STRESS AND COPING

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STRESS AND COPING

• Carita Bird
• Region A Nursing Consortium
• NUR 112

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ANXIETY
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• Anxiety is a state of apprehension, dread,
  uneasiness, or uncertainty generated by a real or
  perceived threat whose actual source is
  unidentifiable

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Components

• ANXIETY
• An emotional, subjective response
• Involves feelings of apprehension, worry
• In an acute form, it is known as state anxiety
• In a chronic form, it is known as trait anxiety
• Primary anxiety is related to psychological
  factors
• Secondary anxiety results as a reaction to a
  physical health problem

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• Fear
• A reaction to a specific danger
• Stress
• State of imbalance
• Stressors
• Internal or external event that causes anxiety
• Clients internal or external environment
• Physical illness
• Perception of the stressor
• Burnout
• State of mental or physical exhaustion

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• Anxiety can be a healthy, adaptive reaction
• Anxiety can be pathological
• Anxiety exists on a continuum
• Mild
• Moderate
• Severe
• Panic

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General Adaptation Syndrome(GAS)

• An automatic physical reaction to stress mediated
  by the sympathetic nervous system.

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How GAS Works

• A stressor is encountered
• Stress is the initial response to the stressor
• The fight or flight reaction occurs
• Increased alertness
• The body mobilizes resources
• Coping and defense mechanisms in play
• Psychosomatic symptoms
• Prolonged stress burnout

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Etiology

• Several theories have been proposed
• Ones theoretical viewpoint affects the selection
  of treatment modalities
• Theory based on Biological factors, Psychodynamic
  factors, Interpersonal factors, and Behavioral
  factors

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Other Theories

• Social theorists
• Intrapersonal theorists
• Cognitive theorists
• Feminist theorists

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OVERVIEW

• A look at clients experiencing
• phobias
• panic disorder
• generalized anxiety disorder

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Phobic Disorders

• Recognize that their fears or phobias are
  irrational
• Contact with or thought of contact with the
  phobia brings high anxiety
• Clients attempt to manage their phobia by
  avoidance
• Avoidance leads to interference with routine
  activities

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Types of Phobias

• Agoraphobia
• The fear of being incapacitated by being forced
  into or trapped in an unbearable situation from
  which there is no escape
• Examples crowds, standing in lines, traveling
  in a vehicle
• Treatment Cognitive therapy and graduated
  exposure or desensitization anxiolytics for
  short term therapy
• Nursing care accept but do not support the
  phobia

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• Social Phobia
• An excessive fear of embarrassment and
  humiliation in public places
• Example may be related to a specific situation
  or generalized to several similar situation i.e.
  business meetings or specific reunions
• They strain interpersonal relationships and the
  individual may escalate when SOs try to help
• Treatment benzodiazepines, beta blockers,
  SSRIs and exposure therapy
• Nursing care acceptance but not support of the
  phobia

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Specific Phobias

• Unrealistic fear of a particular object or
  situation
• Stimulus may be an object or a concern
• Example spiders
• Panic level anxiety
• Consider the ethnic or cultural background of the
  client during assessment
• Treatment Cognitive therapy desensitization,
  short term anxiolytics use
• Nursing care accept that the client has the
  phobia, but do not support it.

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Generalized Anxiety Disorder

• Difficulty controlling unrealistic, excessive
  anxiety associated with common daily experiences

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• Symptoms
• Restlessness
• Irritability
• Fatigue
• Depression
• Difficulty concentrating
• Muscle tension
• Sleep disturbance
• Helplessness

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• Symptoms interfere with ADLs
• May attempt to control symptoms by becoming
  dependent on ETOH or other substances

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• Treatments
• Cognitive therapy
• Relaxation therapy
• Encourage clients to rethink their perceptions of
  the stressor
• Medications Selective serotonin reuptake
  inhibitors, tricyclic antidepressants and
  buspirone

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Panic Disorders

• Individuals who have recurrent panic attacks for
  which the source may not be known. In between
  panic attacks, these individuals worry about
  another attack. The onset of the attack is
  sudden.

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• Symptoms
• Desire to escape
• Chest pain
• Chills/hot flashes
• Choking sensations, dizziness
• Nausea
• Palpitations
• Shortness of breath
• Sweating and trembling
• Fear of loss of control

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• Clients tend to associate their symptoms with
  physical illness
• Feelings of hopelessness, helplessness and
  despair
• Agorophobia may or may not be present

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• Nursing care
• Provide calm, offer reassurance, use short clear
  sentences and remain with client during the panic
  attack
• When the anxiety diminishes, encourage the client
  to assume care for self, reinforce appropriate
  coping strategies
• Medications SSRIs, benzodiazepines, and
  valporic acid are used to treat the panic attack.
  Beta blockers may reduce ANS symptoms

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General Assessment

• Stress affects each client differently
• Determine the level of anxiety
• Anxiety disorders are seen in all settings
• Biological, psychological and social factors
  should be assessed

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• Assessment should focus on the physical,
  affective, cognitive, social and spiritual
  symptoms of stress

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Nursing Diagnoses

• Anxiety
• Fear
• Ineffective individual coping
• Powerlessness
• Social isolation

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Coping Strategies

• Used by clients to manage anxiety
• Coping strategies are determined by the
  individuals intellect, emotional state, physical
  health, beliefs. Values
• Coping strategies may be effective or ineffective
• Common coping strategies include breathing
  exercises, guided imagery, listening to music,
  recreational activities

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• General life management techniques can be used to
  reduce stress
• Diet
• Exercise
• Time management
• Sleep

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Problem Focused Coping

• Assessment of facts
• Development of goal
• Determination of alternatives for coping with the
  problem
• Identification of the risks and benefits
• Selection of an alternative
• Implementation of the selected alternative
• Evaluation of the outcome

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• Modification of actions based on evaluation
• Emotional focused coping

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Common Defense Mechanisms

• Altruism Projection
• Conversion Rationalization
• Denial Reaction Formation
• Displacement Regression
• Identification Repression
• Intellectualization Splitting
• Introjection Sublimation
• Isolation Suppression
• Undoing

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• It is important to note that sublimation and
  altruism are always positive!

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Psychopharmacology

• Anxiety disorders are treated with
  antidepressants
• Selective serotonin reuptake inhibitors
• Tricyclic antidepressants
• Beta adrenergic blockers
• Antihistamines
• Antiepileptics
• Buspirone

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• SSRIs have a more rapid onset of action and fewer
  side effects
• Initially may cause nausea, loose bowel
  movements, headaches and insomnia
• A rare but serious adverse reaction is serotonin
  syndrome

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• Benzodiazepines effective for anxiety Tx
• May lead to dependency
• Absorbed well via the GI tract
• Onset of action is rapid within an hour
• Few drugs interact with benzodiazepines
• Common side effects ataxia, drowsiness,
  impaired cognition, memory and coordination
• Dont mix with alcohol
• Withdrawal symptoms

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• Buspirone a serotonin partial agonist used in
  the short-term treatment of anxiety
• Well absorbed orally
• 2-3 weeks for full effectiveness
• Side effects light-headedness, drowsiness,
  headache, nausea
• Side effects generally decrease over time
• Not habit forming
• Withdrawal is not an issue

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• High cost and slow onset of action preclude it
  from being widely used.
• Should not be used as a PRN medication for anxiety

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• Beta blockers have a calming effect on the CNS
• Propanolol sometimes used for anxiety
• Effective in treating the physical symptoms of
  anxiety such as tremors and tachycardia

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• Antihistamines used to treat lower levels of
  anxiety
• Safe and nonaddictive
• Can be purchased without a prescription
• Used to lower anxiety in clients with substance
  abuse problems
• Anticholinergic effects can be a problem for
  elderly clients

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Therapies

• Individual and group therapy can be used to
  help anxious individuals develop insight into the
  reasons for their anxious feelings
• Individual therapy
• Insight therapy
• Psychoanalysis

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• Group therapy effective therapy for treatment
  of anxiety which provides multiple sources of
  feedback
• Growth groups
• Support groups
• Task groups
• Self-help groups
• Education groups

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• Cognitive therapy assists individuals to
  identify errors in thinking and plan responses to
  stressors
• Encouraged to replace positive thought for the
  negative ones
• Brief and time-limited
• Structured and orderly
• Clients appraise stressors
• Questions are used by the practitioner to
  encourage the client to develop their own
  solutions

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• Behavioral Therapy a variety of activities to
  decrease anxiety
• Response prevention
• Systematic desensitization
• Flooding
• Thought-stopping