Personal definition

What is
Stress?
 Stress and Adaptation
 STRESS
 A condition in which the person
responds to changes in the
normal balanced state
 Selye: non specific response of
the body to any kind of
demand made upon it
 Any event – environmental /
internal demands or both tax or
exceed the adaptive resources of an
 Stress and Adaptation
 STRESSOR
 Any event or stimulus that causes
an individual to experience stress
 They may neither positive or
negative, but they have positive
or negative effects
 Internal Stressor (illness,
hormonal change, fear)
 External Stressor (loud noise,
cold temperature)
 Developmental Stressor
 Situational Stressor
 Stress and Adaptation
 COPING- a problem
solving process that the
person uses to manage
the stresses or events
with which he/she is
presented.
 Stress and Adaptation

 ADAPTATION- the process

by which human system
modifies itself to conform
to the environment. It is a
change that results from
response to stress.
 Stress and Adaptation
SOURCES OF STRESS
2. Internal

3. External

4. Developmental

5. Situational
 Stress Characteristics
 It is a universal phenomenon.
 It is an individual experience.

 It provides stimulus for

growth and change.
 It affects all dimension of
life.
 It is not a nervous energy.
 Effects of Stress on the
Body
 Physical- affects physiologic
homeostasis
 Emotional- affects feeling towards
self
 Intellectual- influences perception
and problem solving abilities
 Social – can alter relationships with
others
 Spiritual- affects one’s beliefs and
values
 Effects of Stress on the
Body
 Metabolic Disorders  CVD
 Coronary artery
 Hyper/hypothyroi
dism disease
 Essential
 Diabetes hypertension
 Cancer  CHF
 Accident proneness  GIT disorders
 Skin disorders  Constipation
 Eczema  Diarrhea
 Pruritus  Duodenal ulcer
 Anorexia nervosa
 Urticaria
 Obesity
 Psoriasis
 Ulcerative colitis
 Respiratory
disorders  Menstrual irregularities
 Asthma
 Musculoskeletal
disorders
 Hay fever  RA
 Tuberculosis 
 GENERAL THEORETICAL
FRAMEWORKS FOR
UNDERSTANDING STRESS
Stress can be defined differently
by the three models
 STIMULUS

 RESPONSE

 TRANSACTION
 Stress and Adaptation
Models of Stress
2. STIMULUS based models

4. RESPONSE based models

6. TRANSACTION based
models
 Stress as a Stimulus
 Holmes and Rahe 1967: They
studied the relationship
between specific life changes
such as divorce or death, and
the subsequent onset of illness.
 Focus: disturbing events within
the environment
 Stress as a Transaction
 The transactional stress theory
includes cognitive, affective, and
adaptive responses from person
and environment interaction. The
person responds to perceived
environmental changes by coping
mechanisms.

 Transactional theory of stress

emphasizes that people & groups
differ in their sensitivity &
vulnerability to certain types of
 Stress As a Response
 Disruptions caused by harmful
stimulus or stressors
 Specifies particular response or
pattern of responses that may
indicate a stressor
 Selye (1976): developed models
of stress, that defines stress as
a non-specific response of the
body to any demand made on it
 Stress As a Response
 Focus: reactions of the BODY
 Selye used the term “stressor’
as the stimulus or agents that
evokes a stress response in the
person .
 A stressor may be anything that
places a demand on the person for
change or adaptation.
 Stress As a Response
 Hans Selye (1976) “ non-specific
response of the body to any kind
of demand made upon it
He called it “non-specific” because
the body goes through a number
of biochemical changes and re-
adjustments without regard to
the nature of the stress
producing agents.
 Any type of stressor may
produce the same responses in
 Stress As a Response
 Advantage : response to
stress is purely physiologic;
determines physiological
response to stress

 Disadvantage: does not

consider individual
differences in response
pattern
 Stress as a response
SELYE proposed two Stress
adaptation responses
2. General Adaptation
Syndrome
3. Local Adaptation
Syndrome
 General Adaptation
Syndrome
 Physiologic responses of the whole
body to stressors
 Involves the Autonomic Nervous
System, and Endocrine System
 Occurs with the release of adaptive
hormones and subsequent changes
in the WHOLE body
General Adaptation
Syndrome
Three stages adaptation to stress for both GAS/LAS:

Stressor

Alarm reaction
Counter-
Shock phase shock
Phase
Epinephrine Cortisone

Normal
Stages of resistance state

Stages of exhaustion

Rest Death
 General Adaptation
Syndrome
I. ALARM REACTION
 Initial reaction of the body; “ fight OR
flight” responses
 Mobilizing of the defense mechanisms
of the body and mind to cope with
stressors.
 SHOCK PHASE- the autonomic nervous
system reacts; release of Epinephrine
and Cortisol
 COUNTERSHOCK PHASE- reversal of
the changes produced in the shock
 General Adaptation
Syndrome
II. STAGE OF RESISTANCE:
 The BODY stabilizes, hormonal levels
return to normal, heart rate, blood
pressure and cardiac output return to
normal
2 things may occur:
 Either the person successfully adapts
to the stressors and returns to
normal, thus resolving and repairing
body damage; or
 The stressor remains present, and
adaptation fails (ex. Long-term
terminal illness, mental illness, and
 General Adaptation
Syndrome
III. STAGE OF EXHAUSTION:
 Occurs when the body can no
longer resist stress and body
energy is depleted.
 The body’s energy level is
compromised and adaptation
diminishes.
 Body may not be able to defend
self that may end to death.
 Stress and Adaptation
A-R-E
ALARM: sympathetic system is
mobilized!
RESISTANCE: adaptation takes
place
EXHAUSTION: adaptation cannot
be maintained
 GAS
Hypothalamus

Anterior Pituitary Gland

Adrenal Gland

Adrenal Cortex
Adrenal medulla
Adrenal gland
Adrenal Gland
Adrenal Gland
 Hormonal Changes
Adrenal Adrenal
Cortex Medulla
 MINERALOCORTICOIDS  NOREPINEPHRINE
 Aldosterone  Peripheral
 Na+ retention vasoconstriction
 WATER retention  Decreased blood to
 Protein anabolism kidney
 Increased renin
 GLUCOCORTICOIDS
 Cortisol
(angiotensin)
 EPINEPHRINE
 (Anti-inflammatory)  Tachycardia
 Protein catabolism  Increased myocardial
 Gluconeogenesis activity
 Increased Bronchial
dilatation
 Increased Blood
 Local Adaptation
Syndrome
 Localized responses to stress
Ex. Wound healing, blood
clotting, vision, response to
pressure
 Adaptive: a stressor is necessary to
stimulate it
 Short- term
 Restorative: assist in homeostasis
 Local Adaptation
Syndrome
Reflex Pain response:
 Localized response of the CNS to pain
 Adaptive response and protects
tissue from further damage
 Involves a sensory receptor, a
sensory serve to the spinal cord, a
connector neuron, motor nerve,
effector’s muscles. Example:
unconscious removal of hand from a
hot surface, sneezing, etc.
Inflammatory Response:
 Stimulated by trauma or infection,
thus preventing it to spread; also
promotes healing
FACTORS INFLUENCING RESPONSE
TO STRESS
 Age, Sex
 Nature of Stressors
 Physiological functioning
 Personality
 Behavioral Characteristics
 Level of personal control
 Availability of support system
 Feelings of competence

 Cognitive appraisal, Economic

Status
 The MANIFESTATIONS OF
STRESS
INDICATORS OF STRESS
 Physiologic

 Psychological

 Cognitive

 Verbal-Motor
 Physiological Indicators
 Dilated pupils
 Diaphoresis
 Tachycardia, tachypnea,
HYPERTENSION, increased blood flow to
the muscles
 Increased blood clotting
 Bronchodilation
 Skin pallor
 Water retention, Sodium retention
 Oliguria
 Dry mouth, decrease peristalsis
 Hyperglycemia
 Remember these Physiologic
Manifestations of Stress

 Pupils dilate to increase visual

perception when serious threats
to the body arise

 Sweat production (diaphoresis)

increases to control elevated
body heat due to increased
metabolism
 Remember these Physiologic
Manifestations of Stress

 Heart rate or pulse rate increases

to transport nutrients &
byproducts of metabolism more
effectively

 Skin becomes pale (Pallor)

because of constriction of
peripheral blood vessels to shunt
blood to the vital organs.
 Remember these Physiologic
Manifestations of Stress

 BP increases due to
vasoconstriction of vessels in
blood reservoir (skin, kidneys,
lungs), due to secretion of renin,
Angiotensin I and II

 Increased rate/depth of
respiration with dilation of
bronchioles, promoting
hyperventilation and increased
oxygen uptake
 Remember these Physiologic
Manifestations of Stress

 Mouth may become dry, urine

output may decrease. The
peristalsis of the intestines
decreases leading to
constipation

 For serious threats, there is

improved mental alertness
 Remember these Physiologic
Manifestations of Stress

 Increased muscle tension to

prepare for rapid motor
activity/defense

 Increased blood sugar

(glucocorticoids &
gluconeogenesis) to supply
energy source to the body.
 Psychological indicators
 Thisincludes anxiety,
fear, anger, depression
and unconscious ego
defense mechanisms
 Anxiety
A state of mental
uneasiness, apprehension,
or helplessness, related to
anticipated unidentified
stress

 Occurs
in the Conscious,
subconscious, or
unconscious levels
 Levels of Anxiety
4 Levels of Anxiety:
 Mild

 Moderate

 Severe

 Panic
 Levels of Anxiety
 Mild- increased alertness, motivation
and attentiveness

 Moderate- perception narrowed,

selective inattention and physical
discomfort
 Levels of Anxiety
 Severe- behaviors become
automatic, details are not seen,
senses are drastically reduced, very
narrow focus on specific details,
impaired learning ability.

 Panic- overwhelmed, unable to

function or to communicate, with
possible bodily harm to self and
others, loss of strong displeasure
Anxiety
 ANXIETY
CATEGOR MILD MODERAT SEVER PANIC
Y E
E
Percepti Increas Narrowe Inability Distorted
on and ed d focus to focus perceptio
attention arousal n
Communication Increase Voice Difficult Trembling
d tremors to unpredicta
questioni Focus on understa ble
ng particular nd response
object Easily
VS NONE Slight distracte
Tachycar Palpitation
changes Increase d
dia, , choking,
Hyperven chest pain
tilation
 Fear

 It is a mild to severe feeling of

apprehension about some
perceived threat.
 The Object of fear may or may not
be based on reality.
 Anxiety versus fear
ANXIETY FEAR
State of mental Emotion of apprehension
uneasiness
Source may not be Source is identifiable
identifiable
Related to the future Related to the present
Vague Definite
Result of Result of discrete physical
psychological or or psychological entity,
emotional conflict definite and concrete
events
 Anger
 Subjective feeling of strong
displeasure
 It is an emotional state
consisting of subjective
feeling of animosity or
strong displeasure
 Depression
Emotional Behavioral signs:
Symptoms:  irritability
 Tiredness  inability to
 emptiness concentrate
 numbness  difficulty making
Physical signs decision
 loss of appetite  loss of sexual
 weight loss desire
 constipation  crying
 headache
 dizziness
 sleep disturbance
 social withdrawal
 Unconscious Ego defense
mechanism
 These are PSYCHOLOGIC adaptive
mechanisms
 Mental mechanisms that develop as
the personality attempts to DEFEND
itself, establishes compromises
among conflicting impulses and
allays inner tensions
 Unconscious Ego defense
mechanism
 The unconscious mind working to
protect the person from anxiety
 Releases tension
 COGNITIVE
MANIFESTATIONS
 Thinking responses that include
problem solving, prayer,
structuring, self control,
suppression and fantasy

 Thinking responses of the

individual toward stress
 COGNITIVE
MANIFESTATIONS
 PROBLEM SOLVING: Use of specific
steps to arrive at a solution

 STRUCTURING: manipulation of a
situation so that threatening events
do not occur
 COGNITIVE
MANIFESTATIONS
 SELF CONTROL / DISCIPLINE:
assuming a sense of being in control
or in charge of whatever situation

 SUPPRESSION: willfully putting a

thought / feeling out of one’s mind
 COGNITIVE
MANIFESTATIONS
 FANTASY / DAYDREAMING: “
make believe” or imagination of
unfulfilled wishes as fulfilled

 PRAYER: identification, description

of the problem, suggestion of
solution, then reaching out for help
or support to the supreme being
 VERBAL / MOTOR
MANIFESTATIONS

 First hand responses to stress

 VERBAL / MOTOR
MANIFESTATIONS

 CRYING: feelings of pain, joy,

sadness are released

 VERBAL ABUSE: release

mechanism toward non living
objects, and stress producing events

 LAUGHING: anxiety reducing

response that leads to constructive
problem solving
 VERBAL / MOTOR
MANIFESTATIONS

 SCREAMING: response to fear or

intense frustration and anger

 HITTING AND KICKING:

spontaneous response to physical
threats or frustrations

 HOLDING AND TOUCHING:

responses to joyful, painful or sad
events
 COPING

A problem solving
process or strategy that
the person uses to
manage the out-of-
ordinary events or
situations with which
he/she is presented.
 Successfully dealing with
 Coping related terms
 Adaptive coping- helps
person deal effectively
with stress
 Maladaptive coping-
results in unnecessary
distress for the person
and stressful events
 MODES OF ADAPTATION
1. Physiologic mode (biologic
adaptation)
 Occurs in response to increased or
altered demands placed on the body
& results in compensatory physical
changes.
2. Psychological Mode
 Involves a change in attitude &
behavior toward emotionally stressful
situations. (Ex. Stopping smoking)
3. Socio-cultural Mode
 Changing persons behavior in
 CHARACTERISTICS OF ADAPTIVE
RESPONSES

 All attempts to maintain homeostasis

 Whole body or total organism
response
 Have limits (Physiologic,
Psychologic/Social)
 Requires time
 Varies from person to person
 Maybe inadequate or excessive
(infection/allergy
 MANIFESTATIONS OF
ALTERED COPING
 Addictive behaviors
 Physical illness

 Anxiety and depression

 Violent behaviors
 Applying the Nursing
Process
 A
 D
 P
 I
 E
 Assessment

1. Utilize the Nursing History

 Subjective data- such as the
functional pattern, risk pattern and
dysfunctional pattern.
2. Physical Examination – centered on
the changes in the ANS and NES.
Objective data- Physical assessment,
Diagnostic tests and procedures
3. Laboratory Examination
 Diagnoses
Utilize those accepted by NANDA
2. Anxiety 7. Fear
3. Caregiver role strain 8.
Impaired adjustment
4. Compromised family coping 9.
Ineffective coping
5. Decisional conflict 10. Ineffective
Denial
6. Defensive coping 11. Post-
trauma Syn
7. Disabled Family coping 12. Relocation
 Planning
There are four important
guidelines to be followed in
choosing nursing goals. The
nurse must choose goals
geared :
 To eliminate as many stressors
as possible
 To teach about the effects of
stress to the body
 To teach how to cope with
 Planning
Examples of Patient outcome criteria
are:
After 3 hours/ 4days:
1. The patient will identify sources
of stress in his/her life
2. The patient will identify usual
personal coping strategies for
stressful situations
3. The patient will define the
effect of stress and coping
 Implementation
There are essentially three
ways to manage Stress:
 Eliminate the causes/sources
of stress
 Produce a relaxation
response in the body
 Suggest a change in lifestyle,
if possible
 Implementation
Stress reduction techniques:
 Proper nutrition
 Regular exercise, physical activity &
recreation
 Meditation, Breathing exercises,
creative imagery, YOGA
 Communication, time management,
expression of feeling, talking it out,
organizing time
 Biofeedback
 Therapeutic touch
 Implementation
Minimize anxiety
 Support the client and the
family
 Orient the client to the
hospital
 Give the client in a
hospital some way of
maintaining identity.
 Provide information when
 Implementation
Massage
 These include effleurage (stroking),
friction, pressure, petrissage
(kneading or large, quick pinches of
the skin, subcutaneous tissue and
muscle), vibration and percussion.
 Purposes
 -enhances or induces relaxation
before sleep
 -stimulates skin circulation
 Implementation
Progressive Relaxation
 Jacobson (1930), the originator of
the Progressive relaxation technique
 Implementation
Guided Imagery
 Imagery is "the formation of a mental
representation of an object that is
usually only perceived through the
senses" (Sodergren 1985). Example:
Visual -A valley scene with its
many greens
Auditory -Ocean waves breaking
rhythmically
Olfactory -Freshly baked bread
Gustatory -A Juicy hamburger
 Implementation
 Biofeedback is a technique that brings
under conscious control bodily
processes normally thought to be
beyond voluntary command. muscle
tension, heartbeat, blood flow,
peristalsis, & skin temperature – can
be voluntarily controlled
feedback provided through:
 a. temperature meters (that indicate
temp. changes)
 b. EMG (electromyogram) that shows
 Implementation
Therapeutic Touch
 “a healing meditation, because
the primary act of the nurse
(healer) is to "center" the self and
to maintain that center (mental
concentration and focusing)
throughout the process.
 Implementation
CRISIS INTERVENTION
A technique of helping the
person go through the crisis
 To mobilize his resources

 To help him deal with the here

and now
 A five step problem solving
technique designed to promote
a more adaptive outcome
including improved abilities to
 Evaluation
 The evaluation of the plan of care is
based on the mutually established
expected outcomes.
 It is important to observe BOTH
verbal and non-verbal cues when
evaluating the usefulness of the plan.
 Stress Management for
Nurses
 Plan daily relaxation program
Plan daily relaxation program
 Establish a regular pattern of
exercise
 Study assertive techniques.
Learn to say “no”
 Learn to accept failures

 Accept what cannot be changed

 Develop collegial support

 Participate in professional