Download Overview of the Stress Response

Running head: STRESS
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Concept 15: Stress
Chelsea C Melrose
Ferris State University
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Abstract
The word stress has been used since the fourteenth century to describe hardship, difficulty, or
suffering (Giddens, 2013). Today, it is a common societal topic and is frequently used to
describe daily hardships felt by all people. There is not one agreed upon definition of stress,
however it is widely understood that stress is a pattern of physiologic and psychologic responses
determined through cognitive appraisals (Giddens, 2013). Stress is a normal process but can be
unhealthy when an individual cannot adapt and exhausts his or her coping resources. It is
important for nurses to be able to recognize when a stressor is beginning to negatively impact a
person’s health. Due to the fact that all individuals perceive stress differently and everyone
responds to stress in a unique way, nurses today are presented with the complex task of trying to
assess and determine the need for clinical management interventions for their patients. The
following paper will explore the pathophysiology of the stress response, how nurses can assess
patients for signs and symptoms of stress, and pharmacological options for treating chronic
stress.
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Concept 15: Stress
The word stress has been used since the fourteenth century to describe hardship,
difficulty, or suffering (Giddens, 2013). Today, it is a common societal topic and is frequently
used to describe daily hardships felt by all people. There is not one scientific definition of stress,
however Giddens (2013) defines stress as “a pattern of physiologic and psychologic responses
determined through cognitive appraisal” (p 280). Stress is a normal response triggered by an
outside stimulus that disturbs our physical or mental states. How individuals perceive stress
triggers is a unique process for each person, which makes stress hard for nurses to recognize
diagnose. Stress is a normal process but can be unhealthy when an individual cannot adapt and
exhausts his or her coping resources. The following paper will explore the pathophysiology of
the stress response, how nurses can assess patients for signs and symptoms of stress, and
pharmacological options for treating chronic stress.
Pathophysiology
According to McCance and Huether (2013), “stress and response is a universal
phenomenon that all people of all ages experience daily” (p 283). If a person has adequate
coping abilities to deal with the stress of daily life, the response does not negatively affect his or
her health. However, if stress becomes prolonged or chronic and the person has inadequate
coping abilities, there is a risk for the response to cause adverse health effects.
When a person is faced with an event or demand, their brain will appraise the event and
categorize it as being not stressful (requires no coping resources), challenging (requiring some
coping resources), or threatening (maxes out coping resources) (Giddens, 2013). If the event or
demand is perceived as the latter two, the brain initiates a response in the central nervous system
and endocrine system. The following sections will give a general overview of the stress response,
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will look at some hormones that are released during the response, how these hormones affect the
body during times of perceived stress, and how this negatively affects health.
Overview of the Stress Response
The body’s response to stress is meant to be a short-term reaction. When an event is
perceived as challenging or threatening, the sympathetic nervous system (SNS) takes control,
which triggers the fight-or-flight response. Once a threat is perceived, the body prepares to fight
its way out, or run away, from the stressor. Hundreds of years ago, stressors were primarily
physical, whereas today a majority of stressors are psychological (i.e. work, finances, families,
etc.). The problem is that these stressors are still perceived by the body as a threatening physical
event and the body reacts as such.
The HPA Axis. The hypothalamic, pituitary, adrenal (HPA) axis is our body’s central
nervous system response. When a person is faced with a stress trigger, the hypothalamus secretes
corticotrophin-releasing hormone (CRH), which binds to specific receptors on pituitary cells.
The pituitary cells produce adrenocorticotropic hormone (ACTH), which is transported through
the blood to the adrenal glands located on the top of the kidneys. The ACTH binds to specific
receptors on the adrenal glands, which leads to the release of glucocorticoid hormones (McCance
& Huether, 2013). Cortisol is the primary glucocorticoid steroid released as a result of this
process. Cortisol is released for several hours after encountering a stressor. At certain cortisol
levels in the bloodstream, the hypothalamus will reduce its output of CRH to help lower the
levels of ATCH and cortisol.
Cortisol. Cortisol is often referred to as the stress hormone. This is because cortisol
prepares the body for a fight-or-flight response by increasing glucose production to supply an
immediate energy source to large muscles. This process is done by tapping into protein stores via
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gluconeogenesis in the liver (Aronson, 2009). Cortisol also curbs functions that are considered
nonessential in a fight-or-flight scenario such as altering immune system responses and
suppressing the digestive system (Mayo Clinic, 2013).
The SNS Response. Corticotrophin-releasing hormone (CRH) also influences the
sympathetic nervous system response. The stress response isn’t always initiated by a challenging
life event, as perceived in mainstream society. Any time a person encounters a perceived threata large dog barks at you during a walk, for instance- the hypothalamus sets off the body’s alarm
system, initiating the responses described in the previous paragraph. When an event like this
occurs the adrenal gland also releases epinephrine (adrenaline) and norepinephrine as part of the
sympathetic nervous system (SNS) response. Epinephrine and norepinephrine are the hormones
responsible for the immediate reactions we feel when an event is perceived as threatening. The
two work together to prepare the body for immediate physical readiness to fight a perceived
threat. Epinephrine attempts to increase cardiac output by accelerating the heart, constricting
blood vessels, and inhibits tear production and salivation (Munch, 2011). Norepinephrine also
accelerates the heart and constricts blood vessels, but it also affects the part of the brain that
increases focus (Munch, 2011).
Effects on Health
The stress response is usually self-limiting, meaning once a perceived threat has passed
the hormone levels will return to normal. As the hormone levels return to normal, so does normal
body function. When stressors are always present and a person constantly perceives events as a
threat, their coping resources become maxed out. When this happens, the fight-or-flight reaction
stays on, which means cortisol, epinephrine and norepinephrine are continuously being released
and disrupting normal body processes. This puts individuals at risk for a number of health
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problems including (but not limited to): acute illness, digestive problems, heart disease, sleep
problems, and diabetes (Mayo Clinic, 2013). This long-term fight-or-flight response is affected
by our perception of stressful events, which determines the amount of stress hormones that are
secreted.
As discussed in the previous sections, Cortisol serves multiple functions in the stress
response. During a fight-or-flight response, immune responses are not necessary so cortisol
works to suppress this body process. Over time, this effort to quash the immune system can be
detrimental because it increases susceptibility to illnesses and disease (Aronson, 2013). Cortisol
also increases the level of glucose in the body to help increase energy stores. When cortisol is
being released continuously, blood sugar levels will be elevated. Theoretically, this puts people
at risk for type 2-diabetes because over long time periods, the pancreas struggles to keep up with
the high demand for insulin to counteract the high blood glucose levels (Aronson, 2013).
During a stress response, the sympathetic nervous system is turned on and the
parasympathetic nervous system (PNS) is turned off, because both cannot be on at the same time.
The PNS is important during quiet activities such as eating, because it allows enzymes and
hormones that control digestion and absorption to work at their peak performance (Aronson,
2013). The PNS is also in control during sleep, so when a person is experiencing chronic stress
the SNS doesn’t want to shut off and the individual isn’t able to sleep.
Another major health risk for those with chronic stress is heart disease. Cortisol and
norepinephrine constricts blood vessels and increases blood pressure to enhance the delivery of
oxygenated blood and increase cardiac output. This gives the body an advantage in fight-or-flight
situations, however it is not good in the long-term. Over time, this can lead to arterial damage
from prolonged hypertension.
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Physical Assessment
According to Giddens (2013), “individuals among all population groups experience risk
from stress throughout the lifespan” (p 282). As stated previously, stress and response is a
phenomenon that all people will experience. What makes stress a hard concept for nurses is that
all people will respond to stress differently and therefore will exhibit signs and symptoms
individually. It is important for nurses to recognize individuals who may be experiencing a
challenging or threatening stress response so that appropriate interventions can be initiated
(Giddens, 2013). Mental status examinations are one of the most complex exams a nurse will
perform (Ball et al, 2015).
History
When conducting a history, the nurse should ask about past and current states of health.
Past or current conditions that can be associated with chronic stress include peptic ulcers, stroke,
hypertension, and heart disease (Giddens, 2013). If symptoms are noted that can be related to
stress, the nurse should ask about the individual’s perception of the event to help link it to
physiologic responses. According to Giddens (2013), the following symptoms can be associated
with stress: abdominal pain, headaches, insomnia, lack of concentration, excessive sweating, hair
loss, skin eruptions, palpitations, tightening of the chest, and anxiety. If a patient presents with
anxiety, palpitations and insomnia, it would be appropriate to ask questions inquiring about
sources of stress (i.e. work, family, etc.) and how those sources of stress are perceived.
Examination
The signs and symptoms listed in the previous section are exam findings that can be
associated with the sympathetic nervous system response (Giddens, 2013). Unfortunately, these
signs and symptoms are not just associated with the stress response, which contributes to the
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difficulty in assessing patients. Therefore, if one or more of these symptoms are recognized in a
patient, the nurse should ask questions to try and recognize whether these symptoms are being
caused by stress. A priority of the exam should be an assessment of the signs and symptoms and
associating them with disease and/or dysfunction. For example, is the stress response so great
that it is interfering with a patient’s activities of daily living?
Patients may also display psychological symptoms such as anxiety, irritability, emotional
ups and downs, insomnia, poor concentration, and depression (Giddens, 2013). Nurses should be
observant throughout the exam noting how the patient is behaving, assessing how the patient is
dressed and/or groomed, and paying attention to whether or not the patient is cognitively
impaired. For nurses who work in physician offices, this can be compared with how the patient
looked and/or acted in previous encounters, because the nurse is familiar with the patient. For
nurses who have never encountered the patient before, this can be a harder task and will depend
heavily on good assessment skills.
Clinical Management
Clinical management of stress is guided by the signs and symptoms obtained during the
physical exam (Ball et al, 2015). The information gathered by the nurse will be used to determine
the severity of the stress response and what interventions need to be initiated. The goal of clinical
management is to prevent disease and dysfunction as well as to restore the patient to optimal
functioning (Giddens, 2013). This is done by utilizing a combination of prevention strategies,
medication treatments, and counseling. The following section will explore the pharmacological
options available to providers.
Pharmacology
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Unfortunately, there is not a drug or a group of drugs that can be taken to magically rid a
person of stress. However, there are medication categories that can be used to help with the
management stress and the symptoms patients are experience due to the stress response. Some
examples of medication categories that can be used to for stress management are
benzodiazepines, antidepressants, and beta-blockers.
Benzodiazepines. Benzodiazepines are a group of drugs used to help reduce anxiety that
have sedating effects. These drugs work quickly to relieve symptoms of stress and anxiety,
however they can become habit forming and have detrimental withdrawal symptoms (Ehrlich,
2012). As discussed in previous sections, a symptom of the stress response can be insomnia. This
is an example of a condition that this type of medication can help treat. Due to the addicting
nature of this drug group, these medications are typically prescribed for short-term use.
Examples of drugs in this category are: Xanax, Klonopin, Valium and Ativan.
Antidepressants. Antidepressants are a group of drugs that act on neurotransmitters that
may be involved in the stress response (Ehrlich, 2012). Drugs from this category are used for
more long-term treatment of stress and anxiety by acting as mood-stabilizers. Examples of drugs
from this category are: Cymbalta, Lexapro, Effexor and Paxil.
Beta-Blockers. Beta-blockers are typically prescribed to patients with heart conditions.
However, this group of medications can help relieve some physical symptoms that are caused by
the release of stress hormones (Ehrlich, 2012). The symptoms that beta-blockers help relieve are
rapid heart rate, shaking, sweating and tension (Ehrlich, 2012). Beta-blockers are not addictive
and do not cause drowsiness like the benzodiazepine drugs. Examples of drugs in this category
include: Inderal, Tenormin, and Lopressor.
Conclusion
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According to Giddens (2013), “individuals among all population groups experience risk
from stress throughout the lifespan” (p 282). How a person perceives their stress and copes with
the event or demand, determines how detrimental it can be to their health. The body’s stress
response is a complex process that involves multiple body organs and hormones. This response
was meant to be a short-term response to physical threats, however the world today presents
people with many psychological threats. These psychological threats are much more complex
and long-term than physical threats, which leads to our body’s stress response to remain on. The
hormones released during this response are good for fighting physical threats but can lead to
problems when on for a long time, such as acute illness, digestive problems, heart disease, sleep
problems, and diabetes (Mayo Clinic, 2013). It is important for nurses to remember that not
everything a person experiences leads to a threat and stress response that impacts health
(Giddens, 2013). However, it is important to recognize when a stressor is beginning to negatively
impact a person’s health. Due to the fact that all individuals perceive stress differently and
everyone responds to stress in a unique way, nurses are presented with the complex task of trying
to assess and determine the need for clinical management interventions for their patients.
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References
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Ball, J., Dains, J., Flynn, J., Solomon, B., & Stewart, R. (2015). Seidel's guided to physical
examination. (8 ed.). St. Louis, MO: Elsevier Mosby.
Ehrlich, S. (2012, July 3). Stress. Retrieved from
http://umm.edu/health/medical/altmed/condition/stress
Giddens, J. (2013). Concepts for nursing practice. St. Louis, MO: Mosby Elsevier.
Mayo Clinic. (2013, July 11). Why you react to life stressors the way you do. Retrieved from
http://www.mayoclinic.org/healthy-living/stress-management/in-depth/stress/art20046037?pg=2
McCance, K., & Huether, S. (2014). Pathophysiology: The biologic basis for disease in adults
and children. (7 ed.). St. Louis, MO: Elsevier Mosby.
Munch, J. (2011). Assessing and addressing the biological effects of stress in cancer patients.
Oncolog, 56(3), Retrieved from
http://www2.mdanderson.org/depts/oncolog/articles/11/3-mar/3-11-2.html