Stress Management: Nursing Interventions
Stress or the potential
for stress is ubiquitous; that is, it is every-where and anywhere at once.
Anxiety, frustration, anger, and feel-ings of inadequacy, helplessness, or
powerlessness are emotions often associated with stress. In the presence of
these emotions, the customary activities of daily living may be disrupted; for
example, a sleep disturbance may be present, eating and activity patterns may
be altered, and family processes or role performance may be disrupted.
Many nursing diagnoses
are possible for patients suffering from stress. One nursing diagnosis related
to stress is Anxiety, which is defined as a vague, uneasy feeling, the source
of which may be nonspecific or not known to the person. Stress may also be
man-ifested as ineffective coping patterns, impaired thought processes, or
disrupted relationships. These human responses are reflected in the nursing
diagnoses of Impaired adjustment, Ineffective coping, Defensive coping, and
Ineffective denial, all of which indicate poor adaptive responses. Other
possible nursing diagnoses include Social isolation, Risk for impaired
parenting, Spiritual distress, Readiness for family coping, Decisional
conflict, Situational low self-esteem, and Powerlessness, among others. Because
human re-sponses to stress are varied, as are the sources of stress, arriving
at an accurate diagnosis allows interventions and goals to be more specific and
leads to improved outcomes.
Stress management is
directed toward reducing and control-ling stress and improving coping. Nurses
might use these meth-ods not only with their patients but also in their own
lives. The need to prevent illness, improve the quality of life, and decrease
the cost of health care makes efforts to promote health essential, and stress
control is a significant health-promotion goal. Stress-reduction methods and
coping enhancements can derive from either internal or external sources. For
example, adopting healthy eating habits and practicing relaxation techniques
are internal re-sources that help to reduce stress; developing a broad social
net-work is an external resource that helps reduce stress. Goods and services
that can be purchased are also external resources for stress management, and it
is much easier for individuals with adequate financial resources to cope with
constraints in the environment, because their sense of vulnerability to threat
is decreased.
An individual’s personal
resources that aid in coping include health and energy. A health-promoting
lifestyle provides these re-sources and buffers or cushions the impact of
stressors. Lifestyles or habits that contribute to the risk of illness can be
identified through a health risk appraisal.
A health risk appraisal
is an assessment method that is de-signed to promote health by examining an
individual’s personal habits and recommending changes when a health risk is
identi-fied. Health risk questionnaires estimate the likelihood that a per-son
with a given set of characteristics will become ill. It is hoped that if people
are provided with this information, they will alter their activities (eg, stop
smoking, have periodic screening exami-nations) to improve their health.
Questionnaires typically address the following information:
1) Demographic data: age,
sex, race, ethnic background
2) Personal and family
history of diseases and health problems
3) Lifestyle choices
a) Eating, sleeping, exercise,
smoking, drinking, sexual ac-tivity, and driving habits
b) Stressors at home and on
the job
c) Role relationships and
associated stressors
4) Physical measurements
a) Blood pressure
b) Height, weight
c) Laboratory analyses of
blood and urine
5) Participation in high-risk
behaviors
The personal information
is compared with average popula-tion risk data, and the risk factors are
identified and weighted. From this analysis, the person’s risks and major
health hazards are identified. Further comparisons with population data can
esti-mate how many years will be added to the person’s life span if the
suggested changes are made. However, research so far has not demonstrated that
providing people with such information en-sures that they will change their
habits. The single most impor-tant factor for determining health status is
social class, and within a social class the research suggests that the major
factor influenc-ing health is level of education (Mickler, 1997).
McCloskey and Bulechek
(1999) identified “coping enhance-ment” as a nursing intervention and defined
it as “assisting a pa-tient to adapt to perceived stressors, changes, or
threats that interfere with meeting life demands and roles” (Chart 6-2). The
nurse can build on the patient’s existing coping strategies, as iden-tified in
the health appraisal, or teach new strategies for coping if necessary.
The five predominant
ways of coping with illness identified in a review of 57 nursing research
studies were as follows (Jalowiec, 1993):
· Trying to be optimistic
about the outcome
· Using social support
· Using spiritual
resources
· Trying to maintain
control either over the situation or over feelings
· Trying to accept the
situation
Other ways of coping
included seeking information, repriori-tizing needs and roles, lowering
expectations, making compro-mises, comparing oneself to others, planning
activities to conserve energy, taking things one step at a time, listening to
one’s body, and using self-talk for encouragement.
The nurse can implement
the coping enhancement interven-tions and explore methods for improving the
patient’s coping abilities.
Relaxation techniques
are a major method used to relieve stress. Commonly used techniques include
progressive muscle relax-ation, the Benson Relaxation Response, and relaxation
with guided imagery. The goal of relaxation training is to produce a response
that counters the stress response. When this goal is achieved, the action of
the hypothalamus adjusts and decreases the activity of the sympathetic and
parasympathetic nervous sys-tems. The sequence of physiologic effects and their
signs and symptoms are interrupted, and psychological stress is reduced. This
is a learned response and requires practice to achieve.
The different relaxation
techniques share four similar ele-ments: (1) a quiet environment, (2) a
comfortable position, (3) a passive attitude, and (4) a mental device
(something on which to focus the attention, such as a word, phrase, or sound).
Progressive muscle
relaxation involves tensing and releasing the muscles of the body in sequence
and sensing the difference in feel-ing. It is best if the person lies on a soft
cushion on the floor, in a quiet room, breathing easily. Someone usually reads
the instruc-tions in a low tone and with a slow and relaxed manner, or a tape
of the instructions may be played. The person tenses the muscles in the whole
body (one muscle group at a time), holds, senses the tension, and then relaxes.
As each muscle group is tensed, the per-son keeps the rest of the body relaxed.
Each time the focus is on feeling the tension and relaxation. When the exercise
is com-pleted, the whole body should be relaxed (Benson, 1993; Benson &
Stark, 1996).
Benson (1993) describes
the following steps of the Benson Re-laxation Response:
·
Pick a brief phrase or word that reflects your
basic belief system.
·
Choose a comfortable position.
·
Close your eyes.
·
Relax your muscles.
·
Become aware of your breathing, and start using
your se-lected focus word.
·
Maintain a passive attitude.
·
Continue for a set period of time.
·
Practice the technique twice daily.
This response combines
meditation with relaxation. Along with the repeated word or phrase, a passive
attitude is essential. If other thoughts or distractions (noises, the pain of
an ailment) occur, Benson recommends not fighting the distraction but sim-ply
continuing to repeat the focus phrase. The time of day is not important, but
the exercise works best on an empty stomach.
Simple guided imagery is the “purposeful use
of imagination to achieve relaxation or direct attention away from undesirable
sen-sations”. The nurse helps the person select a pleasant scene or experience,
such as watching the ocean or dabbling the feet in a cool stream. This image
serves as the mental device in this technique. As the person sits com-fortably
and quietly, the nurse guides the individual to review the scene, trying to
feel and relive the imagery with all of the senses. A tape recording may be
made of the description of the image, or commercial tape recordings for guided
imagery and relaxation can be used.
Other relaxation
techniques include meditation, breathing techniques, massage, Reiki, music
therapy, biofeedback, and the use of humor.
Two commonly prescribed
nursing educational interventions— providing sensory information and providing
procedural infor-mation (eg, preoperative teaching)—have the goal of reducing
stress and improving the patient’s coping ability. This prepara-tory education
includes giving structured content, such as a les-son in childbirth preparation
to expectant parents, a review of cardiovascular anatomy to the cardiac
patient, or a description of sensations the patient will experience during
cardiac catheteriza-tion. These techniques may alter the person–environment
rela-tionship such that something that might have been viewed as harmful or a
threat will now be perceived more positively. Giv-ing patients information also
reduces the emotional response so that they can concentrate and solve problems
more effectively (Calvin & Lane, 1999; Millo & Sullivan, 2000).
The nature of social
support and its influence on coping have been studied extensively; social
support has been demonstrated to be an effective moderator of life stress.
Social support has been found to provide the individual with several different
types of emotional information (Heitzman & Kaplan, 1988; Wineman, 1990).
The first type of information leads people to believe that they are cared for
and loved. This emotional support appears most often in a relationship between
two people in which mutual trust and attachment are expressed by helping one
another meet their emotional needs. The second type of information leads
peo-ple to believe that they are esteemed and valued. This is most effective
when there is recognition that demonstrates the indi-vidual’s favorable
position in the group. It elevates the person’s sense of self-worth and is
called esteem support. The third type of information leads people to believe
that they belong to a net-work of communication and mutual obligation. Members
of this network share information and make goods and services available to the
members on demand.
Social support also
facilitates an individual’s coping behaviors; this depends, however, on the
nature of the social support. Peo-ple can have extensive relationships and
interact frequently, but the necessary support comes only when there is a deep
level of in-volvement and concern, not when people merely touch the sur-face of
each other’s lives. The critical qualities within a social network are the
exchange of intimate communications and the presence of solidarity and trust.
Emotional support from
family and significant others pro-vides a person with love and a sense of
sharing the burden. The emotions that accompany stress are unpleasant and often
increase in a spiraling fashion if relief is not provided. Being able to talk
with someone and express feelings openly may help the person to gain mastery of
the situation. Nurses can provide this support; however, it is important to
identify the person’s social support system and encourage its use. People who
are loners, who are iso-lated, or who withdraw in times of stress have a high
risk of cop-ing failure.
Because anxiety can also
distort a person’s ability to process in-formation, it helps to seek
information and advice from others who can assist with analyzing the threat and
developing a strat-egy to manage it. Again, this use of others helps the person
to maintain mastery of a situation and to retain self-esteem.
Thus, social networks
assist with management of stress by pro-viding the individual with
· A positive social
identity
· Emotional support
· Material aid and
tangible services
· Access to information
· Access to new social
contacts and new social roles
Support groups exist
especially for people in similar stressful sit-uations. Groups have been formed
by parents of children with leukemia, people with ostomies, mastectomy
patients, and those with other kinds of cancer or other serious diseases,
chronic ill-nesses, and disabilities. There are groups for single parents,
substance abusers and their family members, and victims of child abuse.
Professional, civic, and religious support groups are active in many
communities. There are also encounter groups, as-sertiveness training programs,
and consciousness-raising groups to help people modify their usual behaviors in
their transactions with their environment. Being a member of a group with
similar problems or goals has a releasing effect on a person that promotes
freedom of expression and exchange of ideas.
As previously noted, a
person’s psychological and biologic health, internal and external sources of
stress management, and relationships with the environment are predictors of
health out-comes. These factors are directly related to the health patterns of
the individual. The nurse has a significant role and responsibility in
identifying the health patterns of the person receiving care. If those patterns
are not achieving physiologic, psychological, and social balance, the nurse is
obligated, with the assistance and agreement of the patient, to seek ways to promote
balance.
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