Nursing Diagnosis: Fear Application of NANDA, NOC, NIC

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

NANDA Definition: Response to perceived threat that is consciously recognized as a danger

Defining Characteristics: Report of: apprehension; increased tension; decreased self-assurance; excitement; being scared; jitteriness; dread; alarm; terror; panic
Identifies object of fear; stimulus believed to be a threat; diminished productivity, learning ability, problem-solving ability
Increased alertness; avoidance or attack behaviors; impulsiveness; narrowed focus on "it" (i.e., the focus of the fear)
Increased pulse; anorexia; nausea; vomiting; diarrhea; muscle tightness; fatigue; increased respiratory rate and shortness of breath; pallor; increased perspiration; increased systolic blood pressure; pupil dilation; dry mouth

Related Factors: Natural/innate origin (e.g., sudden noise, height, pain, loss of physical support); learned response (e.g., conditioning, modeling from or identification with others); separation from support system in potentially stressful situation (e.g., hospitalization, hospital procedures); unfamiliarity with environmental experience(s); language barrier; sensory impairment; innate releasers (neurotransmitters); phobic stimulus

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
·         Fear Control

Client Outcomes

·         Verbalizes known fears
·         States accurate information about the situation
·         Identifies, verbalizes, and demonstrates those coping behaviors that reduce own fear
·         Reports and demonstrates reduced fear

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
·         Coping Enhancement

Nursing Interventions and Rationales

·         Assess source of fear with client. Fear is a normal response to actual or perceived danger and helps mobilize protective defenses.
·         Have the client draw the object of their fear. This is a reliable assessment tool for children. Because human figure drawings are reliable tools for assessing anxiety and fears in children, practitioners should incorporate these drawings as part of their routine assessments of fearful children (Carroll, Ryan-Wenger, 1999).
·         Discuss situation with client and help distinguish between real and imagined threats to well-being. The first step in helping the client deal with fear is to collect information about the situation and its effect on the client and significant others (Bailey, Bailey, 1993).
·         If irrational fears based on incorrect information are present, provide accurate information. Correcting mistaken beliefs reduces anxiety (Beck, Emery, 1985).
·         If client's fear is a reasonable response, empathize with client. Avoid false reassurances and be truthful. Reassure clients that seeking help is both a sign of strength and a step toward resolution of the problem (Bailey, Bailey, 1993).
·         If possible, remove the source of the client's fear with accurate and appropriate amounts of information. Clients' uncertainty regarding the outcomes can lead to feelings of distress. In one study, the major strategy used to reduce distress was information management, in which the amount and type of incoming information was controlled (Shaw, Wilson, O'Brien, 1994). Fear is a normal response to actual or perceived danger; if the threat is removed, the response will stop.
·         If possible, help the client confront the fear. Self-discovery enhances feelings of control.
·         Stay with clients when they express fear; provide verbal and nonverbal (touch and hug with permission) reassurances of safety if safety is within control. The nurse's presence and touch demonstrate caring and diminish the intensity of feelings such as fear (Olson, Sneed, 1995). Of 376 patients surveyed in 20 family practices throughout Ontario, Canada, 66% believe touch is comforting and healing and view distal touches (on the hand and shoulder) as comforting (Osmun et al, 2000).
·         Explain all activities, procedures (in advance when possible), and issues that involve the client; use nonmedical terms; calm, slow speech; and verify client's understanding. Deficient knowledge or unfamiliarity is one factor associated with fear (Johnson, 1972; Garvin, Huston, Baker, 1992; Whitney, 1992).
·         Explore coping skills used previously by client to deal with fear; reinforce these skills and explore other outlets. Methods of coping with anxiety that have previously been successful are likely to be helpful again (Clunn, Payne, 1982).
·         Provide backrubs for clients to decrease anxiety. The dependent variable, anxiety, was measured before 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).
·         Provide massage before procedures to decrease anxiety. Massage was done by parents before venous puncture of hospitalized preschoolers and school-age children. The results obtained indicated that massage had significant effect on nonverbal reactions, especially those related to muscular relaxation. (Garcia, Horta, Farias, 1997).
·         Use therapeutic touch (TT) 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). Anxiety was reduced significantly in a TT group but was unchanged in a TT placebo group. Healing touch may be one of the most useful nursing interventions available to reduce anxiety (Fishel, 1998).
·         Refer for cognitive behavioral group therapy. In this study of 253 persons with neck or back pain, the experimental group who received the standardized six-session cognitive behavioral group sessions had significantly better results with regard to fear avoidance beliefs than the comparison group (Linton, Ryberg, 2001).
·         Animal-assisted therapy (AAT) can be incorporated into the care of perioperative patients. In a study done on perioperative clients, interacting with animals was shown to reduce blood pressure and cholesterol, decrease anxiety, and improve a person's sense of well-being (Miller, Ingram, 2000).
Refer to care plans for Anxiety and Death Anxiety.
·         Establish a trusting relationship so that all fears can be identified. An elderly client's response to a real fear may be immobilizing.
·         Monitor for dementia and use appropriate interventions. Fear may be an early indicator of disorientation or impaired reality testing in elderly clients.
·         Note if the client is irritable and is blaming others. Recent findings in nursing research support the presence of these other behaviors as symptoms of depression (Proffitt, Augspurger, Byrne, 1996).
·         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 an illness.
·         Observe for untoward changes if antianxiety drugs are taken. Advancing age renders clients more sensitive to both the clinical and toxic effects of many agents.
·         Assess for the presence of culture-bound anxiety/fear states. The context in which anxiety/fear is experienced, its meaning, and responses to it are culturally mediated (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).
·         Identify what triggers fear response. Arab Muslim clients may express a high correlation between fear and pain (Sheets, El-Azhary, 1998).
·         Identify how the client expresses fear. Research indicates that the expression of fear may be culturally mediated (Shore, Rapport, 1998).
·         Validate the client's feelings regarding fear. Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).

Home Care Interventions

·         During initial assessment, determine whether current or previous episodes of fear relate to the home environment (e.g., perception of danger in home or neighborhood or of relationships that have a history in the home). Investigating the source of the fear allows the client to verbalize feelings and determine appropriate interventions.
·         Identify with client what steps may be taken to make the home a "safe" place to be. Identifying a given area as a safe place reduces fear and anxiety when the client is in that area.
·         Encourage the client to seek or continue appropriate counseling to reduce fear associated with stress or to resolve alterations in thought processes. Correcting mistaken beliefs reduces anxiety.
·         Encourage the client to have a trusted companion, family member, or caregiver present in the home for periods when fear is most prominent. Pending other medical diagnoses, a referral to homemaker/home health aide services may meet this need. Creating periods when fear and anxiety can be reduced allows the client periods of rest and supports positive coping.
·         Offer to sit with a terminally ill client quietly as needed by the client or family, or provide hospice volunteers to do the same. Terminally ill clients and their families often fear the dying process. The presence of a nurse or volunteer lets clients know they are not alone. Fears are reduced, and the dying process becomes more easily tolerated.

Client/Family Teaching

·         Teach client the difference between warranted and excessive fear. Different interventions are indicted for rational and irrational fears.
·         Teach stress management interventions to clients who experience emotions of fear. Acute stress caused by strong emotions such as fear can sometimes cause sudden death in people with underlying coronary artery disease (Pashkow, 1999).
·         Teach families to share personal stories about an illness using the computer-based psychoeducational application experience journal. The educational journal was reported to be useful for increasing understanding of familial feelings for families facing pediatric illness (Demaso et al, 2000).
·         Teach client to visualize or fantasize absence of the fear or threat and successful resolution of the conflict or outcome of the procedure.
·         Teach client to identify and use distraction or diversion tactics when possible. Early interruption of the anxious response prevents escalation (Pope, 1995).
·         Teach clients to use guided imagery when they are fearful: have them use all senses to visualize a place that is "comfortable and safe" for them. Results from this study showed that the psychological intervention of guided imagery significantly improved subjects' perceived quality of life and decreased fears (Moody, Fraser, Yarandi, 1993).
·         Teach client to allow fearful thoughts and feelings to be present until they dissipate. Purposefully and repetitively allowing and even devoting time and energy to a thought reduces associated anxiety (Beck, Emery, 1985).
·         Teach use of appropriate community resources in emergency situations (e.g., hotlines, emergency rooms, law enforcement, judicial systems). Serious emergencies need immediate assistance to ensure the client's safety.
·         Encourage use of appropriate community resources in nonemergency situations (e.g., family, friends, neighbors, self-help and support groups, volunteer agencies, churches, recreation clubs and centers, seniors, youths, others with similar interests).
·         Teach client appropriate use of ordered medications.

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