum of function and structure ranging
2. Denial from normal, to adapted, to injured, and to dead cells
- an attempt to screen or ignore unacceptable realities by refusing • pathological processes often start at the cellular level
to acknowledge them
3. Displacement Control of the Steady State:
- transferring or discharging of emotional reaction from one object 1. Negative feedback
or person to another • changes from a predetermined set-point triggers
4. Identification compensatory mechanism to restore homeostasis

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 • integrated by the brain and influenced by the nervous and a. goal of relaxation training is to produce a response that
endocrine system counters the stress response
• Ex. Accumulation of Lactic acid causes vasodilation b. this decreases the sympathetic and parasympathetic
• Organs of homeostasis include: Heart, lungs, liver, GI and response interrupting Physiologic effects and reducing
skin psychological stress

2. Positive Feedback 1. Progressive Muscle Relaxation

- involves tensing and releasing the muscles of the body in
• perpetuates the initial event set in motion by the original
sequence and sensing the difference in feeling
disturbance
- person lies flat on a soft cushion on the floor in a quiet room
• Ex. Clotting breathing easily
- someone reads the instructions
Cellular Adaptation:
2 Functions of Cells: 2. Benson’s Relaxation Response
a. Maintainace - combines meditation with relaxation
b. Specialized Steps:
1. Pick a brief phrase or word that reflect your basic
1. Hypertrophy belief system
2. Atrophy 2. Choose a comfortable position
3. Hyperplasia 3. Close your eyes and relax your muscles
4. Dysplasia 4. become aware of your breathing and start using
5. Metaplasia your selected focus word
5. Maintain a passive attitude
Cell Injury: 6. Continue for a set period of time
- disorder in steady state regulation 7. Practice the technique twice a day
*(further discussion on Unit II – Illness and Inflammatory Process) 3. Relaxation with Guided Imagery
- the purposeful use of imagination to achieve relaxation or
Stress Management: direct attention away from undesirable sensation
- directed toward reducing and controlling stress - assist patient in selecting a pleasant scene or experience
and improving coping - guide patient to review the scene, trying to feel and relive the
- aims to prevent illness, improve quality of life imagery with all the senses
and decrease the cost of health care
Other relaxation technique:
- meditation, breathing technique, massage, music therapy,
use of humor
Possible Nursing Diagnoses:
D. Educating about Stress Management
1. Anxiety - includes providing sensory information and procedural
2. Ineffective coping process information to reduce stress and improving patient’s coping
3. Impaired thought process ability
4. Social Isolation - Ex. Giving lessons in childbirth preparation, discussing the
5. Risk for impaired Parenting anatomy of the heart in patient’s undergoing cardiac
procedure
Nursing Interventions: - The objective is to reduce emotional response so the patient
can concentrate and solve problems more effectively
A. Promoting Healthy Lifestyle
- provides resources and buffers the impact of stressors E. Enhancing Social Support
- lifestyles and habits that contribute to the risk of illness are - Social support makes people feel that they are cared for and
identified and recommendations are done loved, respected and valued, and that they belong to a network of
- Ex. Smoking, sedentary lifestyle communication and mutual obligation
- facilitates individual coping behavior
B. Enhancing Coping Strategies - Critical qualities within a social network is the exchange of
- assisting a patient to adapt to perceived stressor, changes or intimate communication and the presence of solidarity and trust
threat that interferes with meeting life demands and roles - it’s being able to talk with someone and express feelings openly
- Nurses can help patients identify their social support system and
Ways of Coping: encourage them to use it
1. Trying to be optimistic about the outcome
2. Using social support F. Support Groups
3. Using spiritual Resources - usually formed by people with similar stressful situation
4. Trying to maintain control over the situation or over feelings - being a member of a group with similar problems or goals has a
5. Trying to accept the Situation releasing effect on a person that promotes freedom of expression
- seeking information, reprioritizing needs and roles, lowering and exchange of ideas
expectations, comparing self to others , taking things one step
at a time, self talk for encouragement twj-md08

C. Teaching Relaxation Technique