arthritis and other connective tissue disorders; (2) failure to respond, as in immunosuppression; or (3) a weakened immune response, which may contribute to infections and cancer. Even psychological variables such as prolonged anger, feelings of helplessness, and worry can potentially influence the onset and progression of immune system–
mediated diseases (Cohen & Herbert, 1996; Godbout &
Glaser, 2006; Kuster & Merkle, 2004).
Nurses must be aware of potential stressors affecting clients because they add to the cumulative effect of other stressful life events. When a person is experiencing a stressor, nurses do one or several of the following:
• Identify the stressors.
• Assess the client’s response to stress.
• Eliminate or reduce the stressors.
• Prevent additional stressors.
• Promote the client’s physiologic adaptive responses.
• Support the client’s psychological coping strategies.
• Assist in maintaining a network of social support.
• Implement stress reduction and stress management techniques.
NURSING IMPLICATIONS
Assessment of Stressors
Holmes and Rahe (1967) developed a tool, the Social Readjustment Rating Scale, to predict a person’s poten- tial for developing a stress-related disorder. The rating scale is based on the number and significance of social stressors a person has experienced within the previous 6 months (Box 5-2). The risk for a stress-related disorder increases as the person’s score rises. Although the dollar amounts in the mortgage-related items of the scale are outdated, being in debt is still a major stressor. There- fore, with minor modifications, the assessment tool con- tinues to have diagnostic value.
One research study ranked the stressors clients expe- rience in a list modeled after the Social Readjustment Rating Scale (Box 5-3). By being aware of how an illness or interactions with health care personnel and facilities can affect clients, nurses can be instrumental in support- ing those who are especially vulnerable.
Prevention of Stressors
By offering appropriate interventions to people with severe or accumulated stressors, nurses can help to prevent or minimize stress-related illness. Prevention takes place at three levels:
• Primary preventioninvolves eliminating the potential for illness before it occurs. An example is teaching prin- ciples of nutrition and methods to maintain normal weight and blood pressure to adolescents.
• Secondary preventionincludes screening for risk factors and providing a means for early diagnosis of disease.
An example is regularly measuring the blood pressure of a client with a family history of hypertension.
• Tertiary preventionminimizes the consequences of a disorder through aggressive rehabilitation or appro- priate management of the disease. An example is fre- quently turning, positioning, and exercising a client who has had a stroke to help restore functional ability.
Stress-Reduction Techniques
Stress-reduction techniques are methods that promote physiologic comfort and emotional well-being. Some general interventions appropriate during the care of any client include providing adequate explanations in understandable language, keeping the client and family informed, demonstrating confidence and expertise when providing nursing care, remaining calm during crises, being available to the client, responding promptly to the client’s signal for assistance, encouraging family inter- action, advocating on behalf of the client, and referring the client and family to organizations or people who provide post-discharge assistance.
68 U N I T 2 ● Integrating Basic Concepts
Stress-Management Techniques
People susceptible to intense stressors or likely to expe- rience stressors over a long period may benefit from addi- tional stress-management approaches. Stress management refers to therapeutic activities used to reestablish balance
BOX 5-2 ● The Social Readjustment Rating Scale
RANK LIFE EVENT LCU VALUE
1 Death of spouse 100
2 Divorce 73
3 Marital separation 65
4 Jail term 63
5 Death of close family member 63
6 Personal injury or illness 53
7 Marriage 50
8 Fired at work 47
9 Marital reconciliation 45
10 Retirement 45
11 Change in health of family member 44
12 Pregnancy 40
13 Sex difficulties 39
14 Gain of new family member 39
15 Business readjustment 39
16 Change in financial state 38
17 Death of close friend 37
18 Change to different line of work 36
19 Change in number of arguments with spouse 35
20 Mortgage over $10,000 31
21 Foreclosure of mortgage or loan 30
22 Change in responsibilities at work 29
23 Son or daughter leaving home 29
24 Trouble with in-laws 29
25 Outstanding personal achievement 28
26 Wife begins or stops work 26
27 Begin or end school 26
28 Change in living conditions 25
29 Revision of personal habits 24
30 Trouble with boss 23
31 Change in work hours or conditions 20
32 Change in residence 20
33 Change in schools 20
34 Change in recreation 19
35 Change in church activities 19
36 Change in social activities 18
37 Mortgage or loan less than $10,000 17
38 Change in sleeping habits 16
39 Change in number of family get-togethers 15
40 Change in eating habits 15
41 Vacation 13
42 Christmas 12
43 Minor violations of the law 11
Social events are ranked from most stressful to least stressful. Each event is assigned a life change unit (LCU) that correlates with the severity of the stressor. The sum of LCUs over the past 6 months is calculated. A score of less than 150 LCUs is considered low risk, a score between 150 and 199 is an indication of mild risk, moderate risk is associated with a score between 200 and 299, and a score over 300 places the person at major risk.
From Holmes, T. H., & Rahe, R. H. (1967). The Social Readjustment Rating Scale.Journal of Psychosomatic Research, 11, 216. Copyright © 1967, Pergamon Press, Ltd.
between the sympathetic and parasympathetic nervous systems (Table 5-6). Techniques that counter sympathetic stimulation have a calming effect; stimulating tactics counterbalance parasympathetic dominance. Interven- tions that cause the release of endorphins, manipulation of sensory stimuli, and adaptive activities also mediate
physical and emotional responses to stress. Nurses help clients manage stress, for example, by teaching principles of time management and assertiveness techniques.
Endorphins
Endorphins are natural body chemicals that produce effects similar to those of opiate drugs such as morphine.
In addition to decreasing pain, these chemicals promote a sense of pleasantness, tranquility, and well-being.
Endorphins are manufactured in the pituitary gland but are present in the blood and other tissues (Porth, 2007). Some believe that certain activities, such as mas- sage, sustained aerobic exercise, and laughter, trigger the release of endorphins. Once released, endorphins attach themselves to receptor sites in the brain—perhaps in the limbic system, the center where emotions are experienced.
Sensory Manipulation
Sensory manipulation involves altering moods, feelings, and physiologic responses by stimulating pleasure centers in the brain using sensory stimuli. Research is being conducted on the stress-reducing effects of certain colors, full-spectrum lighting in the home and workplace, music, and specific aromas that conjure pleasant associations such as the smell of baking bread.
Adaptive Activities
To enhance adaptation, people experiencing stress may adopt techniques from the following categories: alternative thinking, alternative behaviors, and alternative lifestyles.
BOX 5-3 ● Client-Related Stressors
Thinking you might lose your sight Thinking you might have cancer
Thinking you might lose a kidney or some other organ Knowing you have a serious illness
Thinking you might lose your hearing Not being told what your diagnosis is Not knowing for sure what illness you have Not getting pain medication when you need it Not knowing the results or reasons for your treatments Not getting relief from pain medications
Being fed through tubes Missing your spouse
Not having your questions answered by the staff Not having enough insurance to pay for your hospitalization Not having your call light answered
Having a sudden hospitalization you weren’t planning to have Being hospitalized far from home
Knowing you have to have an operation Not having family visit you
Feeling you are getting dependent on medications
Having nurses or doctors talk too fast or use words you can’t understand Having medications cause you discomfort
Thinking about losing income because of your illness Having the staff be in too much of a hurry
Not knowing when to expect things will be done to you Being put in the hospital because of an accident Being cared for by an unfamiliar doctor
Not being able to call family or friends on the phone Having to eat cold or tasteless food
Worrying about your spouse being away from you
Thinking you might have pain because of surgery or test procedures Being in the hospital during holidays or special family occasions Thinking your appearance might be changed after your hospitalization Being in a room that is too cold or too hot
Not having friends visit you Having a roommate who is unfriendly Having to be assisted with a bedpan
Having a roommate who is seriously ill or cannot talk with you Being aware of unusual smells around you
Having to stay in bed or the same room all day Having a roommate who has too many visitors
Not being able to get newspapers, radio, or TV when you want them Having to be assisted with bathing
Being awakened in the night by the nurse Having strange machines around Having to wear a hospital gown Having to sleep in a strange bed
Having to eat at different times than you usually do Having strangers sleep in the same room with you
The events in this list are arranged in order of their perceived significance as a stressor. The first event is the most stressful, and the rest follow in descending order.
Copyright © 1975, American Journal of Nursing Company. Reproduced, with permission from Nursing Research, 24(5).
INTERVENTIONS FOR STRESS MANAGEMENT
TABLE 5-6
INTERVENTION EXPLANATION Modeling
Progressive relaxation
Imagery Biofeedback
Yoga
Meditation and prayer Placebo effect
Promotes the ability to learn an adaptive response by exposing a person to someone who demonstrates a positive attitude or behavior
Eases tense muscles by clearing the mind of stressful thoughts and focusing on consciously relaxing specific muscle groups
Uses the mind to visualize calming, pleasurable, positive experiences Alters autonomic nervous system func-
tions by responding to electronically displayed physiologic data
Reduces physical and emotional tension through postural changes, muscular stretching, and focused concentration Reduces physiologic activation by placing
one’s trust in a higher power Alters a negative physiologic response
through the power of suggestion C H A P T E R 5 ● Homeostasis, Adaptation, and Stress 69
70 U N I T 2 ● Integrating Basic Concepts ALTERNATIVE THINKING. Alternative thinking techniques are those that facilitate a change in a person’s percep- tions from negative to positive. Reframinghelps a person to analyze a stressful situation from various perspectives and ultimately conclude that the situation is not as bad as it once seemed. For instance, instead of dwelling on the negative consequences of a minor car accident, such as the expense and inconvenience of repairs, the person can choose to focus on the positive aspect of being physically unharmed in the accident.
ALTERNATIVE BEHAVIORS. A behavioral technique for modifying stress is to take control rather than become immobilized. Making choices and pursuing actions pro- mote self-confidence over feeling victimized. Procrasti- nation only prolongs and intensifies the original stressor.
In addition, sharing frustrations with others who are both objective and supportive is more therapeutic than brooding in isolation. Other behavioral approaches to reduce stress include prioritizing what needs to be accom- plished and initially attending to that which is most important or difficult. Less important activities may be postponed or delegated to others. And although other positive behaviors can be cultivated, it is also important sometimes to say “no” to avoid becoming overwhelmed and more stressed.
ALTERNATIVE LIFESTYLE. People prone to stress can make a conscious effort to improve their diet, become more physically active, cultivate humor, and take scheduled breaks throughout the day for leisure, power naps, or listening to uplifting music. Although pet ownership is not possible for everyone, those who do have pets find it soothing and relaxing to stroke and touch an animal
that responds affectionately regardless of a person’s age, physical characteristics, or accomplishments. Pets seem to improve a person’s feelings of self-worth in a way that extends to human relationships as well.
CRITICAL THINKING E X E R C I S E
1. Identify at least five interventions that are both realistic and helpful in reducing the stressors associated with being a student.
NCLEX-STYLE REVIEW Q U E S T I O N S
1. Which nursing intervention is considered primary in pre- venting hypertension in a client with a family history of this disorder?
1. Assess the client’s blood pressure monthly.
2. Provide information about antihypertensive medications.
3. Explain stress-management techniques.
4. Teach the client the health hazards of hypertension.
2. When caring for an older adult with all the following stressors, which has the highest priority for therapeutic interventions?
1. Death of a spouse
2. Change in living conditions 3. Retirement
4. Change in financial state
3. At a team conference, the nurse is most correct in explain- ing that the coping mechanism being demonstrated by a client’s refusal for further treatment because she believes the breast biopsy indicating cancer is incorrect is
1. Somatization 2. Regression 3. Displacement 4. Denial
6
Chapter Culture and
Ethnicity
W O R D S T O K N O W
acultural nursing care African Americans Anglo-Americans Asian Americans bilingual cultural shock
culturally sensitive nursing care