1. Anxiety Responses and Disorders NUR 305 Rochelle Roberts RN MSN

2. Anxiety Disorder Most common psychiatric disorder Affects 10 - 25% of the American population Involves one’s body, perceptions of self, and relationships with others. Occur twice as often in women as in men

3. Anxiety Responses A diffuse apprehension Vague in nature Associated with feelings of uncertainty An emotion without a specific object Is communicated interpersonally

4. Defining Characteristics of Anxiety a threat to one’s self- esteem an energy that can’t be observed directly based on certain behaviors is contagious

5. 4 Levels of Anxiety (Peplau) Mild level-person is alert and perceptual field is increased; can motivate learning and produce personal growth. Moderate level-person focuses only on immediate concerns; involves narrowing of the perceptual field. Severe level- marked by a reduction in the perceptual field. The person focuses on a specific detail.

6. Levels of Anxiety (continued) Panic level- associated with dread and terror. Person is unable to do things even with direction. Involves disorganization of the personality and can be life threatening. Person is unable to communicate or function effectively.

7. Anxiety and Physiological Changes Predominance of the sympathetic autonomic nervous system. (prepares the body to deal with an emergency situation) This is the fight or flight reaction.

8. Behavioral Responses Physical tension Tremors Lack of coordination Hyperventilation Startle reaction Restlessness

9. Cognitive Responses Impaired attention Poor concentration Forgetfulness Confusion Nightmares Errors in judgment Fear of losing control

10. Affective Responses Nervousness Tension Fear Frustration Terror Jitteriness Helplessness

11. Theories regarding origin of anxiety Psychoanalytic (Freud) Interpersonal (Sullivan) Behavioral Family studies Biological basis

12. Precipitating Stressors Threats to physical integrity suggest impending physiological disability. Internal sources: physiological failure; heart, immune system, temperature regulation External sources: exposure to infection, environmental pollutants, lack of adequate housing, food, clothing and trauma.

13. Precipitating Stressors (continued) Threats to self-esteem External sources: loss of a valued person through death, divorce or re-location, change in job status. Internal sources: interpersonal problems at work, or when assuming a new role.

14. Coping Mechanisms for Mild Anxiety Crying Sleeping Smoking Cursing Exercise Drinking Limited self- disclosure

15. Coping Mechanisms (continued) Moderate, severe, and panic levels of anxiety require more energy to cope with the threat. These coping mechanisms are categorized as task oriented and ego- oriented reactions.

16. Task-Oriented Reactions Attack behavior: can be destructive hostility or constructive problem-solving

17. Task-Oriented Reactions cont. Withdrawal behavior: this can be physical or psychological withdrawal

18. Task-Oriented Reactions (continued) Compromise: involves changing usual ways of operating, substituting goals, and sacrificing aspects of personal needs

19. Ego-Oriented Reactions Defense mechanisms are used to protect the self. They are the first line of psychic defense and operate at an unconscious level. They involve a degree of self-deception and reality distortion. One must evaluate if the defense mechanism is adaptive or maladaptive..

20. Defense Mechanisms Compensation Denial Displacement Dissociation Identification Intellectualization Introjection Projection

21. Ego-Defense Mechanisms cont. Rationalization Reaction Formation Regression Repression Splitting Sublimation Suppression Undoing

22. Formulating Nursing Diagnoses Determine the quality & quantity of anxiety experience by the patient. Is the patient’s response out of proportion to the threat?

23. Formulating Nursing Diagnoses (continued) Explore how the patient is coping with the anxiety. Is it constructive or destructive? Determine the overall effect of the anxiety. Is it stimulating growth or interfering with effective living?

24. 4 Primary NANDA Nursing Diagnoses Anxiety Ineffective coping Readiness for enhanced coping Fear

25. Examples of Expanded NANDA Diagnosis Anxiety: moderate anxiety related to financial pressures, as evidenced by episodes of stomach pain and heartburn. Ineffective coping: related to father’s death as evidenced by inability to concentrate and psychomotor agitation and depression. Readiness for enhanced coping: related to mother moving in with daughter secondary to stroke related disability, as evidenced by modification of living environment.

26. Examples of NANDA Diagnoses (cont.) Fear: related to impending biopsy as evidenced by generalized hostility toward staff and family.

27. Medical Diagnoses Patients with mild or moderate anxiety have no medically diagnosed health problem. However, patients with more severe levels of anxiety usually have neurotic disorders that fall under anxiety orders in the DSM-IV- TR.

28. DSM –IV-TR Anxiety Disorders Panic disorder with or without agoraphobia Agoraphobia Specific phobia Social phobia Obsessive-compulsive disorder Posttraumatic stress disorder Acute stress disorder Generalized anxiety disorder

29. Outcome Identification and Nursing Goals The patient will demonstrate adaptive ways of coping with stress. Short-term goals can break the expected outcome down into readily attainable steps.This allows the patient and nurse to see progress even if the ultimate goal appears distant. The highest priority short-term goal should address safety and lowering the anxiety level. The reduced level of anxiety should be evident in a reduction of behaviors associated with severe or panic levels.

30. Nursing Outcome Indicators for Anxiety Self-Control Monitors intensity of anxiety Plans coping strategies for stressful situations Uses effective coping strategies Monitors duration of episodes Monitors length of time between episodes Maintains adequate sleep Seeks information to reduce anxiety Controls anxiety response

31. Practice Guidelines ( Severe &Panic Levels of Anxiety) Establishing a trusting relationship Be aware of your own feelings of anxiety, as a nurse. These can interfere with the therapeutic process. Protecting the patient. Do not force severely anxious patients into situations they are not able to handle. Do not ask “why” questions. Patients don’t understand why their symptoms have developed.

32. Practice Guidelines (cont) ( Severe levels of anxiety) Modifying the environment- identify anxiety- producing situations and attempt to reduce them.Assume a quiet,calm manner and decrease environmental stimulation. Limiting the patient’s interaction with other patients will minimize the contagious aspects of anxiety. Supportive measures include warm baths, massages, and whirlpool baths. Encouraging patient’s interest in activities.(walking, hobbies, physical exercise)

33. Medications Benzodiazepines: ie. Xanax, Librium, Valium, Ativan, Serax, Tranxene) Anxiolytic: BuSpar SSRI’s: Celexa, Prozac, Paxil, Zoloft Tricyclics: Elavil, Norpramin, Anafranil, Tofranil, Pamelor MAOI’s: Nardil

34. Nursing Practice Guidelines ( For Moderate Levels of Anxiety) When patient’s anxiety is reduced to a moderate level, the nurse can help with problem-solving efforts to cope with stress. Long term goals focus on helping the patient understand the cause of the anxiety and learn new ways of controlling it. Goals include pt. education, recognition of the anxiety, insight into the anxiety, and coping with the threat. C.B.T. can be used and promotion of the relaxation response.

35. Cognitive Behavioral Therapy Involves 3 therapeutic strategies: Anxiety reduction: relaxation, biofeedback, systematic desensitization. Cognitive Restructuring: monitor thoughts and feelings, examining alternatives, reframing. Learning new behavior: role-modeling, role playing, social skills training, learning new ways of coping with stress.

36. Promote the Relaxation Response It’s in the scope of nursing practice It requires no special equipment It does not need a physician’s supervision Patient can practice techniques on their own It can be implemented in various settings.