Professional Praetise

Creative Stress-Management Techniques For Self-Renewal

Deborah Antai-Otong

The daily stress and pressure oj today's nurses are profound. As workloads escalate and staffing declines, nurses must be lifestyles. Creative stress management techniques offer health-promoting strategies to manage stress in nurses' lives.

tress affects everyone. Today's societal stress is skyrocketing at an alarming rate and placing tremendous strain on individuals, families, and communities. The explosion of technologic advances in cyberspace and the Internet continue to move information and communication at a soaring pace that continues to direaten the quality of interpersonal relationships. Environmental factors such as air and noise pollution, crowding, societal and workplace violence, and a lack of loyalty by companies and employees add to the growing rate of personal, societal, and workplace stress. Numerous research findings indicate an alarming rise of stress in the workplace {Kohler & Kamp, 1992; Warshaw, 1989). In fact, an earlier study (Shilling & Brackbill, 1987), revealed that about S V or 11 On ' Deborah Antai-Otong, MS, RN, PMHNP, CS, is Director, Employee Support Program (ESP), VANTHCS, Dallas VA Medical Center, Dallas, TX.

million employees in the 1985 U.S. National Health Interview Survey reported that exposure to mental stress in the workplace compromised their health the most. These data reveal that workplace stress contributes to employee burnout, acute and chronic health conditions, poor staff morale, and reduced job performance and productivity. These deleterious effects of stress continue to be costly for individuals and organizations (Davis, Matthews, & McGrath, 2000; Iribarren et al., 2000; Miller, Smith, Turner, Guijarro, & Hallet, 1996). The precise cost of stress-related illnesses on individuals and companies remains obscure. The cost extends beyond organizational losses and includes the human element and quality of life (Davis et al., 2000; Iribarren et al., 2000; Vrijkotte, van Doomen, & De Geus, 1999). Stressrelated workforce losses account for approximately $200 billion annually (United Nations International Labor Organization, 1993). More ominous are data from worker compensation claims and the Social Security Administiation disability claims that confirm the escalating cost of workplace stress (Northwestern National Life Insurance Company, 1991). Understandably, most organizations are offering their employees health promotion and maintenance opportunities that range from health and weUness centers to stress management programs. Over the past 20 years, concepts of high-level wellness, health promotion, disease prevention, and lifestj'le modification reflect a greater focus on a holistic model of health care

(Benson & Stuart, 1992; Gordon, 1981; Moyers, 1993; Pender, 1996; U.S. Public Health Service, 1980). Ironically, during a time when nurses are teaching their clients health promotion and disease prevention, they are failing to integrate these basic principles into their daily lives. The daily stress and pressures of today's nurses are profound. Daily stress often comprises mountingworkloads, higher client acuity, inadequate staffing, confusion, and uncertainty about job security. Perhaps the most pervasive source of stress for nurses is a lack of control over their practice and a need to "do everything for everyone all of the time, perfectly" attitude. This attitude, coupled with ineffective communication skills, often results in chronic anger and hostility or repressed aggression. Additional personal stressors involve one's appraisal systems. These systems are defined by personal belief and value systems, personality type, life experiences, and perception of self and others and locus of control. Appraisal systems determine how people perceive and respond to and ultimately cope with stress. Goping with today's workplace and personal stresses challenges nurses to maintain healthy lifestyles and a sense of well-being. One strategy that has been used extensively to reduce risk factors for mental and physical disabilities and promote healthier lifestyles is stress management (Gallacher, Hopkinson, Bennett, Burr, & Elwood, 1997; Peters & Garlson, 1999). The purpose of this article is to focus on stress management strategies and the potential deleterious

DERMATOLOGY NURSING/February 2Q01/Vol. 13/No.i

impact on health. More importantly, a matrix of health promoting activities that help nurses appraise their responses to stress and manage it effectively through healthy lifestyle changes wiU be provided.

lenging.
Problem-focused coping refers to

What Is Stress?
Daily stress is part of living. Just waking up in the morning and sorting out what one is going to wear produces stress. Stress often emanates from negative or positive situations and feelings. People experience stress when they are upset and when they are happy. Normally, people liken being upset as negative and happy as positive. Webster defines stress as a constraining force or infiuence that results in physical, chemical, or mental tension and plays a role in disease. Hans Seyle (1946) is considered the "father of stress research" and discovered an array of stimuli (stressors) ranging from exposure to extreme temperatures to physical injury. He also surmised that individuals adapt themselves to stressful situations and have little control or nonspecific response to internal and external environmental demands (Seyle, 1946). In contrast, contemporary theorists contend that individuals do have control over their stress responses by changing or modifying distressful aspects of their environments. This premise indicates that stress arises from one's perception or cognitive appraisal of events or situations and resultant responses. Thus, stress management activities must provide opportunities to strengthen one's repertoire of coping skills and promote realistic appraisals and subsequent modification of environmental distress (Folkman & Lazarus, 1985; Lazarus, 1991). The current literature describes two major forms of coping: emotionfocused coping and problem-focused coping (Folkman & Lazarus, 1980;
Lazarus, 1991). Emotion-focmed coping

making attempts to govern or modify the problem situation. This coping style involves adjusting or eliminating the stress, managing the potential consequences, or actively making personal adaptive lifestyle changes. Of the two coping styles the problem-focused coping is a target for stress management techniques because they offer nurses innovative strategies for both coping responses.

How Does Stress Affect Us?

The vast potentially deleterious effects of stress on major body systems is a major health concern. There are two types of stress: acute and prolonged stress and chronic stress. Normally, acute episodes activate potent neuroendocrine processes that generate intricate hormones (catecholamines, cortisol, angiotensin, and endorphins) that modulate stress. These processes are part of a complex network of survival that parallel one's appraisal of a given situation and include the following reactions: Increase in heart rate and strength that increase blood volume. Rise in blood sugar that supplies muscle energy. Diversion of blood away from the GI system to the skeletal muscles that provides a quick get away. Rapid blood clotting to reduce hemorrhaging from wounds. Expansion of the eye pupil to increase fight and enhance visual acuity. Increase respiration to supply more oxygen to vital organs. Secretion of endorphins to reduce sensitivity to pain. As long as the body remains in this alarm state it conserves its resources and neglects other major physiologic and psychologic functions. Prolonged alarm states increase vulnerability to mental and physical strain that eventually compromise one's overall health. Initial reactions reduce energy, increase muscle tension, and produce emotional distress. Additional physical responses generated by prolonged stress states or vigilant reactions include (Phibbs, 1987): Hyperarousal and agitation.

Eat storage. Salt retention. Blood pressure elevation. Loss of essential minerals including potassium and magnesium. Irregular heart rhythms. Increase in serum triglycerides and cholesterol levels. Suppression of sex hormones. Increase in gastric acid. Accelerated blood clot formation. Compromised immune system. Because of the mind-body connection, psychological and emotional changes are also linked to one's appraisal system and resultant acute and chronic stress and include: anxiety, depression, irritability, frustration, anger, worrying, uncertainty, and lack of confidence. Discerning normal acute reactions from chronic vigilant reactions help nurses recognize the potential harmful effects of continuous stress. Predictably, developing stress management skills is critical to health promotion and maintenance. "

Stress Management Techniques

The overall goal of stress management is reducing negative stress, restoring and maintaining a state of holistic well-being. Stress management techniques offer nurses opportunities to embrace and appreciate their positive stress experiences. Gonfidence in mastering stressful events requires asserting oneself in difficult situations. Assertiveness training is a central part of stress management because it involves developing effective communication skills that foster active listening, discipline, and helps nurses express themselves more effectively during challenging situafions. Assertive communication is crucial to anger management, conflict resolution, and time management. Learning how to express one's feelings, including anger, and speaking up for one's rights are basic stress management techniques.

is directed towards modulating emotions generated by stress. This approach is generally used when an appraisal is perceived overwhelming and "I can't do anything about it anyway." Goping responses to this seemingly overwhelming situation involve modifying the stress so it is less injurious, threatening, or chal32

Assertive Communication
The fundamental goal of assertive communication is getting one's needs met without purposely hurting others. Additionally, assertive individuals use active listening skills
continued on page 35

DERMATOLOGY NURSING/February 2001/Vol. 13/No.1

Mat^5'months after

on^:^&uree of therapy.

oretouched pliotos. Undeniable results,

A
CONTRAINDICATIONS AND WARNINGS: Accutane (isotretinoin) must not be used by H females who are pregnant, who may become pregnant while undergoing treatment, or who j j - ^ are unreliable or may not use two separate, effective forms of contraception simultaneously ^ for at least 1 month before treatment, during treatment and for t month after treatment. \1 Major human fetal abnormalities have been reported. Two forms of contracepfion are to be 11 used simultaneously, even when one form is a hormonal contraceptive, because any contra^ ceptive method can fail, Prescribers must obtain negative resjits for two pregnancy tests before iniflating treatment with Accutane. The first test must be done on the day when the prescriber qualifies the patient to take Accutane, and the second test is to be done on the second day of the next menstrual period or 11 days after the l ^ t unprotected sexual activity, whichever is the later calendar date. Accutane is contraindicated in femaies of childbearing potential unless the patient meets all of the condithDns contained in the black box warning in the summary of product information on adjacent page.

calcitrant nodular acne

Less frequent, but potentially serious, Adverse Events include psychiatric disatiers': depression. psych(^is and.rareiy,suicidal \ < ^ m mhde attempts pseudotumor cerebri; pancreaiitis; hy[^rlptdemia; hearing impairmait"; hepatotoxicity; inflammatory bowel disease; skeletal changes: hyperostoss, pren^ture ciosure; ^^on impairment: comeal opacities, decreased night viaon. This rase describes an individual patient. The pretreatment profile and treatment results, including side effetfe, may be different in otter patients. Please see summary of product information, including CONTRAINDICATIONS AND WARNINGS, on adjacent page.

2000 by Roctie LaDotateries Inc All nglits reserveO

ACCUTANE"(Jsotreiinoin) CAPSULES
Belore prescribing, piease see campiete product informaiion. a
iryalwhiciilQiiaws: CONTRAINDICATIONS AND WARNINGS: Accutane must uot be used by lamales wtio are preguani or wbo may

ACCUTANE'(,s.trenin|
receiving tecoinmenfled doses, but it is not known if tbere is a i
orders cf keratiniiaticn witb a mean dose of 2.24 mg/kg/day, two cbiidren sbowed x ray findings suggestive cf prematuri epipbyseai ciosure. Tbe skeietal effects of muitipie Accutane treatment courses for acne are unknown. Vision hnpaliment:

become pregnant while uudergolug treatment. Altbougb not every letus exposed to Accutauebas resulted in a
deformed cnild, there is an extremely high risk that a deformed infant can result if pregnancy occurs while

Visual problems shouid be carefully monitored. Ail patients experencing visuai difficulties sbould discontinue Accutane treatment and bave an opbthalmologicai examination. (iimea/Opaones.Corneai opacities bave occurred in patients receiving Accutane for acne and more frequentiy wben biglier drug dosages were used in patients with disorders of keratnization. The comeai opacities that bave been observed in clinical tnai patients have either compietely resolved or were resolving at follow-

taking Accutane in anyameunt even for short periods of time. Potentially eny fetus exposed during pregnarwy
can be affected. Presently, tiiere are no accurate means of detetmining after Accutane exposure wbich fetus IHE been affected and wbicb fetus bas not been affected. Accutane is contraindicated in females of cbildbearing potential unless the patient meets all of tf>e following conditions: ^K * must bave severe disfiguring nodular acne tbat is recalcitrant to standard tberapies (see

up 5 to 7 weeks after discontinuation of tbe drug (see AOVEPSE REACTIONS). Decrease!!Nigm Vision: Decreased night vision
has been reported during t h e r ^ y and in some instances has persisted after therapy was discontinued Because tlie onset in some patients was sudden, patients shouid be advised of this potentiai probiem and warned to be cautKnis wben driving or

^ n t ^ ^ ^ ^ J v 1 | iw J^M V ^ ^ ^

fNDICATIONS AND USAGE section for definition)

* musl be reliable in understanding and carrying eut instructiens must be capable of complying w i t b tbe mandatory contraceptive measures required fer Accutane tfierapy and understand behaviors asseciated w i t h an increased risk e( pregnancy Q M ) bavaracelvedboth oial and w i i t t e n warnings of the t i a i a i d s ef taking Accutane during pregnancy and exposing] s fetus t o tbe drug * must bave received Oeth orsi and written informationon the types ef centraceptive mettieds and warnings about tbe rates of possible contraceptive failure, and ef tbe need to use twe

operating any vehicle at nigbl. PRECAUTiONS: Information for Patients and Prescribeis: Femaies of cbiidbearing
potentiai sbouid be instructed tbat tbey must not be pregnant when tberapy is initiated, andtiiattbey stiouid use effective contraception wbiie taking Accutane and for 1 montb after Accutane bas been stopped. They sbouid also sign a consent form prior to beginning Accutane therapy. They sbouid be instructed to join the Accutane Suivey and 10 review the patient videotape provided by Rocbe to ttie prescriber tbat provides information about contraception, the most common reasons tbat contraception faiis, andtiieimportance of using effective contraception wben taking teratogenic drugs. Femaie patients sbould aiso be seen montiiiy and bave a urine or senim preg-

nancy test performed eacb montb during treatment to confirm negative pregnancy status (see boxed CONTRAiNDiCATiONS AND WARNINGS). Patients must not share Accutane witb anyone else because of the risk of birth

separate, effective forms of contraception simultaneousiy, uniess abstinence is tbe chosen method, er the patient has undergonea hysterectomy and basacknowiedged In writing her understanding of tbe information
and warnings and of tbe need for using t w o contraceptive metbods simuttaneousiy must bave bad a negative urine or serum pregnancy test witb a sensitivity of at least 50 mlU/mL wben tbe patient is quaiified for Accutane therapy by the prescriber, and must bave bad a second negative urine er serum pregnancy test on the second day of the next normai menstrual period or at least 11 days after the last

defects and other serious adverse events. Patients sbouid not donate bloodduring therapy and for 1 montb foliowing discontinuance of the drug because the bkiod might be given to a pregnant woman whose fetus must not be exposed to Accutane. Transient exacerbation (fiare) of acne has been seen, generaiiy during the initiai period of therapy. Wax epilation and skin

resurfacing procedures (suoh as dermabrasion, iaser) shouid be avoided duing tberapy and for at ieast 6 montbs thereafter
due to the possibiiity of scarring (see ACVERSEREACTIONS). Patients shouid avoid prolonged exposure to U rays or sunlight. V

Patientsmay experience decreased tolerance to contact lenses during and after therapy. Approximately 16% of patients
treated with Accutane in a ciinicai trial developed muscuioskeletal syinptoins (including arthralgia) during treatment. In general, these symptoms were mild to moderate, but occasionally required discontinuation of tbe dnjg. TraiBient pain in ttie chest bas been reported less frequently. In a ciinicai trial, Biese symptoms generally cleared rapidly after discontinuation of Accutane. but in sortie cases persisted Neutropenia and rarecasesofagranulocytosis have been reported. Accutane should be discontinued if clinically significant decreases in white cell counts occur. //ip^sens/ffi^.'Anaphylactk: reactions and other allergic reacticns have been reported. Cutaneous allergic reactions and serious cases of aliergic vascuiitis, often with purpura (bruises and red patches) of the extremities and extraoutaneous invoivement (indiiding renS) bave been reported. Severe aier-

unprotected act of sexual intercourse, whidiever is iater

must understand and agree that her prescriber w iii Issue h e r a prescription ter Accutane only after she has had negative results for t w o pregnancy tests as desribed above must have received Instmctlon t o join the Accutane Survey and have vuatched a videotape, previded by Rocbe t o tier prescriber, that provides intornutlon atieut contraceptive metbeds, pessibie reasons for contra-

ceptive bllure, and importance of using effective cantraceptien wben taking teratogenic drugs.
Major human fetal abnormalities related to Accutane administration bave been documented: CNS abnormaiitles (Induding cerebral abnormalities, cerebellar malformation, hydrecepbaius, microcepbaiy, craniai netve deflcn); skull abnormality; external ear abnonnalities (including anetia, micropmna, smail m absent external auditory canals); eye abnermaiities (including micropbtbaimia); cardievascular abnormalities; faclai dysmor-

glc reaction may necesitate interruption of Iherapy and appropriate medical management. Drug Interactions: Because of the relationship of Accutane to vitamin A, patients shouid be advised against taking vitamin suppiements containing vitamin A to
avoid additive toxic effects Concomitant treatment with Accutane and tetracydines sbouid be avoided. Microdosed proges-

phla; cleft palate; tbymus gland abnormality; parathyroid hormone deficiency, in some cases death has
occurred w i t h certain of tbe abnormalities previeusly noted. Cases of IQ scores less tban 85 witb or witbout obvious CNS abnermaiities bave also been reported. Tbere is an increased risk of spontaneous abortion. In addition, premature births have been repeated, it is strongiy recommended tbat a prescription for Accutane

terone preparations (minipills) may be an inadequate meHiod of contraception during therapy, it is not known if other bormonal contraceptive dnjgs differ in their effectiveness when used with Accutane. Laboratory Tests: Pregnancy Test: Female patients of cbildbeaiing potentiai must have negative resuits from two urine or seium pregnancy tests witb a sensitivity of at

least 60 mlU/mL before a prescription is given Tbe first test is to be performed at tbe office visit when tbe paSent is qualified
for tberapy by her prescribet. The second test is te be performed on the second day of her next menstrual cycle or ^ 1 days after her last unprotected act of sexuai intercourse, whichever is iater. Additionai pregnaicy tests are to be conducted

should not be issued by tbe prescriber untii a femaie patient bas bad negative resuits from two urine or serum
pregnancy tests, as desribed abeve. It is also recommended that pregnancy testing and counseiing about contraception and behaviors associated w i t h an increased risk of pregnancy be repeated montbiy. in addition, the prescriber sbould prescribe ne more than a 1 -mentb suppiy of tbe diug for ali Accutane patients and no a u t o m a t i c refills should be permitted. Roche w i l l supply urine pregnancy test k i t s for femaie Accutane patients for the Initial, secondary, and mentiily testing during therapy. Effective contraception must be used for at least 1 montb before beginning Accutane tberapy, duringtiierapy,and fer 1 mentb foilewing discontinu-

monthly durirtg treatment. Upids: Pretreatment and foliow-up biood iipids should be obtained under fasting conditions, at
least 36 bours after consumption ef alcobol. These tests sbouid be performed at weekly or biweekiy intervals untii tbe lipid response to Accutane is established (see VWBNINGS) Liver Function Tests: Pretreatment and foliow-up liver function tests should be pertormed at weekly or biweekly interv^s untii the response te Accutane has been estabiistffid (see WARNifJGS). Glucose: Some pafients bave experienced problems in the controi ef their biood sugar, in addition, new cases of diabetes have tieen diagnosed during Accutane therapy, aithough no causai relationship has been estabiislted. CPK: Some patients undergoing vigorous pbysicai activity bave experienced eievated CPk levels: however, the clinical ^gnificance is unkncwn. Caranogenesa, MutegenesJs a/KJIinpa'nnejTfirffflffi/rtK. The Ames test was conducted wiUi isctretinoin in two laboratories. The resuits of tbe tests in one laboratoiy were negative whiie in the second i^joratory a weakly positive response (less than 1.6 X background) was noted in S. lyphimurium TAIOO wben tbe assay was conducted with metabolic activation. No doseresponse effect was seen and all otfier strains were negative. Additionaiiy, other tests designed to assess genotoxicity were all negative, in rats, no adverse effects on gonadal function, fertility, conception rate, gestation or parturition were obseived

ation of tberapy even wDere there bas been a bistory ef infertiiity, uniess due te hysterectemy. The patient must be counseled about and understand tbe limitations ef any cbosen centraceptive nwtbod. The patient
must also understand tbe risks associated witb not using t w o contraceptive metbods, even wben one of tbe

cbosen metbods is a bormonal contraceptive method. Any birtb control metbed can fail. Tberefore, it is criticaiiy Important tbat women ot childbearing potential use t w e effective forms of contraception simultaneously, unless abSDiute abstinence is the chosen method, even when one ef the forms is a hormonal contraceptive method. Although hermonai contraceptives are highly effective, there have been reports of pregnancy from women wfie bave used oral contraceptives, as well as injectabie/implantable cortraceptive products. Tbese reperts are mere frequent for women wbo use oniy a singie metbod of contraception, ft is not known if bormonal contraceptives differ i n tbeir affectiveness wtien used w i t i i Accutane. if a pregnancy does occur duiing

"

and patient shoukl discuss the desirability of continumg the pregnancy. Prescribers
aii cases of pregnancy w i t i i specific information about the contraceptive forms used

isotretinoin for appmximateiy 30 weeks at dosages of 20 or 60 m'g*g/day. In generai, ttiere was microscopic evidence for
appreciabie depression of spermatogenesis but some sperm were observed in ali testes examined and in no instance were completely a!ro|*ic tubuies seen, in studies of 66 men, 30 of wbom were patients witb nodular acne under treatment witb oral isotretinoin, no significant changes were noted m the count or motility of spermatozoa in the ejaculate, in a study of 50

therapy and for 1 montb foiiowingtiierapy,eitber to tbe Rocbe Medical Services 31-800-5ZG6367or to tbe Food and Drug Administration MedWatcb Program @ 1-800-F0A-1088. Accutane should be pres c r i b e d oniy by p r e s c r i b e r s w b o have speciai c o m p e t e n c e in tbe diagnosis and t r e a t m e n t ef severe

recaicitrant noduiar acne, are experienced intiie use of systemic retinoids, and understand tbe risK of teratogenicity if AcQutane is used during pregnancy. PrescriUers wbc prescribe Accutane sbeuld use tbe Pregnancy Prevention Program" kit provided by Roche fortiiecounseiing of patients, sbeuld instruct the patient t o par-

men (ages 17 to 32 years) receiving Accutane therapy for nodular acne, no significant effects virere seen on ejaculate volume, sperm count, total sperm motility, morpboiogy or seminai plasma fructose. Pregnancy: Category X. See boxed CONTRAINDiCATIOHS AND WARNINGS. Nursing Mothers: Nursing mothers sbouid not receive Accutane because it is not
hiiown it tbe dnig IS excreted in human milk. ADVERSE REACT1DNS: Ciinicai Trials and PostmarketHig Surveilianee: Tbe

ticipate in the Accutane Survey, and sbouid receive medicai education sponsored by Roctie about effective
contraception, the limitatiens ef contraceptive metiiods and bebaviors associated witb an increased risk of

adverse reactions listed bekiw refiect the experience from investigationai studies, and the pcstmarketing experience. The
reiationsnip of some of tbese events to ttierapy is unknown Many of the side effects and adverse reactons seen in patients receiving Accutane are similar to tbose described in patients taking very bigh doses of vitamin A (dryness of tbe skin and mucous memtiranes, eg, of tbe ilps, nasal passage, and eyes),flowR8/aliens/iv7.-Cbeiiitis and bypertriglyceridemia are usuaiiy dose related. Mcst adverse reactions reported in ciinicai tiiais were reversible wben tbempy was discontinued; however,

contraceptive failure and pregnancy.

INDICATIONS ANO USAGE: Indicated for ths treatment of sev

lesions witb a diameter cf 5 mm or greater. The noduies may be

some persisted after cessation of therapy (see WARNiMSS and ADVERSE REACTIONS). Body as a Whole: ^iergic reactions,

including vascuiitis, systemk; bypersensitivity (see PRECAUT1CMS), edema, fatigue, iymphadenopathy, weight ioss. Canliose effecl
Kl witb its vascutar: paipitation, tacbycardia, vascular tbrembotic disease, stroke. Endocrine/UetaDoiic: hypertrjglyceridemia (see

ns "many" as opposed to "few or several" nodules. Because

Accutane should be reserved fnr natisnlF! witfi jgverg noduiar acne w f a are unresponsive to conventional therapy. incluJinq

svaemic antibiotics. In addition for femaie patientsofchiidbearing potential, Accutane is indicated oniy for those females
wbo are not pregnant (see boxed CDNTRAiNDiCATIONS AND WAHNINGS). CONTKAINDiCATIOflS: Pregnancy: Category X. Sae boxed CONTIMINDICATIONSMD WARNINGS. Aliergic Heactions; Ointi^indicated in patients who are hypersen^ v e to this medicatien or to any of its components. Sbouid not be given to patients viho are sensitive to parabens (see

WARNiNGSA alterations in blood sugar levels (see PflECAUTIONSJ. Gastrointestinal: inflammatory bowel disease (see WARNINGSJ. bepatitis (see WARNINGS;, pancreatitis (see WARfJIMGS], bleeding and Inf iammation of tbe gums, coiitis, ileite. nausea,
other nonspecific gastrointestinai symptoms Hetnatologic' aiiergic reactions (see PRECAUTiONS), anemia, thrombocyto-

oenia, neutropenia, rare reports of agranuiocytosis (see PRECAUTIONS). See PRECAUTIONS: LaDoratory Tests for otber bematoiogical parameters. MuscutosteteB(. skeletal hyperostosis, calcification of tendons and ligaments, premature epiphyseai ciosure (see WAflNiUGS), miid to moderate musculoskeietai symptoms including arthralgia (see PRECAUTiONS pain in the chest (see PRECAUTIONS), elevations of CPK (see PRECAUTIONS), artbritis, tendonitis, other type ra n n

PRECAUTIONS). WARNINGS: Psychiatric Disorders: Accutane may cause depression, psycbesis and, rarely, suicidal ideatien, suicide attempts and suicide. Discontinuation of Accutane tberapy may be insufficient: furtber evaiuation may be necessary. No mecbanism ef action bas been establisfied fer these events (see ADVERSE
flEACTiONS: PaydiiBlric). Pseudotunwr Cerebrt: Accutane use bas been associated witb a number of cases of

abnormalities. Neurological: pxuiMimar

cerebri (see WAflNiNGS), dizziness, drowsiness, beadacbe n m

da dea on p e atfemp rted pa ts

tiiarg

maiaise, nervousness, parestfresias, seizures, stroke, syncope, weakness. Psychiatn suicifle,depression,psychosis(seeWARNiNGS),emotionaiinstab t y O f t i i

pEeudotuinor cerebri (benign intracranial hypertension) seme of wbich invoived concomitant use of tetracyciines. Conccmttant treatment w i t h tet a c y d nes bo d be e o e b e a o d e d Ea y a and omtn and gns and symptoms ef a disturbances. Patients pseudotumor eerebri Include papilledema fieadacbe na

that tbe depression subsided with discontnuation of therapy and

ed

mmediately and be refer tis:tie\ita panereatttis ba p f p o n ma run instances, tatalbemorrhaglc pancreatitis has been eported Ac ces, tatalbemorrhaglc ane c be opped ypertrigiyceridemia cannot be contrciied at an acceptable level or if symptoms of pancreatitis occur. bpiOs: Eieuations of serum trigiycerides baue d
been r ^ r t e d . Marked elevations of serum trigiycetides in excess of B O mg/dL were reported in approximateiy 35% of O

)
giyceride levels In rare

tem: abnormal menses. Respiratory: broncbospasms (witii or witbOL alteration. SWnaniJ/iiCpejTdages.acnefuiminans.alopecia(wbic m ca

mouth, dry nose, dry skin, epistaxis, eruptive xantfiomas, fiushing fraq ty b p

o dry pe a

pigmentation and hypopigmentation, infections (inciudingdissem a ed ing of paims and soies, pbotoailergic/pbotosensitizing reaction p

rp n n n n

living Acci about 7% sbowed an increase in cholesterol le

reversibie upon cessation of therapy. Some pa

-deveioped a decrease in high-density iipoproteins and HDL. ai cticn m weight,

granuiomastosis: see PRECAUTiOf^S), abncrmai wound healing (delayed healing or exuberant granulation tissue with

restriction ef dietary fat and alcoboi. and reduct

performed tiefore Accutane is given and then Especially careful consideration must be g

crusting: see PRECAUTiONS). Speciai Senses: Hearing, hearing impairment (see WARNiNGS), tinnitus. Vision: corneal opacities (see WAFINifJGSJ, decreased night vision wbich may persist (see WARNINGS), cataracts, color vision disorder, conjunctivitis, dry eyes eye lid inflammation, keratitis, ontic neuritis, photophobia, visual disturbances. Urinary System:
giomerulonepbritis (see PRECAUTiONS), nonspecific urogenitai findings (see PRECAUTiONS: LaDoratoiy Testsfor other

metaboiism disorder orfamiiiai History of iipidnof serurn values for lipi[ts and/or biood sugar a
hypertrigiyceridamia associated with ACCL i

ed, morefrequentchecks
uia' consequences ot
3 or 33 mg/kg/day of

urological parameters). Laboratory: Elevation of plasma trigiycerides (see WARNlNGSj, decrease in serum high-density iipoprotein (HDL) ieveis, elevations of serum cholesterol during treatment. Increased alkaline phosphatase. SGOT (ASTI,
SGPT (ALT), GGTP or LDH (see WARNINGS). Eievation of fasting b(ood sugar, elevations of CPK (see PRECAUTICNS), hyperuricemia. Decreases in red blood celi parameters, decreases in white blood ceii counts (including severe neutropenia and rare

isotretinoin for 18 months or ionger, the incide cif icaton of coronary, pulmonary and mesent
than in controi rats of similar age. Focai endoca nary arteries were obseived in two dogs after a|

of the myocardium, calric mucosa were greater ^itit f th ..- bee ported npatie akin A cutane: in some cases,

reports of agranuiocytosis: see PRECAUTIONS), eievated sedimentation rates, eievated platelet counts, thrombocytopenia. White ceiis in the urine. pnMeinuria, microscopic or gross bematuria. OVERDDSAGE The oral LOM of isotretinoin is greater than
4000 mg/kg in rats and mice and is approximateiy 1960 mg1(g in rabbits, in bumans. overdosage bas been associated with vomiting, faciai lushing, cheilosis, abdominai pain, headache, diiiiness. and ataxia All symptoms quickly resoived witiiout

- .-

i y . Hearing.--. .

Die hearing Impairment has been reported to persist after Qierapy has been discontinued. Mechanism(s) and causaiity for this event have not been estabiished. Patients wbo experience persistenttinnitusor hearing impairment shouid discontnue treatment and be refeired to specialized care for furttier evaluation (see ADVERSE REACTIONS). Hepatotoxicity: Clinical hepatitis considered to be possibly or probably related to therapy has been reported. Additionally, mild to moderate elevations of iiver enzymes have been observed in approximately 15% of individuals treated during clinical trials, some of which nomialized witii dosage reduction or continued administration of the drug. If normalization does not readily occur or if bepatitis IS suspected during treatment, ttie drug should be discontinued and the etiofogy further investigated. InHammaloiy Soiw/Disease Acculane has been associated with inflammatory bov^el disease (Including regional iieitis) in patients VJithout a prior history of intestinal disorders In some instances, symptoms have been reported te persist after treatment bas been stopped. Patients e:rperiencing abdominai pain, rectai bleeding orsevere diarrhea should discontinue Accutane immediately (see ADVERSE REACTIONS) Skeletal: H^perostosis. A bigh prevaience of skeietal bypenjstosis was noted in clinical trials for disorders of keratinizatiDn with a mean dose of 2.24 mg/kg/day. Additionaiiy, Weietai hypenjstosis was noted in 6 of 8 patients in a prospective study of disorders of keratinlzation. Minimai skeletal hyperostcsis and caicification of ligaments and tendons have aiso been observed by x-ray in prospective stiidies of noduiar acne patients treated witb a single oourse oftiieiapyat recommended doses. Tiie skeietal effects of multiple Accutane treatment courses for acne are unknown. Piemature^/prtysea/Oosu/e. There are spontaneous reports of premature epiphyseai closure in acne patients

Pharmaceuticals
Roche Laboratories Inc. 340 Kingsland Street Nutley. New Jersey 07110-119;

Table 1 . A Comparison ef Assertive, Passive, and Aggressive Communication

Assertive (Win-Win) High self-esteem Risk taker Self-expressive Honest, straightforward, and tactful Respectful Effective communicator Nonthreatening body language, such as eye contact, arms at side, normal tone voice Takes responsibility for own feelings. thoughts, and behaviors Passive (Lose-Win) Low self-esteem Puts others needs ahead of own Indirect Emotionaliy dishonest Self-denying Inhibited Lack of self-respect Takes responsibility for others feelings, thoughts, and behaviors Self-depreciating Aggressive (Win-Lose) Low self-esteem (even though this individual seems to have high selfesteem) Tactless Self-enhancing Derogatory Embarrassing Intimidating Righteous Controlling Loud Threatening Disrespectful Blames others for own feelings, thoughts, and behaviors Needs met at the expense of others

Creative Stress-Management
continued from page 32

and a willingness to compromise when appropriate (Antai-Otong, 1995; 1997; Burley-AUen, 1995; Johnson, 1992). They are confident, risk takers, straightforward, and tactfijlly honest and direct (see Table 1). Sometimes this is difficult because when we are stressed and angry, we allow our emotions to control our intellect and respond accordingly, usually aggressively. Deep-breathing exercises, visual imagery, and autogenic relaxation are useful in reducing stress responses and angry reactions (see Table 2). The most effective way to learn and understand assertive communication is to compare it to passive and aggressive communication (see Table 1). Developing and using assertive communication skills challenges nurses to practice using four steps using the following scenario: One of your co-workers has been coming to work late for about 2 days and as a result you have paid your babysitter $15.00 extra per day. You are pretty upset, yet you have gotten your emotions under control and you approach your co-worker using nonthreatening body language: 1. Use "I" or "me" statements

(reflects taking responsibility for one's feelings, thoughts, and behaviors ) ("Monte, I am really upset"...). 2. Clearly, describe the behavior that bothers or upsets you and focus on the present (separates the behavior from the individual and reduces defensiveness and argumentiveness) (..."because over the past few days you have been coming to work late"...). 3. Discuss the consequences of the behavior ("and as a result I have had to pay my babysitter $15.00/day"). 4. Prescribe the behavior ("I would really appreciate if you would come to work on time"). This scenario is one example of using assertive communication. Obviously, the co-worker (Monte) may become upset and storm out of the room, but at least an opportunity to resolve this particular conflict was available. Assertive communication requires practice and more practice. Practice or role playing stressful situations is less threatening when tried at home with family members and even rehearsed in front of a mirror to examine one's body language. Overall, assertive communication requires getting your "emotions" under control and using your "intellect" to resolve problems. A failure to respond assertively often results in passive or aggressive responses, both

of which are nonproductive. Passive people tend to "swallow" their anger and eventually "blow up" or lose their temper and behave inappropriately or develop prolonged stressrelated disorders. Aggressive people may have great messages, but because of their intimidating stance, no one listens. Ultimately, assertive communication enables nurses to express their feelings and thoughts effectively, reduce their stress, and form meaningful interpersonal relationships. Other important skills that require assertive communication include anger and conflict management.

Anger Management
Anger management, like assertive communication, is an important stress-reduction skill. Anger is a normal and important emotion. However, it can produce deleterious effects because unless it has a valid basis it can lead to emotional overload. Emotional overload occurs when anger is unconstrained resulting in soaring tension and irrational behaviors. Anger often covers up other feelings, such as fear, embarrassment, guilt, powerlessness, and helplessness. The initial step in anger management is getting it under control. This process begins by recognizing when it
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DERMATOLOGY NURSING/February 2001/Vol. 13/No.i

Table 2. Stress Buster Toolkit

Techniq 1. Deep abdominal breathing exercises How-To 1. Estabiisii a cotnfortabie standing position (ciose eyes and practice x 10 cycies). Hang arms iooseiy. Maintain good posture. Hoid up head and even it with neci<. Siowiy exhaie through mouth; mai<e sure chest taiis. inhaie siowiy through mouth as abdomen eniarges. Pay attention to changes in mentai state. 2. Adopt the right attitude and concentrate. Reiax and prepare mind. Concentrate in preparation tor tocused attention and siow down thinking processes. Focus on an internal or external topic. 3. Use deep-breathing exercises. Focus on your breathing. Fxhaie toiiowing a deep inhaie. Hoid your breath (shortiy). During exhaiation teii your whoie body to RELAX. 4. Preparation inciudes using deep-breathing exercises to reiax ahd visuaiizing a serene tranquii scene (tor exampie, iying on the beach). How does it teel to iie on the beach? Snieii and taste the saity ocean water as it sprays on your face. Feei the heat on your face. Hear the sea guiis atar and chiidrsn piaying. Hear the ocean hitting the shore banks. Visuaiize for 2-3 minutes. Purpose 1. These exercises counter rapid and shallow breathing associated with stressfui reactions. Controiiing breathing for several minutes is an effective way to relax.

2. Focusing

2. Concentration or focusing enables you to be totaiiy present with someone without being deraiied by distractions.

3. Deep breatiiing for stress reduction tor rapid recovery

3. Same as #1.

4. Visualization or imagery

4. This sort of daydreaming exercise provides a whoie body escape using a scene to promote reiaxation.

5. isometric squeeze exercise

5. Whiie keeping the body ioose and reiaxed, gingeriy squeeze your shouiders upward and in unison. Tiit your fiead back to iielp shrug your shoulder and neck muscles in unison. Squeeze them together, massaging your back and pressing out the tension. Squeeze for 5-10 seconds. Reiax. Hang your shouiders fo ailow the tension to dissipate and drift away for 30 seconds. 6. A ciear mentai image or passive concentration of fhe specific body part (the heaviness series). Ciose eyes and relax. Visuaiize or touch the area of interest. Siientiy repeating "my right arm is heavy or warm," etc. Eventuaiiy physioiogicai responses occur, such as tingiing or teeiing lighter Do not expect anything and ailow body to relax. Termination process invoives fiexing the body part, taking a deep breath and opening eyes. (Linden, 1993)

5. Promotes relaxation and reduces tension in shouider and nape of neck (can be used in other muscie groups and invoive tension and reiaxation techniques).

6. Autogenic or "seif-reguiating" reiaxation

6. Provides an opportunity to get in touch with physicai and mentai seif. These techniques also combine the receptive state with seit-suggestion that reduces physioiogicai stress reactions. The word "heaviness" is useful because it is generally associated with reiaxation. (Linden, 1993)

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occurs. Symptoms of anger are liken to those of acute stress reactions and include racing and pounding heart, increased respirations, diaphoresis, muscle tension, and restlessness. These reactions often arise from negative self-talk or mental dialogue, such as "she is trying to embarrass and humiliate me" or "he is challenging my judgment and decision making." The second step in anger management includes "taking a time out." Time outs t^e not just for kids, particularly when adults yeH, pout, throw things, or slam doors. These are certainly not "adult" behaviors are they? Time outs enable nurses to get away from the stressful situation and gain control over their anger. Ordincuily, getting one's anger under control requires getting one's physical responses under control. The third step, taking 10 slow deep breaths is the most effective way to accomplish this task. By using deep abdominal breathing, the heart rate and respirations are reduced and controlled along with other physical responses. More significantly, this time out period allows nurses to reappreuse the situation and respond intellectually rather than emotionally. Reappraising one's anger is the final step of anger management. An important question to entertain during this period is "what am I am angry about and why have I responded so intensely?" If the anger is justified, go back to the individual and use assertive communication skills to resolve the conflict. Otherwise, forget it and let it go. I-tting go of one's anger is an enormous pursuit for most people, and it must be a conscious decision that frees up energy to focus on other important life issues. Deep abdominal breathing exercises, isometric squeeze exercises, and visual imagery are helpful in reducing the physical reactions of anger and facilitating the cognizant decision to let go (see Table 2).

Table 3. Examples of Physical Renewing Activities

Regular exercise program Isometric squeeze relaxation exercises (see Table 2) Roller skating/blading Balanced diet Daily lunch breaks away from the work station Annual vacafions for at least 1 week Permission to take a "menfal health day" (do nof abuse) Annual physical examinations including preventive screening (mammograms, cholesterol, glaucoma, pap smears, prostate exams, colonoscopy) Monfhiy self-breast exams Adequate resf and sleep (8 hours of sleep) Complianoe with medical regimens, including medicafions, diet, stress, exeroise Regular denfal examinations

Conflict Management
Conflicts are a natural part of relationships. They often reflect a difference of opinion stemming from vast factors, including belief and value system, culture, gender, and stress. How one responds to conflicts parallels one's appraisal of the situation as either a liireat or challenge.

Conflicts are fortuitous and enable nurses to sharpen their problem-solving skills and enrich their interpersonal relationships. Ideally, nurses should handle conflicts at the lowest level. For instance, rather than bringing in a third party, initially attempt to deal with the individual. This approach also frees up the supervisor for more important issues. This strategy also fosters trust and healthy and meaningful interpersonal relationships. Major steps in conflict management include: (a) identify the problem, (b) express feelings freely, (c) explore options, and (d) evaluate the results. Unfortunately, sometimes the parties are unable to resolve the conflict and require a third party, such as supervisor, to facilitate resolution. Overall, conflict resolution provides opportunities for problem solving and personal growth. It enhances understanding and appreciation of diverse perspectives and enriches interpersonal relationships. During a time when most people communicate via e-mail and other impersonal contacts, conflict management provides a forum for personal contact and healthy mental sparring. In brief, developing and using these important communication skills provides the mental, emotional, physical, and spiritual freedom to participate in daily self-renewal activities. Self-renewal activities wiU bring stress management to a full circle (see Table 2).

Self-Renewal
Self-renewal includes personal holistic health-promoting activities that foster a state of well-being and stress management. Sometimes busy schedules and "no time to do anything" prevents nurses from taking the time to engage in health-promoting and disease-preventing activities. The concept of self-renewal challenges this premise and stresses the importance of self-care as a priority for today's nurses. Self-renewal activities are the core of stress management. Moreover, stress management activities require valuing and respecting oneself and a belief that life is basically what people make of it. It also necessitates getting rid of negative self-talk and making a conscious decision to feel good about oneself and others despite real and potential life adversities. Self-renewal also requires taking responsibility for one's feelings, Oioughts, and behaviors negative or positive and an openness to appreciate life's basic gifts. Basic components of self-renewal activities include physical, psychological, mental, social, and spiritual. Physical renewing activities include those that promote endurance, stamina, and energy. They include doing things that reduce stress and promote an overall sense of well-being. Examples of physical renewing activities are listed in Table 3.

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