• Stressor: "anything making a demand on the body or system"
• Coping: "efforts to master condition of harm, threat, or challenge when a routine or automatic response is not readily available"
• Assessment of this pattern focuses on gaining an understanding of the interaction of physical, social and emotional reactions to stress
• Interventions are related to maximizing the system's well-being

• Stress - any distrubance in a person's normal balanced state
• Stressor - a stimulus that the person perceives as a challenge or a threat
• Stressors can be internal/external or physiological/psychosocial (or the anticipation of stress)
• Disturbs the person's equilibrium by initiating a physical or emotional resonse

• Developmental/Maturational
• Situational
• Physiologic
• Psychological/Psychosocial

• When stress occurs it produces voluntary and involuntary coping responses aimed at restoring internal and external balance (homeostasis)
• Changes that take place as a result of stress and coping are called adaptations
• Individuals vary greatly in their response to stress

• Coping strategies are the thinking processes and behaviors a person uses to manage stressors
• Can be adaptive or maladaptive

• Alter the stressor
• Adapt to the stressor
• Avoid the stressor: ending a relationship

Physiological Responses to Stress
-Local Adaptation Syndrome (reflexes, inflammation)
-General Adaptation Syndrome
Psychological Responses to Stress
-Feelings, Thoughts, Behaviors
-Defense Mechanisms

• Alarm Reaction - "fight or flight"
• Resistance Stage - body coping with stressor - results in Recovery if effective or:
• Exhaustion (if stress continues or coping ineffective)

Autonomic nervous system activates the fight or flight response

• Increase in epinephrine and norepinephrine and corticosteroids
• Increase in energy levels and mental alertness
• Vasoconstriction, bronchodilation
• Increase in oxygen intake
• Increase in heart rate
• Increase in blood pressure
• Increase may last one minute to several hours

Body attempts to adapt

• Vital signs, hormone levels and energy production return to normal
• If stress is managed, body returns to homeostasis (recovery)
• If stressor remains (too great or severe), and no adaptation, move into the next phase

The body can no longer resist the effects of the stressor and energy to adapt is depleted

• There is a decrease in blood pressure while heart and respiratory rates remain high
• Body can no longer defend itself and death can occur

• Cognitive (fear, ego defense mechanisms)
• Emotional (anxiety, depression, anger)
• Behavioral

Difficulty concentrating

Poor judgment

Decrease in accuracy (e.g., in counting money)

Forgetfulness

Decreased problem-solving ability

Decreased attention to detail

Difficulty learning

Narrowing of focus

Preoccupation, daydreaming

Adjustment disorders

Anger

Anxiety

Depression

Fear

Feelings of inadequacy

Low self-esteem

Irritability

Lack of motivation

Lethargy

Academic difficulties

Aggressiveness

Crying, emotional outbursts

Dependence

Nightmares

Poor job performance

Substance use and abuse

Sleeplessness (or sleeping too much)

Change in eating habits (e.g., loss of appetite, overeating)

Decrease in quality of job performance

Preoccupation (i.e., daydreaming)

Illnesses

Increased absenteeism from work or school

Increased number of accidents

Strained family or social relationships

Avoiding social situations or relationships

Rebellion, acting out

Fear - cognitive response to a known stressor (may be real or imagined)

Anxiety - emotional response to a vague, non-specific stressor

• Does not promote adaptation
• Making unhealthy coping choices
• May temporarily relieve anxiety, but may have other harmful effects (smoking to decrease stress)

• Person's effort to manage psychological stress
• Attempt to reduce stress
• Operate on an unconscious level
• Formation begins in infancy and usually well engrained by adolescence
• If over used, may become ineffective

• Denial - denying the existence of some external reality (denying severity of cancer diagnosis)
• Regression - person returns to an earlier, more comfortable time in life (child wets bed again when family has a new baby)
• Repression - person forces certain thoughts into the unconscious (repressing memories of being abused as a child)
• Displacement - a person transfers an emotion from its original object to a substitute object (yelling at family because mad at boss)

• Assess stressors and risk factors for stress in the individual
• Assess physiological, cognitive, emotional and behavioral responses to stress
• Assess whether responses are adaptive or maladaptive
• Assess coping strategies used in the past

• Personal perception of stressor
• Intensity of the stressor
• Personal factors
• Available supports
• Effectiveness of coping skills

• What in your life is stressful right now?
• What makes you feel tense/anxious?
• What do you do for relaxation?
• Tell me about your support system?
• Have there been any recent changes in support or losses in your life?
• Do you feel safe in your home?
• In the past year, has anyone punched, hit, kicked, choked or talked to you in an intimidating manner?
• How have you handled stress in the past?
• Was this successful?

• Posture
• Describe affect/mood
• Defence Mechanisms used
• Any expressions of hopelessness?
• Observable signs of anxiety?

• Ineffective Coping r/t being a new student a.e.b. yelling at family all the time
• Ineffective Therapeutic Regimen r/t use of denial as an ego defense mechanism a.e.b. patient states "There's absolutely nothing wrong with me," after receiving cancer diagnosis
• Sleep distrubance r/t stress (loss of job)
• Diarrhea r/t stress of divorce
• Impaired adjustment r/t lack of social suppored a.e.b. "My husband doesn't believe in that stuff."

• Anxiety r/t uncertainty about how diabetes will affect their lives
• Anxiety r/t usual coping mechanisms are proving ineffective a.e.b. "My friends just don't understand what I'm going through."
• Readiness for Enhanced Coping a.e.b. Patient states, "I would like to try some alternative therapies to make me less anxious."

A crisis exists when

(1) an event in a person’s life drastically changes the person’s routine and he perceives it as a threat to self, and

(2) the person’s usual coping methods are ineffective, resulting in high levels of anxiety and inability to function adequately.

Such events are usually sudden and unexpected (e.g., serious illness or death of a loved one, serious financial losses, an automobile accident, rape, and natural disasters).

• The client will verbalize a sense of being able to apply coping strategies in the situation
• The client will focus on the immediate future, with plans on what to do and how to manage
• Client will verbalize the need for behavioral change
• Client will identify maladaptive behaviors
• Client will identify strengths
• Client will identify goals and need for changes

• Reports (or physical exam reveals) a reduction in physical symptoms of stress
• Demonstrates less physical tension in facial expressions and other muscle groups
• Verbalizes increased feelings of control in the stressful situation
• Uses problem-solving and anxiety-reducing techniques
• Demonstrates relaxation and stress reducing techniques

• Establish trust through therapeutic presence; calm, reassuring, accepting presence
• Provide opportunity for the client to talk about precipitating factors
• Use therapeutic/active listening
• Work with the client to develop a realistic plan for self
• Support and point out strengths
• Encourage to describe coping skills used effectively in the past

• Advise patients of what to expect
• Promote a sense of control
• Stress management techniques (meditation, biofeedback, Reiki, humor, etc.)
• Identify and use support systems
• Use of spiritual support
• Collaborate with other disciplines
• Coordinate various community resources

• Promote adequate nutrition
• Help client establish a routine that includes regular exercise
• Teach client importance of getting 7-8 hours of sleep per day
• Encourage participation in leisure activities
• Help clients to manage time, balance responsibilities, prioritize tasks
• Advise clients to avoid maladaptive behaviors: excess alcohol, caffeine, sweets, smoking, illicit drugs

• Client states that he feels a certain level of control over his anxieties
• Client states he is experiencing life in a personally satisfying manner
• Client states she has the skills and confidence to return to work, friends, family
• Client demonstrates a decreased frequency of teeth clenching and pacing