Focus on Stress

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Why Study Stress?

Linked to leading causes of death
Cancer Accidents Suicide

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

History
Hans Selye identified stress as a response of the body to any demand made on it.
Research focused on physiologic stressors, or what Selye called diverse nocuous agents.
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Stress
Response to demands Perception that one cannot adequately cope with demands being made on person or wellbeing Perception and personal meaning of how a potential stressor influences response
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Types of Stress
Physiologic or emotional/psychologic stressors Type, duration, and intensity of a stressor influence an individuals adaptive response.

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Examples of Stressors
PHYSIOLOGIC Skin burn Chronic pain Hypothermia Infectious disease EMOTIONAL/PSYCHOLOGIC Diagnosis of cancer Marital problems Failing an examination Inadequate financial resources to meet needs

Excessive noise Starvation Running a marathon Birth of a baby

Grieving the loss of a family member Caring for a disabled child Winning or losing an athletic event Winning the lottery
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Factors Affecting Response to Stressors

Internal and external influences Key personal characteristics

Resilience Attitude

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Resilience and Attitude

Resilience
Resourceful, flexible, and having available source of problem-solving strategies

Attitude
Positive emotional attitude can prevent disease and prolong life.

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General Adaptation Syndrome (GAS)

Physical response to stress GAS has three stages:
Alarm reaction Stage of resistance Stage of exhaustion

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GAS
Alarm Reaction

Perception of a stressor physically or mentally Fight-or-flight response is initiated. Temporarily decreased resistance
May result in disease or death if the stress is prolonged and severe

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GAS
Resistance

Ideal transition from alarm to resistance is quick. Few overt physical signs and symptoms occur compared with the alarm stage. Adaptation occurs or person advances to exhaustion.
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GAS
Exhaustion

Final stage of GAS Occurs when all energy for adaptation has been exhausted

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GAS
Exhaustion

Physical symptoms of alarm reaction may briefly reappear in final effort by body to survive. This stage can be reversed by external sources, such as medication.

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Physiologic Response
Stress affects three interrelated systems (nervous, endocrine, and immune).
Activation of these systems affects other systems (cardiovascular, respiratory, gastrointestinal, renal, and reproductive).

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Interrelation of Body Systems

Fig. 8-3. Neurochemical links among the nervous, endocrine, and immune systems. The communication among these three systems is bidirectional.
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Nervous System
Cerebral cortex
Plans a course of action after evaluating stressor in light of past experiences and future consequences

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Nervous System
Limbic system
Mediator of emotions, feelings, and behavior that ensures survival and self-preservation

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Nervous System
Reticular formation
Contains the reticular activating system to send alertness impulses to limbic system and cerebral cortex Stress increases frequency of alertness impulses.
Leads to wakefulness and sleep disturbances

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Nervous System
Hypothalamus
Central to connection between nervous and endocrine systems Regulates the function of sympathetic and parasympathetic branches of the autonomic nervous system

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Hypothalamic-Pituitary-Adrenal Axis

Fig. 8-4. Hypothalamic-pituitary-adrenal axis. ACTH, Adrenocorticotropic hormone; CRH, corticotropin-releasing hormone.
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Endocrine System
Sympathetic nervous system (SNS) stimulates adrenal medulla to release epinephrine and norepinephrine (catecholamines).
Sympathoadrenal response Fight-or-flight response

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Fight-or-Flight Reaction

Fig. 8-5. Fight-or-flight reaction. Alarm reaction responses resulting from increased sympathetic nervous system activity. SNS, Sympathetic nervous system.
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Endocrine System
Stress activates hypothalamicpituitary-adrenal (HPA) axis. Hypothalamus releases CRH.
Stimulates the anterior pituitary to produce ACTH
Adrenal cortex secretes corticosteroids.

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Endocrine System
Physiologic effects of cortisol
Increases blood glucose levels Potentiates catecholamine action on blood vessels Inhibits the inflammatory response

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Endocrine System
Corticosteroids
Increase cardiac output, blood glucose levels, oxygen consumption, and metabolic rate Blunt aspects of stress response that could be self-destructive if uncontrolled

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Immune System
Psychoneuroimmunology (PNI)
Interdisciplinary science involving the interactions among psychologic, neurologic, and immune responses

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Immune System
Brain is connected to the immune system by neuroanatomic and neuroendocrine pathways. Stressors have the potential to lead to alterations in immune function.

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Immune System

Fig. 8-6. The cerebral cortex processes stressful stimuli and relays the information via the limbic system to the hypothalamus. Corticotropin-releasing hormone (CRH) stimulates the release of adrenocorticotropic hormone (ACTH) from the pituitary gland. ACTH stimulates the adrenal cortex to release corticosteroids. The sympathetic nervous system is also stimulated, resulting in the release of epinephrine and norepinephrine from the adrenal medulla. The end result is the inhibition of the immune system.
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Immune System
Nerve fibers extend from nervous system and synapse on cells and tissues (i.e., spleen, lymph nodes) of immune system.
Receptors for neuropeptides and hormones permit immune cells to respond to nervous and neuroendocrine signals.
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Immune System
Acute and chronic stress can affect immune function.
Decreased number and function of natural killer cells Altered lymphocyte proliferation Decreased production of cytokines

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Effects of Stress on Health

Acute stress leads to physiologic changes that are important to ones adaptive survival. If stress is excessive or prolonged, physiologic responses can be maladaptive, leading to harm and disease.
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Effects of Stress on Health

Stress effects
Cognitive function
Poor concentration, impaired decision making, or memory problems

Behavior
Withdrawing from others, irritability, or substance abuse

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Effects of Stress on Health

Excessive activation of the sympathetic nervous system
Induces hippocampal damage
Memory impairment

Increases risk of cardiovascular disease

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Effects of Stress on Health

Excessive activation of sympathetic nervous system may also cause or worsen:
Migraine headaches Irritable bowel syndrome Peptic ulcers Control of metabolic disorders
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Effects of Stress on Health

Stress-induced immunosuppression may exacerbate or increase risk of progression of immune-based diseases.
Multiple sclerosis Asthma Rheumatoid arthritis
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Coping
A persons cognitive and behavioral efforts to manage specific external or internal stressors that seem to exceed available resources

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Coping
Types of coping
Positive: Activities such as exercise and use of social support Negative: May include substance abuse and denial

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Coping
Coping resources are characteristics or actions drawn on to manage stress and include factors within the person or the environment.

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Coping
Resources
Health status Belief systems Problem-solving skills Social skills and support Financial

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Coping
Emotion-focused coping: Managing emotions that one feels when a stressful event occurs
PurposeTo help decrease negative emotions and help create a feeling of well-being

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Coping
Problem-focused coping: Find solutions to resolve problems causing stress
PurposeAllows one to look at a challenge objectively and take action to address the problem and reduce the stress

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Relaxation Strategies
The relaxation response is a state of physiologic and psychologic deep rest.
Characterized by decreased sympathetic nervous system activity

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Relaxation Strategies
Relaxation breathing Meditation Imagery Music for relaxation Massage

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Relaxation Strategies
Relaxation Breathing

The way one breathes affects every aspect of life. The simplest and most effective way to stop the stress response is to breathe deeply and slowly.

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Relaxation Strategies
Relaxation Breathing

Relaxation (abdominal) breathing

Performed while sitting, standing, or lying down Involves primary use of the diaphragm and less use of the upper chest and shoulders

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Relaxation Strategies
Meditation

Three basic types:

1. Concentration: Directs the mind to a single focus (breath or a mantra) 2. Guided: Similar to guided imagery 3. Mindfulness: Focus on all sensations, perceptions, cognitions, and emotions as they arise moment to moment in the field of awareness
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Relaxation Strategies
Imagery

Generates images that have a calming effect on the body

Involves a focused mind and incorporates all senses to create physiologic and emotional changes Guided imagery: Images are suggested by another person.

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Relaxation Strategies
Imagery

Imagery can also be used to specifically target a disease, problem, or stressor.

See Table 8-8 in the textbook.

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Relaxation Strategies
Music for Relaxation

A diversion from a stressful situation Healing vibrations from music can return mind and body to balance. Music decreases anxiety and pain while evoking the relaxation response.

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Relaxation Strategies
Music for Relaxation

Music that contains approximately 60 to 80 beats/min is generally soothing. Fast-tempo music can be stimulating and uplifting. Low-pitched tones and music without words are best for relaxation.
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Relaxation Strategies
Muscle Relaxation

Muscle tension is a universal reaction to stress.

Muscle relaxation elicits the relaxation response. Two types of muscle relaxation:
Progressive Passive

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Relaxation Strategies
Massage

Involves systematic manipulation of soft tissue to reduce tension and enhance health and healing Adds touch: An essential human need

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Nursing Assessment
The nurse must:
Be aware of situations likely to result in stress. Assess the patients perception of the situation and coping mechanisms used.

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Nursing Assessment
Signs and symptoms of stress response
Physical
Increased HR and BP, hyperventilation, or headache

Behavioral
Anxiety, irritability, or impaired speech

Cognitive
Self-reports of forgetfulness or indecision
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Nursing Implementation
First step in managing stress is being aware it is present.
Identifying and expressing stressful feelings

Nurse should facilitate and enhance processes of coping and adaptation.

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Nursing Implementation
Interventions depend on severity of stress experience or demand. Coping resources and strategies should be adaptive and should not be a source of additional stress.

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Strategies for Clinical Practice

Relaxation breathing Imagery Music for relaxation

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Strategies for Clinical Practice

Exercise Massage Meditation Art therapy Journaling

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Nursing Implementation
Effective stress management provides a sense of control over the situation. Recognize when patient needs to be referred to a professional for counseling.

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