Module 5

This module will help you in dealing with your own stress and helping clients to manage
stress.

Learning Outcomes:
The student is expected to:
1. Differentiate anxiety from fear.
2. Identify the possible cause of anxiety.
3. Describe the nurse’s role in the different levels of anxiety.
4. Utilizes the nursing process in dealing with own/client’s anxiety (hypothetical
case scenario)

Concept of Anxiety
Anxiety is a vague feeling of dread or apprehension. A response to external or internal
stimuli that have behavioral, emotional, cognitive and physical
Fear is indistinguishable from anxiety as fear is feeling afraid or threatened by a clearly
identifiable external stimulus that represents danger to the person.

Causes of Anxiety:
1. Stress - Anxiety occurs when a person has difficulty dealing with life situations,
problems, and goals.
Hans Selye identified the physiologic aspects of stress – General Adaptation
Syndrome (GAS)
a. Alarm Reaction Stage – sends messages from the hypothalamus to the glands (such
as the adrenal gland, to send out adrenalin and norepinephrine for fuel) and organs
(such as the liver, to reconvert glycogen stores to glucose for food) to prepare for
potential defense needs.
b. Resistance Stage – digestive system reduces to function to shunt blood to areas
needed for defense. The lungs take in more air, and the heart beats faster and
harder so it can circulate the highly oxygenated and highly nourished blood to the
muscles to defend the body to fight, flight, or freeze behavior. If the person adapts
to the stress, the body responses relax, and the gland, organ and systemic responses
abate.
c. Exhaustion Stage – occurs when the person has responded negatively to anxiety and
stress; body store are depleted or the emotional components are not resolved,
resulting in continual arousal of the physiologic responses and little reserve capacity.

2. Genetic theories
Anxiety has an inherited component:
a) Panic disorder and social and specific phobias have moderate heritability.
b) GAD and OCD are common in families but requires further in depth study.
3. Neurochemical theories
a) decrease level of GABA (Gamma-amino butyric acid) – GABA is a natural anti-
anxiety agent by reducing cell excitability, thus lessening the rate of neuronal
firing
b) increase level of Norepinephrine
c) Serotonin (5-HT) – affects aggression and mood. It plays a role in OCD, panic
disorder, and generalized anxiety disorder.

4. Psychoanalytic Theories
Anxiety arises from conflicts from any of four sources
a) SUPEREGO anxiety
b) Castration anxiety - fantasy of genital or body mutilation
c) Separation anxiety – potential loss of significant others
d) ID anxiety - - destruction of the person.
5. Interpersonal Theory (Harry Stack Sullivan) – anxiety as being generated from problems
in interpersonal relationship. Caregivers can communicate anxiety to an infant or child
by inadequate nurturing, agitation in handling the child, and distorted message.
6. Behavioral Theory – Anxiety as being learned through one’s experiences. People can
change or “unlearn behaviors through new experiences”
7. Otto Rank – (Birth Trauma Theory) the process of birth involves the sudden, violent
change from the security of intrauterine existence to the uncertainties of the outer
world, produces primal anxiety.
8. Karen Horney - The prime motivating factor in behavior is the need for security. Feelings
of helplessness can lead to an exaggerated need for security.
9. Froda Reichman – (fear of loneliness) Man is a being in continuous conflict with the
environment. Man has to continually seek new solutions to new problems that develop
continuously.

Cultural Considerations:
o People from Asians cultures often express anxiety through somatic symptoms sucha s
headaches, backaches, fatigue, dizziness, and stomach problems.
Example: KORO – a man’s profound fear that his penis will retract into the abdomen
and he will then die. – Person firmly holds his penis until the fear passes, often with
assistance from family members or friends, and clamping the penis to a wooden box.
In women, KORO is the fear that the vulva and nipples will disappear.
o Hispanics – SUSTO – is a case of high anxiety, sadness, agitation, weight loss, weakness,
and heart rate changes believed to occur due to supernatural spirits or bad air from
dangerous places and cemeteries invades the body.
Forms of Anxiety:

a. Reality Anxiety – based on the perception of danger in the external world

b. Neurotic Anxiety – arises when the perception of danger is from the instincts of the
ID. This anxiety is based on the fear that the ego is unable to prevent an instinctual
urging from being expresses or from getting out of control and that person will
engage in acts for which he will be punished.

Levels of Anxiety Responses

Anxiety Level Physical Responses Cognitive Responses Emotional

Responses
Mild (1+) Mild muscle tension Wide perceptual field Automatic
Aware of milieu Secure, confident behaviors’
Relaxed or slight fidgeting Low sense of failure some impatience
Attentive Alert, attends to many Solitary activities
Industrious things Stimulated
Abstracts information Secure
Optimal learning level
Moderate Moderate muscle tension Decreased perceptual Discomfort
(2+) Increased Vital signs field Irritable
Pupils dilate, sweats starts Selective inattention Mixed self-
Some pacing, banging hands Increased focus on stimuli confidence
Voice changes; tremor, Decreased attention span Impatient
pitch Problem solving Excited
Increased alertness, tension decreased
Urinary frequency, Learning occurs with
headache focusing
sleep changes, backache

Severe (3+) Severe muscle tension Limited perceptual field Frantic

Hyperventilation Fragmented processing Agitation
Poor eye contact Thinking is difficult Dread
Increased sweating Poor problem solving Confusion
Speech rapid, high pitched Unable to abstract Inadequacy
Random, purposeless information Withdrawal
actions Attends only to threat Denial
Clench jaw, gnash teeth Preoccupied with Wants relief
Spatial needs increase thoughts
Pacing, shouting Egocentric
Wringing hands, trembling

Panic(4+) Flight, fight, or freeze Tunnel-vision perceptions Overwhelmed

Extreme muscle tension Illogical, distorted Impotent, helpless
 Gross motor agitation thoughts Out of control
Dilated pupils Personality disorganized Rageful, despair
Increased then decreased Cannot solve problems Anger, terror
vital signs Focused on inner Expects bad
Sleepless thoughts outcome
Depleted stress hormones Irrational Aghast, fearful
and neurotransmitters Inaccessible to external Depleted
Facial grimacing, agape stimuli
Hallucinations, delusions,
illusions are possible

Anxiety is manifested in 3 ways:

1. Cognitively – in persons thoughts

2. Behaviorally – in persons actions
3. Somatically – in physiological or biological reaction
Relief of anxiety
1. Conscious efforts – Coping Mechanims
2. unconscious efforts – Defense mechanism
Mild level of anxiety
 is an asset to the client and requires no direct intervention.
 People can learn and solve problems and are eager for information
 Teaching can be very effective
Moderate level of anxiety
 Help client
a. identify anxiety
b. anticipate anxiety provoking situations.
c. express his or her feelings
d. with problem-solving
e. explore past and present coping behaviors
 use nonverbal language to demonstrate interest
 provide outlets for working off excess energy
 Speak in short, simple and easy-to-understand sentences.
 Need to redirect the client back to the topic if the client goes off on an unrelated
tangent
Nursing Diagnosis:

Anxiety – vague uneasy feeling of discomfort or dread accompanied by an automatic

response ; a feeling of apprehension caused by anticipation of danger.

Assessment Data:
Levels of anxiety

Nursing Outcomes:
Will be free from injury
 During Panic level - Person’s safety is the primary concern – cannot perceive
potential harm and have no capacity for rational thoughts.
Reduce own level of anxiety

Nursing Interventions:
 Remain with the client at all times when levels of anxiety are high ( severe or
panic)
 Move the client to a quite area with minimal or decreased stimuli such a s a small
room or seclusion area
 Remain calm and talk to the client in a comforting manner
 Use short, simple, and clear statements.
 If unable to sit well – walk with the client while talking with him or her.
 Help the client take deep even breaths
 Avoid asking or forcing the client to make choices.
 PRN medications may be indicated for high levels of anxiety, delusions,
disorganized thoughts
 Be aware of your own feelings and level of discomfort – anxiety \can be
communicated interpersonally. It can raise your own anxiety level.

Short term anxiety can be treated with anxiolytic medications

Benzodiazepines – not to be given for more than 4 to 6 weeks – have a high potential for abuse
and dependency

CRISIS is a turning point in an individual’s life that produces an overwhelming emotional response.
Stressors or challenges that they can not effectively manage through use of their customary coping
skills.

General categories of Crisis

1) Maturational Crisis
2) Situational Crisis
3) Adventitious or Social Crisis

Nature of Crisis Experience

 1) Problems and Challenges
2) Resolution and Outcomes
a. Returns to the Pre-crisis state
b. Begins to function at a higher level of state
c. The person’s functioning stabilizes at a lower level of the person’s functioning

3) Crisis Intervention Techniques

a. Authoritative Interventions - are designed to assess the person’s health status and promote
problem-solving such as offering the client new information, knowledge or meaning.

b. Facilitative Interventions - are aimed at dealing with the person’s needs for empathetic
understanding such as encouraging the person to discuss and identify feelings, serving as
the sounding board for the client, and affirming the person’s self-worth.

Activities:
1. Study the Module
2. Supplement the module by reading e-book by Videbeck - Psychiatric-Mental Health Nursing.
3. Module Assessment Self- Check No. 7.
4. Make a nursing process (Use the above format) in client with anxiety. Do not select panic
level as it is already been done as sample above.
 Module Assessment
Self-Check No. 7

ANXIETY:
Test I. Psychodynamic Test I
Theories / Cultural A. Anxiety occurs due to profound fear that the penis will
_____1. Otto Rank retract into the abdomen and can result to death
_____2. Koro B. Anxiety arises from conflicts of the ID and SUPEREGO
_____3. Harry Stack Sullivan C. Anxiety is being learned through experiences
_____4. Behavioral Theory D. Anxiety is generated from problems in interpersonal
_____5. Sigmund Freud relationships
E. The process of birth produces primal anxiety
F. Identified the four levels of anxiety and developed nursing
interventions for each level
G.

Test II. Levels of Anxiety Test II

_____1. Tunnel vision perceptions A. Mild Anxiety
_____2. Egocentricity B. Moderate Level of Anxiety
_____3. Very secure and confident C. Severe Level of Anxiety
_____4. Selective inattention D. Panic Level of Anxiety
_____5. Personality disorganization

Give 3 Examples of the following:

1) Maturational Crisis
2) Situational Crisis
3) Adventitious or Social Crisis