Chapter 19 A Primary initial deficit occurs in mood or ability to manage anxiety, although there may be changes in cognition and behavior B Anxiety disorders are the most common of all psychiatric disorders, resulting in distress and functional impairment; rarely treated in inpatient settings unless anxiety is extreme and functioning is impaired or if treated concurrently with another mental health disorder C Anxiety and depressed mood may find expression in physical symptoms associated with somatoform and dissociative disorders D Acting out occurs because of fear, not antisocial tendencies A Provide an environment that limits demands and permits attention to resolution of conflicts; establish a trusting relationship B Identify precipitating stressors and limit them if possible C Intervene to protect from acting out on impulses that may be harmful to self or others D Accept symptoms as real to client; do not emphasize or call attention to them E Attempt to limit client’s use of negative defenses, but do not try to stop them until ready to give them up F Help to develop appropriate ways of managing anxiety-producing situations through problem solving and cognitive/behavioral therapies; assist to expand supportive network; assist significant others to understand the client’s situation G Plan a routine schedule of activities H Manage aggressive behavior progressively (e.g., diversion, limit setting, medication administration, seclusion, restraints) I Collect and document information to assist with determining presence of both an anxiety disorder and depression (comorbidity) J Encourage to develop a balance between work and relaxation 1. Psychologic, behavioral, and neurobiologic theories are postulated; the latter is most promising 2. Functions to permit some measure of social adjustment 3. Commonly begins in early adulthood as a result of environmental factors and pressures of decision making; early life is rigid and orderly 4. Excessive anxiety and worry involves at least two life situations 5. Unrelated to physiologic effects of substances or a medical condition B Behavioral/clinical findings 1. Persistent anxiety (longer than 6 months) and excessive worry associated with three or more of the following symptoms: restlessness (akathisia) or feeling on-edge, becomes easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance 2. Inability to control the anxiety 3. Impairment in social or occupational relationships 4. Symptoms of autonomic hyperarousal (e.g., tachycardia, tachypnea, dizziness, and dilated pupils); however, they are less prominent than in other anxiety disorders C Therapeutic interventions: same as those listed under Panic Disorders 1. Biochemical and genetic theories are most often cited as the underlying cause; no one gene or biochemical dysfunction has been identified 2. Onset varies, most often noted between late adolescence and mid-30s; infrequently may begin in childhood or after age 45; early life rigid and orderly 3. Discrete periods of intense discomfort for more than 1 month in duration 4. Recurrent attacks of severe anxiety may be associated with a stimulus or can occur spontaneously 5. Pressures of decision making regarding lifestyle that occur in early adult years act as precipitating factors B Behavioral/clinical findings 1. Brief attacks of overwhelming, intense discomfort 2. Attack must be accompanied by four or more of the following symptoms: palpitations or accelerated heart rate; sweating; trembling or shaking; shortness of breath; feelings of choking, chest pain, or discomfort; nausea or abdominal distress; depersonalization; fear of losing control; fear of dying; paresthesias; and chills or hot flashes 1. Complete diagnostic workup to rule out physical illness 2. Psychotherapy, family therapy, group therapy, cognitive/behavioral therapies 3. Psychotropic medications: sedative/hypnotic and antianxiety agents are used short term when client is unable to cope or accomplish daily activities and until healthier coping emerges; antidepressants are used prophylactically in long-term therapy (see Chapter 16, Related Pharmacology, Psychotropic Medications, Sedative and Hypnotic Agents and Antianxiety/Anxiolytic Medications) 1. Anxiety unconsciously transferred to an inanimate object or situation, which then symbolically represents the conflict and can be avoided 2. Anxiety is severe if the object, situation, or activity cannot be avoided 3. Multiple theories as to cause (e.g., genetic, psychologic, developmental, and environmental); etiology is unverified 4. Onset begins in childhood; traumatic phobias can occur throughout the life span 5. Pressures of decision making regarding lifestyle that occur in the early adult years act as precipitating factors B Behavioral/clinical findings 1. Anxiety develops when exposed to a situation that threatens the sense of security 2. Active attempts to avoid the precipitating object/situation 3. Lifestyle is often greatly limited depending on the phobic object/situation 4. Fear of being trapped, embarrassed, or humiliated in social situations 5. Able to recognize that the fear is excessive or unreasonable but cannot control it 1. Agoraphobia: fear of being alone or in public places where help would not be immediately available if necessary (e.g., tunnels, bridges, crowds, buses, trains) 2. Social phobia: fear of doing something in public that could be embarrassing or cause negative evaluations (e.g., speaking, dancing, eating) 3. Specific phobia: fear of a particular object, animal, or situation 1. Same as those listed under Panic Disorder 2. Behavior modification: a counter-conditioning technique to overcome fears by gradually increasing exposure to feared object, situation, or animal (desensitization) or by continuous exposure to the feared stimulus until anxiety is extinguished (flooding) 1. See General Nursing Care of Clients with Anxiety Disorders 2. Identify and accept client’s feelings about phobic object or situation 3. Provide constant support if exposure to phobic object or situation cannot be avoided 4. Assist with relaxation and cognitive/behavioral techniques to control or diminish anxiety levels 1. Chronic anxiety disorder with decreased levels of serotonin 2. Control of anxiety with obsessions (intrusive recurring thoughts) or compulsions (repetitive ritualistic behaviors) 3. Compulsive behavior precedes obsessive thinking 4. Symptoms worsen with stress 5. OCD symptoms are similar in adults and children; adults recognize behavior is excessive and interferes with daily activities but cannot be controlled; children do not have this insight 6. Pressures of decision making regarding lifestyle that occur in the early adult years act as precipitating factors; some evidence that early life patterns were rigid and orderly B Behavioral/clinical findings 1. Major defensive mechanisms are isolation, undoing, and reaction formation; intellectual and verbal defenses are used 2. Thoughts persist and become repetitive and obsessive 3. Demonstrates indecisiveness and a striving for perfection and superiority 4. Anxiety and depression present in various degrees, particularly if rituals are prevented 5. Obsessions or compulsions consume most of client’s waking hours (at minimum more than 1 hour per day) and interfere with ADLs, occupation, social activities, or relationships 1. See General Nursing Care of Clients with Anxiety Disorders 2. Allow performance of the ritual initially unless ritual causes harm and must be stopped (e.g., excessive hand washing causing skin damage); eventually attempt to limit length and frequency of the ritual 3. Support attempts to reduce dependency on the ritual 4. Role model appropriate behavior and discuss adaptive responses 1. Follows a devastating event that is outside the range of usual human experience (e.g., rape, assault, military combat, hostage situations, natural or precipitated disasters) 2. Neurobiology of PTSD does not follow the usual fight-or-flight stress response; studies indicate a complex interaction of neuroendocrinology, neuroanatomy, genetics, and traumatic stress 3. Adult’s response involves intense fear, helplessness, or horror; child’s response involves disorganized or agitated behaviors 4. Traumatic event is persistently reexperienced as flashbacks, distressing dreams, sense of reliving the experience, or exposure to situations (including anniversaries) that foster recall of the event B Behavioral/clinical findings 1. Exposure to a traumatic event resulting in death, threatened death, or serious injury to others or self 2. Responds to traumatic event with intense fear, confusion, helplessness, horror, or denial 3. Feelings of isolation and detachment; depression 4. Interrupted concentration; difficulty sleeping 6. Hypervigilance; hyperarousal; exaggerated startle reflex; avoidance of associated stimuli 7. Risk taking behaviors; substance abuse in attempt to control symptoms
Nursing Care of Clients with Disorders Related to Anxiety and Alterations in Mood
Overview
Major Disorders Associated with Anxiety
General Nursing Care of Clients with Anxiety Disorders
Generalized Anxiety Disorder (GAD)
Data Base
Panic Disorder
Data Base
Phobic Disorders
Data Base
Nursing Care of Clients with Phobic Disorders
Planning/Implementation
Obsessive-Compulsive Disorder (OCD)
Data Base
Nursing Care of Clients with Obsessive-Compulsive Disorders
Planning/Implementation
Posttraumatic Stress Disorder (PTSD)
Data Base
Nursing Care of Clients with Posttraumatic Stress Disorder
