Anxiety
A vague, uneasy feeling of discomfort or dread accompanied by an
autonomic response, with the source often nonspecific or unknown to the
individual; a feeling of apprehension caused by anticipation of danger.
It is an altering signal that warns of impending danger and enables the
individual to take measures to deal with threat.
Defining Characteristics:
Behavioral
Diminished productivity;
scanning and vigilance;
poor eye contact;
restlessness;
glancing about;
extraneous movement (e.g., foot shuffling, hand/arm movements);
expressed concerns resulting from change in life events;
insomnia;
fidgeting
Affective
Regretful;
irritability;
anguish;
scared;
jittery;
overexcited;
painful and persistent increased helplessness;
rattled;
uncertainty;
increased wariness;
focus on self;
feelings of inadequacy;
fearful;
distressed;
apprehension;
anxious
Physiological
Voice quivering
Objective
Trembling/hand tremors; insomnia
Subjective
Shakiness; worried; regretful
Physiological-sympathetic
Increased pulse;
increased blood pressure;
increased tension;
cardiovascular excitation;
heart pounding;
superficial vasoconstriction;
respiratory difficulties;
increased respiration;
increased perspiration;
facial flushing;
facial tension;
pupil dilation;
anorexia;
dry mouth;
weakness;
increased reflexes;
twitching
Physiological-Parasympathetic
Decreased pulse;
decreased blood pressure;
abdominal pain;
nausea;
diarrhea;
urinary urgency;
urinary hesitancy;
urinary frequency;
tingling in extremities;
fatigue;
faintness;
sleep disturbance
Cognitive
Blocking of thoughts;
confusion;
preoccupation;
forgetfulness;
rumination;
impaired attention;
decreased perceptual field;
fear of nonspecific consequences;
tendency to blame others;
difficulty concentrating;
diminished ability to problem solve;
diminished learning ability;
awareness of physiological symptoms
Related Factors:
Unconscious conflict regarding essential values or life goals;
threat to self-concept;
threat of death;
threat to or change in health status,
environment,
interaction patterns;
situational or maturational crises;
interpersonal transmission of contagion; unmet needs
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
Anxiety Control
Aggression Control
Coping
Impulse Control
Client Outcomes
Identifies and verbalizes symptoms of anxiety
Identifies, verbalizes, and demonstrates techniques to control anxiety
Verbalizes absence of or decrease in subjective distress
Has vital signs that reflect baseline or decreased sympathetic stimulation
Has posture, facial expressions, gestures, and activity levels that reflect decreased distress
Demonstrates improved concentration and accuracy of thoughts
Identifies and verbalizes anxiety precipitants, conflicts, and threats
Demonstrates return of basic problem-solving skills
Demonstrates increased external focus
Demonstrates some ability to reassure self
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
Anxiety Reduction
Nursing Interventions and Rationales
1. Assess client's level of anxiety and physical reactions to anxiety
(e.g., tachycardia, tachypnea, nonverbal expressions of anxiety).
Validate observations by asking client, "Are you feeling anxious now?"
Anxiety is a highly individualized, normal physical and psychological
response to internal or external life events (Badger, 1994).
2. Use presence, touch (with permission), verbalization, and demeanor to
remind clients that they are not alone and to encourage expression or
clarification of needs, concerns, unknowns, and questions.
Being supportive and approachable encourages communication (Olson, Sneed, 1995).
3. Accept client's defenses; do not confront, argue, or debate.
If defenses are not threatened, the client may feel safe enough to look at behavior (Rose, Conn, Rodeman, 1994).
4. Allow and reinforce client's personal reaction to or expression of
pain, discomfort, or threats to well-being (e.g., talking, crying,
walking, other physical or nonverbal expressions).
Talking or otherwise expressing feelings sometimes reduces anxiety (Johnson, 1972).
5. Help client identify precipitants of anxiety that may indicate interventions.
Gaining insight enables the client to reevaluate the threat or identify new ways to deal with it (Damrosch, 1991).
6. If the situational response is rational, use empathy to encourage client to interpret the anxiety symptoms as normal.
Anxiety is a normal response to actual or perceived danger (Peplau, 1963).
7. If irrational thoughts or fears are present, offer client accurate
information and encourage him or her to talk about the meaning of the
events contributing to the anxiety.
This study shows that during diagnosis and management of cancer,
highlighting the importance of the meaning of events to an individual is
an important factor in making people anxious. Acknowledgment of this
meaning may help to reduce anxiety (Stark, House, 2000).
8. Encourage the client to use positive self-talk such as "Anxiety won't
kill me," "I can do this one step at a time," "Right now I need to
breathe and stretch," "I don't have to be perfect."
Cognitive therapies focus on changing behaviors and feelings by changing
thoughts. Replacing negative self-statements with positive
self-statements helps to decrease anxiety (Fishel, 1998).
9. Avoid excessive reassurance; this may reinforce undue worry.
Reassurance is not helpful for the anxious individual (Garvin, Huston, Baker, 1992).
10. Intervene when possible to remove sources of anxiety.
Anxiety is a normal response to actual or perceived danger; if the threat is removed, the response will stop.
11. Explain all activities, procedures, and issues that involve the
client; use nonmedical terms and calm, slow speech. Do this in advance
of procedures when possible, and validate client's understanding.
With preadmission patient education, patients experience less anxiety
and emotional distress and have increased coping skills because they
know what to expect (Review, 2000). Uncertainty and lack of
predictability contribute to anxiety (Garvin, Huston, Baker, 1992).
12. Explore coping skills previously used by client to relieve anxiety; reinforce these skills and explore other outlets.
Methods of coping with anxiety that have been successful in the past are
likely to be helpful again. Listening to clients and helping them to
sort through their fears and expectations encourages them to take charge
of their lives (Fishel, 1998).
13. Provide backrubs for clients to decrease anxiety.
In one study the dependent variable, anxiety, was measured prior to back
massage, immediately following, and 10 minutes later on four
consecutive evenings. There was a statistically significant difference
in the mean anxiety (STAI) score between the back massage group and the
no intervention group (Fraser, Kerr, 1993). In a discussion of the
results of a systematic review of 22 articles examining the effect of
massage on relaxation, comfort, and sleep, the most consistent effect of
massage was reduction in anxiety. Out of 10 original research studies, 8
reported that massage significantly decreased anxiety or perception of
tension (Richards, Gibson, Overton-McCoy, 2000).
14. Provide massage before procedures to decrease anxiety.
In one study parents performed massage on their hospitalized
preschoolers and school-age children before venous puncture. The results
obtained indicate that massage had a significant effect on nonverbal
reactions, especially those related to muscular relaxation (Garcia,
Horta, Farias, 1997).
15. Use therapeutic touch and healing touch techniques.
Various techniques that involve intention to heal, laying on of hands,
clearing the energy field surrounding the body, and transfer of healing
energy from the environment through the healer to the subject can reduce
anxiety (Fishel, 1998). In a recent study, anxiety was significantly
reduced in a therapeutic touch placebo condition. Healing touch may be
one of the most useful nursing interventions available to reduce anxiety
(Gagne and Toye in Fishel, 1998).
16. Provide clients with a means to listen to music of their choice.
Provide a quiet place and encourage clients to listen for 20 minutes.
Music is a simple, inexpensive, esthetically pleasing means of
alleviating anxiety. When allowed to participate in decision-making
regarding their care, patients can regain a partial sense of control. As
patient advocates, nurses should take advantage of the therapeutic
effect of music by incorporating it into their plan of care (Evans,
Rubio, 1994). Immediately and 1 hour after listening to music for 20
minutes in a quiet environment, reductions in heart rate, respiratory
rate, and myocardial oxygen demand were significantly greater in the
experimental group of patients with myocardial infarction than in the
control group (White, 1999).
17. For the client experiencing preoperative anxiety, provide music of their choice for listening.
A study indicates that music combined with preoperative instruction can
be more beneficial than preoperative instruction alone for reducing the
anxiety of ambulatory surgery patients. Patients who listened to their
choice of music before surgery in addition to receiving preoperative
instruction had significantly lower heart rates than patients in the
control group who received only preoperative instruction (Augustin,
Hains, 1996).
18. Animal-assisted therapy (AAT) can be incorporated into the care of perioperative patients.
A study of perioperative clients has shown that interacting with animals
reduces blood pressure and cholesterol, decreases anxiety, and improves
a person's sense of well-being ( Miller, Ingram, 2000).
19. Rule out withdrawal from alcohol, sedatives, or smoking as the cause of anxiety.
Withdrawal from these substances is characterized by anxiety (Badger, 1994).
20. Identify and limit, discontinue, or be aware of the use of any
stimulants such as caffeine, nicotine, theophylline, terbutaline
sulfate, amphetamines, and cocaine.
Many substances cause or potentiate anxiety symptoms.
Geriatric
1. Monitor client for depression. Use appropriate interventions and referrals.
Anxiety often accompanies or masks depression in elderly adults.
2. Provide a protective and safe environment. Use consistent caregivers and maintain the accustomed environmental structure.
Elderly clients tend to have more perceptual impairments and adapt to
changes with more difficulty than younger clients, especially during
illness (Halm, Alpen, 1993).
3. Observe for adverse changes if antianxiety drugs are taken.
Age renders clients more sensitive to both the clinical and toxic effects of many agents.
4. Provide a quiet environment with diversion.
Excessive noise increases anxiety; involvement in a quiet activity can be soothing to the elderly.
Multicultural
1. Assess for the presence of culture-bound anxiety states.
The context in which anxiety is experienced, its meaning, and responses
to it are culturally mediated. The following culture-bound syndromes are
related to anxiety: Susto-Latin America, Nervios-Latin America,
Dhat-Asia, Koro-Southeast Asia, Kayak angst-Eskimo, Taijin
kyousho-Japan, Nervous breakdown-African Americans (Kavanagh, 1999;
Charron, 1998).
2. Assess for the influence of cultural beliefs, norms, and values on the client's perspective of a stressful situation.
What the client considers stressful may be based on cultural perceptions (Leininger, 1996).
3. In the culturally diverse client identify how anxiety is manifested.
Anxiety is manifested differently from culture to culture through cognitive to somatic symptoms (Charron, 1998).
4. Acknowledge that value conflicts from acculturation stresses may contribute to increased anxiety.
Challenges to traditional beliefs and values are anxiety provoking (Charron, 1998).
Client/Family Teaching
1. Teach client and family the symptoms of anxiety.
If client and family can identify anxious responses, they can intervene
earlier than otherwise (Reider, 1994). Information is empowering and
reduces anxiety (Fishel, 1998).
2. Because intensive care unit (ICU) stays are increasingly shorter,
provide written teaching information that is readily available to
clients when they are transferred out.
Time constraints have become a barrier to effective teaching. A pamphlet
(available in Spanish and English) has been developed to ease the move
for patients, families, and critical care and medical nurses from a
medical ICU (MICU) to a general floor. Reading this pamphlet has helped
to reduce symptoms of anxiety (Maillet, Pata, Grossman, 1993).
3. Help client to define anxiety levels (from "easily tolerated" to "intolerable") and select appropriate interventions.
Mild anxiety enhances learning and adaptation, but moderate to severe anxiety may impede or immobilize progress (Peplau, 1963).
4. Consider referral for the prescription of antianxiety medications for
clients who have panic disorder (PD) associated with anxiety.
PD may be treated with drugs, psychosocial intervention, or both. In a
recent study, the combination of imipramine and cognitive-behavioral
therapy appeared to confer limited advantage acutely but more
substantial advantage by the end of maintenance (Barlow et al, 2000).
5. Teach client techniques to self-manage anxiety.
Mental health interventions during hospitalization should emphasize
teaching patients to manage their own anxiety instead of directly
intervening to reduce current levels of anxiety (Rose, Conn, Rodeman,
1994).
6. Teach client to identify and use distraction or diversion tactics when possible.
Early interruption of the anxious response prevents escalation.
7. Teach client to allow anxious thoughts and feelings to be present until they dissipate.
Allowing and even devoting time and energy to a thought, purposefully
and repetitively, reduces associated anxiety (Beck, Emery, 1985).
8. Teach progressive muscle relaxation techniques.
In one study, a significant reduction in anxiety level was obtained by
using progressive muscle relaxation interventions (Weber, 1996).
9. Teach relaxation breathing for occasional use: client should breathe
in through nose, fill slowly from abdomen upward while thinking "re,"
and then breathe out through mouth, from chest downward, and think
"lax."
Anxiety management training effectively treats both specific and generalized anxiety (Fishel, 1998).
10. Teach client to visualize or fantasize about the absence of anxiety
or pain, successful experience of the situation, resolution of conflict,
or outcome of procedure.
Use of guided imagery has been useful for reducing anxiety (Weber, 1996).
11. Teach relationship between a healthy physical and emotional lifestyle and a realistic mental attitude.
Health and well-being are influenced by how well-defined and met needs
are in areas of safety, diet, exercise, sleep, work, pleasure, and
social belonging. Exercise is an excellent means of decreasing anxiety
(Fishel, 1998). Results of cross-sectional and longitudinal studies seem
to indicate that aerobic exercise training has antidepressant and
anxiolytic effects and protects against harmful consequences of stress
(Salmon, 2000).
12. Teach use of appropriate community resources in emergency situations
(e.g., suicidal thoughts), such as hotlines, emergency rooms, law
enforcement, and judicial systems.
The method of suicide prevention found to be most effective is a
systematic, direct-screening procedure that has a high potential for
institutionalization (Shaffer, Craft, 1999).
13. Encourage use of appropriate community resources: family, friends,
neighbors, self-help and support groups, volunteer agencies, churches,
clubs and centers for recreation, and other persons with similar
interests.
One of the most reassuring elements of care includes access to the
family (Fishel, 1998). Vicarious experience provided through dyadic
support is effective in helping patients undergoing cardiac surgery to
cope with surgical anxiety and in improving self-efficacy expectations
and self-reported activity after surgery (Parent, Fortin, 2000).
14. Provide family members with information to help them to distinguish
between a panic attack and serious physical illness symptoms. Instruct
family members to consult a health care professional if they have
questions.
Education on managing anxiety disorders must include family members
because they are the ones usually called upon to take the client for
emergency care. Family members can be expert informants because of their
familiarity with the client's history and symptoms (Fishel, 1998).
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