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Chapter 37
Stress and Coping
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Scientific Knowledge Base
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Fight-or-flight
response
Neurophysiological
responses:
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Medulla oblongata
Reticular formation
Pituitary gland
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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General Adaptation Syndrome (GAS)
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An immediate physiological response of the
whole body to stress; involves several body
systems, especially the autonomic nervous
and endocrine systems, and includes
immunological changes
A three-stage reaction to stress:
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Alarm reaction
 Resistance stage
 Exhaustion stage
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Quick Quiz!
1. You are a nurse working in the college
student health center. You receive a call that
an athlete has just fallen and has been
injured. You know that according to the
general adaptation syndrome, the athlete will
be exhibiting
A. An increased appetite.
B. An increased heart rate.
C. A decrease in perspiration.
D. A decrease in respiratory rate.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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General Adaptation Syndrome
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Psychological stress
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Primary appraisal
Secondary appraisal
Coping
Personal characteristics that influence
response to a stressor:
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Level of personal control
Presence of a social support system
Feelings of competence
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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General Adaptation Syndrome
(cont’d)
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Primary appraisal: evaluating an event for
its personal meaning
Secondary appraisal: focuses on possible
coping strategies
Coping: the person’s effort to manage
psychological stress
Ego-defense mechanisms: regulate
emotional distress and give a person
protection from anxiety and stress
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study
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Rachael Bennett, a 32-year-old married
mother of three children, works as the nurse
manager in a medical intensive care unit.
Recently, patient and staff satisfaction has
been declining, and Rachael feels pressured
to improve the satisfaction scores. In addition,
within the past year Rachael’s husband has
had several hospitalizations related to heart
disease, and he is unable to work.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Types of Stress
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Chronic
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Chronic stress occurs in stable conditions and
results from stressful roles.
Acute
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Time-limited events that threaten a person for a
relatively brief period provoke acute stress.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study (cont’d)
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Until recently, Rachael has felt very happy
with her job. For the past 6 weeks, she has
been feeling defeated and hopeless; she has
no energy; and she has difficulty organizing
her thoughts.
When her supervisor noticed Rachael’s
frequent severe headaches, reported lack of
sleep, and use of wine at night to relax, she
referred her to the hospital’s employee health
office to help her cope with her stress.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Types of Stress
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Posttraumatic stress disorder:
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An acute stress disorder that begins when a
person experiences, witnesses, or is confronted
with a traumatic event
May include flashbacks = Recurrent and intrusive
recollections of the event
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Types of Crises
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Developmental
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Situational
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Developmental crises occur as a person moves
through the stages of life.
External sources such as a job change, motor
vehicle crash, death, or severe illness provoke
situational crises.
Adventitious
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A major natural or man-made disaster or a crime
of violence can create an adventitious crisis.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Quick Quiz!
2. A patient comes into the emergency
department complaining of chest pain. When
discussing possible reasons why the chest
pain has occurred, the nurse learns that the
patient is depressed because of the loss of a
job. This type of crisis can be classified as
A. Maturational.
B. Situational.
C. Sociocultural.
D. Posttraumatic.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Nursing Knowledge Base:
Nursing Theory and Role of Stress
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Neuman systems model:
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Based on the concepts of stress and reaction to
stress
Nurses develop interventions to prevent or reduce
stress on patients or to help them cope.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Nursing Knowledge Base: Nursing
Theory and Role of Stress (cont’d)
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Neuman systems model
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Primary prevention promotes patient wellness by
stress prevention and reduction of risk factors.
Secondary prevention occurs after symptoms
appear.
Tertiary prevention begins when the patient’s
system becomes more stable and recovers.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Nursing Knowledge Base:
Factors Influencing Stress and Coping
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Situational factors
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Maturational factors
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Arise from job changes, illness, caregiver stress
Vary with life stages
Sociocultural factors
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Environmental, social, and cultural stressors
perceived by children, adolescents, and adults
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Critical Thinking
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Keep in mind the neurophysiological changes
the patient may be experiencing.
Use clear communication principles.
Be confident.
Utilize the Standards of Care for Psychiatric
Mental Health Nursing Practice (ANA).
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Nursing Process
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Assessment
Nursing diagnosis
Planning
Implementation
Evaluation
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Nursing Process: Assessment
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See through the patient’s eyes:
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Gather information (including patient’s perception).
Synthesize the information.
Apply critical thinking.
Subjective findings
Objective findings
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study (cont’d)
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Becky Howard, a nurse practitioner in the employee health
office, does preliminary screening and crisis intervention with
staff members experiencing stress and potential substance
abuse problems.
Becky wants to be thorough in assessing the responses and
symptoms Rachael has been experiencing.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Nursing Process: Nursing Diagnosis
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Nursing diagnoses for stress:
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Coping
Ineffective coping
Multiple diagnoses
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study (cont’d)
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During her assessment, Becky observes that
Rachael fidgets, uses poor eye contact, and
bursts into tears and expresses feelings of
being overwhelmed.
Rachael’s vital signs show changes in
response to stress.
She has lost weight and has trouble sleeping.
She expresses shame at not coping better
and admits to drinking at night to “unwind.”
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Nursing Process: Planning
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Goals and outcomes
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Desirable outcomes frequently include
• Effective coping, family coping, caregiver emotional
health, and psychosocial adjustment: life change
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Setting priorities
Teamwork and collaboration
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study (cont’d)
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Becky’s goal is that Rachael will manage the
stressors that have been taxing her individual
resources.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Nursing Process: Implementation
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Health promotion
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Regular exercise
Support systems
Time management
Guided imagery and
visualization
Progressive muscle
relaxation
Assertiveness training
Journal writing
Stress management in
the workplace
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Nursing Process: Implementation
(cont’d)
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Crisis: When stress overwhelms a person’s
usual coping mechanisms and demands
mobilization of all available resources, the
situation becomes a crisis.
Acute care
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Crisis intervention
Restorative and continuing care
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study (cont’d)
Goal
Expected Outcomes (NOC)
Coping • Rachael will differentiate effective and
ineffective coping patterns.
• Rachael will verbalize a decrease in
stress.
• Rachael will modify her lifestyle to
reduce stress.
• Rachael will use her personal support
system.
• Rachael will verbalize the need for
assistance.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Nursing Process: Evaluation
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Through the patient’s eyes:
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Has stress been reduced?
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study (cont’d)
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Rachael has taken steps to manage her
stress:
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She appears less anxious.
She is eating healthy foods and is no longer
drinking to reduce her stress.
During the past week, she began to sleep through
the night.
She has resumed a friendship with a neighbor.
She now asks for assistance from her husband at
home and her coworkers at work.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Nursing Process: Evaluation
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Patient outcomes:
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Measure outcomes for each diagnosis.
Maintain communication.
Continually assess needs for additional support.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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