Nursing Dx

Definition:Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat.

RELATED FACTORS
Unconscious conflict about essential [beliefs]/goals and values of life
Situational/maturational crises
Stress
Familial association/heredity
Interpersonal transmission/contagion
Threat to self-concept [perceived or actual]; [unconscious conflict]
Threat of death [perceived or actual]
Threat to or change in health status [progressive/debilitating disease, terminal illness], interaction patterns, role function/status, environment [safety], economic status
Unmet needs
Exposure to toxins
Substance abuse
[Positive or negative self-talk]
[Physiological factors, such as hyperthyroidism, pulmonary embolism, dysrhythmias, pheochromocytoma, drug therapy including steroids]

DEFINING CHARACTERISTICS
Subjective
Behavioral
Expressed concerns due to change in life events; insomnia
Affective
Regretful; scared; rattled; distressed; apprehensive; uncertainty; fearful; feelings of inadequacy; jittery;
worried; painful/persistent increased helplessness; [sense of impending doom]; [hopelessness]
Cognitive
Fear of unspecific consequences; awareness of physiological symptoms
Physiological
Shakiness
Sympathetic
Dry mouth, heart pounding; weakness; respiratory difficulties; anorexia; diarrhea
Parasympathetic
Tingling in extremeties; nausea; abdominal pain; diarrhea; urinary frequency/hesitancy; faintness; fatigue; sleep disturbance; [chest, back, neck pain]

Objective
Behavioral
Poor eye contact, glancing about, scanning and vigilance, extraneous movement [e.g., foot shuffling, hand/arm movements, rocking motion]; fidgeting; restlessness; diminished productivity; [crying/tearfulness]; [pacing/purposeless activity], [immobility]

Affective
Increased wariness; focus on self; irritability; overexcited; anguish
Cognitive
Preoccupation; impaired attention; difficulty concentrating; forgetfulness; diminished ability to problem-solve; diminished learning ability; rumination; tendency to blame others; blocking of thought; confusion; decreased perceptual field
Physiological
Voice quivering; trembling/hand tremors; increased tension, facial tension, increased perspiration
Sympathetic
Cardiovascular excitation; facial flushing; superficial vasoconstriction; increased pulse/respiration; increased blood pressure; pupil dilation; twitching, increased reflexes
Parasympathetic
Urinary urgency; decreased blood pressure/pulse

Sample Clinical Applications:Major life changes/events, hospital admissions/surgery, cancer, hyperthyroidism, drug intoxication/abuse, mental health disorders

DESIRED OUTCOMES/EVALUATION CRITERIA

Client Will (Include Specific Time Frame)
• Appear relaxed and report anxiety is reduced to a manageable level.
• Verbalize awareness of feelings of anxiety.
• Identify healthy ways to deal with and express anxiety.
• Demonstrate problem-solving skills.
• Use resources/support systems effectively.

ACTIONS/INTERVENTIONS

NURSING PRIORITY NO.1. To assess level of anxiety:
• Review familial/physiological factors, such as genetic depressive factors, psychiatric illness; active medical conditions (e.g., thyroid problems, metabolic imbalances, cardiopulmonary disease, anemia, dysrhythmias); recent/ongoing stressors (e.g., family member illness/death, spousal conflict/abuse, loss of job). These factors can cause/exacerbate anxiety/anxiety disorders.

• Determine current prescribed medication regimen and recent drug history of prescribed or OTC medications (e.g., steroids, thyroid preparations, weight-loss pills, caffiene. Can heighten feelings/sense of anxiety.
• Identify client’s perception of the threat represented by the situation. Distorted perceptions of the situation may magnify feelings. Understanding client’s point of view promotes a more accurate plan of care.
• Note cultural factors that may influence anxiety. Individual responses are influenced by the cultural values/beliefs and culturally learned patterns of family of origin. (For example, ArabAmericans are very expressive about feelings, whereas Chinese are more reticent). Biological factors may also be involved.
• Monitor physical responses; for example, palpitations/rapid pulse, repetitive movements, pacing. Changes in vital signs may suggest degree of anxiety client is experiencing or reflect the impact of physiological factors such as endocrine imbalances, medication effect.
• Observe behavior indicative of anxiety, which can be a clue to the client’s level of anxiety:
Mild
Alert, more aware of environment, attention focused on environment and immediate events.
Restless, irritable, wakeful, reports of insomnia.
Motivated to deal with existing problems in this state.
Moderate
Perception narrower, concentration increased and able to ignore distractions in dealing with problem(s).
Voice quivers or changes pitch.
Trembling, increased pulse/respirations.
Severe
Range of perception is reduced; anxiety interferes with effective functioning.
Preoccupied with feelings of discomfort/sense of impending doom.
Increased pulse/respirations with reports of dizziness, tingling sensations, headache, and so forth.
Panic
Ability to concentrate is disrupted; behavior is disintegrated; client distorts the situation and does not have realistic perceptions of what is happening. May be experiencing terror or confusion or be unable to speak or move (paralyzed with fear).
• Note own feelings of anxiety or uneasiness. Feelings of anxiety are circular, and those in contact with the client may find themselves feeling more anxious.
• Note use of drugs (including alcohol), insomnia, or excessive sleeping, and limited/avoidance of interactions with others, which may be behavioral indicators of use of drugs/withdrawal to deal with problems.
• Review results of diagnostic tests (e.g., drug screens, cardiac testing, complete blood count, chemistry panel), which can point to physiological sources of anxiety.
• Review coping skills used in past. Can determine those that might be helpful in currentcircumstances.

NURSING PRIORITY NO.2 To assist client to identify feelings and begin to deal with problems:
• Establish a therapeutic relationship, conveying empathy and unconditional positive regard. Enables client to become comfortable and to begin looking at feelings and dealing with situation.
• Be available to client for listening and talking. Establishes rapport, promotes expression of feelings, and helps client/SO look at realities of the illness/treatment without confronting issues they are not ready to deal with.

• Encourage client to acknowledge and to express feelings—for example, crying (sadness), laughing (fear, denial), swearing (fear, anger), and using Active-listening, reflection. Often acknowledging feelings enables client to accept and deal more appropriately with situation, thus relieving anxiety.
• Assist client to develop self-awareness of verbal and nonverbal behaviors. Becoming aware helps client to control these behaviors and begin to deal with issues that are causing anxiety.
• Clarify meaning of feelings/actions by providing feedback and checking meaning with the client. Validates meaning and ensures accuracy of communication.
• Acknowledge anxiety/fear. Do not deny or reassure client that everything will be all right. Validates reality of feelings. False reassurances may be interpreted as lack of understanding or honesty, further isolating client.
• Be aware of defense mechanisms being used (e.g., denial, regression, and so forth). Use of defense mechanisms may be helpful coping mechanisms initially. However, continued use of such mechanisms diverts the energy that the client needs for healing, thus delaying the client from focusing and dealing with his actual problems.
• Identify coping skills the individual is using currently, such as anger, daydreaming, forgetfulness, eating, smoking, or lack of problem-solving. These may be useful for the moment but may eventually interfere with resolution of current situation.
• Provide accurate information about the situation. Helps client to identify what is reality based and provides opportunity for client to feel reassured.
• If the client is a child, be truthful, avoid bribing, and provide physical contact (e.g., hugging, rocking). Soothes fears and provides assurance. Children need to recognize that their feelings are not different from others.