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Answers may include any of the following stress-induced responses:

Cardiovascular system. Continued secretion of epinephrine may cause cardiovascular disorders, including angina, myocardial infarction, cardiomegaly, and congestive heart failure, all of which lead to decreased cardiac output. As cardiac output decreases, less oxygen circulates to meet cellular metabolic demands, and the body becomes fatigued. Prolonged secretion of epinephrine and renin result in vasoconstriction, causing hypertension. ADH, aldosterone, ACTH, and cortisol create electrolyte imbalance and retention of sodium and water, thus promoting peripheral edema.

Endocrine system. Continuing high levels of blood glucose and insulin can cause diabetes. Metabolic disorders of hyperthyroidism or hypothyroidism can result as persistent demands for thyroid hormone production cause a rebound failure of the gland. Even prenatal stress can cause adaptive changes in fetal endocrine and metabolic processes that impact later adult health (Sullivan, Hawes, Winchester, et al., 2008).

Immune system. Stress reduces the ability of the body's immune cells to differentiate between self and nonself. Thus, the immune cells begin to attack body tissues, producing autoimmune illness. Common autoimmune illnesses include rheumatoid arthritis, lupus, cancer, and allergies. Research has linked stress to suppression of the immune system and even to viral replication in HIV patients (e.g., Davidson, Kabat-Zinn, Schumacher, et al., 2003; McCain, Gray, Elswick, et al., 2008 ).

Gastrointestinal system. The gastrointestinal system may respond to central nervous system stimulation with constipation or diarrhea, gastroesophageal reflux, colitis, or irritable bowel syndrome. Continued secretion of hydrochloric acid produces gastric hyperacidity and erosion of the gastrointestinal tract, especially in the presence of H. pylori.

Musculoskeletal system. Constant readiness for fight or flight produces muscle tension and pain in various body sites. Tension headache and temporomandibular joint pain result from prolonged muscle tension in the head, neck, and spine.

Respiratory system. Epinephrine and circulating hormones dilate the bronchial tubes and increase the rate of respiration. Hyperventilation can produce symptoms of alkalosis, including dizziness, tingling hands and feet, and anxiety. Distress in the respiratory system can exacerbate existing asthma, hay fever, and allergies.

To obtain this information, ask questions such as the following:

What coping strategies have you used previously? What was successful, and what was not successful?

Tell me about previous experiences you have had with stressful situations in your life.

What do you usually do to handle stressful situations? (If the client needs prompting, you can ask, "Do you cry, get angry, avoid people, talk to family or friends, do physical exercise, pray? Some people laugh or joke, others meditate, others try to control everything, and others just work hard and look for a solution. What is your usual response?")

How well do these methods usually work for you?
What have you been doing to cope with the present situation?

How well is that working?
During the interview, you should also observe for the use of psychological defense mechanisms. If the patient has not exhibited any defense mechanisms, you could ask about the common ones. For example, "Do you ever cope with a situation by denying that it exists or just trying to put it out of your mind?"

Go to Chapter 12 , Table 12-1, in Volume 1.
Also ask Gloria about physiological changes and diseases caused by ongoing stress. For data that might indicate maladaptation to stress,
go to Chapter 12,"Stress-Induced Organic Responses," in Volume 1.

Check the client's records for a history of somatoform disorders. Ask the client:
What physical illnesses do you have? How long have you had them?

What, if any, physical changes have you noticed?

Do you have other physical conditions—for example, hypertension, cardiac disease, diabetes, arthritis, joint pains, and cancer?

The following health promotion activities can help prevent or relieve stress:

Nutrition. Nutrition is important for maintaining physical homeostasis and resisting stress. For example, adequate nutrition is essential to maintain the integrity of the immune system, and proteins are needed for tissue building and healing. In addition, obesity and malnutrition are stressors that may lead to illness.
Refer to Chapter 27 in Volume 1 for detailed information about nutrition, but to summarize, you should advise clients to:

Maintain a normal body weight

Limit the intake of fat (especially animal fat) to no more than 30% of daily calories

Limit the intake of sugar and salt

Eat more fish and poultry and less red meat

Eat smaller, more frequent meals to aid digestion

Consume 25 grams of fiber (fruits, vegetables, and whole grains) daily to promote bowel elimination

Consume no more than two alcoholic beverages per day

Exercise. Regular exercise promotes physical homeostasis by improving muscle tone and controlling weight. It also improves the functioning of the heart and lungs and reduces the risk of cardiovascular disease.

Exercise improves emotional homeostasis by promoting relaxation and reducing tension. During exercise, endogenous opioids are released, creating a feeling of well-being.

To achieve health benefits, the client needs to exercise for at least 30 minutes at least 5 days a week.

Advise clients who are obese, chronically ill, or who have always been sedentary to consult a primary care provider before beginning a new exercise program.

Suggest that the client identify a variety of physical activities that he or she enjoys (e.g., swimming, bicycling, walking, sports), and, if possible, schedule regular sessions with one or more exercise "buddies." These strategies help the client adhere to the exercise routine.
Sleep and rest. Sleep and rest restore energy levels, allow the body to repair itself, and promote mental relaxation.

Most people need 7 or 8 hours of sleep a day, but the amount of sleep varies among individuals. Stress, pain, and illness may interfere with the ability to sleep, so some clients may need help identifying and implementing techniques for relaxing and going to or staying asleep.

Refer to Chapter 34 in Volume 1 for more information on sleep.

Leisure activities. As compared with exercise, which not everyone enjoys, leisure activities are any activities that provide joy and satisfaction. They may involve physical activity (after all, many people do enjoy exercising), or they may be sedentary activities, such as reading, painting, and even watching television. Leisure activities are a form of rest and, as such, are restorative.

Time management. People who manage their time efficiently and organize their life routines feel more in control and therefore less stressed. If clients feel overwhelmed, you can help them to prioritize tasks and make "to do" lists. It is also important they learn to delegate responsibilities and set boundaries on the use of time. A working couple with three children may need to assign each child mealtime tasks, such as setting the table, drying the dishes, and so forth. Or they may need to limit the amount of time they spend cooking, reserving elaborate meals for weekends. They might also consider limiting the number of extracurricular activities and/or sports each child is involved in. Time management also includes saying no. Out of a need to be liked or a strong sense of responsibility to others, people sometimes try to make everyone happy by agreeing to all/most requests for assistance: from spouse, children, parents, friends, church, school, and the community. You can prompt clients to identify how much they can realistically accomplish—what is essential to do, and what would be "nice" to do. Help clients to work out a balance between their responsibilities to self and their responsibilities to others.

Avoiding maladaptive behaviors. Some people use maladaptive behaviors as a response to stress. For others, the behaviors themselves become stressors. Advise clients to help avoid the following unhealthy behaviors:
Drinking more than two alcoholic beverages per day
Consuming excess caffeine (e.g., coffee, tea, colas, energy drinks)
Eating large quantities of nutrient-poor food, such as sweets, chips
Smoking or chewing tobacco
Using illegal street drugs
Abusing over-the-counter medications or prescription drugs (for uses other than prescribed)
Avoiding social interaction

Use the following interventions for dealing with an angry person:

Be aware of how you are responding to angry clients. Are you relieving your own stress, or are you relieving the client's stress? If you respond angrily to relieve your own stress, you may provoke further anger in the client and even escalate the situation to the point of violence.

Keep reminding yourself not to take anger personally; remind family members of this as well.

Recognize the client's right to be angry. Do not discount feelings by saying something like, "Please don't be so angry" or "You shouldn't talk like that."

Encourage the client and family to express feelings verbally and appropriately.

Listen instead of defending. If the client yells, "Everything about this place stinks," don't respond with something like, "This hospital is highly rated by the Joint Commission" or "We really are all trying to do the best we can for you." Instead, say something to encourage the person to express his feelings or give you more information: "You seem really angry; what's going on?" or "Maybe I can help. Tell me a little more about what stinks."

Do not take responsibility for the client's anger. It is not your fault, so don't apologize (unless you really do have something to apologize for). In the preceding example, for instance, it is not your fault that "the place stinks" or that the patient feels that way. So do not say, "I'm sorry we haven't been meeting your expectations."

Remain calm; this reassures the person.

Help the client identify what is causing the anger and try to meet those needs.

Be alert to your own and the client's safety needs. If the person seems violent, do not allow him to get between you and the door. Be sure you know how to call for help from staff or security personnel when you think you or someone else is in danger.

Refer to the NIC intervention Anger Control Assistance (Bulechek, Butcher, & Dochterman, 2008, pp. 134-135) for other suggestions.

The purpose of positive self-talk is to promote self-esteem, sense of control over one's situation, and feelings of optimism. Self-esteem helps clients to recognize and use the resources they have for coping with their stressors. Each time you hear negative self-talk, stop the client and ask him or her to rephrase the statement so that it is positive, affirming, or confident.

List the seven steps of crisis intervention.

Note: You are asked only to list the steps. However, you may wish to describe and discuss the steps, as well.

Step 1. Assess the situation.

What is the nature of the patient's condition and the severity of the crisis?

Step 2. Ensure safety.

Call for help if you or the patient is in physical danger.
Do not leave the patient unless you think you are in imminent danger.
First ensure your own safety; then provide for the patient's safety.

Step 3. Defuse the situation.

Keep in mind that a person in crisis may not be in control of his actions.

Try to calm the person verbally.

Maintain an outward appearance of being calm yourself.

Attempt physical restraint only as a last resort and only when there is enough help to do it safely for staff and patient.

Step 4. Decrease the person's anxiety.

Reassure the patient that he is in a safe place and that you are concerned and want to help.

Explain gently but firmly that you need his help and cooperation.

Help the patient to vent feelings of fear, guilt, and anger.

Use physical contact very cautiously. The patient in turmoil may interpret touch as aggression or sexual innuendo.

Step 5. Determine the problem.

Find out what the patient believes to be the cause of the crisis.

Remain calm and do not pressure the patient to give reasons for his feelings. Any tension on your part will create further panic in the patient.

Step 6. Decide on the type of help needed.

You may be able to calm the patient enough for him to understand what just happened, or you may not.

Evaluate your ability to calm the patient on your assessment of his coping skills and resources.

Put in place the help needed to restore the person to a minimal level of functioning.

This may require long-term treatment. In that case, make the referrals.

Step 7. Return the person to pre-crisis level of functioning. This may involve crisis counseling and/or home crisis visits.

The goal of crisis counseling is to provide immediate relief, solve the most urgent problems, and give long-term counseling if needed. Crisis centers often rely on telephone counseling ("hotlines").

If telephone counseling is not adequate, or if observations of the home environment are needed, home visits may be made.