Transcript Nursing Care For Anxiety Disorder

Nursing Care of Clients with
Anxiety Disorders
Nursing care of a client with
Panic Disorder
Generalized Anxiety Disorders
Associated Nursing Diagnosis
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Panic anxiety
Powerlessness
Fear
Social Isolation
Ineffective Coping
Ineffective Role Performance
Post-traumatic Syndrome
Disturbed Body Image
Disturbed Sensory Perception
Disturbed Thought process
Nursing Diagnosis: Panic Anxiety
Panic Anxiety
 Related to: real or perceived threat to
biological integrity or self-concept
 Evidenced by: Any or all of the physical
symptoms identified by the DSM-IV-TR
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Outcome Criteria: Panic Anxiety
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Short Term Goals:
◦ The client will verbalize ways to intervene in
escalating anxiety within 1 week
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Long Term Goals:
◦ By discharge the client will be able to
recognize symptoms of anxiety onset and
intervene before reaching panic level
Nursing Interventions: Panic Anxiety
Develop trust relationship through
communicating core communication
values (caring, acceptance, empathy, …)
 Stay with the client and offer reassurance
of safety & security
 Maintain a calm (staff & client),
nonthreatening, matter-of-fact approach
 Use simple wards & messages, spoken
calmly & clearly, to explain any procedure
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Nursing Interventions: Panic Anxiety
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Decrease environmental stimuli (dim light,
decrease number of people, simple décor,…)
Administer PRN Tranquilizers
When level of anxiety decrease,
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Explore possible reasons for occurrence
Help client recognize precipitating factors
Help client recognize early signs
Teach client ways to interrupt escalation of signs
(progressive relaxation, breathing exercises, or
physical exercises…)
Nursing Diagnosis: Powerlessness
Powerlessness
 Related to:
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◦ Impaired cognition
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Evidenced by:
◦ Verbal expression of no control over life
situation & non participation in decision
making related to own care
Outcome Criteria: Powerlessness
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Short Term Goal:
◦ Client will participate in decision making
regarding own care
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Long Term Goal:
◦ Client will be able to use problem solving
skills to control situations in own life
Nursing Interventions: Powerlessness
Develop a trust relationship
Allow the client to take responsibility for his\her own
self care
 Include client in setting goals & decision making by
providing choices that increase his/her sense of
control.
◦ Allow client to establish own schedule for self care.
◦ Include client in setting goals of care
◦ Provide client with privacy as need is determined
◦ Provide positive feedback for responsible
behaviours.
◦ Respect client’s right of decisions he/she made
independently, & refrain from trying to influence
him/her toward decisions that might seem more
logical
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Nursing Interventions: Powerlessness
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Assist the client to set realistic goals for his\her
daily activities; expectations from others and
self.
Help client identify areas of his\her life for
which control can be achieved.
Help the client to identify areas of life for which
control cannot be achieved
Help client to verbalize feelings about situations
that he/she can not control & discuss ways how
to live with it and accept it
Nursing care of client with Phobic
Disorder
Nursing Diagnosis: Fear
Fear
 Related to:
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◦ Thought of causing embarrassment to self in
front of others, being in a place from which
one is unable to escape, or specific stimuli
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Evidenced by:
◦ Behavior directed toward avoidance of the
feared object or situation
Outcome Criteria: Fear
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Short term Goal:
◦ Verbalize feelings of fear and discomfort
◦ Respond to relaxation techniques with decreased
anxiety
◦ Effectively decrease own anxiety level
◦ Decrease avoidance behaviors
◦ Manage the anxiety response effectively
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Long Term Goal:
◦ The client will be able to function in the presence
of phobic object or situation without
experiencing a panic attack
Nursing Interventions: Fear
Reassure client of his/her safety
 Allow the client to express feelings
openly.
 Teach the client and family or significant
others about phobic reactions. Dispel any
myths.
 Reassure the client that he or she can
learn to decrease the anxiety and gain
control over the anxiety attacks
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Nursing Interventions: Fear
Reassure the client that he or she will not be
forced to confront the phobic situation until
prepared to do so
 Assist the client to distinguish between the
phobic trigger and those problems related to
avoidance behaviors that are interfering with
daily life
 Instruct the client in progressive relaxation
techniques. These include deep breathing,
focusing on specific muscles to decrease
tenseness, and imagining.
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Nursing Interventions: Fear
Encourage the client to practice
relaxation until he or she is comfortable
and successful.
 Explain systematic desensitization
thoroughly to the client (see below).
 Reassure the client that you will allow
him or her as much time as needed at
each step.
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Nursing Interventions: Fear
Have the client develop a hierarchy of
situations that relate to the phobia.
 Begin with the least anxiety-producing
situation. Have the client use progressive
relaxation in that situation until he or she
is able to decrease the anxiety.
 If the client becomes excessively anxious
or begins to feel out of control, return to
the former step with which the client was
comfortable and successful.
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Nursing Interventions: Fear
Give positive feedback for the client's
efforts at each step. Avoid equating
success only with mastery of the entire
process.
 Discuss the previously identified
avoidance behaviors with client to
determine if there is a corresponding
decrease as client progress in systematic
desensitization
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Nursing Diagnosis: Social Isolation
Social Isolation
 Related to:
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◦ Fear of being in a place from which escape is
not possible
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Evidenced by:
◦ Staying alone, refusing to leave room or home
Outcome Criteria: Social Isolation
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Short Term Goals:
◦ The client will willingly attend therapy
activities by trusted support person for 1
week
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Long Term Goals:
◦ Client will spend time voluntarily with staff
members in group activities by discharge
Nursing Interventions: Social Isolation
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Develop trust relationship through:
◦ Conveying acceptance and regard
◦ Being honest and keeping promises
◦ Making brief frequent contacts
Attend group activities with client to provide
emotional security for client
Give space and avoid touch
Administer PRN tranquilizers
Discuss with client signs of increased anxiety
and techniques to interrupt it (relaxation …)
Give positive reinforcement for voluntary
interaction with others
Nursing Care of a client with OCD
Nursing Diagnosis: Ineffective Coping
 Ineffective
Coping
 Related to:
◦ Underdeveloped ego, punitive superego,
avoidance learning, biochemical changes
(OCD)
◦ Repressed anxiety, unmet dependency needs
(Somatoform disorder)
◦ Severe psychosocial stressors or substance
abuse and repressed severe anxiety
(Dissociative disorder)
Nursing Diagnosis: Ineffective Coping
Ineffective coping
 Evidenced by:
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◦ Ritualistic behavior, obsessive thoughts (OCD)
◦ Verbalization of numerous physical complaints,
self centered, presence of physical symptoms
with no path-physiology (somatic disorders)
◦ Sudden travel away from home with inability
to recall previous identity (dissociative
disorders)
Outcome Criteria: Ineffective coping
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Short Term Goals:
◦ Client will decrease participation in ritualistic
behavior by half within 1 week
◦ Client will verbalize understanding of
correlation between physical symptoms or
dissociative behavior & anxiety or stressful
psychosocial stress
◦ Client will verbalize more adaptive ways of
coping in stressful situations than resorting to
dissociation or physical complaint or
symptoms
Outcome Criteria: Ineffective coping
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Long Term Goals:
◦ Client will demonstrate the use of healthy
coping strategies without resorting to
previous unhealthy coping
Nursing Intervention: Ineffective coping
Develop trust relationship through
communicating acceptance, understanding,
respect ….
 Reassure the client for safety & security by your
presence
 Accept client’s behavior (physical complaint) &
do not deny client’s feelings
 Give space and allow ritualistic behavior of
complaint at the beginning of treatment without
judgment
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Nursing Intervention: Ineffective coping
Initially meet the client’s dependency needs as
required, & encourage independence & give
positive rewards for independent behavior
 Identify factors or stressors that precipitate
severe anxiety
 Support client & help him/her to verbalize &
explore meaning & purpose the exhibited
behavior (OCD, dissociative or physical
complaint)
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Nursing Intervention: Ineffective coping
Provide structured schedule to divert from the
unwanted behavior (ritualistic or physical
complaint) – allow some time for ritualistic
behavior then decrease the allocated time for it
gradually Explain that new physical complaint will be
referred to the physician with no further
attention
 Help client to learn ways to interrupt
unhealthy behaviors (ritualistic, complaining of
physical symptoms)
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Nursing Intervention: Ineffective coping
Discuss possible alternative coping strategies to
use in response to stress – relaxation,
exercise… Give positive reinforcement for use of healthy
coping strategies
 Help client identify ways of getting recognitions
from others without resorting to physical
symptoms
 Identify community resources for support to
prevent unhealthy coping behaviors from
reoccurring
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Nursing Diagnosis: Ineffective Role Performance
Ineffective Role Performance
 Related to:
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◦ Need to perform rituals
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Evidenced by:
◦ Inability to fulfill usual patterns of
responsibility
Outcome Criteria: Ineffective Role Performance
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Short Term Goal:
◦ Client will verbalize understanding that rituals
interfere with role performance in order to
decrease anxiety
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Long Term Goal
◦ Client will be able to resume role related
responsibilities by discharge
Nursing Interventions: Ineffective Role Performance
Assess extent of role alteration by exploring
client’s role and other family members’ roles
 Discuss client & family members perception of
the role and determine if it is realistic
 Encourage the client to discuss conflict within
family system in order to produce change in
family system if needed
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◦ Identify specific stressors
◦ Identify adaptive or maladaptive responses of both
client & family members
Nursing Interventions: Ineffective Role Performance
Explore available options for changes or
adjustments in role
 Plan & rehearse through role play, of potential
role transition this will help to decrease anxiety
 Encourage the participation of family members
who are directly involved in planning and
helping client to work through the changes
 Give the client positive reinforcement for
ability to resume role responsibilities
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Nursing Diagnosis: Disturbed Body Image
Disturbed Body Image
 Related to:
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◦ Repressed anxiety
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Evidenced by:
◦ Preoccupation with imagined or real defect,
verbalizations that are out of proportion to any
actual physical abnormality that may exist,
numerous visits to dermatologists to seek help
Outcome Criteria: Disturbed Body Image
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Short Term Goal:
◦ Client will verbalize understanding that
changes in bodily structure or function is
exaggerated (specific time)
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Long Term Goal:
◦ Client will verbalize perception of own body
that is realistic to actual structure or function
by discharge
Nursing Interventions: Disturbed Body Image
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Assess client’s perception of his/her body image, keep
in mind that body image is real for the client
Help client to see that his/her body image is
distorted and exaggerated recognition is necessary
before accepting reality
Encourage verbalization of fears & anxieties
associated with life situations-verbalization help the
client to come to term with unresolved issues
Discuss alternative coping strategies
Involve client in activities that reinforce positive self
image –to develop self satisfaction based on
accomplishments
Nursing care of a client with Posttraumatic Disorder
Nursing Diagnosis: Post-trauma
Syndrome
Post-trauma Syndrome
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◦ Distressing event considered to be outside
the range of usual human experience
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Evidenced by:
◦ Flashbacks, intrusive recollections, nightmares,
psychological numbness related to the event,
dissociation, or amnesia.
Outcome Criteria: Post-trauma
Syndrome
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Short Term Goals:
◦ Client will begin a healthy grief resolution,
initiating the process of psychological healing
(within time frame specific to individual).
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Long Term Goal:
◦ The client will integrate the traumatic
experience into his or her persona, renew
significant relationships, and establish
meaningful goals for the future.
Nursing Interventions: Post-trauma Syndrome
Assign the same staff as often as possible.
 Use a nonthreatening, matter of-fact, but
friendly approach.
 Respect client’s wishes regarding interaction
with individuals of opposite sex at this time
(especially important if the trauma was rape).
 Be consistent; keep all promises; convey
acceptance; spend time with client.
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Nursing Interventions: Post-trauma Syndrome
Stay with client during periods of flashbacks
and nightmares.
 Offer reassurance of safety and security and
that these symptoms are not uncommon
following a trauma of the magnitude he or she
has experienced.
 Obtain accurate history from significant
others about the trauma and the client’s
specific response.
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Nursing Interventions: Post-trauma Syndrome
Encourage the client to talk about the trauma
at his or her own pace.
 Provide a nonthreatening, private
environment, and include a significant other if
the client wishes.
 Acknowledge and validate client’s feelings as
they are expressed.
 Discuss coping strategies used in response to
the trauma, as well as those used during
stressful situations in the past.
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Nursing Interventions: Post-trauma Syndrome
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Determine those that have been most helpful,
and discuss alternative strategies for the
future. Include available support systems,
including religious and cultural influences.
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Identify maladaptive coping strategies (e.g.,
substance use, psychosomatic responses) and
practice more adaptive coping strategies for
possible future post-trauma responses.
Nursing Interventions: Post-trauma Syndrome
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Assist the individual to try to comprehend
the trauma if possible.
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Discuss feelings of vulnerability and the
individual’s “place” in the world following the
trauma.
Nursing Diagnosis: Complicated
Grieving
Complicated Grieving
 Related to:
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◦ Loss of self as perceived prior to the trauma
or other actual/perceived losses incurred
during/following the event.
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Evidenced by:
◦ Irritability and explosiveness, selfdestructiveness, substance abuse, verbalization
of survival guilt or guilt about behavior
required for survival
Outcome Criteria: Complicated
Grieving
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Short Term Goals:
◦ Client will verbalize feelings (guilt, anger, selfblame, hopelessness) associated with the
trauma.
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Long Term Goal:
◦ Client will demonstrate progress in dealing
with stages of grief and will verbalize a sense
of optimism and hope for the future.
Nursing Interventions: Complicated Grieving
Acknowledge feelings of guilt or self-blame
that client may express.
 Assess stage of grief in which the client is
fixed.
 Discuss normalcy of feelings and behaviors
related to stages of grief.
 Assess impact of the trauma on client’s ability
to resume regular activities of daily living.
 Consider employment, marital relationship,
and sleep patterns.
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Nursing Interventions: Complicated Grieving
Assess for self-destructive ideas and behavior.
 Assess for maladaptive coping strategies, such
as substance abuse.
 Identify available community resources from
which the individual may seek assistance if
problems with complicated grieving persist.
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Nursing care of a client with
Somatic Disorders
Nursing Diagnosis: Chronic Pain
Chronic Pain
 Related to:
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◦ Repressed anxiety & learned maladaptive
coping skills
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Evidenced by:
◦ Verbal complaints of pain with no pathophysiology, excessive use of analgesics
Outcome Criteria: Chronic Pain
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Short Term Goals:
◦ Client will verbalize relief from pain
◦ Client will verbalize understanding of the
relationship between pain & psychological
problem
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Long Term Goal:
◦ Client will demonstrate the ability to cope
with life situations with decreased experience
of pain responses
Nursing Interventions: Chronic Pain
Monitor physician on going assessment & lab
reports
 Accept the reality of the pain to the client
 Observe & record the onset, precipitating
factors, duration & intensity of the pain
 Provide prescribed pain medication
 Provide comfort measures such as back rub,
warm bath, hot pads that will meet the
secondary gains from being in pain
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Nursing Interventions: Chronic Pain
Offer attention when client is not complaining
of pain
 Identify activities that helps to distract the
client’s attention from complaints
 Encourage verbalization of feelings by
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◦ Exploring meaning of pain
◦ Connecting between pain & anxiety
◦ Identify situations that cause anxiety
Nursing Interventions: Chronic Pain
Encourage client to identify new health coping
strategies with stress
 Explore ways to intervene with pain (so that it
will not become disabling) such as deep
breathing, imagery, relaxation
 Provide positive reinforcement for times when
client is not focusing on pain
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Nursing Diagnosis: Fear (of having a serious illness)
Fear (of having a serious illness)
 Related to:
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◦ Past experience with life threatening illness of
self or significant others
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Evidenced by:
◦ Preoccupation with & unrealistic
interpretation of bodily signs & sensations
Outcome Criteria: Fear (of having a serious illness
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Short Term Goal:
◦ Client will verbalize that fear is associated with
bodily sensation are irrational
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Long Term Goal:
◦ Client will interpret bodily sensation correctly
Nursing intervention: Fear (of having a serious illness)
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Monitor physician’s ongoing assessment & lab reports
Refer to physician if new complaint occur
Assess gain or met needs by fear of illness
Assess precipitating factors, onset, duration & intensity
of fear & level of anxiety
Allocate specific time to discuss physical symptoms
(start with a certain length of session then decrease the
allocated time gradually)
◦ Verbalize feelings instead of converting it to physical symptoms
◦ Do not provide positive reinforcement to expressing of feelings
physically
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Teach the client coping strategies that will be helpful to
decrease levels of anxiety such as deep breathing,
relaxation, exercise
Nursing care of a client with
Dissociative Disorders
Nursing Diagnosis: Disturbed Thought Process
Disturbed Thought Process
 Related to:
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◦ Severe psychological stress & repression of
anxiety
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Evidenced by:
◦ Loss of memory
Outcome Criteria: Disturbed Thought Process
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Short Term Goals:
◦ The client will verbalize understanding that loss
of memory is related to stressful situation
◦ Client will discuss the stressful situation
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Long Term Goal:
◦ The client will
 Recover deficit in memory
 Develop more adaptive coping strategies to
deal with stress
Nursing Interventions: Disturbed Thought Process
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Obtain information from family about the client’s likes
& dislikes, important people, activities
Do not provide the client with excessive information
about his/her past
Expose client to pleasant experiences similar to ones
in his/her past to stimulate memory
Discuss underlying feeling of stressful situations &
how to deal with it
Assist client in identifying conflicts, identify solutions
& follow up on carrying out the resolution
Nursing Diagnosis: Disturbed Sensory Perception
(visual/kinesthetic)
Disturbed Sensory Perception
(visual/kinesthetic)
 Related to:
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◦ Repressed severe anxiety & psychological
stress
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Evidenced by:
◦ Loss or alteration in physical functioning with
no physical pathology (conversion); alteration
in the perception of the self or the
environment (depersonalization)
Outcome Criteria: Disturbed Sensory Perception
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Short Term Goal:
◦ Client will verbalize understanding of emotional
problems as a contributing factor to the
alteration in physical functioning
◦ Client will verbalize adaptive ways of coping
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Long Term Goal:
◦ Client will recover from lost or altered function
◦ Client will demonstrate the ability to perceive
stimuli correctly
◦ Client will maintain a sense of reality during
stressful situations
Nursing Interventions: Disturbed Sensory Perception
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Monitor physician’s on going assessment & lab
reports
Identify primary & secondary gains from physical
symptoms (dependency, attention, protection from
experiencing stress)
Provide support & encouragement during times of
depersonalization to lessen fear & anxiety
Explain the depersonalization (conversion) behavior &
the purpose it serves
Explain the relationship between severe anxiety and
depersonalization (conversion)
Nursing Interventions: Disturbed Sensory Perception
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Do not focus on disability & encourage client to
become more independent
Discuss painful experiences by exploring past
experiences and possible painful situations such as
trauma, losses ..etc.
Encourage client to deal with underlying feelings
associated with the stressful situation
Teach client more health ways of responding to stress
through role play
Give positive reinforcement for identification or
demonstration of more healthy coping skills that will
help in enhancing self esteem