NANDA-I approved*
Pathophysiologic
Any factor that interferes with physiologic stability.
Examples:
- Pain*
- Respiratory distress
- Mind-altering drugs
- Chest pain
- Cancer diagnosis
Treatment Related
Examples:
- Impending surgery
- Invasive procedure
- Effects of chemotherapy
Situational (Personal, Environmental)
Related to:
Conflict about life goals*
Interpersonal contagion
Interpersonal transmission*
Stressors*
Substance abuse*
Threat of death
Threat to current status*
Unmet needs*
Value conflict*
Unfamiliar situation*
Related to threat to self-concept secondary to:
Failure (or success)
Intrusive, unwanted thoughts
Lack of recognition from others
Loss of valued possessions
Cessation of ritualistic behavior
Exposure to phobic object or situation
Flashbacks
Fear of panic attack
Related to loss of significant others secondary to:
Cultural pressures
Temporary or permanent separation
Divorce
Moving
Related to threat to biological integrity secondary to:
Invasive procedures
Assault
Disease (specify)
Related to change in environment secondary to:
Hospitalization
Retirement
Environmental pollutants
Moving
Safety hazards
Incarceration
Natural disasters
Refugee issues
Military or political deployment
Airline travel
Related to change in socioeconomic status secondary to:
Unemployment
Promotion
New job
Displacement
Related to idealistic expectations of self and unrealistic goals (specify)
Maturational
Infant/Child
Related to:
Separation, unfamiliar environment, people
Changes in peer relationships
Death of (specify) with unfamiliar rituals and grieving adults
Adolescent
Related to death of (specify):
Related to threat to self-concept secondary to:
Sexual development
Academic failure
Peer relationship changes
Adult
Related to multiple changes/stressors associated with:
Pregnancy
Career changes
Parenting
Aging
Related to previous pregnancy complications, miscarriage, or fetal death
Related to lack of knowledge of changes associated with pregnancy
Related to lack of knowledge about labor experience
Older Adult
Related to multiple changes/stressors associated with:
Sensory losses
Motor losses
Financial problems
Retirement changes
Mental disorders
AUTHOR'S NOTEAnxiety is a vague feeling of apprehension and uneasiness in response to a threat to one's value system or security pattern (*May, 1977). The individual may be able to identify the situation (e.g., surgery, cancer), but actually the threat to self relates to the enmeshed uneasiness and apprehension. In other words, the situation is the source of, but is not itself, the threat. In contrast, fear is feelings of apprehension related to a specific threat or danger to which one's security patterns respond (e.g., flying, heights, snakes). When the threat is removed, fear dissipates (*May, 1977). Anxiety is distinguished from fear, which is feeling afraid or threatened by a clearly identifiable external stimulus that represents danger to the person. Anxiety is unavoidable in life and can serve many positive functions by motivating the person to take action to solve a problem or to resolve a crisis (Varcarolis, 2014).
Anxiety and fear produce a similar sympathetic response: cardiovascular excitation, pupillary dilation, sweating, tremors, and dry mouth. Anxiety also involves a parasympathetic response of increased gastrointestinal (GI) activity; in contrast, fear is associated with decreased GI activity. Behaviorally, the fearful person exhibits increased alertness and concentration, with avoidance, attack, or decreasing the risk of threat. Conversely, the anxious person experiences increased tension, general restlessness, insomnia, worry, and helplessness and vagueness concerning a situation that cannot be easily avoided or attacked.
Clinically, both anxiety and fear may coexist in a response to a situation. For example, an individual facing surgery may be fearful of pain and anxious about possible cancer. According to Yokom (*1984), "Fear can be allayed by withdrawal from the situation, removal of the offending object, or by reassurance. Anxiety is reduced by admitting its presence and by being convinced that the values to be gained by moving ahead are greater than those to be gained by escape."
CARP'S CUESNurses who do not practice in a mental health setting sometimes use this as a reason they cannot intervene when confronted with an individual who is anxious, panicking, depressed, or aggressive. In fact, most individuals experiencing ineffective or harmful behaviors present in nonmental health settings. It should no longer be acceptable to think or say "I am not a psychiatric nurse." Instead, seek out the interventions that are appropriate in a nonmental health setting. Sometimes one interaction can have a powerful influence on someone who is suffering, as "Are you aware that panic attacks are a creditable medical diagnosis?" or "Are you aware that opioid addiction is a creditable medical diagnosis?" or "How may I help you?" The power of nursing is in every nurse; use your power to heal, not judge and hurt.**
**This author, in the process of this text revision, discovered a very clinically useful document addressing various mental disorders with interventions that nurses in nonmental health settings could utilize: Queensland Mind Essentials (2010). This second edition publication was revised by Mental Health Directorate, Queensland Health, Australia. Retrieved from www.health.qld.gov.au/__data/assets/pdf_file/0029/444773/mindessentialsfinal.pdf.
Level 1 Fundamental Focused Assessment (all acute settings)
Subjective
- How may I make you more comfortable?
- What kind of hospital/emergency room experiences have you had?
- What are you feeling now?
- Who do you turn to for help?
Objective
- Quiet, asking questions, crying, aggressive
- Appropriate interactions with family members/significant others
- Problematic behavior toward one member or all members
Level 2 Extended Focused Assessment
Refer to agency admission documents or utilize the following:
Subjective and Objective Data
Usual Coping Behavior
"How do you usually handle a new situation that is distressing?" (i.e., anger, leave, problem-solving)
"What happens when you do that?" (relevant coping mechanism)
Present Coping Behavior
Appropriate "Acting-Out" Behaviors
Derogatory
Arguing, threatening
Restlessness
Pacing
Intimidating
Smoking, substance abuse
Problematic Behaviors
Withdrawing
Showing signs of depression
Avoiding talking about self
Minimizing signs and symptoms
Engaging in denial
Suicidal
Diverting attention
Engaging in ritualistic behavior
Somatizing
Headache
Dyspnea
Multiple complaints
Hives, eczema
Anorexia
Colitis
Syncope
Menstrual disturbance
NOCAnxiety Level, Coping, Impulse Self-Control
The individual will relate increased psychological and physiologic comfort, evidenced by the following indicators (*Queensland Mind Essentials, 2010):
- Has an understanding of the features of an anxiety disorder.
- Can describe effective strategies for coping with anxiety.
- Relates an intent to improve health behaviors, including medication compliance (if appropriate) and healthy lifestyle choices (e.g., diet, exercise, not smoking).
- Engages with their social and support network.
NICAnxiety Reduction, Impulse Control Training, Anticipatory Guidance
Level I Fundamental Focused Interventions (initial encounter all settings)
Nursing interventions for Anxiety can apply to any individual with anxiety regardless of etiology.*
How Can I Make You More Comfortable?
Assist to Reduce Present Level of Anxiety
- Speaking clearly and in layman's terms, explaining what will occur in the next hour.
- Simplify explanations.
- Respect personal space.
R:Focus on the present. Too much information can be overwhelming and increase anxiety (Boyd, 2018).
Assess Level of Anxiety: Mild, Moderate, Severe, or Panic
- Reassure the person that anxiety is normal or that a chronic disorder is a real medical condition.
- Stay with the person. Speak slowly and calmly.
- Support present coping mechanisms (e.g., allow the individual to talk or cry); do not confront or argue with defenses or rationalizations.
- Convey empathic understanding (e.g., quiet presence, touch, allowing crying, talking).
- Provide reassurance that a solution can be found.
- Remind the individual that feelings are not harmful.
R:Nursing strategies should focus on reducing stimuli and simplifying decisions (Boyd, 2018).
If Anxiety Is at Severe or Panic Level (Boyd, 2018; Halter, 2018)
Provide a quiet, nonstimulating environment with soft lighting. Remain calm in your approach.
Use short, simple sentences; speak slowly.
R:An individual with severe anxiety or panic does not retain learning.
- Try to determine the source of panic.
R:Encouraging sharing may help the individual to clarify and verbalize fears, allowing the nurse to give realistic feedback and reassurance.
- Remove excess stimulation (e.g., take to a quieter room); limit contact with others (e.g., family) if they are also visibly anxious.
- Provide physical measures that will aid in relaxation, such as a quiet environment, aromatherapy, and music. Ask them what would help them to be less anxious.
- Consult a physician/NP/PA) for possible pharmacologic therapy, if indicated.
- Provide an opportunity to walk.
R:Exercise helps to dispel some anxiety.
R:The anxious person tends to overgeneralize, assume, and anticipate catastrophe. Resulting cognitive problems include difficulty with attention and concentration, loss of objectivity, and vigilance. Provide emotional support and relaxation techniques, such as audio recordings or music (Varcarolis, 2014).
If the Person Is Hyperventilating or Experiencing Dyspnea
- Demonstrate breathing techniques; ask the person to breathe with you.
- Acknowledge the person's fear and give positive reinforcement for efforts.
- Acknowledge feelings of helplessness.
- Avoid suggesting that they "relax." Do not leave alone.
- Provide assistance with all tasks during acute episodes of dyspnea.
- During an acute episode, do not discuss preventive measures.
- During nonacute episodes, teach relaxation techniques (e.g., audio recordings, guided imagery).
R:An anxious person has a narrowed perceptual field with a diminished ability to function. Anxiety tends to feed on itself, trapping the individual in a spiral of increasing anxiety, hyperventilation, and physical pain (Halter, 2018).
Level 3 Advanced Focused Interventions (specialty, all mental health settings)
CARP'S CUESThe diagnosis of fecal incontinence (FI) must be differentiated from diarrhea. Individuals with FI may inaccurately report diarrhea as the presenting problem. Conversely, diarrhea can be mislabeled as primary FI. Many of the causes of acute and chronic diarrhea in the older adult are treatable as adverse effects of medications, tube feedings, lactose intolerance, celiac disease, microscopic colitis, ischemic colitis, radiation proctitis, hypersecretory tumors, and diabetic diarrhea (Shah, Chokhavatia, & Rose, 2012). Fecal incontinence, defined as the involuntary loss of solid or liquid stool, is a common problem affecting 0.8 to 8.3% of the adult population. Individuals suffering from fecal incontinence often live a restricted life with reduced quality of life (Duelund-Jakobsen et al., 2016). First-line therapy should be conservative and usually include dietary adjustments, fiber supplements, constipating agents, mini enemas, or colonic irrigations, which can improve quality of life (Robson & Lembo, 2020).
Initiate Level 1 Interventions
When anxiety diminishes, assist the individual in recognizing signs and symptoms of anxiety and panic, including triggers.
R:Helping the individual to recognize the symptoms is also the first step in teaching him or her self-management techniques (*Queensland Mind Essentials, 2010).
- Help to see that mild anxiety can be a positive catalyst for change and does not need to be avoided.
- Request validation of your assessment of anxiety (e.g., "Are you uncomfortable now?").
- If the response is yes, continue with the learning process; if they cannot acknowledge anxiety, continue supportive measures until he or she can.
- When the individual can learn, determine usual coping mechanisms: "What do you usually do when you get upset?" (e.g., read, discuss problems, walk away, seek social support, or use addictive substances, such as smoke, drink alcohol, or use illicit drugs).
- Assess for unmet needs or expectations; encourage recall and description of what client experienced immediately before feeling anxious.
- Assist in reevaluation of perceived threat by discussing the following:
- Were expectations realistic? Too idealistic?
- Was it possible to meet expectations?
- Where in the sequence of events was change possible?
R:Verbalization allows sharing and provides an opportunity to correct misconceptions.
"Keep focused on manageable problems; define them simply and concretely" (Varcarolis, 2014).
R:Simply defined problems can result in concrete interventions (Varcarolis, 2014).
Teach anxiety interrupters for use when the individual cannot avoid stressful situations:
- Look up. Lower shoulders.
- Control breathing.
- Slow thoughts. Alter voice.
- Give self-directions (out loud, if possible).
- Exercise.
- Change facial expression.
- Change perspective: imagine watching a situation from a distance (*Grainger, 1990).
R:Relaxation techniques help the person switch the autonomous system from the fight-or-flight response to a more relaxed response (Varcarolis 2014).
Reduce or Eliminate Problematic Coping Mechanisms
Depression, withdrawal (see Ineffective Coping)
Violent behavior (see Risk for Other-Directed Violence)
Denial
- Develop an atmosphere of empathic understanding.
- Assist in lowering the level of anxiety.
- Focus on the present situation.
- Give feedback about current reality; identify positive achievements.
- Have the person describe events in detail; focus on specifics of who, what, when, and where.
R:Denial can be an effective defense mechanism when the situation is too stressful to cope. If the denial is interfering with function, refer to Ineffective Denial.
CLINICAL ALERTSomatic disorders include one or more physical symptoms that cause major persistent distress, problems in functioning, and disruption of life, which usually are not explained by medical evidence (APA, 2019). Henningsen explores somatic disorders and interventions that can be utilized by nurses in a nonmental health setting (2018). Suffering is not confined to the experience of bodily complaints; it also entails psychological and behavioral aspects, such as high health anxiety and checking behavior (Ibid). In most individuals, their suffering is dominated by the experience of bodily distress itself, but for others, anxiety is central to their suffering, and bodily symptoms are minor (Ibid). These individuals are often seen as "difficult to treat" (Ibid).
- One or more somatic symptoms that are distressing and/or result in significant disruption in daily life.
- One or more excessive thoughts, feelings, and/or behaviors related to the following somatic symptoms or associated health concerns: (1) disproportionate and persistent thoughts about the seriousness of one's symptoms; (2) persistently high level of anxiety about health or symptoms; and (3) excessive time and energy devoted to these symptoms or health concerns.
- Although any one symptom may not be continuously present, the state of being symptomatic is persistent and lasts more than 6 months.
If the Individual Has Multiple Physical Complaints, as with Somatic Disorder:
- Encourage expression of feelings.
- Acknowledge that symptoms must be burdensome.
- Initiate contact when not complaining.
R:This will provide positive feedback when symptom free.
- Listen to complaints. Explore with the person what increases the severity of the distress, stress, work conflicts, and home conflicts to help the individual see the link between stressors and symptoms.
R:Identifying factors that increase the person's symptoms rather than focusing on the causes may help (Henningsen, 2018).
Explain Toxic Thoughts (*Lyon, 2002)
- Avoid assigning negative meaning to an event.
- Avoid "reading someone else's mind."
- Avoid all-or-nothing, black-or-white thinking.
- Avoid making the worst of a situation.
- Attempt to fix the problem; avoid assigning blame.
- Practice "thought stopping" with toxic thinking.
R:Toxic thoughts can confuse the situation, increase anxiety, and reduce effective coping (Varcarolis, 2014).
Teach to Recognize That Certain Autonomic Thinking Can Trigger Anxiety (e.g., should, never, always); Role-play Alternative Thinking (Varcarolis, 2014)
R:Words that are more neutral and objective can reduce anxiety, e.g., sometimes, I can now (Varcarolis, 2014).
Advise How to Promote Resiliency (*Tusaie & Dyer, 2004; APA, 2019)
R:Resilience is a combination of abilities and characteristics that interact to allow an individual to bounce back, cope successfully, and function above the norm in spite of significant stress or adversity (*Tusaie & Dyer, 2004; APA, 2019). Environmental factors that favor resilience are perceived social support or a sense of connectedness (*Tusaie & Dyer, 2004; APA, 2019).
CLINICAL ALERTThe American Psychiatric Association (2020) describes resilience as the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress, such as family and relationship problems, serious health problems, or workplace and financial stressors. Research has shown that resilience is ordinary, not extraordinary.
Being resilient does not mean that a person does not experience difficulty or distress. Emotional pain and sadness are common in people who have suffered major adversity or trauma in their lives. In fact, the road to resilience is likely to involve considerable emotional distress.
Resilience is not a trait that people either have or do not have. It involves behaviors, thoughts, and actions that can be learned and developed in anyone. www.apa.org/helpcenter/road-resilience.
- Avoid minimizing positive experiences.
- Gently encourage humor.
- Encourage optimism.
- Avoid seeing crises as insurmountable problems (APA, 2019).
- During difficult times, keep a long-term perspective.
- Accept that change is a part of living (American Psychiatric Association, 2020).
- Share your situation with your support person(s).
- Encourage the pursuit of spiritual comfort through religion, nature, prayer, meditation, or other methods.
- Pay attention to your own needs and feelings.
- Take care of yourself to keep your mind and body primed to deal with situations that require resilience.
- Let yourself experience strong emotions, and also realize when you may need to avoid experiencing them at times in order to continue functioning (APA, 2019).
Initiate Health Teaching and Referrals as Indicated
- Encourage a healthy lifestyle and physical, social, and other activities, such as sleep hygiene, regular exercise, and fulfilling hobbies.
- Refer people identified as having chronic anxiety and maladaptive coping mechanisms for ongoing mental health counseling and treatment.
- Instruct (or refer) the individual for assertiveness training.
R:Assertiveness training helps one ask for what he or she wants, learn how to say no, and reduce the stress of unrealistic expectations of others.
- Instruct to increase activity level and reduce TV watching (refer to Risk-Prone Health Behavior for specific interventions).
R:Any type of physical movements can effectively reduce anxiety (*Blanchard, Courneya, & Laing, 2001). Exercise is an effective method for reducing state anxiety in breast cancer survivors (*Blanchard, Courneya, & Laing, 2001).
- Instruct in use of relaxation techniques (e.g., aromatherapy [orange, lavender], hydrotherapy, music therapy, massage, reflexology).
R:Complementary therapies, such as massage, aromatherapy, and hydrotherapy are useful in managing stress and anxiety (Decker, 2018). Music therapy is an effective nursing intervention in decreasing anxiety (*Wong, Lopez-Nahas, & Molassiotis, 2001).
- Provide telephone numbers for emergency intervention: hotlines, psychiatric emergency room, and on-call staff if available.
R:Providing access to help in the community can reduce feelings of aloneness and powerlessness.
Level 2 Extended Focused Interventions (pediatrics) (Hockenberry, Rodgers, & Wilson, 2018)
- Explain events that are sources of anxiety using simple, age-appropriate terms and illustrations, such as puppets and dolls, and allow to see or touch equipment.
R:Provide explanations that are age-appropriate events that can cause anxiety in children, such as water or strangers.
- Allow child to wear underwear and have familiar toys or objects.
R:Any strategy that increases comfort and familiarity can reduce anxiety.
- Assist the child to cope with anxiety.
- Establish a trusting relationship.
- Minimize separation from parents.
- Encourage expression of feelings.
- Involve the child in play.
- Prepare the child for new experiences (e.g., procedures, surgery).
- Provide comfort measures.
- Allow for regression.
- Encourage parental involvement in care.
- Allay parental apprehension, and provide them with information.
R:The presence of parents provides a familiar, stabilizing support. Parental anxiety influences the child's anxiety (Hockenberry, Rodgers, & Wilson, 2018).
- Assist a child with anger.
- Encourage the child to share anger (e.g., "How did you feel when you had your injection?").
- Tell the child that being angry is okay (e.g., "I sometimes get angry when I cannot have what I want.").
- Encourage and allow the child to express anger in acceptable ways (e.g., loud talking, running outside around the house, not hitting or throwing things).
R:Children need opportunities and encouragement to express anger in a controlled, acceptable way (e.g., choosing not to play a particular game or with a particular person, slamming a door, voicing anger). Unacceptable expressions of anger include throwing or breaking objects and hitting others. Children who are not permitted to express anger may develop hostility and perceive the world as unfriendly (Hockenberry, Rodgers, & Wilson, 2018).
Maternal Considerations
Level 2 Specialty Interventions
- Discuss expectations and concerns regarding pregnancy and parenthood with a woman alone, her partner alone, and then together as indicated.
R:Some fears are based on inaccurate information, which accurate data can relieve.
- Acknowledge anxieties and their normality (*Lugina et al., 2001):
- 1 week postpartum: worried about feeling tired and nervous about breasts, perineum, and infection
- 1 week postpartum: worried about baby's eyes, respirations, temperature, safety, and crying
- 6 weeks' postpartum: worried about partner's reaction to her and their baby
R:Providing emotional support and encouraging sharing may help clarify and verbalize fears, allowing the nurse to give realistic feedback and reassurance. If there was a previous fetal or neonatal death, provide opportunities for both mother and partner to share their feelings and fears.
R:Partners of women with a previous pregnancy loss or neonatal death are often expected to appear strong to support their partner. Research reported that men who experience this very personal tragedy need as much emotional support and opportunities to share their grief as the mother (*McCreight, 2004).