The Anxious Patient

Learning Objectives

• Differentiate among the cognitive, affective, behavioral, and physical symptoms of anxiety.
• Use the different manifestations of anxiety to assess the anxious patient.
• Select the most appropriate interventions for dealing with the patient with anxiety.
• Identify possible nurses' reactions to an anxious patient.

Glossary

Acute stress disorder– A disorder characterized by a high level of anxiety immediately after a traumatic event.

Agoraphobia– Fear, anxiety, or avoidance of places or situations from which escape may be difficult or where help may not be available.

Anxiety – An unpleasant feeling of tension, apprehension, and uneasiness or a diffuse feeling of dread or unexplained discomfort; accompanied by physiological, psychological, and behavioral symptoms; may serve as an early warning that alerts the individual to impending real or symbolic threat to self, significant others, or way of life; motivates the individual to take corrective action to relieve the unpleasant feelings. The source of the anxiety is often nonspecific or unknown to the individual.

Anxiety disorder due to a General Medical Condition – Anxiety characterized by prominent symptoms directly related to the physiological consequences of a general medical condition (e.g., hyperthyroidism or hypothyroidism, hypoglycemia, chronic obstructive pulmonary disease).

Fear – A reaction to a specific danger.

Generalized anxiety disorder– A disorder characterized by at least 6 months of persistent and excessive anxiety and worry.

Obsessive-compulsive disorder (OCD)– Recurrent thoughts or ideas (obsessions) that an individual is unable to put out of his or her mind and actions that an individual is unable to refrain from performing (compulsions).

Panic attack – A discrete, sudden, unpredictable, intense episode of severe anxiety characterized by personality disorganization; a fear of losing one's mind, going crazy, being unable to control one's behavior; a sense of impending doom, helplessness, and being trapped.

Post-traumatic stress disorder (PTSD)– Anxiety and stress symptoms that occur after a massive traumatic event; often includes the feeling that the event is reoccurring, lasting for weeks, months, or years.

Post-traumatic stress response – A persistent, disorganizing, and distressing reaction to a catastrophic event that affects a person's emotional, cognitive, and behavioral dimensions and relationships and extends beyond the time of the immediate crisis.

Social anxiety disorder– Intense, persistent fear of social situations.

Specific phobias – Irrational fears characterized by clinically significant anxiety provoked by exposure to a specific feared object or situation, often leading to avoidance behavior.

Substance-induced anxiety disorder– A disorder characterized by prominent anxiety symptoms directly related to physiological consequences of drug abuse, medication use, or toxin exposure.

Anxiety is the primary emotion from which many other emotions or responses, such as anger, guilt, shame, and grief, are generated. The term anxiety brings up images of someone pacing and wringing his or her hands with pounding heart and rapid breathing, perhaps before taking an important test in school or while waiting to hear from the doctor about results of a biopsy. Words such as worry, concern, fear, and uncertainty are often associated with the term anxiety.

Anxiety can also have a positive meaning, implying eagerness and readiness to face a challenge or perform some skill. Being mildly anxious can enhance experiences such as performing in a piano recital or completing a term paper. Anxiety is a healthy response to novel and unique experiences. In fact, being mildly anxious helps us to perform our best because perceptual, emotional, and physiological arousal can enhance learning, problem-solving, satisfaction, and pleasure during and after an event. Just as pain serves as a cue and a response to potential or actual physical danger, anxiety can serve as a cue and response to emotional, social, or spiritual danger.

Anxiety is a universal emotion; everyone has experienced some level of anxiety associated with life events. Anxiety disorders are the most common psychiatric disorder in America (Merikangus, 2006; Hollander & Simeon, 2003). Anxiety disorders affect 25% of the U.S. population (Merikangus, 2006). Social anxiety disorders are the most frequent form of anxiety disorders. It is triggered by certain types of performance situations (Bernardo, 2007). People vary significantly in their ability to manage feelings of anxiety and in their styles and patterns of coping with anxiety-producing situations. Knowing the meaning of the subjective experience to a particular individual is essential in understanding how to intervene with that individual. Fears are more specific, but the body reacts similarly to both fear and anxiety.

The DSM-IV-TR (2000) divides anxiety into these diagnostic categories: Panic Disorder with or without Agoraphobia, Social Phobia (also called social anxiety disorder), Specific Phobias, Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, Acute Stress Disorder, Anxiety Disorder due to a General Medical Condition, Generalized Anxiety Disorder, and Substance-Induced Anxiety Disorder. Panic attacks and Agoraphobia may occur alone or in the context of several of these disorders. For treatment purposes, anxiety is often categorized into four levels: mild, moderate, severe, and panic (Table 7-1 Characteristics of Anxiety Levels).

Mild or moderate anxiety usually speeds up physiological operations, whereas severe anxiety may slow them down. Prolonged panic can cause complete paralysis of functioning and occasionally result in death. Anxiety can also be classified as normal or abnormal. The same feelings and behaviors (uncertainties, helplessness, and an intense sense of personal discomfort) characterize both, and the level of anxiety may be equally intense.

Normal anxiety results from a realistic perception of the danger and prepares the person for defense or change in face of the threat. Normal anxiety can be motivating and useful (e.g., to motivate a student to study harder and therefore to do better on a test). Abnormal anxiety arises when the perception of danger is distorted, unrealistic, and out of proportion, resulting in maladaptive, defensive coping and inappropriate behavior.

Theoretical approaches to anxiety are wide ranging. In the biological perspective, anxiety is the uneasy feeling aroused by a threat or danger and is accompanied by a physiological response. This response prepares the person for “fight or flight.” The fight response (sympathetic stimulation) causes changes primarily in the cardiovascular and neuroendocrine systems. During the flight response (parasympathetic stimulation), which occurs in acute fear states, an effort is made to conserve body resources. Other evidence suggests a biological basis for anxiety. Research on the metabolism of monoamines and the function of the limbic system are central to the expression of emotions such as anxiety; the discovery of the benefits of benzodiazepines for chronic anxiety; and studies on sodium lactate in persons with panic attacks.

In psychoanalytical theory, anxiety represents a person's struggle with the demands and prohibitions in his or her environment, including the internal struggle among the person's instinctual drives (id), the realistic assessment of the possibility for need fulfillment (ego), and the conscience (superego). Anxiety is a signal from the ego that an unacceptable drive is pressing for conscious discharge. A conflict results between the drive, usually of a sexual or aggressive nature, and fear of punishment or disapproval. Phobias are fears that are disproportionate to the situation and cannot be explained or reasoned away. The significance and meaning of anxiety depend on the nature of the underlying conflict.

Interpersonaltheorists believe that anxiety arises from experiences in relationships with significant others (SOs) throughout a person's development. If a child is treated malevolently, the foundation is laid for the child to become insecure and feel inferior and anxious in future situations. The child is forced to use coping strategies to allay anxiety; these become part of the personality when the child becomes an adult.

Learning and behavioral theorists explain anxiety as the result of a conditioning process in which a neutral stimulus has come to represent punishment, pain, or fear. The individual learns to reduce anxiety by avoiding a negative stimulus or by approaching a positive reinforcer. Extinction of behavior is a process of reducing response strength by nonreinforcement.

An eclectic understanding of anxiety, incorporating components of all these theories, is most helpful. Anxiety can be understood as experienced at conscious, unconscious, or preconscious levels. Sources of anxiety fall into two major categories:

1. Threats to biologic integrity: Actual or impending interference with basic human needs such as food, drink, shelter, warmth, safety and health
2. Threats to self-security or self-esteem which can include:
• Unmet expectations important to self-integrity
• Unmet needs for status and prestige
• Anticipated disapproval by SOs
• Inability to gain or reinforce self-respect or to gain recognition from others
• A severe, sudden, unexpected threat to sense of security, self-esteem, or well-being
• Guilt or discrepancies between self-perception and actual behavior

Experiences with anxiety in early life lead to the development of coping behaviors, personality traits, and defense mechanisms intended to reduce anxiety and increase a sense of security. Over time, the individual develops characteristic patterns of relief behaviors intended to provide comfort and protection in the face of anxiety. When these behaviors, traits, or mechanisms fail to relieve anxiety, the patient experiences intense emotional or physical discomfort.

Behavioral responses to anxiety can be constructive (problem-solving, task-oriented) or destructive (defensive, aggressive, violent). When anxiety levels exceed a person's adaptive coping abilities, maladaptive behaviors may develop. Disturbed coping mechanisms are characterized by the inability to make choices, conflict, repetition and rigidity, and alienation. Frustration and anxiety can lead to anger, hostility, and violence.

Anxiety often increases when a person expects one thing and is suddenly confronted with something very different. The same stressor may not always lead to anxiety or the same level of anxiety in everyone or even in the same person at different times. Generally, the patient experiences anxiety as very painful and unbearable if it continues for any length of time. Behavior patterns used to cope with anxiety include the following:

Acting out:Converting anxiety into anger, which is either overtly or covertly expressed

Paralysis or retreating: Withdrawing or being immobilized by anxiety

Somatizing: Converting anxiety into physical symptoms such as stomachache or headache

Avoidance:Evasive behaviors performed unconsciously to ward off or relieve anxiety before it is directly experienced (alcohol, sleeping, keeping busy)

Constructive action: Using anxiety to learn and problem solve (goal setting, learning new skills, seeking information)

Syndromes of abnormal anxiety frequently observed in patients include the following:

Panic attacks: Acute, intense attacks of anxiety associated with extreme changes in physical and emotional behavior that can last from minutes to hours, are severely debilitating, and are characterized by sudden, intense, and discrete periods of anxiety and fear that may occur without warning in previously calm and untroubled individuals. Recent research points to physical or organic causes for some patients.

Post-traumatic stress disorder (PTSD): Re-experience of the trauma of a previous traumatic event (e.g., rape, assault, military combat, flood, earthquake, major car accident, airplane crash, bombing, torture). The symptoms are usually more severe and last longer when the cause is a manmade rather than a natural disaster. Three subtypes of PTSD are recognized:

• Acute: Symptoms begin within 6 months of the event and do not last longer than 6 months.
• Chronic: Symptoms last for 6 months or more.
• Delayed: Symptoms begin after a latency period of 6 months or more.

Re-experiencing the trauma in PTSD may include recurrent and intrusive recollections of the event, recurrent dreams or nightmares of the event, or sudden acting or feeling as if the event were recurring because of an association with an environmental or mental stimulus. Other behaviors and affect associated with the syndrome include decreased interest in usually significant activities, feelings of detachment or estrangement from others, and constricted affect. Symptoms not present before the trauma include hyperalertness or exaggerated startle response, sleep disturbance, guilt about surviving while others died or about behavior required for survival, memory impairment, difficulty concentrating, avoidance of activities that arouse recollection of the event, or intensification of symptoms by exposure to events that symbolize or resemble the traumatic event.

Phobia: An intense, irrational fear response to a specific external object or situation. Unlike an anxiety reaction, in which the anxiety is free floating and the person cannot easily identify the cause or source, a phobia is a persistent fear of specific places, things, or situations. The major dynamic mechanism of phobic behavior is the displacement of the original anxiety from its real source and the symbolization of the stressor in the phobia (e.g., fear of sex becomes a fear of snakes).

The hallmark of phobias is that they are irrational and persist even though the person recognizes that they are irrational. The unconscious operations involved in the phobia help the person to control anxiety by providing a specific object to attach it to. The phobic person can then control the intensity of the anxiety by avoiding the object or situation to which the anxiety has become attached. Some of the more common phobias include claustrophobia (fear of closed places), agoraphobia (fear of leaving home and of open spaces), acrophobia (fear of heights), xenophobia (fear of strangers), and zoophobia (fear of animals).

Obsessive-compulsive disorder (OCD): A paralyzing anxiety disorder associated with repetitive, compulsive thoughts (obsessions) and behaviors (compulsions). These patterns of thoughts and behaviors are senseless and distressing but help achieve the goal of avoiding anxiety. This disorder has been treated very effectively with some of the newer antidepressants, leading some investigators to think this disorder is related to serotonin reuptake.

Related Clinical Concerns

Anxiety is the most common complaint in medical practice (Epstein & Hicks, 2005). It presents in many ways and with great variation in intensity and duration; therefore, treatment must be individualized and monitored very closely. Anxiety may be caused by many other medical and psychiatric problems such as cardiac and vascular disorders, sleep disorders, hyperthyroidism, anemia, depression with agitation, dementia, delirium, hypochondriasis, schizophrenia, mania, and personality disorders. Some medications, caffeine intoxication, and withdrawal from alcohol or sedatives may cause anxiety. Anxiety can also contribute to medical illness such as arrhythmias and labile hypertension (Epstein & Hicks, 2005). Physical illness or underlying major psychiatric syndromes must be considered and ruled out before treatment for anxiety is undertaken. Because many patients with anxiety disorders do not present to mental health providers, general medical practitioners may be the first to identify anxiety disorders.

Children

The anxiety most frequently experienced by children is separation anxiety. When a child is separated from those to whom he or she is attached, excessive anxiety to the point of panic may occur. Onset may be as early as preschool age. The child may refuse to go to sleep or go to school. Complaints of physical symptoms, such as headache, stomachache, and nausea and vomiting are also common. The most common sign of anxiety in children is increased motor activity (Wong, 2003).

Older Adults

Anxiety in elderly people has not been systematically investigated. It is the consensus of clinical gerontologists that anxiety is a common response to the stresses of late life, including fear of dependency, illness, dying, and multiple losses of friends, home, or lifestyle. A long-standing tendency toward excessive anxiety can persist into late life and usually is not dysfunctional in the patient who has adapted to it. Anxiety in elderly persons may be the presenting symptom of a new illness, especially depression with agitation; of early dementia; or of low-grade or chronic toxic states caused by drugs or alcohol.

Possible Nurses' Reactions

• May be apprehensive and even fearful about caring for patients experiencing severe anxiety or a panic attack. Intense anxiety can be very contagious, not only to staff members but also to other patients.
• May try to determine the cause of patient’s anxiety and do what is possible to reassure and assist patient to decrease it, then become frustrated when patient’s anxiety continues.
• May find it too strenuous to work with patient for more than a day at a time if patient’s anxiety does not subside as the nurse thinks it should.
• May interpret the anxiety as a weakness in the patient, who is seen as unable or unwilling to control it or may judge the anxiety as part of a more serious psychological problem and feel very uncomfortable caring for these patients.
• May prefer to keep patient sedated.
• May feel resentment and even hostility toward anxious patients who require more attention and time than their physical conditions alone warrant.
• May want to avoid family members or SOs who are also quite anxious and make unreasonable requests in a demanding or complaining manner. Most of these behaviors may be caused by the families’ own frustration or apprehension in dealing with the patient’s anxiety, and they are often unaware that their behavior is affecting the staff.

Behavior and Appearance

See Table 7-1 Characteristics of Anxiety Levels for Characteristics of Anxiety Levels.

Mood and Emotions

• Dread, fear, apprehension
• Lack of control or self-confidence
• Guilt
• Anger
• Grief
• Sense of imminent catastrophe

Thoughts, Beliefs, and Perceptions

• Narrowed focus of attention
• Perceptual focus scattered or fixed
• Inability to focus on reality
• Inability to learn or remember, forgetfulness
• Inability to reason or problem solve
• Difficulty concentrating, lack of awareness of environment
• Distorted perceptions

Relationships and Interactions

• Withdrawal and isolation, avoidance behaviors
• Demanding, complaining, quarreling, attention-seeking behavior
• Defensive, uses denial
• Tense, strained relationships; others frustrated over dealing with patient's anxiety and maladaptive coping

Physical Responses

See Table 7-1 Characteristics of Anxiety Levels for physical responses to various anxiety levels.

Pertinent History

• Medical conditions that present with anxiety as a symptom
• Thyroid, pituitary, and adrenocortical disorders
• Low hemoglobin
• Hypoglycemia
• Impending heart attack
• Use if stimulants including crystal meth, cocaine, amphetamines
• Synergistic or idiosyncratic drug reactions
• Alcohol or sedative withdrawal
• Cerebrovascular disorders
• Sequelae to head injury
• Chronic anxiety
• Recent loss of loved one, significant object, work, finances, or self-esteem
• Phobic behavior
• Recent re-exposure to anxiety-causing situation
• Traumatic experience

Collaborative Management

Anxiety disorders are usually treated with some form of counseling or psychotherapy or pharmacotherapy, either alone or in combination. The milder forms may be effectively treated with cognitive or behavior therapy alone, but more severe and persistent symptoms may require pharmacotherapy.

Pharmacological

The medications typically used to treat patients with anxiety are benzodiazepines and antidepressants. Benzodiazepines, such as diazepam, lorazepam, clonazepam, and alprazolam, are the medications commonly prescribed for treating most types of anxiety, including short-term (situational) anxiety and long-term (generalized) anxiety. Unfortunately, because they are so efficacious and safe, these medications are often prescribed without full appreciation of the potential problem of physical dependency. OCD and PTSD are more effectively treated by antidepressants. Several drugs in the selective serotonin reuptake inhibitors (SSRIs) class of antidepressants including fluoxetine, sertraline, paroxetine, and fluvoxamine have emerged as the preferred type of antidepressant for treatment of OCD. Clonidine and beta blockers such as propranolol and atenolol are also used. Herbal products include kava kava and valerian. Another nonbenzodiazepine used for more long-term treatment is buspirone.

Psychological

During the past decade, there has been increasing enthusiasm and demand for focused, time-limited therapies that address ways of coping with anxiety symptoms directly rather than exploring unconscious conflicts or other personal vulnerabilities. These therapies emphasize cognitive and behavioral assessments and interventions, such as relaxation training, biofeedback, systematic desensitization, reframing, thought stopping, aversion therapy, and social skills training.

The hallmarks of cognitive-behavioral therapies are evaluating cause-and-effect relationships among thoughts, feelings, and behaviors, as well as using straightforward strategies to lessen symptoms and reduce avoidant behaviors. Therapeutic modalities such as guided imagery and muscle relaxation, exercise and rest programs, aromatherapy, and music and art therapy may be used as adjuncts to medication or alone. All mental health disciplines, including psychiatric mental health nurses, psychiatric social workers, psychologists, and psychiatrists, may use these anxiety reduction approaches in their collaborative treatment of clients with anxiety.

Anxiety

ANXIETY manifested by tension, distress, uncertainty related to threat to health, self-concept and lifestyle.

Patient Outcomes

• Demonstrates decreased level of anxiety
• Will report feeling less anxious after using coping strategies
• Will use coping strategies effectively when anxiety is recognized
• Demonstrates increased ability to prevent episodes of anxiety by problem solving

Interventions

• Speak in a calm, quiet voice; convey a sense of confidence and control and a tolerant, understanding attitude.
• Place patient in quiet environment; reduce distracting stimuli (e.g., noise, activity, light).
• Use discretion in conversations with patient and near patient's room.
• Recognize factors that may stimulate more anxiety.
• Reduce demands placed on patient until anxiety is reduced. Provide rest periods between tests, activities, and visitors.
• Provide diversional activity and exercise. Monitor changes in level of activity.
• Allow supportive others (clergy, social workers, volunteers) to visit patient. Explain tests and equipment to them so they can in turn be more relaxed around patient.
• Provide realistic feedback about patient's situation; do not give false reassurances. Help patient understand the anxiety by having him or her name the feeling.
• Encourage patient to express feelings (some crying and anger are appropriate).
• Have patient identify what happened just before the anxiety started and try to identify the causative event. Discuss the possible connection between the precipitating event and the meaning it has for the patient.
• Determine patient's usual coping mechanism in similar situations.
• Encourage patient to recall and think through similar instances of anxiety, what alternative behaviors could be used to cope more adaptively.
• Attempt to discuss what patient understands as cause of anxiety or panic once the anxiety level is reduced.
• Stay with patient but do not require explanations for the distress; individuals with severe or panic-level anxiety may become more agitated by attempts to communicate with them.
• Provide measures to relieve anxiety (e.g., warm bath, back rub, walk). Discuss other techniques for reducing anxiety (relaxation exercises, stress-reduction techniques) when patient is calmer and more rested. Encourage slow, deep breathing if patient is hyperventilating; breathing with patient to set pattern may be helpful.
• Assist patient in learning and problem solving when anxiety is diminished enough to allow concentration.
• Evaluate need for antianxiety medications; anxiolytics can be very effective in relieving panic; if none have been ordered, consult with physician for pharmacologic therapy.
• Assess for potential injury or violence to self or others.
• Give feedback about patient's current coping ability; reinforce any attempts to cope adaptively.
• Refer patients with recurrent anxiety and maladaptive coping mechanisms for further psychiatric/psychological evaluation and treatment.
• For patients with panic-level anxiety:
• Take patient to a quiet area with minimal stimuli.
• Administer anxiolytics as needed (ask what medications patient has used in past)
• Remain with patient through the attack.
• Give patient clear, honest feedback (“You are having a panic attack; I will stay with you”).

Ineffective Coping

INEFFECTIVE COPING. Individual evidenced by anxiety/fear/avoidance of objects or events, as well as irrational thoughts related to phobias, extreme guilt.

Patient Outcomes

• Demonstrate increased ability to think rationally and without undue guilt
• Identify thoughts and situations that evoke anxiety
• Show decreased anxiety related to improved thought processes and problem solving
• Demonstrate appropriate coping strategy for reducing anxiety related to phobia

Interventions

• Realize that phobic reactions are irrational and are not changed by rational, logical explanations; work around phobias (e.g., do not require a claustrophobic patient to use an elevator).
• Promote communication that reinforces rational thinking and decreases guilt.
• Verify your interpretation of what patient is experiencing (e.g., “I understand that you are afraid to go to the radiology department.”)
• Use words familiar to patient when describing new events or expectations.
• Help patient to clarify thoughts and avoid misinterpretation; ask meaning of anything that you do not understand.
• Do not talk around or whisper near patient; include patient in conversation and check that he or she heard what you actually said by asking him or her to repeat it.
• Set limits on discussing irrational material; focus on topics based in reality that you can verify.
• Avoid belittling or derogating when patient misinterprets stimuli or is irrational; do not laugh or make fun of the individual.
• Assist patient to set limits on own behavior; suggest alternative ways to cope with anxiety (e.g., take a walk instead of crying).
• Be aware of potential for violence; observe for changes in behavior indicating increased anxiety, irrational thoughts, or any destructive behavior that requires attention.
• Anticipate difficulties in adjusting to return or transfer to home or other facility; discuss concerns with family or SO.
• Let patient have some control in anxiety-provoking situation; do not force patient to do anything that seems to be extremely frightening.
• Provide time to discuss anxiety or fear while continuing supportive verbal and behavioral interventions.
• Refer patients with phobias for more specific treatment (e.g., desensitization, behavioral modification) to a psychiatrist, psychologist, advanced practice nurse, or social worker if anxiety is not managed by previous interventions.

Alternate Nursing Diagnoses

• Comfort, Impaired
• Fear
• Gas Exchange, Impaired
• Perception, Disturbed
• Post-Trauma Syndrome
• Sleep Deprivation
• Spiritual Distress
• Thought Processes, Disturbed
• Violence, Risk for

When to Call for Help

• Increased anxiety leading to refusal of treatment or noncompliance
• Onset of paranoid, psychotic thinking
• Onset of panic attack
• Staff conflict over management of patient behavior
• Increased staff anxiety over caring for patient.

Who to Call for Help

• Psychiatric Team
• Social Worker
• Chaplain
• Colleagues who know patient
• Patient's family/friends
• Coworkers

Patient & Family Education

• Teach patient and family or SO anxiety-reducing exercises such as muscle relaxation, guided imagery, music, or other activities for distraction.
• Discuss with patient and family or SO the causes and treatment of patient's anxiety.
• Review possible negative short-term and long-term effects of anxiety on physical and mental health.
• If patient is using antianxiety medications, review the need to monitor their use and potential problems when overused or discontinued without weaning.
• Educate on the use of appropriate medications to treat paralyzing symptoms such as OCD.

• Use objective assessment and nonjudgmental terms to describe behavior.
• Use patient's own words to describe amount and type of anxiety experienced.
• Note which interventions are most helpful in decreasing patient's anxiety and specific treatments that patient successfully learned to control own anxiety.
• Document family or SO responses to education about anxiety reduction methods.
• Document use of antianxiety medications and patient's response to them.

Community-Based Care

• Discharge can be a particularly anxiety-provoking time for many patients. Begin discharge planning early and include all caretakers in planning for future care needs.
• Allow enough time to discuss alternatives and provide as much emotional support as possible during the transition time.
• Discuss available community resources: their functions, services, capabilities, and limitations.
• If transferring patient to another facility or agency for follow-up care, provide information about patient's progress in and successful interventions for dealing with anxiety.
• Refer to a psychiatrist or internist specializing in psychotropics if patient has frequent panic attacks or chronic, moderate to severe anxiety.
• Refer family for counseling early in patient's hospitalization so that therapeutic behaviors that will minimize patient's anxious behavior can be learned before patient returns home.
• To ensure consistency, record and communicate to family or others responsible for patient after discharge, those interventions that worked well.