Learning Objectives
By the end of this section, you will be able to:
- Identify the experience of stress
- Recognize concepts of stress and adaptation that affect health
- Describe the maintenance of physiological and psychological homeostasis
A physiological response by the body to a stimulus, or stressor, is called stress. The physiological changes involved in the stress response can be beneficial, life sustaining, and lifesaving, particularly in the face of danger. Acute stressful events are short lived, with prompt resolution and return to a steady state with little or no long-lasting results. Chronic stress, on the other hand, involves sustained effects of the stress response and no relief from the stimulated sympathetic nervous system, which can be detrimental to health.
The stress response, including its activation and subsequent resolution (or not), is a complex process involving multiple body systems, with resultant normal or pathophysiological changes. This module delves more deeply into the experience of stress: the normal response, positive reactions to it, including effective adaptation (the body’s changes in response to stress), and negative results that can cause health problems. The body has an innate drive for homeostasis, or physiological balance. Stress can support or challenge this steady state.
Experience of Stress
People experience stress in different ways, based on factors such as past experiences, support systems, and overall attitudes. Whether the stress is from something perceived as positive or negative, however, the physiological responses involve the same basic chemical actions and reactions (Figure 34.2).
- When a person recognizes a stressor, their hypothalamus releases corticotropin-releasing hormone (CRH), which causes the anterior pituitary gland to secrete adrenocorticotropic hormone (ACTH).
- The ACTH causes the adrenal glands to release corticosteroids, most notably cortisol (a glucocorticoid), and to activate the autonomic nervous system (ANS), specifically the sympathetic nervous system (SNS).
- The SNS releases catecholamines: norepinephrine (noradrenalin), epinephrine (adrenaline), and dopamine. These chemicals generate the fight-or-flight response: heart rate and blood pressure increase, bronchioles dilate, and glycogen in the liver is converted to glucose.
Under normal circumstances, when the stressor has been resolved, the effects of SNS stimulation are opposed by its counterpart, the parasympathetic nervous system (PSNS). The stress hormones dissipate, and body processes normalize.
Distress
Stress that is perceived negatively is called distress. It manifests in many ways, including anxiety (a feeling of unease, worry, or nervousness), sadness, pain, and varied vague symptoms that make isolating the cause difficult. The signs and symptoms of stress are similar to those of a stimulated SNS, such as tachycardia, hypertension (HTN), tachypnea, bronchiole and pupillary dilation, and release of glucose. Distress may be acute and relative to a particular event, such as a frightening encounter. Other causes of acute distress may include temporary illness or injury and the feelings of loss when a friend moves away.
Chronic stress develops when the distress is long lasting and unresolved. Medically, chronicity refers to something that develops slowly and is apt to worsen over time (Whitlock, 2023). Chronic stress tends to be responsible for the negative physiological changes associated with the stress experience, such as chronic occurrences of HTN, gastrointestinal upset, anxiety disorder, and heart failure (HF). Chronic distress can also damage or reduce the function of various body systems, including the immune system, increasing the risk of infection or autoimmune disorders. People who do not have supportive systems of family or friends are more prone to chronic stress, as a caring environment and positive relationships decrease levels of stress hormones.
Unfolding Case Study
Unfolding Case Study #5: Part 3
Refer to Chapter 33 Sexuality for Unfolding Case Study Parts 1 and 2 to review the patient data. Mr. Morales, a 46-year-old male, is being seen in the clinic for an annual wellness examination. During the examination, Mr. Morales reports that he has been having trouble achieving and maintaining erections during sex. He states, “My wife is getting frustrated and so am I. I’m not even that old yet. Why is this happening to me?”
| Past Medical History | Medical history: Type 2 diabetes, hypertension, depression Family history: Both parents alive and well, mother has hypertension and depression Social history: Married twenty years, two teenage children. Wife recently diagnosed with breast cancer. Current medications:
|
| Assessment | 1000: Neurological: Alert and oriented ×4 Respiratory: Clear lung sounds, normal breathing pattern Cardiovascular: Tachycardia, bounding pulses, trace edema noted in bilateral lower extremities Abdominal: Bowel sounds present in all four quadrants, no pain or tenderness noted Musculoskeletal: Full range of motion in all joints, bilateral muscle strength of extremities equal Integumentary: Skin warm, dry, and intact |
| Flow Chart | 1030: Blood pressure: 155/92 mm Hg Heart rate: 103 beats/min Respiratory rate: 20 breaths/min Temperature: 98°F (36.6°C) Oxygen saturation: 99 percent on room air Pain: No pain reported at this time |
| Nursing Notes | 1035: Patient expresses concern about erectile dysfunction (ED). He reports frustration about being unable to participate fully in sexual intercourse with his wife. He reports his wife is also frustrated with the situation, especially given her new diagnosis of breast cancer. He states, “I don’t want to start taking Viagra in my 40s. That’s just embarrassing. Surely there is something else I can do. My wife thinks I don’t want to have sex with her because she has cancer, which isn’t even remotely true. My body is failing me.” When asked about other potential contributing factors, patient reports experiencing a significant amount of stress at work lately, and worry about how he will afford his wife’s cancer treatments. |
Eustress
Positive stress, or eustress, is stress that initiates a positive response or feeling. Whether a person experiences eustress or distress typically depends on their perception of the stressor, which may itself reflect personality and attitude toward the stressor. Persons who are naturally optimistic tend to perceive stressful events positively, as opportunities for growth. In contrast, pessimists tend to assume stressful events will have negative outcomes, leading to distress (Conde Moreno & Ramalheira, 2022; Lindberg, 2019; Moore, 2019; Villines, 2024).
Link to Learning
This video describes eustress or positive stress. As you watch it, think of examples of positive stressors you have encountered and how they made you feel.
The experience of eustress is essential for healthy development, as it supports the brain’s ability to respond to events in beneficial ways. The source of eustress may be psychological or physiological, and results tend to be constructive, with associated feelings of accomplishment and excitement. For example, think of a student studying for an exam they are confident they will pass; an exam is a stressor, but the student’s positive perception converts the stress into energy, excitement, and focus. These positive effects are episodic and short lived, without long-term, harmful effects, so eustress is associated with acuity. Figure 34.3 contrasts eustress and distress.
Concepts of Stress and Adaptation
An individual’s ability to cope with stress allows for adaptive results. These may be effective, promoting health and wellness, or ineffective, causing unhealthy behaviors. Adaptation includes the body’s own physiological changes following exposure to a stressor. These adaptive changes are necessary for survival and ultimately a return to homeostasis; however, individuals can also play a more active role in adaptation by learning and practicing stress management techniques and coping strategies.
Stressors
When a person is threatened or senses looming danger, that threat or danger is perceived consciously or subconsciously as a stressor. Stressors can be categorized by the extent to which they involve substantial changes in one’s life: are they catastrophic events, frequent annoyances, or the various irritations and inconveniences that are omnipresent in daily life? Significant life changes are not necessarily negative; they can be joyful or represent the achievement of a goal. For example, a new job or promotion is typically a welcome change that comes with benefits such as increased income, but it also entails additional responsibilities and stress (Table 34.1). Stressors can be physical or psychological or both.
| Type of Stressor | Examples |
|---|---|
| Significant life change | Marriage, divorce, new job, loss of job, move, birth or adoption of a child, injury/illness/surgery, death of a loved one or friend, change of school or political environment |
| Catastrophic event | Natural disaster (hurricane, tornado, blizzard, volcanic eruption, forest fire), act of war, life-threatening illness or injury, mental health crisis |
| Frequent annoyances | Heavy traffic, weather change, equipment malfunctions, changes to plans, forgetting lunch, running out of gas, experiencing a flat tire |
| Omnipresent irritations | Smog, bad roads or walking paths, distance to school or work |
Physiological Stressors
Physiological stressors are physical stimuli that initiate the body’s innate stress response. The following are some examples of physiological stressors:
- illness or injury
- malnutrition
- temperature extremes
- pain
Nursing care and anticipated treatment orders for physiological stressors focus on relieving symptoms and restoring homeostasis. Considering the listed items, restoration of homeostasis is attempted by treating the particular illness or injury, initiating parenteral feedings, avoiding or preparing for extreme temperatures, and implementing treatment for pain.
Patient Conversations
Nursing Care for Physiological Stressors
Scenario: Mrs. Feldman has come to the emergency department because she’s had “stomach flu” for two days, and she’s feeling very weak. She’s been vomiting several times a day, and can’t even keep down sips of water or ginger ale. After the emergency physician has entered orders, the nurse returns to the patient’s room with a medication and syringe.
Nurse: Mrs. Feldman, you’ve been throwing up so much, you’re very dehydrated. Now, one of the problems is you can’t have anything to drink right now, or you’ll just keep throwing up.
Patient: I’m so miserable.
Nurse: I’ll bet you are. The medication I brought for you should help you feel better soon. It’s called ondansetron, and it is injected into your IV so you don’t have to drink or swallow anything. It should help you stop throwing up.
Patient: Good. I’ve been vomiting so much, my throat burns.
Nurse: I can ask the doctor for some lozenges to soothe your throat. The vomit has acid in it, so it’s no wonder your throat feels burned. Meanwhile, I’ve been worried about your blood pressure. You’re so dry, your blood pressure has been low. Because you can’t drink, you’re getting what’s called a “bolus” of IV fluid, to replace some of what’s been lost. Once that finishes, I’ll restart your other IV, with more fluids and also the electrolytes and some glucose (sugar) you need.
Patient: I can’t wait to feel better. I even feel a bit dizzy when I sit up.
Nurse: That doesn’t surprise me. When you’re dehydrated like this, your blood pressure can drop too low when you change positions: like sitting up after lying down or standing up after sitting or lying down. So, I want you to make changes like that very slowly. And when some of this fluid starts to work, you’ll need to pee. I don’t want you to go all the way to the bathroom, though, so I’ll bring a commode and put it next to your bed. Don’t get up by yourself. Here’s your call light. You need to have your nursing assistant, Sean, or me here to help you to the commode.
Patient: Okay. I’ll call when I feel I need to pee.
Nurse: I’ll be back in about fifteen minutes. Your bolus IV should finish up about then, and I want to see if you’re feeling a little better when that’s done.
Psychosocial Stressors
Stressors can also have psychosocial origins. While psychosocial stressors are rooted in a psychological threat and subsequent imbalance, the same physiological results associated with the stress response occur as when the source is a physical stressor. The following are some examples of psychosocial stressors:
- grief
- job pressure/job loss
- addiction
- interpersonal strain or conflict
- mental illness
- ineffective coping
Consider this situation: a person is experiencing cravings for a particular addictive substance but is unable to acquire the substance and fulfill the need. Psychosocial stressors for this patient include mental health diagnoses, including ineffective coping and addiction. Because of the inability to access the desired substance of abuse, the patient experiences a withdrawal syndrome, which initiates a physiological stress response, such as tachycardia, HTN, and anxiety.
Clinical Judgment Measurement Model
Prioritize a Hypothesis: Alcohol Withdrawal
A patient came to the day surgery for a laparoscopic cholecystectomy. The patient experienced more blood loss than anticipated and was admitted to the surgical floor to receive fluid bolus and blood transfusion. The patient normally drinks eight to ten beers or four to five vodka tonics each evening; however, because of preoperative nausea and abdominal pain, he had not consumed alcohol for two days prior to admission. Today is postoperative day two, and the patient tells the nurse he “feels a little nervous.” His hands are shaky. The patient describes his pain as four on a zero to ten scale. The nurse reviews the chart and finds vital signs are as follows:
- temperature: 99.3°F (37.4°C)
- heart rate: 118 beats/min
- blood pressure: 196/124 mm Hg
- respiratory rate: 23 breaths/min
- oxygen saturation: 96 percent on room air
The nurse considers each vital sign and concludes that since the patient’s last alcoholic beverage was almost four days ago, the low-grade fever, tachycardia, slight tachypnea, and hypertension are likely physiological indicators that he is withdrawing from alcohol. The patient’s nervousness is a psychological indication of rising anxiety, also likely related to alcohol withdrawal. At this point, however, the nurse is most concerned about the patient’s blood pressure.
Knowing that the patient’s body is responding to the stress of a withdrawal syndrome, the nurse plans to call the healthcare provider to update on current physical and mental status. The nurse anticipates orders for IV hydralazine to bring the blood pressure down. Also, the nurse will ask about starting the alcohol withdrawal protocol, using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale for objective monitoring, and obtaining a prescription for chlordiazepoxide to help with the psychobiological factors of alcohol addiction and withdrawal.
Because there are physiological signs and symptoms occurring because of substance use and withdrawal, they have to be addressed as part of the treatment plan, along with psychosocial therapies. Psychosocial treatment may include mental health and behavioral therapy to directly address appropriate diagnoses and improve coping skills, as well as medications to support psychosocial treatment and prevent and/or treat withdrawal syndrome.
Adaptation
Adaptation describes the body’s response to stress. Some of these changes are positive and result in the development of effective coping mechanisms and resilience. However, sometimes the body adapts to stress in negative ways, leading to sustained stress responses and development of chronic disorders.
Because adaptation can be adaptive and effective or maladaptive and ineffective, the focus of nursing care is to help patients adapt to stress in positive ways that lead to healthy changes. Nurses play key roles in helping patients identify stress and stressors, minimize maladaptive behaviors, learn coping skills, and increase effective adaptation.
Clinical Judgment Measurement Model
Generate Solutions: Alcohol Withdrawal
Continue to consider the patient withdrawing from alcohol.
What are the desired outcomes?
- Patient will report feeling less nervous.
- Patient’s blood pressure will be maintained at less than 140/80.
- Patient’s pain will continue to be adequately controlled with PO analgesics.
What interventions can achieve those outcomes?
- Chlordiazepoxide: 75 mg PO; to be increased per prescription order if needed, based on the CIWA protocol
- Hydralazine: 20 mg IV bolus
- Ibuprofen: 800 mg PO Q8 hours
Maintenance of Homeostasis
Homeostasis describes a steady, balanced, or uniform state in the body. This equilibrium is desirable, and the body tries to return to it when it is challenged and taken off-balance. Activation of the SNS by stress disrupts the steady state that is homeostasis. When nurses treat stressed patients, what they are mainly treating are symptoms of alterations to homeostasis, as well as the body’s compensatory mechanisms as it attempts to resolve the perceived threats and return to a steady, stable state.
The process of the body making ongoing changes in response to stress is called allostasis (Guidi et al., 2021). These adaptive processes involve frequent physiological adjustments when a loss of equilibrium has occurred in order to reestablish and sustain normal function. Effective adaptations result in positive coping and outcomes representative of a return to homeostasis. While healthy function involves regular adjustments to the body’s internal environment, recurrent stress leads to chronic effects of the stress response and maladaptive physical alterations from normal (Figure 34.4).
Physiological Homeostasis
Physiological homeostasis is a state of equilibrium in which the body’s physical systems are in balance. When the body is not in a state of homeostasis, it initiates feedback mechanisms intended to return the body to equilibrium. The feedback can be negative or positive, depending on what factor is out of normal range and whether it is high or low. An example of negative feedback is hypotension. When the brain receives signals that blood pressure is too low, it initiates the stress response, releasing the hormone cortisol and the catecholamines epinephrine and norepinephrine. These cause vasoconstriction and tachycardia, thereby raising blood pressure and cardiac output. In addition, the release of the mineralocorticoid aldosterone causes the body to retain sodium and, therefore, water, improving the fluid volume deficit.
Another example of negative feedback is the opposite situation: hypertension. Under normal circumstances, elevated blood pressure causes responses such as vasodilation, to expand blood vessels, and increased urinary excretion, thereby decreasing blood pressure and returning the body to homeostasis.
Link to Learning
This video explains homeostasis and feedback mechanisms in the body. While the previous examples about hypotension and hypertension both involve negative feedback, the video also illustrates positive feedback.
Local Adaptation Syndrome
To this point, this chapter has explained the stress response as a generalized reaction involving organs, neurotransmitters, hormones, and systemic results. This whole-body response to stress is known as the general adaptation syndrome (GAS). The stress response can also be isolated to a particular region, and when this is the case, it is called the local adaptation syndrome (LAS). The GAS is discussed in more depth in 34.4 Adaptation Theories and Models.
The generalized and localized syndromes respond similarly to stressors, although there are differences besides locality or extent of reaction. Essentially, the LAS is a smaller version of the GAS, in which the body attempts to minimize the negative effects of stress by isolating it. In either case, the ideal response is adaptive, with a return to homeostasis. In certain circumstances, the response may become so severe that it results in the systemic effects of the GAS. The LAS tends to be associated with reflex reactions and the inflammatory processes described in the following paragraphs.
Reflex Pain Response
Reflex responses are an example of the LAS in which the central nervous system reacts to pain. The reflex arc allows the central nervous system to bypass the longer, normal processes involved in coordination of movement by the neuromuscular system. While the conscious processes of muscle movement may not appear to take much time, the reflex response further minimizes reaction time, allowing for a nearly immediate, involuntary, and protective reaction (Figure 34.5).
Inflammatory Response
The LAS is closely associated with the inflammatory process. Stressors tend to cause inflammatory agents to be produced, and the stress responses (GAS and LAS) involve production of anti-inflammatory chemicals, including the powerful glucocorticoids. The five cardinal signs of inflammation (erythema, edema, warmth, pain, and loss of function) are integral in the protective and adaptive reactions that prevent further injury and aid return to homeostasis.
Examples of stressors that can cause an LAS reaction include injuries like lacerations, which involve bleeding and subsequent clotting. The injury, like a small razor cut, initiates the LAS (or if large, the GAS). Signs of inflammation often quickly include pain, erythema, sometimes some loss of function, and edema soon after. Internal responses include vasoconstriction and the clotting process, both of which help minimize bleeding. Healing responses close the wound and form scar tissue. Vasoconstriction, clotting, and wound repair are restorative processes of the LAS. The GAS produces a larger inflammatory reaction. Such systemic responses are seen in disorders categorized by immune or autoimmune diagnoses.
Selye (1956/1976) describes the LAS reaction triggering the inflammatory process in response to invasion and infection by mycobacterium tuberculosis (TB): the inflammatory response as stimulated by the LAS creates a physical barrier around a collection of the bacteria, isolating and preventing their spread (latent TB). While this process relative to TB is not flawless, as it does not always trap and confine all the bacteria, the body’s own response to the bacterial assault is remarkable.
Psychological Homeostasis
Homeostasis is also helpful in maintaining psychological well-being and avoiding stress. Whether the impetus for activation of the stress response is a physical or mental stressor, the resultant release of catecholamines, steroids, and other chemicals is the same. The stressor initiates the stress response, and if not relieved, development of adaptation-related disorders becomes a risk. The mechanisms for restoring homeostasis after psychological stressors initiate a stress response may be either psychological or physical. The following paragraphs discuss the relationship between the mind and body, anxiety, coping and defense mechanisms, and the fight-or-flight response, as ways of restoring homeostasis.
Mind-Body Interaction
The actions and interactions of the mind and the body are complex. It can also be challenging to describe where each begins and ends in relation to the other. The stress response is a perfect example of such a close relationship between the two body systems, as a stressor initially affecting either the mind or the body will result in the same cascade of physiological events. Dr. Jean Watson (2024) has been involved in the development of Caring Science in nursing, and in understanding the relationship between mind, body, and spirit. Dr. Watson connects these aspects of the person as a whole and relates the three components so closely as to connect them in written form, without spaces, as “mindbodyspirit.”
When the stressor is psychological, there may be initial signs and symptoms of mental distress, such as anxiety (discussed further in the next section), even before the SNS response may also present with some of the same manifestations. Signs and symptoms of exposure to a psychological stressor may conversely appear as physical, in the form of anginal chest pain or gastrointestinal upset, for example. Effective adaptation may involve both the mind and body (and potentially spirit) through behavioral and cognitive stress management efforts, in conjunction with physiological therapies as indicated. An example of such coordinated efforts of restoring homeostatic balance is a patient who experiences a psychotic crisis episode, with symptoms reflecting a loss of connection from reality. Psychotic symptoms may include disordered thoughts and actions and hallucinations, as well as physical symptoms. Physical symptoms reflect the patient’s experiences of psychosis, so if the patient is experiencing upsetting and anxiety-producing events, vital signs are apt to demonstrate stress.
Clinical Safety and Procedures (QSEN)
QSEN Competency: Patient-Centered Care
Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs (QSEN, 2022).
The PCC Competency (QSEN, 2022) Knowledge (K), Skills (S), and Attitudes (A) are exemplified through a patient scenario.
The patient is brought to the emergency department by ambulance after being found walking naked on a main shopping street at 0315. Vital signs:
- temperature: 96.5°F (35.7°C)
- heart rate: 124 beats/min
- blood pressure: 206/124 mm Hg
- respiration rate: 22 breaths/min
- oxygen saturation: 97 percent on room air
Labs: Positive for cocaine, methamphetamine, and tetrahydrocannabinol (THC). Complete Blood Count: normal. Comprehensive Metabolic Panel: pending.
Knowledge: “Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort” (QSEN, 2022).
- Psychobiological effects of use of stimulant and depressant drugs
- Priority symptoms:
- Malignant HTN
- Hypothermia
- Tachycardia
Skills: “Assess presence and extent of pain and suffering” and “Assess levels of physical and emotional comfort” (QSEN, 2022).
- Urgent focused physical and emotional assessment, followed by comprehensive assessment when stable.
Attitude: “Appreciate the role of the nurse in relief of all types and sources of pain or suffering” (QSEN, 2022).
- Restore psychological and physiological homeostasis
- Hydralazine to lower blood pressure
- Warm room and blankets to raise temperature
- Case management for available resources
- Psych consult for longer-term treatment
- Inpatient versus outpatient substance use treatment
- Appropriate mental health drug therapy
Anxiety
A certain level of occasional anxiety is considered normal and can be protective. Anxiety may also occur as a result of the stress response. Some symptoms of anxiety as a stress response include feelings of nervousness, restlessness, impending doom, hyperventilation, tachycardia, difficulty focusing, gastrointestinal upset, and insomnia.
Anxiety disorders are associated with intense manifestations of fear and anxiousness, or even extreme anxiety referred to as panic (Cleveland Clinic, 2020). Anxiety can therefore be its own mental health disorder and stressor, or a symptomatic result of another stressor and the stress response. While there is still some mystery to the etiology of anxiety disorders, there are some people who are more liable to be affected by it, and certain events can contribute to anxiety (Cleveland Clinic, 2020). Family history of anxiety disorder is also important as a potential contributor to occurrence of an anxiety disorder, as there is often a familial pattern to its diagnosis.
Certain medical diagnoses are associated with occurrence of anxiety. These medical problems include chronic obstructive pulmonary disease (COPD), heart disease and HTN, gastrointestinal symptoms, and chronic pain syndrome (Cherney, 2023). Patients who are experiencing a critical physical episode, such as myocardial infarction, often have a feeling of impending doom. Patients with COPD who are in the midst of a severe exacerbation of the disease are also usually very anxious, as air hunger is a frightening experience. These patients frequently do not have any personal or family history of anxiety. It is physiologically stress-induced, with the disease process as stressor.
Link to Learning
The Anxiety Network’s suggestions for statements to assist with various circumstances when anxiety is likely may help you with patients, and they may be personally helpful for you as well.
Coping
An adaptive mechanism for managing stress is known as coping, which can reflect effective adaptation or ineffective, maladaptive results. Coping encompasses adaptations in both the cognitive and behavioral realms that help people decrease negative emotions such as sadness, anger, or fear (Wilson, 2023). People begin to develop coping strategies from early exposures to stress and build on such techniques with subsequent stressful experiences. Because negative consequences of stress are often cumulative, they emerge after repeated, chronic experiences. Adaptation-related disease processes are typically exemplified by chronic illnesses such as HTN, DM, and COPD, although children can also develop problems related to maladaptive coping.
Early childhood is an optimal time for positive coping mechanisms to be identified, encouraged, and developed. However, there are many circumstances and many children for whom such an environment is not present. Adverse childhood experiences (ACEs) involve stress responses that begin in childhood and, for many affected without appropriate, effective interventions, potentially lead to a multitude of health problems.
Link to Learning
In this video, California’s Surgeon General Dr. Nadine Burke Harris explains more about ACEs and discusses their effects. Pay particular attention to the significance of these experiences, her recommendations for screening, and her goals for prevention.
During stressful situations, nurses can work with patients and their families to set goals as a coping mechanism. Patients may need help realizing that some behaviors are contrary to their effective adaptation, and they may benefit from counseling regarding changes from maladaptive actions toward positive coping strategies.
Wilson (2023) identified several mechanisms for positive coping, which include the following:
- sincerity
- openness
- optimism
- resilience
- establishing and using social support systems
There are many strategies recommended for developing positive coping skills. Of course, the choice of method(s) should be individualized. Coping, like stress, is not one-size-fits-all. Some strategies identified include the following (Peterson, 2021; Wilson, 2023):
- Participate in active relaxation.
- Regulate emotions.
- Rethink how stressors are approached.
- Create supportive interpersonal relationships.
- Reframe emotions through positive self-talk.
- Seek positive activities.
- Participate in religious/spiritual routines.
Certain behaviors are considered maladaptive, and nurses can assist patients in identifying them, as well as guiding them to change the negative coping strategies to techniques more likely to have positive outcomes. Patients’ goals are rarely intentionally focused on deleterious behaviors; the ineffective strategies may have been developed years previously and subconsciously continued to develop over time. Following are some examples of maladaptive coping mechanisms:
- avoidance
- procrastination
- self-harm
- anorexia or bulimia nervosa
- risky behaviors
- self-deprecation
Defense Mechanisms
In the animal world, defense mechanisms are naturally occurring physical or behavioral traits that offer protection or safety from threats. Some translate to human defenses and reactions to stressors. An example is changing one’s size—to make oneself appear larger or smaller than normal in order to present a more alarming presence or hide. Another example in some species is to live in a herd; for humans, being surrounded by a community or support group is a similar protective mechanism.
The purpose of defensive mechanisms as a means of coping is protection, in this case, from anxious feelings, self-esteem challenges, and events or experiences the person does not want to face or directly cope with (Cherry, 2022). Defense mechanisms may be effectively adaptive, although they are often related to maladaptation, or unhealthy behaviors. Higher-level adaptation, associated with positive coping, may be found with sublimation, suppression, humor, and altruism. Certain methods avoid maladaptive results and thereby assist in restoring homeostasis (Cherry, 2022). These include improved self-awareness, establishing and using effective coping strategies, and seeking mental health care if and when needed (Table 34.2).
| Defense Mechanism | Description | Example |
|---|---|---|
| Acting out | Avoiding feelings by not acknowledging or sharing them but instead displaying the feelings through actions | Avoiding verbal confrontation by pounding fists on a table, or head on a wall |
| Altruism | Avoiding feelings by lack of direct acknowledgment; helping others as a way of satisfying internal needs | Volunteering at a preschool as a way to alleviate low self-esteem |
| Avoidance | Not facing a situation, person, or item by minimizing encounters | Refusing to return to a room where a negative experience occurred |
| Compensation | Overachievement of a strength to compensate for a weakness or failure | Excessive efforts in mathematics to compensate for poor understanding of grammar |
| Denial | Denying an event or item’s existence | A person who has experienced abuse as a child denies that it happened |
| Displacement | Assigning emotions (e.g., anger) to a person or object other than the focus of the emotion | Kicking a pet after an argument with a spouse |
| Dissociation | Separating oneself from a negative or stressful experience | A person does not recall the events after being the victim of a sexual assault |
| Fantasy | Avoiding reality by retreating to a self-created inner, fictional reality | Creation and inhabitance of a self-world, away from specific stressor(s) |
| Humor | Identifying humorous facets of an experience | Making a joke during a crisis situation |
| Intellectualization | Avoiding emotional response for extreme intellectual pursuit and/or understanding | Performing excessive research into a particular diagnosis to avoid personal connection to it |
| Projection | Transferring certain qualities to another person | Feeling inadequate in caring for children and older adult parents, but criticizing one’s sibling for not regularly visiting parents |
| Rationalization | Justifying behavior with a logical explanation | Being fired from a job and explaining that the “boss had it out for me all along” |
| Regression | Returning to behaviors of the past | A school-age child sucking their thumb |
| Repression | Subconsciously removing negative experience(s) from consciousness | Not recollecting a traumatic car accident |
Fight-or-Flight Response
When someone is said to have a rush of adrenaline, the image of bungee jumpers or skydivers usually comes to mind. But adrenaline, also known as epinephrine, is an important chemical in coordinating the body’s fight-or-flight response. To respond to a threat—to fight or to run away—the sympathetic system causes divergent effects as many different effector organs are activated together for a common purpose. More oxygen needs to be inhaled and delivered to skeletal muscle. The respiratory, cardiovascular, and musculoskeletal systems are all activated together. Additionally, sweating keeps the excess heat that comes from muscle contraction from causing the body to overheat. The digestive system shuts down so that blood is not absorbing nutrients when it should be delivering oxygen to skeletal muscles.
How extreme the responses are differs based on the perceived significance and danger of the stressor. Someone whose resistance and resilience abilities are diminished by underdeveloped coping skills or constant stressful assaults may be overwhelmed by a stressor that a person with better coping skills would find a minor inconvenience. A stress response may also be consciously acknowledged or remain unrecognized. Patients who can recognize physical signs of stress are able to actively attempt behavior modifications to reduce stress and minimize negative results (Figure 34.6). Unrecognized stress and acute disruption of homeostasis can lead to physical and mental illness.