SEMINAR ON STRESS STRESSOR & STRESS

MANAGEMENT FOR PATIENT AND HEALTH CARE

PROFESSIONALS

1. Introduction
People use the term stress in many ways. Stress is an
experience a person is exposed to through a stressor. Stressor are
disruptive force exit in many forms. Stress is a conscious or
unconscious psychological feeling or physical situation which comes
after as a result of Physical or Mental, Positive or Negative pressure to
over whelm adaptive capacities. Nurse must recognize the signs and
symptoms of stress and be knowledgeable about stress management
technique to aid personal coping as well as design stress management
Intervention for their clients and families.
2. CONCEPT OF STRESS:
Stress is a state produced by a change in the environment that is
perceived as challenging threatening or damaging to the persons
dynamic balance or equilibrium. The person is unable to meet the
demands of the new situations. The change that bring this state is the
stressor.
The desire goal is adaptation or adjustment to the change so that the
person is again in the equilibrium and has the energy and ability to
meet new demands.
3. Types of Stress:-
Selye Identified two types of stress:-

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  Distress or damaging stress
 Eustress that protect Health.
There are several other types of stress including:
1. Work place, Family stress, Acute stress, Cronic stress, Post
traumatic Stress etc.
4. COMMON FACTORS OF STRESS
Potential Stressors and coping mechanism vary across the life span for
example adolescence, adulthood and old age bring different stressor.
Following are the factors:-
A. Situational factor :
B. Maturational :
C. Social
D. Cultural
A. SITUATIONAL FACTOR: It came arise from job changes transfer,
adjusting to Chronic Illness like hypertension diabetes, coronary
artery disease etc.
B. MATURATIONAL : Stressor very with the life stage that is pre
adolescent experiences stress related to self esteem, adult experiences
stress around major changes in life that is carrier marries loosing
parents etc. in old age stressor include loss of autonomy and mastery
due to health problem.
C. SOCIAL : Social stress can lead to developmental problems the social
factor are divorce imprisonment or abuse disorders.
D. CULTURAL : The clients cultural defines what is stressful to the person
and way of coping with stress. Some cultures stress that emotions
should be controlled whereas others believes in expressing emotions.

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5. STRESSORS:
Stressor are Psychologically and Physically demanding event or
Circumstances. Stressors don't always increase the risk of illness.
They tend to affect health more when they are Chronic highly
disruptive or perceived as uncontrollable.
6. SOURCES OF STRESS:
There are tow type of sources:
1. External Sources
2. Internal Sources
1. External Sources : These are usually three types of stressors :
(a) Catastrophic events
 Large Earthquakes
 Hurricanes
 Floods
 Wars.
(b) Major life changes : Positive/Negative
 Marriage
 Divorce
 Disruptive social and family relationship
 Death of Parents, Lover or Life Partner, Child
 Beginning of new Job.
 Competitive sports
 Unmet basic needs (Hunger, Sexual Desire)
 Anticipated Stress full event (Courtroom hearing)
 Painful diagnostic test
 Normal changes in physiological function ( Puberty,
Pregnancy or menopause)

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 (c) Minor Hassles
 Activities of every day life
 standing in a line
 Traffic Jams
 Noisy Environment
 Change of Residence
2. Internal Sources : Exposure to difficult circumstances doesn't produce
stress by itself, rather stress occurs when people
experiences Frustration, conflict and pressure.

1. Frustration : It is the experience of being thwarted when trying to

achieve a goal. ex. A student worked very hard on a term paper with
the hope of getting an A but ends up with a. B.
2. CONFLICT : Occurs when people have two or more incompatible
desires or motives. Conflict can occur in three forms
 APPROACH- APPROACH CONFLICT (Least stressful)
When people try to choose between two desirable alternatives.
 APPROACH - AVOIDANCE CONFLICT (More stressful)
It is quite common occurs when people must decide whether to do
something that has both positive ad negative aspects.
 AVOIDANCE-AVOIDANCE CONFLICT
It occurs when people have to choose between two undesirable
options.
3. PRESSURE : Pressure occurs when people feel compelled to
behave in a particular way because of expectation set by
themselves or others.

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7. INDICATORS OF STRESS:
1. Laboratory measurement:
 Blood level of catecholamine, corticoids, ACTH and
eosinophils.
 Blood level of serum Creatine/ Creatinn
 Serum Cholesterol and free fatty acid.
2. Psychological Measurement
 Questionnaires
3. Physical Measurement
 Blood pressure
 Heart rate
8. SIGNS AND SYMPTOMS OF STRESS
 General irritability, hyper excitation, depression
 Dryness of the throat and Mouth
 Easily fatigued, lose of interest
 Floating anxiety
 Speech difficulties
 Gastrointestinal signs and symptoms
 Change in menstrual cycle.
 Loss or excessive appetite.
 Increased use of legally prescribed drugs such as anxiolytics or
antidepressants
 Disturbed behavior, emotional instability
 Inability to concentrate or think clearly
 Feeling of unreality, weakness and dizziness
 Tension, alertness, Insomnia, nightmares
 Increased frequency of Urination, constipation
 Increased smoking, Alcohol & Drug Addiction.

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9. STRESS RESPONSES
Stress responses are PHYSIOLOGIC and PSYCHOLOGICAL
reactions to stress. The manner in which an individual responds to
stressful situations is mediated by Personality, Perception of the
stressor, Resources for copy
(i) PHYSIOLOGIC : Over 60 years ago WALTER CANNON
proposed the Fight or Flight responses to stress which is arousal of
sympathetic nervous systems

GENERAL ADAPTATION SYNDROME

Hans Selye a Pioneer in the filed of stress research describe the
General Adaptation Syndrome (GAS) Which has three stage reaction to
stress. The GAS describes how the body responds to stressors through the
alarms reactions, the resistance stage and the exhaustion stage.
In Stressful situation the brain sends signals to the rest of the body
along two path way. In the first path way the Hypothalamus of the brain
activates the sympathetic division of the autonomic nervous system which
in terms stimulates the inner part of the adrenal glands which is called the
Adrenal Medulla. The Adrenal Medulla releases hormones called
Catecholamine which include epinephrine and nor epinephrine. The action
of the Catecholamine result in the fight or flight response.
In second path way the hypothalamus sends signals to the pituitary
gland. It releases Adrenocorticotropic Hormones (ACTH) which stimulates
outer part of the adrenal glands that is Adrenal Cortex.

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 Adrenal Cortex release hormones called Corticosteroid which
include cortical. These hormones are responsible for increasing blood sugar
levels providing energy.

STAGES OF GAS
1. Alarm Reaction: During the Alarm Reaction rising hormone level
result in increased blood volume, blood glucose level, heart rate,
blood flow to muscles, Oxygen intake and mental alertness. This
changes in body systems prepares an individual for fight or flight. If
the stressors poses an extreme threat to life or remains for a long time
the persons progresses to the second stage.
2. Resistance Stage : During this stage the body stabilizes and
responds in an opposite manner to the alarms reactions. However if
the stressors remains and there is no adaptation the person enters the
third stage that is Exhaustation.
3. Exhaustation : If the stress is prolonged organisms reach the
exhaustion stage. The body is unable to defends it self against the
impact of events, Physiological regulation diminishes and if the stress
continues death my result.
Selye noted that a prolonged state of stress can cause disease as
a result of
 Increased level of powerful hormones
 Coping choices that are unhealthy such as not getting rest, diet
and use of tobacco.
 Neglect warning signs of illness
As Selye emphasized "Complete freedom from stress is death"

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 GENERAL ADAPTATION SYNDROME (GAS)
ALARM REACTION
1. Hypothalamus Recovery

2. Posterior pituitary
ADH water reassertion Resistance
Urine Output
1. Stabilization
3. Anterior Pituitary 2. Hormonal level Exhaustion
ACTH Adrenal Cortex return to normal
3. Para.symp.ne. 1.Decrease
Cortisol activity Energy Level
Glucogenesis 4. Adaptation to 2. Decrease
stressor Physiological
Protein catabolism
level
Fat Catabolism 3. Death
Aldosterone Sodium Reabsorption
Water reabsorption
Urine output
Potassium Excretion
4. Sympathetic N-system and A.M.
Epinephrine
Heart rate
O2 Intake
Blood Glucose
Mental Acuity
Nor Epinephrine
Blood Flow to skeletol muscles
Ateraial blood pressure
5. Fight or Flight Response

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 PSYCHOLOGICAL RESPONSES
The ability to respond adaptively to stress depends on previous
experience with positive stressor. In addition "Hardiness" is a
personality trait that defends a person against stressors. The Hardly
person believes that:-
 Life has meaning
 People can influence the environment.
 After the recognition of a stressor, an individual consciously or
unconsciously reacts to manage the situtations. This is called
the mediating process.

LAZARUS THEORY OF APPRAISAL OF THE STRESSFUL

EVENT
Cognitive appraisal is a process by which an event is evaluated with
respect to what is at stake (Primary appraisal) and what might can be
done (Secondary Appraisal)
Primary Appraisal: An out come of primary appraisal the situation is
identified as either stressful or non stressful. A stressful situation may
be one of three kinds:-
 One in which harm or loss occurred
 One that is threatening in that harm
 One that is challenging in that some opportunity or gain is
anticipated.
Secondary Appraisal : It is an evaluation of what might and can be
done about this situation.

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REAPPRAISAL
A change of opinion based on new information also occurs. The
appraisal process is not necessarily sequential, Primary, Secondary ad
reappraisal may occur simultaneously. The appraisal process contributes to
the development of an emotions. Negative emotions such as fear and anger,
positive emotions accompany challenge.
Another psychological adaptive behavior are also referred to as
mental mechanism. These mechanism are known as Ego Defense
Mechanism. Which First described by Sigmund Freud. These mechanism
are used by every one and help protect against feeling of worthlessness and
anxiety.
1) Rationalization:- Assigning logical reason for what we have done.
ex. A grapes are sore.
2) Projection:- It is a very popular method of resolving conflict in this
mechanism person blames another person for his own mistake ex.
Teacher failed me
3) Compensation:- It is a adjusting behavior by which tension or anxiety
in relived.
4) Displacement:- Emotional feelings is transferred to person or object
who are less dangerous than those who initially aroused the emotions.
5) Denial:- In this mechanism the individual does not accept the
existence of some thing that is disturbing. ex. The denial of illness is a
fairly common behavior pattern.
6) Substitution:- To reduce tension and to get satisfaction we substitute
our actions or aim.
7) Sublimation:- In which the primitive impulses are transferred to a
socially acceptable goal.
8) Repression:- Un acceptable feelings are unconsciously kept out of
awareness.

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10. DEFENSE AGAINST STRESSOR
FIRST LINE OF DEFENSE
The more common response of stressful situation anxiety and it arises
from the frustration and conflicts of life so psychological defense
mechanism are used to remove these anxiety.
When a person perceives that a stressor is overwhelming
against the psycho physiological response then disease may result.

SECOND LINE OF DEFENSE

Some stress responses may e so distressing that they demands the
persons attention. Three methods of stress, management, identified in
second line defense
1) Deal with the problem: by
 Identifying the source of the problem
 Changing the situation
 Changing our perception and
 Changing our response
2) Deal with the feeling: We deal with our attitude by acknowledging
identifying and expressing feelings
3) Reduce the physiological arousal by
 Resting
 Engaging in physical exercise
 Eating properly.
 Using relaxation technique.

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THIRD LINE DEFENSE
1) Professional help: Once serious illness develop the individual must
reach out beyond self help. At this point:
 Drug therapy
 Hospitalization
 Physical therapy
 Psycho therapy
 Crises intervention.
If professional help is not sought in time or it is inadequate chronic
disease may develop and death my result.

11. CONCEPT OF CRISES

Cruses is a movement or turning point, a situation in which turns o
event an decision determine whether the result will be better or worse.
A crises is a challenge, an opportunity for learning and growth.
We define a crises as disequilibrium in a steady state, occurring when the
usual problem solving strategies are infective.
ex.
 Sudden death of family member
 Chile abuse
 Serious accidents.
 Lost of job
 Rape
 Natural disaster.
In each case disequilibrium occur. These crises interrupt in normal
routine of our life.

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 If people is able to manage these crises they may be mentally healthy
and strong on other hand people who do not work through a dilemma will
find it more difficult to deal with feature problem.
Crises may be of two types:
 Maturational crises
 Situational crises.
Maturational Crises: These are stressful event that occur during each
person's developmental process for which the person has no coping skill.
In infancy, childhood, adolescence and adulthood.
Event that may lead to crises are usually related to family and poor
relationship.
Situational crises : These are usually sudden unexpected stressful event that
happen to an individual at any point of life and that can not be controlled by
individual.
Ex.
Divorce, Death, Natural Disaster.

CHARACTERISTICS OF CRISES
1. Crises is universal experience.
2. Crises is usually time limited.
3. All crises develop in a predictable manner.

PHASES OF CRISES
1. When a serious problem occur people become tense & used problem
solving technique
2. People grow more upset with each failure and enter in disequilibrium.

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3. As tension continue people re evaluate the problem and solve it with
new angle.
4. If the problem is not resolved emotional pressure continue and severe
anxiety or depression occur. Crises tend to occur in cycle with one
crises following another.

CRISES INTERVENTION:
People in crises display typical psychological and physiologic reactions.
1. Fear anxiety, Anger, Panic, Tension all these response activate fight
or flight mechanism.

HOPPING WITH POTENTIAL CRISES

Crises are preventable. The situation develops in to crises depend on three
factor:-
 Individual's perceptions.
 Available situational support.
 Coping mechanisms.

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12. STRESS MANAGEMENT:
Stress or potential for stress is every where, any where at once
Anxiety, frustration, anger powerlessness are emotions often
associated with stress. In the presence of these emotions activities of
daily life disturbed.
ex. Sleep disturbance, eating pattern disturb, Family routine disturb

ASSESSMENT :
1. Before interview assess physical signs like B.P. pulse and respiration
2. Establish trust with client.
3. Arrange non threatening physical environment.
4. Ask the client to share personal and sensitive information.
5. Observe non verbal behavior.
6. Interview to determine clients view.
7. Ask open question.

NURSING DIAGNOSIS
After analysing the collected data along with our knowledge and
experiences with client stress we are able to find the nursing diagnosis.
These are :-
 Anxiety,
 Care giver role strain.
 Compromise family coping
 In effective community coping
 Fear
 Chronic pain

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  Post trauma syndrome
 Powerlessness
 Disturbed sleep pattern
 Impaired social interaction.

PLANNING:
Goal and out comes:
 Effective coping
 Family coping
 Care giver emotional health
 Psychosocial adjustment life change.
Planning for nursing intervention may be within the frame work of
 Primary prevention
 Secondary prevention and
 Tertiary prevention

In primary prevention to identified the individual and population

who may be at risk to develop stress.
In secondary prevention action directed and symptoms such as
protecting client by self harm.
In tertiary prevention assisting the client in rehabilitating it include
relaxation training, Time management etc.

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SETTING PRIORITIES
Prioritizing needs has special meaning for a person experiencing
stress or crises. The question we ask to client is "What is happening in your
life that you need to come today"

CONTINUITY CARE
The nurse collaborate with:-
 Occupational therapists
 Dietitian
 Mental health nurse
 Psychiatrist
 Psychologist and
 Psychiatrist social worker

IMPLEMENTATION
1. Health promotion :-
It is primary mode of prevention of stress. It reduces the physiological
response to stress.
2. Regular exercise
 Improved muscles tone
 Improve posture
 Controls weight
 Reduce tension
 Promote relaxation
 Reduce Cardio vascular disease
 Improve Cardiopulmonary function

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3. Support systems:
 Family members and colleague who listen
 Emotional support
 Support group like mental health organization
4. Time management :
 It is a technique to performed work in order of priority to reduce
stress.
(i) Make a list of task
(ii) Classified the task as
 Routine task
 Immediate attention task
 Delayed task
 Not necessary task
5. Progress muscles relaxation
 Deep breathing
 Alternately tighten and relaxing special group of muscles
6. Assertiveness training:
It is skill for helping the individual to communicate effectively
regarding their needs and desire.
7. Journal writing:
With the help of writing client can express a full range of emotions
and feelings without hurting any one's feelings.

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13. STRESS MANAGEMENT IN WORK PLACE
Rapid changes in health technology diversity in workforce and
changing work system can place a stress on any one.
The stressor at work place are:
 Job assignment
 Difficult schedules
 Shift work
 Fear of failure
 In adequate support service
 Not knowing where you stand

BURNOUT Occurs as a result of chronic stress

SIGNS OF BURNOUT:
 Client realize that they are not performing up to standard
 Physical exhaustion
 Emotional exhaustion
 Blem them self
 Guilt feeling
 Decreased productivities and quality
 Frequent mistake
 Act of poor judgment
 Forget fullness
 Reduce attention
 Absenteeism & Lethargy

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PHYSICAL SIGNS
 Elevated blood pressure
 Increase muscles tension
 Headache
 Change in appetite
 Restless ness

EMOTIONAL SIGNS
 Irritability
 Depression
 Hostile and aggressive
 Feeling of worthlessness
 Hopelessness and helplessness

PREVENTION
 Recognize the problem and deal with the problem
 Self help Deal with our feelings
 Reduce the magnitude of stress response by appropriate activities like.
Join support group
Join exercise classes as Yoga, meditation aerobes
 Time management
 Assertive ness

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14. 5 R'S OF STRESS / ANXIETY REDUCTION
1. Recognition of the cause and sources of the threat
2. Relationships identified for support, help, reassurance
3. Removal from threat and stressor
4. Relaxation through techniques: meditation, massage breathing
exercise
5. Re-engagement

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 BIBLIOGRAPHY
1. Brunner and Siddarth's (2004) " Medical Surgical Nursing",
10th edition, Philadelphia, Lippincott, Pp 80-96
2. Black M Joyce & Hawks Hokason Jane, "Medical Surgical
Nursing" 7th edition, Pp 532-554.
3. Isaccs Amn & Shies Louse Rebracy, " Basic concept - mental
health nursing" 5th edition Lippincott, Pp 9-13
4. Luckman's and Sorensen, "Basic Nursing a Psychological
Approach", 3rd edition Pp 267-292
5. Potter A Patricia & Perry a Griffin, "Fundamentals of Nursing",
6th edition 2006, Pp 596-615
6. Potter A Patricia & Perry a Griffin, "Basic Nursing", 6th edition
2006, Pp 592-606
7. Williams & Berger, "Fundamentals of Nursing", 2nd edition,
Vol.-1, Pp 127-148
www.wikipedia "stress, coping and health study guide"

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 Stress Stressor
&
Stress Management for
Patient and Health Care
Professionals

GUIDE
ARCHNA SELVAN
Principal and Professor
KALPANA BORSE
Associate Professor

PRESENTED BY:

SANGEETA TIWARI
M.Sc. (N) Ist Year
19.12.2007

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