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Stress Theory: the Nature of Stress and the Body’s Response to Stress

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    Stress Theory; Selyle/Psychoneuroimmunology By Jessica Cronin RN, Teri Lieser RN Unit Summary Unit 10 examines stress, the stress response as described by Dr. Hans Selye in addition to clinical situations and research involving Stress Theory, a borrowed theory used in nursing practice. Unit Objectives 1. Describe the background, development and concepts of Stress Theory 2. Identify the relationship among Stress Theory concepts 3. Outline the phenomena, populations and clinical situations Stress Theory explains Assigned Readings

    Clancy, J. & McVicar, A. (1993). Subjectivity of stress. British Journal of Nursing, 2(8), 410- 417. Hays, M. , All, A. , Mannahan, C. , Cuaderes, E. , & Wallace, D. (2006). Reported stressors and ways of coping utilized by intensive care nurses. Dimensions of Critical Care Nursing, 25(4), 185-193. McEwen, M. & Wills, E. M. (2007). Theoretical Basis for Nursing. Chapter 13 (314-317, 323), Chapter 14 (338-340). Unit 10 Key Points Background, development and concepts of Stress Theory Relationship among Stress Theory concepts

    Phenomena, populations and clinical situations explained by Stress Theory Find the definitions of the following terminology of Stress Theory Equilibrium/disequilibrium Stress, Distress, Eustress General Adaptation Syndrome Psychoneuroimmunology Overview of Stress Theory Introduction The patient is a 27 year old female, vital signs are normal, lab values are WNL. Normal is a very subjective term. It can have many different meanings to many different people. In nursing, normal can often be described in terms of homeostasis.

    Homeostasis is a concept that was first conceived by Claude Bernard, a 20th century physiologist. Walter Canon, a physician in the 20th century expounded upon this concept, using feedback mechanisms to explain Bernard’s concept’s regulation. These men discussed the body’s physiologic processes, and acknowledged that they have the ability to adapt to environmental changes. Hans Selye came along a little later in the picture. He was a Doctor of Medicine and Chemistry, originally studying in Prague and moving on to Johns Hopkins.

    He began to research the concept of stress in 1926 at McGill University in Canada. His initial inspiration for general adaptation syndrome (GAS, a theory of stress) came from an endocrinological experiment, in which he injected mice with extracts of various organs. At first, he believed he had discovered a new hormone, but was proved wrong when every irritating substance he injected produced the same symptoms (swelling of the adrenal cortex, atrophy of the thymus, gastric and duodenal ulcers).

    This, paired with his observation that people with different diseases exhibit similar symptoms, led to his description of the effects of “noxious agents” as he at first called it. While caring for people who were ill, Selye noted that the recurring clinical manifestations were loss of appetite, weight loss, feeling and looking ill, and generalized muscle aching and pain. He later coined the term “stress,” which has been accepted into the lexicon of various other languages. We chose Stress Theory, because it is applicable in so many different settings. We all experience stress in our lives, as do our patients.

    By understanding the predictable physiologic response to stress, we can focus our nursing care to note when patients are experiencing “noxious stimuli,” as well as prevent complications from occurring. Selye’s work is proof that nursing theory is applicable to our daily practice, and can often withstand the test of time. Description and Analysis of the Theory and Components Dr. Hans Selye (1930’s-1970’s) defined stress (whether positive or negative stress) as “wear and tear on the body” and developed the General Adaptation Syndrome (GAS), which explains the physiologic response to stress.

    Selye described General Adaptation Syndrome as having three stages: * alarm reaction, where the body detects the external stimulus and exhibits fight or flight response * adaptation, where the body engages defensive countermeasures against the stressor * exhaustion, where the body begins to run out of defenses and experiences depletion According to Clancy and McVicar (1993), stress includes distress, the result of negative events (unhealthy), and eustress, the result of positive events (beneficial). Stress is additive, whether good or bad. If your dog dies and you win the lottery, one does not cancel the other.

    Both are stressful events. Stress can originate internally or externally, may be acute or chronic, and related to daily hassles or major life events and has different meaning for everyone (McEwen & Wills, 2007). General or specific disorders of body and mind can directly and indirectly result from stress. Stress can have a major impact on the physical functioning of the human body. Such stress raises the level of adrenaline and corticosterone in the body, which in turn increases the heart rate, respiration, blood pressure and puts stress that is more physical on bodily organs.

    Heart disease, high blood pressure, stroke, and other illnesses result from long-term stress. After a person is exposed to a stressor, the person enters the alarm phase. Here, initial shock occurs and sympathetic arousal is prolonged by adrenaline/epinephrine and nor epinephrine. The results include the following: increased heart rate, increased blood flow to the heart, brain, and skeletal muscles, decreased blood flow to viscera, and enlargement of the adrenal glands that release hormones. All of this activity is labeled as counter shock.

    If additional stressors occur or the initial stressor remains, the person enters the resistance phase. The attempt of the endocrine system that primarily controls the resistance stage is to restore homeostasis. Hormones released by the adrenal glands increase blood sugar levels in attempt to provide the body energy to cope with stressors. This is referred to as adaptation energy. If adaptation energy resists the effects of stressors, homeostasis will result. However, if coping mechanisms do not enable the person to accomplish homeostasis, then exhaustion occurs.

    Here, the signs of the alarm stage recur as homeostatic control systems have failed. Stress related illness occurs. Intervention is now needed to restore homeostasis. Medical intervention is necessary at this point in order to diagnose and treat the stressor associated with the illness. Adaptation energy is finite, because continuous distress causes depletion and exhaustion, and death occur. (McEwen, B. , 2005). Application of Theory As stress is “inevitable in everyone’s life, and individuals must deal with stress by adapting through coping” (McEwen & Wills, 2007, p. 14), stress theories provide a framework for nursing to understand the effects that stress has on the individual and the response of the individual to the stress. If the individual adapts to the stress successfully, equilibrium is reached; if not, disequilibrium may result in physiologic or psychological disorders. The nurse can utilize Stress Theory to assess the individual’s stressors, resources and support that the individual has for coping with the stressors and to assist with problem-solving or cognitive restructuring for improved coping and adaptation (McEwen & Wills, 2007).

    For example, a patient may present with a host of physical complaints that may or may not be explainable by medical diagnosis. However, upon closer assessment, the nurse can assess the patient’s stressors and coping and offer resources or referrals if needed. Chronic stress may contribute to cancer, hypertension, heart disease, stroke, peripheral vascular disease, asthma, tuberculosis, emphysema, irritable bowel syndrome, sexual dysfunction, obesity, anorexia, bulimia, connective tissue disease, ulcerative colitis, Crohn’s disease, infections and allergic or hypersensitivity diseases.

    According to Clancy and McVicar (1993), Seyle defined freedom from stress as death. Various additional theories and studies, including those focusing on psychological changes, have arisen out of Seyle’s work. With such a wide variety of diseases that can be affected by stress, all categories and spectrums of nursing can relate to this theory. Stress Theory explains many types of physical and psychological ailments for people of all ages.

    This theory can be specifically applied to a situation encountered in an outpatient therapy setting with an adult female patient with high levels of anxiety, Tourette’s and Crohn’s disease. As this patient’s treatment (group therapy, education, meeting with psychiatrist and medications) progressed, her anxiety decreased and her physical symptoms diminished. This shows the strong mind/body correlation of stress. An example of Stress Theory’s use in research is the assigned reading (Hays, All, Mannahan, Cuaderes and Wallace) which studied stressors and ways of coping used by ICU nurses.

    Findings included: the most frequently reported high to maximum stressor was shortage of staff, followed by issues concerning patients’ families; the most frequently reported method of coping was escape-avoidance and confrontive; weak statistical correlation was found between the identified stressors and ways of coping and that statistical significance was not found regarding differences in the identified stressors and chosen coping methods among the demographic variables of gender, length of employment in ICU, age, marital status and highest level of education.

    Kenney & Bhattacharjee’s (2000) article describes a study utilizing Seyle’s (and others’) theory was conducted on women’s stressors, personality traits and health problems. This same article describes how per the psychoneuroimmunology (PNI) model, stress reactions contribute to changes in the immune system, which may lower resistance to a variety of illnesses. An article by Olofsson, Bengtsson and Brink (2003) described another stress theory study, incorporating Seyle’s work, which studied nurse’s experience of stress in the workplace.

    This article also described how the body’s autonomic nervous system (sympathetic and parasympathetic) mobilizes when faced with a perceived or actual threat, for example converting stored energy to usable energy. Summary In summary, we have learned that the body follows a natural and predictable physiologic pattern in response to stress. Selye determined the three phases of this response in his description of General Adaptation Syndrome: Alarm, Resistance, and Exhaustion.

    This theory that the body will exhibit these symptoms has been applied and further tested in nursing research, including how it has related to the psychoneuroimmunology (PNI) model. Recommendations for this theory are mainly based on its application. GAS should be incorporated into undergraduate nursing education, in order to introduce nursing theory early in a nursing career, as has been previously discussed in this course. Selye’s work is an excellent example of how theory can be easily related to the basics of our care.

    Undergraduate education begins with a strong core understanding of physiology; it is a perfect opportunity to introduce theories such as Selye’s. GAS should also be applied in terms of our anticipatory guidance. If we, as nurses, recognize the profound impact stress can have on the body, we can provide education to our patients on these effects. We know people often learn best with concrete information and examples. If we can utilize Selye’s theory to educate people on the consequences of not reducing stressors in their lives, we will be utilizing the tools of nursing theory.

    We can also use the stages described to monitor our patients (especially those who see patients in an outpatient or long-term setting), and attempt to reduce unnecessary stressors created by our own healthcare interventions. We, as aspiring advanced practice nurses, have a responsibility to our patients, and our profession, to build upon the work done by those before us. Selye’s General Adaptation Syndrome may be basic and fundamental, but it is still completely relevant, and an excellent tool to further our individual care, as well as our discipline.

    Unit 10 Points to Ponder The following questions below relate to the unit content and will appear on the Unit Discussion which is open for reading and posting during the week of November 3, 2009. Post entries to select questions during that period. 1. Identify the three stages of Stress Theory, The General Adaptation Syndrome, and apply the theory to a clinical situation. Explain what is occurring during the three phases as they apply to your situation and state how you can provide nursing intervention. 2.

    After reading the research article regarding stressors and ways of coping utilized by ICU nurses, provide examples of stressors in your area of employment and the coping methods you use to resist those stressors. Have you ever attended an educational or work related program that taught you coping and stress reduction methods?

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