nursing care of clients with anxiety disorders. nursing care of a client with panic disorder...

Nursing Care of Clients Nursing Care of Clients with Anxiety Disorderswith Anxiety Disorders

Nursing care of a client Nursing care of a client with with

Panic Disorder Panic Disorder Generalized Anxiety Generalized Anxiety

Disorders Disorders

Associated Nursing Associated Nursing DiagnosisDiagnosis

Panic anxietyPowerlessnessFearSocial IsolationIneffective Coping Ineffective Role Performance Post-traumatic SyndromeDisturbed Body ImageDisturbed Sensory PerceptionDisturbed Thought process

Nursing Diagnosis: Panic AnxietyNursing Diagnosis: Panic Anxiety

Panic AnxietyRelated 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

Outcome Criteria: Panic AnxietyOutcome 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

Nursing Interventions: Panic Nursing Interventions: Panic AnxietyAnxiety

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

Nursing Interventions: Panic Nursing Interventions: Panic AnxietyAnxiety

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…)

Nursing Diagnosis: Powerlessness Nursing Diagnosis: Powerlessness

PowerlessnessRelated to:

◦Impaired cognitionEvidenced by:

◦Verbal expression of no control over life situation & non participation in decision making related to own care

Outcome Criteria: PowerlessnessOutcome 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

Nursing Interventions: Nursing Interventions: PowerlessnessPowerlessness

Develop a trust relationshipAllow the client to take responsibility for his\

her own self careInclude 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

Nursing Interventions: Nursing Interventions: PowerlessnessPowerlessness

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

Nursing care of client with Nursing care of client with Phobic DisorderPhobic Disorder

Nursing Diagnosis: FearNursing Diagnosis: Fear

FearRelated 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

Outcome Criteria: FearOutcome 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

Nursing Interventions: FearNursing Interventions: Fear

Reassure client of his/her safetyAllow 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


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.


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.


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.


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

Nursing Diagnosis: Social Nursing Diagnosis: Social IsolationIsolation

Social IsolationRelated to:

◦Fear of being in a place from which escape is not possible

Evidenced by:◦Staying alone, refusing to leave

room or home

Outcome Criteria: Social IsolationOutcome 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

Nursing Interventions: Social Nursing Interventions: Social IsolationIsolation

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

Nursing Care of a client with Nursing Care of a client with OCDOCD

Nursing Diagnosis: Ineffective Nursing Diagnosis: Ineffective CopingCoping

Ineffective CopingRelated 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)

Nursing Diagnosis: Ineffective Nursing Diagnosis: Ineffective CopingCoping

Ineffective copingEvidenced 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)

Outcome Criteria: Ineffective Outcome Criteria: Ineffective copingcoping

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

Outcome Criteria: Ineffective Outcome Criteria: Ineffective copingcoping

Long Term Goals:◦Client will demonstrate the use of

healthy coping strategies without resorting to previous unhealthy coping

Nursing Intervention: Ineffective Nursing Intervention: Ineffective copingcoping

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


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)


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)


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

Nursing Diagnosis: Ineffective Role Nursing Diagnosis: Ineffective Role PerformancePerformance

Ineffective Role PerformanceRelated to:

◦Need to perform rituals Evidenced by:

◦Inability to fulfill usual patterns of responsibility

Outcome Criteria: Ineffective Role Outcome Criteria: Ineffective Role PerformancePerformance

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

Nursing Interventions: Ineffective Role Nursing Interventions: Ineffective Role PerformancePerformance

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

Nursing Interventions: Ineffective Role Nursing Interventions: Ineffective Role PerformancePerformance

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

Nursing Diagnosis: Disturbed Body ImageNursing Diagnosis: Disturbed Body Image

Disturbed Body ImageRelated to:

◦Repressed anxietyEvidenced 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

Outcome Criteria: Disturbed Body Outcome Criteria: Disturbed Body ImageImage

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

Nursing Interventions: Disturbed Body Nursing Interventions: Disturbed Body ImageImage

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 strategiesInvolve client in activities that reinforce

positive self image –to develop self satisfaction based on accomplishments

Nursing care of a client with Nursing care of a client with Post-traumatic DisorderPost-traumatic Disorder

Nursing Diagnosis: Post-Nursing Diagnosis: Post-trauma Syndrometrauma SyndromePost-trauma SyndromeRelated 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.

Outcome Criteria: Post-Outcome Criteria: Post-trauma Syndrometrauma 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.

Nursing Interventions: Post-trauma Nursing Interventions: Post-trauma SyndromeSyndrome

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.


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.


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.


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.


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.

Nursing Diagnosis: Nursing Diagnosis: Complicated GrievingComplicated GrievingComplicated GrievingRelated 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

Outcome Criteria: Outcome Criteria: Complicated GrievingComplicated 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.

Nursing Interventions: Complicated Nursing Interventions: Complicated GrievingGrieving

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.

Nursing Interventions: Complicated Nursing Interventions: Complicated GrievingGrieving

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.

Nursing care of a client with Nursing care of a client with Somatic Disorders Somatic Disorders

Nursing Diagnosis: Nursing Diagnosis: Chronic PainChronic Pain

Chronic PainRelated to:

◦Repressed anxiety & learned maladaptive coping skills

Evidenced by:◦Verbal complaints of pain with no

patho-physiology, excessive use of analgesics

Outcome Criteria: Chronic Outcome Criteria: Chronic PainPain

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

Nursing Interventions: Chronic PainNursing 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 painProvide prescribed pain medication Provide comfort measures such as back

rub, warm bath, hot pads that will meet the secondary gains from being in 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


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

Nursing Diagnosis: Fear (of having a Nursing Diagnosis: Fear (of having a serious illness)serious illness)

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

Outcome Criteria: Fear (of having a Outcome Criteria: Fear (of having a serious illnessserious 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

Nursing intervention: Fear (of having a serious Nursing intervention: Fear (of having a serious illness)illness)

Monitor physician’s ongoing assessment & lab reports

Refer to physician if new complaint occurAssess gain or met needs by fear of illness Assess precipitating factors, onset, duration &

intensity of fear & level of anxietyAllocate 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

Nursing care of a client Nursing care of a client with Dissociative with Dissociative

Disorders Disorders

Nursing Diagnosis: Disturbed Thought Nursing Diagnosis: Disturbed Thought ProcessProcess

Disturbed Thought ProcessRelated to:

◦Severe psychological stress & repression of anxiety

Evidenced by:◦Loss of memory

Outcome Criteria: Disturbed Thought Outcome Criteria: Disturbed Thought Process 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

Nursing Interventions: Disturbed Thought Nursing Interventions: Disturbed Thought ProcessProcess

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

Nursing Diagnosis: Disturbed Sensory Nursing Diagnosis: Disturbed Sensory PerceptionPerception

(visual/kinesthetic)(visual/kinesthetic)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)

Outcome Criteria: Disturbed Sensory Outcome Criteria: Disturbed Sensory PerceptionPerception

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

Nursing Interventions: Disturbed Sensory Nursing Interventions: Disturbed Sensory PerceptionPerception

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)

Nursing Interventions: Disturbed Sensory Nursing Interventions: Disturbed Sensory PerceptionPerception

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

nursing care of clients with anxiety disorders. nursing care of a client with panic disorder...

Documents

client ways

care slide

panic anxiety panic

occurrence help client

life slide

panic level slide

nursing interventions

calm staff client