Stress and Anxiety Nursing Care Plan & Management

Notes

Description

People have various meanings for stress and anxiety. However, here is how the books define the two concepts:

  • Stress is the brain’s response to any demand. It is most often triggered by change (positive or negative, real or perceived).
  • Anxiety is anticipation of future threat.
Anxiety Levels and Effects

Anxiety is divided into different levels and each level has unique effects:

Mild

  • Characterized by an individual’s awareness that something is different and his attention is warranted by it.
  • There is increased in sensory stimulation which helps the individual focus his attention for learning.
  • Rarely threatens one’s coping ability; may motivate the individual to try new things and take risks.
  • Alert; more aware of environment and motivated to deal with existing problems in this state.
  • Behavioral and emotional responses: unable to sit still, fine tremors, a little impatient

Moderate

  • Person starts getting nervous or agitated. His perception is narrower and concentration is increased.
  • Feels fearful or uneasy but is still able to function. However, voice quivers and there may be changes in pitch.
  • Behavioral and emotional responses: uncomfortable, shaken, and sensitive

Severe

  • Believes that there is a threat.
  • Person feels very agitated, confused, and inadequate. Range of perception is reduced and anxiety interferes with effective functioning.
  • Person will feel threatened and either avoid the anxiety or become overwhelmed by it. Person is experiencing increased pulse/respirations with reports of dizziness, tingling sensations, and headache.

Panic

  • Ability to concentrate is disrupted; behavior is disintegrated.
Causes of Stress and Anxiety

Here are the causes of stress and anxiety:

  1. Psychobiological. These are the stressors that affect the integrity of the body (e.g. injuries).
  2. Psychological. Include various kinds of trauma.
  3. Psychosocial. Originates from interaction to people and manifested in different ways (e.g. sweating, high blood pressure, rapid heartbeat, etc.)
Anxiety-Related Disorders

When anxiety ceased to be beneficial, real illness sets in. In fact, anxiety disorders are the most common type of psychiatric disorders.

Overview
  • Anxiety disorders are group of conditions that share features of excessive fear(emotional response to real or perceived imminent threat) and anxiety and related behavioral disturbances.
  • Anxiety disorders appear comorbid but they differ in the types of objects or situations that induce fear and anxiety. These fear and anxiety are excessively and persistently beyond developmentally appropriate periods.
Generalized Anxiety Disorder (GAD)
  • Is characterized by anxiety that is persistent, overwhelming, uncontrollable, and out of proportion to stimulus.
  • Emerges slowly and tends to be chronic.
  • Usual onset is early 20s and affects 3% of the population.

Panic Disorder
  • Represents anxiety in its most severe form.
  • Characterized by recurrent, unexpected panic attacks that cause intense apprehension and feelings of impending doom. It may change patient’s behavior.
Obsessive-Compulsive Disorder (OCD)
  • Characterized by unwanted, recurrent, intrusive thoughts or images (obsession) that the person tries to alleviate through repetitive behaviors or mental acts (compulsions).
  • Obsession produces anxiety and compulsions are meant to reduce anxiety or prevent some dreaded event from happening. Compulsions typically are overt behaviors like hand washing, counting, and praying.
Phobic Disorder
  • Social phobia commonly involves anxieties about speaking or eating in public and using public restroom. It is associated with deep concern that others will see the patient’s anxiety symptoms (e.g. sweating, blushing) or will judge him as weak and stupid.
  • Specific phobias are divided into five subtypes: natural environment, animal, blood-injection-injury, situational, and others.
Post-traumatic Stress Disorder (PTSD)
  • Characterized by persistent, recurrent images and memories of a serious traumatic event that the person has either experienced or witnessed, impairing his ability to function. 
Causes of Anxiety-Related Disorders

Anxiety-related disorders are linked to a variety of factors:

  1. Genetic Factors. Some anxiety disorders (e.g. panic disorder, OCD, GAD) are inherited. A possibility of defective genes that regulate the neurotransmitters serotonin and dopamine is being researched.
  2. Biochemical Factors. Scientists believe in biological vulnerability to stress.
  3. Neuroanatomic Factors. MRI and other neuroimaging techniques reveal brain atrophy, underdeveloped frontal and temporal lobes, amygdala abnormalities (region for fear, memory, and emotion regulation), and hippocampus (region for emotion and memory storage).
  4. Other factors include traumatic events, medical conditions, and gender’s role in disorder development (women are at higher risk than men). Additional risk factors include marital separation or divorce, history of childhood physical or sexual abuse, and low socioeconomic status.
Medical Management

Individuals who are stressed and anxious can benefit from these therapies:

  • Social supports, psychotherapy, cognitive or behavioral therapy
  • Pharmacotherapy
  • Supportive counselling
Nursing Management

Here are the nursing responsibilities for taking care of patients who are stressed and anxious:

Nursing Assessment
  • Assess level of anxiety. Review familial and physiological factors (e.g. genetic depressive factors); psychiatric illness; active medical conditions (e.g. thyroid problems, metabolic imbalances). Monitor vital signs.
  • Description of feelings (expressed and displayed). Conduct interview and observe behaviors.
  • Awareness and ability to recognize and express feelings.
  • Related substance use, if present.
Nursing Diagnosis
  • Anxiety related to unconscious conflict about essential goals and values of life, threat to self-concept, positive or negative self-talk, or physiological factors (e.g. hyperthyroidism, pulmonary embolism, dysrhythmias).
Planning and Goals
  • Treatment plan and individual responsibility for activities.
  • Teaching plan.
Nursing Interventions
  • Assist clients to identify feelings and begin to deal with problems. Establish a therapeutic relationship. Be available to client for listening and talking. Assist client to develop self-awareness of verbal and nonverbal behaviors. Clarify meaning of feelings and actions by providing feedback and checking meaning with client. Most of all, acknowledge anxiety and fear. When dealing with children, be truthful and avoid bribing.
  • Promote wellness. Assist client with identifying new methods of coping with disabling anxiety. Review happenings, thoughts, and feelings preceding the anxiety attack. List helpful resources and people. Assist in developing skills (e.g. awareness of negative thoughts, saying “Stop”, and substituting a positive thought).
Evaluation
  • Client involvement
  • Client response to interventions, teaching, and actions performed.
Discharge and Home Care Guidelines

Instruct patient and family to adhere to these reminders:

  • Relaxation techniques (e.g. deep breathing, imagery, music therapy)
  • Maintaining learned positive coping strategies
  • Avoidance of triggers
  • Stress management techniques
  • Strict adherence to medication (if doctor prescribed) and therapy schedule

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Nursing Care Plan

Anxiety and Panic Disorders Nursing Care Plans

Anxiety

Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.

May be related to
  • lack of knowledge regarding symptoms, progression of condition, and treatment regimen.
  • actual or perceived threat to biologic integrity.
  • unconscious conflict about essential values and goals of life.
  • Situational and maturational crises.
Possibly evidenced by
  • Decreased attention span
  • Restlessness
  • Poor impulse control
  • Hyperactivity, pacing
  • Feelings of discomfort, apprehension or helplessness
  • Delusions
  • Disorganized thought process
  • Inability to discriminate harmful stimuli or situations
Desired Outcomes
  • Be free from injury
  • Discuss feelings of dread, anxiety, and so forth
  • Respond to relaxation techniques with a decreased anxiety level.
  • Reduce own anxiety level.
  • Be free from anxiety attacks.
Nursing Interventions Rationale
Maintain a calm, non threatening manner while working with the client. Anxiety is contagious and may be transferred from health care provider to client or vice versa. Client develops feeling of security in presence of calm staff person.
Establish and maintain a trusting relationship by listening to the client; displaying warmth, answering questions directly, offering unconditional acceptance; being available and respecting the client’s use of personal space. Therapeutic skills need to be directed toward putting the client at ease, because the nurse who is a stranger may pose a threat to the highly anxious client.
Remain with the client at all times when levels of anxiety are high (severe or panic); reassure client of his or her safety and security. The client’s safety is utmost priority. A highly anxious client should not be left alone as his anxiety will escalate.
Move the client to a quiet area with minimal stimuli such as a small room or seclusion area (dim lighting, few people, and so on.) Anxious behavior escalates by external stimuli. A smaller or secluded area enhances a sense of security as compared to a large area which can make the client feel lost and panicked.
Maintain calmness in your approach to the client. The client will feel more secure if you are calm and inf the client feels you are in control of the situation.
Provide reassurance and comfort measures. Helps relieve anxiety.
Educate the patient and/or SO that anxiety disorders are treatable. Pharmacological therapy is an effective treatment for anxiety disorders; treatment regimen may include antidepressants and anxiolytics.
Support the client’s defenses initially. The client uses defenses in an attempt to deal with an unconscious conflict, and giving up these defenses prematurely may cause increased anxiety.
Maintain awareness of your own feelings and level of discomfort. Anxiety is communicated interpersonally. Being with an anxious client can raise your own anxiety level. Discussion of these feelings can provide a role model for the client and show a different way of dealing with them.
Stay with the patient during panic attacks. Use short, simple directions. During a panic attack, the patient needs reassurance that he is not dying and the symptoms will resolve spontaneously. In anxiety, the client’s ability to deal with abstractions or complexity is impaired.
Avoid asking or forcing the client to make choices. The client may not make sound and appropriate decisions or may unable to make decisions at all.
Observe for increasing anxiety. Assume a calm manner, decrease environmental stimulation, and provide temporary isolation as indicated. Early detection and intervention facilitate modifying client’s behavior by changing the environment and the client’s interaction with it, to minimize the spread of anxiety.
PRN medications may be indicated for high levels of anxiety. Watch out for adverse side effects. Medication may be necessary to decrease anxiety to a level at which the client can feel safe.
Encourage the client’s participation in relaxation exercises such as deep breathing, progressive muscle relaxation, guided imagery, meditation and so forth. Relaxation exercises are effective nonchemical ways to reduce anxiety.
Teach signs and symptoms of escalating anxiety, and ways to interrupt its progression (e.g., relaxation techniques, deep- breathing exercises, physical exercises, brisk walks, jogging, meditation). So the client can start using relaxation techniques; gives the client confidence in having control over his anxiety.
Administer SSRIs as ordered. Panic attacks are caused by neuropsychiatric disorder that responds to SSRI antidepressants.
Help the client see that mild anxiety can be a positive catalyst for change and does not need to be avoided. The client may feel that all anxiety is bad and not useful.
Cognitive-behavioral therapy 
Positive reframing Turning negative messages into positive ones.
Decatastrophizing It involves the therapist’s use of questions to more realistically appraise the situation. It is also called the “what if” technique because the worst case scenario is confronted by asking a “what if” question.
Assertiveness training Helps the person take more control over life situations. These techniques help the person negotiate interpersonal situations and foster self-assurance.
When level of anxiety has been reduced, explore with the client the possible reasons for occurrence. Recognition of precipitating factors is the first step in teaching client to interrupt escalation of anxiety.
Encourage client to talk about traumatic experience under nonthreatening conditions. Help client work through feelings of guilt related to the traumatic event. Help client understand that this was an event to which most people would have responded in like manner. Support client during flashbacks of the experience. Verbalization of feelings in a nonthreatening environment may help client come to terms with unresolved issues.

Fear

Fear: Response to perceived threat that is consciously recognized as a danger.

May be related to
  • Phobic stimulus
  • Physiological symptoms, mental/cognitive behaviors indicative of panic
Possibly evidenced by
  • Acknowledge and discuss fears.
  • Demonstrate understanding through use of effective coping behaviors and active participation in treatment regimen.
  • Resume normal life activities.
Desired Outcomes
  • Client will be able to discuss phobic object or situation with the nurse.
  • Client will be able to function in presence of phobic object or situation without experiencing panic anxiety by time of discharge from treatment.
Nursing Interventions Rationale
Reassure client of his safety and security. At panic level anxiety, client may fear for own life.
Explore client’s perception of threat to physical integrity or threat to self-concept. It is important to understand the client’s perception of the phobic object or situation in order to assist with the desensitization process.
Present and discuss reality of the situation with client in order to recognize aspects that can be changed and those that cannot. Client must accept the reality of the situation before the work of reducing the fear can progress.
Suggest that the client substitute positive thoughts for negative ones. Emotion connected to thought, and changing to a more positive thought can decrease the level of anxiety experienced. This also gives the client an alternative way of looking at the problem.
Include client in making decisions related to selection of alternative coping strategies. Allowing the client choices provides a measure of control and serves to increase feelings of self-worth.
Encourage client to explore underlying feelings that may be contributing to irrational fears. Help client to understand how facing these feelings, rather than suppressing them, can result in more adaptive coping abilities. Verbalization of feelings in a nonthreatening environment may help client come to terms with unresolved issues.
Discuss the process of thinking about the feared object/situation before it occurs. Anticipation of a future phobic reaction allows client to deal with the physical manifestations of fear.
Encourage client to share the seemingly unnatural fears and feelings with others, especially the nurse therapist. Clients are often reluctant to share feelings for fear of ridicule and may have repeatedly been told to ignore feelings. Once the client begins to acknowledge and talk about these fears, it becomes apparent that the feelings are manageable.
Encourage to stop, wait, and not rush out of feared situation as soon as experienced. Support use of relaxation exercises. Client fears disorganization and loss of control of body and mind when exposed to the fear producing stimulus.This fear leads to an avoidance response, and reality is never tested. If client waits out the beginnings of anxiety and decreases it with relaxation exercises, then she or he may be ready to continue confronting the fear.
Explore things that may lower fear level and keep it manageable (e.g. singing while dressing, repeating a mantra, practicing positive self-talk while in a fearful situation). Provides the client with a sense of control over the fear. Distracts the client so that fear is not totally focused on and allowed to escalate.
Use desensitization approach:
  • Systematic desensitization
Systematic desensitization (gradual systematic exposure of the client to the feared situation under controlled conditions) allows the client to begin to overcome the fear, become desensitized to the fear. Note: Implosion or flooding (continuous, rapid presentation of the phobic stimulus) may show quicker results than systematic desensitization, but relapse is more common or client may become terrified and withdraw from therapy.
  • Expose client to a predetermined list of anxiety-provoking stimuli rated in hierarchy from the least frightening to the most frightening.
Experiencing fear in progressively more challenging but attainable steps allows client to realize that dangerous consequences will not occur. Helps extinguish conditioned avoidance response
  • Pair each anxiety-producing stimulus (e.g. standing in an elevator) with arousal of another affect of an opposite quality (e.g. relaxation, exercise, biofeedback) strong enough to suppress anxiety.
Helps client to achieve physical and mental relaxation as the anxiety becomes less uncomfortable.
  • Help client to learn how to use these techniques when confronting an actual anxiety-provoking situation. Provide for practice sessions (e.g.role-play), deal with phobic reactions in real- life situations.
Client needs continued confrontation to gain control over fear. Practice helps the body become accustomed to the feeling of relaxation, enabling the individual to handle feared object/situation.
Encourage client to set increasingly more difficult goals. Develops confidence and movement toward improved functioning and independence.
Administer antianxiety medications as indicated; watch out for any adverse side effects
Benzodiazepines:

  • Alprazolam (Xanax),
  • Clonazepam (Klonopin),
  • diazepam (Valium),
  • lorazepam (Ativan)
  • chlordiazepoxide (Librium),
  • oxazepam (Serax)
Biological factors may be involved in phobic/panic reactions, and these medications (particularly Xanax) produce a rapid calming effect and may help client change behavior by keeping anxiety low during learning and desensitization sessions. Addictive tendencies of CNS depressants need to be weighed against benefit from the medication.

Ineffective Coping

Ineffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.

May be related to
  • Situational crises
  • Maturational crises
  • Fear of failure
Possibly evidenced by
  • Ritualistic behavior or obsessive thoughts
  • Inability to meet basic needs
  • Inability to meet role expectations
  • Inadequate problem solving
Desired Outcomes
  • Client will decrease participation in ritualistic behavior.
  • Client will demonstrate ability to cope effectively.
  • Client will verbalize signs and symptoms of increasing anxiety and intervene to maintain anxiety at manageable level.
  • Client will demonstrate ability to interrupt obsessive thoughts and refrain from ritualistic behaviors.
Nursing Interventions Rationale
Assess client’s level of anxiety. Investigate the types of situations that increase anxiety and result in ritualistic behaviors. Helping the client recognize the precipitating factors is the first step in teaching the client to interrupt the escalating anxiety.
Initially meet the client’s dependency needs as necessary. Sudden and complete elimination of avenues for dependency would create anxiety and will burden the client more.
Encourage independence and give positive reinforcement for independent behaviors. Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors.
During the beginning of treatment, allow plenty of time for rituals. Do not be judgmental or verbalize disapproval of the behavior. To deny client this activity can precipitate panic level of anxiety.
Support and encourage client’s efforts to explore the meaning and purpose of the behavior. Client may be unaware of the relationship between emotional problems and compulsive behaviors. Recognition and acceptance of problems is important before change can occur.
Gradually limit the amount of time allotted for ritualistic behavior as client becomes more involved in unit activities. Anxiety is minimized when client is able to replace ritualistic behaviors with more adaptive ones.
Encourage the recognition of situations that provoke obsessive thoughts or ritualistic behaviors. Recognition of precipitating factors is the first step in teaching client to interrupt escalation of anxiety.
Provide positive reinforcement for nonritualistic behaviors. Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors.

Powerlessness

Powerlessness: The perception that one’s own action will not significantly affect an outcome; a perceived lack of control over a current situation or immediate happening.

May be related to
  • Lifestyle of helplessness
  • Fear of disapproval from others
  • Consistent negative feedback
Possibly evidenced by
  • Apathy
  • Dependence on others that may result in irritability, resentment, anger, and/or guilt.
  • Verbal expressions of having no control
  • Nonparticipation in care or decision making when opportunities are provided.
  • Reluctance to express true feelings.
Desired Outcomes
  • Client will participate in decision making regarding own care.
  • Client will be able to effectively problem-solve ways to take control of his or her life situation.
Nursing Interventions Rationale
Have client take as much responsibility for own self-care practices. Providing client with choices and responsibility will increase his or her feelings of control.
Help client set realistic goals. Unrealistic goals set the client up for failure and reinforce feelings of powerlessness.
Help identify areas of life situation that client can control. Client’s emotional condition prevents his ability to solve problems. Support is required to perceive the benefits and consequences of available alternatives.
Help the client identify areas of life situation that are not with his ability to control; encourage verbalization of these feelings. To deal with unresolved issues and accept what cannot be changed.
Identify ways and instances in which the client can achieve and encourage participation in these activities; provide positive reinforcement for participation. Positive reinforcement enhances self-esteem and encourages repetition of positive behaviors.

Social Isolation

Social Isolation: Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state.

May be related to
  • Maturational crisis.
  • Panic level of anxiety.
  • Past experiences of difficulty in interaction with others.
  • Repressed fears.
Possibly evidenced by
  • Uncommunicative
  • Withdrawn
  • No eye contact
  • Insecurity in public
  • Expression of feelings of rejection
  • Preoccupation with own thoughts; repetitive meaningless actions
Desired Outcomes
  • Client will willingly attend therapy activities accompanied by trusted support person.
  • Client will voluntarily spend time with other clients and staff members in group activities.
Nursing Interventions Rationale
Convey an accepting and positive attitude by making brief, frequent contacts. An accepting attitude increases feeling of self-worth and facilitates trust.
Show unconditional positive regard. To convey your belief in the client as a worthwhile individual.
Be with the client to offer support during group activities that may be frightening or difficult for him or her. The presence of a trusted individual provides emotional security for the client.
Be honest and keep all promises. Honesty and dependability promote a trusting relationship.
Be cautious with touch. Allow client extra space and avenue for exit if he becomes too anxious. A person in panic level anxiety may perceive touch as a threatening gesture.
Administer tranquilizing medications as ordered; monitor adverse side effects. Short-term use of antianxiety medications helps to reduce the level of anxiety in most individuals.
Discuss with the client the signs of increasing anxiety and techniques for interrupting the response such as breathing exercises, thought stopping, relaxation, meditation. Maladaptive behaviors are manifested during times of increased anxiety.
Give recognition and positive reinforcement for client’s voluntary interaction with others. Positive reinforcement enhances self-esteem and encourages repetition of acceptable behaviors.

Self-Care Deficit

Self-Care Deficit: Impaired ability to perform or complete activities of daily living (ADL) independently.

May be related to
  • Excessive ritualistic behavior
  • Disabling anxiety
  • Withdrawal
  • Unmet dependency needs
Possibly evidenced by
  • Unwillingness to perform self-hygiene.
  • Uncombed hair, dirty clothes, offensive body odor
  • Lack of interest in selecting appropriate clothing to wear
  • Incontinence
Desired Outcomes
  • Client will verbalize desire to take control of self-care activities.
  • Client will be able to take care of own ADLs and demonstrate a willingness to do so.
Nursing Interventions Rationale
Urge client to perform normal ADLs to his level of ability. Successful performance of independent activities enhances self-esteem.
Encourage independence. Intervene when client is unable to perform. Safety and comfort of the client are nursing priorities.
Offer recognition and positive reinforcement for independent accomplishments. Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors.
Show client how to perform activities with which he is having difficulty with. During high levels of anxiety, client may require simple, concrete demonstrations of activities that would be performed without difficulty under normal conditions.
Keep strict records of food and fluid intake. For an accurate nutritional assessment.
Offer nutritious snacks and fluids between meals. Client may be unable to tolerate large amounts of foods and mealtimes and may therefore require additional nourishment.

Deficient Knowledge

Deficient Knowledge: The state in which an individual or group experiences a deficiency in cognitive knowledge or psychomotor skills concerning the condition or treatment plan.

May be related to
  • Unfamiliarity with medications used and potential adverse effects.
Possibly evidenced by
  • Verbalizes a deficiency in knowledge or skill or requests information.
  • Expresses an inaccurate perception of health status.
  • Does not corretly perform desired or prescribed health behavior.
Desired Outcomes
  • Client states correct information about medications and adverse side effects.
Nursing Interventions Rationale
Explain the physiologic action of SSRI in relieving anxiety. Anxiety disorders are caused by neuropsychiatric disorder that responds to medication.
Assess for nausea, headache, nervousness, insomnia, agitation, sexual dysfunction. These are the common adverse effects of SSRIs. Treatment should be started at low doses and increased gradually as patient tolerates.
Assess for fatigue, drowsiness, and cognitive impairments. Common side effects of benzodiazepines.
A gradual tapering is necessary when a benzodiazepine is discontinued. Abrupt discontinuation can cause recurrence of anxiety.
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