1. Nursing Care of Clients with Anxiety Disorders

2. Nursing care of a client with Panic Disorder Generalized Anxiety Disorders

3. Associated Nursing Diagnosis
Panic anxiety
Powerlessness
Fear
Social Isolation
Ineffective Coping
Ineffective Role Performance
Post-traumatic Syndrome
Disturbed Body Image
Disturbed Sensory Perception
Disturbed Thought process

4. Nursing Diagnosis: Panic Anxiety
Related to: real or perceived threat to biological integrity or self-concept
Evidenced by: Any or all of the physical symptoms identified by the DSM-IV-TR

5. Outcome Criteria: Panic Anxiety
Short Term Goals:
The client will verbalize ways to intervene in escalating anxiety within 1 week
Long Term Goals:
By discharge the client will be able to recognize symptoms of anxiety onset and intervene before reaching panic level

6. Nursing Interventions: Panic Anxiety
Develop trust relationship through communicating core communication values (caring, acceptance, empathy, …)
Stay with the client and offer reassurance of safety & security
Maintain a calm (staff & client), nonthreatening, matter-of-fact approach
Use simple wards & messages, spoken calmly & clearly, to explain any procedure

7. Nursing Interventions: Panic Anxiety
Decrease environmental stimuli (dim light, decrease number of people, simple décor,…)
Administer PRN Tranquilizers
When level of anxiety decrease,
Explore possible reasons for occurrence
Help client recognize precipitating factors
Help client recognize early signs
Teach client ways to interrupt escalation of signs (progressive relaxation, breathing exercises, or physical exercises…)

8. Nursing Diagnosis: Powerlessness
Related to:
Impaired cognition
Evidenced by:
Verbal expression of no control over life situation & non participation in decision making related to own care

9. Outcome Criteria: Powerlessness
Short Term Goal:
Client will participate in decision making regarding own care
Long Term Goal:
Client will be able to use problem solving skills to control situations in own life

10. Nursing Interventions: Powerlessness
Develop a trust relationship
Allow the client to take responsibility for his\her own self care
Include client in setting goals & decision making by providing choices that increase his/her sense of control.
Allow client to establish own schedule for self care.
Include client in setting goals of care
Provide client with privacy as need is determined
Provide positive feedback for responsible behaviours.
Respect client’s right of decisions he/she made independently, & refrain from trying to influence him/her toward decisions that might seem more logical

11. Nursing Interventions: Powerlessness
Assist the client to set realistic goals for his\her daily activities; expectations from others and self.
Help client identify areas of his\her life for which control can be achieved.
Help the client to identify areas of life for which control cannot be achieved
Help client to verbalize feelings about situations that he/she can not control & discuss ways how to live with it and accept it

12. Nursing care of client with Phobic Disorder

13. Nursing Diagnosis: Fear
Related to:
Thought of causing embarrassment to self in front of others, being in a place from which one is unable to escape, or specific stimuli
Evidenced by:
Behavior directed toward avoidance of the feared object or situation

14. Outcome Criteria: Fear
Short term Goal:
Verbalize feelings of fear and discomfort
Respond to relaxation techniques with decreased anxiety
Effectively decrease own anxiety level
Decrease avoidance behaviors
Manage the anxiety response effectively
Long Term Goal:
The client will be able to function in the presence of phobic object or situation without experiencing a panic attack

15. Nursing Interventions: Fear
Reassure client of his/her safety
Allow the client to express feelings openly.
Teach the client and family or significant others about phobic reactions. Dispel any myths.
Reassure the client that he or she can learn to decrease the anxiety and gain control over the anxiety attacks

16. Nursing Interventions: Fear
Reassure the client that he or she will not be forced to confront the phobic situation until prepared to do so
Assist the client to distinguish between the phobic trigger and those problems related to avoidance behaviors that are interfering with daily life
Instruct the client in progressive relaxation techniques. These include deep breathing, focusing on specific muscles to decrease tenseness, and imagining.

17. Nursing Interventions: Fear
Encourage the client to practice relaxation until he or she is comfortable and successful.
Explain systematic desensitization thoroughly to the client (see below).
Reassure the client that you will allow him or her as much time as needed at each step.

18. Nursing Interventions: Fear
Have the client develop a hierarchy of situations that relate to the phobia.
Begin with the least anxiety-producing situation. Have the client use progressive relaxation in that situation until he or she is able to decrease the anxiety.
If the client becomes excessively anxious or begins to feel out of control, return to the former step with which the client was comfortable and successful.

19. Nursing Interventions: Fear
Give positive feedback for the client's efforts at each step. Avoid equating success only with mastery of the entire process.
Discuss the previously identified avoidance behaviors with client to determine if there is a corresponding decrease as client progress in systematic desensitization

20. Nursing Diagnosis: Social Isolation
Related to:
Fear of being in a place from which escape is not possible
Evidenced by:
Staying alone, refusing to leave room or home

21. Outcome Criteria: Social Isolation
Short Term Goals:
The client will willingly attend therapy activities by trusted support person for 1 week
Long Term Goals:
Client will spend time voluntarily with staff members in group activities by discharge

22. Nursing Interventions: Social Isolation
Develop trust relationship through:
Conveying acceptance and regard
Being honest and keeping promises
Making brief frequent contacts
Attend group activities with client to provide emotional security for client
Give space and avoid touch
Administer PRN tranquilizers
Discuss with client signs of increased anxiety and techniques to interrupt it (relaxation …)
Give positive reinforcement for voluntary interaction with others

23. Nursing Care of a client with OCD

24. Nursing Diagnosis: Ineffective Coping
Related to:
Underdeveloped ego, punitive superego, avoidance learning, biochemical changes (OCD)
Repressed anxiety, unmet dependency needs (Somatoform disorder)
Severe psychosocial stressors or substance abuse and repressed severe anxiety (Dissociative disorder)

25. Nursing Diagnosis: Ineffective Coping
Evidenced by:
Ritualistic behavior, obsessive thoughts (OCD)
Verbalization of numerous physical complaints, self centered, presence of physical symptoms with no path-physiology (somatic disorders)
Sudden travel away from home with inability to recall previous identity (dissociative disorders)

26. Outcome Criteria: Ineffective coping
Short Term Goals:
Client will decrease participation in ritualistic behavior by half within 1 week
Client will verbalize understanding of correlation between physical symptoms or dissociative behavior & anxiety or stressful psychosocial stress
Client will verbalize more adaptive ways of coping in stressful situations than resorting to dissociation or physical complaint or symptoms

27. Outcome Criteria: Ineffective coping
Long Term Goals:
Client will demonstrate the use of healthy coping strategies without resorting to previous unhealthy coping

28. Nursing Intervention: Ineffective coping
Develop trust relationship through communicating acceptance, understanding, respect ….
Reassure the client for safety & security by your presence
Accept client’s behavior (physical complaint) & do not deny client’s feelings
Give space and allow ritualistic behavior of complaint at the beginning of treatment without judgment

29. Nursing Intervention: Ineffective coping
Initially meet the client’s dependency needs as required, & encourage independence & give positive rewards for independent behavior
Identify factors or stressors that precipitate severe anxiety
Support client & help him/her to verbalize & explore meaning & purpose the exhibited behavior (OCD, dissociative or physical complaint)

30. Nursing Intervention: Ineffective coping
Provide structured schedule to divert from the unwanted behavior (ritualistic or physical complaint) – allow some time for ritualistic behavior then decrease the allocated time for it gradually-
Explain that new physical complaint will be referred to the physician with no further attention
Help client to learn ways to interrupt unhealthy behaviors (ritualistic, complaining of physical symptoms)

31. Nursing Intervention: Ineffective coping
Discuss possible alternative coping strategies to use in response to stress – relaxation, exercise…-
Give positive reinforcement for use of healthy coping strategies
Help client identify ways of getting recognitions from others without resorting to physical symptoms
Identify community resources for support to prevent unhealthy coping behaviors from reoccurring

32. Nursing Diagnosis: Ineffective Role Performance
Related to:
Need to perform rituals
Evidenced by:
Inability to fulfill usual patterns of responsibility

33. Outcome Criteria: Ineffective Role Performance
Short Term Goal:
Client will verbalize understanding that rituals interfere with role performance in order to decrease anxiety
Long Term Goal
Client will be able to resume role related responsibilities by discharge

34. Nursing Interventions: Ineffective Role Performance
Assess extent of role alteration by exploring client’s role and other family members’ roles
Discuss client & family members perception of the role and determine if it is realistic
Encourage the client to discuss conflict within family system in order to produce change in family system if needed
Identify specific stressors
Identify adaptive or maladaptive responses of both client & family members

35. Nursing Interventions: Ineffective Role Performance
Explore available options for changes or adjustments in role
Plan & rehearse through role play, of potential role transition this will help to decrease anxiety
Encourage the participation of family members who are directly involved in planning and helping client to work through the changes
Give the client positive reinforcement for ability to resume role responsibilities

36. Nursing Diagnosis: Disturbed Body Image
Related to:
Repressed anxiety
Evidenced by:
Preoccupation with imagined or real defect, verbalizations that are out of proportion to any actual physical abnormality that may exist, numerous visits to dermatologists to seek help

37. Outcome Criteria: Disturbed Body Image
Short Term Goal:
Client will verbalize understanding that changes in bodily structure or function is exaggerated (specific time)
Long Term Goal:
Client will verbalize perception of own body that is realistic to actual structure or function by discharge

38. Nursing Interventions: Disturbed Body Image
Assess client’s perception of his/her body image, keep in mind that body image is real for the client
Help client to see that his/her body image is distorted and exaggerated recognition is necessary before accepting reality
Encourage verbalization of fears & anxieties associated with life situations-verbalization help the client to come to term with unresolved issues
Discuss alternative coping strategies
Involve client in activities that reinforce positive self image –to develop self satisfaction based on accomplishments

39. Nursing care of a client with Post-traumatic Disorder

40. Nursing Diagnosis: Post-trauma Syndrome
Related to:
Distressing event considered to be outside the range of usual human experience
Evidenced by:
Flashbacks, intrusive recollections, nightmares, psychological numbness related to the event, dissociation, or amnesia.

41. Outcome Criteria: Post-trauma Syndrome
Short Term Goals:
Client will begin a healthy grief resolution, initiating the process of psychological healing (within time frame specific to individual).
Long Term Goal:
The client will integrate the traumatic experience into his or her persona, renew significant relationships, and establish meaningful goals for the future.

42. Nursing Interventions: Post-trauma Syndrome
Assign the same staff as often as possible.
Use a nonthreatening, matter of-fact, but friendly approach.
Respect client’s wishes regarding interaction with individuals of opposite sex at this time (especially important if the trauma was rape).
Be consistent; keep all promises; convey acceptance; spend time with client.

43. Nursing Interventions: Post-trauma Syndrome
Stay with client during periods of flashbacks and nightmares.
Offer reassurance of safety and security and that these symptoms are not uncommon following a trauma of the magnitude he or she has experienced.
Obtain accurate history from significant others about the trauma and the client’s specific response.

44. Nursing Interventions: Post-trauma Syndrome
Encourage the client to talk about the trauma at his or her own pace.
Provide a nonthreatening, private environment, and include a significant other if the client wishes.
Acknowledge and validate client’s feelings as they are expressed.
Discuss coping strategies used in response to the trauma, as well as those used during stressful situations in the past.

45. Nursing Interventions: Post-trauma Syndrome
Determine those that have been most helpful, and discuss alternative strategies for the future. Include available support systems, including religious and cultural influences.
Identify maladaptive coping strategies (e.g., substance use, psychosomatic responses) and practice more adaptive coping strategies for possible future post-trauma responses.

46. Nursing Interventions: Post-trauma Syndrome
Assist the individual to try to comprehend the trauma if possible.
Discuss feelings of vulnerability and the individual’s “place” in the world following the trauma.

47. Nursing Diagnosis: Complicated Grieving
Related to:
Loss of self as perceived prior to the trauma or other actual/perceived losses incurred during/following the event.
Evidenced by:
Irritability and explosiveness, self- destructiveness, substance abuse, verbalization of survival guilt or guilt about behavior required for survival

48. Outcome Criteria: Complicated Grieving
Short Term Goals:
Client will verbalize feelings (guilt, anger, self- blame, hopelessness) associated with the trauma.
Long Term Goal:
Client will demonstrate progress in dealing with stages of grief and will verbalize a sense of optimism and hope for the future.

49. Nursing Interventions: Complicated Grieving
Acknowledge feelings of guilt or self-blame that client may express.
Assess stage of grief in which the client is fixed.
Discuss normalcy of feelings and behaviors related to stages of grief.
Assess impact of the trauma on client’s ability to resume regular activities of daily living.
Consider employment, marital relationship, and sleep patterns.

50. Nursing Interventions: Complicated Grieving
Assess for self-destructive ideas and behavior.
Assess for maladaptive coping strategies, such as substance abuse.
Identify available community resources from which the individual may seek assistance if problems with complicated grieving persist.

51. Nursing care of a client with Somatic Disorders

52. Nursing Diagnosis: Chronic Pain
Related to:
Repressed anxiety & learned maladaptive coping skills
Evidenced by:
Verbal complaints of pain with no patho- physiology, excessive use of analgesics

53. Outcome Criteria: Chronic Pain
Short Term Goals:
Client will verbalize relief from pain
Client will verbalize understanding of the relationship between pain & psychological problem
Long Term Goal:
Client will demonstrate the ability to cope with life situations with decreased experience of pain responses

54. Nursing Interventions: Chronic Pain
Monitor physician on going assessment & lab reports
Accept the reality of the pain to the client
Observe & record the onset, precipitating factors, duration & intensity of the pain
Provide prescribed pain medication
Provide comfort measures such as back rub, warm bath, hot pads that will meet the secondary gains from being in pain

55. Nursing Interventions: Chronic Pain
Offer attention when client is not complaining of pain
Identify activities that helps to distract the client’s attention from complaints
Encourage verbalization of feelings by
Exploring meaning of pain
Connecting between pain & anxiety
Identify situations that cause anxiety

56. Nursing Interventions: Chronic Pain
Encourage client to identify new health coping strategies with stress
Explore ways to intervene with pain (so that it will not become disabling) such as deep breathing, imagery, relaxation
Provide positive reinforcement for times when client is not focusing on pain

57. Nursing Diagnosis: Fear (of having a serious illness)
Related to:
Past experience with life threatening illness of self or significant others
Evidenced by:
Preoccupation with & unrealistic interpretation of bodily signs & sensations

58. Outcome Criteria: Fear (of having a serious illness
Short Term Goal:
Client will verbalize that fear is associated with bodily sensation are irrational
Long Term Goal:
Client will interpret bodily sensation correctly

59. Nursing intervention: Fear (of having a serious illness)
Monitor physician’s ongoing assessment & lab reports
Refer to physician if new complaint occur
Assess gain or met needs by fear of illness
Assess precipitating factors, onset, duration & intensity of fear & level of anxiety
Allocate specific time to discuss physical symptoms (start with a certain length of session then decrease the allocated time gradually)
Verbalize feelings instead of converting it to physical symptoms
Do not provide positive reinforcement to expressing of feelings physically
Teach the client coping strategies that will be helpful to decrease levels of anxiety such as deep breathing, relaxation, exercise

60. Nursing care of a client with Dissociative Disorders

61. Nursing Diagnosis: Disturbed Thought Process
Related to:
Severe psychological stress & repression of anxiety
Evidenced by:
Loss of memory

62. Outcome Criteria: Disturbed Thought Process
Short Term Goals:
The client will verbalize understanding that loss of memory is related to stressful situation
Client will discuss the stressful situation
Long Term Goal:
The client will
Recover deficit in memory
Develop more adaptive coping strategies to deal with stress

63. Nursing Interventions: Disturbed Thought Process
Obtain information from family about the client’s likes & dislikes, important people, activities
Do not provide the client with excessive information about his/her past
Expose client to pleasant experiences similar to ones in his/her past to stimulate memory
Discuss underlying feeling of stressful situations & how to deal with it
Assist client in identifying conflicts, identify solutions & follow up on carrying out the resolution

64. Nursing Diagnosis: Disturbed Sensory Perception (visual/kinesthetic)
Related to:
Repressed severe anxiety & psychological stress
Evidenced by:
Loss or alteration in physical functioning with no physical pathology (conversion); alteration in the perception of the self or the environment (depersonalization)

65. Outcome Criteria: Disturbed Sensory Perception
Short Term Goal:
Client will verbalize understanding of emotional problems as a contributing factor to the alteration in physical functioning
Client will verbalize adaptive ways of coping
Long Term Goal:
Client will recover from lost or altered function
Client will demonstrate the ability to perceive stimuli correctly
Client will maintain a sense of reality during stressful situations

66. Nursing Interventions: Disturbed Sensory Perception
Monitor physician’s on going assessment & lab reports
Identify primary & secondary gains from physical symptoms (dependency, attention, protection from experiencing stress)
Provide support & encouragement during times of depersonalization to lessen fear & anxiety
Explain the depersonalization (conversion) behavior & the purpose it serves
Explain the relationship between severe anxiety and depersonalization (conversion)

67. Nursing Interventions: Disturbed Sensory Perception
Do not focus on disability & encourage client to become more independent
Discuss painful experiences by exploring past experiences and possible painful situations such as trauma, losses ..etc.
Encourage client to deal with underlying feelings associated with the stressful situation
Teach client more health ways of responding to stress through role play
Give positive reinforcement for identification or demonstration of more healthy coping skills that will help in enhancing self esteem