Nursing Field Notes / Mental Health · Fundamentals of Nursing
Stress 🌊
General Adaptation Syndrome, the HPA axis, and what the nurse actually does about it
NG-009Mental HealthADHD-friendly visual edition
Stress can be good AND bad. Good when it helps us adapt to changes in the body and the environment — bad when it is chronic or persistent, with no periods of rest between stressful events. That kind raises blood pressure, raises cortisol, and puts loads of strain on the body. It is typically caused by family drama, money issues, and normal life events — like nursing school.
Hypothalamus releases CRH → anterior pituitary releases ACTH → adrenal cortex releases cortisol. Cortisol then feeds back and switches the whole axis off again — unless the stressor never stops.
🧠 “Hypothalamus Pages the Adrenal.” H-P-A. CRH is the page, ACTH is the messenger, cortisol is the response — and cortisol is supposed to hang up the phone afterwards.
📈 General Adaptation Syndrome — the three stages, drawn as one curve
Hans Selye described the body's non-specific response to any demand. It is the same three stages whether the stressor is a bacterium, a bereavement, or a nursing exam.
🧠 “A-R-E you okay?”Alarm · Resistance · Exhaustion. And the answer at stage three is no.
⭐ Eustress vs distress
😀 EUSTRESS (good)
😰 DISTRESS (bad)
Helps us adapt to changes in the body and the environment
Chronic or persistent, with no periods of rest between stressful occurrences
Motivating, time-limited, ends with recovery
Raises blood pressure and cortisol, and puts loads of strain on the body
A wedding, a promotion, exam week that ends
Money issues, family drama, caregiving with no break, an unrelenting semester
🧠 It is not the size of the stressor — it is whether there is a gap afterwards. Same load, no rest, and eustress becomes distress.
📖 The vocabulary you will be tested on
Stressor — the thing that triggers it. Stress — the body's response.
General Adaptation Syndrome (GAS) — the whole-body response: alarm → resistance → exhaustion.
Local Adaptation Syndrome (LAS) — a local response in one area: the reflex pain response and the inflammatory response.
Homeostasis — the balance the body is trying to get back to.
Adaptation — the successful adjustment; maladaptation when the coping makes things worse.
Appraisal — how this client interprets the stressor. Two people, one event, two completely different stress responses.
🧠 G is General (whole body), L is Local (one spot). A sprained ankle gets LAS; the exam that made you sprain it gets GAS.
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SIGNS & SYMPTOMS
STEP 2 · SPOT IT
Stress presents as a physical complaint far more often than as “I am stressed.”
🧍 Where stress shows up — a body map
🧠 “Head, heart, gut, muscles, immunity, sleep.” Six places to ask about. A client who ticks four of the six is telling you about stress even if they never use the word.
⚔️ Fight-or-flight vs rest-and-digest — the same organs, opposite orders
🧠 Breathing is the only autonomic function you can drive on purpose. That is why every relaxation technique starts there — slow exhalation is a direct switch from the left column to the right.
🔎 Assessment — what to ask
What is the stressor? And how long has it been going on?
How does the client see it? (appraisal) — threat or challenge?
What have they tried? What has worked before?
Support system — who is around? What changed recently?
Sleep, appetite, weight, energy, concentration.
Substance use — alcohol, nicotine, cannabis, caffeine, sedatives.
Always screen for self-harm and suicidal ideation when stress is severe. Ask directly — asking does not plant the idea.
🧠 Ask “what has changed lately?” It gets the stressor faster than “are you stressed?”, which almost everyone answers “a bit.”
🚨 When stress stops being “just stress”
Crisis — usual coping has failed and function has broken down. Safety first, then crisis intervention. Typically time-limited (about 4–6 weeks) and resolves with support.
Panic attack — abrupt, intense, peaks within 10 minutes: palpitations, chest pain, dyspnea, sense of doom. Stay with the client, calm short sentences, safe quiet space.
Acute stress disorder / PTSD — after a traumatic event, with re-experiencing, avoidance and hyperarousal.
Burnout & compassion fatigue — in the caregiver and in you.
🧠 Chest pain in a stressed client is still chest pain. Rule out the physical cause before you call it anxiety — that is the tested trap.
🧘
COPING SKILLS & NURSING CARE
STEP 3 · WHAT YOU DO
Teach the skill, build the plan, and know when to hand off.
✅ Coping skills — the source list, expanded
🏃Exerciseregularly — the single best one
🧘Meditationmindfulness
🌬️Breathingslow, long exhale
😴Sleeproutine & hygiene
📓Journalingname the stressor
🗣️Talkingto someone safe
⏰Time managementbreak it into steps
🚫Boundaries“no” is a coping skill
🎨Hobbiesmusic, art, nature
Teach one technique concretely:
Diaphragmatic breathing — hand on the belly, breathe in through the nose so the hand rises, out slowly through pursed lips. Make the out-breath longer than the in-breath.
Progressive muscle relaxation — tense a muscle group for a few seconds, then release, working up the body.
Guided imagery — a detailed, sensory safe place.
Grounding — name what you can see, hear and feel right now.
🧠 “Long exhale = the vagus nerve's off switch.” A longer out-breath than in-breath physically shifts the client toward parasympathetic. It is free, portable, and it works during an exam.
⚖️ Adaptive vs maladaptive coping
✅ Adaptive
❌ Maladaptive
Exercise · meditation · breathing · problem-solving · asking for help · rest · humor · planning
Alcohol & drugs · avoidance & denial · isolation · overeating or not eating · aggression · overworking · self-harm
Reduces the stressor or the response, and does not create a new problem
Relieves it briefly, then adds a second problem on top of the first
Problem-focused coping changes the stressor (make a plan, get the tutor). Emotion-focused coping changes the feeling (reframe, relax, talk). Use problem-focused when the situation is changeable, emotion-focused when it is not.
🧠 Can I change it? Change it. Can't change it? Change how I carry it. That single question sorts the two strategies.
📉 The cortisol rhythm — and what chronic stress does to it
🧠 Cortisol is supposed to be a morning hormone. When it is still high at midnight, sleep, immunity and glucose all suffer at once.
🩺 The nursing interventions — in the order you would use them
1
🛡️ Safety first. Screen for self-harm, harm to others, and unsafe coping (substances, driving, neglecting a dependent).
↓
2
👂 Therapeutic communication. Sit down, open-ended questions, silence, reflect feelings, do not say “don't worry” or “it will be fine.”
↓
3
🧩 Help them name the stressor and separate what can be changed from what cannot.
↓
4
🌬️ Teach one concrete technique and practice it with them once. One skill learned beats five skills listed.
↓
5
😴 Protect the basics — sleep, food, movement, daylight, caffeine and alcohol reduction.
↓
6
🤝 As nurses we identify available community resources and refer the client to counseling if needed.
🧠 Presence is an intervention. “I'll sit with you for a few minutes” scores higher on an exam than any advice you could give.
💊 Where medication fits — and where it doesn't
Stress itself is not primarily a drug problem. Behavioral and cognitive strategies come first.
Anxiolytics (benzodiazepines) are for short-term, situational use only — sedation, fall risk, dependence and rebound anxiety are real.
Longer-term anxiety and depression are usually treated with antidepressants, which take 4–6 weeks to work — teach that so the client does not quit at day 4.
CBT has the best evidence for changing the appraisal that drives the stress response.
📎 NG-236 Anxiolytics for the drug detail · 📎 NG-221 CBT for the therapy · 📎 NG-271 Therapeutic Communication for the words to use at the bedside.
🧠 “Talk first, pill second, and never a benzo forever.”
🩺 And the one nobody teaches: your own stress
Nursing school is the stressor in the source's own example. Treat yourself like a client: sleep, movement, food, boundaries, people.
Build the rest period between stressors deliberately — that is the whole difference between eustress and distress.
Debrief after a hard shift. Use the employee assistance program, peer support, or counseling without shame.
Watch for compassion fatigue: numbness, cynicism, dreading work, snapping at people you love.
🧠 You cannot pour from an empty cup — and you cannot chart your way out of exhaustion. Schedule the recovery the way you schedule the study block.
⚡
QUICK RECALL
SAY IT OUT LOUD
3️⃣ A · R · EAlarm → Resistance → Exhaustion.
🧬 H · P · AHypothalamus (CRH) → Pituitary (ACTH) → Adrenal (cortisol).
🌬️ Long exhaleBreathing is the switch from fight-or-flight to rest-and-digest.
🎯 Cover & check — 7 rapid-fire questions
Q1: Name the three stages of the General Adaptation Syndrome.
Alarm (sympathetic fight-or-flight fires), Resistance (the body adapts and looks fine while reserves are spent), Exhaustion (reserves gone → illness, immunosuppression, hypertension, depression, collapse).
Q2: Trace the HPA axis with the three hormones.
Hypothalamus releases CRH → anterior pituitary releases ACTH → adrenal cortex releases cortisol → cortisol feeds back negatively on the hypothalamus and pituitary.
Q3: What does cortisol do to blood glucose and immunity?
Raises glucose (gluconeogenesis) and suppresses immune/inflammatory function — which is why chronically stressed clients get more infections and heal more slowly.
Q4: When is stress “good”?
When it helps us adapt to changes in the body and the environment — eustress. It becomes harmful when it is chronic or persistent, with no periods of rest between stressful occurrences.
Q5: List the source's signs & symptoms of stress.
Aches & pain, chest pain/tightness, GI upset, changes in appetite, exhaustion, trouble sleeping, and decreased immunity.
Q6: What is the nurse's role once coping skills are taught?
Identify available community resources and refer the client to counseling if needed — plus keep screening for safety and reassess whether the coping is working.
Q7: A stressed client reports chest tightness. What do you do first?
Assess it as chest pain — vital signs, ECG per protocol, rule out a cardiac cause. Never label chest pain as “just stress” before the physical cause is excluded.