Page 2 - Psychosocial Integrity Study Guide for the NCLEX-RN Exam

Stress Management and Coping Mechanisms

A new medical diagnosis and/or undergoing a medical treatment regimen (chemotherapy, surgery, etc.) will be stressful for most patients and their families. Every patient has a unique set of coping mechanisms that he or she (and family) will use to get through this time. Nurses play a critical role in this process. Nurses need to be able to assess the level of stress, identify existing coping mechanisms, teach or provide resources to learn necessary skills, and evaluate whether or not a patient is coping well, intervening when necessary.

Human Responses to Stress

Every patient will react differently to stress. Some may verbalize their feelings while others will not. Be able to identify the most common responses to stress to help patients effectively deal with their situations.


The physiological effects of stress can produce an upset in the body’s equilibrium. The increased demands placed on a patient’s body produce a “fight or flight” response dominated by the sympathetic nervous system. Physical responses to stress can increase a patient’s ability to recover from an illness and become more susceptible to disease. Chronic stress can produce changes in certain organ systems (ulceration in the gastrointestinal tract), atrophy of the lymphatic system (thymus, spleen, and nodes), and adrenal enlargement. Nursing interventions should focus on providing external adaptive resources such as supplemental \(O_2\), proper nutrition, and increased physical activity to support a patient’s physical ability to heal.


Psychological changes produced by stress can alter or influence a patient’s emotions. Patients may feel overwhelmed and become anxious. They may have drastic and/or wide mood swings. Chronic states of stress may result in a depressive state. Patients and their caregivers will often flow through stages of grief including rationalization, hopefulness, anger, and despair. While the psychological response to stress is often negative, occasionally a positive response, such as relief, may occur. Nursing interventions should focus on ways to help reduce the psychological effects of stress (anxiety reduction, relaxation techniques, anger management, etc.).


Some patients facing stressful situations may suffer cognitive problems as a result. The disruption of daily life can leave them unable to process information about their situations and environment and affect their decision-making ability. For patients suffering with cognitive difficulties of stress, nursing interventions can focus on helping patients think more clearly (organization, time management, etc.), which gives them a sense of control over their situation.

Minimizing Stress

Nurses must identify ways to help their patients minimize the negative effects of stress. It may be easier for some patients than for others, but it is important to understand that stress will be present and may affect each patient.

Identify stressors— Talk with patients about what they perceive to be stressors. Discuss which ones they may be able to modify and which are beyond their control.

Verbalization— Gently encourage patients to communicate their feelings regarding the effects of stress.

Identify patient strengths— Help patients understand and utilize the resources they do have, rather than focusing on what they lack.

Identify regular coping mechanisms— Discuss ways that a patient has successfully dealt with stress in the past. Determine if his or her coping skills are adequate.

Find new coping strategies— Discuss other ways to deal with stress if a patient lacks sufficient skills. Tailor the discussion and identify strategies that would most benefit the patient’s situation.

Listen, support, and teach— Allow the patients to speak. Listen and acknowledge their concerns. Provide support and encourage friends and family to do the same. Teach new skills and strategies when able, or provide the proper resources to do so.

Recognition of the Inability to Cope

Again, each patient’s coping skills are different. Each will have a unique social support system and set of problem-solving skills (or lack thereof) that influences his or her ability to cope. Be alert for and recognize signs that a patient is not coping well.

Verbalization— Many patients will not volunteer that they are having difficulty coping. Discuss this openly with them on a regular basis.

Decision-making problems— A patient that cannot make decisions or verbalize needs will likely feel overwhelmed. Offer guidance to help the patient improve his or her ability to function more normally.

Destructive behavior— Some patients will lash out or act aggressively when they are overwhelmed. They may also engage in self-destructive behaviors such as self-harm or even attempt suicide. Monitor these clients closely.

Physical signs— Anxiety, depression, gastrointestinal symptoms, headaches and other vague, non-specific physical complaints may be physical signs of a patient’s inability to properly cope.

Lack of emotional control— Patients may demonstrate emotional lability and have erratic mood swings.

Irritability— General irritability is also a sign of poor coping. This may manifest as complaints from everything from caretakers to meals and housekeeping.

Causes of Stress

Whenever a patient demonstrates the inability to cope, carefully consider the source(s) of stress for each patient. This may help to identify and implement appropriate coping interventions.

Serious illness diagnosis— conditions that are terminal, inoperable, or rare

Change in health— setbacks in treatment, nosocomial infections, complications from medication or surgery

Support system problems— lack of social support or a dysfunctional support system

Lack of psychological resources— poor or inadequate coping mechanisms; lack of knowledge or experience despite previous stressors or previous negative outcome with a major life event/stressor

Situational crisis— a major life event that is viewed as a crisis to the particular individual that is affected (loved one’s death, divorce, etc.)

Defense Mechanisms

Defense mechanisms are unconscious behaviors or reactions to a stressor or stressful situation. Every patient will implement some sort of defense mechanism. The nurse may become responsible for identifying these actions as well as determining if they are helpful or harmful to the patient.

Denial— when a patient does not recognize or acknowledge a thought or feeling

Suppression— when a patient acknowledges a thought or feeling, but then ignores or tries to hide it

Projection— when a patient believes that someone else has the same thought or feeling

Acting out— when a patient uses disruptive or drastic behavior to express a thought or feeling that he or she otherwise feels incapable of expressing.

Displacement— when a patient directs a thought or feeling to another, usually powerless target

Isolation of affect— when a patient separates a thought or feeling from the rest of his or her thoughts

Intellectualization— when a patient “rationalizes” a thought or feeling to avoid its emotional impact

Regression— when a patient utilizes an immature behavior or reaction to deal with a thought or feeling

Reaction formation— when a patient changes a thought or feeling to its exact opposite and adopts that stance

Rationalization— when a patient denies his or her own personal thoughts and adopts one or more explanations to justify the situation

Sublimation— when a patient turns a negative thought or feeling into an action that produces a positive outcome

Dissociation— when a patient (in part) detaches him/herself from the current situation/reality in order to avoid a thought or feeling


The Nurse’s Role

Provide plenty of opportunities for patients to express their thoughts, feelings, and apprehensions. Discuss ways to set realistic goals for their health and learn constructive methods of problem-solving. Alternatively, identify potential helpful resources and discuss the importance of proper support systems to relieve stress and improve coping skills.

Crisis Intervention

A crisis is a sudden, often unexpected, impactful event that has a significant emotional effect on a patient and dramatically affects his or her daily life. Crises can be a critical time where nurses can help patients effectively deal with multiple changes and emotions to avoid a potentially negative health outcome.

Nursing Responsibilities

Nurses must first recognize when a patient is in crisis. When a crisis is determined, the nurse should be able to handle these tasks:

Patient history with this problem— Identify all of the information contributing to the current crisis situation.

Patient’s current feelings— Help the patient discuss and identify all of the emotions present.

Current support systems— Assess the patient’s access to and functioning of his or her available support systems.

Crisis intervention techniques— Protect the patient’s safety first, then provide physical and emotional support to return them to pre-crisis functioning. Teach coping skills when necessary.

Patient’s potential for harm or self-harm— Constant, sometimes one-on-one supervision is often necessary to assess the potential for violent behavior that may be self-directed (suicidal ideation, attempts, etc.) or toward others.

Crisis Intervention Goals

After gathering information regarding the situation, nurses should assess and develop nursing diagnoses to implement an effective care plan. Goals should include:

Reducing stress— Teach effective coping skills such as relaxation, visualization, etc. to help manage anxiety and stress. Encourage open communication about emotions, and protect the patient from additional stress when possible.

Organizing a solution— Help the patient identify existing or find new support systems and mobilize them based on his or her specific needs.

Returning to normal function— Ensure patients adhere to and follow the treatment plan. This includes scheduling and attending regular follow-ups after the resolution of the acute phase of the crisis.

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