Anxiety Disorders - Nursing Care PDF

CHAPTER 27 Anxiety Disorders: Nursing Care of Patients with Anxiety, Phobia, and Panic MDE - NURSN6302 Isper Crissey Anxiety Disorder Anxiety Anxiety – universal human experience. Uncomfortable feeling of apprehension or dread in r...

CHAPTER 27 Anxiety Disorders: Nursing Care of Patients with Anxiety, Phobia, and Panic MDE - NURSN6302 Isper Crissey Anxiety Disorder Anxiety Anxiety – universal human experience. Uncomfortable feeling of apprehension or dread in response to internal or external stimuli and real or perceived threat. Normal anxiety – Necessary for survival and appropriate to situation. Dissipates when situation resolves. Abnormal anxiety – determined by intensity of anxiety relative to the situation, trigger and symptomAnxiety clusters disorders manifested. 2  Symptoms of Anxiety: Cognitive, Affective, Physical, Behavioral Anxiety disorders 3 Peplau’s Model Levels of Anxiety Mild anxiety Moderate anxiety Severe anxiety Panic Anxiety disorders 4 Levels of Anxiety Mild anxiety - occurs in the normal experience of everyday living. Cognitive - perceive reality in sharp focus, sees, hears, and grasps more information, and problem solving becomes more effective. Physical - slight discomfort, restlessness, irritability, or mild tension-relieving behaviors (e.g., nail biting, foot or finger tapping, fidgeting) Anxiety disorders 5 Moderate anxiety Cognitive  perceptual field narrows,. sees, hears, and grasps less information, selective inattention, ability to think clearly is hampered. Affective  disturbing feeling that something is wrong  Feeling nervous or Anxiety disorders agitated 6  Severe anxiety Cognitive  Dazed and confused.  Learning problem solving are not possible  Perceptual field greatly reduced. Affective  Sense of impending doom or dread. Physical  headache, nausea, dizziness, insomnia.  Trembling and a pounding heart, hyperventilation. Behavioral  automatic and aimed at reducing or relieving anxiety. Anxiety disorders 7  Panic Panic is the most extreme level of anxiety. Cognitive  Unable to process what is going on in the environment and may lose touch with reality.  Hallucinations, or false sensory perceptions. Behavioral  Markedly dysregulated behavior.  Pacing, running, shouting, screaming, or withdrawal  Erratic, uncoordinated, and impulsive. Automatic behaviors are used to reduce and relieve anxiety, although such efforts may be ineffective. Anxiety disorders 8 Question 1 A parent is shopping with a 5-year-old child in a large, busy urban mall. The parent suddenly realizes the child is missing. Which level of anxiety would likely result? A. Mild B. Moderate C. Severe D. Panic Anxiety disorders 9 Answer Answer: Panic D Anxiety disorders 10  Case Study What behaviors might this parent be exhibiting that would indicate severe or panic-level anxiety? Anxiety disorders 11 Behaviors that may be manifested are: Pacing Running Shouting Screaming Also, physical behavior may become: Erratic Uncoordinated Impulsive Anxiety disorders 12 Defenses Against Anxiety Defense mechanisms – Automatic coping styles – Protect people from anxiety – Maintain self-image by blocking Feelings - Conflicts - Memories – – Sublimation and Altruism - healthy coping mechanisms.  Most defense mechanisms can be used in both adaptive and maladaptive ways. Anxiety disorders 13 Defenses Against Anxiety Adaptive use of defense mechanisms helps people lower anxiety to achieve goals in acceptable ways. Maladaptive use of defense mechanisms occurs when one or several are used in excess, particularly in the overuse of immature defenses. Anxiety disorders 14 Overview of Anxiety Disorders Most common psychiatric disorder Chronic and persistent Interferes with personal, occupational, or social functioning. Comorbidities: physical comorbidities commonly heart disease and respiratory disease Anxiety disorders across the life span  Children  Older adults Anxiety disorders 15 Anxiety Disorder Factors that determine if anxiety is a symptom of mental disorder: – Intensity of anxiety relative to situation – Trigger for anxiety – Symptom clusters manifested Anxiety disorder 16 Epidemiology of Anxiety Disorders  More than 19 million adults in US  14.6% experience anxiety disorder during lifetime  Affect women more than men  Increased risk: smokers, < age 45, separated/divorced, survivors of abuse  Commonly associated with other psychiatric illnesses or physiologic disorders Anxiety disorders 17  Psychological Theories Psychodynamic theories – Sigmund Freud - results when threatening repressed ideas or emotions are close to breaking through from the unconscious mind and conscious mind. – Harry Stack Sullivan - “contagious,” being transmitted to the infant from the mother or caregiver – Behavior theories - learned response to specific environmental stimuli (classical conditioning). – Cognitive theories - caused by distortions in an individual’s thoughts and perceptions. Anxiety disorders 18. DSM5 Classification of Anxiety Disorders Anxiety disorders 19 Panic Disorder Extreme and overwhelming Feelings of being in real or perceived life-threatening situation. Panic attacks are the key feature. Sudden onset of extreme apprehension or fear Feeling of impending doom. The feelings of terror present - “heart attack” Comes “out of the blue” lasts a matter of minutes, and then subside. “fear the fear” results to Avoidance Across the Life Span Anxiety disorders 20 Panic disorder Anxiety disorders 21 Panic disorder Co-morbidities Major depression - before the onset of panic disorder or may occur at the same time. Substance use - probably as attempts to self-medicate. Nonpsychiatric disorders - hyperthyroidism, dizziness, cardiac arrhythmias, asthma, chronic obstructive pulmonary disease (COPD), and irritable bowelAnxiety syndrome. disorders 22  Panic Attack DSM Criteria Discrete period of intense fear or discomfort in which 4 or more of the following symptoms developed abruptly and reached a peak within 10 minutes: – Palpitations, pounding heart or accelerated heart rate – Sweating – Trembling or shaking – Sensations or SOB or smothering – Chest pain or discomfort – Nausea or abdominal distress – Feeling dizzy, unsteady, lightheaded or faint – Derealization or depersonalization – Fear of losing control or going crazy – Feeling of choking – Fear of dying – Paresthesias – Chills or hot flushes Anxiety disorders 23 Generalized Anxiety Disorder Key pathological feature is excessive worry. Worry, which is out of proportion to the true impact of events or situations. Inadequacy in interpersonal relationships, job responsibilities, finances, and health of family members. Spent in preparing for activities. Avoidance are key symptoms. Family members and friends are overtaxed - seeks continual reassurance and perseverates about meaningless details. Anxiety disorders 24 Generalized Anxiety Disorder Anxiety disorders 25  Obsessive-Compulsive Disorders A group of related disorders that all have obsessive-compulsive characteristics. Obsessions  thoughts, impulses, or images persist that are difficult to dismiss  Senseless to the individual who experiences them (ego-dystonic). Most common fear of contamination.  Causes severe anxiety. Compulsions –  ritualistic behaviors an individual feels driven to perform to reduce anxiety  Temporarily reduces anxiety  Relief is only temporary, the compulsive act must be repeated again and again. (handwashing, counting) Anxiety disorders 26 OCD Anxiety disorders 27 Posttraumatic Stress Disorder DSM criteria Person has been exposed to a traumatic event Event is reexperienced Persistent avoidance of stimuli associated with event Symptoms of increased arousal Anxiety disorders 28 Acute Stress Disorder DSM CRITERIA Person has been exposed to a traumatic event Person has 3+ – Numbing, detachment – Reduction of awareness of surroundings – Derealization – Depersonalization – Dissociative amnesia Reexperienced Avoidance 2 days – one month Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 29  The Nursing Process Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 30 Application of the Nursing Process Assessment  General assessment of symptoms  Self-assessment Nursing diagnosis Outcomes identification Interventions Implementation Counseling Teamwork and safety Promotion of self-care activities Anxiety disorders 31 Assessment Panic Disorder – Determine patterns of attacks, symptoms, responses – Mental status – Suicide assessment – Family functioning – Cultural factors – Cognitive thought patterns – Avoidance behavior patterns Generalized Anxiety Disorder – Mental status – Thought content – Coping techniques Anxiety disorders 32 Assessment Obsessive Compulsive Disorder – Type and severity of obsessions and compulsions – Degree to which symptoms interfere with functioning – Consequences of compulsions – Nutrition and sleep – Suicide assessment Anxiety disorders 33 Nursing Diagnoses Anxiety Sleep deprivation Powerlessness Ineffective coping Impaired skin integrity Ineffective tissue perfusion Risk for injury Compromised family coping Disturbed thought processes Anxiety disorders 34  Case Study What would be some appropriate interventions for the parent whose child is missing at the mall and is experiencing panic level anxiety? Anxiety disorders 35 Case Study Maintain a calm manner Remain with the parent Minimize environmental stimuli if possible Move to a quieter setting if possible and stay with the parent Use clear, simple statements and repetition Use a low-pitched voice; speak slowly Recognize the anxious person's distress Being willing to listen Anxiety disorders 36 Interventions PANIC OCD  Provide for basic needs  Stay with patient and remain calm  Ask specific questions about  Give clear, simple instructions thoughts, behaviors  Non-stimulating environment  Maintain accepting attitude  Reassurance  Allow time to carry out ritualistic behavior  Administer PRN anxiolytic medications  Explain unit routines, PTSD expectations, changes  Monitor suicidal thoughts,  Encourage patient to express behavior grief and gain coping skills  Set realistic expectations and  Help clients identify situations that identify progress precipitate  Administer and Monitor medication anxiety and when anxiety level changes  Patient education  Encourage verbal vs. physical expressions of anger  Teach relaxation techniques  Sleep hygiene Anxiety disorders 37 Implementation Pharmacological interventions Antidepressants  Selective Serotonin Reuptake Inhibitor (SSRIs) - first line of defense.  paroxetine (Paxil), fluoxetine (Prozac), escitalopram (Lexapro), fluvoxamine (Luvox), and sertraline (Zoloft).  Serotonin norepinephrine reuptake inhibitor (SNRI)  Venlafaxine (Effexor) duloxetine (Cymbalta).  Monoamine oxidase inhibitors (MAOIs)  Isocarboxazid (Marplan), phenelzine sulfate (Nardil) Anxiety disorders 38 Pharmacological interventions  Antianxiety drugs  Benzodiazepines  quick onset of action/fast actin  High potential for dependence – short term use only.  Rebound anxiety  Contraindicated in COPD, sleep apnea  Drug-drug interactions  Avoid alcohol due to increased sedative effects  Cigarette smoking increases clearance  Withdrawal symptoms  Side effects: sedation, confusion, dizziness, headache and visual disturbances Anxiety disorders 39 Benzodiazepines Alprazolam (Xanax) Lorazepam (Ativan) Clonazepam (Klonopin) Diazepam (Valium) Anxiety disorders 40. Other Pharmacological interventions Alternative antianxiety medication that does not cause dependence, takes 2 to 4 weeks to reach full effects. Added if the first course of treatment is ineffective. Atypical Anxiolytics  Zolpidem (Ambien)  Buspirone (BuSpar) Antihistamines  Diphenhydramine (Benadryl)  Hydroxizine (Vistril) Beta-blockers Anticonvulsants 41 c. Non -  Psychobiological Pharmacological interventions interventions  ECT Integrative therapy – herbal therapy i.e.  Psychosurgery such as kava Gamma Knife and deep brain stimulation has been used in obsessive-compulsive disorder for those most severely affected. Anxiety disorders 42 Health teaching is a significant nursing intervention for patients with anxiety disorders. Stress management Relaxation techniques Anxiety disorders 43 Advanced Practice Interventions  Cognitive therapy Cognitive-behavioral therapy – replace negative thoughts. Identify, evaluate and restructure cognitive distortions, Thought stopping.  Behavioral therapy - Systematic desensitization (break down fearful situation into small, manageable steps),helps with situational avoidance. Exposure and Response prevention  Relaxation training – ease physical symptoms and refocus attention. Techniques such as deep breathing exercises, progressive relaxation, guided imagery, listening to music.  Interoceptive exposure technique – exposure to sensations experienced during panic attack, evoke feared sensations, sensations do not have to progress to panic attacks. Anxiety disorders 44 Audience Response Questions 1. What is your usual level of anxiety on the day of a nursing exam? A. Mild B. Moderate C. Severe D. Panic Anxiety disorders 45 Answer  ANS: Answers will vary.  Discuss the benefits of mild anxiety Anxiety disorders 46  Mild anxiety - occurs in the normal experience of everyday living. Cognitive symptoms - perceive reality in sharp focus, sees, hears, and grasps more information, and problem solving becomes more effective. Anxiety disorders 47