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Carita Bird Region A Nursing Consortium NUR 112 ANXIETY Anxiety is a state of apprehension, dread, uneasiness, or uncertainty generated by a real or perceived threat whose actual source is unidentifiable ANXIETY • An emotional, subjective response • Involves feelings of apprehension, worry • In an acute form, it is known as “state anxiety” • In a chronic form, it is known as “trait anxiety” • Primary anxiety is related to psychological factors • Secondary anxiety results as a reaction to a physical health problem Fear • A reaction to a specific danger Stress • State of imbalance Stressors • Internal or external event that causes anxiety Client’s internal or external environment Physical illness Perception of the stressor Burnout • State of mental or physical exhaustion Anxiety can be a healthy, adaptive reaction Anxiety can be pathological Anxiety exists on a continuum • Mild • Moderate • Severe • Panic An automatic physical reaction to stress mediated by the sympathetic nervous system. A stressor is encountered Stress is the initial response to the stressor The “fight or flight” reaction occurs Increased alertness The body mobilizes resources Coping and defense mechanisms in play Psychosomatic symptoms Prolonged stress burnout Several theories have been proposed One’s theoretical viewpoint affects the selection of treatment modalities Theory based on Biological factors, Psychodynamic factors, Interpersonal factors, and Behavioral factors Social theorists Intrapersonal Cognitive Feminist theorists theorists theorists A look at clients experiencing phobias panic disorder generalized anxiety disorder Recognize that their fears or phobias are irrational Contact with or thought of contact with the phobia brings high anxiety Clients attempt to manage their phobia by avoidance Avoidance leads to interference with routine activities Agoraphobia • The fear of being incapacitated by being forced into or trapped in an unbearable situation from which there is no escape • Examples: crowds, standing in lines, traveling in a vehicle • Treatment: Cognitive therapy and graduated exposure or desensitization; anxiolytics for short term therapy • Nursing care: accept but do not support the phobia Social Phobia An excessive fear of embarrassment and humiliation in public places • Example: may be related to a specific situation or generalized to several similar situation i.e. business meetings or specific reunions • They strain interpersonal relationships and the individual may escalate when SOs try to help • Treatment: benzodiazepines, beta blockers, SSRIs and exposure therapy • Nursing care: acceptance but not support of the phobia Unrealistic fear of a particular object or situation • Stimulus may be an object or a concern • Example: spiders • Panic level anxiety • Consider the ethnic or cultural background of the client during assessment • Treatment: Cognitive therapy; desensitization, short term anxiolytics use • Nursing care: accept that the client has the phobia, but do not support it. Difficulty controlling unrealistic, excessive anxiety associated with common daily experiences Symptoms: • Restlessness • Irritability • Fatigue • Depression • Difficulty concentrating • Muscle tension • Sleep disturbance • Helplessness Symptoms May interfere with ADLs attempt to control symptoms by becoming dependent on ETOH or other substances Treatments: • Cognitive therapy • Relaxation therapy • Encourage clients to rethink their perceptions of the stressor • Medications: Selective serotonin reuptake inhibitors, tricyclic antidepressants and buspirone Individuals who have recurrent panic attacks for which the source may not be known. In between panic attacks, these individuals worry about another attack. The onset of the attack is sudden. Symptoms: • Desire to escape • Chest pain • Chills/hot flashes • Choking sensations, dizziness • Nausea • Palpitations • Shortness of breath • Sweating and trembling • Fear of loss of control Clients tend to associate their symptoms with physical illness Feelings of hopelessness, helplessness and despair Agorophobia may or may not be present Nursing care: • Provide calm, offer reassurance, use short clear sentences and remain with client during the panic attack • When the anxiety diminishes, encourage the client to assume care for self, reinforce appropriate coping strategies • Medications: SSRIs, benzodiazepines, and valporic acid are used to treat the panic attack. Beta blockers may reduce ANS symptoms Stress affects each client differently Determine the level of anxiety Anxiety disorders are seen in all settings Biological, psychological and social factors should be assessed Assessment should focus on the physical, affective, cognitive, social and spiritual symptoms of stress Anxiety Fear Ineffective individual coping Powerlessness Social isolation Used by clients to manage anxiety Coping strategies are determined by the individual’s intellect, emotional state, physical health, beliefs. Values Coping strategies may be effective or ineffective Common coping strategies include: breathing exercises, guided imagery, listening to music, recreational activities General life management techniques can be used to reduce stress • Diet • Exercise • Time management • Sleep Assessment of facts Development of goal Determination of alternatives for coping with the problem Identification of the risks and benefits Selection of an alternative Implementation of the selected alternative Evaluation of the outcome Modification of actions based on evaluation Emotional focused coping Altruism Conversion Denial Displacement Identification Intellectualization Introjection Isolation Projection Rationalization Reaction Formation Regression Repression Splitting Sublimation Suppression Undoing It is important to note that sublimation and altruism are always positive! Anxiety disorders are treated with antidepressants • Selective serotonin reuptake inhibitors • Tricyclic antidepressants • Beta adrenergic blockers • Antihistamines • Antiepileptics • Buspirone SSRIs have a more rapid onset of action and fewer side effects • Initially may cause nausea, loose bowel movements, headaches and insomnia • A rare but serious adverse reaction is serotonin syndrome Benzodiazepines – effective for anxiety Tx • May lead to dependency • Absorbed well via the GI tract • Onset of action is rapid – within an hour • Few drugs interact with benzodiazepines • Common side effects: ataxia, drowsiness, impaired cognition, memory and coordination • Don’t mix with alcohol • Withdrawal symptoms Buspirone – a serotonin partial agonist used in the short-term treatment of anxiety • Well absorbed orally • 2-3 weeks for full effectiveness • Side effects – light-headedness, drowsiness, headache, nausea • Side effects generally decrease over time • Not habit forming • Withdrawal is not an issue • High cost and slow onset of action preclude it from being widely used. • Should not be used as a PRN medication for anxiety Beta blockers – have a calming effect on the CNS • Propanolol – sometimes used for anxiety • Effective in treating the physical symptoms of anxiety such as tremors and tachycardia Antihistamines – used to treat lower levels of anxiety • Safe and nonaddictive • Can be purchased without a prescription • Used to lower anxiety in clients with substance abuse problems • Anticholinergic effects can be a problem for elderly clients Individual and group therapy – can be used to help anxious individuals develop insight into the reasons for their anxious feelings • Individual therapy Insight therapy Psychoanalysis Group therapy – effective therapy for treatment of anxiety which provides multiple sources of feedback • Growth groups • Support groups • Task groups • Self-help groups • Education groups Cognitive therapy – assists individuals to identify errors in thinking and plan responses to stressors • Encouraged to replace positive thought for the • • • • negative ones Brief and time-limited Structured and orderly Clients appraise stressors Questions are used by the practitioner to encourage the client to develop their own solutions Behavioral Therapy – a variety of activities to decrease anxiety • Response prevention • Systematic desensitization • Flooding • Thought-stopping