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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. 2 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 components. 3 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 motivation. • Stress can cause discomfort and retreat. 4 Types of Stressors • Stressors may be described as physical, physiologic, or psychosocial. – 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 birth. • 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. 5 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 parent. 6 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. 7 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. 8 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 peers. • 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. 10 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. 11 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. 12 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 response. • Predictability: Anticipating a stressor, even without ability to control it, generally results in reduced experience to stress. 13 • 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. 14 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. 15 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. 16
"Stress and coping"