2ANXIETY DISORDERS Anxiety—Vague, subjective non specific feeling. *uneasiness, apprehension*tension,feeling of dread or impending doomCauses- result of threat to one’s Biologic, Physiologic and Social Integrity- external influences
3Types of Anxiety Signal Anxiety- (Phobic Disorders) Precipitant is identifiedA learned anxiety response-results from situations successfully repressed or coped with using another defense mechanism
4Trait anxiety A function of Personality structure Link with developmental process/eventsMay be linked to unresolved conflict/confusion (Anxiety Diathesis)a pre-disposition to anxiety when exposed to stressor.E.g.. One had a chronically ill mother and is overprotective w/own children.
5State Anxiety Develops in conflict or stressful situations Experiences limited controlAnxiety occurs before the situation arisesE.g.. Woman who avoids making appt w/PMD after finding breast mass and has a strong family hx. Of cancer.
6Free Floating Anxiety Pervasive sense of dread or doom Cannot be attached to any idea or eventMay result in panic state if stressors exceed the individuals ability to cope.
7Levels of AnxietyHildegard Peplau “Interpersonal Relations in Nursing 1952” identified Four stages of anxiety on a continuumMildModerateSevere PanicPanic
8Behavioral & Physiologic changes in Mild Anxiety Perceptual field widensÎ awareness & motivationÎ problem solving & learningIrritableRelated client Needs:Restlessness“butterflies in stomach”Î sleep disturbanceMore sensitive to noise
9Behavioral & Physiologic changes Moderate Anxiety Immediate task orientedAttentive to immediate taskDifficulty w/concentration,but can be redirectedV/S normal –increasedFrequent urinationDry mouth/muscle tensionÎ rate of speechdiaphoretic
10Behavioral & Physiologic changes in Severe Anxiety Narrowed perceptual field-one detailDifficulty completing task or solving problemsCannot learn effectivelyFeelings of dread/doomCryingRitualistic behaviors ie. RockingHeadache/nausea&vomitingVertigoPaleTachycardiaC/o chest painRigid stance
11Behavioral & Physiologic changes in Panic level anxiety Unable to process environmental stimuliDistorted perceptionsCan only focus on selfRisk for self harmUnable to communicateIrrational thoughts/behaviorsPossible delusions/hallucinationsCan run away from scene orCan be immobilized & muteDilated pupilsÎ B/P, P, RFlight,fight or freeze reaction
12Etiological Theories/Anxiety Biologic ModelHans Selye- expanded the idea that endocrine system and CNS (hypothalamus and Pituitary gland ) have reciprocal relationshipsStudies of the neuropharmacology of the Autonomic Nervous System (ANS) re: regulation of Cardiovascular/GI/Motor systems –was shown responsive to stimuliRX’s target seratonin, noradrenergic,& y-amino-butyric acid(GABA)
13Psychodynamic Model Concept views Anxiety as a warning to the ego Three types Anxiety identifiedREALITY Anxiety(painful emotional experience resulting from perception of danger in external world)MORAL Anxiety (THE Ego’s experience of Guilt and Shame)NEUROTIC Anxiety (perception of threat according to one’s instincts)Neurotic sx’s develop to defend against anxiety
14Interpersonal /Social Psychology Models/Anxiety Anxiety is the response to external environmentSullivan:”Anxiety is the first great educative experience in living”Symptoms were response to expectations/insecurities/frustrations/conflicts between person and Primary Groups i.e..family, colleagues, social associates.Emphasis on early development
15Behavioral Model/Anxiety Based on Learning theory- etiology of sx’s based on generalization of an earlier traumatic experience to a benign setting or object.Links past experiences with present responses – anxiety occurs when a “signal” predicts a painful or feared eventMay be linked to PTSD
16Epidemiology of Anxiety Disorders Anxiety D/O’s ---6 – 8% of populationMore prevalent in women y/o & in separated/divorced groupExcept for OCD’s and Social Phobias –anxiety greater in womenClients w/major Depression –18.8% inc.risk for panic d/o and 15/3% risk for agoraphobia10-12% of general population have simple phobias
17Epidemiology of Anxiety Disorders in the Older Adult 3.5 –10 % of elders suffer from Anxiety disorders10-15% of Women >65 y/o seek help from MD (Hegel, et.al 2002)RISK factors: female; urban living;hx. Of worry or rumination;poor physical health; low socioeconomic status; stressful life events;depression & alcoholismGAD – most common anxiety D/O in the elderlyC/b worry- co-exist w/depression.
18Behavioral manifestations of Panic attacks PANIC ATTACK-sudden onset –intense apprehension-fearfulness-terror assoc w/impending doom-lasts minutes4 or more sx’s i.e..palpitations, sweating, trembling; SOB,choking,smothering sensation
19Behavioral manifestations of Phobias PHOBIAS – avoidance of object or situationSignificant distress or impairment of daily routines,occupation or social functioning.Fear recognized as excessive or unreasonable
20Post Traumatic Stress Disorder (PTSD) C/b re-experiencing an extremely traumatic event(begins within 3 months to years after event –lasting months or yearsPerson avoids the stimuli associated with the event,numbing of responsiveness,increased arousal
21PTSD---characteristics Intense fear /helplessness/horror upon exposureDreams,flashbacks,Physical/psychological distress over reminders of the eventAvoids memory provoking stimuliFeeling detached or estranged from othersIncreased arousal (irritability,angry outburst,sleep problems,hypervigilance,exaggerated startle response)
22PTSD interventionsPromote desensitization through gradual exposure to event or situation similar to the eventTeach relaxation techniquesProvide individual therapy to address loss of control issuesEncourage use of support groupsEncourage use of hypnotherapy
23Generalized Anxiety Disorder C/b at least 6 months of persistent, excessive worry and anxiety.Uncontrollable worryingSignificant distress w/impaired social or occupational functioning3 of the following:restlessness, fatigues easily,difficulty w/concentration, thought blocking,irritability, muscle tension sleep disturbance.
24Interventions Attend to physical symptoms Assist client to identify thoughts that arouse the anxiety & their basesAssist client to change unrealistic thoughts to more realistic thoughtsUse cognitive re-structuringAdminister anti-anxiety medications as prescribed
25Obsessive Compulsive Disorder Obsessions –( thoughts, impulses or images) which cause marked anxiety or Compulsions(repetitive behaviors or mental acts)Recurrent, persistent, unwanted thoughts impulses or imagesAttempts to ignore,suppress,or neutralizes obsessions with compulsions –are mostly ineffective.
26OCD interventionsIdentify the situation that precipitates the behaviorDo not interrupt compulsive behaviorsAllow time for compulsive ritualsProvide safety related to behaviorsProvide schedule to distract behaviorsSet limits on rituals that may interfere with client well-beingEstablish written contract-decrease frequency of compulsive behaviors
28Cultural Considerations for Anxiety disorders in: HispanicAfrican –AmericanAsianEuropean- AmericanMiddle Eastern
29The nurse is working with the family of a client with Obsessive Compulsive D/O.Which of the following should the nurse incorporate in the teaching plan?A.) the thoughts images and impulses are voluntaryB.) the family should pay immediate attention to symptomsC.) the thoughts, images and impulses worsen the stressD.) OCD is a chronic disorder not responsive to treatment
30A client displays isolation, bizarre behaviors, unsafe actions and poor hygiene. Which will be the first priority in the nursing care plan?A.) SafetyB.)HygieneC.)IsolationD.) Bizarre behaviors
31The nurse would analyze the symptoms of muscle rigidity, GI upset, rapid speech,and need to urinate as which level of anxiety?A.) MildB.) ModerateC.) SevereD.) Panic
32A client has recently been involved in assisting with the clean-up from a flood that washed away many homes in his area and caused loss of life.Which of these interventions would assist the client in dealing with the traumatic experience.A. Provide the opportunity to talk about the experience.B. Encourage the client to leave the area in order to forget the experience.C. Suggest admission to a mental health facility.D. Arrange for a minister to speak with the client.
33Appropriate discharge criteria for a client with chronic anxiety disorder is the client will--- A.) experience no more anxietyB.) suppress the anxiety symptoms and focus on the futureC.) Identify situations and events that trigger anxietyD.) recognize the need to take medications for the rest of his/her life to control anxiety
34The nurse is working with a client with chronic anxiety The nurse is working with a client with chronic anxiety. The goal is that the client will identify early warning symptoms of anxiety.The nurse would analyze the client as moving towards this goal when the client:A.) begins to connect panic symptoms with thoughts about a recent break-up in a relationship.B.) is free of anxiety for one weekC.)practices relaxation techniques daily and when anxiety increasesD.)recognizes that others also experience anxiety in varying situations
35A client is to receive medication therapy for an anxiety disorder A client is to receive medication therapy for an anxiety disorder. To reduce the risk of dependence and problems related with withdrawal, which of the following agents would the nurse most likely anticipate as being prescribed? (select all that apply)Paroxetine (Paxil)Sertaline (Zoloft)Lorazepam (Ativan)Venlafaxine (Effexor)Clonazepam (Klonopin)
36The nurse assesses a client with a diagnosis of Generalized Anxiety disorder for which of the following symptoms?Fear and avoidance of specific situations or places.Persistent obsessive thoughtsRe-experience of feelings associated with traumatic eventsUnrealistic worry about a number of events in one’s life.
37A 4 year-old girl who is a victim of a bomb blast that demolished the building which housed her daycare constantly builds block houses and blows them up. She also has nightmares frequently. Which one of the following diagnoses is appropriate for the nurse to make regarding this child?Post-trauma response related to terrorist attack as evidenced by destructive behaviors and sleep disturbance.Explosive disorder related to dysfunctional personality as evidenced by destructive behaviors.Sleep disturbance related to emotional trauma as evidenced by nightmares.Ineffective individual coping related to internal stressors as evidenced by destructive behaviors and nightmares.
38Nursing Care Plan: Anxiety Assessment data:Appearance,Behavior,Conversation i.e.:Wringing hands,decreased communication,restlessness, irritability,pacing,decreased attn, poor impulse controlIdentify stressors- intra,inter, extrapersonalIdentify lines of defense
39Goals/expected outcomes: Short term:The client will: be –free of injuryDiscuss feelings of dread or anxietyRespond to relaxation techniquesDemonstrate ability to perform relaxation
40Implementation: anxiety Remain with client at all times if level is severe or panic(safety important)Remove client to Quiet area( client is not able to deal with excessive stimuli)Remain calm upon approaching client(client will feel more secure if you are in control of situation)Use short simple clear statements(impaired ability to deal with abstractions/complexities)Use PRN meds as indicated
41Nursing interventions: Educate client re use of caffeine, nicotine etc.(prevents/minimizes cardiovascular responses i.e. Inc heart rate and jitteriness)Provide instruction regarding anxiety reduction stretagiesProgression relaxation techniquesListening to smoothing music or relaxation tapes
42When planning discharge for a client with chronic anxiety the nurse directs the goal of promoting a safe environment at home.The most appropriate maintenance goal should focus on which of the following:A.Continues contract with a crisis counselorB.Identifying anxiety producing situationsC.Ignoring feelings of anxietyD.Eliminating all anxiety from daily situations
43A client with OCD is admitted to the psychiatric unit for hand washing rituals. The day after admission she is scheduled for lab tests. To assure that he client is there on time, the nurse should:Remind the client several times of her appointment.Limit the number of hand washingsTell her it is her responsibility to be there on timeProvide ample time for her to complete her rituals.
44A client admitted for ritualistic behaviors is constipated and dehydrated. Which nursing intervention would this client most likely comply with?Drinking Ensure between mealsDrinking extra fluids with mealsDrinking 8 oz. Of water every hour between mealsDrinking adequate amounts of fluid during the day
45A woman comes into the emergency room in a severe state of anxietyfollowing a car accident. The mostappropriate nursing intervention is to:Remain with the clientPut the client in a quiet roomTeach the client deep breathingEncourage the client to talk about her feelings and concerns
46A client is unwilling to go out of the house for “fear of doing something crazy in public”. As a result the client remains homebound except when accompanied outside by the spouse.Based on this data the nurse determines that the client is experiencing:A.Social phobiaB. AgoraphobiaC. ClaustrophobiaD. Hypochondriasis
47A client is admitted to a psych unit after having many test for acute blindness for which there is no organic cause.The nurse learns the client became blind after witnessing a hit and run accident, when a family of three was killed. The nurse suspects the client may be experiencing:PsychosisConversion DisorderDissociative DisorderRepression