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Chapter: Medical Surgical Nursing: Homeostasis, Stress, and Adaptation

Stress Management: Nursing Interventions

Stress or the potential for stress is ubiquitous; that is, it is every-where and anywhere at once.

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


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’s Relaxation Response


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.


Relaxation With Guided Imagery


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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