5.2 Coping, Stress, Crisis & Abuse

Coping, Stress, Crisis, and Responding to Abuse

Stress, Coping, and Adaptation

Hans Selye's General Adaptation Syndrome (GAS) describes the body's physiological response to a stressor in three stages: alarm (the fight-or-flight sympathetic surge), resistance (the body adapts and attempts to cope), and exhaustion (reserves deplete and illness can result if the stressor persists). Coping mechanisms are either problem-focused (acting to change the stressor) or emotion-focused (managing the emotional response). Unconscious defense mechanisms — denial, projection, rationalization, regression, displacement, and the mature mechanism sublimation — reduce anxiety and become maladaptive only when overused. The PN supports adaptive coping and models healthy stress management.

On the exam, recognizing a defense mechanism guides a supportive rather than confrontational response: denial refuses reality, projection attributes one's own feelings to another, rationalization makes excuses, regression returns to earlier behaviour under stress, displacement redirects emotion onto a safer target, and sublimation channels impulses into acceptable activity. Support systems — family, friends, peer groups, and community services — buffer stress, so part of the PN's role is to assess and strengthen them, because isolation worsens coping.

Crisis Intervention

A crisis is a state of disequilibrium that arises when usual coping fails, and it typically resolves within four to six weeks. There are three types: situational (job loss, sudden illness), maturational/developmental (retirement, adolescence, new parenthood), and adventitious (disaster, assault, mass violence). Crisis intervention is short-term, reality-oriented, and directive: ensure safety first, establish rapport, help the client name the problem and feelings, mobilize support and resources, and build a concrete plan. The goal is to restore the client to at least the pre-crisis level of functioning — not to resolve long-standing personality issues.

Grief and Loss

Elisabeth Kübler-Ross's stages — Denial, Anger, Bargaining, Depression, Acceptance (DABDA) — are not strictly linear; clients move back and forth at their own pace, and not everyone experiences every stage.

Anticipatory grief occurs before an expected loss; complicated (prolonged) grief is intense and persistent and impairs daily function. The PN offers presence, honest information, and permission to grieve — false reassurance and rushing the client toward acceptance are barriers.

Suicide Risk Assessment and Safety

Suicidal ideation is a safety emergency. Ask directly and calmly about ideation, plan, means, and intent — direct questioning does not plant the idea. Risk is higher with a specific plan, available lethal means, a prior attempt, hopelessness, and recent loss. Priority interventions:

1. Never leave a high-risk client alone; provide continuous one-to-one observation.
2. Remove the means — belts, cords, sharps, glass, and hoarded medications.
3. Create a safe environment and document objective findings and the client's exact words.
4. A "no-suicide contract" is not a substitute for observation and means restriction.

Substance Use

• Alcohol withdrawal begins within hours; delirium tremens (DTs) — confusion, hallucinations, autonomic instability, and seizures — peaks 48-72 hours after the last drink and can be fatal. Monitor closely (CIWA protocol), and expect benzodiazepines and thiamine.
• Opioid withdrawal is very uncomfortable (yawning, muscle aches, GI upset, dilated pupils) but rarely fatal.
• Screen with CAGE (Cut down, Annoyed, Guilty, Eye-opener) and use a non-judgmental, harm-reduction approach.

Recognizing and Responding to Abuse, Neglect, and Family Violence

Abuse takes several forms: physical, sexual, emotional/psychological, financial, and neglect. Red flags include injuries inconsistent with the reported history, delayed care, fear of a caregiver, and bruises in various stages of healing. The cycle of violence (tension building, acute incident, then a honeymoon/reconciliation phase) helps explain why survivors stay. The nursing response is to ensure immediate safety, interview the client privately and away from the suspected abuser, document objective findings and the client's own words verbatim, and follow mandatory reporting law.

Exam point: Reporting suspected child abuse is mandatory for everyone in every Canadian province and territory. For competent adults, reporting generally requires consent, but abuse of dependent adults and residents of licensed care facilities triggers legislated reporting. Never confront the suspected abuser or promise to keep abuse secret.

De-escalation

For an escalating or aggressive client: use a calm voice and non-threatening posture, keep a safe distance with a clear exit, set simple firm limits, offer realistic choices, reduce stimulation, and call for help early. Restraints and PRN medication are the last resort, used only after verbal de-escalation fails, and require an order and frequent reassessment. Recognizing the assault cycle (triggering, escalation, crisis, recovery, and post-crisis depression) lets the nurse intervene early — during triggering and escalation, when talking-down is still effective. Always document the behaviours observed, the interventions attempted, and the client's response after any de-escalation or restraint event.