Nursing Care of Clients with Anxiety Disorders

1. Nursing Care of Clients with Anxiety Disorders

2. Nursing care of a client with Panic Disorder Generalized Anxiety Disorders

3. Associated Nursing Diagnosis • Panic anxiety • Powerlessness • Fear • Social Isolation • Ineffective Coping • Ineffective Role Performance • Post-traumatic Syndrome • Disturbed Body Image • Disturbed Sensory Perception • Disturbed Thought process

4. 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

5. Outcome Criteria: Panic Anxiety • Short Term Goals: • The client will verbalize ways to intervene in escalating anxiety within 1 week • Long Term Goals: • By discharge the client will be able to recognize symptoms of anxiety onset and intervene before reaching panic level

6. 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

7. Nursing Interventions: Panic Anxiety • Decrease environmental stimuli (dim light, decrease number of people, simple décor,…) • Administer PRN Tranquilizers • When level of anxiety decrease, • 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…)

8. Nursing Diagnosis: Powerlessness • Powerlessness • Related to: • Impaired cognition • Evidenced by: • Verbal expression of no control over life situation & non participation in decision making related to own care

9. Outcome Criteria: Powerlessness • Short Term Goal: • Client will participate in decision making regarding own care • Long Term Goal: • Client will be able to use problem solving skills to control situations in own life

10. 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

11. Nursing Interventions: Powerlessness • 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

12. Nursing care of client with Phobic Disorder

13. Nursing Diagnosis: Fear • Fear • Related to: • Thought of causing embarrassment to self in front of others, being in a place from which one is unable to escape, or specific stimuli • Evidenced by: • Behavior directed toward avoidance of the feared object or situation

14. Outcome Criteria: Fear • 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 • Long Term Goal: • The client will be able to function in the presence of phobic object or situation without experiencing a panic attack

15. 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

16. 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.

17. 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.

18. 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.

19. 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

20. Nursing Diagnosis: Social Isolation • Social Isolation • Related to: • Fear of being in a place from which escape is not possible • Evidenced by: • Staying alone, refusing to leave room or home

21. Outcome Criteria: Social Isolation • Short Term Goals: • The client will willingly attend therapy activities by trusted support person for 1 week • Long Term Goals: • Client will spend time voluntarily with staff members in group activities by discharge

22. Nursing Interventions: Social Isolation • 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

23. Nursing Care of a client with OCD

24. 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)

25. Nursing Diagnosis: Ineffective Coping • Ineffective coping • Evidenced by: • 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)

26. Outcome Criteria: Ineffective coping • 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

27. Outcome Criteria: Ineffective coping • Long Term Goals: • Client will demonstrate the use of healthy coping strategies without resorting to previous unhealthy coping

28. 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

29. 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)

30. 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)

31. 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

32. Nursing Diagnosis: Ineffective Role Performance • Ineffective Role Performance • Related to: • Need to perform rituals • Evidenced by: • Inability to fulfill usual patterns of responsibility

33. Outcome Criteria: Ineffective Role Performance • Short Term Goal: • Client will verbalize understanding that rituals interfere with role performance in order to decrease anxiety • Long Term Goal • Client will be able to resume role related responsibilities by discharge

34. 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 • Identify specific stressors • Identify adaptive or maladaptive responses of both client & family members

35. 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

36. Nursing Diagnosis: Disturbed Body Image • Disturbed Body Image • Related to: • Repressed anxiety • 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

37. Outcome Criteria: Disturbed Body Image • Short Term Goal: • Client will verbalize understanding that changes in bodily structure or function is exaggerated (specific time) • Long Term Goal: • Client will verbalize perception of own body that is realistic to actual structure or function by discharge

38. Nursing Interventions: Disturbed Body Image • 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

39. Nursing care of a client with Post-traumatic Disorder

40. Nursing Diagnosis: Post-trauma Syndrome • Post-trauma Syndrome • Related to: • Distressing event considered to be outside the range of usual human experience • Evidenced by: • Flashbacks, intrusive recollections, nightmares, psychological numbness related to the event, dissociation, or amnesia.

41. Outcome Criteria: Post-trauma Syndrome • Short Term Goals: • Client will begin a healthy grief resolution, initiating the process of psychological healing (within time frame specific to individual). • 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.

42. 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.

43. 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.

44. 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.

45. Nursing Interventions: Post-trauma Syndrome • Determine those that have been most helpful, and discuss alternative strategies for the future. Include available support systems, including religious and cultural influences. • Identify maladaptive coping strategies (e.g., substance use, psychosomatic responses) and practice more adaptive coping strategies for possible future post-trauma responses.

46. Nursing Interventions: Post-trauma Syndrome • Assist the individual to try to comprehend the trauma if possible. • Discuss feelings of vulnerability and the individual’s “place” in the world following the trauma.

47. Nursing Diagnosis: Complicated Grieving • Complicated Grieving • Related to: • Loss of self as perceived prior to the trauma or other actual/perceived losses incurred during/following the event. • Evidenced by: • Irritability and explosiveness, self-destructiveness, substance abuse, verbalization of survival guilt or guilt about behavior required for survival

48. Outcome Criteria: Complicated Grieving • Short Term Goals: • Client will verbalize feelings (guilt, anger, self-blame, hopelessness) associated with the trauma. • Long Term Goal: • Client will demonstrate progress indealing with stages of grief and will verbalize a sense of optimism and hope for the future.

49. 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.

50. 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.