NCLEX-RN: Nursing Concepts

Nursing Concepts: STRESS AND ADAPTATION

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Nursing Concepts: Homeostasis

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Definition: The maintenance of a constant state in the internal environment through self-regulatory techniques that preserve the organism’s ability to adapt to stresses.

A. Dynamics of homeostasis.

  • Danger or its symbols, whether internal or external, result in the activation of the sympathetic nervous system and the adrenal medulla.
  • The organism prepares for fight or flight (attack–withdrawal; one’s immediate response to stress—an archaic and often inappropriate response, but part of our biological heritage).

B. Adaptation factors.

  • Age—adaptation is greatest in youth and young middle life, and least at the extremes of life.
  • Environment—adequate supply of required materials is necessary.
  • Adaptation involves the entire organism.
  • The organism can more easily adapt to stress over a period of time than suddenly.
  • Organism flexibility influences survival.
  • The organism usually uses the adaptation mechanism that is most economical in terms of energy.
  • Illness decreases the organism’s capacity to adapt to stress.
  • Adaptation responses may be adequate or deficient.
  • Adaptation may cause stress and illness (e.g., ulcers, arthritis, allergy, asthma, and overwhelming infections).

Nursing Concepts: Stress

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A. Definitions of stress.

1. A physical, chemical, or emotional factor that causes bodily or mental tension and that may be a factor in disease causation; a state resulting from factors that tend to alter an existing equilibrium.
2. Selye’s definition of stress.

  • The state manifested by a specific syndrome that consists of all the nonspecifically induced changes within the biologic system.
  • The body is the common denominator of all adaptive responses.
  • Stress is manifested by the measurable changes in the body.
  • Stress causes a multiplicity of changes in the body.

3. Wolff ’s theory of stress.

  • Poor adaptation to a life situation may lead to a breakdown in homeostasis with subsequent development of disease.
  • Wolff believed that a person’s total life situation (with its positive as well as negative aspects) affects a person’s susceptibility to disease.
  • Disease may result from attempts to restore homeostasis.

B. General aspects of stress.
1. Body responses to stress are a self-preserving mechanism that automatically and immediately becomes activated in times of danger.

  • Caused by physical or psychological stress: disease, injury, anger, or frustration.
  • Caused by changes in internal and/or external environment.

2. There are a limited number of ways an organism can respond to stress (for example, a cornered amoeba cannot fly).

Nursing Concepts: Stress and Disease

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A. Stress and individual methods of coping are associated with heart disease, cancer, and other diseases.
B. Actual physical changes occur with high stress levels.

  • Increased release of adrenalin, cortisol, and other hormones lead to increased heart rate, blood pressure, and platelet stickiness, which may accelerate atherosclerosis and other causes of heart disease.
  • Changes in immune system may interfere with individual ability to recognize and destroy cancer cells.

C. Stress can be both positive and negative. Individual must have adaptive mechanism to cope with stress to increase health and avoid risk for disease.

Nursing Concepts

Nursing Concepts: Selye’s Theory of Stress

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A. General adaptive syndrome (GAS).

1. Alarm stage (call to arms).

  • Shock: The body translates it as sudden injury, and the GAS becomes activated.
  • Countershock: The organism is restored to its preinjury condition.

2. Stage of resistance: The organism is adapted to the injuring agent.
3. Stage of exhaustion: If stress continues, the organism loses its adaptive capability and goes into exhaustion, which is comparable to shock.

B. Local adaptive syndrome (LAS).

  • Selective changes within the organism.
  • Local response elicits general response.
  • Example of LAS: a cut, followed by bleeding, followed by coagulation of blood.
  • The ability of parts of the body to respond to a specific injury is impaired if the whole body is under stress.

C. Whether the organism goes through all the phases of adaptation depends on both its capacity to adapt and the intensity and continuance of the injuring agent.

  • Organism may return to normal.
  • Organism may overreact; stress decreases.
  • Organism may be unable to adapt or maintain adaptation, a condition that may lead to death.

Nursing Concepts: SELYE’S STRESS ADAPTATION SYNDROME

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Nursing Concepts

D. Objective of stres5s response.

  • To maintain stability of the organism during stress.
  • To repair damage.
  • To restore body to normal composition and activity.

Nursing Concepts: Psychological Stress

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Definition: All processes that impose a demand or requirement upon the organism, the resolution or accommodation of which necessitates work or activity of the mental apparatus.

Characteristics

A. May involve other structures or systems, but primarily affects mental apparatus.

1. Anxiety is a primary result of psychological stress.
2. Causes mental mechanisms to attempt to reduce or relieve psychological discomfort.

  • Attack/fight.
  • Withdrawal/flight.
  • Play dead/immobility.

B. Causes of psychological stress.

1. Loss of something of value.
2. Injury/pain.
3. Frustrations of needs and drives.
4. Threats to self-concept.
5. Many illnesses cause stress.

  • Disfigurement.
  • Sexually transmitted diseases (STDs).
  • Long-term or chronic diseases.
  • Cancer.
  • Heart disease.

6. Conflicting cultural values (e.g., the American values of competition and assertiveness vs. the need to be dependent).
7. Future shock: physiological and psychological stress resulting from an overload of the organism’s adaptive systems and decision-making processes brought about by too rapidly changing values and technology.

8. Cultural shock: stress developing in response to transition of the individual from a familiar environment to an unfamiliar one.

  • Involves unfamiliarity with communication, technology, customs, attitudes, and beliefs.
  • Examples: individual moving to new area from foreign country or individual placed in hospital environment.

9. Social stress: stress that develops as a result of social rather than psychological problems.

  • Personal relationships may be a source of stress.
  • A sense of not belonging or lack of identification with a social group or friends.
  • Feelings of isolation or separation from others.
  • Social pressure of being pushed to join group activities or engage in social behaviors that make one uncomfortable.

Nursing Concepts: Assessment

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A. Assess increased anxiety, anger, helplessness, hopelessness, guilt, shame, disgust, fear, frustration, or depression.
B. Evaluate behaviors resulting from stress.

  • Apathy, regression, withdrawal.
  • Crying, demanding.
  • Physical illness.
  • Hostility, manipulation.
  • Senseless violence, acting out.

Nursing Concepts: Implementation

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A. Gather information about client’s internal and external environment.
B. Modify external environment so that adaptation responses are within the capacity of the client.

C. Support the efforts of client to adapt or to respond.
D. Provide client with the materials required to maintain constancy of internal environment.
E. Understand body’s mechanisms for accommodating stress.
F. Prevent additional stress.
G. Reduce external stimuli.
H. Reduce or increase physical activity depending on the cause of and response to stress.

Nursing Concepts: DEVELOPMENT THROUGH THE LIFE CYCLE*

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Nursing Concepts: Early Adolescence

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A. Physical development.

  • Exhibits further development of secondary sex characteristics.
  • Shows poor posture.
  • Exhibits rapid growth and becomes awkward and uncoordinated.
  • Shows changes in body size and development.

✦B. Social development.

  • Needs social approval of peer group.
  • Strives for independence from family.
  • Has one or two very close friends in peer group.
  • Becomes more interested in opposite sex.
  • Period of upheaval: Displays confusion about body image.
  • Must again learn to control strong feelings (e.g., love, aggression).

✦C. Counseling guidelines.

  • Provide adult understanding when adolescent deals with social, intellectual, and moral issues.
  • Allow some financial independence.
  • Provide limits to ensure security.
  • Provide necessary assurance to help adolescent accept changing body image.
  • Show flexibility in adjusting to emotional and erratic mood swings.
  • Be calm and consistent when dealing with an adolescent.

✦D. Developmental tasks .

  • Finds identity; moves out of role diffusion.
    a. Integrates childhood identifications with basic drives.
    b. Expands concept of social roles.
  • Moves toward heterosexuality.
  • Begins separation from family.
  • Integrates personality.

Nursing Concepts: PIAGET’S COGNITIVE DEVELOPMENT

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Nursing Concepts

Nursing Concepts: Adolescence to Young Adulthood

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A. Physical development.

  • Completes sexual development.
  • Exhibits signs of slowing down of body growth.
  • Is capable of reproduction.
  • Shows more energy after growth spurt tapers off.
  • Exhibits increased muscular ability and coordination.

B. Menstruation.

  • Menstruation is the sloughing off of the endometrium that occurs at regular monthly intervals if conception fails to take place. The discharge consists of blood, mucus, and cells, and it usually lasts for 4 to 5 days.
  • Menarche—onset of menstruation—usually occurs between the ages of 11 and 14.
  • Discomforts associated with menstruation.
    a. Breast tenderness and feeling of fullness.
    b. Tendency toward fatigue.
    c. Temperament and mood changes—because of hormonal influence and decreased levels of estrogen and progesterone.
    d. Discomfort in pelvic area, lower back, and legs.
    e. Retained fluids and weight gain.
  • Abnormalities of menstruation.
    a. Dysmenorrhea (painful menstruation).
    (1) May be caused by psychological factors: tension, anxiety, preconditioning (menstruation is a “curse” or should be painful).
    (2) Physical examination is usually done to rule out organic causes.
    b. Treatment.
    (1) Oral contraceptives—produce anovulatory cycle.
    (2) Mild analgesics such as aspirin.
    (3) Urge client to carry on normal activities to occupy her mind.
    (4) Dysmenorrhea may subside after childbearing.
    c. Amenorrhea (absence of menstrual flow).
    (1) Primary—over the age of 17 and menstruation has not begun.
    (a) Complete physical necessary to rule out abnormalities.
    (b) Treatment aimed at correction of underlying condition.
    (2) Secondary—occurs after menarche; does not include pregnancy and lactation.
    (a) Causes include psychological upsets or endocrine conditions.
    (b) Evaluation and treatment by physician is necessary.
    d. Menorrhagia (excessive menstrual bleeding)—may be due to endocrine disturbance, tumors, or inflammatory conditions of the uterus.
    e. Metrorrhagia (bleeding between periods)—symptom of disease process, benign tumors, or cancer.
  • Counseling guidelines.
    a. Provide education about the physiology of normal menstruation and correct misinformation.
    b. Provide education about abnormal conditions
    associated with menstruation— absence of menstruation, bleeding between menstrual periods, etc.
    c. Provide education related to normal hygiene during menstruation.
    (1) Importance of cleanliness.
    (2) Use of perineal pads and tampons.
    (3) Continuance of normal activities.

C. Social development.

  • Is less attached to peers.
  • Shows increased maturity.
  • Exhibits more interdependence with family.
  • Begins romantic love affairs.
  • Increases mastery over biologic drives.
  • Develops more mature relationship with parents.
  • Values fidelity, friendship, and cooperation.
  • Begins vocational development.

D. Counseling guidelines.

  • Assist adolescent in making a vocational choice.
  • Provide safety education, especially regarding driving and drugs.
  • Encourage positive attitudes toward health in issues of nutrition, drugs, smoking, and drinking.
  • Attempt to understand own (parental) difficulties in accepting transition of the adolescent to independence and adulthood.

E. Developmental tasks (Table 3-3).

  • Intimacy and solidarity versus isolation.
    a. Moves from security of self-involvement to insecurity of building intimate relationships with others.
    b. Becomes less dependent and more self-sufficient.
  • Able to form lasting relationships with others.
  • Learns to be productive and creative.
  • Handles hormonal changes of developmental period.

Nursing Concepts: Adulthood

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Nursing Concepts: Developmental Tasks

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✦A. Achieves goal of generativity versus stagnation or self-absorption.

  • Shows concern for establishing and guiding next generation.
  • Exhibits productiveness, creativity, and an attitude of looking forward to the future.
  • Stagnation results from the refusal to assume power and responsibility of the goals of middle age.
    a. Suffers pervading sense of boredom and impoverishment.
    b. Undergoes but does not resolve midlife crisis.

B. Has relaxed sense of competitiveness.
C. Opens up new interests.

D. Shifts values from physical attractiveness and strength to intellectual abilities.
E. Shows productivity (may be most productive years of one’s life).
F. Has more varied and satisfying relationships.
G. Exhibits no significant decline in learning abilities or sexual interests.
H. Shifts sexual interests from physical performance to the individual’s total sexuality and need to be loved and touched.
I. Assists next generation to become happy, responsible adults.
J. Achieves mature social and civic responsibility.
K. Accepts and adjusts to physiological changes of middle life.
L. Uses leisure time satisfactorily.
M. Failure to complete developmental tasks may cause the individual to approach old age with resentment and fear.

  • Neurotic symptoms may appear.
  • Increased psychosomatic disorders develop.

Nursing Concepts: ERIKSON’S EIGHT STAGES OF PERSONALITY DEVELOPMENT—INFANT TO ADULT

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Nursing Concepts

Nursing Concepts: Values of Adulthood

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A. Becomes more introspective.
B. Shows less concern as to what others think.
C. Identifies self as successful even though all life goals may not be achieved.
D. Shows less concern for outward manifestations of success.
E. Lives more day to day and values life more deeply.
F. Has faced one’s finiteness and eventual death.

Nursing Concepts: Parenting in Adulthood

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A. Characteristics.

  • Tendency toward smaller families.
  • Career-oriented women who limit family size or who do not want children.
  • Early sexual experimentation, necessitating sexual education, and contraceptive information.
  • Tendency toward postponement of children.
    a. To complete education.
    b. Economic factors.
  • High divorce rates.
  • Alternative family designs.
    a. Single parenthood.
    b. Communal family.

✦B. Family planning.*

  • General concepts.
    a. Dealing with individuals with particular ideas regarding contraception.
    b. No perfect method of birth control.
    c. Method must be suited to individual.
    d. Individuals involved must be thoroughly counseled on all available methods and how they work—including advantages and disadvantages. This includes not only female but also sexual partner (if available).
    e. Once a method is chosen, both parties should be thoroughly instructed in its use.
    f. Individuals involved must be motivated to succeed.
  • 2. Effectiveness depends on several factors:
    a. Method chosen.
    b. Degree to which couple follows prescribed regimen.
    c. Thorough understanding of the chosen method.
    d. Motivation on part of individuals concerned.

Nursing Concepts: Physiological Changes

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Menopause

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A. Characteristics.

  • The cessation of menstruation caused by physiologic factors; ovulation no longer occurs.
  • Menopause usually occurs between the ages of 45 and 55.

B. Mechanisms in menopause.*

  • Ovaries lose the ability to respond to pituitary stimulation and normal ovarian function ceases.
  • Gradual change due to alteration in hormone production.
    a. Failure to ovulate.
    b. Monthly flow becomes smaller, irregular, and gradually ceases.
  • Menopause is accompanied by changes in reproductive organs. The vagina gradually becomes smaller; the uterus, bladder, rectum, and supporting structures lose tone, leading to uterine prolapse, rectocele, and cystocele.
  • Atherosclerosis and osteoporosis are more likely to develop at this time.

Nursing Concepts: Assessment

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A. Assess presence of symptoms—varies with individuals\ and may be mild to severe.
B. Assess feelings of loss as children grow and leave home and aging process continues.
C. Assess presence of physiological symptoms: hot flashes, night sweats, vaginal atrophy, mood swings, and fatigue.

Nursing Concepts: Implementation

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A. Refer client to physician who can discuss hormone replacement therapy (HRT), now controversial, versus natural methods of controlling symptoms.

  • Diet: more vegetarian with essential fatty acids; limiting caffeine, sugar, meat and dairy, and saturated oils.
  • Herbs: black cohosh, dong quai, fennel, red clover, and other phytoestrogen plants.
  • Progesterone substitute—skin cream made from the Mexican yam, natural progesterone, and natural estrogen (estriol) via a skin patch.

B. Monitor estrogen therapy—usually given on cyclic basis: one pill daily except for 5 days during the month; progesterone 10–12 days per month.
C. Evaluate need for treatment of psychological problems.

Nursing Concepts: Major Health Problems

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A. Heart disease occurs in both male and female clients (as of 2010 more than 500,000 die each year).
B. Diabetes.
C. Hypertension.
D. Accidents.
E. Confrontation with the most acute psychological problems of any age group.

  • Depression.
  • Involutional psychosis.

F. Cancer.

Nursing Concepts: Psychosocial Changes

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Midlife Crisis

A. A normal stage in the ongoing life cycle in which the middle-aged person reevaluates his or her total life situation in relation to youthful achievements and actual accomplishments.

  • Struggles to maintain physical attractiveness in relation to younger people.
  • Feels partner or lover is essential.
  • Feels he or she has peaked in ability.
  • Blames environment or others for failure to succeed.
  • Displays increased interest in sexuality.
  • Exhibits competitiveness in career plans.

B. Unresolved crisis.

  • May result in stagnation, boredom, and decreased self-esteem and depression.
  • Age for crisis varies.
    a. Women usually pass through it at age 35 to 40.
    b. Men usually experience the crisis at age 40 to 45.

Nursing Concepts: Causes of Psychological Problems

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A. Fear of losing job.
B. Competition with younger generation.
C. Loss of job.
D. Loss of nurturing functions.
E. Loss of spouse, particularly females.
F. Realization that person is not going to accomplish some of the things that he or she wanted to do.
G. Changes in body image.
H. Illness.
I. Role change within and outside of family.
J. Fear of approaching old age.
K. Physiological changes.

Nursing Concepts

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