Understanding Stress and Coping Mechanisms

Stress and Coping

• A stressor is any event that triggers a stress response
• Stress involves the body's physiological and psychological reaction to a stressor
• Appraisal is an individual's evaluation of a stressor as a threat, challenge, or neutral situation
• A crisis occurs when coping mechanisms are overwhelmed, requiring new coping strategies

Allostatic Load and Long-Term Effects

• Allostatic load refers to the cumulative impact of chronic stress on the body
• Long-term effects may include:
• Hypertension
• Cardiovascular disease
• Obesity
• Diabetes
• Impaired immune function
• Cognitive decline
• Mental health issues such as anxiety and depression

Hormones Released in Stress Response

• Adrenal glands release glucocorticoids, such as cortisol, which:
• Increases glucose availability
• Suppresses the immune system
• Inhibits wound healing
• Contributes to memory and mood regulation
• Mineralocorticoids, like aldosterone:
• Regulate sodium and water balance
• Increase blood pressure
• The sympathetic nervous system (SNS) releases catecholamines:
• Epinephrine (adrenaline) increases heart rate and blood pressure, enhances airway dilation, and increases glucose production
• Norepinephrine constricts blood vessels and heightens alertness

PTSD vs. Secondary Traumatic Stress (STS)

• PTSD develops after exposure to death, injury, or sexual violence
• PTSD symptoms: Flashbacks, hypervigilance, nightmares, and emotional numbness
• STS occurs in individuals indirectly exposed to trauma through their work, such as healthcare workers
• STS symptoms mimic PTSD but result from exposure to others' trauma

Types of Crisis

• Developmental Crisis: Normal life transitions that cause stress, like retirement or menopause
• Situational Crisis: Sudden events such as job loss, illness, or divorce
• Disaster Crisis: Large-scale traumatic events like natural disasters, war, or mass violence

Non-Verbal Communication and Patient Appearance in Assessment

• Non-Verbal Cues:
• Facial expressions indicate fear, sadness, or confusion
• Body posture such as slouching (depression) or rigidity (anxiety)
• Eye contact indicating distress or fear via avoidance
• Gestures like fidgeting can show nervousness
• Patient Appearance:
• Poor hygiene or disheveled clothing may suggest depression or neglect
• Unintentional weight loss can indicate stress, malnutrition, or chronic illness
• Increased muscle tension and fidgeting suggest anxiety or fear

Stressors Particular to Older Adults (65+)

• Common stressors include:
• Chronic illness and pain
• Loss of independence, such as driving or mobility
• Financial insecurity
• Death of a spouse or close friends
• Cognitive decline and memory loss
• Social isolation and loneliness

Positive Coping Strategies for Patient Care

• Cognitive strategies involve reframing negative thoughts
• Behavioral strategies include mindfulness and relaxation techniques
• Lifestyle changes such as exercise, physical activity, and engaging in hobbies
• Supportive interventions may include therapy, counseling, spiritual support, or education

Symptoms of Sleep/Wake Disruptions

• Difficulty falling or staying asleep can disrupt sleep/wake cycles
• Excessive daytime sleepiness
• Frequent nighttime awakenings
• Feeling unrefreshed despite adequate sleep

Symptoms of Sleep Deprivation

• Cognitive impairments: Poor memory, difficulty concentrating
• Mood changes such as irritability, depression, and anxiety
• Weakened immune function
• Increased risk of hypertension, diabetes, and heart disease
• Decreased reaction time, leading to increased risk of accidents

Positive Effects of Sleep and Rest

• Enhances cognitive function and memory consolidation
• Supports emotional regulation and stress reduction
• Strengthens the immune system
• Promotes muscle and tissue repair
• Helps regulate metabolism and appetite

Hypothalamus and Factor S in Sleep Regulation

• The hypothalamus:
• Regulates the circadian rhythm (body's internal clock)
• Contains the suprachiasmatic nucleus (SCN) that responds to light cues
• Releases neurotransmitters to maintain wakefulness
• Promotes sleep via the ventrolateral preoptic nucleus (VLPO), which inhibits wake-promoting neurons
• Factor S:
• Sleep-regulating factor that builds up with prolonged wakefulness
• Accumulates in the brain and promotes slow-wave sleep

Sleep Stages and Their Functions

• N1 (Stage 1, Light Sleep): Transition from wakefulness, easily awakened
• N2 (Stage 2, Intermediate Sleep): Body temperature drops and heart rate slows
• N3 (Stage 3, Deep Sleep): Deepest sleep, essential for physical restoration
• REM (Rapid Eye Movement Sleep): Vivid dreaming occurs, important for cognitive processing

Key Distinctions in Sleep

• The deepest sleep occurs in Stage N3 (slow-wave sleep)
• Vivid dreaming occurs in REM sleep

Sleep Disorders and Differences

• Insomnia involves difficulty falling or staying asleep
• Sleep-Related Breathing Disorders: e.g., sleep apnea, lead to disrupted sleep due to breathing difficulties
• Hypersomnias: Excessive daytime sleepiness not related to disturbed sleep
• Parasomnias: Unusual behaviors during sleep, night terrors, REM sleep behavior disorders
• Circadian Rhythm Sleep Disorders: Mismatch between sleep schedule and demands
• Sleep-Related Movement Disorders: Repetitive movements that interfere with sleep

Recommended Sleep Duration by Age Group

• Neonates (0-3 months): 14-17 hours/day
• Infants (4-12 months): 12–16 hours (including naps)
• Toddlers (1-2 years): 11–14 hours (including naps)
• Preschoolers (3–5 years): 10–13 hours
• School-Age Children (6-12 years): 9–12 hours
• Teenagers (13-18 years): 8–10 hours
• Adults (18-64 years): 7–9 hours
• Older Adults (65+ years): 7–8 hours

Why Younger Humans Need More Sleep

• Brain development and memory consolidation
• Physical growth and immune function
• Enhances learning and emotional regulation

Factors That Impact Sleep (Positive & Negative)

• Physical Illness:
• Chronic pain disrupts sleep
• Respiratory conditions cause awakenings
• Drugs/Substances:
• Alcohol reduces sleep onset but disrupts REM sleep
• Nicotine stimulates the nervous system, causing fragmented sleep
• Caffeine blocks adenosine, reducing sleep quality
• Diuretics cause frequent urination, disrupting sleep
• Exercise & Fatigue:
• Regular exercise improves sleep quality but should be done 3–4 hours before bedtime
• Excessive fatigue can lead to difficulty falling asleep
• Food/Caloric Intake:
• Heavy meals before bed can cause acid reflux and discomfort
• Carbohydrates and warm milk promote sleep

Assessing Sleep and Implementing Solutions

• Sources of Information on Sleep Patterns:
• Patient's self-report: Subjective assessment
• Bed partner or caregiver reports: For observing snoring, apneic episodes, restless movements
• Tools for Sleep Assessment:
• Sleep Diary: Tracks sleep duration, wake time, nighttime awakenings, and habits
• Sleep Environment Assessment: Evaluates temperature, noise levels, safety, and comfort
• Bedtime Routine Evaluation: Looks at relaxation techniques, screen time, and habits
• Physical Illness & Medication Review: Identifies potential causes of disrupted sleep
• Interventions to Reduce Sleep Problems:
• Encourage a consistent bedtime routine
• Reduce screen exposure 30–60 minutes before bed
• Improve sleep hygiene by maintaining a dark, quiet, cool environment
• Address underlying medical conditions affecting sleep
• Promote relaxation techniques: Deep breathing, meditation, and progressive muscle relaxation

Anatomy of the Urinary Tract

• Kidneys on the right and left flanks filter blood and form urine
• Ureters transport urine from kidneys to the bladder
• The bladder stores urine
• The urethra carries urine from the bladder to the outside
• The urethral Os (Meatus) is the external opening of the urethra
• The nephron is the functional unit of the kidney responsible for filtration
• Glomeruli are capillary clusters that filter waste from the blood

Act of Urination

• The brain regulates urination
• Spinal cord reflexes help control involuntary aspects such as holding urine while asleep
• Normal bladder capacity: ~400–600 mL
• Urge to void starts at ~150–200 mL in adults
• Bladder contraction and sphincter relaxation are coordinated for urination
• Normal kidney output: ~30 mL/hour
• Decreased output (<30 mL/hr) suggests kidney dysfunction

Urinary Diversions

• Continent Urinary Diversions:
• Ileal Reservoir: Uses a piece of intestine to create a storage pouch
• Neobladder: A new bladder formed from the intestine
• Incontinent Urinary Diversions:
• Ileal Conduit: A segment of the intestine drains urine into an external bag
• Ureterostomy: The ureters are redirected to the skin draining into an external pouch

Catheter-Associated Urinary Tract Infections (CAUTIs)

• Infections caused by prolonged catheter use.
• Typically caused by bacteria
• CAUTIs are preventable
• Prevention Strategies:
• Proper care of indwelling catheters
• Proper insertion using sterile technique
• Closed drainage system
• Urine specimen collection from the sampling port (never from the bag)
• Catheter bag placement below bladder level

Urinalysis Findings

• Common Findings:
• Color: Pale yellow to amber
• Clarity: Clear to slightly cloudy
• pH: 4.6-8.0
• Specific gravity: 1.005–1.030
• No glucose, ketones, or proteins present
• Abnormal Findings:
• Protein indicates kidney disease
• Glucose suggests diabetes
• Ketones suggest starvation or diabetes ketoacidosis
• Leukocytes & Nitrites suggest a UTI
• Blood could indicate trauma, infection, or kidney stones

Equipment Used for Urine Collection

• Bedside commodes for mobility-limited patients
• Toilet hats collect urine in a toilet for measurement
• Urometers measure urine output accurately

Types of Urinary Catheters

• Urinals are hand-held containers
• Condom catheter: External non-invasive catheter for males
• Straight catheter: Used for intermittent catheterization
• Indwelling catheter: Left in place for continuous drainage
• Triple-lumen catheter: Used for bladder irrigation
• Larger catheter size = larger French Scale number

Medications for Urinary Tract Abnormalities

• Acetylcholine Agonists stimulate bladder contractions to treat urinary retention
• Acetylcholine Antagonists reduce bladder spasms to treat overactive bladder

UTI Prevention Strategies

• For Catheterized Patients:
• Use catheters when necessary
• Maintain closed drainage systems
• Perform daily perineal hygiene
• Keep catheter bag below bladder level
• For Non-Catheterized Patients:
• Encourage frequent urination
• Promote hydration
• Teach proper perineal hygiene
• Avoid scented soaps or douching
• Recommend cranberry juice

Locations of Bodily Fluids

• Intracellular Fluid (ICF) is inside cells (~2/3 of total body water)
• Extracellular Fluid (ECF) is outside cells (~1/3 of total body water):
• Interstitial Fluid is between cells
• Intravascular Fluid: Plasma is within blood vessels
• Transcellular Fluid includes specialized fluids
• Components of Bodily Fluids:
• Electrolytes: Sodium, Potassium, Calcium, Magnesium
• Proteins: Albumin, Globulins
• Nutrients and Waste Products: Glucose, Urea
• Gases: Oxygen, Carbon Dioxide

Third Spacing

• Abnormal accumulation of fluid in areas where fluid isn't easily exchanged
• Fluid is trapped causing hypovolemia

Effects of Hypertonic & Hypotonic Solutions on Cells

• Hypertonic Solution → Cell Shrinks
• Fluid moves out of the cell
• Example: 3% NaCl solution
• Hypotonic Solution → Cell Swells
• Fluid moves into the cell
• Example: 0.45% NaCl solution
• Osmosis drives water from low solute concentration to high solute concentration

Fluid Intake and Output (I/O)

• Intake sources:
• Oral (drinks, food)
• IV fluids
• Enteral feedings
• Metabolic water
• Output routes:
• Urine (major route)
• Sweat
• Feces
• Insensible losses (lungs, skin evaporation)

Electrolyte Imbalances

• Hypernatremia: High Sodium, causing thirst, confusion, seizures, dry mucous membranes, edema
• Hyponatremia: Low Sodium, causing headache, nausea, weakness, seizures
• Hyperkalemia: High Potassium, causing muscle weakness, cardiac arrhythmias, paralysis
• Hypokalemia: Low Potassium, causing muscle cramps, weakness, arrhythmias
• Shared Symptoms Hypocalcemia & Hypomagnesemia: Neuromuscular excitability (tetany)
• Hypocalcemia & Hypermagnesemia: Muscle weakness, decreased reflexes, lethargy

Therapeutic Ranges:

• Potassium: 3.5 – 5.0 mEq/L
• Sodium: 135 – 145 mEq/L
• Calcium: 8.5 – 10.5 mg/dL

Factors Affecting Fluid Balance

• Kidney disease, heart failure, & diabetes
• Older adults: Decrased thirst perception = higher risk of dehydration
• Environment: Heat exposure increases sweat loss
• Sodium and protein intake affect fluid retention
• Diuretics, steroids, and chemotherapy affect fluid balance

Causes of Fluid Loss & Imbalance

• Vomiting & diarrhea
• Burns
• Fever
• Excessive sweating
• Diuretics or fluid restrictions

Intake & Output (I/Os)

• Track intake and output to manage fluid balance

Nursing Care Plan Goals

• Strict I/Os: Track precisely
• Intake: Includes IV fluids, enteral feedings, oral fluids
• Output: Includes urine, emesis, drains, stool, and sweat
• Nursing Care Plan Goal: A goal must be Specific and Measurable

Kidney & Heart Role

• Kidney: Regulates sodium, potassium, & fluid retention and excretion
• Heart: Maintains blood pressure and fluid circulation

IV Fluids

• Colloids (Plasma Expanders): Contain large molecules, increase oncotic pressure; used for shock
• Crystalloids: Contain electrolytes, move freely, and used for dehydration

IV Lines

• Peripheral IV Line: Short-term and in small veins
• Central Line (CVC, PICC): Long-term, in large veins
• PICC Line is a Central Line because it reaches a central vein
• Sterile Technique: Central Line sterile and Peripheral IV clean

IV Tubing Changes

• Continuous Infusions: Change every 96 hours
• Intermittent Infusions: Change every 24 hours

IV Complications

• Infiltration: Fluid leaks into surrounding tissue, creating a cool and pale site
• Phlebitis: Vein inflammation (warm, red, swollen site)

Blood Transfusion Basics

• Antigens determine blood type
• Antibodies react with antigens

Blood Type Antibody Reactions

• A Antigens have Anti-B Antibodies
• B Antigens have Anti-A Antibodies
• AB Antigens have No Antibodies, thus they are Universal Recipient
• O No Antigens have Anti-A & Anti-B Antibodies, thus they are Universal Donor

Blood Transfusion Reactions

• Allergic Reaction: Rash, itching
• Febrile Reaction: Fever & chills
• Hemolytic Reaction MOST SEVERE: Flank pain & shock
• Monitoring: Monitor the patient