Excessive amounts and types of demands that require action

Difficulty with decision-making

Expresses feeling pressured

Expresses increased anger

Expresses tension

Impaired functioning

Increased impatience

Negative impact from stress

For the related factors of Stress Overload, one person can be influenced by multiple coexisting stressors that can be pathophysiologic, maturational, treatment related, situational, environmental, personal, or all of these.

Pathophysiologic

Related to coping with:

Acute illness (myocardial infarction, fractured hip)

Chronic illness* (arthritis, depression, chronic obstructive pulmonary disease)

Terminal illness*

New diagnosis (cancer, genital herpes, HIV, multiple sclerosis, diabetes mellitus)

Disfiguring condition

Situational (Personal, Environmental)

NANDA-I approved*

Related to inadequate resources*

Related to repeated stressors*

Related to actual or anticipated loss of a significant other secondary to:

Death, dying

Moving

Divorce

Military duty

Related to coping with:

Dying

War

Assault

Related to actual or perceived change in socioeconomic status secondary to:

Unemployment

New job

Promotion

Illness

Foreclosure

Destruction of personal property

Related to coping with:

Family violence

New family member

Substance abuse

Relationship problems

Maturational

Related to coping with:

Retirement

Financial changes

Loss of residence

Functional losses

AUTHOR'S NOTE

The following symptom clusters have been identified in a small well-executed study (Amirkhan, Landa, & Huff, 2018).

Somatic symptoms:

• Body complaints (BC) - symptoms reflecting physiological changes resulting from stress. Examples include reduced sex drive, frequent urination, teeth grinding, fatigue/weakness, body aches, and itching, etc.
• Gastrointestinal disturbances (GD) - symptoms specifically linked to the gastrointestinal system. Examples include stomach pains, complexion change, nausea, vomiting, skin sores/pimples, etc.
• Respiratory problems (RP) - stress-related symptoms focusing on the respiratory system and nasal tract. Examples include stuffy/runny nose, earache, sore throat, temperature change, sneezing, etc.

Behavioral clusters:

• Moodiness (M) - Behavioral symptoms linked to mood issues. Examples include waking up tired, irritability, volatile emotions, impatience, increase in drug/alcohol use, nervous tics/twitches, losing one's temper.
• Nervous habits (NH) - Behaviors suggestive of nervousness or compulsiveness. Examples include pacing back and forth, neglecting personal grooming, making mistakes, shaking or trembling, chewing nails/pencils/twitching.
• Cognitive disruption (CD) - Signs of reduced cognitive functioning. Examples include losing focus, difficulty making decisions, memory problems, forgetting appointments.
• Researchers identified an important distinction between cognitive problems versus somatic symptoms. Findings suggest that behavior symptoms, particularly cognitive disruption, tend to be more useful as overload warning signs than somatic symptoms. The effects of stress overload on cognitive function remains strong over time and shows no sign of subsiding like many other symptoms do (Amirkhan, Landa, & Huff, 2018).

Level 2 Extended Focused Assessment (all settings)

Subjective/Objective Data

Ask to Rate His or Her Usual Level of Stress

Little 0 - 10 Overwhelming

Ask to Describe How His or Her Stress Is Affecting Their Ability to Function

Work

Sleep

Relationships

Assess for Feelings of:

Anger

Unhappiness

Impatience

Edginess

Despair

Boredom

Apathy

Easily upset

Lack of intimacy

Intolerance

Assess for Cognitive Symptoms

Forgetfulness

Constant worry

Memory loss

Thoughts of abandonment

Difficulty making decisions

Loss of sense of humor

Assess for:

Excess sleep

Tobacco use

Excess alcohol

Excess food

Drugs (prescription, street)

The individual will verbalize intent to change 2 behaviors to decrease or manage stressors, as evidenced by the following indicators:

• Identifies stressors that can be controlled and those that cannot.
• Identifies one successful behavior change to increase stress management.
• Identifies one behavior to reduce or eliminate that will increase successful stress management.

Level 2 Extended Focused Interventions (all settings)

Explain that stress can build up from a variety of sources, whether through major life events—such as losing your job or ending a marriage—or through a buildup of daily hassles until your inner resources and coping abilities are depleted (Vitelli, 2017). In response to stress, individuals initiate or increase unhealthy behaviors such as overeating, sedentary lifestyle, excessive use of drugs or alcohol, smoking, and social isolation.

Discuss the Effects of Chronic Stress on the Development of (Levensen, 2020):

• Chronic heart disease, high blood pressure, diabetes, obesity, a weakened immune system, sexual dysfunction, gastrointestinal disorders, skin irritation, respiratory infections, autoimmune diseases, insomnia, and schizophrenia

CARP'S CUES

Hippocrates wrote that "It is more important to know what sort of person has a disease than what sort of disease a person has" (*Schindler, 1985).

Psychological factors affecting other medical conditions (PFAOMC) is a disorder that is diagnosed when a general medical condition is adversely affected by psychological or behavioral factors; the factors may precipitate or exacerbate the medical condition, interfere with treatment, or contribute to morbidity and mortality (Levensen, 2020; APA, 2019). In addition, the factors are not part of another mental disorder (e.g., unipolar major depression) (APA, 2019).

Assist the Individual to Recognize His or Her Thoughts, Feelings, Actions, and Physiologic Responses

R:Self-awareness can help the individual reframe and reinterpret their experiences (*Edelman & Mandle, 2006).

Teach How to Break the Stress Cycle and How to Decrease Heart Rate, Respirations, and Strong Feelings of Anger (*Edelman & Mandle, 2006)

• Purposefully distract yourself by thinking of something pleasant.
• Engage in a diversional activity.

Initiate Relaxation Breathing: Inhale through Nose for 4 Seconds

Refer to resources to learn relaxation techniques, such as listening to audio recordings, reading printed material, and practicing yoga.

R:Faced with overwhelming multiple stressors, the individual can be assisted to differentiate which stressors can be modified or eliminated (*Edelman & Mandle, 2006).

Ask the Individual to List 1 or 2 Changes They Would Like to Make in the Next Week

• Diet (eat one vegetable a day)
• Exercise (walk 1 to 2 blocks each day)

R:In an individual who is already overwhelmed, small changes in lifestyle may have a higher chance for success and will increase confidence (*Bodenheimer, MacGregor, & Sharifi, 2005).

If Sleep Disturbances Are Present, Refer to Insomnia

• Ask what activity brings the individual feelings of peace, joy, and happiness. Ask them to incorporate one of these activities into each week.

R:Overwhelmed individuals usually deny themselves such activities. Leisure can break the stress cycle (*Wells-Federman, 2000).

If Spiritual Needs Are Identified as Deficient, Refer to Spiritual Distress

• Ask what is important, and if change is needed in his or her life.

R:Values clarification assists the overwhelmed individual to identify what is meaningful and valued and if it is present in their actual living habits (*Edelman & Mandle, 2006).

Assist the Individual to Set Realistic Goals to Achieve a More Balanced Health-Promoting Lifestyle (*Wells-Federman, 2000)

• What is most important?
• What aspects of your life would you like to change most?
• What is the first step?
• When?

R:Setting realistic goals will increase confidence and success (*Bodenheimer, MacGregor, & Sharifi, 2005).

Initiate Health Teaching and Referrals, as Necessary

• If an individual is engaged in substance or alcohol abuse, refer for drug and alcohol abuse.
• If an individual has severe depression or anxiety, refer for professional counseling.
• If family functioning is disabled, refer for family counseling.