1. Stress Management

1. 1. Stress: a universal phenomenon, stress requires change or adaptation so that the person can maintain equilibrium

   2. Stress can be internal or external

   3. Nature of stressor involves:

      3. Intensity

      4. Scope

      5. Duration

      6. Other stressors: their number and nature

   4. Categories of stressors - and examples

      3. Physical - drugs or alcohol

      4. Psychological - such as adolescent emotional upheaval, or unexpressed anger

      5. Social - isolation, interpersonal loss

      6. Cultural - ideal body image

      7. Microbiologic - infection

   5. The greater the stressor as preceived by the client, the greater the stress response

   6. Stress response involves both localized and general adaptation 

7. Factors affecting stress response

   1. Personal: heredity, gender, race, age personality, cognitive ability

   2. Sociocultural: finances, support systems

   3. Interpersonal: self-esteem, prior coping mechanisms

   4. Spiritual: belief system

   5. Environmental: crowding, pollution, climate

   6. Occupational: work overload, conflict, risk

8. Physiologic indicators of stress 

9. Emotional/behavioral indicators of stress 

10. Stress can cause a variety of emotional and physical disorders 

11. Stress management strategies 

12. The non-compliant client does not cooperate with the treatment plan

    1. Behavior characteristics

       1. does not take prescrived medication

       2. continues activities restricted by provider of care, such as smoking

       3. does not follow prescribed activities, such as exercise

2. Nursing interventions

   1. explore the reasons for non-compliance

      1. lack of understanding - reinforce teaching

      2. lack of family support - involve family and support groups

      3. side effects - refer to provider of care

      4. finances and access - refer to Social Services

      5. negative attitude toward treatment - encourage expression

2. express genuine concern for client

3. discuss imporvement potential

5. Mood Disorders (Affective Disorders)

11. 11. Definition:

        2. Elevated or depressed mood, with disturbances in behavioral response

        3. Divided into bipolar and depressive disorders

    12. Bipolar disorders: mood disorders that include one or more manic or hypomanic episodes and usually one or more depressive episodes

    13. Mania:

        2. Person's elevated mood described as euphoric

        3. Inflated self-esteem

        4. Impaired judgment

        5. Constant physical activity

        6. Pressured speech

        7. Racing thought patterns

        8. Requires hospitalization

    14. Hypomania:

        2. Findings less severe

        3. Does not impair social, occupational or interpersonal functioning

        4. Treated in outpatient setting

    15. The seven traits typical of mood disorders

        2. Impair job functioning

        3. Impair social activities

        4. Impair relationships

        5. Necessitate hospitalization (in most cases)

        6. No time longer than two weeks has client had delusions or hallucinations without the mood disturbance

        7. Findings are not superimposed on

           1. schizophrenia

           2. delusional disorder

           3. psychotic disorder

        8. Findings are not caused by organic disease

    16. Etiology - unknown; possible genetic, biochemical predisposition

        2. Psychosocial theories of depression

           1. Freud: anger internalized and directed against ego

           2. Seligman: depression results from learned helplessness: individual who fails over time learns to expect poor outcomes and eventually gives up

           3. Beck: cognitive theory: over time, cognition is altered, resulting in negative attitudes; events can trigger depression

        3. Biological cycles affect mood (via Circadian rhythm)

           1. light affects mood by increasing melatonin

           2. melatonin is a mood modulator which decreases in depression

           3. Seasonal Affective Disorder (SAD)

3. Biochemical theories of mood disorders

   1. mania

      1. probably a genetic factor

      2. biochemical influences

         • possible deficiency of neurotransmitter GABA (gamma aminobutyric acid)

         • possible excess of norepinephrine and dopamine hydrochloride

• possible increase in electrolytes: sodium and calcium

1. depression

   1. possible deficit of serotonin, dopamine, norepinephrine

   2. possible deficit of TSH (thyroid-stimulating hormone) and/or other neuroendocrine disturbances

   3. depression is more common in viral infections (AIDS, mononucleosis, hepatitis)

   4. possible deficit in vitamin intake or metabolism: (vitamin B complex, folic acid)

   5. genetics may be involved

G. Types of mood disorders: mania, bipolar, depression

3. Mania - DSM IV criteria for mania

   1. period of abnormally/persistently elevated mood or irritability

   2. at least three of these six signs

      1. grandiosity

      2. decreased sleep

      3. hypertalkative, with pressured speech and flight of ideas or racing thoughts

      4. highly goal-directed activity (sexual, work)

      5. highly distractible

      6. pursues pleasure, but overestimates own skill and luck

2. Bipolar disorders onset usually before age 30

   1. bipolar disorder, mixed: both manic and depressive episodes present

      1. bipolar I

         • consists of one or more periods of major depression plus one or more periods of clear-cut mania

         • findings as in Definition of mood disorder (on page 15 of this lesson)

         • no marked drop in social and job functioning

         • manic episode requires hospitalization

      2. bipolar II

         • consists of one or more periods of major depression plus periods of hypomania

         • includes all symptoms in Definition of mood disorder (on page 15 of this lesson) and does not require hospitalization

   2. bipolar disorder, manic: fulfills criteria for manic episode (see Findings below)

   3. bipolar disorder, depressed: major depressive episode and at least one manic episode, current or past

   4. cyclothymic mood disorder:

      1. many milder findings of mania and depression

      2. periods of normal mood are short

      3. usually does not require hospitalization

3. Depression

   1. includes all 7 typical traits of mood disorders 

   2. specific criteria for depression (see Findings below)

8. Findings

2. Mania

   1. elation, euphoria; inappropriate laughter; very talkative

   2. irritable, hostile, aggressive

   3. flight of ideas, delusions of grandeur, exhibitionism, sexual acting-out

   4. reduced sleep

   5. unlimited energy; no time for food or drink

   6. impulsive, easily distracted

   7. manipulative behavior

2. Depression

   1. melancholia, crying, absence of pleasure; slumped posture

   2. apathy; loss of desire for food and/or sex

   3. slower reactions

   4. low self-confidence; inhibition, introversion

   5. ruminating, decreased communication, social isolation

   6. fatigue and/or insomnia

   7. decreased concentration

   8. poor hygiene

   9. hopelessness, pessimism

   10. self-destructiveness

9. Treatments

2. Treatments for mania

   1. pharmacologic

      1. lithium carbonate (Lithane), carbamazapine (Carbatrol), valproic acid (Depakene)

      2. antipsychotics: chlorpromazine (Thorazine), haloperidol (Haldol)

   2. occupational therapy

   3. recreational therapy

2. Depression

   1. pharmacologic antidepressants 

      1. tricyclic antidepressants - amitriptyline HCl (Elavil), doxepin (Sinequan), imipramine (Tofranil)

      2. monoamine oxidase inhibitors - phenelzine (Nardil), tranylcypromine (Parnate)

      3. selective serotonin reuptake inhibitors (SSRI) - fluoxetine (Prozac), sertraline (Zoloft)

   2. ECT: electroconvulsive therapy

   3. psychotherapy

   4. occupational therapy

   5. recreational therapy

   6. cognitive therapy

10. Nursing care in mood disorders

2. Mania

   1. protect client and others from harm

   2. provide quiet environment with few stimuli

   3. give medications as ordered; be sure client swallows meds

   4. establish trust relationship

   5. do not argue with client or provoke hostility

   6. redirect client to task at hand

   7. set firm, consistent limits; explain them simply

   8. allow client to express anger in positive ways

   9. offer finger foods

   10. increase client's fluid intake to at least 1000cc/day

   11. allow client to pace

   12. teach client

       1. acceptable ways to release anger

       2. medications and side effects

       3. importance of taking medication

2. Depression

   1. monitor suicidal thoughts

   2. take suicide precautions  as indicated and observe for suicide warning signs 

   3. build trust with client

   4. speak slowly and clearly in simple sentences

   5. administer medications as ordered

   6. encourage client to ventilate

   7. provide relaxation exercises

   8. help with hygiene and feeding as indicated

   9. help client assess negative thoughts more objectively

   10. divert client from morose thoughts

   11. encourage client to focus on positive attributes

   12. teach client

       1. medications and side effects

       2. importance of taking medication

       3. problem-solving techniques

7. Anxiety Disorders

   1. Definition: group of disorders in which anxiety is predominant symptom. Degrees range from mild anxiety to severe (panic attack)

      1. Seven types

         1. GAD: generalized anxiety disorder

         2. phobic disorders

         3. panic disorder

         4. dissociative disorder

         5. somatoform disorder

         6. obsessive-compulsive disorder (OCD)

         7. PTSD: Post-traumatic stress disorder

2. Etiology

   1. Found equally in men and women

   2. Hereditary predisposition

   3. Biochemical factors: neurotransmitters may play a role

   4. Psychologic and interpersonal factors

      1. early psychic trauma,

      2. pathogenic parent-child relationship,

      3. pathogenic family patterns

      4. loss of social supports

3. Findings

   1. Fear, dread, or apprehension

   2. Feeling powerless

   3. Crying

   4. Irritability

   5. Scattered thoughts, inability to concentrate or solve problems

   6. Preoccupation with self

   7. Rapid speech, hyperventilation, tachycardia

   8. Palpitations, chest pains, jittery behavior

   9. Diaphoresis

   10. Insomnia

   11. Diarrhea and/or urinary urgency and frequency

4. Treatments for anxiety disorders

   1. Pharmacologic: anxiolytics (antianxiety drugs) such as alprazolam (Xanax) and diazepam (Valium)

   2. Psychotherapy

   3. Occupational therapy

   4. Recreational therapy

5. Nursing care

   1. Provide a nondemanding environment; stay with client if indicated

   2. Acknowledge client's feelings of fear, worry, helplessness

   3. Do not force contact with feared item or situation

   4. If client demonstrates compulsive behavior, allow the compulsion but set reasonable limits

   5. Provide distracting activities

   6. Allow temporary dependence

   7. Speak calmly, slowly and clearly

   8. Assist client in ADL as indicated

   9. Encourage relaxation techniques and regular physical exercise

   10. Administer medications as ordered

   11. Limit caffeine intake

   12. Teach client

       1. medications and side effects

       2. relaxation techniques