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Stress, Anxiety, Coping, and Adaptation Brenda McMillan RN, MS.

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2 Stress, Anxiety, Coping, and Adaptation Brenda McMillan RN, MS


4 Case Scenario: Stress, Coping, and Adaptation An 82-year-old male patient, recently diagnosed with Alzheimer’s disease, has been admitted to the hospital for pneumonia. The patient’s oldest daughter visits and expresses her concern to you that her father will have to move in with her family so she can take care of him. Her mother passed away 5 years ago, and her father has been living on his own since that time; however, his Alzheimer’s disease is progressing and he needs assistance. It is financially and emotionally difficult for the daughter to place him in assisted living type of facility. She also promised her mother before her death that she would take care of him. The daughter is feeling terribly stressed at the thought of how this will disrupt her family’s home life in addition to her father having to move from his home of 54 years.

5 Case Scenario: Stress, Coping, and Adaptation  Major nursing responsibilities associated with assisting patients to manage stress include assessing a patient’s ability to cope with stressors, identifying personal factors that could interfere with coping, promoting effective coping and stress management, and implementing nursing interventions to modify coping as the situation warrants.  Once you have completed this lecture and have incorporated stress, coping, and adaptation into your knowledge base, review the above scenario and reflect on the following areas of Critical Thinking:

6 Case Scenario: Stress, Coping, and Adaptation  1. Clarify how you will proceed with this assessment.  2. Identify potential stressors to the people in the situation.  3. Identify factors that may affect the daughter’s coping behaviors.  4. Explore factors that place this family at risk for dysfunctional coping.  5. Describe possible manifestations of altered coping in this scenario.  6. Based on the information, plan appropriate nursing interventions.

7 Stress, Anxiety, Coping, and Adaptation  Stress is the body’s physiological reaction to any stimulus that evokes a change.  A stressor is any situation, event, or agent that threatens a person’s security.  A certain amount of stress is necessary for survival.


9 Stress Defined  An adaptive response, moderated by individual differences that is the consequence of any action, situation or event that places special demands on a person  Holistic effects

10 Stress Defined  Stress is a condition or feeling experienced when a person perceives that “demands exceed the personal and social resources the individual is able to mobilize.”  In less formal terms, we feel stressed when we feel that “things are out-of-control”.

11 Stress, Anxiety, Coping, and Adaptation  Anxiety is a vague, nonspecific, uncomfortable subjective response as the result of a perceived or actual threat to one’s biologic, psychologic, or social integrity.  Anxiety is a pervasive feeling of dread or apprehension.

12 Stress, Anxiety, Coping, and Adaptation  Coping is a complex of behavioral, cognitive, and physiologic responses that aim to prevent or minimize unpleasant or harmful experiences that challenge one’s personal resources.

13 Stress, Anxiety, Coping, and Adaptation  Adaptation is an ongoing process by which individuals adjust to stressors in order to achieve homeostasis.  Homeostasis is the equilibrium between physiological, psychological, sociocultural, intellectual, and spiritual needs.

14 Sources of Stress  Individuals experience stress primarily from their bodies, their thoughts, and the environment.  A situation or event that evokes stress in one person, may not affect another person.

15 What are some of the common unpleasant stresses in our lives?  Illness  Unemployment  Conflict  Increasing demands  Crime  Death  Information overload

16 What are some of the common pleasant stresses in our lives?  Retirement  Vacation  New baby  Moving  New job  New phase of life  Children leaving home  Family visits

17 Response to Stress One of the pioneers in stress research, Hans Selye, defined stress as the “nonspecific response of the body to any demand made upon it”. By “nonspecific” he meant that the same pattern of response could be produced by any number of stressful stimuli.

18 Factors affecting the level of stress felt by an individual Perception of Stressor Coping Skills Personality and Behavior

19 Type A Behavior Pattern Highly competitive, achievement oriented Quick motor movements Constant sense of time urgency, unrelenting drive Sense of guilt when relaxing or slowing down Hurried, explosive speech patterns Aggressive, restless and impatient manner

20 Homeostasis Maintenance of Internal Equilibrium Insulin secretion Blood glucose level decreases Glucagon secretion Blood glucose level increases



23 Responses to Stress  Every individual has unique responses to stress.  A person’s response to stress is influenced by mental attitude, lifestyle, perception, and heredity.


25 50 Common Signs and Symptoms of Stress Frequent headaches, jaw clenching or pain Gritting, grinding teeth Stuttering or stammeringTremors, trembling of lips, hands Neck ache, back pain, muscle spasmsLight headedness, faintness, dizziness Ringing, buzzing or “popping soundsFrequent blushing, sweating Cold or sweaty hands, feet Dry mouth, problems swallowing Frequent colds, infections, herpes sores Rashes, itching, hives, “goose bumps” Unexplained or frequent “allergy” attacksHeartburn, stomach pain, nausea Excess belching, flatulence Constipation, diarrhea, loss of control Difficulty breathing, frequent sighing Sudden attacks of life threatening panic attacks

26 50 Common Signs and Symptoms of Stress Chest pain, palpitations, rapid pulseFrequent urination Diminished sexual desire or performanceExcess anxiety, worry, guilt, nervousness Increased anger, frustration, hostilityDepression, frequent or wild mood swings Increased or decreased appetiteInsomnia, nightmares, disturbing dreams Difficulty concentrating, racing thoughts Trouble learning new information Forgetfulness, disorganization, confusionDifficulty in making decisions Feeling overloaded or overwhelmedFrequent crying spells or suicidal thoughts Feelings of loneliness or worthlessnessLittle interest in appearance, punctuality Nervous habits, fidgeting, feet tappingIncreased frustration, irritability, edginess

27 50 Common Signs and Symptoms of Stress Overreaction to petty annoyances Increased number of minor accidents Obsessive or compulsive behaviorReduced work efficiency or productivity Lies or excuses to cover up poor work Rapid or mumbled speech Excessive defensiveness or suspiciousnessProblems in communication, sharing Social withdrawal and isolationConstant tiredness, weakness, fatigue Frequent use of over-the-counter drugsWeight gain or loss without diet Increased smoking, alcohol or drug use Excessive gambling or impulse buying

28 How are Stress and Health Related? Holmes and Raye  More than 200 points on the Social Readjustment Assessment Scale in one year was associated with an increased incidence of  Myocardial infarction, Psychiatric illness, Peptic ulcer disease, Infection

29 Responses to Stress  Manifestations of Stress  Physiological  Psychological  Cognitive  Behavioral  Spiritual

30 Responses to Stress  Physiological Response to Stress  General Adaptation Syndrome (GAS)  Alarm  Resistance  Exhaustion





35 Outcomes of Stress  Anxiety  Behavioral responses observed in the anxious person are personal and interpersonal.  Usually accompanied by other closely connected emotions such as anger, guilt, hostility, or depression.

36 Levels of Anxiety Mild Moderate Severe Panic

37 Outcomes of Stress  Coping Behaviors  Problem-focused mechanisms  Cognitively-focused mechanisms  Emotion-focused use of ego-defense mechanisms

38 Outcomes of Stress  Defense Mechanisms  Protective mechanisms against feelings of inadequacy and unworthiness.  Thought to safeguard against feelings and thoughts that are too difficult for the conscious mind to deal with.  Some are automatic responses.  Other responses are purposeful and planned.

39 Top 7 Psychological Defense Mechanisms  Rationalization  Identification  Displacement  Projection  Regression  Reaction Formation  Repression


41 Rationalization

42  Rationalization is a defense mechanism that involves explaining an unacceptable behavior or feeling in a rational or logical manner, avoiding the true reasons for the behavior. For example, a person who is turned down for a date might rationalize the situation by saying they were not attracted to the other person anyway, or a student might blame a poor exam score on the instructor rather than his or her lack of preparation.  Rationalization not only prevents anxiety, it may also protect self- esteem and self-concept. When confronted by success or failure, people tend to attribute achievement to their own qualities and skills while failures are blamed on other people or outside forces.

43 Identification

44  Identification can be an attempt to overcome inferiority by taking on the characteristics of someone important, such as a parent or teacher, but it is often part of a more natural development process. In the former, the individual feels that doing so will help her to be perceived as worthwhile, and self- worth is enhanced.  Identification is adaptive in that it creates a process of assuming culturally appropriate behaviors, but it can also be negative when it is used to mask feelings of inferiority.

45 Displacement

46  Displacement  Have ever had a really bad day at work and then gone home and taken out your frustration on family and friends? Then you have experienced the ego defense mechanism of displacement. Displacement involves taking out our frustrations, feelings, and impulses on people or objects that are less threatening. Displaced aggression is a common example of this defense mechanism. Rather than express our anger in ways that could lead to negative consequences (like arguing with our boss), we instead express our anger towards a person or object that poses no threat (such as our spouse, children, or pets).

47 Projection

48  Projection  Projection is a defense mechanism that involves taking our own unacceptable qualities or feelings and ascribing them to other people. For example, if you have a strong dislike for someone, you might instead believe that he or she does not like you. Projection works by allowing the expression of the desire or impulse, but in a way that the ego cannot recognize, therefore reducing anxiety.

49 Regression

50  When confronted by stressful events, people sometimes abandon coping strategies and revert to patterns of behavior used earlier in development. Anna Freud called this defense mechanism regression, suggesting that people act out behaviors from the stage of psychosexual development in which they are fixated. For example, an individual fixated at an earlier developmental stage might cry or sulk upon hearing unpleasant news.  Behaviors associated with regression can vary greatly depending upon which stage the person is fixated at:  An individual fixated at the oral stage might begin eating or smoking excessively, or might become very verbally aggressive.  A fixation at the anal stage might result in excessive tidiness or messiness.

51 Reaction Formation

52  Reaction formation reduces anxiety by taking up the opposite feeling, impulse or behavior. An example of reaction formation would be treating someone you strongly dislike in an excessively friendly manner in order to hide your true feelings. Why do people behave this way? According to Freud, they are using reaction formation as a defense mechanism to hide their true feelings by behaving in the exact opposite manner.

53 Repression

54  Repression is another well-known defense mechanism. Repression acts to keep information out of conscious awareness. However, these memories don't just disappear; they continue to influence our behavior. For example, a person who has repressed memories of abuse suffered as a child may later have difficulty forming relationships.  Sometimes we do this consciously by forcing the unwanted information out of our awareness, which is known as suppression. In most cases, however, this removal of anxiety-provoking memories from our awareness is believed to occur unconsciously.

55 Sublimation  Sublimation is a defense mechanism that allows us to act out unacceptable impulses by converting these behaviors into a more acceptable form. For example, a person experiencing extreme anger might take up kick-boxing as a means of venting frustration. Freud believed that sublimation was a sign of maturity that allows people to function normally in socially acceptable ways.

56 Denial  Denial is probably one of the best known defense mechanisms, used often to describe situations in which people seem unable to face reality or admit an obvious truth (i.e. "He's in denial."). Denial is an outright refusal to admit or recognize that something has occurred or is currently occurring. Drug addicts or alcoholics often deny that they have a problem, while victims of traumatic events may deny that the event ever occurred.

57 Intellectualization  Intellectualization works to reduce anxiety by thinking about events in a cold, clinical way. This defense mechanism allows us to avoid thinking about the stressful, emotional aspect of the situation and instead focus only on the intellectual component. For example, a person who has just been diagnosed with a terminal illness might focus on learning everything about the disease in order to avoid distress and remain distant from the reality of the situation.

58 Stress and Illness  Illness occurs when a person’s adaptive attempts are unsuccessful.  A major outcome of prolonged periods of stress is impairment of the immune system.  The body is less able to protect itself from disease.

59 Impact of Illness and Treatment  Hospitalization, surgery, and long-term care admission are major disruptions that can evoke the stress response.  An unfamiliar environment, loss of control over one’s schedule, and being dependent on others for care require adaptation in order to maintain a steady state.

60 Impact of Illness and Treatment  Some cues that a person may be reacting adversely to hospitalization  Increased stress response  Higher levels of anxiety  Increased or impaired use of coping mechanisms  Inability to function  Disorganized behavior

61 Stress and the nursing process Assessment Nursing history p. 1590 focused assessment guide 41-1 Standardized tests Open ended questions PE to look for indicators of stress

62 Assessment  Patterns of stressors  Typical responses to stressful situations  Cause-and-effect relationships between stressors and thoughts, feelings, and behaviors  Past history of successful coping mechanisms

63 Nursing Diagnoses  Anxiety  Ineffective Coping  Ineffective Denial  Powerlessness  Impaired Adjustment  Ineffective Role Performance

64 Nursing Diagnoses  Disturbed Thought Processes  Defensive coping  Fear  Post-Trauma Syndrome  Impaired Social Interaction  Spiritual Distress  Risk for Violence

65 Outcome Identification and Planning  The nurse should work with the client in coping with their crises by establishing outcomes together.  Helping clients learn to cope successfully is part of the empowerment process.

66 Nursing process Outcome identification/planning  Identify goal and time frame for achieving goal  Example: The patient will verbalize a decreased level of anxiety by discharge.  The patient will state 3 methods to cope with stress at the end of the teaching session.

67 Nursing process Implementation  Guidelines for nursing care pp1591-1594 (Taylor)  Examples p. 1591 (Taylor)

68 Implementation  Meeting Basic Needs  Environmental Strategies  Verbalization  Involvement of Family and Significant Others

69 Implementation  Stress Management Techniques  Exercise  Relaxation Techniques  Progressive Muscle Relaxation  Guided Imagery  Cognitive Reframing or Thought Stopping  Rapid Relaxation Response  Keeping a Stress Diary

70 Implementation  Crisis Intervention  Identification of the Problem  Identification of Alternatives  Selection of an Alternative  Implementation  Evaluation

71 Evaluation  Evaluating the effectiveness of a client’s coping abilities is an ongoing, comprehensive process that must include client input.

72 Nursing process Evaluation  Observe verbal and non verbal cues  Goal met: The patient identified and utilized sources of support to cope with stress at the end of the teaching session.  Goal met: The patient verbalized a decrease I anxiety and an increase in anxiety on discharge.

73 What is a Crisis?  Crisis can be defined several ways.  It is a turning point in a person’s life, a stressful life experience affecting the stability of an individual so that their ability to cope or even function may be seriously compromised or impaired.  It is a hazardous situation that is itself, in terms of the person’s perception, a precipitant; dimensions of the event are an integral part of the experience.

74 What is Crisis?  Crisis is a temporary state of upset, disequilibrium, accompanied by confusion and disorganization. The disorganization may be integral to reducing problem-solving abilities to a point that traditional management strategies may not be effective.

75 Types of Crises  Crises are time-limited, and involve a precipitating event. They can be situational as well as developmental. There is a cognitive key: perception and expectations. Crisis is a state of disorganization and disequilibrium. Crisis brings about vulnerability and reduced defensiveness, as well as a heightened state of suggestibility. Crisis also involves a breakdown in coping. Crisis is not mental illness, and it should not be confused as such.

76 Crisis Intervention  The principal goal of crisis intervention is to facilitate the regaining of the level of functioning (as close as possible) that there was before the event, restoring equilibrium. But even with effective intervention, people rarely go back to exactly the way they were before. The event becomes a milestone that defines their lives.

77 Panic Attacks and Panic Disorder  A panic attack is a sudden episode of intense fear that triggers severe physical reactions when there is no real danger or apparent cause. Panic attacks can be very frightening. When panic attacks occur, the client might think they're losing control, having a heart attack or even dying.

78 Panic Attack Symptoms  Panic attacks typically begin suddenly, without warning.  They can strike at almost any time — when you're driving the car, at the mall, sound asleep or in the middle of a business meeting.  Panic attacks have many variations, but symptoms usually peak within 10 minutes.  You may feel fatigued and worn out after a panic attack subsides.

79 Panic Attack Symptoms Panic attacks typically include a few or many of these symptoms: Sense of impending doom or dangerFear of loss of control or death Rapid heart rateSweating TremblingShortness of breath HyperventilationChills Hot flashesNausea Abdominal crampingChest pain HeadacheDizziness FaintnessTightness in your throat Trouble swallowing

80 Complications of Panic Attacks  Left untreated, panic attacks and panic disorder can result in severe complications that affect almost every area of your life. You may be so afraid of having more panic attacks that you live in a constant state of fear, ruining your quality of life.  Complications that panic attacks may cause or be linked to include:  Development of specific phobias, such as fear of driving or leaving your home  Avoidance of social situations  Problems at work or school  Depression  Increased risk of suicide or suicidal thoughts  Alcohol or substance abuse  Financial problems

81 Stress Management Techniques  Meditation  Yoga, Pilates, and Thai Chi  Music Therapy  Cognitive Therapy  Stress Diary*  Visualization and Guided Imagery  Hypnosis

82 Stress Management Techniques  Religious/Spiritual Practices  Distraction and Humor  Food and Pets as Stress Relief

83 Nurses & Burnout Syndrome


85  Emotional Exhaustion  Attitudinal Exhaustion  Feelings of low personal accomplishment  Physical exhaustion

86 Personal Stress Management Approaches for the Nurse  Nurses must cope successfully with stress in order to maintain their own wellness, and to model health- promoting behaviors to others.

87 Burnout and Nurses  Burnout occurs when the nurse is overwhelmed by stress.  As a result, the nurse experiences physical, emotional, and behavioral dysfunction, including decreased productivity.

88 Burnout and Nurses  Phases of Burnout  Initial feeling of enthusiasm for the job  Loss of enthusiasm  Continuous deterioration  Crisis  Inability to work effectively

89 Personal Stress Management Approaches for the Nurse  Humor helps nurses manage the stress created by the nature and intensity of their work.

90 Personal Stress Management Approaches for the Nurse  Stress Hardiness  Nurses who cultivate hardiness will likely be resilient to stress.  The three components to stress hardiness are commitment, challenge, and control.

91 Personal Stress Management Approaches for the Nurse  Exercise  Relaxation techniques  Environment changes  Journaling  Writing poetry  Hobbies as health promoting strategies

92 An unemployed, single woman is seen at a prenatal visit. Which of the following assessment findings would indicate the effects of chronic stress? a. Elevated blood glucose b. Decreased immune response c. Dilated pupils d. Rapid breathing Question  An unemployed, single woman is seen at a prenatal visit. Which of the following findings would indicate the presence of chronic stress? A.Elevated blood glucose B.Decreased immune response C.Dilated pupils D.Rapid breathing pattern

93 Critical Thinking Challenge  Kathleen O’Brien, a registered nurse and staff member at a clinic, is sitting in the break room alone one morning, looking sad and preoccupied. Jean enters to get a cup of coffee.



96 Critical Thinking Challenge



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