STRESS, COPING &

ADAPTATION
LAUREN FLORES RN, BSN
 STRESS

• An actual or potential threat to homeostasis

• Homeostasis: The body is constantly working
to maintain balance against environmental
factors
• Physiological and psychological components
 PHYSIOLOGICAL HOMEOSTASIS

• CNS- Central Nervous System

• Brain and Spinal Cord
• Brain processes stress and responds
• Brain controls Neuroendocrine, (ANS)
Autonomic Nervous System, Immune
Regulation
NEUROENDOCRINE REGULATION

• Complex process involving hypothalamus,

pituitary and adrenal glands
• Brain alerts the endocrine system to release
hormones
• Hormones lead to changes in the body
 AUTONOMIC REGULATION

• Responds to actual or potential stress

• Affects cardiovascular, respiratory,
gastrointestinal, renal and endocrine function
• Sympathetic and Parasympathetic
 AUTONOMIC REGULATION

• Sympathetic Response
• Stressful situation  secrets norepinephrine and
adrenaline  pupil dilation, increased HR and
contractility, bronchial dilation, increased blood
sugar, decreased digestive function, prevent
urination, inhibit insulin secretion
 AUTONOMIC REGULATION

• Parasympathetic Response
• Following a stressful event  acetylcholine
released  pupil constriction, watery secretions of
salivary glands, decreased HR, bronchiole
constriction, increased digestive function, increased
insulin secretion, urination promotion
• Attempt to return body to homeostasis
 IMMUNE REGULATION

• Acute stress onset (trauma, infections)

activates immune response
• Long-term stress hurts immune system
• Infection risk, allergies, autoimmune
disorders
 STRESS AS A STIMULUS

• Stress is reliant on individual interpretation

• Stressors stimulate stress
• Environmental changes, changes in ADLs,
trauma and tragedies
 STRESS AS A STIMULUS

• General Adaptation Syndrome (GAS)

• 3 stages
• Alarm stage- physiologic response
• Stage of resistance- restore balance
• Stage of exhaustion- resolution
• Full recovery or disease
 STRESS AS A RESPONSE

Cognitive and Psychological

• Stress begins at cognitive level
• Real or not, if stressor is perceived as real body will respond
• Defense mechanisms- temporary removal from stressor
• Daydreaming, sleeping, alcohol or drugs
• Denial, Repression, Suppression, Projection, Isolation,
Compensation, Rationalization, Displacement
 STRESS AS A RESPONSE

Defense Mechanisms
• Denial- refusing to believe something
• Repression- immersing something in the
subconscious or unconscious level
• Suppression- consciously dismissing
something from the mind
 STRESS AS A RESPONSE

Defense Mechanisms
• Projection- projecting one’s thoughts/emotions
to another
• Compensation- attempt to achieve respect in
one activity to make up for inability in another
 STRESS AS A RESPONSE

Defense Mechanisms
• Rationalization- concealing the motive for behavior
by giving some socially acceptable reason
• Displacement- transferring emotion away from the
person/situation that incited the emotion to an
inappropriate person/object
 STRESS AS A RESPONSE

Physiological
• Individual reactions to stressors vary, but the
physiological response to stress is similar for all
• ANS is the first responder (fight or flight)
• Chronic stress associated with depression,
cardiovascular disease, respiratory problems, poor
wound healing, autoimmune disorders
 QUESTION #1

Which changes occur during the sympathetic response?

(Select all that apply)
A. Pupil dilation
B. Increased digestive function
C. Increased heart rate
D. Increased blood sugar
E. Bronchiole constriction
 CORRECT ANSWER

ACD

Digestive function is decreased and bronchioles dilate during the

sympathetic response.
 ANXIETY

• Can motivate one to act or can produce

paralyzing fear
• Symptoms of anxiety exist in healthy
individuals
• Diagnosed as anxiety disorder if anxiety is
excessive or out of proportion to the situation
 DEGREES OF ANXIETY

Mild Aware, alerted, sees, hears and grasps more than before;
Learning is enhanced
Moderate Sees, hears, and grasps less than previously; Able to sustain
attention on a particular focus; Aware of anxiety

Severe Tendency toward dissociation; May be unaware of anxiety;

Requires intervention

Panic Massive dissociation; Learning is impossible; Perplexity;

Terror; Requires intervention
 ANTIANXIETY MEDICATIONS

Benzodiazepines
• Anxiolytics
Diazepam (Valium) • Short term relief of anxiety
or anxiety associated with
Chlordiazepoxide (Librium) depression
Clorazepae (Tranxene)
• Mechanisms of action not
well understood
Lorazepam (Ativan) • Buspar, a
nonbenzodiazepine used to
Alprazolam (Xanax)
control anxiety symptoms
Clonazepam (Klonopin) but no effect on panic
disorder
 ANTIANXIETY MEDICATIONS

Side Effects • Risk for dependence

Drowsiness • Gradually taper off
Intellectual Impairment • Rebound of target symptoms
• Tremors, sweating,
Memory Impairment
palpitations
Ataxia • Toxicity
Reduced motor • Confusion
coordination
• Delirium
Dry mouth • Agitation
Constipation • Hypotension
• Lethargy
 ANTIANXIETY MEDICATIONS
Sedative-Hypnotics • Sedatives reduce activity,
Benzodiazepine Hypnotics: nervousness, irritability and
- Flurazepam
- Temazepam (Restoril)
excitability without causing
sleep
Nonbenzodiazepine
Hypnotics: • If given in large enough
- Eszopiclone (Lunesta)
- Zolpidem (Ambien)
doses, they have a hypnotic
effect
Melatonergic Hypnotics: • Depress CNS
- Melatonon
• Facilitate onset and
Antihistamines:
- Hydroxyzine (Vistaril) maintenance of sleep
 ANTIANXIETY MEDICATIONS

Nursing Interventions
• Monitor older patients for confusion,
incontinence, and dizziness
• Monitor for phlebitis and thrombosis if given
IV
• Monitor for signs and symptoms of depression
and suicide
• Monitor for signs of toxicity
 QUESTION #2

Mr. Jones usually gets coffee with his friend and plays
cards but today all he can think about is his sick
brother. He can’t seem to cook or clean either. Which
degree of anxiety does Mr. Jones represent?
A. Mild
B. Moderate
C. Severe
D. Panic
 CORRECT ANSWER

C. Severe anxiety

Mr. Jones has disassociated himself from the rest of the

world but has not reached a state of terror. Severe
anxiety requires intervention.
 NORMAL COPING PATTERNS

• Coping is the process of applying thoughts and

actions to deal with stressful events
• Lifespan considerations affect coping
• Genetic predisposition, environment, history
of dealing with stressful events
FACTORS AFFECTING COPING PATTERNS

Lifestyle considerations
• Diet- body better equipped to handle stress with the
right nutrients and balance
• Activity and Exercise- can be used as defense
mechanism, physiological benefits
• Sleep- need at least 6-9 hours, can cope with stress
better
• Safety and Security- security is based on perception,
safety can affect coping ability
FACTORS AFFECTING COPING PATTERNS

Previous Experience
• The way each stressor is handled and the outcome of
the event will influence subsequent stressful
situations
• Success in managing stress can build confidence and
lead to further success
FACTORS AFFECTING COPING PATTERNS

Involuntary Relocation
• Moving, hospitalization, discharge, nursing home
Social Interaction
• Abuse, divorce, death
• Dysfunctional home situations can lead to a lifetime of
ineffective coping skills
Sensory Deficits
• Under stress it is difficult for a person with loss of vision or
hearing to effectively cope
 ALTERED COPING PATTERNS

Addictive Behaviors
• Substance abuse, smoking, oversleeping, over/under
eating, over exercising, excessive daydreaming,
fantasizing
Physical Illness
• Chronic stress can lead to illness
• Impairs immune function
 ALTERED COPING PATTERNS

Anxiety and Depression

• Extreme response to chronic stress can lead to
depression and suicide
• Poor coping mechanisms and inadequate support can
lead to suicide
Violent Behavior
• Poor impulse control and poor coping mechanisms
can lead to acting out violently and abusing others
 QUESTION #3

Mr. Smith smokes 1 pack of cigarettes/day. He’s

complaining of having frequent colds. He states he has
gained 30 lbs. in 6 months. He also states that the
blister on his hand won’t heal. Mr. Smith is likely
undergoing…
A. Flight or fight response
B. Mild anxiety
C. Chronic stress
D. Repression
 CORRECT ANSWER

C. Chronic stress

Altered coping patterns > chronic stress > decreased

immune response and poor wound healing
 ASSESSMENT

• Normal Pattern Identification

• Subjective data: How do you handle stressful
situations? What support systems do you rely on?
What present situations are causing you stress?
• Objective data: body language, facial expressions,
voice and speech
 ASSESSMENT

• Risk Identification
• Moving
• Divorce, child custody, prison, hospitalization
• Fatigue, malnutrition and illness
• Dysfunction Identification
• What people consider stressful varies from person to person
• Identify typical coping behaviors, are they being used at this
time?
 PHYSICAL ASSESSMENT

Do not assume that the only cause of some physical findings is

stress
• Cardiovascular System
• Directly effected by epinephrine and norepinephrine
• Increased heart rate, “pounding chest”
• Increased blood pressure (systolic and/or diastolic)
• Irregular heartbeat and rhythm changes
• Angina
• Headaches
 PHYSICAL ASSESSMENT

• Respiratory System
• Norepinephrine increases breathing rate and
bronchodilates
• ^RR
• hyperventilation
• “air hunger”
• dizziness
• tingling of hands and feet
 PHYSICAL ASSESSMENT

• Gastrointestinal System
• Loss of appetite
• Nausea/vomiting
• Increased peristalsis
• hyperactive bowel sounds
• Increased # of bowel movements
• ^ hydrochloric acid  ulcers or gastritis
 PHYSICAL ASSESSMENT

• Musculoskeletal System
• Increased tension in larger muscles
• Shakiness/tremors in smaller muscles
• Prolonged tension can lead to muscle spasms in back,
shoulders and neck
• Integumentary System
• Diaphoresis (sweating) and cool to touch
• Arrector pili muscle contraction
 NURSING DIAGNOSES

• Ineffective Coping
• Interventions: coping enhancement, counseling,
family support, support group
• Outcomes: acceptance of health status, social
interaction skills, self-esteem
 NURSING DIAGNOSES

Related to Stress and Coping

• Caregiver Role Strain
• Risk for Caregiver Role Strain
• Readiness for Enhanced Coping
• Risk for Post-trauma Syndrome
 OUTCOME IDENTIFICATION AND
PLANNING

• Work with patient to identify goals and interventions

• Consider history, areas of risk, evidence of
dysfunction
• “The patient will identify sources of stress in his or
her life”
• Make timeframe attainable
 IMPLEMENTATION

Health Promotion
• Reducing stressors- recognize stress, its sources and
meanings
• Addressing perfection- enhances stress
• Supportive Internal Messages
• Substitute a positive, assertive statement for a
negative one
 IMPLEMENTATION

• Using Assertiveness- stand up for themselves, express

feelings openly and honestly
• Making Lifestyle changes- rest and nutrition
• Exercising
• Relaxation techniques- meditation, deep breathing,
yoga
 IMPLEMENTATION

• Modifying the Environment

• Increased noise
• Constant lights
• Unfamiliar procedures
 EVALUATION

• Individualize goals and outcome criteria

• Goals
• The patient will identify sources of stress in his or
her life
• Outcomes
• The patient defines events that create personal
stress by listing them before the next meeting with
nurse
 QUESTION #4

Which patient does the nursing diagnosis, “Ineffective Coping”

most apply?
A. Single 32 y/o female caring for her mother with end-stage
Alzheimer’s
B. 28 y/o male has been in therapy for 2 years coping with his
history of child abuse
C. 13 y/o male with history of child abuse has been skipping
class to drink
D. 28 y/o mother of 3 works full time while helping her
husband manage Multiple Sclerosis
 CORRECT ANSWER

C. 13 y/o male with history of child abuse has been

skipping class to drink

A. and D. represent Caregiver Role Strain and B.

would benefit most from Readiness for Enhanced
Coping
STRESS MANAGEMENT FOR NURSES

• Risks
• Stressful environment, noisy and overcrowded, depressing
situations, various shifts, understaffing
• Burnout: depleted energy and low morale from demanding
and needy environment
• Interventions
• Be aware of your stress levels
• Exercise, limit alcohol, support systems, be optimistic 
 CRISIS

• A positive or negative breaking point

• If negative: suicide, homelessness or depression can result
• Functioning is severely impaired
• Lasts 4-6 weeks
• Individual must learn a new way of coping to survive
• Available support system affects outcome
 TYPES OF CRISES

Developmental Situational Traumatic

Significant Person’s Unexpected, unusual
maturational events biopsychosocial events
• Leaving home for the integrity is • National disasters
first time threatened- results in • Natural disasters
• Completing school • Violent crimes
psychological
disequilibrium
• Move to another city
• Job promotion
 CRISIS

Nursing Management
• Return patient to pre-crisis level of functioning
• Provide a framework of support systems
• Promote the use of positive coping skills
• Assess for suicide risk
• Assess need for admission in mental health facility
 QUESTION #5

Bob graduated high school this month and moved out of town to
start college where a tornado struck his dorm leaving him only
with the clothes on his back. You are treating him in the ER for
minor injuries.
The following are appropriate nursing interventions except:
A. Tell Bob he’s going to be fine and discharge him.
B. Assist Bob in contacting his parents back home.
C. Assess Bob’s suicide risk
D. Inform Bob of the clothing donation center.
 CORRECT ANSWER

A. Tell Bob he’s going to be fine and discharge him.

Telling Bob he’s going to be fine is dismissing his

actual feelings of distress during crisis.
 REFERENCES

Boyd, M. (2012). Psychiatric Nursing: Contemporary Practice (5th ed.,

enhanced update). Philadelphia: Wolters-Kluwer. Chapters 9, 11

and 20.

Craven, R, Hirnle, C. & Jensen, S.(2013). Fundamentals of Nursing (7th

ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

Chapter 40.