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Stress and coping


									          Stress and Adaptation

Dr. Belal Hijji, RN, PhD
April 21 & 22, 2012
                     Learning Outcomes

By the end of this lecture, students will be able to:
• Define stress, stressors and prons and cons of stress
• Identify types of stressors
• Discuss the psychological and physiological human responses
  to stress
• Describe factors influencing response to stress
• Discuss the various situational, maturational, and sociocultural
  factors related to stress.
• Describe the nursing implications associated with stress.

             Definition of Stress and Stressors

• Stress: Stress is a state produced by a change in the
  environment that is perceived as challenging, threatening, or
  damaging to the person’s dynamic balance. The change that
  evokes this state is the stressor, which is a disruptive [‫]معطلة‬
  force operating within or on any system.
• A person appraises [evaluates the significance] and copes
  [deals with and attempts to overcome problems and
  difficulties] with changing situation. The desired goal is
  adaptation, or adjustment to the change so that the person is
  again in equilibrium and has the energy and ability to meet
  new demands. This is the process of coping with the stress, a
  compensatory process with physiologic and psychological
                  Prons and Cons of Stress

• Stress can stimulate thinking processes and help a person to
  stay alert to environment.
• Stress is necessary for survival; it can provide stimulation and
• Stress can cause discomfort and retreat.

                       Types of Stressors
• Stressors may be described as physical, physiologic, or
   – Physical stressors include cold, heat, and chemical agents.
   – physiologic stressors include pain and fatigue.
   – Examples of psychosocial stressors are fear of failing an
     examination and losing a job.
• Stressors can also occur as normal life transitions, such as
  going from childhood into puberty, getting married, or giving
• Stressors have also been classified as: (1) day-to-day
  frustrations; (2) major complex occurrences involving even
  entire nations; and (3) stressors that occur less frequently and
  involve fewer people.

                     Types of Stressors
– The day-to-day stressors include common occurrences such as
  traffic jam, computer downtime, and having an argument with a
  spouse. These daily stressors have been shown to have a greater
  health impact than major life events because of the cumulative
  effect they have over time. They can lead to high blood pressure
  or palpitations.
– The second group of stressors influences larger groups of people,
  or the entire nation. These include events of history, such as
  terrorism and war, which are threatening situations when
  experienced either directly, in the war zone, or indirectly, as
  through live news coverage.
– The third group of stressors concerns relatively infrequent
  situations that directly affect the individual. This category
  includes the influence of life events such as death, birth,
  marriage, divorce, and retirement. More enduring chronic
  stressors have also been placed in this category and may include
  such things as having a permanent functional disability or coping
  with the difficulties of providing long-term care to a frail elderly
              Psychological Response to Stress

• After the recognition of a stressor, an individual consciously or
  unconsciously reacts to manage the situation. This is called the
  mediating process. A theory developed by Lazarus emphasizes
  cognitive appraisal and coping as important mediators of stress.
   – Appraisal of the stressful event: Cognitive appraisal is a process
     by which an event is evaluated with respect to what is at stake
     [degree of risk] (primary appraisal) and what might and can be
     done (secondary appraisal). What individuals see as being at stake
     includes how important the event is to them, whether the event
     conflicts with what they want or desire, and whether the situation
     threatens them.
   – As an outcome of primary appraisal, the situation maybe stressful.
     A stressful situation may be one of three kinds: (1) one in which
     harm has occurred; (2) one in which harm is anticipated; and (3)
     one in which some opportunity or gain is anticipated.

            Psychological Response to Stress
– Secondary appraisal is an evaluation of what might and can be
  done about this situation. Actions include assigning blame to
  those responsible for a frustrating event and thinking about
  whether one can do something about the situation (coping
  potential) A comparison of what is at stake and what can be done
  about it determines the degree of stress.
– Coping with a stressful event: Coping refers to a person’s effort to
  manage psychological stress. Or, as a behaviour that protects
  people from being psychologically harmed by problematic social
  experiences. Coping serves a protective function that can be
  exercised by eliminating or modifying stressful conditions.
  Coping allows people to use various skills to manage the
  difficulties they face in life. Coping may be emotion focused or
  problem-focused and both usually occur in a stressful situation.
  Both types are discussed next.

        Psychological Response to Stress
• Emotion - focused coping seeks to make the person feel better by
  lessening the emotional distress felt. It is most useful when the
  individual appraises the experience as one for which nothing can
  be done to modify the event or stressor, or when the stressor is
  transitory and will resolve itself. There are many such coping
  strategies including avoidance, minimization, distancing, and
  finding positive value in negative events. For a diabetic for
  example, avoidance of managing diabetes (not performing blood
  glucose testing or administering injections) provides a way of
  coping with the emotional distress of being different from one's
• Problem-focused coping aims at solving the problem that faces
  the person and is most likely to be used when the stressor is
  appraised by the individual as amenable to change. For a diabetic
  client for example, problem-oriented coping strategies may be
  used in managing difficult eating situations. Even if the situation
  is viewed as challenging or beneficial, coping efforts may be
  required to develop and sustain the challenge— that is, to
  maintain the positive benefits of the challenge and to ward off
  any threats. In harmful or threatening situations, successful
  coping reduces or eliminates the source of stress and relieves the
  emotion it generated.                                               9
             Physiological Response to Stress
• The physiologic response to a physical or a psychological
  stressor is a protective and adaptive mechanism to maintain the
  homeostatic balance of the body. The response occurs through
  two mechanisms known as the general adaptation syndrome
  (GAS) and local adaptation syndrome.
• About 70 years ago, Walter Cannon proposed the fight-or-
  flight-response to stress, which is the arousal of the autonomic
  nervous system.
• This arousal prepares a person for action by increasing HR;
  diverting blood to the brain and striated [cardiac & skeletal]
  muscles; increasing BP, HR, RR, and blood glucose.
• Later on, Seyle (1991) expanded Cannon’s hypothesis by
  suggesting the GAS, which describes how the body responds to
  stressors through 3 stages described next.
            The General Adaptation Syndrome
• Alarm reaction: Hormonal levels increase resulting in
  increased blood volume, blood glucose levels, epinephrine and
  norepinephrine amounts, HR, blood flow to muscles, oxygen
  intake, and mental alertness. This change in body systems
  prepares a person for fight or flight and may last from 1
  minute to many hours. If the stressor poses an extreme threat
  to life or persists for long time, the person progresses to the
  second stage.
• Resistance stage: In this stage, the person stabilises and
  responds in an opposite manner to the first stage. If the stressor
  persists without any adaptation, the person progresses to the
  third stage.
• Exhaustion stage: Occurs when the body can no longer resist
  the effects of the stressor and when the energy necessary to
  maintain adaptation is depleted. The body is unable to defend
  itself against the impact of the event.
              The Local Adaptation Syndrome
• According to Selye’s theory, a local adaptation syndrome
  occurs and includes the inflammatory response and repair
  processes that occur at the local site of tissue injury. The
  syndrome occurs in small, topical injuries, such as contact
  dermatitis. If the local injury is severe enough, the general
  adaptation syndrome is activated as well.
• Selye emphasized that stress is the nonspecific response
  common to all stressors, whether they are physiologic,
  psychological, or social.

         Factors Influencing Response to Stress
• Intensity: The greater the magnitude of the stressors, the
  greater the response to it.
• Scope: The greater the scope of a stressor, the greater the
  stress response.
• Duration: The greater the length of time of stress, the greater
  the person’s response to it.
• Number and nature of other stressors present: Multiple
  stressors experienced simultaneously or a succession of single
  stressors with no opportunity to rest results in greater stress
• Predictability: Anticipating a stressor, even without ability to
  control it, generally results in reduced experience to stress.

• Level of personal control: Believing that one has control over
  an unpleasant experience, even if that control never exercised
  or the belief is erroneous, lessens the level of stress & anxiety.
• Feeling of competence: Greater self-confidence in one’s ability
  to manage a stressful event results in less tension and anxiety.
• Cognitive appraisal: The greater the personal meaning of an
  event, the greater the stress associated in different people.
• Availability of social support: The emotional concern and
  support from others reduce the negative effects of stress.

   Situational, Maturational, and Sociocultural Factors
                    Related to Stress
• Situational factors: Situational stress can arise from job changes and
  relocation, adjusting to chronic illness, or being a family caregiver
  for someone with chronic illness.
• Maturational factors: Stressors depend on the developmental stage.
  Preadolescents experience stress related to self-esteem, changing
  family structure, or hospitalisations. Stress for adults centre around
  major changes in life circumstances. These include beginning a
  family and a career, losing parents, seeing children leave home, and
  accepting physical aging.
• Sociocultural factors: Environmental and social stressors can lead to
  developmental stressors. Potential stressors include prolonged
  poverty, physical handicap, and chronic illness. Children are
  vulnerable when relationships with parents and caregivers are lost.

                     Nursing Implication
• It is important for the nurse to realize that the optimal point of
  intervention to promote health is during the stage when the
  individual can take appropriate action. Early identification of
  both physiologic and psychological stressors remains a major
  role of the nurse. The nurse should be able to relate the
  presenting signs and symptoms of distress to the physiology
  they represent and identify the individual’s position on the
  continuum of function. For example, if an anxious middle-
  aged woman presented for a checkup and was found to be
  overweight, with a blood pressure of 130/85 mm Hg, the nurse
  would counsel her with respect to diet, stress management, and
  activity. The nurse would also encourage weight loss and
  discuss the woman’s intake of salt (which affects fluid
  balance) and caffeine (which provides a stimulant effect). The
  patient and the nurse would identify both individual and
  environmental stressors and discuss strategies to decrease the
  lifestyle stress, with the ultimate goal being to create a healthy
  lifestyle and prevent hypertension and its sequelae.

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