Anxiety and Stress Related Illness
Videbeck, p. 242-262 (omit Box 13.1 & 13.2)
· Info
o What is anxiety?
§ Feeling of dread that you get from either a real or perceived threat. Source of anxiety is usually unknown
o What is stress?
§ Your reaction to that crap. Happens to all of us. The wear and tear of life that we see with stress
o What is fear?
§ Reaction to a specific danger.
· Levels of Anxiety Symptoms
o Mild
§ Usually able to work with them, can usually make someone do better. A little more alert usually. Restless, may tap or shake your leg or whatever, may be impatient and a little irritable. Can usually respond appropriately
o Moderate
§ Not quite as aware of what is going on around you, may respond well to guidance, able to problem solve but not quite as well as the mild level. May complain of “butterflies” in your stomach. BP and pulse may increase. Usually pretty tense
o Severe
§ Not aware of what’s going on around us, not able to think well, many times people feel like a sense of impending doom for no explainable reason. May hyperventilate while moving into panic mode. Can be tachycardic, very load and inconsolable.
o Panic
§ Totally unable to focus or concentrate. Be very specific and point out what’s going on, but they still won’t be able to reason with you. Can become very immobile and they are almost catatonic or may walk out in front of a car or some shit. They may hallucinate or have delusions, out of touch with reality.
· Defense Mechanisms
o Are used to relieve anxiety
o Become maladaptive when used to extremes
o Need to be recognized and understood by the nurse so that the nurse assist the patient in learning more adaptive coping skills
· Anxiety Disorders
o Agoraphobia with or without panic disorder
§ Anxiety about or avoidance of places or situations from which escape might be difficult or help might be unavailable
o Panic disorder
§ Panic attacks-key feature – panic attack is the sudden onset of intense apprehensions, fearfulness, or terror associated with feelings of impending doom
§ Symptoms include feelings of terror, losing their mind, having heart attack palpitations, breathing difficulties, choking, hot flashes, chills
§ Treatment-CBT, medications, decrease stimulation, deep breathing, journaling
o Specific phobia
§ A phobia is an illogical, intense, persistent fear of a specific object or social situation that causes extreme distress and interferes with normal life functioning
§ Treatment-Behavioral therapy, medication
o Social phobia
§ Anxiety provoked by certain types of social or performance situations, which often leads to avoidance behavior
o Obsessive–compulsive disorder (OCD)
§ Obsessions-
· Thoughts, impulses, or images that persist and recur and cannot be dismissed from the mind
§ Compulsions-
· Ritualistic behaviors that an individual feels driven to perform to reduce anxiety
§ Treatment- CBT and medications, Anfrenil is DOC
o Generalized anxiety disorder
§ Excessive worry and anxiety that is unwarranted more days than not
§ Symptoms include uneasiness, irritability, muscle tension, fatigue, difficulty thinking, and sleep alterations
§ Seen most often by family physician, must last at least 6 months
§ Always assess for suicide
o Acute stress disorder
§ Onset within 4 weeks of event lasting 2-4 days
§ Exposure to a traumatic event involving threat of death/injury
§ Feeling numb/detached/amnesic/fearful
§ Flashbacks
§ Increased anxiety, irritability, decreased concentration, sleep disturbances
o Posttraumatic stress disorder
§ Onset within 6 months of event, lasting more than 3 months
§ Experiencing, witnessing a frightening event
§ Re-experience the trauma/hallucinations
§ Sudden flashbacks
§ Irritability, sleep disturbances, increased anxiety, outbursts of anger
· Overview of Anxiety Disorders
o Etiology
§ Are some genetic predispositions
o Cultural considerations
§ Different cultures handle anxiety differently
o Elder considerations
§ Can look like dementia or depression
o Community-Based Care
§ Most of the time anxiety is treated out patient unless they’ve gotten to the point where they can’t function
· Incidence of Anxiety Disorders
o More prevalent in women except for OCD
o Prevalent in those less than 45 years of age
o Most common psychiatric disorders in the U.S., affecting 25% of adults
o More common in divorced, separated, and lower socioeconomic status
o Onset and clinical course are variable
o Many co-occur with other psychiatric conditions
o Related Disorders
§ Anxiety disorder due to a general medical condition
§ Substance-induced anxiety disorder
§ Separation anxiety disorder
§ Adjustment disorder
· Primary / Secondary Gain in Anxiety Disorders
o Primary Gain
§ Is the relief of anxiety by performing specific anxiety driven behavior
o Secondary gain
§ Is the attention received from others as a result of those behaviors
· General Treatment
o Combination of medication and therapy
o SSRIs,TCAs, benzodiazipines, beta blockers, anti-epileptics
o Cognitive–behavioral therapy (aka CBT)
o Combination of these two gives a much better result that one or the other used separately
· Nursing Interventions for Mild to Moderate Levels of Anxiety
o Help patient identify the anxiety.
o Anticipate anxiety-provoking situations.
o Use nonverbal language to demonstrate interest.
o Encourage talk about patients feeling and concerns.
o Focus on patients concerns.
o Ask questions to clarify what is being said
o Help patient identify thoughts or feelings before onset of anxiety.
o Encourage problem solving with the patient.
o Assist in developing alternative solutions to a problem.
o Find out what has helped relieve anxiety in the past.
o Provide outlets for working off excess energy
· Nursing Interventions for Severe to Panic Anxiety
o Maintain a calm manner.
o Remain with the person experiencing a severe to panic level of anxiety.
o Minimize environmental stimuli.
o Use clear simple statements.
o Use low-pitched voice. Speak slowly.
o Reinforce reality if distortions occur
o Listen for themes in communication.
o Attend to safety and physical needs.
o Speak in firm authoritative voice. Limit set for safety.
o Provide opportunities for exercise.
o Offer high calorie foods.
o Assess need for medication or seclusion
· Overview of Anti-Anxiety Meds
o Benzodiazepines
§ Reminder: high risk for dependence, withdrawal, and tolerance
§ Common side effects: drowsiness, fatigue, decreased coordination, slow reflexes
§ Used as anxiolytic, hypnotic, muscle relaxant, anticonvulsant, amnesic
§ Paradoxical responses possible
§ (Refer to Table 13.2)
§ Benzo Teaching
· Not for everyday stressors
· Avoid driving/operating machinery
· Do not exceed prescribed dose
· Taper dose before stopping
· Avoid Kava, Valerian, other herbal therapies
· Avoid alcohol
o Buspirone
o Anti-depressants (SSRIs, TCAs, MAOIs)
§ SSRIs
§ First line treatment for anxiety disorders
§ Common side effects: tremor, akathesia, nausea, headache, insomnia, drowsiness, sexual dysfunction
§ Serotonin syndrome
§ SSRI Teaching
· Take with food
· Avoid alcohol
· Take medication as prescribed
· Do not discontinue abruptly
· Takes several weeks to reach therapeutic level
o Beta-blockers
o Antihistamines
o Anticonvulsants
o Review Videbeck Table 13.3
· Anti-Anxiety Meds
o Buspirone (Buspar) – not a benzo, takes 1-6 to be effective
o Propanolol (Inderal) – beta-blocker especially useful in treating social anxiety d/o
o Hydroxzine ( Vistaril) – antihistamine that relieves anxiety
o Gabapentin (Neurontin) – anticonvulsant with antianxiety properties
· Application to Nursing Process
o Assessment- physical and psychosocial exam, assess for self-harm or suicide, assess for cultural beliefs and background.
o Diagnosis- Nanda, signs and symptoms
o Outcomes Identification- culturally appropriate, reflect patient values, measurable goals within a time frame.
o Planning- interventions that are appropriate for setting and anxiety level
o Implementation- follow Psychiatric-Mental Health nursing standards, identify community resources and support groups, use therapeutic communication, milieu therapy, promote self-care activities, and health teaching and promotion.
o Evaluation- is anxiety level reduced, can patient assume usual roles and satisfying relationships, are obsessions, compulsions, phobias, worrying decreased, can patient recognize symptoms related to anxiety and use new learned behaviors to manage anxiety
· Self Awareness issues
o Nurses must understand what and how anxiety behaviors work
o Nurses are just as vulnerable to stress and anxiety as others
o Avoid allowing your own feelings and needs to hinder the care of your patients