Chapter 9: Stress and Stress Management
Chapter 9: Stress and Stress Management
Chapter 9: Stress and Stress Management
• Stress occurs when individuals perceive that they cannot adequately cope with the demands
being made on them or with the threats to their well-being.
• The physiologic response of the person to stress is reflected in the interrelationship of the
nervous, endocrine, and immune systems. Stress activation of these systems affects other
systems, such as the cardiovascular, respiratory, gastrointestinal, renal, and reproductive
systems.
• Stress can have effects on cognitive function, including poor concentration, memory
problems, distressing dreams, sleep disturbances, and impaired decision-making.
• Long-term stress may increase the risk of cardiovascular diseases such as atherosclerosis
and hypertension. Other conditions either precipitated or aggravated by stress include
migraine headaches, irritable bowel syndrome, and peptic ulcers.
• Coping is defined as a person’s cognitive and behavioral efforts to manage specific external
or internal stressors that seem to exceed available resources.
• Coping can be either positive or negative. Positive coping includes activities such as
exercise and use of social support. Negative coping may include substance abuse and denial.
• Coping strategies can also be divided into two broad categories: emotion-focused coping
and problem-focused coping.
• Emotion-focused coping involves managing the emotions that an individual feels when a
stressful event occurs. Problem-focused coping attempts to find solutions to resolve the
problems causing the stress.
• Relaxation strategies can be used to cope with stressful circumstances and elicit the
relaxation response.
• The relaxation response is the state of physiologic and psychologic deep rest. It is the
opposite of the stress response and is characterized by decreased sympathetic nervous
system activity, which leads to decreased heart rate and respiratory rate, decreased blood
pressure, decreased muscle tension, decreased brain activity, and increased skin temperature.
• Regular elicitation of the relaxation response can be achieved through relaxation breathing,
meditation, imagery, music, muscle relaxation, and massage.
• Pain is defined as whatever the person experiencing the pain says it is, existing whenever
the person says it does.
• Untreated pain can result in unnecessary suffering, physical and psychosocial dysfunction,
impaired recovery from acute illness and surgery, immunosuppression, and sleep
disturbances.
• Inadequate pain management may be due to (1) insufficient knowledge and skills to assess
and treat pain; (2) unwillingness of providers to believe patients’ report of pain; (3) lack of
time, expertise, and perceived importance of conducting regular pain assessments; (4)
inaccurate and inadequate information regarding addiction, tolerance, respiratory
depression, and other side effects of opioids; and (5) fear that aggressive pain management
may hasten or cause death.
• Components of the nursing role include (1) assessing pain and communicating this
information to other health care providers, (2) ensuring the initiation and coordination of
adequate pain relief measures, (3) evaluating the effectiveness of these interventions, and (4)
advocating for people with pain.
• The emotional distress of pain can cause suffering, which is defined as the state of severe
distress associated with events that threaten the intactness of the person.
• Culture also affects the experience of pain, specifically the pain expression, medication use,
and pain-related beliefs and coping.
• Acute pain and chronic pain are different as reflected in their cause, course, manifestations,
and treatment.
o Acute pain typically diminishes over time as healing occurs.
o Chronic pain, or persistent pain, lasts for longer periods, often defined as longer
than 3 months or past the time when an expected acute pain or acute injury should
subside.
• The goals of a nursing pain assessment are (1) to describe the patient’s multidimensional
pain experience for the purpose of identifying and implementing appropriate pain
management techniques and (2) to identify the patient’s goal for therapy and resources for
self-management.
• Breakthrough pain is a transient, moderate to severe pain that occurs beyond the pain
treated by current analgesics.
• Pain scales are useful tools to help the patient communicate pain intensity. Scales must be
adjusted for age and cognitive development.
• Nociceptive pain may be described as sharp, aching, throbbing, and cramping. Associated
symptoms such as anxiety, fatigue, and depression may exacerbate or be exacerbated by
pain.
• Strategies for pain management include prescription and nonprescription drugs and nondrug
therapies such as hot and cold applications, complementary and alternative therapies (e.g.,
herbal products, acupuncture), and relaxation strategies (e.g., imagery).
o All strategies must be documented, both those that work and those that are
ineffective.
o Patient and family beliefs, attitudes, and expectations influence responses to pain and
pain treatment.
• Pain medications generally are divided into three categories: nonopioids, opioids, and co-
analgesic or adjuvant drugs.
o Mild pain often can be relieved using nonopioids alone.
o Moderate to severe pain usually requires an opioid.
o Neuropathic pain often requires a co-analgesic and adjuvant drug.
o Nonopioid pain medications include acetaminophen, aspirin, and nonsteroidal
antiinflammatory agents (NSAIDs).
• NSAIDs are associated with a number of side effects, including bleeding tendencies,
gastrointestinal ulcers and bleeding, and renal and CNS dysfunction.
• Appropriate analgesic scheduling focuses on prevention or control of pain rather than the
provision of analgesics only after the patient’s pain has become severe.
• Neuroablative interventions are performed for severe pain that is unresponsive to all other
therapies.
• Neuroaugmentation involves electrical stimulation of the brain and the spinal cord.
• Exercise is a critical part of the treatment plan for patients with chronic pain, particularly
those experiencing musculoskeletal pain.
• Acupuncture is a technique of Traditional Chinese Medicine in which very thin needles are
inserted into the body at designated points to reduce musculoskeletal pain, repetitive strain
disorders, myofascial pain syndrome, postsurgical pain, postherpetic neuralgia, peripheral
neuropathic pain, and headaches.
• Heat therapy can be either superficial or deep.
• Cold therapy involves the application of either moist or dry cold to the skin.
• Techniques to alter the affective, cognitive, and behavioral components of pain include
distraction, hypnosis, and relaxation strategies.
• The nurse acts as planner, educator, patient advocate, interpreter, and supporter of the patient
in pain and the patient’s family. It is important to realize that a nurse’s beliefs and attitudes
may hinder appropriate pain management.
• Gerontologic considerations:
o Treatment of pain in the elderly patient is complicated.
o Older adults metabolize drugs more slowly than younger persons and thus are at
greater risk for higher blood levels and adverse effects.
o The use of NSAIDs in elderly patients is associated with a high frequency of serious
GI bleeding.
o Older people often take many drugs for one or more chronic conditions.
o Cognitive impairment and ataxia can be exacerbated when analgesics such as
opioids, antidepressants, and antiseizure drugs are used.
o Health care providers for older patients should titrate drugs slowly and monitor
carefully for side effects.