Anxiety

Anxiety

NANDA Definition

Anxiety is a vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat.

Discussion of the Problem

Anxiety is a common reaction to stress. It is experienced at conscious, subconscious, or unconscious level. Anxiety is probably present at some point in every person, but its degree and frequency of its manifestation differs. Some people are capable of using the emotional rim that anxiety provokes to inspire creativity or problem-solving abilities, while others can become immobilized to a pathological degree. It is categorized in four levels namely: mild, moderate, severe, and panic. Medical and surgical conditions that could trigger anxiety as follows: angina, myocardial infarction, lung cancer, ventilatory assistance, ruptured intervertebral disc, gastrectomy, peritonitis, tyrotoxicosis, renal dialysis, BPH, mastectomy, burns, transplantation, phychosocial conditions, surgical interventions, cancer, and disaster situations. The presence of the nurse may provide support to an anxious patient and offer some strategies for traversing anxious moments or panic attacks.

Nursing Interventions Classification (NIC)

• Anxiety Reduction
• Presence
• Calming Technique
• Emotional Support

Nursing Outcomes Classification (NOC)

• Anxiety or Fear Control
• Coping

Goal and Objectives

• Patient may describe a decrease in the level of anxiety experienced.
• Patient will acknowledge and discuss fears or concerns
• Patient will appear calmed and relaxed
• Patient will be able to identify or recognize feelings and signs of anxiety.
• Patient will demonstrate problem-solving skills and behaviors to cope with current situations.
• Patient will identify or use available resources appropriately
• Patient will identify possible causes or contributing factors to the current situation
• Patient will report beginning the use of individually appropriate coping strategies.
• Patient will use available resources or support systems effectively.
• Patient will verbalize or communicate awareness of feelings and healthy ways to deal with them

Subjective and Objective Data

• Physiological:

Ø  Anger and irritability

Ø  Apprehension, increased tension, restlessness

Ø  Dizziness, light-headedness

Ø  Dry mouth

Ø  Dyspnea

Ø  Feelings of helplessness and discomfort

Ø  Flushing

Ø  Frequent urination

Ø  Headaches

Ø  Hypervigilance; overexcited

Ø  Impaired functioning; verbal expressions of having no control or influence over situation, outcome, or self-care

Ø  Increase in blood pressure, pulse, and respirations

Ø  Increased muscle/facial tension

Ø  Insomnia, nightmares

Ø  Nausea and/or diarrhea

Ø  Pacing

Ø  Palpitations

Ø  Perspiration

Ø  Pupil dilation

Ø  Restlessness

Ø  Somatic complaints/sympathetic stimulation; extraneous movements (restlessness, foot shuffling, hand/arm fidgeting, rocking movements)

Ø  Trembling

• Behavioral:

Ø  Apprehension, uncertainty, restlessness, worry, sense of impending doom

Ø  Association of diagnosis with loss of healthy body image, loss of place/influence

Ø  Crying

Ø  Difficulty concentrating

Ø  Expressed concern regarding changes in life events

Ø  Expressions of denial, shock, guilt, insomnia

Ø  Expressions of helplessness

Ø  Fear of death as an imminent reality

Ø  Feelings of inadequacy

Ø  Fight (e.g., belligerent attitude) or flight behavior

Ø  Focus on self, expressions of concern about current and future events

Ø  Focus on self/negative self-talk

Ø  Inability to problem-solve

Ø  Preoccupation

Ø  Rumination

Ø  Scanning and vigilance; or lack of awareness of surroundings

Ø  Uncertainty, feelings of inadequacy

Ø  View of self as noncontributing member of family/society

Ø  Withdrawal

Related Factors

• Changes in environment and routines
• Changes in role function

·         Embarrassment/loss of dignity associated with genital exposure before, during, and after treatment; concern about sexual ability

• Interpersonal conflicts

·         Interpersonal transmission/contagion

• Intrusive diagnostic and surgical tests and procedures

·         Negative self-talk

·                   Perceived threat of death/dependency on mechanical support

• Physiological factors, hypermetabolic state

·         Sensory impairment; environmental stimuli; substance abuse; stress

·         Separation from support system(hospitalization, treatments); knowledge deficit

·         Side effects of steroids and/or cyclosporine

• Situational (hospitalization/isolation procedures, interpersonal transmission and contagion, memory of the trauma experience, threat of death and/or disfigurement) and maturational crises
• Threat or perceived threat to physical and emotional integrity
• Threat or perceived threat to self-concept (altered image/abilities; [perceived or actual] organ rejection, threat of death)
• Threat to (or change in) socioeconomic status

·         Threat to or change in health status (disease course that can lead to further compromise, debility, even death)

·         Unconscious conflict about essential values, beliefs, and goals of life

·         Underlying pathophysiological response

·         Unmet needs

Assessment (Dx)

• Monitor and document patient’s level of anxiety. Patient’s awareness and ability to identify and solve problems are enhanced by mild anxiety. While moderate anxiety limits awareness of environmental stimuli and problem solving can occur but may be more difficult, and patient may need help. In severe anxiety, patient’s ability to integrate information and solve problems decreases. With panic, the final state of anxiety, the patient is unable to follow directions and may experienced hyperactivity, agitation, and immobilization.

ANXIETY ASSESSMENT GUIDELINE Background             Anxiety disorders are not negligible – they cause as much distress and social interference as depressive disorders. It affects all ages. Thus, there is a real need for the following: early and precise identifications in all ages, differentiation from other clinical problems, and effective management. Screening Possible questions which can help with an initial evaluation of whether anxiety is present include the following: v  Have you been feeling tense or anxious lately? v  If so, please can you tell me more? v  Have you been worrying a lot about things lately? v  Have you been experiencing any unusual physical symptoms? v  What situations make the symptoms worse? v  What do you do when stressed or anxious? v  What makes the symptoms better? Levels of anxiety Level 1 Mild Anxiety increased alertness to inner feelings/environment; increased ability to learn Level 2 Moderate Anxiety concentration is focused to a specific thing; characterized by tremors and rapid speaking Level 3 Severe Anxiety ability to perceive is narrowed: characterized by inability to communicate, decreased intellectual functioning and feeling of worthlessness Level 4 Panic State ability to perceive is completely disrupted: characterized by disintegration of personality and loss of control Common signs and symptoms of anxiety disorders PHYSICAL AFFECTIVE/ EMOTIONAL COGNITIVE BEHAVIOURAL ·         appetite changes ·         chest pains ·         cold hands ·         dizziness/light-headedness ·         dry mouth ·         fatigue ·         hyperventilation ·         muscular aches/pains ·         palpitations ·         shortness of breath ·         sleep problems ·         sweating ·         tension headache ·         tremor ·         anger ·         anxiety ·         depersonalisation ·         depression ·         derealisation ·         fear ·         guilt ·         irritability ·         numbness ·         panic ·         catastrophising ·         excessive, worrying thoughts ·         fear of losing control ·         impaired concentration ·         jumping to negative conclusions ·         memory impairment ·         negative anticipation ·         negative predictions ·         self-blaming ·         thoughts of impending doom/catastrophe ·         agitation ·         avoidance ·         checking ·         drinking alcohol/substance abuse ·         escape ·         fidgeting ·         hypervigilance ·         inhibition ·         restlessness ·         safety behaviour ·         tearfulness

• Acknowledge positive behaviors indicative of beginning acceptance and/or use of effective strategies to deal with situation. Fear/anxiety will decrease as patient begins to accept/deal positively with reality.

• Establish how patient deal with anxiety. Interviewing the patient may be done to determine the effectiveness of his coping strategies.

• Explore changes in mentation and occurrence of hypervigilance, hallucinations, sleep disturbances (e.g., nightmares), agitation/apathy, disorientation, and labile affect, all of which may vary from time to time. These are signs of extreme anxiety/delirium state in which patient is literally struggling for life. Although psychologically based can be a cause, pathological life-threatening causes (e.g., shock, sepsis, hypoxia) must be ruled out.

• Monitor and document mental status, including mood/affect, understanding of events, content of thoughts and judgement, e.g., false impressions or manifestations of terror/panic. Initially, patient may use defense mechanism or coping mechanism- denial and repression- to minimize and sort out information that might be overwhelming. While some patient exhibit calm behavior and alert mental status, representing dissociation from truth or reality, which is also a defense mechanism.

• Observe behavioral cues and clues, e.g., restlessness, irritability, withdrawal, narrowed attention, lack of eye contact, demanding behavior. Indicators of level of anxiety/stress, e.g., patient may feel uncontrollable at home or work in managing personal problems. Stress may build up as a result of physical symptoms of condition and the reaction of others.

• Observe presence of aggression, withdrawal, and or denial (inappropriate refusal or rejection to comply with medical regimen).  Reinforce patients coping strategies/abilities.

• Recommend that the patient notes episodes of anxiety. Instruct patient to describe what is experienced and the events leading up to and surrounding the event. Patient should note how the anxiety starts or what triggers it. Symptoms often provide the care provider with information regarding the degree of anxiety being experienced. Physiological symptoms and/or complaints intensify as the level of anxiety increases.

• Watch for physical responses, e.g., restlessness, changes in vital signs, repetitive movements and agitation. Note for conformity of verbal/nonverbal communication. This is helpful in evaluating extent/degree of concerns, especially when compared with “verbal” comments.

Therapeutic Interventions (Tx)

• Acknowledge but do not reinforce use of denial. Avoid confrontations as much as possible. Denial can be beneficial in reducing anxiety but can delay dealing with the truth or reality of the current situation. Confrontation can promote anger and boost use of denial which eventually reduces cooperation and recovery may be delayed.

• Acknowledge patient’s awareness of anxiety. Acknowledgment of the patient’s feelings confirms the feelings and corresponds acceptance of those feelings.

• Answer all questions truthfully. Provide information that is consistent; repeat as necessary. Factual information about the situation decreases fear, builds up nurse-patient relationship, and assists patient/significant others to deal realistically with the current situation. Attention span may be short, and repetition of information aids with retention.

• As patient’s level of anxiety subsides, encourage exploration of specific events prior to both the beginning and reduction of the anxious feelings. Recognition and exploration of causative factors leading to or reducing anxious feelings are essential steps in developing alternative reactions.

• Assist the patient in developing anxiety-reducing skills (e.g., relaxation, deep breathing, positive visualization, and reassuring self-statements). Using anxiety-reduction strategies enhances patient’s sense of personal mastery and confidence.

• Assist the patient to identify or recall positive coping behaviors used in the past. Successful behaviors in the past can be reinforced in dealing with current problems/stress, enhancing patient’s sense of self-control.

• Be empathic and nonjudgmental while working with patient and family. Showing empathy and nonjudgmental attitude enhances cooperation of the patient and family.

• Familiarize patient to the environment, routine procedures, anticipated activities and new experiences or people as necessary. Encourage participation when possible. Expectedness of information can promote comfort and may lessen anxiety.

• Identify and discuss with patient and significant others the safety and standard precautions being taken, e.g., power supply backup and emergency equipment. Discuss the meanings and significant of alarm system. Provides reassurance to help allay anxiety, decrease concerns of the unknown, and preplan for response in emergency condition.

• Maintain a calm and confident behavior while interacting with patient (without false reassurance). A calm and nonthreatening atmosphere can enhance patient’s feeling of stability. Honest explanations can lessen fear and anxiety.

• Maintain matter-0f-fact approach in dealing with patient. Protect patient’s privacy. Communicates acceptance and reduces patient’s embarrassment.

• Minimize sensory stimuli by promoting a quiet environment; keep "threatening" equipment out of sight. Anxiety may be triggered by excessive conversation, noise, and equipment around the patient.

• Observe for congruency of verbal/nonverbal signs of anxiety, and stay with patient. Intervene if patient displays destructive behavior. Patients may not express concerns directly through words, but actions may suggest sense of agitation, aggression, and hostility.

• Provide adequate rest periods or uninterrupted time for sleep, quiet surroundings, with patient controlling type, and the amount of external stimuli. Conservation of energy and enhances patients coping abilities.

• Provide Therapeutic Touch, massage, and other adjunctive therapies as indicated e.g., tapping of shoulders. Helps patient in meeting basic human need, reducing sense of isolation, and assisting patient to feel less anxious. Note: Therapeutic Touch entails the nurse to have specific knowledge and experience with the use of hands correctly in order alley patient’s feeling of anxiety.

• Reassure patient that he or she is safe. If necessary, stay with the patient. The existence of a trusted person may be helpful to reduce fear/ anxiety during an attack.

• Set up a working relationship with the patient through continuity of care. A continuing relationship establishes a foundation for comfort in communicating anxious feelings.

• Utilize simple language and brief statements when teaching patient about self-care measures or about diagnostic and surgical procedures. Keep it short and simple. Attention span may be reduced, concentration lessen, limiting capacity to understand information.

• Help patient in acknowledging problem-solving capabilities.

1. Provide positive feedback when patient exhibits better ways to manage anxiety and is able to calmly and /or realistically evaluate own situation. Promotes acknowledgement and reinforcement, and enhances ability to deal with anxious feelings.
2. Provide support of normal grieving process, including time necessary for resolution. Can provide encouragement that feelings are normal response to situation or perceived alterations.
3. Refer to spiritual counselor as needed. Facing one’s mortality may aggravate feelings of anxiety and questions about one’s spiritual beliefs and practices.
4. Stress the importance of logical strategies that patient can use when experiencing anxiety. Learning to recognize a problem and evaluate alternatives to resolve it assists the patient to cope.

Education/Continuity of Care

• Assist patient in guided imagery/relaxation techniques; e.g., imaging a pleasant place, use of music/tapes, deep-breathing, meditation, and mindfulness. Reduces anxiety by promoting the release of endorphins which assists in developing internal locus of control, enhancing coping skills, and allowing body to go about its work of healing. Note: Mindfulness is a technique of being in the here and now concentrating on what is occurring at the moment.

• Demonstrate how to utilize relaxation techniques, e.g., focused breathing, progressive relaxation, and guided imagery. Provide music therapy, biofeedback as needed. This promotes active management of situation to decrease feelings of helplessness.

• Discuss to patient the proper use of medications and educate him or her to identify adverse reactions. Medication may be used if patient’s anxiety continues to rise and the feeling of anxiety becomes disabling or hindrance to activities of daily living.

• Encourage autonomy, self-care, and decision making within accepted treatment plan. Increased independence and autonomy from staff promotes self-confidence and reduces feelings of abandonment.

• Encourage patient to verbalize feelings of anxiety and assess anxiety-provoking situations if able to identify them. Helps patient in evaluating the situation realistically and recognizing causative factors to the anxious feelings. Avoid false reassurances. Establish a therapeutic and working relationship to assists patient and significant others in identifying problems causing stressful situations.

• Help patient in identifying symptoms of increasing feeling of anxiety; identify other alternatives use to prevent the anxiety from immobilizing her or him. The ability to distinguish anxiety symptoms at lower-intensity levels facilitates the patient to intervene faster to manage his or her anxiety.

• Refer the patient for psychiatric assistance if anxiety becomes disabling to activities of daily living. May need additional support in regaining control and coping with acute and chronic episodes/exacerbations and consequences of the disease and therapeutic regimen.

• Reiterate to patient that mild anxiety level can encourage growth and development.

• Support patient to look for assistance from an understanding significant other or health care provider when difficulty arises from feelings of anxiety. The presence of significant others strengthens feelings of safety and security for the patient.