STRESS AND CRISIS

Definition of the Terms

Stress

• Stress is a physical and emotional state always

present in the person, one influenced by

various environmental, psychological and various environmental, psychological and

social factors but uniquely perceived by the

person and intensified in response when

environmental change or threat occurs

internally or externally and the person must

respond.

• The manifestations of the stress are overt and

covert, purposeful, initially protective,

maintaining equilibrium, productivity and

satisfaction to the extent possible

• According to Hans Selye, stress is nonspecific

response of the body to any demand made

upon it, whether is caused by the results of upon it, whether is caused by the results of

pleasant and unpleasant situation.

• In small doses, stress can be a good thing. It

can give you the push you need, motivating

you to do your best

• But when the stress gets too tough and life's

demands exceed your ability to cope, stress

becomes a threat to both your physical and becomes a threat to both your physical and

emotional well-being

• According to old concept “To be alive is to be

under stress”.

Stressor

• A stressor is any event or stimulus that causes

an individual to experience stress.

• For example

�Internal stressor originates inside the body

such as fever, pregnancy, menopause, such as fever, pregnancy, menopause,

emotion etc.

� External stressor originates outside the

individual for example physical stressors,

biological stressors, social stressors etc.

Crisis

• Crisis is a situation that can not be resolved by

usual method of coping mechanism; as a

result a person becomes unable to function

normally and requires intervention to regain

equilibrium.equilibrium.

• Crisis occurs when coping and defensive

mechanism that has been used to solve

problems and adapt to change is no longer

effective

• A crisis is an acute, time-limited state of

disequilibrium resulting from situational,

developmental or social sources of stress. A

person in crisis is temporarily unable to cope

with or adapt to the stressor by using methods

of problem solving. People in crisis generally

have a distorted perception of the event and do

of problem solving. People in crisis generally

have a distorted perception of the event and do

not have adequate situational support or coping

mechanisms.

• Crises always involve change and loss

Coping

• According to Folkman and Lazarus (1991),

coping is “the cognitive and behavioral effort

to manage specific external and/or internal

demands that are appraised (estimated) as

taxing or exceeding the resources of the taxing or exceeding the resources of the

person”.

• A coping strategy (coping mechanism) is a

natural or learned way of responding to a

changing environment or specific problem or

situation.

Local Adaptation Syndrome

Definition

• Response of the body tissue, an organ, or part

of the body to the stress of trauma, illness, or

other physiological change

• is the method used to wall off and control • is the method used to wall off and control

effects of physical stressors locally

• Examples

– Reflex pain response: localized response of

CNS to stimulus of pain (remove hand from

hot surface)

– Inflammatory response

General Adaptation Syndrome

Definition

• Physiological response of the whole body to

stress

• Involves several body systems, primarily the

autonomic nervous system and endocrine systemautonomic nervous system and endocrine system

Stages

• Alarm Reaction (AR)

• Resistance stage (SR)

• Exhaustion stage (ES)

Alarm stage

Alarm Reaction (AR)

• In the first stage of GAS

• During the alarm phase, a stressor disturbs

homeostasis

• The brain subconsciously perceives the

stressor and prepares the body either to fight stressor and prepares the body either to fight

or to run away, a response sometimes called

the fight or flight response

• Body releases adrenaline and a variety of

other psychological mechanisms to combat

the stress and to stay in control

• Rising hormone levels results in increased blood

volume, blood glucose levels, epinephrine and

nor-epinephrine amount, heart rate, blood flow

to muscles, oxygen intake and mental alertness.

• In addition , the pupils of the eye dilate to

produce greater visual field

• May last from 1 minute to many hours

• Once the cause of the stress is removed, the

body will go back to normal.

• If not resolved………. person enters into

resistance or adaptation stage

Resistance stage

Resistance stage (SR)

• In this phase, the body has reacted to the

stressor and adjusted in a way that begins to

allow the body to return to homeostasis

• This is the body’s response to long term

protection.

• It secretes further hormones that increase

blood sugar levels to sustain energy and raise

blood pressure. The adrenal cortex (outer

covering) produces hormones called

corticosteroids for this resistance reaction.

• Overuse by the body's defense mechanism in

this phase eventually leads to disease

• If this adaptation phase continues for a

prolonged period of time without periods of

relaxation and rest to counterbalance the

stress response, sufferers become prone to

fatigue, concentration lapses, irritability and fatigue, concentration lapses, irritability and

lethargy as the effort to sustain arousal slides

into negative stress.

• If stressor remains for prolonged period and

person unable to adapt…. Person enters into

Exhaustion Stage

Exhaustion stage

Exhaustion Stage (ES)

• In this stage, the body has run out of its

reserve of body energy and immunity.

• Mental, physical and emotional resources

suffer heavily.

• The body experiences "adrenal exhaustion". • The body experiences "adrenal exhaustion".

• The blood sugar levels decrease as the

adrenals become depleted, leading to

decreased stress tolerance, progressive

mental and physical exhaustion, illness and

collapse.

• If stress continues, death may result

References• http://www.angelfire.com/la2/stress/general.

html

• http://helpguide.org/mental/stress_signs.htm

• Kozier, B. & Erb, G. (2000). Fundamentals of

Nursing: Concept and Practice (6th ed.) USA: Nursing: Concept and Practice (6 ed.) USA:

Prentice Hall.

• Perry, A.G. & Potter, P.A. (2005). Clinical

Nursing Skills and Techniques. St. Louis:

Mosby.

• Murray, R.B. & Zentner, J. P.(2000). Health

Promotion Strategies Through the Life Span.

(7th ed.)

• Taylor, C.,Lillis, C., & LeMone, P.(2006).

Fundamentals of Nursing(5th ed.). Wolters

Kluwer Health (India) Pvt. Ltd., New Delhi.

• http://www.holisticonline.com/stress/stress_g• http://www.holisticonline.com/stress/stress_g

as.

• htmhelpguide.org/.../burnout_signs_symptom

s.htm

Difference between Stress and Crisis

Stress Crisis1. Stress comes frequently in

our daily life.1. It comes rarely or can’t be

come.1. Stress can be overcome

easily by coping mechanism.2. Crisis can’t be overcome

easily and it takes long time tobe in previous normal state.

3. It doesn’tharman individual 3. Thereis no alternativeincase3. It doesn’tharman individualif he/she faces it positivelybecause stress is normallypresent in living animals.

3. Thereis no alternativeincaseof crisis. When it occurs itchanges the whole pattern ofliving style of an individualwhich is very miserable(unhappy) and terrible.

4. Stress is a chronic conditionin which the perceived dangerpersists over a long period oftime without resolving it.

4. Crisis is the acute conditionwhich causes potentialeminent danger that needsimmediate attention

Difference between Stress and Crisis

Stress Crisis

5. Stress makes a persontempered and irritated.

5. It makes a person shockincluding helpless, anxiety,confusion, depression, anger,withdraw, psychosomaticsymptoms, insufficiency andhopeless. Suicidal andhomicidal thoughts may bepresent.

6. Various ways of tension relief 6. Less ways of tension relief.

The difference is that if crisis is not dealt with or resolved, itbecomes stress over time.

Causes of Stress

• General Causes

�Threat: A perceived threat will lead a person

to feel stressed.

• This can include physical threats, social

threats, financial threat, and so on. threats, financial threat, and so on.

• In particular it will be worse when the person

feels they have no response that can reduce

the threat, as this affects the need for a sense

of control.

�Fear: Threat can lead to fear, which again

leads to stress.

� Fear leads to imagined outcomes, which are

the real source of stress.

�Uncertainty: When we are not certain, we are

unable to predict, and hence feel we are not unable to predict, and hence feel we are not

in control, and hence may feel fear or feel

threatened by that which is causing the

uncertainty.

• Cognitive Dissonance: When there is a gap

between doing and thinking, then experience

of cognitive dissonance occurs, which is felt as

stress. Thus, if a person think he is a nice

person then does something that hurts

someone else, he will experience dissonance

and stress.and stress.

• Dissonance also occurs when person cannot

meet his/her commitments due to certain

circumstances (ie a social threat).

Life Causes

• Death: of spouse, family, friend

• Health: injury, illness, pregnancy

• Crime: Sexual molestation, mugging, burglary,

pick-pocketed

• Self-abuse: drug abuse, alcoholism, self-harm • Self-abuse: drug abuse, alcoholism, self-harm

• Family change: separation, divorce, new baby,

marriage

• Sexual problems: getting partner, with partner

• Argument: with spouse, family, friends, co-

workers, boss

Life Causes

• Physical changes: lack of sleep, new work

hours

• New location: vacation, moving house

• Money: lack of it, owing it, investing it

• Environment change: in school, job, house, • Environment change: in school, job, house,

town, jail

• Responsibility increase: new dependent, new

job

Stress at work

• The demands of the job

• The control over staff how they do their work

• The support they receive from colleagues and

superiors

• Their relationships with colleagues • Their relationships with colleagues

• Whether they understand their roles and

responsibilities

• How far the company consults staff over

workplace changes

Other stress indicators at work

• Poor communication between teams

• Sickness absence

• Lack of feedback on performance

• High staff turnover

• Lack of clarity of roles and responsibilities • Lack of clarity of roles and responsibilities

• Bullying (harassment/maltreatment)

• Dissatisfaction with non-monetary benefits

• Value and contribution

• Boring and mundane work

• Technological change

• Uncomfortable workplace

• Working long hours

• Lack of training On-off incidents

Causes of Stress

The causes of stress depends on the perception

of it. Something that's stressful to one person

may not disturb other; he/she may even enjoy

it.

Common external causes of stressCommon external causes of stress

Not all stress is caused by external factors. Stress

can also be self-generated:

• Major life changes

• Work

• Relationship difficulties

• Financial problems

• Being too busy

• Children and family

Common internal causes of stress

• Inability to accept uncertainty

• Pessimism • Pessimism

• Negative self-talk

• Unrealistic expectations

• Perfectionism

• Lack of assertiveness

Top Ten Stressful Life Events

• Spouse’s death

• Divorce

• Marriage separation

• Jail term (imprison)

• Death of a close relative • Death of a close relative

• Injury or illness

• Marriage

• Fired from job

• Marriage reconciliation

• Retirement

Effects of Stress

�Physical Effects

• GI system: Stomachache, nausea, dry mouth,

constipation, diarrhea, hungry

• Circulatory System: Palpitation, flushing, high

BP, feeling cold, dizziness, hot flushingBP, feeling cold, dizziness, hot flushing

• Respiratory: Breathlessness, restlessness,

holding breath, etc.

• Reproductive system: decreased sexual drive

• Urinary system: Frequency of micturation

� Emotional Symptoms

• Moodiness

• Irritability or short temper

• Agitation, inability to relax

• Feeling overwhelmed

• Sense of loneliness and isolation • Sense of loneliness and isolation

• Depression or general unhappiness

�Cognitive Symptoms

• Memory problems

• Inability to concentrate

• Poor judgment

• Seeing only the negative

• Anxious or racing thoughts

• Constant worrying

�Behavioral Symptoms

• Eating more or less

• Sleeping too much or too little

• Isolating yourself from others

• Procrastinating or neglecting responsibilities

• Using alcohol, cigarettes, or drugs to relax

• Nervous habits (e.g. nail biting, pacing)

Health Problems Linked to Stress

• Stroke: People who are prone to stress face

the risk of hypertension and clogged arteries.

This increases the chances of stroke if they

experience prolonged periods of stress.

• Diabetes: Studies have shown that chronic

stress is associated with deficient production

of insulin in the body.

• Eating problems: Stress is often linked to

weight gain and obesity. When people are

stressed they develop a craving towards salt

and sugar and end up eating fatty and starchy

foods to combat stress. Stressed people may

also suffer a loss of appetite and loss of also suffer a loss of appetite and loss of

weight. In rare cases, chronic stress triggers

hyperactivity of thyroid gland, and this causes

the body to burn up calories at a rapid rate.

• Ulcers: Chronic stress is commonly linked with

peptic ulcers. Peptic ulcers are caused by

bacteria or by the excessive intake of some

medicines (such as aspirin, ibuprofen). Some

studies indicate that stress does increase the

susceptibility to ulcers or prolongs the cure of

an existing ulcer. A chronic stress condition an existing ulcer. A chronic stress condition

also ends up irritating the large intestine

(Irritable bowel syndrome).

Sexual Problems

• Stress can lead to loss of libido, or even

temporary impotence in men. In women it can

lead to inability to achieve orgasm, reduced

fertility, and higher chances of miscarriage,

reduced estrogen levels, or even

discontinuation of menstruation. discontinuation of menstruation.

Memory loss

• Acute stress can cause impaired memory and

lack of concentration, thus inhibiting learning

ability and work efficiency.

• Infections; As stress weakens the immune

system, people who are stressed face an

increased risk of infections. Many studies have

shown that people with chronic stress have a

reduced white blood cell count and are

vulnerable to common diseases such as cold,

cough, etc. cough, etc.

• Insomnia

• Substance abuse

• Depression

• Obesity and Heart attack

• Hypertension etc.

Measures to Reduce Stress

General guidelines for helping the clients who

are stressed and feeling anxious are as below:

• Listen attentively; try to understand the

client’s perspective on the situation.

• Provide an atmosphere of warmth and trust; • Provide an atmosphere of warmth and trust;

convey a sense of caning and empathy.

• Determine if it is appropriate to encourage

clients’ participation in the plan of care; give

them choices about some aspects of care but

do not overwhelm them with choices.

• Stay with clients as needed to promote safety

and feelings of security and to reduce fear.

• Control the environment to minimize

additional stressors such as reducing noise,

limiting the number of persons in the room,

and providing care by the same nurse as much and providing care by the same nurse as much

as possible.

• Implement suicide precautions if indicated.

• Communicate in short, clear sentence.

• Help clients to

�Determine situations that precipitate anxiety

and identify signs of anxiety.

�Verbalize feelings, perceptions, and fears as

appropriate. Some cultures discourage the

expression of feelings.

Identify personal strengths.�Identify personal strengths.

�Recognize usual coping patterns and

differentiate positive from negative coping

mechanisms.

�Identify new strategies for managing stress (e.g.

exercise, massage, progressive relaxation).

�Identify available support systems

• Teach clients about

�The importance of adequate exercise, a

balanced diet, and rest and sleep to energize

the body and enhance coping abilities.

�Educational programs available such as time �Educational programs available such as time

management, assertiveness training, and

meditation groups

Coping with Stress by the Nurse

• Identify the possible cause of stress

• Develop good rapport with others

• Do one thing at a time

• Balance the life activities with work and play,

family and friends and time for herself.family and friends and time for herself.

• Exercise body everyday or at least four times a

week (sports, yoga, dancing or walking)

• Meditate to promote relaxation.

• Relax body regularly through a systematic

method of tensing and relaxing all muscles.

• Understand and accept what you can and

what you can not do or be.

• Assume a more positive attitude toward

irritating and frustrating situations or events.irritating and frustrating situations or events.

• Determine to enjoy selected stressors as a

challenge e.g. examination

• Accept loved support from others, their

encouragement, and suggestion, be willing to

receive help.

• Set a time for relaxation each day e.g.

meditation, yoga, seek source of joy and

rumors.

• Talk about your feelings with friends and

counselors

• Accept the things that one can not change.• Accept the things that one can not change.

• Try to correct the aspects of your life that

causes stress.

• Don not push yourself beyond your limit of

achievement and expectation but be satisfied

with less while you do your best.

• Organize life with priorities so that you will

accomplish what must be done at the right

time.

• Develop healthy social relationship.

• Practice coping statement

Characteristics of Crisis

• Crisis occurs in everybody’s life at one time or

another

• Crisis is personal in nature. Any situation

which is stress for one individual may not be

so far for another.so far for another.

• Crisis is acute and will be solved one way or

another within a brief period

• A crisis situation contains the potential for

psychological growth or deterioration

• A crisis situation may be dangerous for

individual, may harm self or another

• Crisis usually lasts one to six weeks.

Types of Crisis

• Developmental crisis

• Situational crisis

• Cultural crisis• Cultural crisis

• Community crisis

Developmental Crisis

• It is a transient period which everybody

experiences in the process of bio-psychosocial

growth and development which is

accompanied by chance in thought, feelings

and abilities of individual who is not able to and abilities of individual who is not able to

cope with the crisis

• Examples: entry into school, puberty,

marriage, pregnancy, child birth, menopause,

old age, leaving home, retirement, facing

death of others and of the self etc.

• Onset of development crisis is gradual and

move from one stage to another and stage

does last for whole life.

• Reasons for developmental crisis: The main

reason for this type of crisis is persons’

inability to make role changes as per their inability to make role changes as per their

needs

Developmental Stage Developmental Crisis

Child Beginning school, establishing peerrelationships, peer competition.

Adolescent Changing physique, relationships involvingsexual attraction, exploring independence,choosing career.

Young Adult Marriage, leaving home, managing a home,getting startedin an occupation,continuinggetting startedin an occupation,continuingone’s education and children.

Middle Adult Physical changes of aging, maintainingsocial status and standard of living, helpingteenage children to become

Older adult Decreasing physical abilities and health,changes in residence, retirement and reducedincome, death of spouse and friends etc.

Reasons for persons not being able to

make role changes

• Person’s inability to picture himself in a new

role

• Lack of resources, inadequate communication

skills, inability to realize alteration to his skills, inability to realize alteration to his

present life style as well as achievement of

central goal

• Refusal by others in social system to see the

person in a different role.

Community crisis or Social Crisis

• A crisis which affects whole community is

known as community crisis or social crisis or

adventitious.

• Example of community crisis are natural

disaster, armed conflictsdisaster, armed conflicts

Situational crisis

• Any external events or situation which occurs

often suddenly, unexpectedly and

unfortunately which is not a part of normal

living.

• Examples are natural disaster, accidents, • Examples are natural disaster, accidents,

suicide, death of loved one, illness or

hospitalization

• Both situational and developmental crisis may

occur at the same time e.g. suicidal attempt

followed by unwanted marriage

Cultural crisis

• Cultural crisis is a situation where a person

experienced cultural shock in the process of

adjustment or adaptation to new culture or

returning to one’s culture after being

assimilated into anotherassimilated into another

Phases of crisis

�Initial impact or shock: In this phase person

experiences shock and depersonalization

�Realization: In this phase, collapse of self

structure occurs.

• The person experiences high level of anxiety, • The person experiences high level of anxiety,

panic and helplessness.

• The person can not plan, reason and

understand the situation

�Defensive retreat: There is an attempt to

establish previous identity, avoidance of

reality or denial.

• Wishful thinking may ensure to relieve the

anxiety.

�Recoil or acknowledgement ( ‘yes’ stage): The �Recoil or acknowledgement ( ‘yes’ stage): The

individual experiences depression without

intervention.

• The person may become more disorganized,

depressed and have more suicidal tendency.

• In this stage person realizes events

�Resolution or adaptation: If help is adequate,

changes occur and new identity appears along

with hope.

• The person struggles to solve the situation

and may involve other people to help them

Factors Affecting Outcome of Crisis

1. Individual’s Perception of the Events

• If the event (or the implications or

consequences of it) threatens the self-

concept; conflicts with the value system, self-

expectations, or wishes for the future; expectations, or wishes for the future;

contributes to a sense of shame or guilt; or is

demoralizing or damaging to self, family, or

personal objects, the situation is defined as

hazardous.

• The perception of the event is reality for the

person of family, regardless of how others

might define reality.

• How the event is perceived depends in large

measure on past experience.

2. Individual’s physical and emotional status

• This includes level of health, amount of energy

present, age, genetic endowment, and

biological rhythms of the person or family, or

the general well-being of the community.

• Working through crisis takes considerable • Working through crisis takes considerable

energy.

3. Coping mechanism and level of maturity

• If adaptive capacities are already strained, or if

the stress is overwhelming, the person will

cling to old habits or existing defenses, and

behavior will very likely be inappropriate to

the task at hand. the task at hand.

• The person or family who has met

developmental tasks all along and who

perceives self as able to cope will adapt more

easily in any crisis.

• The group or community that has

mechanisms, policies, or procedures defined

and in operation to cope with the unexpected

event or disaster can better meet the crisis.

4. Previous Experiences with Similar Situation

• The person, family, or group needs to learn to

cope with stress, change, and loss.

• If past crises were handled by distorting reality

or by withdrawing, when similar crises arise,

burdens of the prior failure will be added to the

problem of coping with the new situation. problem of coping with the new situation.

• Unresolved crises are cumulative in effect.

• The most recent crisis revives the denial,

depression, anger, or mal-adaption that was left

unsettled from past crises.

• If the person, family, or group successfully

deals with crises, self-confidence and self-

esteem will thereby be increased, and future

crises will be handled more effectively.crises will be handled more effectively.

5. Cultural Influences

• How the person is trained and socialized in the

home to solve problems and meet crisis

situations; the use of religious, cultural, or

legal ceremonies or rituals to handle

separation or loss and facilitate mourning; separation or loss and facilitate mourning;

expectations of how the social group will

support the person or family during crisis; and

the method established by the community to

provide help-all influence present behavior.

6. Support of Family, Friends or Other

Resources

• The less available the environmental or

emotional support systems are to decrease

stress or buttress (support) the coping

response, the more hazardous the event will

be. be.

• The family system, by its influence on

development of self-concept and maturity,

can increase or decrease the person’s

vulnerability to crisis.

7. Realistic Aspect of the Current Situation

• These include personal, material, or economic

losses, the extent to which group ties or

community services are interrupted, and

changes in living pattern or family life

necessitated by the loss.

8. Degree of Perceived Dependency on a Lost

Object

• This is always crucial; the greater the

dependency, the more difficult the resolution

of loss.

Crisis Intervention

Goals of crisis intervention are

• To reduce the impact of stressful events

• To help those affected with present problems

There are 4 phases of crisis intervention

techniques which are similar to nursing

process

Assessment

• In this phase, nurses gather information

regarding the precipitating stressors and the

resulting crisis

• Nurses assess the followings;

�Determine the events or situation that �Determine the events or situation that

precipitated the crisis and what caused the

individual to seek help.

�Assess the person’s coping style and strength

�Assess the support available to the person

• In addition determine whether or not the

crisis situation has produced feeling of severe

despair or anger, self destructive or suicidal.

• If nurses find such types of feeling on patients,

nursing actions to prevent self harm should be

instituted immediately.instituted immediately.

Planning

• After assessment, nurses make nursing

diagnosis for each problem identified during

assessment. Nursing diagnosis (NANDA, 2000)

that is common in person’s undergoing crisis

• Diagnosis may be made as follows• Diagnosis may be made as follows

• Fear related to the precipitating

factors/events.

• Hopelessness related to the sense of inability

to recover from the crisis

Planning Contd.

• After making nursing diagnosis, nurses select

the appropriate nursing actions for identified

nursing diagnosis. nursing diagnosis.

• Then the nurse will establish short term as

well as long term goals of care.

Intervention

• Establish trust with the client, ensure

confidentiality and develop a good

understanding of patients or client’s

experiences and feelings.experiences and feelings.

• Let the client verbalize his/her feelings

• Encourage honest disclosure and does not

attempt to avoid emotional reactions like

anger/crying

Intervention contd.

• If necessary, change environment; it may

serve to alleviate stress or feeling of comfort

and safety.

• Support the client in the use of defense

mechanism that supports him/her.mechanism that supports him/her.

• Never criticize clients coping mechanism at a

time of crisis but may gently suggest ways.

Intervention contd.

• Identify support systems and new social

networks from which the individual may seek

assistance at a time of crisis.

• Always remain with the clients experiencing

panic anxiety.panic anxiety.

• Discourage lengthy explanation of the situation;

provide an atmosphere for verbalization of true

feeling.

• Set limits on aggressive and destructive

behaviors.

Evaluation

• At last, nurses assess the outcomes of the

crisis.

• The nurse and client together can determine • The nurse and client together can determine

whether it was a successful resolution of the

crisis.

Evaluation Continue

– Does the client feel he/she can return to a

normal life?

– Does he/she have the skills and confidence to

return to the work?

– Have positive behavioral changes occurred?– Have positive behavioral changes occurred?

– If the client wishes to pursue continue

therapy, group support and development

after resolution of crisis, the nurses should

refer the client to available resources.