Learning Objectives
By the end of this section, you will be able to:
- Describe pharmacological treatment for stress
- Describe nonpharmacological treatments for stress
- Identify appropriate CAM therapies based on the patient’s presentation
- Explain the nurse’s role in educating patients on pharmacotherapy and CAM
As established, stress is part of life, but how one responds to stress depends on many factors and individual variables. What makes stress become distress also varies among individuals, their interpretations of stress, and their ability to cope with the stressor and resources available. Pharmacological and nonpharmacological resources are available to help. Nurses must be able to recognize the signs and symptoms of stress and be ready to help. When a nurse recognizes that a patient is experiencing stress or anxiety, they should share that information with the prescriber so pharmacological options can be offered to help the patient. If medications are not available or appropriate, the nurse needs to know about and offer nonpharmacological options. Nurses must be aware of both approaches because there are limitations and different outcomes with each strategy.
Pharmacotherapy and Stress
There is no medication that can cure stress; however, there are medications available to help address the cause of stress, as well as medications to help promote relaxation, allowing for a mind and body reset. Many people need help getting through a stressful event or difficult time, and pharmacological options are available. They help decrease the brain’s stimulation of the sympathetic nervous system, which can provide a respite from the barrage of activated stress hormones. Pharmacotherapy is the use of medications to treat a condition or disease. Prescription medications are those ordered by a prescriber, who can be a doctor, nurse practitioner, physician assistant, or dentist. A concern about prescription medication is the patient’s compliance with taking the medication as ordered in the correct quantity and prescribed directions. Nonprescription drugs are those available at a store and can be purchased without a doctor’s order. The concern about over-the-counter (OTC) drugs is if the medication will be taken correctly as outlined on the medication label. Any medication has the potential for side effects and adverse reactions and requires good patient education.
The classes of medications commonly given for stress include anxiolytics, hypnotics, antidepressants, sedatives, psychotherapeutics, muscle relaxants, antimigraine agents, and narcotic pain medications. The most common drugs given for chronic stress are selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants. The most common overall medications taken OTC for stress are for tension headaches and pain associated with stress.
An interesting new option many Americans have begun to use is medical marijuana. Although federally illegal to purchase and use, the Federal Drug Administration has approved several medications with marijuana components, such as Megace, which is used as an appetite stimulant, and other compounds used for certain types of seizures. Medical marijuana is still a very controversial issue and states have been left to regulate its use. Some states have approved medical marijuana with various mixtures of the active components of tetrahydrocannabinol (THC) and cannabidiol (CBD), and medical marijuana clinics have expanded exponentially across the nation. There is anecdotal evidence that medical marijuana helps treat stress and anxiety disorders.
Anxiety and Depression
A category of medications that can be used successfully for a short time during stress is anxiolytics. The term literally means to lyse (or breakdown) anxiety. They are used commonly in a hospital setting to help patients relax before a procedure and can also be used for acute episodes of panic. Anxiolytics can be very effective and can administered orally or intravenously. This group of medications helps people relax and even calm down during an acute anxiety or panic attack. To strengthen the effectiveness of this class, the nurse can also provide guided imagery, deep breathing exercises, and anticipatory guidance to help a patient know what to expect, which also can decrease anxiety. The most common anxiolytics include alprazolam (Xanax), chlordiazepoxide (Librium), clonazepam (Klonopin), diazepam (Valium), and lorazepam (Ativan).
Antidepressants can be effective for elevating the baseline mood of a person so they can cope better. Patients need good education about each class of medication because they are not “magic pills” to take away their problems. It is common with many of these classes of medications that the therapeutic level is not reached until 4–6 weeks after the patient begins taking them; at that point, the patient may begin to feel relief and a change in their depressed mood. Making sure patients are aware of that caveat and providing them additional resources to manage stress are key. There are documented genetic variations in the effectiveness of medications within each category. A challenge is that without genetic testing, patients may be given one of the many types of SSRIs available without seeing any improvement until they switch to another medication, which, again, takes an additional 4–6 weeks to evaluate for effectiveness. The most common classes of antidepressants (Saffai, 2022) are SSRIs, serotonin-noradrenaline reuptake inhibitors, noradrenaline and specific serotonergic antidepressants, tricyclic antidepressants, serotonin antagonists and reuptake inhibitors, and monoamine oxidase inhibitors.
Selective serotonin reuptake inhibitors are the most commonly prescribed antidepressants. The top four SSRIs used to treat depression are citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), and sertraline (Zoloft).
Nurses must be aware of the side effects possible with any class of medication and follow the rights of medication administration: right patient, right medication, right dose, right time, and right dose. With each medication administration, the nurse should also provide correct patient education regarding the medication and possible side effects the patient should alert the nurse about. For instance, a condition the nurse must be aware of when administering SSRIs is serotonin syndrome. This potentially life-threatening condition is caused by an excess of serotonin in the body, typically resulting from the use of certain medications. Symptoms can range from mild to severe and may include agitation, confusion, rapid heart rate, high blood pressure, dilated pupils, muscle rigidity, and tremors. Prompt recognition and management, including discontinuation of the medications and supportive care, are essential to prevent complications. It is important for a nurse to recognize serotonin syndrome because it can rapidly progress to a life-threatening condition if left untreated. Identifying the signs and symptoms early allows for prompt intervention and management to prevent complications such as seizures, coma, and even death
Post-Traumatic Stress Disorder
PTSD was first identified among U.S. veterans who experienced major mental health trauma during wartime. Experiencing any assault or violence has a huge negative impact on any individual. Flashbacks of the trauma can haunt a person and disrupt their ability to move forward in life. According to the Mayo Clinic and VA studies, symptoms include:
- always being on guard for danger
- being easily startled or frightened
- irritability, angry outbursts, or aggressive behavior
- overwhelming guilt or shame
- self-destructive behavior, such as drinking too much or driving too fast
- trouble concentrating
- trouble sleeping
Years later, the same symptoms of PTSD were recognized among rape victims and victims of other personal assault or violence. Pharmacological interventions and counseling have been the mainstay of therapy.
Medical Marijuana
A controversial option that has evolved over the past four decades is the use of marijuana to treat symptoms of stress, anxiety, and chronic pain. The debate continues as medical research studies demonstrate confusing results. Some studies have shown marijuana, which includes both the hallucinogenic ingredient THC and the CBD components, decreases pain, anxiety, and acute stress, whereas other studies have revealed negative complications or no positive results at all. What complicates the use of this product is that it is currently illegal at the federal level, as is possession of it. Some states, however, have legalized medical marijuana if it is prescribed by a medical professional with prescribing rights (Pacula et al., 2017).
There are many anecdotal stories of the effectiveness of marijuana, which perpetuates its use and popularity among the public. It has become an option for those without medical insurance because it can be purchased even without a medical prescription. A variety of products are available, including flowers and buds of the marijuana plant, as well as capsules, topical patches and gels, edibles, creams, drops, solids, and liquids (Pacula et al., 2017).
Marijuana is available by prescription in the form of Megace and dronabinol, with proven effectiveness seen in preventing certain types of seizures or stimulating appetite in those with poor nutritional intake. There is inconclusive evidence for its use in many other conditions for which people are using it, including amyotrophic lateral sclerosis, bipolar disorder, other psychoses, dystonia, glaucoma, and Huntington’s disease.
Federal and Local Marijuana Laws
Since the 1970s, states have pushed against the federal law to prohibit the production, farming, and use of marijuana. Various states have successfully decriminalized medical marijuana growing and distribution. As of February 2022, 37 US states, 3 territories, and the District of Columbia have legalized cannabis. The THC component is the hallucinogenic component, which has not been shown to have any healthful benefits; however, cannabinoid products that contain CBD have shown some benefit.
Nurses need to be well informed about this issue because medical marijuana use has increased and patients want education. When assessing a patient or doing a medication reconciliation, the use of marijuana needs to be addressed without judgment or shame toward the patient.
Overview of Complementary and Alternative Medicine
The term complementary and alternative medicine (CAM) refers to health practices that are used that are not within allopathic (traditional Western) practice. The term alternative means “other” and is used to describe health practices that are other methods not generally taught in Western medicine. Because of the increasing diversity of the US population and the common use of home remedies not prescribed by providers, nurses need to know about CAM. Another term is integrative medicine, which means the CAM is used in combination with, rather than instead of, a prescribed order. For example, a client who has hypertension may take his prescribed medication but also drink herbal tea and practice meditation to help decrease blood pressure.
With the increasing use of CAM therapies in the United States, the National Institute of Complementary and Integrative Health was formed to collect research and establish guidelines for its use (National Institute of Complementary and Integrative Health, 2023). A barrier to having ample research is the lack of entities, typically pharmaceutical companies, interested in paying for the research. Without the hope of a monetary profit, pharmaceutical companies do not generally complete expensive research on organic products such as herbs, which are commonly used in CAM therapies.
As shown in Figure 8.6, CAM therapies can be categorized as follows: energy therapies, biologically based practices, manipulative and body-based therapies, mind-body techniques, and whole medical systems.
Energy Therapies
The core concept in many complementary and alternative therapies is the belief that energy in the body can be manipulated for healing. The foundation is that illness and disease are caused by a blockage in the body’s natural energy flow. Each of the following therapies attempts to restore normal energy flow through different means:
- aromatherapy
- body manipulations
- biological based therapies
- energy therapy
- homeopathy
- herbal remedies
- naturopathy
- nutritional therapies
- whole systems
Energy therapies are the use of any therapy that affects the vital flow of energy through the body. First coined by Franz Mesmer in the 1800s, “mesmerized” was a term used to describe someone who was affected by a change in their energy flow. The concept of energy has been used by medical practitioners of many cultures, including traditional Chinese medicine (TCM), which identifies life energy as chi. In ayurvedic medicine, concentrated areas of energy are known as chakras. Manipulation of the body through massage and movement is also based on the belief of vital force energy.
More modern forms of energy therapy include red light therapy, which uses infrared or blue lights under which a patient can sit to stimulate circulation and redirect energy. Acupuncture used in TCM attempts to open blocked channels of energy. Reiki and qui gong also originated in TCM traditions and move energy throughout the body by self-movement or having a skilled practitioner move energy above body areas.
Many CAM therapies are based on the belief of vital source energy. Examples include the use of herbal medicine, acupuncture or acupressure, moxibustion, and cupping to help correct imbalances in the biofield of energy in the body to restore health. Without scientific proof, most people have experienced the stress relief that comes from a good massage.
Biologically Based Therapies
Biologically based therapies use herbs, plants, and aromas to bring relief and restore health. Biologically based therapies include modifying nutrition components, aromatherapy, homeopathy, and naturopathy.
Diets high in certain macro- or micronutrients have been used to decrease the stress response as seen in diets that eliminate known allergens such as gluten, dairy, and eggs. Other forms include consuming certain herbs and vitamins as supplements for the desired outcome.
Aromatherapy in the form of scented candles has been used casually in homes for generations but has now received approval for use in hospital and surgery centers to reduce anxiety and stress. Smell is associated with memories and emotions through the olfactory nerve and can have stimulating or relaxing properties.
Homeopathy was first identified when practitioners took extracts of an active ingredient and administered them in much smaller quantities to provide the desired effects. The concept is that the essence of an herb or plant can be as effective as the entire medicine. Naturopathy is a general category of an approach to health promotion and disease prevention. A naturopath practitioner may use many types of CAM therapy in healing, whereas homeopathy refers to a specific focus on healing with tinctures of plants and herbs.
Manipulative and Body-Based Therapies
A core belief of manipulative and body-based work is to align the body’s vital source of energy. Many of the practices focus on realigning the body and organs for the better flow of energy. Massage and chiropractic adjustments are two commonly used therapies. More complex methods are the Feldenkrais method of body alignment.
Whole Medical Systems
Whole medical systems incorporate elements of all these categories and originate from traditional cultural practices for millennia. Such systems include Ayurvedic medicine, Mexican folk medicine, American Indian health practices, and TCM. Most ethnic cultures and peoples around the world have their own versions of folk medicine that have been passed down through family members for centuries.
Studies show that immigrants to the United States may be leery of Western medicine and still prefer to practice their own cultural medicine. Nurses need to be open-minded and ask in a nonjudgmental tone what home remedies patients may be using. Often, the practices can be used with Western medicine, but occasionally there are contraindications, such as the avoidance of ginseng, ginger, and garlic as anticoagulants before surgery. Whole medicine practices may also include prayer, rituals, chanting, and other activities that may be quite helpful to decrease acute stress. These practices may even be used a complement to modern medical practices in the hospital setting if they are not disruptive to the medical and nursing care and do not disturb others.
Mind-Body Therapies
Mind-body therapies focus on calming the mind, which, in turn, can help calm the body. Strategies include mindfulness, meditation, yoga, breathing techniques, and even CBT. Nurses can easily use these strategies and guided imagery with patients who are stressed and anxious in the hospital setting.
Stress Management Techniques
Nursing students would do well to practice these techniques before exams also! Although there is no way to eliminate stress from our lives, we can learn to successfully manage our stress. Lists of strategies can be helpful, but ultimately, they must be individualized to whatever works for the person. The following are some strategies to help decrease stress:
- Avoid drugs and alcohol.
- Eliminate high-sugar and processed foods.
- Enjoy something that is energizing to you.
- Engage with faith-based activities and people.
- Engage in exercise.
- Get a massage.
- Provide self-care with rest and nutrition.
- Schedule time to relax.
- Spend time in healing nature.
- Talk to others.
- Take breaks from watching, reading, or listening to news stories, including social media.
- Do yoga and stretch.
Cognitive Techniques
Because there is such a direct correlation between the mind and body during the stress response, there are many activities that can used to help calm the mind and body. Challenging one’s negative thoughts is the beginning of CBT. Thoughts create emotions, which affect behavior. If the thoughts can become controlled, they can help eliminate the anxiety producing physical manifestations of stress. Often asking “what is the worst thing that could happen now” creates introspection and connection with reality that the worst-case scenario is not even realistic. Using cognitive strategies can help decrease stress by controlling the downward spiral of negative and unrealistic thinking.
Physical Techniques
There are many strategies available to use the body to decrease stress. Learning biofeedback through breathing techniques can help decrease blood pressure and heart rate. Using cold compresses to the head, face, and neck can create vasoconstriction and reverse the dilation that occurs during the normal acute inflammatory response or catecholamine response of stress. Because there is such a direct correlation between the mind and body during the stress response, there are many activities that can used to help calm the mind and body. There is a direct correlation between stress in the body and stress in the mind. By learning to relax the body, the mind will follow, and vice versa.
Environmental Techniques
Environmental stimuli can either relax the mind or stimulate it toward stress. Using a calming environment can bring peace to the mind and body. Research has shown that nature is a potent stress reducer and can decrease blood pressure, respirations, and pulse. In our urban settings, people often become disconnected from their physical environment. People may become so accustomed to the noise of traffic and horns and people that they cannot hear the peaceful sounds of birds anymore. A simple action nurses can do is to turn off the noise of a television in a patient’s room and allow them to sleep. Many hospitals have a television system in the room that can play nature sounds, which are much more healing than the news. Be aware of the physical environment that may be adding to the stress of a patient and try to exchange it for a peaceful ambience.
Nursing Management
The tasks of nursing management make for busy days and, at times, can be overwhelming. It is human nature to experience stress, but nurses must be cognizant of how their emotional state can influence others. For example, your demeanor as you step into a patient’s room can set the tone for the interaction you are about to have. If you are in a hurry and impatient to complete your tasks, the patient will feel that energy and may make them feel as though they are the cause of your stress. It is important to plan your day and go about your work in a well-organized and purposeful way that decreases your stress and helps prevent any stress from being transferred to coworkers and patients.
Promote a Healthy Lifestyle
Nurses are in a unique position to teach healthy lifestyle behaviors to patients. Patients will “hear” your message in your own persona. If you come into a patient’s room smelling of smoke or looking disorganized and complaining about not getting a meal break, they will sense your message of healthy living may be hypocrisy. As the saying goes, “the best sermon is your life.” Learning about stress in this chapter may be a good opportunity for an assessment of your own stress and management strategies. What is working for you and what is not? Are there lifestyle behaviors you need to make that could decrease your stress? When will you begin? Nursing school is an ideal time to practice stress reduction strategies!
Coping Strategies as Interventions
Interventional strategies to help people cope vary based on what works for them. As a nurse, you can offer patients a list of strategies and help them identify several they are willing to try. Nurses can help the patient identify positive and negative types of coping strategies by asking, “How is that working for you?” If the outcome is negative, the nurse can help strategize about additional methods that could be used.
In a study done with nursing students, origins of stress revealed identified as exams, limited time for family and friends, negative interactions with clinical staff or faculty, work demands, and school-related finances. The study revealed that good coping strategies that helped nursing students included open communication, thinking through desired outcomes, staying organized, and finding meaning and purpose in the stress (Labrague et al., 2017). Although nursing school is stressful, the desired outcome is graduating as a registered nurse, which is worth it!