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Running head: STRESS 1 Concept 15: Stress Chelsea C Melrose Ferris State University STRESS 2 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. STRESS 3 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, STRESS 4 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 STRESS 5 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 STRESS 6 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. STRESS 7 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 STRESS 8 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 STRESS 9 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 STRESS 10 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. STRESS 11 References Aronson, D. (2009, November). Cortisol: Its role in stress, inflammation, and indications for diet therapy. Today’s Dietitian, 11(11), Retrieved from http://www.todaysdietitian.com/newarchives/111609p38.shtml 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