Unit: 4

STRESS AND COPING STRATEGIES

Lecturer Shristi
Rana
MMIHS
• It is a universal phenomenon.
• All persons have experienced a multitude of
uncomfortable subjective emotional and
bodily changes that reflect its presence.

• A state produced by change in environment

that is perceived as challenging,
threatening or damaging to the individual
dynamic equilibrium.
• The non specific response of the body to
any demand made upon it.
 TYPES OF STRESS
• Selye identified two types of stress
A. Distress: it is negative, noxious, unpleasant,
damaging stress that results when adaptation
capacity is decreased or exhausted. E.g.
death of spouse, filing a divorce,
hospitalization, illness or injury.

B. Eustress: it is a stress that protects health in

motivating energy such as happiness, hopeful
and purposeful movement. e.g. getting to
know someone, getting over a rejection
 STRESSORS
• The agent which may cause stress is known as
stressor.

• A stressor is any event or stimulus that causes an

individual to experience stress. When a person
faces stressors, responses are made. The
responses are often referred to as coping
mechanism.
 CRISIS
• is any event that is going (or is expected) to
lead to an unstable and dangerous situation
affecting an individual, group, community,
or whole society.

• negative changes in
the security, economic, political, societal,
or environmental affairs, especially when
they occur abruptly, with little or
no warning.

• E.g. natural disaster, medical emergencies,

long-term illness
 FACTORS INFLUENCING STRESS

• Physical factor: e.g. poison, heat, cold,

radiation, electricity, drugs etc.
• Psychological factors: refers to all
processes, whether originating in the external
environment or within the person. They affect
the brain and central nervous system.
• Chemical factor: E.g. increased peptic juice
• Socio-cultural factor: environmental
(noise, light, color, smell) and social
stressors
• Ecological factors: wildfire, pollution

• Occupational factors: promotion,

transfer, downsizing, restructuring,
changes in supervisors and additional
responsibilities.
 SOURCES OF STRESS

• Attack by bacteria, viruses or parasites

• Competitive sports

• Trauma (injury, burns, assault, electric shock)

• Inadequate food, warmth, protection

• Disruptive social and family relationship

• Normal changes in physiologic function. E.g.

puberty, menstruation, pregnancy, menopause
• Pathological changes caused by disease or injury
• War and social unrest
• Social isolation
• Natural disasters (earthquake, floods) etc
• Imagined threats of injury
• Long period of separation from family.
 STRESSFUL FACTORS DURING
HOSPITALIZATION

• Unfamiliarity of surroundings
• Loss of independence
• Separation from spouse/family
• Financial problems
• Isolation with other people
• Lack of information
• Problems with medication
 BODY RESPONSE TO STRESS

• Stress: Physical, emotional, intellectual,

social and spiritual consequences.
• Affects the whole person having mixed
effects.
 Physically stress can threaten a person’s
physiological homeostasis.
 Emotionally, stress can produce negative
or non constructive feelings about the self.
 Socially, stress can alter a person’s
relationship with others.

 Spiritually, stress can challenge one’s

belief and values. Many illnesses have
been linked to stress.
• The body has a preserving mechanism
that automatically comes in action in times
of stress or danger.
• Changes in the internal environment of
the body results stress.
• Most affected system: nervous endocrine
and immunological system (CNS, adrenal
gland, lymph glands) that affect all organ of
the body.
• Hypothalamus is stimulated in response to
stress, Sympathetic nerves prepare the
body for self defense.
 STRESS RESPONSE

A. Physiological response
B. Psychological response
 A. PHYSIOLOGICAL RESPONSE

• Flight and fight response: the body prepares

itself for survival.
• When an individual faces stress, his/her
body adjust automatically to maintain
equilibrium there are major 3 homeostatic
mechanism:
a) medulla oblongata b) reticular formation
c) pituitary gland.
a. Medulla oblongota: controls vital
functions (either increase or decrease)

b. Reticular formation: controls vital

function as well as continuously monitor the
physiological status of the body.
Pituitary gland:
• supplies numerous hormone that control
vital function,
• Hormones are necessary for adaptation to
stress in case of the stress, the pituitary
gland work of all the glands, some of the
hormones it releases will stimulate certain
gland to produce hormone and other to
produce less hormone.
• A body reacts to stress both generally and
in local way.
 General Adaptation Syndrome (GAS)

• Developed by a Hungarian endocrinologist, Hans

Selye.
• A theory used to explain how we respond to
stress.
• It is used to describe the body’s short term and
long term reaction to stress.
• 3 stages of GAS:
1. Alarm stage
2. Resistance stage
3. Exhaustion stage
 Stage 1: Alarm stage
• Initial phase having immediate reaction to a
stressor.

• known as the fight or flight response as it

prepares a person to respond to the stressor they
are experiencing.

• In this stage, a distress signal is sent to the

hypothalamus which release the hormone
glucocorticoids to let other parts of the body to
know that you're in a dangerous situation by
releasing the hormones glucocorticoids.
• Glucocorticoids trigger the release of adrenaline
and cortisol (a stress hormone). The
adrenaline gives a person a boost of energy. Their
heart rate increases and their blood
pressure rises. Meanwhile, blood sugar levels also
go up.

• These physiological changes are governed by

sympathetic branch of autonomic nervous
system.

• also decrease the effectiveness of the immune

system, making persons more susceptible to
illness during this phase.

• The alarm reaction stage of the GAS This is often

 Stage 2: Resistance stage
• Also named as stage of adaptation
• Governed by a parasympathetic part of the ANS.
• The body tries to counteract the physiological
changes that happened during the alarm reaction
stage.
• The parasympathetic branch of the ANS tries to
return the body to normal by reducing the amount
of cortisol produced. The heart rate and blood
pressure begin to return to normal.
• If the stressful situation comes to an end, during
the resistance stage, the body will then return to
normal.

• However, if the stressor remains, the body will

stay in a state of alert, and stress hormones
continue to be produced.

• This physical response can lead to a person

struggling to concentrate and becoming irritable.
• E.g. after hearing a good news we react with joy
in the first moment but gradually we calm down
and the feeling of happiness is not so strong.
 Stage 3: Exhaustion stage
• Occurs when the person is unable to continue to
adopt the internal and external environment
demands.

• The organism has depleted much of its reserves, one

feels exhausted, has no strength to deal with the
stressor anymore and the necessary recreation

• So, physical or psychic disease or death results

because the body can no longer compensate for or
correct homeostatic balance, if the stressor is too
strong or continue.
• The person may experience tiredness,
depression, anxiety and feeling unable to cope.
• If a person does not find ways to manage stress
levels at this stage, they are at risk of developing
stress-related health conditions.
 Local Adaptation Syndrome

• The localized response of a tissue, organ or

system that occurs as a reaction to stress is the
method used to wall off and control effects of
physical stressor locally e.g. inflammation
response, reflex pain response.
• It shares four characteristics
 Localized
 Adaptive Response
 Short term response
 Restorative response- homeostasis
 PSYCHOLOGICAL RESPONSES

• A healthy individual develops psychological

adaptive behavior to cope with stressor.

• These behavior are acquired through learning and

experience.

• Psychological adaptive behavior is self referred to

coping mechanism for stress management.

• It can be constructive or destructive .

• Constructive behavior helps and individual accept
challenge to resolve the conflict.

• Destructive behavior affects an individual’s reality

orientation, problem solving abilities,
personalities and in severe circumstances,
his/her ability to function.
 Effects of Stress
Indicator Sign and symptoms
Physical
Circulatory system Elevated heart rate, blood
(cardiovascular) pressure
Tightness of chest
Respiratory system Tachypnea

Neuro/Endocrine Headache, Migraine

system Fatigue, Exhaustion
Insomnia, Sleep
disturbance
Restlessness, Hyperactivity
Tremor
Sweating (palms)
Dry mouth
Indicator Sign and symptoms
Gastrointestinal Nausea, Diarrhea,
System vomiting, Weight gain or
loss
Change in appetite
Constipation
Gastrointestinal
Tachypnea
Musculoskeletal system Backache, muscle ache
Bruxism (clenched jaw)
Slumped posture
Increased muscle tension
in neck.
Indicator Sign and symptoms
Reproductive System Amenorrhea, failure to
ovulate
Impotence in men
Loss of libido

Frequent or prolonged
Immunological system colds/flu
Genitourinary system Frequency of urination
Decreased urinary output

Diagnostic Blood in stool/vomitus

Elevated blood glucose
level
Indicator Sign and symptoms
Psychological Cognitive, forgetfulness
Denial, poor concentration
Decreased creativity
Slower thinking, reactions
Learning difficulties
Apathy
Confusion
Difficulties in calculation

Emotional Disruption of logical

thinking
Blaming others
Lack of motivation to get
up in the morning/ loss of
motivation, Crying
tendencies
Lack of interest
Indicator Sign and symptoms
Behavioural/ lifestyle Worry
Decreased involvement with
others
Burn out
Change in activity level
Loss of self esteem
Withdrawl, Suspiciousness
Change in communication
Change in interaction with
others
Increased or decreased food
intake
Higher pitched voices
Excessive humor or silence
Others
Increased or slightly decreased
temperature
Dilated pupils
 COPING MECHANISM OF STRESS

a. Coping
• A process that a person uses to manage events that
he or she encounters, perceives and interprets as
stressful.
• Coping is the person’s effort to manage
psychological stress (Lazarus-1999)
• Coping may be described as dealing with problems
and situations or contending with them successfully.
 b. Defense Mechanism

• Defense mechanisms are unconscious

psychological and behavior strategies that
help, protect a person from anxiety.

• When an individual is faced with problems,

difficulties or failures, he employs certain
ways or devices to achieve health happiness
or success.
• These are called defense mechanism.
 Techniques of coping with stress
1. Relaxation techniques
2. Biofeedback training
3. Stress reducing programmes.
4. Development of rational philosophy of life
5. Time management

Benefits:
• They decrease sympathetic nervous system
activity. E.g. decrease oxygen demand, blood
pressure, pulse and respiration
• They bring about change in state of
consciousness
 1. RELAXATION TECHNIQUES
• It is a state of generalized decreased cognitive
psychological and or behavioral arousal. It helps
to develop cognitive skills reducing the negative
ways in which they respond to situations within
their environment.
• Relaxation technique is widely used
• It brings about physiological changes, reduces the
psycho-physiological effects of stress and
promote a sense of physical and mental well
 Relaxation Techniques

a. Progressive g. Yoga
relaxation h. Journal writing
b. Meditation i. Music therapy
c. Prayer j. Humor and
d. Imaginary laughter
e. Autogenic training k. Support system
f. Hypnosis l. Therapeutic touch
a. Progressive Relaxation

• Used extensively to reduce high levels

of stress and chronic pain

• Enables client to exert control over the

body’s response to tension and anxiety.

• In progressive technique the individual

concentrates on various gross muscle
groups in the body.

• Involves tensing and relaxing of

specific group of muscles with deep
breathing. About 20-30 minutes should
be spent in this exercise.
b. Meditation
• A technique used to quiet the mind and focus in
the present and release fears, worries, anxiety
and doubts concerning the past and the future
and that reduces daily stress.

• It produces a state of deep peace and rest

combined with mental alertness.

• Relieve patient from chronic pain, insomnia,

anxiety and depression and can help in coping
with the side effects of uncomfortable therapy,
twice a day for 10-20 minutes.
• Sit quietly in a comfortable position with their
eyes closed and repeat a sound, phrase or sacred
word in rhythm with breathing, gently
disregarding intrusive thoughts as they do so,
experience decreased metabolism and heart rate,
easier breathing and slower brain waves
c. Prayer

• Similar to the meditation but is intended to be

communication with God, a saint or some other
being who answers the prayers.
• Prayer gives an opportunity to renew personal
faith and belief in a higher being in a specific
focused way that may be highly ritualized and
formal or quiet spontaneous and informal.
• May conducted individually or in group
 d. Imagery
• Internal experience of memories, dreams,
fantasies, and visions that serves as bridge
connecting body, mind and spirit.

• A visualizing technique uses the conscious

mind to create mental image to stimulate
physical changes in the body, improve
perceived well being and or enhance self
awareness.

• Imagery enable people to open their minds

to mental ideas of positive creative images
that foster self healing and bring about
desired achievements.

• It can be self directed or guided.

e. Autogenic training
• Systematic technique teaching the body and
mind to respond to verbal commands, allowing
the person to achieve a deep state of relaxation
through self suggestion.

• First sit in comfortable position

• Induce the sensation of heaviness of limbs, to do

this think, ‘my arms are heavy.’

• Induce sensation of warmth in the limb. Think,

‘my arm is warm.’’
• For respiration, think, ‘I breath normally.’
• The autogenic regulation require 4-10 months to
develop the sense of passive concentration.
f. Hypnosis
• It is an altered state of consciousness in
which an individual’s concentration is
focused and distraction is minimized
• It can be used to control pain, alter body
functions and change in lifestyle habits.
• For e.g. once the subject is comfortable,
the hypnotherapist may say imagine
descending in an elevator, as you pass
each floor on the way down you feel a
little more relaxed.
• Auto hypnosis is also possible.
g. Yoga
• It is a discipline that focuses on muscles,
posture, breathing and consciousness, or is
a discipline that focuses on the body’s
musculature, posture, breathing
mechanism and consciousness.

• Goal : attainment of physical and mental

well being through mastery of body
achieved through exercise, holding of
postures, proper breathing and meditation.

• It involves practice of physical exercise

and meditation

• The correct performance of yoga results in

deep relaxation without sleep
h. Journal writing
• For many people, keeping a private personal journal
provides a therapeutic outlet for stress, and it is
well within the realm of nursing to suggest journal
keeping to clients experiencing difficult situation.

• In a private journal, client can express a full range

of emotion and their honest feelings without
hurting any one’s feeling and without concern for
how they might appear to others.
i. Music therapy

• Musical vibration that are closely

related to the body’s fundamental
frequency of vibrating pattern can
have a profound healing effect on the
entire human body, mind and spirit
bringing about changes in emotions,
organs, hormones, enzymes, cells and
atoms.
• Theoretically carefully selected music
helps to restore regulatory function
that are out of tune during times of
stress and illness.
• Music aligns the body, mind and spirit with
its own fundamental frequency.

• Music therapy consists of listening, rhythm

body movement and singing.
j. Humor and laughter

• It involves the ability to discover, express or

appreciate the comical or absurdly in congruous.

• Humor in nursing is defined as helping the client

“to perceive, appreciate and express what is
funny, amusing or ludicrous in order to establish
relationship, relieve tension, release anger,
facilitate learning or “cope with painful feeling.

• Humor also has physiologic benefits that involve

alternating states of stimulation and relaxation.
• Laughter stimulates increases in respiratory rate,
heart rate, muscle tension and oxygen exchange.
• A state of relaxation follows laughter, during
which heart rate, blood pressure, respiration and
muscle tension decrease
• Humor stimulate the production of
catecholamines and hormones.
• It also release endorphins, thereby increasing
pain tolerance.
e. Support system

• A support system, of family, friends and

colleagues who will listen and offer advise and
provide emotional support benefits a client
experiencing stress.
f. Therapeutic touch

• It is a training specific therapy that was developed by a

nurse.
• It is similar in that it involves trained health care
professionals who attempt to direct their own balanced
energies in an intentional and motivated manner toward
those of the client.
• It is a method used to diagnose and relieve symptoms in
ill patient by using the hands.
• It is the use of touch to reduce anxiety and stress, relief
pain and promote comfort.
 2. BIOFEEDBACK TRAINING

• Biofeedback is a type of therapy that uses sensors

attached to the body to measure key body
functions.
• Biofeedback helps to learn more about how the
body works during stress.
• This information may help to develop better control
over certain body functions of their autonomic
(involuntary) nervous system (heart rate, blood
pressure, skin temperature, muscle tension, and
• Individuals learn to control these functions by
observing monitoring devices and reproducing
desired behavior. Relaxation techniques are also
used to control these bodily functions.
• A typical biofeedback session lasts between 30
and 60 minutes.
• Requires monitoring devices like ECG machine
• It can immediately demonstrate to client their
ability to control some physiological responses.
• It is used by some physician to treat HTN, lower
back pain, tension, headache and insomnia
associated with anxiety and muscle tension.
 3. STRESS REDUCTION
PROGRAMME
• Needed to reduce stress
• 6 steps

a. Identify the problem

b. Assess the cause of the problem
c. Become aware of personal behavior patterns that
contribute to the problem
d. Develop a plan of action
e. Putting into action
f. Evaluate plan and modify if necessary
 4. DEVELOPMENT OF RATIONAL
PHILOSOPHY OF LIFE

• An individual has a plan and balance the activities in

his/her life which helps to achieve maximum
physiological and psychological well being.
• To achieve his goals, the individual must identify and
manage the source of stress.
• This helps to improve the self esteem of the
individual and reinforces positive behavior patterns.
 TIME MANAGEMENT
• Includes developing lists of tasks to be
performed in order of priority.

• People who manage their time effectively usually

experience less stress because they feel more in
control their circumstances.

• For e.g. those tasks that require immediate

attention, those that are important and can by
delayed, can those tasks that are routine and can
accomplishes when time becomes available.
• In many cases setting priorities help individual is
identify tasks that are not necessary or perhaps
can even be delegated to someone else
Nurse’s Role in Stressful Situation

1. Help client to:

• Determine situations that precipitate anxiety and
identify signs of anxiety
• Help him to find out his facts rather than imagine
worse
• Identify personal strengths
• Recognize usual coping patterns and differentiate
positive from negative coping mechanism
• Identify and develop support system with
colleagues and friends
• Verbalize feelings, perceptions and fears as
appropriate. Some cultures discourage the
expression of feeling
• Tell him the truth as much as possible
• Do not give false reassurance
• Encourage him to face the crisis
• Help him to put blame in the right place
• Listen attentively; try to understand the client’s
perception on the situation
• Provide atmosphere of warmth of trust; convey a
sense of caring and empathy
• Encourage client in participation in the plan of
care; give them choice about appropriate aspects
of care.
• Stay with client as needed to promote safety and
feelings of security and to reduce fear.
• Instruct the client how to increase her resistance
to stress
2. Exercising regularly
• Enhancing self esteem by using positive self talk
and by becoming successful in a skill for which
the person takes pride.
• Developing alternative to goals that are
problematic.
• Building coping resources such as social support,
continuing education, a financial reserve and it
improve personal experience

• Train the client in skills that help reduce the

physiological reaction to stress, including as a
means of managing stress

• Eliminate or restrict the amount of alcohol, coffee

and other mood altering substances as a means of
managing stress.

• Learn to accept failure and turn it into a

constructive experience.
• Develop techniques for assertiveness to have
more feelings of personal control.
• Have an optimistic view of the world and believe
that most people are doing the best they can.
• Discuss with other family members about the
needs of the family and the client.
• Nurses must consider the client’s cultural socio-
economic and ethnic values
• Provide support by asking of priest to visit the
family; family with strong faith or religion may
appreciate the visit of a priest or lama
• Nurses must inform the family about the
prognosis of the disease and treatment at their
level of understanding.
Thank u!!