Table 1.

Overview of stress management strategies4,5,11-14,16

Stress management strategy	Description and explanation of strategy	Guidance or instructions for NPs	Strategy benefits
Breathing techniques	The patient breathes slowly and deeply to focus their thoughts solely on inhaling, taking a pause, and exhaling. By breathing in a very focused and controlled manner, the patient can distract their mind from negative thoughts, reduce their respiratory and pulse rates, and increase their oxygenation.	Diaphragmatic breathing: Ask the patient to inhale slowly through their nose, allowing air to fill the upper then lower lobes of their lungs by contracting the diaphragm downward and causing the abdomen to expand and rise. Then, have the patient hold their breath for a few seconds. Finally, ask the patient to control their exhalation of air slowly through their mouth, allowing the diaphragm to relax upwards and the abdomen to return to its resting state. Four-square (or box) breathing: Advise the patient to inhale slowly through the nose to the count of 4 seconds, hold their breath to the count of 4 seconds, slowly exhale through their mouth to the count of 4 seconds, and rest for a count of 4 seconds. Repeat the cycle.	Reduces pulse rate Lowers BP Reduces muscle tension Reduces cortisol levels
Guided imagery	The patient experiences an imaginary environment that they feel is a relaxing setting as well as the accompanying sensations of the imagined environment. Guided imagery is performed by using soothing words, providing detailed explanations of restful settings, and discussing sensations they would experience to allow for full engagement, helping to achieve relaxation of the patient's mind and body.	Ask the patient to close their eyes and focus on taking slow, deep breaths. Then, in a soft voice, describe a step-by-step journey into an imaginary relaxing environment, such as walking on a beach, strolling around a flower garden, or fishing at a lake. Engage all the patient's senses in the imaginary scene to promote a feeling of relaxation during a healthcare visit, test, or procedure. Spend the amount of time that is needed or is possible to guide the patient through the imagined setting.	Reduces symptoms related to the activation of the SNS Activates the PNS
Mindfulness and meditation	The patient experiences detached awareness while observing their surroundings. They focus on being objective about their experience and fully present while performing an easy everyday activity, such as walking, eating, or drinking. This distracts the patient's mind from stressful thoughts as they fully engage in the present moment by experiencing the sensations of the activity.	Encourage the patient to be fully present by experiencing and focusing on all their senses during a daily activity, such as slowly walking, eating, or drinking. Advise the patient to experience this activity in a focused but objective manner with no associated judgment.	Reduces pain Promotes a feeling of peacefulness Fosters feelings of transcendence Reduces SNS arousal Enhances PNS engagement
Laughter and humor	When laughing or engaged in humor, the patient experiences a eustress stimulus, which produces a positive emotion. Laughter creates a physical response that exercises the facial and abdominal muscles, which causes the patient to take deeper breaths and reduces stress-related hormone levels.	There are a variety of humor types and numerous ways to engage patients in laughter. Some examples include keeping a notebook with a variety of funny cartoons (intended to suit different humor types) to share with patients; keeping some short funny videos on a laptop or cell phone to share with patients; keeping a journal with a variety of jokes; and engaging patients with one's natural wit. For all suggestions, be sure to use humor that is not offensive to others.	Decreases feelings of anger and fear Exercises the muscles, then helps enhance relaxation of muscles after laughter is over Increases tolerance to pain Reduces levels of stress hormones Stimulates blood circulation Elevates mood Increases pleasure in life Improves relationships Provides feelings of connection with others Reduces negative thoughts

Abbreviations: PNS, parasympathetic nervous system; SNS, sympathetic nervous system.