In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of coping mechanisms in order to: Show
Simply defined, coping, is the patient's ability to institute, maintain and regain psychological homeostasis when this homeostasis is disrupted for one reason or another. Coping can be adaptive and it can also be useless and maladaptive. Coping is adaptive when it resolves the stress, and it is maladaptive when it does not resolve the stress and/or it creates further problems for the client. For example, alcoholism that results from a client's self medication to cope with the loss of a loved one not only does not resolve the stress associated with this situation crisis, it also leads to depression and other psychological and physical health problems. Coping strategies are thoughts, behaviors, perceptions, and emotions that a client can and does use to cope with stress and any of their disruptions of psychosocial homeostasis. Stress significantly and adversely impacts on the wholistic client and their physical, mental and social health and wellbeing. Stress occurs as the result of significant life events such as illness, divorce, moving, parenthood, financial problems, and the death of a loved one and it also can occur secondary to the daily stressors that occur in normal life. The adverse effects of stress are intensified as based on the intensity of the stress, the duration of the stress, the effectiveness of the client's protective mechanisms against stress, and the effectiveness of the coping mechanisms that the client is using to cope with the stress. Excessive and intense stress can lead to distress and the damaging physiological effects of the General Adaptation Syndrome Hans Selye developed the General Adaptation Syndrome theory, in addition to the Local Adaptation theory which details the inflammatory process, as previously discussed with the "Infection Control" section at the beginning of this NCLEX-RN review. The General Adaptation Syndrome theory describes the stages of stress and the effects of this stress on the human being. The stages of stress, according to the General Adaptation Syndrome theory, in correct sequential order, include:
Assessing the Client's Support Systems And Available ResourcesSome patients use a wide variety of coping mechanisms and other patients may have only a few or no coping mechanisms. Coping mechanisms are learned; some are effective and others are not. Patients with no effective coping mechanisms must be taught about new and more effective ways to cope with stress and stressors. Those who have effective methods of coping should be encouraged to use and refine them during times of crisis. Commonly used coping mechanisms include changing one's perception of the issue at hand, using humor, using problem solving skills, employing stress management and relaxation techniques, seeking out and using the support of others, ventilating feelings, embarking on a physical exercise and activity routine, decreasing personal expectations, and avoiding self-blame. Assessment data and information that should be collected in respect to the client's level of psychosocial functioning and coping mechanisms should entail the client's age at the onset of the coping disorder, the client's specific psychosocial signs and symptoms, the duration of these episodes, the number of episodes that required intense treatment, the client's family history of any psychiatric mental health disorders, the client's use of support systems, the effectiveness of these support systems, the client's utilization of available resources in their community, the effectiveness of these available resources in terms of the client's needs, the client's past coping mechanisms, and the client's current use of adaptive and effective and/or maladaptive and non effective coping strategies. Two standardized assessment measurement tools that can be used to collect psychosocial data and information are the "Interval Follow Up Evaluation" and the "Range of Impaired Functioning" tool which assess and measure the client's level of functioning in terms of their interpersonal relationships, their work, their leisure and recreational activities, and their overall level of satisfaction with life over time as well as the measurement and assessment of these same variables at the current time, respectively. Coping and stressors can also be assessed and measured with standardized tests like the "Hommes and Rahe Life Change Scale" and the "Lazarus Cognitive Appraisal Scale". Some of the signs and symptoms of maladaptive coping, in addition to the signs and symptoms associated with the General Adaptation Syndrome, include subjective complaints of not feeling or believing that one is able to cope. Prolonged stress can affect the body in physical, emotional or psychological ways. For example, stress can lead anxiety, chronic pain, a weight gain or loss, distress, tension, distress, dangerous and harmful behaviors towards self and/or others, irritability, depression, a lack of focus, forgetfulness, hypertension, fatigue, poor concentration levels, headaches, sleeping impairments, trembling, stomach aches, muscular tension and other somatic complaints, increased vulnerability to disorders and diseases such as a cerebrovascular accident, infections, a myocardial infarction, and poor control of preexisting diabetes. In addition to the assessment of individual client's signs and symptoms, nurses also assess their support systems, available resources, coping strategies of families, other groups, communities and populations. Assessing the Abilities of the Client to Adapt to Temporary and Permanent Role ChangesNurses must be able to assess and plan care for clients to enhance and facilitate their ability to adapt to temporary and permanent life changes. Temporary role changes are typically less stressful to the client when compared to permanent role changes that can lead to stressful major life changes and an increasing dependency on others which are also often coupled with a decrease in the client's levels of self-worth and self-esteem. Examples of temporary role changes include things like an extensive loss of work as the result of an injury such as a back injury that prohibits one's working and the temporary inability of the client to adequately care for their children because of a physical or psychological problem such as a broken leg or a substance related addiction; and examples of permanent role changes include the loss of children as the result of child abuse or neglect and a client's permanent lack of ability to perform their basic activities as the result of paralysis. Permanent as well as temporary role changes can often lead to anxiety and stress. After a complete focused assessment relating to the client and their responses to role changes, registered nurses plan interventions that are appropriate for the individual client and their assessed needs. Some of these interventions can include facilitating and encouraging the client to ventilate their true feelings about this loss in an accepting, open and trusting nurse-client relationship, engaging the client with the identification of realistic expectations of self and then nurses can assist patients with their responses and reactions to permanent and temporary role changes by allowing and encouraging the patient to ventilate their feelings and also by helping the patient explore and identify realistic goals and to establish realistic expectations of what they are able to do despite some role changes and losses. Assessing the Client's Reactions and Responses to Acute and Chronic Illnesses Including Mental IllnessSome of the most commonly occurring psychological and emotional alterations associated acute and chronic illness, including a mental illness can include:
Distress: Distress can range from mild to severe and even disabling with signs and symptoms which can be behavioral as well as physical in nature. Distress can be characterized with signs and symptoms such as irritability, insomnia and social withdrawal. Distress can manifest with client forgetfulness, irritability, restlessness, hyperactivity, and somatic complaints such as headaches and insomnia in addition to some of the signs and symptoms of stress as detailed above under the General Adaptation Syndrome. Anger: Anger can be turned inward and lead to depression and anger can also be turned outward and lead to hostility, anger, harm to others, harm to self, and destructiveness, all of which are not socially acceptable. Anger is often displaced onto another as will be discussed below under the section entitled "Evaluating the Constructive Use of Defense Mechanisms by a Client". Denial: Denial, like rationalization and displacement, is another psychological defense mechanism. Denial occurs when the client pushes the threatening situation into the subconscious so that the client is not forced to deal and cope with it until the client's psyche is better able to deal with it. Rationalization: Rationalization occurs when the client explains away the threatening event or situation with faulty thinking rather than dealing and coping with it. Rationalization will also be more fully discussed later in this review with the section entitled "Evaluating the Constructive Use of Defense Mechanisms by a Client" Guilt: The ultimate purpose of guilt is to let a human know and gain insight into something that they have done that is wrong. The identification and the recognition of guilt give the person the opportunity to change their unacceptable behaviors and to make amends for their transgressions and wrong doings. Unresolved guilt, however, can lead to despair, distress, spiritual distress, physical signs and symptoms and psychological signs and symptoms. Nurses can help the patient to overcome and resolve their guilt by emotionally and spiritually supporting the client, by facilitating the client's ventilation of feelings, by encouraging the patient to change behaviors, and by encouraging the client to make necessary amends to others for their wrong doings. Grief: Grief, as defined by the North American Nursing Diagnosis Association (NANDA), is the "normal complex process that includes emotional, physical, spiritual and intellectual responses and behaviors by which the individuals, families, and communities incorporate a loss into their daily lives". All losses can be accompanied with grief. For example, the loss of the use of a limb as the result of paralysis is a physical loss, the loss of a loved one and the loss of self-esteem are losses which can be accompanied with grief. Although grief is a normal, adaptive response to loss, complicated and unresolved grief is maladaptive. More details about grief and loss will be provided in a later section of this NCLEX-RN review under the section entitled "Grief and Loss". Depression: Depression commonly occurs as the result of an acute or chronic illness, including mental health disorders; depression can affect both the client and the family unit. This symptom can lead to physical, psychological and cognitive changes. Some of the signs and symptoms associated with depression include feelings of helplessness, hopelessness, low self-esteem, decreased sense of self-worth, sadness, insomnia, poor problem solving and decision making processes, and decreased libido among other signs and symptoms. Severe and unresolved depression can, in some cases, lead to suicidal and/or homicidal ideation. Fear: Fear is a response to a perceived impending or actual danger, including illness. Although there are similarities with both anxiety and fear, there are also some distinct differences. Fear is less vague and less diffuse than anxiety; fear is most often associated with a current threat and anxiety is most often associated with a future threat, and fear, unlike anxiety, is most often associated with a specific physical threat and anxiety is most often associated with psychological and emotional conflicts. Some of the signs and symptoms of fear include tachycardia, hypertension, pallor, dilated pupils, aggression, hostility and fatigue. Loss of hope and meaning: A loss of hope or hopelessness, as defined by the North American Nursing Diagnosis Association (NANDA), is "the subjective state in which an individual sees limited or no alternatives for personal choices available and is unable to mobilize energy on one's own behalf". A loss of hope and meaning has physical, psychological, spiritual and social consequences such as distress, apathy, impaired appetite, passivity, withdrawal, a lack of motivation, spiritual distress, despondency, psychological distress, and a lack of involvement by the client in terms of their activities of daily living and their plan of care. Assessing the Client in Coping with Life Changes and Providing SupportAll changes threaten the homeostasis of the human being. As such, clients have to be able to effectively cope with physical, psychological, social, and economic changes in a healthy and adaptive way with coping. Life changes can be broadly classified and categorized as permanent or temporary, physical, psychological and social, mild to highly significant, and situational or maturational. Despite the nature of the particular change, all changes have to be coped with. Change affects not only individual clients, but it also affects and impacts on family units, groups, populations and communities, including the global community. Examples of permanent and temporary changes are a physical disfigurement that occurs as the result of a bomb blast and a transient episode of depression or grief, respectively; examples of physical, psychological and social changes can include the loss of a breast secondary to breast cancer or alopecia secondary to therapeutic cancer chemotherapy, grief that occurs as the result of a loved one, and the loss of financial income, respectively; examples of moderate or mild and significantly powerful changes include the birth of a newborn into a previously childless family unit and the loss of a home as the result of a disaster like a cyclone or tornado; and examples of change that can be classified and categorized as situational and developmental or maturational are the loss of work and a salary as the result of an acute illness or accident and the empty nest syndrome that is often seen among middle aged clients as the children leave the home and the normal changes associated with the aging process and disabilities, respectively. Disabilities as the result of a situational life change can be classified and characterized in a number of different ways. Some of the models and frameworks that can be used to gain a fuller understanding of these situational changes and their nursing considerations are discussed below.
According to Nagi, "Disability is a limitation in performing socially defined roles and tasks expected of an individual within a sociocultural and physical environment. These roles and tasks are organized in spheres of life activities such as those of the family or other interpersonal relations; work, employment, and other economic pursuits; and education, recreation, and self-care. Not all impairments or functional limitations precipitate disability, and similar patterns of disability may result from different types of impairments and limitations in function. Furthermore, identical types of impairments and similar functional limitations may result in different patterns of disability. Several other factors contribute to shaping the dimensions and severity of disability. These include the:
Nurses plan and implement care as based on the assessed needs of clients who are affected with change. In addition to establishing a supportive and open client-nurse relationship, the nurse also establishes trust with the client and allows and encourages the client to openly ventilate their feelings in an environment that is nonjudgmental and supportive, and they also facilitate the client's learning and utilization of coping mechanisms such as:
Identifying Situations Which May Necessitate Role Changes for a ClientRole changes occur along the life span. Some of these role changes are maturational or developmental and others are situational. All role changes, like other changes, have to be adaptively coped with by the individual, family, group, population and community. Some of the maturational and developmental role changes and challenges along the life span include:
Some of the situational role changes and challenges include those physical, psychological and social changes that occur as the result of some acute or chronic disorder or disease. The signs, symptoms and interventions for these changes were discussed above under the sections entitled "Assessing the Client's Reactions and Responses to Acute and Chronic Illnesses Including Mental Illness" and "Assessing the Client in Coping with Life Changes and Providing Support". Some of the nursing diagnoses associated with role performance and ineffective role performance include:
Some of the interventions that are used to promote the client's ability to cope with role changes, both maturational and situational, include:
Providing Support to the Client with An Unexpected Altered Body ImageClients can be expectedly and predictably affected with an alteration of their bodily image along the life span and they can also be unpredictably affected with body image changes along the lifespan and they can be also be unpredictably and unexpectedly as the result of an illness, disease, disorder and some therapeutic treatments. Some of the normally occurring and predictable body image changes that occur along the life span include changes and events such as adolescent puberty, middle years female menopause, middle years male climacteric, and in the elder years when the normal changes of the aging process occur. Major traumatic accidents that lead to disfigurement and/or physical disability, alopecia secondary to cancer chemotherapy treatments, a loss of cognitive functioning, disfiguring surgeries such as a radical mastectomy and an orchiectomy, and therapeutic interventions such as a structural fecal diversion colostomy are examples of unexpected and unpredicted altered bodily image changes. A disturbed or altered body image, simply defined, is some confusion in the client's mental picture of one's physical body and self. Impaired body image is characterized with avoidance and hiding of the affected bodily part, a focus and emphasis on the client's past body image, depersonalization of self, subjective client statements that indicate a loss, and feelings of helplessness and hopelessness. Patents with actual and perceived body image changes and alterations need the support of nurses and other members of the health care team in order to successfully cope with these losses. After a complete assessment of the client's perception of their body image which can include the use of standardized assessment measurement scales such as the Body Image Quality of Life Inventory, the nurse will plan care for the client. Some of the interventions that are often used among clients who are affected with an impaired body image include encouraging the client to express and ventilate their feelings about the alteration, facilitating the client's coping with this alteration and some of the resulting feelings such as depression, anger, hopelessness and helplessness, facilitating the client to learn and develop more realistic expectation of self in terms of their body image, and focusing on the client's strengths and abilities, rather than these alterations and their weaknesses. Evaluating the Constructive Use of Defense Mechanisms by a ClientThe ultimate purpose of defense mechanisms is to psychologically protect the client from unmanageable stress until the client is ready to cope with these stressors effectively and without any maladaptive mechanisms. Based on this fact, nurses and other health care professionals should never debate or argue with the client about their use of these subconscious ego defense mechanisms; they should not be stripped away until the client has garnered the psychological health and fortitude to deal with the threatening stress that they are confronted and affected with. The psychological ego defense mechanisms, their purposes and some examples will be discussed now.
Evaluating Whether the Client has Successfully Adapted to Situational Role ChangesAs with all aspects of nursing care, nurses evaluate whether or not the client has successfully adapted to situational role changes in terms of whether or not the client has achieved the pre-established goals that were established after a complete assessment of the affected client, their family members, and other significant others. Some of the areas that the registered nurse may explore, as based on the client's specific needs, can include:
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Alene Burke, RN, MSN Alene Burke RN, MSN is a nationally recognized nursing educator. She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. She got her bachelor’s of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. She graduated Summa Cum Laude from Adelphi with a double masters degree in both Nursing Education and Nursing Administration and immediately began the PhD in nursing coursework at the same university. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Association’s task force on competency and education for the nursing team members. Latest posts by Alene Burke, RN, MSN (see all) What are the behavioral symptoms of generalized anxiety disorder?Symptoms of GAD include:. Feeling restless, wound-up, or on-edge.. Being easily fatigued.. Having difficulty concentrating.. Being irritable.. Having headaches, muscle aches, stomachaches, or unexplained pains.. Difficulty controlling feelings of worry.. Having sleep problems, such as difficulty falling or staying asleep.. What should you assess for a patient with anxiety?Assess the patient for physical symptoms of anxiety, such as tachycardia, diaphoresis, elevated blood pressure, increased respirations, and pain. 7. Assess the patient for somatic symptoms of anxiety, such as stomach distress, headaches, or muscle tension.
Which action would the nurse take first for a client with generalized anxiety disorder?The nursing interventions for anxiety disorders are: Stay calm and be nonthreatening. Maintain a calm, nonthreatening manner while working with client; anxiety is contagious and may be transferred from staff to client or vice versa. Assure client of safety.
Which signs and symptoms would the nurse expect to find in a patient with generalized anxiety disorder?Physical signs and symptoms may include:. Fatigue.. Trouble sleeping.. Muscle tension or muscle aches.. Trembling, feeling twitchy.. Nervousness or being easily startled.. Sweating.. Nausea, diarrhea or irritable bowel syndrome.. Irritability.. |