Notes: Stress

HEALTH CHALLENGES 1:

Ch. 8: Stress
Stress has been de ned as a stimulus, process, and response. However, researchers typically
de ne stress as an individualized reaction or response to a stimulus, when real or perceived
demands exceed their available coping resources (Arnold, 2020). In the late 1930s, Hans

Selye, a researcher at McGill University in Montreal, described stress as a

nonspeci c response of the body to any demand, regardless whether
it is caused by a pleasant or unpleasant source. An inability to cope
with these pressures may further threaten an individuals’ mental,
emotional, or spiritual well-being.

Eustress, a term coined by Selye, is used to describe this mild but motivating and protective
form of stress.
Distress is a negative response to stress that occurs when the demands made exceed a
person’s normal coping ability.

Types of Stressors: Physiological, psychological, and spiritual.

Cognitive appraisal is conceptualized as a judgement or evaluative process whereby the

individual recognizes the degree of stress and its e ect on well-being. As a result of this
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appraisal, the individual uses coping resources that respond to the demand placed on them.
Cognitive appraisal is divided into two stages: primary and secondary. Primary appraisal
involves determining whether the stress poses a threat (e.g., you have an exam the next day—
identify this is a threat). Secondary appraisal involves the individual’s evaluation of coping
strategies or resources to manage any perceived threat (e.g., access readings and lecture
notes, review content—ability to cope with stressor).

Hans Selye (1974) elaborated on this preliminary work, through his classic formulation of the
general adaption syndrome (GAS), which included three successive stages of physiological
responses: alarm or reaction, resistance or adaptation, and exhaustion. This predictable,
uniform pattern in the physiological response to various stressors occurs regardless of the type
of stressor encountered. Once a stressor stimulates the central nervous system, multiple
responses occur because of activation of the hypothalamic–pituitary–adrenal axis and the
autonomic nervous system (Figure 8.1). The alarm reaction stimulates the central nervous
system and mobilizes bodily defences in a ght-or- ight response to the acute stress. When
the stressor is of su cient intensity to threaten the homeostasis of the individual, it leads to a
series of physiological changes that promote adaptation. This temporarily decreases the
individual’s resistance and may even result in disease or death if the stress is prolonged and
severe. If the stressor is not resolved during this initial phase, a second adaptive phase, or
stage of resistance occurs as the body attempts to adapt to the stressor. Overt signs diminish
as the immune system attempts to help the body adapt to the stressor demands. Physiological
reserves are mobilized to increase the resistance to stress and so that adaptation may occur.
Although few overt physical signs and symptoms occur in the resistance stage in comparison
to the alarm stage, the person is expending energy to adapt. Allostasis is the process of
achieving homeostasis in the presence of a challenge (Sterling, 1988). The amount of
resistance to the stressor varies among individuals, depending on the level of physical
functioning, coping abilities, and total number and intensity of stressors experienced. If
homeostasis is not achieved, and if these allostatic responses do not terminate, adaptation
does not occur, and the person may move to the nal phase, of exhaustion. The stage of
exhaustion occurs when all the energy for adaptation has been expended. The individual in
the stage of exhaustion usually becomes ill and may die if assistance from outside sources is
not available. This stage can often be reversed by external sources of adaptive energy.
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Physiological In uence
-The body responds to both the physiological, objective and perceived (emotional-
psychological and subjective).
-The nervous, endocrine and immune systems are the rst key systems to respond
physiologically to stress, which can a ect the cardiovascular, respiratory, GI, Renal- kidneys,
and reproductive.
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The Nervous System

Cerebral Cortex (Perception of stress)

-Perception of stressor— Emotional-psychological event (stressor)-is evaluated with past
experiences and future consequences, and plans a course of action.

Limbic System (Emotions)

-In the brain-inner mid portion of the brain near the base of the skull-important mediator of
emotions and behaviour.
-When stimulated, emotions, feelings, and behaviour is activated to ensure survival and self-
preservation starts.

Reticular Formation (Wakefulness)

-Located lower end of the brainstem and the Thalamus.
-Reticular activating system-crucial in the state of wakefulness
-Stimulation of this system sends impulses to the Limbic system and the Cerebral cortex,
which provide arousal and emotional responses to the stressor.
-Stress usually increases wakefulness and can also lead to sleep disturbances.

Hypothalamus
-Base of the brain just above the pituitary gland
-Function is to adapt to stress.
-Central connection between nervous and endocrine systems in the stress response.
 - the emotional-psychological stressors (perceived) activate the limbic system, in turn,
stimulates the SNS and releases hormones that regulate the secretion of ACTH
adrenocorticotrophic hormone by the anterior pituitary gland
- physiological stressors may start in the limbic system or in portions of the brain that receive
sensory information, stimulating the hypothalamus.

The Endocrine System

-When Hypothalamus is stimulated from stress-this system starts…
-SNS stimulates the adrenal medulla to release epinephrine, and norepinephrine starts a
ght-or- ight response re ex.
-Stress activates the hypothalamic-pituitary-adrenal axis-hypothalamus releases corticotropin-
releasing hormone-which stimulates the anterior pituitary release of pro-opiomelanocortin
(POMC). (Both ACTH and B-endorphin (neuropeptide) are from POMC. )

-Endorphins blunt pain perception by causing an analgesic e ect in a stressful situation

involving pain stimuli.
-ACTH starts the adrenal cortex or produces and secrete corticosteroids, Cortisol, and
Aldosterone (small amount).
-posterior pituitary increases the production of antidiuretic hormone, water is retained and
decrease of urine output.

Immune System
Psychoneuroimmunology is an interdisciplinary science in which investigators study the
interactions among psychological, neurological, and immune responses that a ect human
health and behaviour (Slavich, 2019).

-It is now known that the brain is connected to the immune system by neuroanatomical and
neuroendocrine pathways; thus, stressors have the potential to cause alterations in
immune function (Figure 8.6).
-The network that links the brain and immune system is bidirectional, allowing for reciprocal
communication among these systems. Therefore, emotions modify not only the immune
response but also the products of immune cells which send signals back to the brain, altering
its activity.
-Much of the communication from the immune system to the brain is mediated by cytokines,
which are crucial in the coordination of the immune response.
-For example, interleukin-1 (a cytokine made by monocytes) acts on the temperature-
regulatory centre of the hypothalamus and initiates the febrile response to infectious
pathogens.
-Nerve bres extend from the nervous system and reach synapses on cells and tissues (e.g.
spleen, lymph nodes) of the immune system.
-In turn, the cells of the immune system have receptors for many neuropeptides and hormones,
which enable them to respond to nervous and neuroendocrine signals. As a result, the
mediation of stress by the central nervous system leads to corresponding changes in immune
cell activity.

Stress-Related Disorders
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 -Acute-stress Disorder ASD
-Post-stress disorder PTSD

Stress Coping Examples:

Receiving a diagnosis of terminal cancer

Emotion-Focused Coping Seeking spiritual guidance from one’s place of worship

Problem-Focused Coping Preparing advanced health care directives

Exacerbation of chronic Joining a support group Quitting smoking

obstructive pulmonary
disease (COPD)
Renal failure that Enjoying relaxing music and Arranging for a volunteer
necessitates reading during travel time driver
frequent travel for dialysis
Extended hospital stay for Communicating on Skype Arranging for child or family
stem cell with family and friends care before hospital
transplantation regularly while in hospital admission

Coping Strategies
Relaxation Response (Benson Assessment Tool)
-It is characterized by decreased central nervous and sympathetic nervous system activity,
which leads to decreased heart and respiratory rates, blood pressure, muscle tension, and
brain activity and increased skin temperature.
-The relaxation response can be elicited through various relaxation strategies, including
relaxation breathing, meditation, mindfulness, guided imagery, hypnosis, biofeedback,
muscle relaxation, yoga, prayer, and music and laughter therapies (Table 8.8).
-Components of relaxation include a quiet space, comfortable position, receptive attitude, and
focused attention.
-It is an e ective intervention for stress-related disorders, including chronic pain, insomnia, and
hypertension.
-Individuals who regularly engage in relax strategies can cope better with their stressors,
increase their sense of control over these stressors, and reduce their tension.

Biofeedback
-Biofeedback is a mind–body therapy involving special instruments and methods to expand the
body’s natural internal feedback system to promote well-being (Micozzi, 2019). With initial
guidance from a trained professional, patients can monitor, measure, and subsequently learn
how to control bodily functions that are not normally within conscious awareness, such as
muscle tension, skin temperature, sweat activity, heart rate, and breathing. Patients learn
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 empirically through trial and error by adjusting their thinking and other involuntary bodily
processes using feedback received through an attached monitoring device.
-There are ve common forms of biofeedback therapy: electromyographic or
neurofeedback, thermal, electrodermal, nger pulse, and breathing biofeedback therapies.
During a typical 30 to 60 minute session, a trained therapist, for example, a nurse, educates
the patient on the use of the machine and di erent relaxation strategies, such as progressive
muscle relaxation. Through the provision of feedback, patients learn to use these strategies to
monitor and master the techniques, which subsequently change their responses. The number
of sessions required to accomplish this is individually dependent.
-When practised under the care of certi ed therapists, biofeedback is a safe technique.
However, some patients may experience dizziness or anxiety during a session. Biofeedback is
useful in treating Raynaud’s disease, certain types of incontinence, headaches, anxiety, teeth
clenching, asthma, and blood pressure and muscle disorders (Kennedy & Henrickson Parker,
2019). Additionally, conditions such as epilepsy, attention-de cit disorder, and attention-
de cit/hyperactivity disorder have also responded positively to biofeedback therapy.

Muscle Relaxation
Muscle tension is a universal physiological reaction to stress. As the stress response sets in,
muscles of the entire body tend to tighten. Muscle relaxation is therefore a common method of
eliciting the relaxation response. Progressive muscle relaxation (PMR) involves the tensing and
relaxing of muscles. This method is intended to help patients di erentiate between when a
muscle is tensed and when it is relaxed. This recognition enables an individual to reduce overall
muscle tension when it occurs during times of stress. PMR is based on the principle that when
the muscles are relaxed, the mind relaxes.
In a session of PMR, relaxation typically begins at the extremities and gradually moves across
the whole body in a systematic fashion. A typical session lasts approximately 15 minutes and
should be practised twice daily for the rst few weeks until the individual masters the process.
In addition to reducing overall tension, PMR can minimize physical conditions such as stomach
aches and headaches and improve sleep (Anxiety Canada, 2019).

Yoga
Evidence supports the e ective use of yoga in prevention and management of musculoskeletal
and psychological issues, leading to improved quality of life, such as attaining better quality of
sleep. A synergistic positive e ect can be achieved when yoga is combined with other stress-
reducing methods (Cocchiara et al., 2019).

Nursing Management of Stress

Nursing Implementation

-The rst step in managing stress is to become aware of its presence. Health-related stressors
for patients may include a fear of death or illness, uncertainty or anxiety about a diagnosis,
changes in roles or family life, and nancial burdens that may arise as a result.

-Stress can further be exacerbated in hospital settings through the physical discomforts of an
illness, strange surrounding noises, unfamiliar people, and the use of unfamiliar processes. The
nurse’s role is to facilitate and enhance the processes of coping and adaptation, which include
identifying and expressing stressful feelings.

-Nursing interventions depend on the severity of the stress experience or demand. The person
with multiple traumas expends energy in an attempt to physically survive. The nurse’s e orts
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 are directed toward life-supporting interventions and the inclusion of approaches to reduce
additional stressors to the patient.

-The individual who has endured signi cant trauma is much less likely to adapt or recover if
faced with additional stressors, such as sleep deprivation or an infection.

-The importance of cognitive appraisal in the stress experience should prompt the nurse
to assess whether changes in how a person perceives and labels particular events or
situations (cognitive reappraisal) are possible. Some experts also propose that the nurse
consider the positive e ects of successfully meeting stressful demands. Greater emphasis
should also be placed on how cultural values and beliefs can enhance or constrain various
coping options.

-Because coping with physical, social, and psychological demands is an integral part of daily
experiences, the coping behaviours used should be adaptive and not be a source of additional
stress to the individual.

-Generalizing about which coping strategies are most adaptive is not possible. However, in
evaluating coping behaviours, the nurse should examine the short-term outcomes (e.g., the
e ect of the strategy on the reduction or mastery of the demands and the regulation of the
emotional response) and the long-term outcomes related to health, morale, and social and
psychological functioning.

-Caregiver stress is a well-identi ed phenomenon that may occur in various situations, such as
caring for a partner or loved one and thus should also be considered in a stress assessment.

-To improve the quality of life among caregivers, nurses can provide adequate education
regarding patient care and caregiver support. Referrals to appropriate support groups and
respite services must also be considered (Piersol et al., 2017). Nurses are well positioned to
assess patients and their signi cant others, to assist them in identifying periods when
they are at high risk for stress, and to implement stress management strategies.

-Teaching problem-solving skills can equip individuals better to handle present and
future encounters with stressful circumstances. Stress-reducing activities can be
incorporated into nursing practice (Table 8.13). These activities provide mechanisms through
which an individual can develop a sense of control over the situation. As stress-reducing
practices are incorporated into daily activities, the individual can increase their con dence and
self-reliance while limiting their emotional response to stressful circumstances. Possessing a
sense of control over one’s life, believing that one can overcome adversity, and being
committed to that end are important characteristics that can avert the harmful e ects
inherent in the stress response.

Questions/Answers:
Review Questions
The number of the question corresponds to the same-numbered objective at the beginning of
the chapter.
1. How does Selye de ne stress?
a. Any stimulus that causes a response in an individual
b. A response of an individual to environmental demands
c. A physical or psychological adaptation to internal or external demands
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 d. The result of a relationship between an individual and the environment that exceeds the
individual’s resources
2. A client who has undergone extensive surgery for multiple injuries endures a period of
increasing blood pressure, heart rate, and alertness. Which stage of general adaptation
syndrome are these symptoms most characteristic of?
a. The resistance state of general adaptation syndrome
b. The alarm reaction of the general adaptation syndrome
c. The stage of exhaustion of general adaptation syndrome
d. An individual response stereotype

3. Which actions best demonstrate that a client is using an emotion- focused coping process?
(Select all that apply.) a. Joining a support group for women with breast cancer
b. Considering the advantages and disadvantages of the various treatment options
c. Delaying treatment until her family can take a weekend trip together
d. Telling the nurse that she has a good prognosis because the tumour is small
e. Engaging in meditation

4.The nurse would expect which of the following ndings in a client as a result of the
physiological e ect of stress on the limbic system?
a. An episode of diarrhea while awaiting painful dressing changes
b. Refusing to communicate with nurses while awaiting a cardiac catheterization
c. Inability to sleep the night before beginning to self-administer insulin injections
d. Increased blood pressure, decreased urine output, and hyperglycemia after a car accident

5. Which of the following best demonstrates that the nurse is applying knowledge of the
e ects of stress on the immune system?
a. Encouraging clients to sleep for 10 to 12 hours per day
b. Encouraging clients to receive regular immunizations when they are stressed
c. Encouraging clients to use emotion-focused rather than problem- focused coping strategies
d. Encouraging clients to avoid exposure to upper respiratory infections when physically
stressed

6. Chronic stress or daily hassles may place a person at higher risk of developing which of the
following conditions? (Select all that apply.)
a. Osteoporosis
b. colds and u
c. Low blood pressure
d. Irritable bowel syndrome e. Depression

7. During a stressful circumstance that is uncontrollable, which type of coping strategy is the
most e ective?
a. Avoidance
b. Coping exibility
c. Emotion-focused coping d. Problem-focused coping

8. Which of the following clients is least likely to respond to stress e ectively?

a. One who feels that the situation is directing their life
b. One who sees the situation as a challenge to be addressed
c. One who has a clear understanding of their values and goals
d. One who uses more problem-focused than emotion-focused coping strategies

9. Which of the following is an appropriate nursing intervention for a client who has a nursing
diagnosis of reduced coping
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 resulting from inadequate resources?
a. Controlling the environment to prevent sensory overload and
promote sleep
b. Encouraging the client’s family to o er emotional support by frequent visiting
c. Arranging for the client to phone family and friends to maintain emotional bonds
d. Asking the client to describe previous stressful situations and how they managed to resolve
them

Answers:

- 1. d; 2. b; 3. a, e; 4. c; 5. d; 6. b, d, e; 7. c; 8. a; 9. d.
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