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Anxiety
General s/s: feelings of apprehension, uneasiness, uncertainty, dread
Criteria: excessive anxiety and worry about several events or activities for MORE THAN 6 MO Inability to cope w/anxiety Associated w/3+ symptoms: feeling restless or on edge, easily tired, poor attention span, irritability, muscle tension, difficulty sleeping Causes significant distress or impaired ability to work/maintain relationships NO concurrent substance use or misuse NO underlying medical cause NOT explained by another mental health problem Nursing actions: provide calm environment, decrease environment stimuli and stay with pt Ask pt to identify what or how they feel Encourage pt to describe and discuss feelings Help pt identify causes of feelings if they are having difficulty doing so Listen to pt expressions of helplessness and hopelessness Document event, significant information, actions taken and F/U actions, pts response o Mild: sense of sight/sound increased, perceptual field increased, restlessness, irritability, mild tension Experienced in everyday life Motivation, produce growth, enhance creativity, increase learning Nursing actions: allow expression of feelings, empathy in communication, demonstrate active listening, help pt identify problems, assist with problem solving, evaluate and explore results, plan o Moderate: lingers and continues to influence person’s life experience feeling of being overwhelmed and troubled S/S: increased HR, perspiration, gastric discomfort, urinary urgency, mild tremors, HA Learning and problem solving still occurs Nursing actions: offer cool beverage, respect need for personal space, active dialog to share feelings, create activities for distraction, exploration alternation coping mechanism, help pt focus on here and now o Severe: person’s stress level has not been reduced, more obvious, negative behavior begins to intrude (somatic complaints, agitations, anger) S/S: stimulation of sympathetic nervous system (HA, N, Dizziness, sleep disturbance), increased tremors, pounding HR, hyperventilation Learning and problem solving NOT possible ALL behavior aimed at relieving anxiety Focus on minute/scattered details Nursing actions: begin limit setting, make simple and direct statements, describe behavior needed, notify MD and administer medication, remove other patients from day room, explain consequences of behavior o Panic: physically and emotionally exhausted from stress, ability to cope and exert self-control virtually non-existent Dread and terror and impending doom S/S: loss of rational thought, increased motor activity (pacing, shouting, screaming), withdrawal, impulsive and erratic behavior, FULL fight or flight mode, gross motor skills at highest level If Prolonged exhaustion or death Nursing actions: assess potential for injury to self/others, conduct debriefing of unit community, call for therapeutic team support, call physician for onsite assessment, conduct debriefings of staff and patient post- containment
