CHAPTER 7 :ANXIETY DISORDERS
DEFINITION OF ANXIETY
Anxiety is a vague, uneasy emotional feeling that is normally experienced by a person in
response to a perceived threat or danger

As the stimulus of a threatening situation is processed by the brain, the result is fear,
and when the person realizes the fear, he feels Anxiety

Sometimes the person can identify the stimulus that is causing the uncomfortable
feeling, but in other cases, a cause cannot be identified
FREE-FLOATING ANXIETY
It occurs when the person is unable to connect the anxiety to stimuli. This factor in
itself can create additional anxiety.

The manifestations of anxiety can take many forms ranging from vague discomfort
to extreme panic

Increased levels of anxiety can be experienced continuously or periodically

Thoughts, feelings, and behaviors are all affected as anxiety increases

A person may act "out of character" or in a bizarre manner, such as shouting and
screaming or in other situations, slight manifestations of anxiety, such as clenching
the jaws, tapping fingers on a table, and fidgeting could occur. These behaviors are
called Automatic Relief Behaviors
Automatic Relief Behaviors
Are simple unconscious behaviour that are aimed at relieving anxiety

Although the person may be unaware of his or her actions, they may be annoying to
other people such as clicking a ballpoint pen continuously

If no certain measures are taken to remove the cause, anxiety will continue to grow.

If it is unrelieved and continues over time, an underlying disorder may be identified.

Beyond the normal experiences of anxiety, it is called Anxiety Disorders
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ANXIETY DISORDERS
DEFINITION OF ANXIETY DISORDERS
Anxiety Disorders are a group of disorders characterized by uncontrolled anxiety that
leads to impairment in social, interpersonal, and work functioning levels

Although signs and symptoms may vary from disorder to disorder, the common
thread or feature of these conditions is overwhelming anxiety that is out of control.

Unlike the anxiety felt briefly during a thunderstorm, the level of anxiety that leads
to a disorder is disabling and progressive unless treatment is obtained.
TYPES OF ANXIETY DISORDERS
1. PANIC DISORDER
Panic Attack: A panic attack is described as an intense feeling of fear or terror that
occurs suddenly and intermittently without warning

The person experiencing the panic is unable to determine when these attacks will
occur or reoccur
Uncued Panic Attack: is a panic attack that occurs when the person is unable to
connect the attack to any particular stimulus
Cued Panic Attack: is a panic attack that occur when the person is able to connect
the attack to a particular stimulus

Some people may only experience a single attack, while others go on to develop a
panic disorder.
Panic Disorder: is characterized by recurrent, unexpected panic attacks

The frequency and severity of these attacks may vary. Some people may be able to
endure brief exposure to the situation that causes panic. Others may not be able to
expose themselves to the situation at all. When this occurs, the consequences of the
disorder are much greater, and the functional capacity of the person decreases
significantly.
Signs and Symptoms of Panic Disorder
1. Heartbeat rapid and pounding
2. Heart palpitation
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3. Chest pain
4. Sweating and Dizziness
5. Increased perspiration
6. Chilling or flushing
7. Feeling weak and shaky
8. Tingling or numbness of hands
9. Nausea
10. Feeling of being suffocated
11. Fear of being out of control
12. Fear of dying or having a heart attack
13. Agoraphobia
14. Depression

Attacks may occur daily, weekly, or monthly

Attacks occur during the day and also the night

Most attacks last only a few minutes, but they may last longer

People experiencing panic attacks often have a fear of "going crazy" or "losing it."

Self-esteem may also be affected in varying degrees

Fear of having the "next attack" can cause significant impairment in the person's
overall functioning.

Individuals with panic disorder often develop agoraphobia, or an avoidance of
certain places or situations that tend to trigger the panic attacks

Because they fear a reoccurrence of the panic state, they often restrict their activities
to avoid the possibility of this happening

Everyday activities such as shopping and going to mosque or family events may be
avoided because of fear that escape from these situations might be difficult or
embarrassing

They may have fears of being in a crowd or on a bridge or travelling in a bus,
airplane, or automobile

Should the person be entrapped in this situation, the anxiety experienced would lead
to a feeling of helplessness and panic

By limiting the possibilities that this would happen, the person often becomes
homebound or restricted to home surroundings.
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
Unemployment and school dropout are common

Decreased work functioning is evidenced by the inability to complete tasks, repeated
absences, and difficulty interacting with others.

Up to two thirds of people with panic disorder also experience depression or engage
in substance abuse to cope with the anxiety.
Incidence and Etiology

Although they can occur at any age, panic disorders typically have an onset between
late adolescence and the mid-30s.

First-generation biologic relatives are more likely to develop the disorder.

Agoraphobia and panic disorders are also more prevalent in females than in males.

More than 95% of patients diagnosed with agoraphobia have an accompanying
diagnosis of panic disorder.
2. SPECIFIC PHOBIA

Specific Phobia is characterized by an excessive and persistent irrational fear of
specific objects or situations that actually pose little threat or danger

When a person comes in contact with the object or situation that causes the fear, the
person usually experiences an immediate severe anxiety or panic attack.

The distance between the person and the feared object will affect the level of
response.

A person who fears dogs will experience the most anxiety while in close proximity to
the animal.

Whether there is a way to escape from the feared stimulus also plays a role in the
intensity of the anxiety the person feels.

A person who has a fear of going over bridges, for example, will have the most
anxiety if there is no way to avoid crossing the bridge.

Although children may not be aware of the stimulus causing the anxiety, adolescents
and adults are usually aware that their response is extreme and unrealistic.

Those with intense fears may experience anxiety
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Examples of Specific Phobias
1. Zoophobia: fear of animals
2. Pyrophobia: fear of fire
3. Amaxophobia: fear of riding in a car
4. Somniphobia: fear of sleep
5. Claustrophobia: fear of confined spaces
6. Arachnophobia: fear of spiders
7. Xanthophobia: fear of yellow colour
8. Phasmophobia: fear of ghosts
9. Hematophobia: fear of blood
10. Triskaidekaphobia: fear of the number thirteen
11. Acrophobia: fear of heights
12. Gephyrophobia: fear of crossing a bridge
13. Microphobia: fear of germs
14. Algophobia: fear of pain
15. Brontophobia: fear of thunder
Signs and Symptoms of Specific Phobia
1. Irrational and persistent fear of an object or situation
2. Immediate anxiety on contact with the feared object or situation
3. Loss of control, tainting, or panic response • Avoidance of activities involving feared
stimulus
4. Anxiety when thinking about stimulus • Worry with anticipatory anxiety
5. Possible impaired social or work functioning significantly impairs the person's
ability to continue functioning in social and work settings that the diagnosis of a
specific phobia is made.
Incidence and Etiology

Specific phobias affect over 6 million adult Americans.

They are twice as common in females as males.

Although phobias are common, they are rarely severe enough to be diagnosed.

Symptoms usually have an onset during childhood or adolescence and persist
throughout adult life.
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
The fear of a particular stimulus is usually present for some time before it is severe
enough to be considered a disorder.

Phobias following a traumatic event such as the fear of water after a near- drowning
situation can develop at any age.
3. SOCIAL PHOBIA (SOCIAL ANXIETY DISORDER)

Social phobia, also known as social anxiety disorder, is characterized by an excessive
fear of any social situation in which embarrassment is possible.

The person with this disorder experiences intense discomfort when being watched
or at risk of being judged or ridiculed by others.

This experience typically occurs during social activities and occasions where the
person will be speaking, dining, or writing in public.

Although the person may recognize that the fear is extreme and unrealistic, he or
she is helpless to stop it.

Social anxiety may be related to one particular situation such as indoor activities or
loud music, or it may be related to social occasions in general.

Symptoms may be severe enough to interfere with the person's work or school
functioning.

Social isolation may result in which the person has few friends or contacts.
Signs and Symptoms of Social Phobia

The person may be embarrassed by the symptoms, which adds to his or her
discomfort.

Most people will avoid the difficult situation altogether, while others will tolerate
the activity but experience -intense anxiety.
3. Hyperventilation
4. Sweating, cold, and clammy hands
5. Blushing
6. Palpitations
7. Confusion
8. Gastrointestinal symptoms
9. Trembling hands and voice
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10. Urinary urgency
11. Muscle tension
12. Anticipatory anxiety
13. Fear of embarrassment or ridicule
Incidence and Etiology

The incidence of social phobia tends to be equally distributed between men and
women.

The disorder usually has an onset in childhood or early adolescence.

Onset may be abrupt, following an embarrassing event, or may be insidious or slow.

There is a tendency for this condition to run in families.
4. POSTTRAUMATIC STRESS DISORDER

Posttraumatic stress disorder (PTSD) is characteristically seen when a person has
been subjected to a situation that involves a death or threat of severe injury.

The person with PTSD experiences an intense feeling of fear and dread with each
recurring mental rerun of the event.

The traumatic event can be related to one's own personal physical well-being,
observing someone else's death or severe injury, or receiving word that a close
relative has been seriously injured or has died.

Traumatic events may include military combat, terrorist attack, robbery, automobile
accident, sexual assault, murder, kidnapping, or natural disaster.
Signs and Symptoms

The person with PTSD is plagued with increased anxiety that was not present before
the precipitating event.

Some people may feel extreme guilt for surviving when others did not survive.

People, activities, or places that may be connected to the situation are avoided
because of the emotional numbing that accompanies the exposure.

This numbness is shown by an expression of little or no emotion soon after the event
as an attempt to prevent future mental pain.

The person may continue to show a lack of affect for the remainder of his or her life.
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
It is common for the person to re-experience the event mentally or to reencounter
the trauma in dreams.

The duration of symptoms must be longer than 1 month to be given the diagnosis of
PTSD.
Common Signs and Symptoms of PTSD
1. Insomnia
2. Inability to concentrate
3. Impaired social or work functioning.
4. Dissociative behaviour or depersonalize as a result of the mental anguish they
experience.
5. General lack of trust that impairs their ability to interact with others.
6. Panic attacks
7. Perceptual alterations or hallucinations
8. Depression.

Some people may resort to violence, drugs, or suicide to deal with the recurring
disturbing mental pictures.

Exposure to similar events can also cause flashbacks or mental images that increase
the chances of these complications.

This return to the trauma may increase the likelihood that the person will resort to
extreme means of dealing with the continued emotional pain.
5. OBSESSIVE-COMPULSIVE DISORDER (OCD)

Obsessive-compulsive disorder (OCD) is characterized by obsessions or the
reoccurrence of persistent unwanted thoughts or images that cause the person
intense anxiety, coupled with compulsions, which are repetitive behaviors or rituals
the person engages in to reduce the high level of anxiety provides common types of
obsessive thought content.

For diagnosis, the obsessions and compulsions have to be severe enough to cause a
significant decline in the client's level of functioning with the actions consuming at
least 1 hour of the person's day.

Persons with social phobia often try to decrease the overwhelming anxiety felt in the
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feared situation by using drugs and/or alcohol.

Those who have obsessive-compulsive symptoms often feel a painful sense of shame
and ridicule over the behaviors.

Anticipatory anxiety occurs well in advance of a particular situation such as a public
speech or social event which leads to thoughts of dread leading up to the event.

The added anxiety results in actual or perceived failure in the situation, leading to
embarrassment and further anxiety.

This pattern sets up a vicious cycle of persistent discomfort that can be
incapacitating.

Many people who have social phobia are underachievers because of test anxiety,
poor job performance, or poor communication skills.

They may have few or no friends, a decreased support system, and poor
interpersonal relationships.
Signs and Symptoms of OCD

It is common for a person to have some recurring uncomfortable thoughts or
concern such as whether a car is locked or garage door closed.

These thoughts are frequently invasive and inappropriate.

The person may recognize the thoughts as unusual and self-generated but has no
ability to control them.

This lack of control leads to the extreme anxiety.
Incidence and Etiology

Occurrence of OCD is evenly distributed between males and females.

The symptoms manifest since childhood.

There tends to be Signs and Symptoms of occurrence of the behavior pattern in
families.
Types of OCD
Typically a person’s OCD will fall into one of the following four areas.
1. Checking
2. Contamination
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3. Mental Contamination
4. Hoarding
5. Ruminations
6. Intrusive Thoughts

This list categorizes the most common forms of OCD and some of the fears
associated with them.

If the person is experiencing distressing and unwanted obsessions and compulsions,
that impact significantly on your everyday functioning, this could represent a
principal component in the clinical diagnosis of Obsessive-Compulsive Disorder.
Diagnosing OCD
Obsessive Compulsive Disorder is diagnosed when the Obsessions and Compulsions:
1. Consume excessive amounts of time (approximately an hour or more).
2. Cause significant distress and anguish.
3. Interfere with daily functioning at home, school, or work; or interfere with social
activities/ family life/relationships.
1. Checking

The need to check is the compulsion, the obsessive thought might be to prevent
damage, fire, leaks or harm.

Common checking includes:
1. Water taps (fear of flooding property and damaging irreplaceable treasured items).
2. Gas or electric stove knobs (fear of causing explosion and therefore the house to
burn down).
3. Door locks (fear of allowing a burglar to break in and steal or cause harm).
4. House alarm (fear of allowing a burglar to break in and steal or cause harm).
5. Windows (fear of allowing a burglar to break in and steal or cause harm).
6. Appliances (fear of causing the house to burn down).
7. House lights (fear of causing the house to burn down).
8. Car doors (fear of car being stolen).
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9. Re-reading postal letters and greetings cards before sealing / mailing (fear of
writing something inappropriate or offensive).
10. Candles (fear of causing the house to burn down).
11. Route after driving (fear of causing an accident).
12. Wallet or purse (fear of losing important bank cards or documents).
13. Illnesses and symptoms online (fear of developing an illness, constant checking of
symptoms).
14. People – Calling and Texting (fear of harm happening to a loved one).
15. Reassurance (fear of saying or doing something to offend or upset a loved one).
16. Re-reading words or lines in a book over and over again (fear of not quite taking in
the information or missing something important from the text).

The checking is often carried out multiple times, sometimes hundreds of times, and
for hours on end, resulting in the person being late for work, dates and other
appointments. This can have a serious impact on a person’s ability to hold down
jobs and relationships. The checking can also cause damage to objects that are
constantly being checked.
2. Contamination

The need to clean and wash is the compulsion, the obsessive thought is that
something is contaminated and/or may cause illness, and ultimately death, to a
loved one or oneself.

Common contaminations include
1. Using public toilets (fear of contracting germs from other people).
2. Coming into contact with chemicals (fear of contamination).
3. Shaking hands (fear of contracting germs from other people).
4. Touching door knobs/handles (fear of contracting germs from other people).
5. Using public telephones (fear of contracting germs from other people).
6. Waiting in a GP’s surgery (fear of contracting germs from other people).
7. Visiting hospitals (fear of contracting germs from other people).
8. Eating in a cafe/restaurant (fear of contracting germs from other people).
9. Washing clothes in a launderette (fear of contracting germs from other
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people).
10. Touching bannisters on staircases (fear of contracting germs from other
people).
11. Touching poles (fear of contracting germs from other people).
12. Being in a crowd (fear of contracting germs from other people).
13. Avoiding red objects and stains (fear of contracting HIV/AIDS from blood like
stains).
14. Clothes (having to shake clothes to remove dead skin cells, fear of
contamination).
15. Excessive Tooth Brushing (fear of leaving minute remains of mouth disease).
16. Cleaning of Kitchen and Bathroom (fear of germs being spread to family).

The cleaning or washing is often carried out multiple times often accompanied by
rituals of repetitive hand or body washing until the person ‘feels’ it is clean, rather
than someone without OCD who will wash or clean once until they ‘see’ they are
clean.

The time this takes can have a serious impact on a person’s ability to hold down jobs
and relationships and there is also a secondary physical health impact of the
constant scrubbing and cleaning on the skin, especially the hands.

A person may also avoid entire places if they experienced contamination fears there
previously.

There is also a cost implication of the constant use and purchase of cleaning
products, and also of items (especially electrical) that are damaged through
excessive liquid damage.
3. Mental Contamination

It is a less obvious form of OCD.

Feelings of mental contamination can be evoked by times when a person perhaps
felt badly treated, physically or mentally, through critical or verbally abusive
remarks.

It is almost as if they are made to feel like dirt, which creates a feeling of internal
uncleanliness even in the absence of any physical contact with a dangerous/dirty
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object.

A distinctive feature of mental contamination is that the source is almost always
human, unlike the contact contamination that is caused by physical contact with
inanimate objects.

The person will engage in repetitive and compulsive attempts to wash the dirt away
by showering and washing which is where the similarities with traditional
contamination OCD return.
4. Hoarding

Is the inability to discard useless or worn out possessions, commonly referred to as
‘hoarding’?
5. Ruminations

Rumination is a train of prolonged thinking about a question or theme that is
undirected and unproductive.

Unlike obsessional thoughts, ruminations are not objectionable and are indulged
rather than resisted.

Many ruminations dwell on religious, philosophical, or metaphysical topics, such as
the origins of the universe, life after death, the nature of morality, and so on.

One such example might be where a person dwells on the time-consuming question:
'Is everyone basically good?'. They would ruminate on this for a long period of time,
going over in their mind various considerations and arguments, and contemplating
what superficially appeared to them to be compelling evidence.

Another example might be someone that ruminates about what would happen to
them after death. They would weigh up the various theoretical possibilities, visualise
scenes of heaven, hell, and other worlds and try to remember what philosophers and
scientists have said about death.

Rumination it inevitably never leads to a solution or satisfactory conclusion and the
person appears to be deeply pre-occupied, very thoughtful, and detached.
6. Intrusive Thoughts

Intrusive thoughts, in the spectrum of OCD, are where a person generally suffers
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with obsessional thoughts that are repetitive, disturbing and often horrific and
offensive in nature.

For example, thoughts of causing violent or sexual harm to loved ones.

Because the intrusive thoughts are repetitive and not voluntarily produced, they
cause the sufferer extreme distress - the very idea that they are capable of having
such thoughts in the first place can be horrifying.

People with Obsessive-Compulsive Disorder are the least likely people to actually
act on the thoughts, partly because they find them so offensive and go to great
lengths to avoid them and prevent them happening.

Intrusive thoughts can cover absolutely any subject, but the more common areas of
OCD related concerns covers the following sub-categories:
Relationships:
a. Constantly analysing the depth of feelings for one's partner, placing the
partner and the relationship under a microscope and finding fault.
b. Constantly needing to seek reassurance and approval from one's partner.
c. Doubts that one's partner is being faithful.
d. Doubts that one may cheat on their partner.
Sexual Thoughts:
a. Fearing being a pedophile and being sexually attracted to children.
b. Fearing being sexually attracted to members of one's own family.
c. Fearing being attracted to members of the same sex (homosexual OCD).
d. Thoughts about touching a child inappropriately.
e. Intrusive sexual thoughts about God, saints or, religious figures.
Magical Thinking:
a. A certain color or number has good or bad luck associated with it.
b. Certain days have good or bad luck associated with them.
c. A loved one’s death can be predicted.
d. One’s thoughts can cause disasters to occur.
e. Stepping on cracks in the pavement can make bad things happen.
f. Whatever comes to mind can come true.
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g. Breaking chain letters will actually bring bad luck.
h. Attending a funeral will bring death.
i.
One can inadvertently cause harm to others with thoughts or
carelessness.
Religious:
a. Sins committed will never be forgiven by God and one will go to hell.
b. One will have bad thoughts in a religious building.
c. One will scream blasphemous words loudly in a religious location.
d. Prayers have been omitted or recited incorrectly.
e. Certain prayers must be said over and over again.
f. Religious objects need to be touched or kissed repeatedly.
g. One is always doing something sinful.
h. Repetitive blasphemous thoughts.
i.
That the person has lost touch with God or their beliefs in some way.
j.
Intrusive sexual thoughts about God, saints or, religious figures.
k. That the person has broken religious laws concerning speech, or dress or
modesty.
l.
Intrusive bad thoughts that occur during prayer will contaminate and
ruin or cancel out the value of these activities.
Violent Thoughts:
a. Violently harming children or loved ones.
b. Killing innocent people.
c. Using kitchen knives and other sharp objects (compulsion will include
locking away knives and sharp objects).
d. Jumping in front of a train or fast moving bus.
e. Poisoning the food of loved ones (compulsion will include avoiding
cooking for family).
f. Acting on unwanted impulses, e.g. running someone over, stabbing
someone.
g. Thoughts about accidentally touching someone inappropriately, with the
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aim of hurting them.
Symmetry and Orderliness
a. Having everything neat and in its place at all times.
b. Having pictures hanging aligned and straight.
c. Having canned food items all facing the same way, usually forward.
d. Having clothes on the rail all hanging perfectly and facing the same way.
e. Having everything spotless, with no marks or smudges on windows and
surfaces.
f. Having books lined up perfectly in a row on a bookshelf.
6. GENERALIZED ANXIETY DISORDER GAD

In generalized anxiety disorder, the person experiences an increased level of anxiety
and worry about various situations on most days over a period of at least 6 months.

The person has difficulty controlling the anxiety, leading to considerable discomfort,
lack of concentration, and impaired ability to function.
Signs and Symptoms of Generalized Anxiety Disorder
a. Chronic excessive worry and anxiety (no particular stimulus)
b. Negative self-talk
c. Fatigue
d. Difficulty falling or staying asleep
e. Increased startle reflex
f. Inability to relax
g. Muscle tension
h. Anticipating the "worst
i.
Inability to control the anxiety
j.
Tremors
k. Irritability
l.
Headaches
m. Breathing difficulties
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n. Increased urinary frequency
o. Gastrointestinal disturbances
p. Teeth grinding (bruxism)
TREATMENT OF ANXIETY DISORDERS

Treatment of anxiety disorders focuses on reducing the client's anxiety level.

The two main approaches to the treatment include medications and psychotherapy,
either singly or in combination.

The medications used are antianxiety drugs (anxiolytics), such as benzodiazepines

The greatest rate of treatment success is experienced when Antianxiety drugs are
used in combination with psychotherapy sessions.

For the psychotherapy component of treatment, research demonstrates that
cognitive-behavioral therapy is most effective in helping the individual to replace
negative thoughts and behaviour with more positive and productive ones.

The basis for the outcome is that individuals have the ability to control and change
their thinking and, consequently, their actions.

Anxiety support groups can also provide sharing of experiences and offer
suggestions for coping.
APPLICATION OF THE NURSING PROCESS TO THE CLIENT WITH AN
ANXIETY DISORDER

'When establishing a nurse—client relationship with the person experiencing
excessive anxiety, it is important to initially take steps to lower the anxiety level.

The person cannot identify the problem until this is accomplished.

The nurse can best encourage trust by a calm and reassuring approach.
Nursing Assessment

When collecting data about clients with high levels of anxiety, observe basic
characteristics such as: thought processes, affect, communication, psychomotor and
physiologic responses, and ability to complete tasks.
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
Use direct questions to collect subjective information about how the client is
currently feeling and what happened before the onset of symptoms.

Use leading statements to use to gain an understanding of the situation from the
client's perspective.

Ask the client about other somatic symptoms such as muscle aches, eating patterns,
bowel habits, sleeping patterns, and fatigue that might further indicate a
psychological origin for the complaints.

Observe the client during activities of daily living and interaction with others to
determine when symptoms are most obvious.

Assessing the client during usual activities can also provide clues about the client's
thought processes.

When questioning a client, consider that your questioning may increase the client's
anxiety and interfere with his or her ability to answer.

When faced with a frightening situation, a person's anxiety levels increase, and his
or her thoughts can become
Leading Statements That Encourage Client Participation in Providing Information
a. Tell me what happened
b. Tell me details of what happened.
c. How did you feel at that time?
d. What were you thinking when that happened?
e. What emotion were you feeling at that particular time?
f. Give me a specific example of what that was like for you.
g. Tell me more about that
h. Who were you there with?
i.
What year did this occure?
j.
What did friends and family say to you?
k. Can you describe your feeling?
l.
How do you feel right now?
m. What emotion do you feel?
n. What are you doing to decrease that feeling?
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
It is important to note the client's affect. Facial expressions are not easily disguised
and may provide more meaningful insight into the client's feelings.

A client may report that he is fine but display a facial grimace.

The facial expression usually reflects true feelings before behaviors or words do.

When assessing for interactive skills, consider the client's level of education.

Also observe the client's ability to perform and complete tasks. Psychomotor
responses can teach a hyperactive level and be counterproductive when anxiety is
high. On the other hand, when anxiety is extremely high, psychomotor responses can
become slowed and also decrease functional ability.

Collecting observations helps to determine if the client's inability to perform tasks is
the result of impaired thought processes or impaired motor responses.

Observation of the client with particular attention to specific anxiety-reducing
behaviors should be part of the initial and ongoing assessment for each client.

Sometimes symptoms are expressed in subtle ways, such as leaving group therapy
to go to the bathroom or avoiding an activity where several clients are participating.

It is important to note if behaviors are improving with the administration of
antianxiety medications or if the client is experiencing any side effects from the
drug.
Nursing Diagnosis

Once the assessment is made and data are collected, the information is reviewed and
sorted into meaningful clusters.

From these data, problems are identified to determine applicable nursing diagnoses.
Relevant nursing diagnoses for the client with an anxiety disorder include:
a. Anxiety, related to a feeling of actual or perceived threat
b. Anxiety, related to intrusive thought processes
c. Coping, Ineffective, related to unmet needs
d. Fear, related to extreme and unrealistic perceptions
e. Powerlessness, related to lack of control over anxiety
f. Violence, Self- or Other-Directed, Risk for, related to reoccurring intrusive
thoughts
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g. Sleep Pattern Disturbed, related to excessive worry and anxiety
h. Social Isolation, related to feelings of guilt or emotional numbness
i.
Family Processes, Interrupted, related to a situation crisis
j.
Skin Integrity, Impaired, related to compulsive repetitive behaviors
k. Self-Esteem, Situational or Chronic Low, related to feelings of inadequacy
Expected Outcomes

Once the nursing diagnosis is made, appropriate outcomes for clients can be
determined.

Careful consideration should be given to a realistic time frame in which the
outcomes can be achieved.

Outcomes are always client centered and time limited.
Examples of outcomes may include:
1. Within 7 days, the client will:
a. Identify initial signs and symptoms of anxiety
b. Identify effective coping methods to use when anxiety begins to occur
c. Demonstrate effective strategies to lower anxiety • Experience increased energy
d. Identify alternative methods of coping that decrease social isolation
e. Demonstrate decreased cleaning rituals
f. Participate in small group discussions with decreased anxiety
g. Look at pictures of a phobic stimulus without excessive anxiety
2. Ventilate anxiety appropriately and safely to others
3. Experience improved sleep pattern
4. Demonstrate improved impulse control
Nursing Interventions

When dealing with anxiety in others, take into consideration your own anxiety level
and how it may affect nursing care.

Subtle behaviors such as a change in the tone of voice, rushed movements, or
spending less time with the client can communicate your anxiety to the client.

This, in turn, can generate increased anxiety in the client, resulting in a decreased
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ability to function.

Establishing a sense of trust includes maintaining a calm and supportive
environment in which the client feels a sense of safety and security.

Nursing interventions should be timely, client centered, and realistic.

Interventions should include only what the client is able to do at that time.

It may be difficult for the client to take more than small steps toward reaching
expected outcomes.

Overwhelming the client with unrealistic expectations may indicate anxiety on the
nurse's part and lead to counterproductive results in the client.

Assessing the client's tolerance for change is essential for planning appropriate
client-centered nursing interventions.

Reassessment should occur to ensure the continuing relevance of the interventions.

Every effort should be made to assist the client in identifying the issues that
precipitate the feelings of anxiety.

Linking the behavior exhibited by the client to a particular situation can help the
client to develop an awareness of feelings that precede the anxiety attacks.

As the nurse, you can also model and help the client to try new, more adaptive
coping strategies.
Additional nursing interventions include the following:
1. Encourage participation in social interaction and exercise activities.
2. Give positive reinforcement for the client's efforts to participate.
3. Teach stress-management techniques (progressive relaxation, music therapy, deep
breathing).
4. Assist the client with compulsive behaviors to find ways to set limits on the rituals.
5. Acknowledge the behaviors but do not focus on them—it is important to express an
empathetic response rather than criticize the behavior. For example, in response to
a client who has shampooed her hair four times in 2 hours, you might say, "I am sure
your scalp is getting sore from washing your hair so much," rather .than, "You only
need to wash your hair once a day."
6. Observe for automatic relief behaviors.
7. Encourage open discussion of feelings and thoughts.
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8. Monitor for indications of escalating anxiety.
9. Encourage time-out for impulsive clients to regain self-control.
10. Provide client education regarding anxiety and precipitating factors.
11. Administer prescribed antianxiety medications.
12. Provide explanations regarding medications and side effects to the client and family.
13. Avoid giving advice to the client.
14. Provide sources of information about anxiety disorders such as those found in
Evaluation

Evaluation of the plan of care occurs at the end of the time frame that was set to
reach client outcomes.

Success is determined based on whether the outcome criteria were achieved.

The plan of care is revised if outcomes were not met, if the problem persists, or if a
new problem has developed.

Effectiveness of planned interventions will be demonstrated in the client's ability to
recognize and deal with the anxiety-producing factors.

Once the client identifies the relationship between unreasonable thoughts and
subsequent behaviors, it is more realistic to anticipate the use of more effective
coping strategies to reduce his or her anxiety.

It is important for the client to express openly feelings and thoughts related to the
situation.

The effectiveness of active listening by the nurse and learned coping skills are
shown when the client reports that anxiety has been reduced to a manageable level.

This can also be demonstrated as the client shows relaxed participation in activities
and reports longer periods of restful sleep.

Further indication of learned skills is shown as the impulsive client resolves conflict
situations using improved self-control.

It is anticipated that through learning what precipitating factors can be changed and
steps that can be taken to lower anxiety for those that cannot be changed, the client
will demonstrate more effective problem-solving methods to improve overall
functioning and well-being.
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