Anxiety disorders are recognized as chronic conditions characterized by an overwhelming and persistent sense of apprehension. This often manifests in recurrent episodes of intense fear, terror, or acute nervousness, commonly known as panic attacks. The pervasive anxiety associated with these disorders can significantly impair an individual’s daily life, becoming difficult to manage and enduring for extended periods. A spectrum of anxiety disorders exists, each with unique characteristics.
Note: The term “Anxiety” in nursing diagnosis has been updated to “Excessive Anxiety” by NANDA International. However, for the purpose of broader understanding and accessibility, this article will continue to use “Anxiety” to align with common terminology, until the updated label is more widely adopted.
Types of Anxiety Disorders
- Anxiety disorder related to an underlying medical condition
- Generalized anxiety disorder
- Panic disorder
- Separation anxiety disorder
- Social anxiety disorder
- Specific phobias
Prevention Strategies
Predicting who will develop anxiety is complex, and individual experiences and coping mechanisms vary greatly. However, proactive prevention is crucial. Untreated anxiety increases the risk of depression, substance misuse, sleep disturbances, social isolation, reduced quality of life, and suicidal ideation. Recognizing these potential complications and addressing anxiety early, coupled with patient education on preventive and coping strategies, is paramount.
Causes of Anxiety
Anxiety can stem from a multitude of factors, and pinpointing a single cause is often challenging. Below are some common potential causes; however, this is not an exhaustive list:
- Co-existing medical conditions (e.g., heart disease, diabetes, chronic pain)
- Medication side effects
- Family history of anxiety disorders
- Stressful life events
- Other mental health conditions
- Substance or alcohol use
- Trauma – past traumatic experiences in childhood or adulthood
Signs and Symptoms of Anxiety
Individuals experiencing anxiety may present a wide array of symptoms, both verbalized feelings and observable physical manifestations. Nurses should be vigilant in recognizing and documenting these signs and symptoms.
Subjective Symptoms (Patient-Reported)
- Feelings of nervousness or unease
- Verbalizing a sense of impending danger or doom
- Difficulty controlling worry or racing thoughts
Objective Symptoms (Nurse-Observed)
- Restlessness or agitation and a tense demeanor
- Tachycardia (rapid heart rate)
- Tachypnea (rapid breathing)
- Hyperventilation (deep, rapid breathing)
- Diaphoresis (excessive sweating)
- Trembling or tremors
- Generalized weakness or fatigue
- Difficulty concentrating or focusing
- Sleep disturbances or insomnia
- Gastrointestinal distress
Expected Outcomes in Anxiety Care
The following are typical nursing care plan goals and desired outcomes for patients experiencing anxiety:
- Patient will acknowledge and openly discuss their fears and anxieties.
- Patient will articulate feelings of anxiety and propose healthy coping strategies.
- Patient will develop and effectively demonstrate problem-solving skills.
- Patient will identify and access appropriate support resources.
- Patient’s vital signs will stabilize and return to their normal baseline.
- Patient will establish and maintain a consistent sleep schedule.
Nursing Assessment for Anxiety
The initial step in nursing care is a thorough nursing assessment, encompassing physical, psychosocial, emotional, and diagnostic data collection. The subsequent sections detail subjective and objective data relevant to anxiety assessment.
1. Recognize and Validate Anxiety: Acknowledge the patient’s feelings of anxiety, assuring them that their emotions are valid and important.
2. Conduct a Comprehensive Head-to-Toe Assessment: This assessment helps identify physical manifestations of anxiety that the patient may not verbalize, and may uncover underlying medical conditions contributing to the anxiety.
3. Monitor Vital Signs: Anxiety can manifest in vital sign abnormalities, such as elevated heart rate (tachycardia) or breathing rate (tachypnea).
4. Determine the Degree of Anxiety and Perceived Threat: Assess the intensity of anxiety (mild, moderate, severe) and the patient’s perception of the anxiety-provoking situation. Individual responses to anxiety are unique, and care should be tailored accordingly.
5. Evaluate the Patient’s Ability to Focus: Anxiety often impairs concentration. Difficulty focusing can be an indicator of anxiety severity.
6. Observe Speech Patterns: Speech can provide insights into anxiety levels. Changes in speech rate, word choice, repetition, humor, or profanity may be observed.
7. Assess Situation Perception: A patient’s interpretation of a situation significantly influences their response and coping mechanisms.
8. Evaluate Current Coping Mechanisms: Understanding existing coping strategies helps tailor patient education and identify areas for improvement in managing anxiety.
Nursing Interventions for Anxiety
Nursing interventions and holistic care are vital for patient recovery and anxiety management. The following section outlines effective nursing interventions for patients experiencing anxiety.
1. Validate and Acknowledge Feelings: Acknowledging the patient’s feelings fosters trust and comfort in the nurse-patient relationship, promoting open communication.
2. Administer Medications as Prescribed: For patients with a history of anxiety, PRN (as needed) anxiety medications may be prescribed to manage breakthrough anxiety or panic attacks.
3. Practice Active Listening: Provide a safe space for patients to verbalize their feelings and explore the root causes of their anxiety. Active listening builds a therapeutic alliance.
4. Guide Patient in Relaxation Techniques: Instruct patients in guided imagery and other relaxation methods to promote relaxation and release endorphins, naturally reducing anxiety.
5. Educate on Coping Mechanisms: Teach new coping strategies or reinforce previously effective ones, empowering patients with self-management skills for future anxiety episodes.
6. Identify and Plan for Resources: Collaboratively identify resources for home and future support, and develop a plan for managing breakthrough anxiety episodes, promoting patient independence and security.
7. Encourage Regular Exercise and Activity: Educate patients on the anxiety-reducing benefits of regular physical activity, which elevates endorphin levels and improves well-being.
8. Teach Positive Self-Talk: Guide patients to identify and challenge negative internal dialogue, promoting positive self-perception and anxiety reduction through constructive self-talk techniques.
Nursing Care Plans for Anxiety
Nursing care plans prioritize assessments and interventions for both immediate and long-term care goals. The following sections present examples of nursing care plans for anxiety.
Care Plan #1
Diagnostic Statement:
Anxiety related to chest pain secondary to heart failure, as evidenced by diaphoresis and crying.
Expected Outcomes:
- Patient will report reduced or absent chest pain.
- Patient will maintain stable vital signs.
- Patient will exhibit a relaxed appearance without respiratory distress.
Assessment:
1. Assess Feelings Towards Chest Pain: Irrational thoughts, fears, and intense negative emotions associated with pain can exacerbate anxiety and potentially trigger panic.
2. Monitor Vital Signs: Elevated blood pressure and heart rate due to sympathetic nervous system activation during pain are expected. Post-treatment, a rapid decrease in blood pressure may occur.
Interventions:
1. Administer Prescribed Medications: Treat chest pain with indicated medications. Chest pain may indicate myocardial ischemia. Nitroglycerin, administered sublingually, is a vasodilator providing rapid relief from angina. Continuous monitoring of blood pressure, heart rate, and oxygen saturation is crucial.
2. Maintain a Calm Environment: Nurses’ anxiety can be contagious to sensitive patients. A calm and reassuring environment enhances patient stability and reduces anxiety.
3. Administer Supplemental Oxygen as Ordered: Oxygen supplementation increases oxygen supply to the heart, addressing the myocardial oxygen supply-demand imbalance.
4. Provide Comfort Measures: Comfort measures like massage, guided imagery, and aromatherapy reduce myocardial oxygen demand, making more oxygen available to the heart and alleviating chest pain.
5. Educate on Anxiety-Reducing Techniques: Teach techniques for managing anxiety in stressful situations:
- Look upwards, relax shoulders.
- Practice controlled deep breathing.
- Use self-affirmations (verbalize if possible).
- Engage in exercise.
- Visualize calming scenes.
These relaxation techniques shift the autonomic nervous system from “fight-or-flight” to a “rest and digest” response.
6. Educate on Chest Pain Triggers: Non-adherence to medications, emotional stress, and excessive exertion are potential angina triggers. Patient education on identifying and avoiding these triggers helps prevent anginal attacks and reduces associated anxiety.
Care Plan #2
Diagnostic Statement:
Anxiety related to impending surgery, as evidenced by restlessness and angry outbursts.
Expected Outcomes:
- Patient will demonstrate effective anxiety control techniques.
- Patient will exhibit reduced distress, indicated by calm facial expressions, gestures, and activity levels.
Assessments:
1. Assess Anxiety Level: Physiological signs and behaviors fluctuate with anxiety intensity. Mild anxiety may present with normal vital signs and reported nervousness. Moderate anxiety may show facial expression and voice tone changes with tension. Severe anxiety involves increased autonomic activity, manifesting as tachycardia, hypertension, diaphoresis, dry mouth, and muscle tension, along with agitation and irritability.
2. Assess Understanding of Surgery: Understanding the patient’s comprehension of the surgical procedure helps tailor health education to address specific knowledge gaps.
Interventions:
1. Use Simple and Concise Language: When explaining procedures, use clear, simple language and brief statements, as moderate to severe anxiety can impair comprehension of complex instructions. Adapt communication to the patient’s educational level, using visuals for pediatric patients if necessary.
2. Encourage Expression of Anxious Feelings: Talking about anxieties helps patients gain a realistic perspective and identify contributing factors.
3. Provide a Calm and Non-Threatening Environment: Excessive noise can escalate anxiety to panic. A calm environment minimizes external stimuli and promotes patient well-being.
4. Administer Medications as Indicated: Anxiolytics are used to treat anxiety disorders. In severe anxiety, when comfort measures are insufficient and the patient poses a threat to themselves or others, medication may be necessary.
5. Teach Anxiety Signs and Prevention: Educating patients about anxiety signs and triggers promotes self-awareness and enables proactive use of relaxation techniques for management.
6. Implement Non-Pharmacological Measures: Massage, therapeutic touch, and music therapy can reduce pre-surgical physiological stress and anxiety levels.
Care Plan #3
Diagnostic Statement:
Anxiety related to flashbacks secondary to PTSD, as evidenced by rumination and fidgeting.
Expected Outcomes:
- Patient will identify, verbalize, and demonstrate anxiety control techniques.
- Patient will report reduced or absent subjective distress.
Assessment:
1. Assess Anxiety Level and Physical Reactions: Utilize validated tools like the Hamilton Anxiety Scale to quantify anxiety symptoms (mood, fear, tension, insomnia, concentration, somatic complaints) on a severity scale. Observe physical signs like tachycardia, tachypnea, and nonverbal expressions of fear.
2. Determine Coping Strategies and Defense Mechanisms: Identify adaptive (exercise, self-care) and maladaptive (denial, projection) coping mechanisms used to manage anxiety. Assist patients in developing healthier coping strategies.
3. Identify Perceived Threat: Explore the patient’s perception of the threatening situation, as distorted perceptions can amplify anxiety. Understanding their perspective is crucial for personalized care planning.
Interventions:
1. Provide PTSD Education: Psychoeducation and social support can alleviate PTSD-related anxiety and worries. Understanding their condition empowers patients and promotes a sense of control. Deliver education with empathy and understanding.
2. Address Irrational Thoughts and Fears: Provide accurate information about procedures, diseases, or situations to counter irrational fears and enhance patient empowerment through knowledge.
3. Encourage Verbalization of Meaningful Events: Encourage patients to discuss the events contributing to their anxiety to understand the situation’s impact and facilitate processing.
4. Promote Positive Self-Talk: Reduce negative self-talk and cultivate positive self-affirmations to decrease anxiety levels.
5. Minimize Anxiety Sources: When feasible, remove or mitigate identified sources of anxiety or stress to provide long-term management and prevent anxiety-related physiological symptoms and comorbidities.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Kim, K.H., Kerndt, C.C., Adnan, G., et al. (2022). Nitroglycerin. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK482382/
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