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Anxiety Anxiety Disorders Chapter 8 Nursing


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Title: Anxiety Anxiety Disorders Chapter 8 Nursing

Anxiety Anxiety Disorders
  • Chapter 8

Concept of Anxiety and Psychiatric Nursing
  • Anxiety
  • Universal human experience
  • Dysfunctional behavior often defends against
  • Legacy of Hildegard Peplau (1909-1999)
  • Operationally defined concept and levels of
  • Suggested specific nursing interventions
    appropriate to each of four levels of anxiety

Psychological Adaptation to Stress
  • Anxiety and grief have been described as two
    major, primary psychological response patterns to
  • A variety of thoughts, feelings, and behaviors
    are associated with each of these response
  • Adaptation is determined by the extent to which
    the thoughts, feelings, and behaviors interfere
    with an individuals functioning.

Anxiety and Fear
  • Anxiety feeling of apprehension, uneasiness,
    uncertainty, or dread resulting from real or
    perceived threat whose actual source is unknown
    or unrecognized
  • Fear reaction to specific danger
  • Similarity between anxiety and fear
  • Physiological response to these experiences is
    the same (fight-or-flight response)

  • A diffuse apprehension that is vague in nature
    and is associated with feelings of uncertainty
    and helplessness.
  • Extremely common in our society.
  • Mild anxiety is adaptive and can provide
    motivation for survival.

Types of Anxiety
  • Normal
  • Motivating force that provides energy to carry
    out tasks of living
  • Acute or state
  • Anxiety that is precipitated by imminent loss or
    change that threatens ones security (crisis)
  • Chronic or trait
  • Anxiety that persists over time
  • Mild
  • Occurs in normal everyday living
  • Increases perception, improves problem solving
  • Manifested by restlessness, irritability, mild
    tension-relieving behaviors

Types of Anxiety
  • Moderate
  • Escalation from normal experience
  • Decreases productivity (selective inattention)
    and learning
  • Manifested by increased heart rate, perspiration,
    mild somatic symptoms
  • Severe
  • Greatly reduced perceptual field
  • Learning and problem solving not possible
  • Manifested by erratic, uncoordinated, and
    impulsive behavior
  • Panic
  • Results in loss of reality focus
  • Markedly disturbed behavior occurs
  • Manifested by confusion, shouting, screaming,

Peplaus four levels of anxiety
  • Mild seldom a problem
  • Moderate perceptual field diminishes
  • Severe perceptual field is so diminished that
    concentration centers on one detail only or on
    many extraneous details
  • Panic the most intense state

Behavioral adaptation responses to anxiety
  • At the mild level, individuals employ various
    coping mechanisms to deal with stress. A few of
    these include eating, drinking, sleeping,
    physical exercise, smoking, crying, laughing, and
    talking to persons with whom they feel

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Defense Mechanisms
  • Help protect people from painful awareness of
    feelings and memories that can cause overwhelming
  • Operate all the time
  • Adaptive (healthy) or maladaptive (unhealthy)
  • First outlined and described by Sigmund Freud and
    his daughter Anna Freud

Properties of Defense Mechanisms
  • Major means of managing conflict and affect
  • Relatively unconscious
  • Discrete from one another
  • Hallmarks of major psychiatric disorders
  • Can be reversible
  • Can be adaptive as well as pathological

Healthy, Intermediate, and Immature Defense
  • Healthy
  • Altruism, sublimation, humor, suppression
  • Intermediate
  • Repression, displacement, reaction formation,
    undoing, rationalization
  • Immature
  • Passive aggression, acting-out behaviors,
    dissociation, devaluation, idealization,
    splitting, projection, denial

Defense Mechanisms
  • Rationalization
  • Reaction formation
  • Regression
  • Repression
  • Sublimation
  • Suppression
  • Undoing
  • Compensation
  • Denial
  • Displacement
  • Identification
  • Intellectualization
  • Introjection
  • Isolation
  • Projection

  • Anxiety at the moderate to severe level that
    remains unresolved over an extended
  • period of time can contribute to a number of
    physiological disorders for example, migraine
    headaches, IBS, and cardiac arrhythmias.
  • Extended periods of repressed severe anxiety can
    result in psychoneurotic patterns of behaving
    for example, anxiety disorders and somatoform

Introduction Anxiety Disorder
  • Anxiety provides the motivation for achievement,
    a necessary force for survival.
  • Anxiety is often used interchangeably with the
    word stress however, they are not the same.
  • Anxiety may be differentiated from fear in that
    the former is an emotional process, whereas fear
    is cognitive.

  • Extended periods of functioning at the panic
    level of anxiety may result in psychotic
    behavior for example, schizophrenic,
    schizoaffective, and delusional disorders.

Epidemiological statistics
  • Anxiety disorders are the most common of all
    psychiatric illnesses
  • More common in women than men
  • Minority children and children from low
    socioeconomic environments at risk
  • A familial predisposition probably exists
  • How much is too much?
  • When anxiety is out of proportion to the
    situation that is creating it.
  • When anxiety interferes with social,
    occupational, or other important
  • areas of functioning.

Predisposing Factors
  • Psychodynamic theory
  • Cognitive Theory
  • Biological aspects
  • Transactional Model of Stress Adaptation

Panic Disorders Panic Attack, Panic Disorder
with Agoraphobia
  • Panic attack
  • Sudden onset of extreme apprehension or fear of
    impending doom
  • Fear of losing ones mind or having a heart
  • Panic disorder with agoraphobia
  • Panic attacks combined with agoraphobia
  • Agoraphobia is fear of being in places or
    situations from which escape is difficult or help
  • Feared places avoided, restricting ones life

  • Phobia persistent, irrational fear of specific
    objects, activities, or situations
  • Types of phobias
  • Specific response to specific objects
  • Social result of exposure to social situations
    or required performance
  • Agoraphobia fear of being in places/situations
    from which escape is difficult or help

Obsessive-Compulsive Disorder (OCD)
  • Obsession
  • Thoughts, impulses, or images that persist and
  • Ego-dystonic symptom feels unacceptable to
  • Unwanted, intrusive, persistent ideas, thoughts,
    impulses, or images that cause marked anxiety or

  • Ritualistic behaviors that individual feels
    driven to perform
  • Primary gain from compulsive behavior anxiety
  • Unwanted repetitive behavior patterns or mental
    acts that are intended to reduce anxiety, not to
    provide pleasure or gratification

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Generalized Anxiety Disorder (GAD)
  • Excessive anxiety or worry about numerous things
    lasting at least 6 months
  • Common symptoms
  • Restlessness
  • Fatigue
  • Poor concentration
  • Irritability
  • Tension
  • Sleep disorders

Post-traumatic Stress Disorder (PTSD)
  • Development of characteristic symptoms following
    exposure to an extreme traumatic stressor
    involving a personal threat to physical integrity
    or to the physical integrity of others
  • Characteristic symptoms include reexperiencing
    the traumatic event, a sustained high level of
    anxiety or arousal, or a general numbing of
    responsiveness. Intrusive recollections or
    nightmares of the event are common.

  • Psychosocial theory
  • The traumatic experience
  • Severity and duration of the stressor
  • Extent of anticipatory preparation before onset
  • Exposure to death
  • Numbers affected by life threat
  • Extent of control over recurrence
  • Location where trauma was experienced
  • The individual
  • Degree of ego-strength
  • Effectiveness of coping resources
  • Presence of preexisting psychopathology
  • Outcomes of previous experiences with
  • Behavioral tendencies
  • Current psychosocial developmental stage
  • Demographic factors

  • The recovery environment
  • Availability of social supports
  • Cohesiveness and protectiveness of family and
  • Attitudes of society regarding the experience
  • Cultural and subcultural influences
  • Learning theory
  • Negative reinforcement as behavior that leads to
    a reduction in an aversive experience, thereby
    reinforcing and resulting in repetition of the
  • Avoidance behaviors
  • Psychic numbing
  • Cognitive theory
  • A person is vulnerable to post-traumatic stress
    disorder when fundamental beliefs are invalidated
    by experiencing trauma that
    cannot be comprehended and when a sense of
    helplessness and hopelessness prevails.

Treatment Modalities
  • Psychopharmacology
  • PTSD
  • Antidepressants
  • Anxiolytics
  • Antihypertensives
  • Others

  • Biological aspects
  • It has been suggested that a person who has
    experienced previous trauma is more likely to
    develop symptoms after a stressful life event.
  • Disregulation of the opioid, glutamatergic,
    noradrenergic, serotonergic, and neuroendocrine
    pathways may be involved in the pathophysiology
    of PTSD.
  • Transactional Model of Stress Adaptation
  • The etiology of PTSD is most likely influenced by
    multiple factors

Acute Stress Disorder
  • Occurs within 1 month after exposure to highly
    traumatic event
  • Characterized by at least three dissociative
    symptoms during/after event
  • Subjective sense of numbing
  • Reduction in awareness of surroundings
  • Derealization
  • Depersonalization
  • Dissociative amnesia

Anxiety Caused by Medical Conditions
  • Direct physiological result of medical conditions
    such as
  • Hyperthyroidism
  • Pulmonary embolism
  • Cardiac dysrhythmias
  • Evidence must be present in history, physical
    exam, or laboratory findings in order to diagnose

Nursing Process Assessment Guidelines
  • Determine if anxiety is primary or secondary (due
    to medical condition)
  • Ensure sound physical/neurological exam
  • Use of Hamilton Rating Scale
  • Comprehensive data related to anxiety
  • Determine potential for self-harm/suicide
  • Perform psychosocial assessment
  • Determine cultural beliefs and background

Nursing Process Diagnosis and Outcomes
  • NANDA-International (NANDA-I)
  • Nursing diagnoses useful for patient with anxiety
    or anxiety disorder
  • Nursing Outcomes Classification (NOC)
  • Identifies desired outcomes for patients with
    anxiety or anxiety disorders

Considerations for Outcome Selection for Patients
with Anxiety Disorders
  • Reflect patient values and ethical and
    environmental situations
  • Be culturally relevant
  • Be documented as measurable goals
  • Include a time estimate of expected outcomes

Nursing Process Planning and Implementation
  • Planning
  • Select interventions that can be implemented in a
    community setting
  • Include patient in process of planning
  • Implementation
  • Follow PsychiatricMental Health Nursing Scope
    and Standards of Practice (ANA, 2007)

Nursing Interventions for Patients with Anxiety
  • Identify community resources offering specialized
    treatments proven as effective
  • Identify community support groups
  • Use therapeutic communication, milieu therapy,
    promotion of self-care activities, and
    psychobiological and health teaching and health

Nursing Interventions
  • Milieu Therapy
  • Cognitive-Behavioral Therapy (CBT)

Common Benzodiazepine Anxiolytics
  • Generic
  • diazepam
  • lorazepam
  • alprazolam
  • clonazepam
  • chlordiazepoxide
  • oxazepam
  • Brand
  • Valium
  • Ativan
  • Xanax
  • Klonopin
  • Librium
  • Serax
  • Non- Anxiolytic BusSpar
  • Non-sedating, non habit forming and not a prn.
    Good for the elderly

Non-benzodiazepine Hypnotic
  • Generic
  • Zolpidem
  • Zalepon
  • Eszopiclone
  • Ramelteon
  • Brand
  • Ambien, Ambien CR
  • Sonata
  • Lunesta
  • Rozerem
  • contains a two layer coat
  • One layer releases it simmediataely and other
    layer has a slow release of additional drug

The Nursing Process Antianxiety Agents
  • Background Assessment Data
  • Indications anxiety disorders, anxiety symptoms,
  • alcohol withdrawal, skeletal muscle
    spasms, convulsive
  • disorders, status epilepticus, and
    preoperative sedation
  • Action depression of the CNS
  • Contraindications/Precautions
  • Contraindicated in known hypersensitivity in
  • with other CNS depressants in pregnancy and
  • narrow-angle glaucoma, shock, and coma
  • Caution with elderly and debilitated clients,
    clients with
  • renal or hepatic dysfunction, those with a
    history of drug
  • abuse or addiction, and those who are
    depressed or
  • suicidal

  • Interactions
  • Increased effects when taken with alcohol,
    barbiturates, narcotics, antipsychotics
    antidepressants, antihistamines, neuromuscular
    blocking agents, cimetidine, or disulfiram
  • Decreased effects with cigarette smoking and
    caffeine consumption
  • Nursing Diagnosis
  • Risk for injury
  • Risk for activity intolerance
  • Risk for acute confusion

  • Planning/Implementation
  • Monitor client for these side effects
  • Drowsiness, confusion, lethargy tolerance
    physical and psychological dependence
    potentiation of other CNS depressants
    aggravation of depression orthostatic
    hypotension paradoxical excitement dry mouth
    nausea and vomiting blood dyscrasias delayed
    onset (with buspirone only)
  • Educate client/family about the drug
  • Outcome Criteria/Evaluation

Common Medications
  • BZAs short-term treatment only
  • Causes dependence
  • Buspirone management of anxiety disorders
  • Selective serotonin reuptake inhibitors (SSRIs)
    first-line treatment for all anxiety
    disordersSelective norepinephrine reuptake
    inhibitors (SNRIs) venlafaxine approved for
    panic disorder, GAD, and SAD
  • Tricyclic antidepressants (TCAs) second- and
    third-line treatment

Nursing Process Evaluation
  • Does patient maintain satisfactory relationships?
  • Can patient resume usual roles?
  • Is patient compliant with medications?
  • Does patient maintain satisfactory relationships?
  • Can patient resume usual roles?
  • Is patient compliant with medications?