Nursing Diagnosis: Anxiety Application of NANDA, NOC, NIC

Nursing Diagnosis: Anxiety
Pam B. Schweitzer and Gail B. Ladwig

NANDA Definition: 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

·         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).

·         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).

·         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).

·         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).

·         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).

·         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).

·         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).

·         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).

·         Avoid excessive reassurance; this may reinforce undue worry. Reassurance is not helpful for the anxious individual (Garvin, Huston, Baker, 1992).

·         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.

·         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).

·         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).

·         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).

·         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).

·         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).

·         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).

·         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).

·         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).

·         Rule out withdrawal from alcohol, sedatives, or smoking as the cause of anxiety. Withdrawal from these substances is characterized by anxiety (Badger, 1994).

·         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

·         Monitor client for depression. Use appropriate interventions and referrals. Anxiety often accompanies or masks depression in elderly adults.

·         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).

·         Observe for adverse changes if antianxiety drugs are taken. Age renders clients more sensitive to both the clinical and toxic effects of many agents.

·         Provide a quiet environment with diversion. Excessive noise increases anxiety; involvement in a quiet activity can be soothing to the elderly.

Multicultural

·         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).

·         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).

·         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).

·         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

·         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).

·         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).

·         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).

·         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).

·         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).

·         Teach client to identify and use distraction or diversion tactics when possible. Early interruption of the anxious response prevents escalation.

·         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).

·         Teach progressive muscle relaxation techniques. In one study, a significant reduction in anxiety level was obtained by using progressive muscle relaxation interventions (Weber, 1996).

·         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).

·         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).

·         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).

·         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).

·         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).

·         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).