STRESS AND ANXIETY

Introduction:
Stress and anxiety are basic to life, no matter how wealthy, powerful; good working and happy you might be mild stress can be stimulating, motivating and sometimes even desirable. The word stress was originally used by selyle in 1956 to describe the pressure experienced by a person in response to life demands. These demands are referred to as stressors.

Terminologies:
Stress: a state of mental or emotional strain or suspense Stressors: Any agent that causes stress to an organism Compensation: a defence mechanism that conceals your undesirable shortcomings by exaggerating desirable behaviours Denial: a defence mechanism that denies painful thoughts Introjections: Incorporate (attitudes or ideas) into one's personality unconsciously Projection: a defence mechanism by which your own traits and emotions are attributed to someone else Rationalization: a defence mechanism by which your true motivation is concealed by explaining your actions and feelings in a way that is not threatening Reaction formation: a person unconsciously develops attitudes and behaviour that are the opposite of unacceptable repressed desires and impulses and serve to conceal them Regression: flee from reality by assuming a more infantile state Repression: the classical defence mechanism that protects you from impulses or ideas that would cause anxiety by preventing them from becoming conscious Sublimation: modifying the natural expression of an impulse or instinct (especially a sexual one) to one that is socially acceptable Undoing: An act that makes a previous act of no effect (as if not done) Displacement: mechanism that transfers affect or reaction from the original object to some more acceptable one

Definition:
Stress is a process of adjusting to or dealing with circumstances that disrupt or threaten to disrupt a persons physical or psychological functioning Selyle 1976 Stress is a physical or emotional state always present in a person as a result of living.

Sources of stress:
There are many sources of stress: there are broadly classified as: o Internal stressors: they originate within a person eg: cancer, feeling of depression o External stressors: it originates outside the individual eg: moving to another city, a death in family. o Developmental stressors: it occurs at predictable times throughout an individuals life. Eg: child- beginning of school. o Situational stressors: they are unpredictable and occur at any time during life. It may be positive or negative eg death of family member, marriage/ divorce.

Indicators of stress:
It may be physiological, psychological and cognitive: Physiological indicators: the physiological signs and symptoms of stress result from activation of sympathetic and neuro- endocrine systems of body. Pupils dilate to increase visual perception Sweat production increases Heart rate and cardiac output increases Skin is pallid due to peripheral blood vessel constriction Mouth may be dry Urine output decreases Blood sugar increases Psychologic indicators: the manifestations: of stress includes anxiety, fear, anger, depression and unconscious ego defense mechanism. Anxiety: state of mental uneasiness, apprehension, dread or feeling of helpness. It can be experienced at conscious, subconscious or unconscious level. Fear: it is an emotion/ feeling of apprehension aroused by impending or seeming danger, pain or threat.

Depression: it is an extreme feeling of sadness, despair, lack of worth or emptiness. Unconscious ego defense mechanism: it is a Psychologic adaptive mechanism developing as the personality attempts to defend itself and alay inner tensions. Cognitive indicators: problem solving: the person assesses the situation or problem analyzes, chose alternatives, carries out selected alternatives and evaluates. Structuring: arrangement/ manipulation of a situation so that threatening events does not occur. Self control: assuming a manner and facial expression that conveys a sense of being in control or in change. Suppression: willfully putting a thought or feeling out of mind. Day dreaming: unfulfilled wishes and desires are imagined as fulfilled or a threatening experience is re worked or re played so that it ends differently from reality.

Types of stressors:
1. Physiological stressors: a. Chemical agents b. Physical agents c. Infectious agent d. Nutrition imbalances e. Genetic or immune disorders 2. Psychological stressors: a. Accidents can cause stress for the victim, the person who caused the accident and the families of both b. Stressful experiences of family members and friends c. Fear of aggression or mutilation from others such as murder, rape, terrorist and attacks. d. Events that we see on T.V. such as war, earthquake, violence e. Developmental and life events f. Rapid changes in our world, including economic and political structures and technology

Stress models:
Stimulus based models: in this model, stress is defined as a stimulus, a life event or a set of circumstances that arouses physiologic or Psychologic reactions may increase the individuals vulnerability to illness Transaction based model: it is based on the works of Lazarus (1966) who states that stimulus theory and response theory do not consider individual differences. It encompasses a set of cognitive, affective and adaptive responses that arises out of person environment transactions. As the person and environment are inseparable, each affects and is affected by other. Response based model: it consists of mainly 2 responses, Local adaptation syndrome: it is a localized response of body to stress. The local adaptation syndrome may be traumatic or pathologic,. Eg: inflammatory responses of a body part in response to a trauma or injury. General adaptation syndrome: it describes bodys general response to stress. It consists of 3 stages The alarm reaction: it is initiated when a person perceives a specific stressor, various defence mechanisms are activated. The autonomic nervous system initiates the flight or flight response preparing the body to either fight off the stressor or to run away from it. Resistance: the body attempts to adapt to stressor, after perceiving the threat. Vital signs and hormone levels return to normal. If the stress can be managed or confirmed to small area the body regains homeostasis. Exhaustion: it results when the adaptive mechanism are exhausted. Without defence against the stressor, the body either rest or mobilize its defence to return to normal or reach total exhaustion and die.

Stress adaptation model:

The model was given by Gail stuart so it is called Stuart stress adaptation model. It integrates biological, socio cultural, psychological, environmental and legal- ethical aspects of patient care in to a unified frame work for practice. The first assumption of Stuart stress adaptation model is the nature is ordered as a society hierarchy from the simplest unit to the most complex. Each level is a part next higher level, so nothing exists in isolation. Thus individual is a part of family, group,

community, society and the large biosphere, through which material and information flows across various levels

BIOSPHERE

Society

Community

Group

Family

Individual

Body system

Organ

Tissue

Cell
Second assumption of the model is that nursing care is provided within a biological, psychological, sociolcultural, environmental and legal- ethical context. The nurse must understand each of them to provide holistic nursing care. Third assumption of the model is that health/ illness and adaptation / maladaptation are 2 distinct continuums: The health/illness continuum comes from a medical world view The adaptation/ maladaptation continuum comes from a nursing world view. This means that a person with a medically diagnosed illness may be adapting well to it. In contrast a person without a medical illness may have adaptative coping resources. Fourth assumption is that the model includes the primary, secondary, and tertiary levels of prevention by describing four stages of psychiatric treatment: crisis, acute, maintenance and health promotion. For each stage of treatment, the model suggests a treatment goal, a focus of nursing assessment, nature of interventions and expected outcomes of nursing care. Fifth assumption is based on the use of nursing process and standards of care professional performance. Each step of the process is important and the nurse assumes full responsibility for all nursing implemented.

Psychological response to stress:

Various emotional responses occur due to stress including depression and anger. The most common response is anxiety. Anxiety- it is vague, uneasy feeling of discomfort or dread accompanied by autonomic response. The four levels are: Mild: present in day to day living. It is manifested by restlessness and increased questioning. Moderate: narrows the person perceptual field and focus on immediate concerns. Manifested by a quivering, voice, tremors, increased muscle tension, slight increase in respiration and pulse.

Severe: creates the person to lose control and experience dread and terror. Manifested by difficulty to communicate verbally, agitation, trembling, poor motor control, sweating tachycardia, dyspnoea palpitations, chest pain or pressure in chest Panic: state of apprehension. Here mild anxiety has a positive effect. For eg: mild anxiety motivates a student to do the required reading for an upcoming examination

Physiological responses to stress:

It can occur as local adaptation syndrome and general adaptation syndrome. Local adaptation response It is a localized response of body to stress and it involves only specific body part (tissues, organs) instead of the whole body. It is a short term adaptive response which primarily is homeostatic. 2 most common stress responses that influence nursing care are reflex pain response and the inflammatory response Reflex pain response:

It is the response of central nervous system to pain. It is rapid, automatic and serves as a protective mechanism to prevent injury. Eg: if you are about to step into a bath tub filled with dangerous hot water, skin senses the heat and immediately sends a message to the spinal cord. A message is then sent to motor nerve, which consciously realize that the water is too hot not safe. Inflammatory response:

It is a local response to injury or infection. It helps to localize and prevent the spread of infection and promote wound healing. There are 3 phases: First phase: vasoconstriction occurs to control bleeding initially. Histamines are realised and capillary permeability increases resulting in increased blood flow to wbcs to the area. Then the blood flow returns to normal but wbcs remain to help resist the infection. Second phase: exudates (made up of fluids, cells and inflammatory by products) are realised from the wound. The amount of exudates depends up on the site, severity of wound. Third phase: damaged cells are repaired by regeneration (replacement with identical cells) or formation of scar tissue.

Coping mechanisms:
They are behaviours used to reduce stress and anxiety like Crying, laughing, sleeping and cursing Coping: coping may be described as dealing with problems or situations or contending with them successfully. A coping mechanism is an innate or acquired way of responding to changing environment or specific situation. Types of coping: *Problem focused coping: it refers to efforts to improve a situation by making changes or taking some action. *Emotion focused coping: it includes thoughts and actions that relieve emotional distress. It does not improve the situation but the person often feels better. Coping can also be classified as *Short term coping: it reduces stress to a tolerable limit temporarily, but ineffective way to deal with reality. Eg: day dreaming *Long term coping: it is constructive and realistic.eg: talking to others about problems. *Adaptive coping: It helps a person to deal with a stressful event and minimizes distress associated with them. *Maladaptive coping: it can result in unnecessary distress for a person and others associated with person or stressful events. Stress management strategies: Take a breath: when you feel uptight try taking a minute to slow down and breathe deeply. Breathe in through your nose and out through your mouth. Try to inhale enough so that your lower abdomen rises and falls. Count as you exhale- slowly. Practice specific relaxation techniques: Techniques are meditation, self hypnosis, and deep muscle relaxation work in a similar fashion. In this state both body and mind are at a rest and outside world is screened out for a time period. The practice of this for a regular basis provides calming and relaxing feeling that seems to have lasting effect for many people.

Manage time: Give priority to important ones. And do those first. If a particularly unpleasant task faces you, tackle it early in the day and get over with it; the rest your day will include much less anxiety. Schedule time for both work and recreation. Connect with others: A good way to combat sadness, boredom and loneliness is to see out activities involving others. Talk it out: Share your feelings. Bottled up emotions increase frustration and stress. Talking with someone else can help clear your mind of confusion so that you can focus on problem solving. Also consider writing down thoughts and feelings. Putting problems on paper can assist you in clarifying the situation and allow you a new perspective. Take a minute vacation: Imaging a quiet country scene can take you out of a stressful situation. When you have opportunity, take a moment to close your eyes and imagine a place where you feel relaxed. Notice all details of your chosen place, including pleasant sounds, smells and temperature or change your mental channel by reading a good book or playing relaxing music to create a sense of peace. Monitor your physical comfort: Wear comfortable clothing. If its too hot, go somewhere where its not. If chair is comfort is uncomfortable change it. If computer causes eye strain change it. Dont wait until discomfort changes to real problem. Get physical: When you feel nervous, angry or upset, release the pressure through exercise or physical activity. Running, walking or swimming are good options for some people, while others prefer dance etc. working in the garden, washing your car or playing with children can relieve uptight feeling. Aerobics can be done for 20 min daily to reduce stress. Take of your body: Healthy eating and adequate sleep fuels your mind as well as body. Avoid consuming too much caffeine and sugar. Take time to have breakfast in morning. Well nourished bodies will cope better with stress. Increase the amount fruits and vegetables in diet. Take time for personal interests and hobbies. Listen to ones body. Laugh: Maintain your sense of humour, including the ability to laugh at yourself. Know your limits: There are many circumstances in life beyond your control, consider the fact that we live in an imperfect world. Know your limits. If a problem is beyond your control and cannot be changed at the moment, dont fight the situation. Learn to accept what is, for now, until such time when you can change things.

Think positively: Refocus the negative to be positive. Make an effort to stop negative thoughts.

Clarify your values and develop a sense of life meaning: Clarify your values and deciding what you really want out of your life, can help you feel better about yourself and have that sense of satisfaction and centeredness that helps you deal with the stresses of life. Compromise: Consider cooperation or compromise rather than confrontation. A little give and take on both sides may reduce the strain and help you feel more comfortable. Have a good cry: A good crying during periods of stress can be a healthy way to bring relief to your anxiety, and it might prevent a headache or other physical consequences of bottling things up. Avoid self medication: Alcohol and other drugs do not remove stress. Although they may seems to mask or disguise problems. In the long run, alcohol use increases rather than decreases stress, by changing the way you think and solve problems and by impairing your judgments and other cognitive capacities. Look for the pieces of gold around you: Pieces of gold are positive or enjoyable moments or reactions thee may seem like small events but as these pieces of gold accumulate them can often provide a big lift to energy and spirits and help you begin to new, more balanced way

Role of a nurse in a stress management:

Assessment: Assessment of the person: -Assess for the following characteristics in the individual. Such individuals are at high risk of developing stress related disorders -Rigid and self punishing and moral standards -High and unrealistic expectations -Too much dependence on others for love and affection and approval -Inability to master change or learn new ways of dealing with frustration. -Easily prone to extreme emotional responses of fear, anxiety and depression -Type personality persons

-In addition the stressful events like birth, deaths, marriages, divorces, retirement etc. can predispose to stress related illness. Assessment of the family: -Assess the family perception of the problem, and whether it is supportive of the clients efforts at coping. -Assessment of the environment: -Occupations with a high degree of stress; adverse environmental influences like too much of lightning, temperature etc. Interventions: -They are directed towards relief of acute or chronic stress. a nurse can help person to examine the situation, identify possible solutions and accept his feelings without guilt or fear. -People suffering from acute stress related illness often needs to change their life styles and ways of relating to others. The initial work of nurse involves helping the client to recognize that change is essential in relation to the change. -Some clients show resistance to necessary changes. These includes -Increasing the client awareness as an actual or potential health problem exists. -Helping him realize that the health problem can increase if personal changes do not occur. -Identifying all personal resources. To support the client through the process of change and cooperation with the treatment -When the client becomes aware of the nature of the health problems and is told of the change need, he often experiences a feeling of anxiety, depression and anger. -The client is encouraged to talk about the losses that has resulted from the behaviour change. -Family members also need accurate information about nature of the disorder, and how they can help the client in coping with stress. The client and families also need to be informed about various alternatives such as meditation, yoga, relaxation training etc. these technique have a valuable role to play in helping individuals cope with stressful life events. -In all this, the nurse must always bear in mind that they are only facilitators of the change process, and the clients have rights and responsibilities in relation to change.