Anxiety is a vague feeling of dread or apprehension (uneasiness); it is the activation of the autonomic nervous system in response to external or internal stimuli that can have behavioral, emotional, cognitive, and physical symptoms. In contrast, fear is the feeling of apprehension over a specific threat or danger to a person.
Anxiety disorders, according to the American Psychiatric Association, are the most common type of psychiatric disorder. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), anxiety disorders include disorders that share features of excessive fear and anxiety and related behavioral disturbances. These disorders include the following:
Anxiety disorders are diagnosed when anxiety no longer functions as a signal of danger or motivation for needed change but becomes chronic and permeates major portions of the person’s life, resulting in maladaptive behaviors and emotional disability.
Anxiety disorders appear to be caused by an interaction of biopsychosocial factors, including genetic vulnerability, which interacts with situations, stress, or trauma to produce clinically significant syndromes (Bhatt & Bienenfeld, 2019).
Anxiety disorders have high rates of comorbidity with major depression and alcohol and drug abuse. Severe anxiety disorders may be complicated by suicide, with or without secondary mood disorders. Anxiety disorders occur more frequently in females than in males with an approximate 2:1 ratio (Chand & Marwaha, 2022).
Nurses encounter anxious clients and families in a variety of situations. The nurse must first assess the person’s anxiety level because this determines what interventions are likely to be effective. Treatment of anxiety disorders usually involves medication and therapy. A combination of both produces better results than either one alone. When working with an anxious person, the nurse must be aware of her anxiety level. It is easy for the nurse to become easily anxious – remaining calm and in control is essential if the nurse is going to work effectively with the client.
Nursing care plans and management for clients with anxiety disorders typically include reducing anxiety levels, promoting self-care, improving coping skills, enhancing social support, and encouraging treatment compliance.
The following are the nursing priorities for patients with anxiety disorders:
Assess for the following subjective and objective data:
Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with anxiety disorders based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.
Goals and expected outcomes may include:
Therapeutic interventions and nursing actions for patients with anxiety disorders may include:
Patients with anxiety disorders experience excessive and persistent feelings of fear, worry, and unease that go beyond what is considered normal. This anxiety can manifest as intense physical symptoms such as racing heart, shortness of breath, and trembling, as well as intrusive thoughts, avoidance behaviors, and difficulties with daily functioning. The anxiety experienced is often disproportionate to the actual threat or trigger, significantly impacting their quality of life and requiring intervention.
Assess physical and behavioral symptoms of anxiety, such as increased heart rate, sweating, and restlessness.
Anxiety also plays a role in somatoform disorders, which are characterized by physical symptoms such as pain, nausea, weakness, or dizziness that have no apparent physical cause. Because anxiety manifests with several physical symptoms, any client who presents with a de novo complaint of physical symptoms suggesting an anxiety disorder should have a physical examination and basic laboratory workup to rule out medical conditions that might present with anxiety-like symptoms (Bhatt & Bienenfeld, 2019).
Assess the client’s anxiety triggers, including situational factors and personal history.
This is to identify the specific causes or situations that are contributing to the client’s anxiety. Anxiety can be triggered by medications, herbal medications, substance abuse, trauma, childhood experiences, or panic disorders (Chand & Marwaha, 2022). Clients with anxiety disorder tend to imagine the worst possible scenario and avoid situations they think are dangerous, such as crowds, heights, or social interaction (Bhatt & Bienenfeld, 2019).
Perform a mental status assessment.
A complete mental status examination should be obtained for each client with anxiety symptoms, assessing appearance, behavior, ability to cooperate with the exam, level of activity, speech, mood, affect, thought processes, content, insight, and judgment. Two main elements of the mental status exam should be assessed in generalized anxiety disorder. The first involves asking about suicidal/homicidal ideations or plans. The second involves formal testing of orientation/recall (Bhatt & Bienenfeld, 2019)l.
Establish and maintain a trusting relationship by listening to the client; displaying warmth, answering questions directly, offering unconditional acceptance; being available, and respecting the client’s use of personal space.
Therapeutic skills need to be directed toward putting the client at ease, because the nurse who is a stranger may pose a threat to the highly anxious client. Use appropriate verbal techniques that are clear and concise to respond to an anxious client. Use brief statements that acknowledge the client’s current state of feelings, such as “It seems to me that you are anxious” or “I notice that you seem anxious. These techniques provide reassurance and prevent further escalation of anxiety (Elsevier, 2021).
Maintain a calm, non-threatening manner while working with the client.
Anxiety is contagious and may be transferred from the healthcare provider to the client or vice versa. The client develops a feeling of security in presence of a calm staff person. Use appropriate nonverbal behaviors, such as maintaining a relaxed and calm posture and active listening skills. These behaviors, though nonverbal, express interest and help alleviate anxiety (Elsevier, 2021).
Remain with the client at all times when levels of anxiety are high (severe or panic); reassure the client of his or her safety and security.
The client’s safety is an utmost priority. A highly anxious client should not be left alone as his anxiety will escalate. Staying with the client may also make them feel that they are valued and someone is willing to give them time and attention. Offering to stay or simply sitting with the client for a while can help boost their mood (Rivier University, 2023).
Move the client to a quiet area with minimal stimuli such as a small room or seclusion area (dim lighting, few people, and so on.)
Anxious behavior escalates by external stimuli. A smaller or secluded area enhances a sense of security as compared to a large area which can make the client feel lost and panicked. Make the physical environment as quiet and calm as possible and allow ample personal space for the client. Provide a safe environment based on unit practice and client preference so that the client can feel accepted and may promote the verbalization of feelings (Elsevier, 2021).
Provide reassurance and comfort measures.
This helps relieve anxiety. It is difficult to deal with emotional issues when experiencing extreme or persistent physical discomfort. It is important to note that every client’s experience with anxiety is different and what works for one client may not work for another. Music or aromatherapy may help the client relax. Listening to calming music or using essential oils can help promote relaxation and reduce anxiety.
Educate the client and/or family members that anxiety disorders are treatable.
Pharmacological therapy is an effective treatment for anxiety disorders, these may include antidepressants and anxiolytics. Anxiety disorders do get better with therapy. The course depends on the type of anxiety disorder. Medications, psychotherapy, or a combination of both can usually relieve troubling symptoms. According to a psychiatrist and neuroscientist, Dr. Daniel Pine, anxiety disorders are one of the most treatable mental health problems (News in Health, 2016).
Support the client’s defenses initially.
The client uses defenses in an attempt to deal with an unconscious conflict, and giving up these defenses prematurely may cause increased anxiety. When a client copes with anxiety, they must use effective, not maladaptive defense mechanisms. Maladaptive defense mechanisms may interfere with care and client and family cooperation with treatment (Elsevier, 2021).
Maintain awareness of your feelings and level of discomfort.
Anxiety is communicated interpersonally. Being with an anxious client can raise your anxiety level. Discussion of these feelings can provide a role model for the client and show a different way of dealing with them. The nurse should recognize their own anxiety level and remain calm by breathing slowly and deeply. They should also be aware of nonverbal cues that indicate their anxiety such as body language, posture, and speech cadence (Elsevier, 2021).
Use short, simple directions when the client is in a panic attack.
During a panic attack, the client needs reassurance that he is not dying and the symptoms will resolve spontaneously. In anxiety, the client’s ability to deal with abstractions or complexity is impaired. During the episode, the client may have the urge to flee or escape and have a sense of impending doom, as though they are dying from a heart attack or suffocation (Bhatt & Bienenfeld, 2019).
Avoid asking or forcing the client to make choices.
The client may not make sound and appropriate decisions or may be unable to make decisions at all. Forcing a client to make choices can be counterproductive and potentially harmful. These clients may struggle with den-making due to their heightened sense of uncertainty and fear of making the wrong choice. If the client feels forced, this can undermine the client’s trust and damage the therapeutic relationship between the nurse and the client.
Instruct the client that medications prescribed as needed may be indicated for high levels of anxiety. Watch out for adverse side effects.
Medication may be necessary to decrease anxiety to a level at which the client can feel safe. Benzodiazepines act quickly but carry the liability of physiologic and psychologic dependence. Initiation of antidepressants is thought to cause early worsening of anxiety, agitation, and irritability, particularly when used to treat anxiety (Bhatt & Bienenfeld, 2019).
Encourage the client’s participation in relaxation exercises such as deep breathing, progressive muscle relaxation, guided imagery, meditation, and so forth.
Relaxation exercises are effective nonchemical ways to reduce anxiety. Relaxation training has also been used to treat anxiety with some degree of success. Relaxation techniques include methods such as progressive muscle relaxation, which emphasizes reducing muscle tension and achieving relaxed states and applied relaxation, which focuses on making relaxation a skill to be used in natural settings (Montero-Marin et al., 2017).
Teach signs and symptoms of escalating anxiety and ways to interrupt its progression (e.g., relaxation techniques, deep-breathing exercises, physical exercises, brisk walks, jogging, and meditation).
By recognizing the early signs of escalating anxiety, clients can learn how to manage the symptoms and prevent them from becoming more severe, which gives the client confidence in having control over his/her anxiety. Somatic concerns of death from cardiac or respiratory problems may be a major focus of clients during panic attacks. These clients may end up in the emergency department (ED) (Bhatt & Bienenfeld, 2019).
Administer selective serotonin reuptake inhibitors (SSRIs) as ordered.
Panic attacks are caused by a neuropsychiatric disorder that responds to SSRI antidepressants. SSRIs are generally used as first-line agents for the long-term management of anxiety disorders, with control gradually achieved over a 2 to 4-week course, depending on required dosage increases. Fluoxetine has a very long half-life, making it well-suitable for clients who have difficulty remembering to take all of their medications each day (Bhatt & Bienenfeld, 2019).
Help the client see that mild anxiety can be a positive catalyst for change and does not need to be avoided.
The client may feel that all anxiety is bad and not useful. Anxiety may be a part of our body’s innate way of dealing with stress. Known as the fight-or-flight response, anxiety is meant to protect from danger and allow the client to react faster to emergencies. Mild anxiety may act as a warning sign to bring awareness to a current situation and make necessary life changes (Star, 2020).
Exposure therapy
Exposure-based techniques are some of the most commonly used CBT methods in treating anxiety disorders. Exposure is proposed to modify the pathological fear structure by first activating it and then providing new information that disconfirms the pathological, unrealistic associations in the structures. By confronting the feared stimulus or responses and integrating corrective information in the fear memory, fear is expected to decrease (Kaczkurkin & Foa, 2022).
Cognitive therapy
Cognitive therapy is based on Beck’s tri-part model of emotion which proposes that thoughts, feelings, and behaviors are interrelated. Cognitive therapy targets distorted thoughts using several techniques such as identifying inaccurate thinking, examining the evidence for and against automatic thoughts, challenging and changing maladaptive thoughts, altering problematic behaviors, and relating to other people in more adaptive ways (Kaczkurkin & Foa, 2022).
Behavioral therapy
Behavioral therapy involves sequentially greater exposure of the client to anxiety-provoking stimuli’ over time, the client becomes desensitized to the experience (Bhatt & Bienenfeld, 2019).
Respiratory training
Respiratory training can help control hyperventilation during panic attacks and helps clients control anxiety with controlled breathing.
When the level of anxiety has been reduced, explore with the client the possible reasons for the occurrence.
Recognition of precipitating factors is the first step in teaching the client to interrupt the escalation of anxiety. Environmental factors such as early childhood trauma can contribute to the risk of later anxiety disorders. Some individuals may appear resilient to stress, while others are vulnerable to stress, which precipitates an anxiety disorder (Bhatt & Bienenfeld, 2019).
Reinforce information about interpersonal psychotherapy (IPT).
IPT is a time-limited, focused, and evidence-based approach to treating mood disorders. The main goal of IPT is to improve the quality of a client’s interpersonal relationships and social functioning (Psychology Today, 2022). It has also shown some efficacy in the treatment of anxiety disorders. Eight trials examined the use of IPT for anxiety disorders and found large effects in comparison with control groups. There was no evidence suggesting that IPT is less effective than CBT for anxiety (Bhatt & Bienenfeld, 20
Determine the type of the client’s fear by thorough, rational questioning and active listening.
Active listening and thorough questioning promote trust and rapport between the client and the nurse. This, in turn, can encourage clients to be more open and honest about symptoms and feelings, which can lead to more effective treatment and improved outcomes. Anxiety is linked to fear and manifests as a future-oriented mood state that consists of a complex cognitive, affective, physiological, and behavioral response system associated with preparation for the anticipated events or circumstances perceived as threatening (Chand & Marwaha, 2022).
Explore the client’s perception of a threat to physical integrity or a threat to self-concept.
It is important to understand the client’s perception of the phobic object or situation to assist with the desensitization process. Triggers of panic can include injury, illness, interpersonal conflict or loss, use of cannabis, use of stimulants (caffeine, decongestants, cocaine), certain settings such as stores and public transportation, use of sertraline, and the SSRI discontinuation syndrome (Bhatt & Bienenfeld, 2019).
Present and discuss the reality of the situation with the client to recognize aspects that can be changed and those that cannot.
The client must accept the reality of the situation before the work of reducing the fear can progress. Anxiety disorders often involve excessive and persistent worry about future events or past experiences, which can lead to a sense of disconnection from the present moment. Additionally, clients with anxiety disorder tend to ruminate, focusing on negative thoughts and worrying about things that may or may not happen in the future.
Reassure the client of his safety and security.
At panic-level anxiety, the client may fear for their own life. Reassure and calm the client. Untreated panic attacks can subside spontaneously within 20 to 30 minutes, especially with reassurance and a calming environment (Bhatt & Bienenfeld, 2019).
Suggest that the client substitute positive thoughts for negative ones.
Emotion is connected to thought, and changing to a more positive thought can decrease the level of anxiety experienced. This also gives the client an alternative way of looking at the problem. By accepting these emotions, the client can learn to regulate their emotional responses and develop more effective coping strategies.
Include the client in making decisions related to the selection of alternative coping strategies.
Allowing the client choices provides a measure of control and serves to increase feelings of self-worth. This sense of control can reduce anxiety symptoms, as clients feel more empowered and better able to manage their anxiety. Additionally, when the client is involved in decision-making, healthcare providers can personalize treatment plans to meet the client’s unique needs, resulting in effective treatment.
Encourage the client to explore underlying feelings that may be contributing to irrational fears. Helping the client to understand how facing these feelings, rather than suppressing them, can result in more adaptive coping abilities.
Verbalization of feelings in a non-threatening environment may help the client come to terms with unresolved issues. The nurse may give the client a broad opening during conversations. Therapeutic communication is often most effective when clients direct the flow of the conversation and decide what to talk about. To that end, giving the client a broad opening such as “What’s on your mind today?” or “What would you like to talk about?” can be a good way to allow the client an opportunity to discuss their feelings (Rivier University, 2023).
Discuss the process of thinking about the feared object/situation before it occurs.
Anticipation of a future phobic reaction allows the client to deal with the physical manifestations of fear. Exposure can take several forms including imaginal, in vivo, and interoceptive. In vivo exposure involves a gradual approach to places, objects, people, or situations that were previously avoided although they are safe. Interoceptive exposure involves deliberately inducing physical sensations the client fears are indicative of a panic attack (Kaczkurkin & Foa, 2022).
Encourage the client to share seemingly unnatural fears and feelings with others, especially the nurse therapist.
Clients are often reluctant to share feelings for fear of ridicule and may have repeatedly been told to ignore feelings. Once the client begins to acknowledge and talk about these fears, it becomes apparent that the feelings are manageable. The client may be more likely to open up about their fears if they feel comfortable and safe with their nurse therapist. It is essential to establish a trusting relationship by being empathetic, non-judgmental, and validating their experiences.
Encourage to stop, wait, and not rush out of feared situations as soon as experienced. Support the use of relaxation exercises.
The client fears disorganization and loss of control of body and mind when exposed to the fear-producing stimulus. This fear leads to an avoidance response, and reality is never tested. If the client waits out the beginnings of anxiety and decreases it with relaxation exercises, then she or he may be ready to continue confronting the fear.
Explore things that may lower fear level and keep it manageable (e.g. singing while dressing, repeating a mantra, practicing positive self-talk while in a fearful situation).
This provides the client with a sense of control over the fear. It also distracts the client so that fear is not focused on and is allowed to escalate. Distraction techniques are often used along with other coping mechanisms. The client may try to control their breathing, use entertainment such as reading or watching TV, engage in a relaxation technique, or participate in a creative pursuit (Star, 2020).
Systematic desensitization
Systematic desensitization (gradual systematic exposure of the client to the feared situation under controlled conditions) allows the client to begin to overcome the fear and become desensitized to the fear. Note: Implosion or flooding (continuous, rapid presentation of the phobic stimulus) may show quicker results than systematic desensitization, but relapse is more common, or the client may become terrified and withdraw from therapy.
Expose the client to a predetermined list of anxiety-provoking stimuli rated in a hierarchy from the least frightening to the most frightening.
Experiencing fear in progressively more challenging but attainable steps allows the client to realize that dangerous consequences will not occur. This helps extinguish conditioned avoidance responses. Systematic desensitization begins with imaginary exposure to feared situations. The client uses their anxiety hierarchy to break down the feared situation into manageable components (Ankrom, 2020).
air each anxiety-producing stimulus (e.g. standing in an elevator) with the arousal of another effect of an opposite quality (e.g. relaxation, exercise, biofeedback) strong enough to suppress anxiety.
This helps the client to achieve physical and mental relaxation as the anxiety becomes less uncomfortable. For example, the client may stand in the checkout line, which could be their highest fear response. Then the client starts to focus on the action that causes the least amount of distress and then works their way up (Ankrom, 2020).
Help the client to learn how to use these techniques when confronting an actual and anxiety-provoking situation. Provide practice sessions (e.g.role-play) to deal with the phobic reactions in real-life situations.
The client needs a continued confrontation to gain control over fear. Practice helps the body become accustomed to the feeling of relaxation, enabling the individual to handle feared objects/situations. This technique is based on the principles of classical conditioning and the premise that what has been learned can be unlearned (Ankrom, 2020).
Encourage the client to set increasingly more difficult goals.
This develops confidence and movement toward improved functioning and independence. Systematic desensitization usually starts with the client imagining themselves in a progression of fearful situations and using relaxation strategies that compete with anxiety. Once successfully managed, the client may use the technique in real-life situations (Ankrom, 2020).
Administer benzodiazepines as indicated; watch out for any adverse side effects.
See Pharmacologic Management
Administer anti-anxiety agents as prescribed.
See Pharmacologic Management
Administer beta-blockers as indicated.
See Pharmacologic Management
Provide information about cranial electrotherapy stimulators (CES).
In 2019, the FDA approved CES for the treatment of anxiety, depression, and insomnia. The prescription device delivers micro pulses of electrical current across the brain, which in clinical trials led to a reduction in anxiety levels, insomnia, and depressed mood. It is the first CES integrated into noise-canceling, Bluetooth-enabled headphones, and the first CES managed through an app (Bhatt & Bienenfeld, 2019).
When isolated, patients with anxiety disorders may struggle with heightened distress and a sense of being overwhelmed by their thoughts and emotions. They may resort to various coping mechanisms such as seeking reassurance, engaging in avoidance behaviors, or experiencing heightened hypervigilance. The feeling of lack of control intensifies their anxiety, making it challenging to manage daily activities and leading to increased reliance on coping strategies to regain a sense of security and stability.
Assess the client’s ability to identify and communicate their emotions and stressors.
This helps understand how the client perceives and responds to anxiety symptoms. This information can help the nurse to develop an individualized plan of care that includes strategies for treating anxiety and improving coping skills. A client with the phobic disorder may present with neuro vegetative signs such as tremors or diaphoresis, but they can identify the reason for their anxiety. The thought content is significant for phobic ideation because it may reveal an unrealistic and out-of-proportion fear (Bhatt & Bienenfeld, 2019).
Assess the client’s coping strategies and evaluate their effectiveness in managing anxiety symptoms.
This will help in formulating any maladaptive coping mechanisms and developing a plan for the implementation of more effective coping strategies. Research supports the idea that coping ability plays an important role in adaptation to stressors. As such, the effective use of coping strategies may protect a person from the psychological and social factors associated with the development of anxiety (Wen Li & Miller, 2020).
Assess the impact of the client’s personal beliefs on their ability to cope.
Negative beliefs about themselves may affect how the client copes effectively. It has been suggested that a proactive belief system is essential for the development of coping abilities. The proactive belief system has two elements. First is the belief that one’s life course is determined by oneself rather than external factors. The second is the belief that life is full of resources. If these beliefs are in place, the client can take responsibility to shape their life outcomes (Wen Li & Miller, 2020).
Initially meet the client’s dependency needs as necessary.
The sudden and complete elimination of avenues for dependency would create anxiety and will burden the client more. Instrumental support as a coping strategy emphasizes dealing with stressors by obtaining advice, information, and feedback from one’s social network, even bedside nurses. However, it should be noted that older adults may be more reluctant to seek help compared to their younger counterparts, possibly due to the stigma around having mental health issues (Wen Li & Miller, 2020).
Encourage independence and give positive reinforcement for independent behaviors.
Positive reinforcement enhances self-esteem and encourages the repetition of desired behaviors. A study reveals that higher anxiety was associated with larger responses to both negative feedback and errors as the task progresses compared to those with lower anxiety, suggesting that anxiety makes reactions to negative cues more persistent (Tobias & Ito, 2021).
During the beginning of treatment, allow plenty of time for rituals. Do not be judgmental or verbalize disapproval of the behavior.
To deny the client this activity can precipitate a panic level of anxiety. Bronislaw Malinowski theorized that rituals are inherently tied to anxiety-provoking situations because they help decrease the anxiety that may impede normal functioning (Lang et al., 2020). However, these rituals may become maladaptive in the long run, therefore, they should be gradually reduced.
Support and encourage the client’s efforts to explore the meaning and purpose of the behavior.
The client may be unaware of the relationship between emotional problems and compulsive behaviors. Recognition and acceptance of problems are important before change can occur. Acceptance can improve the client’s overall emotional health. Identifying emotions is the first of multiple steps to achieving this. Remind the client that anxiety is influenced by a host of factors and not because the client is flawed in any way (Meek, 2021).
Gradually limit the amount of time allotted for ritualistic behavior as the client becomes more involved in unit activities.
Anxiety is minimized when the client can replace ritualistic behaviors with more adaptive ones. To reduce anxiety and distress associated with intrusive thoughts, the client may employ compulsions or rituals. These rituals may be personal and private, or they may involve others participating; the rituals are to compensate for the ego-dystonic feelings of obsessional thoughts and can cause a significant decline in function (Brock & Hany, 2022).
Encourage the recognition of situations that provoke obsessive thoughts or ritualistic behaviors.
Recognition of precipitating factors is the first step in teaching the client to interrupt the escalation of anxiety. It will be helpful for the client to pay attention to the situations that seem to trigger their anxiety. Although it won’t always be an option to avoid those triggers, being aware of them can help the client gain clarity and take steps toward managing stress in those specific situations (Meek, 2021).
Provide positive reinforcement for nonritualistic behaviors.
Positive reinforcement enhances self-esteem and encourages the repetition of desired behaviors. Positive reinforcement involves the addition of a reinforcing stimulus following a behavior that makes it more likely that the behavior will occur again in the future. When a favorable outcome, event, or reward occurs after an action, that particular response or behavior will be strengthened (Cherry, 2023).
Avoid reinforcing maladaptive behaviors.
Positive reinforcement can also strengthen undesirable behaviors. Waiting too long to deliver reinforcement or reinforcing the wrong behaviors can lead to the wrong associations. Use positive reinforcement when the client is displaying good behavior, not when they are using maladaptive coping mechanisms (Cherry, 2023).
Provide information about the different coping styles.
Coping is the outcome of the individual taking responsibility by employing visions of success. Proactive coping incorporates and utilizes social and non-social resources and includes goal setting and determined goal pursuit. Preventive coping involves identifying potential stressors while they are manageable and then making preparations before they develop fully. Reflective coping refers to brainstorming alternative plans of action to solve a problem and then mentally comparing their effectiveness. Avoidance coping involves coping by avoiding thinking about stressors (Wen Li & Miller, 2020).
Promote the consumption of a balanced diet and adequate hydration.
The benefits of a balanced diet and healthy lifestyle have been widely accepted to reduce and protect from the development of anxiety disorders and depression and their sustainability. Practices such as balanced nutrient load, appropriate hydration (in combination with limited alcohol and caffeine consumption), complex carbohydrate intake, magnesium (spinach, legumes, nuts, seeds, and whole grain), zinc sources (cashews, liver, beef, and egg yolks), omega-3 fatty acids, probiotics (kefir and asparagus), vitamin B (avocado and almonds), and antioxidants (beans, berries, walnuts, broccoli, artichoke, turmeric, and ginger) are all associated with lower anxiety and may help reduce anxiety symptoms (Batsikoura et al., 2021).
Encourage social support, especially from family members.
Clients who have family support will have more to adapt to their disease and may live longer. Basically, the family plays an important role in one’s ability to adapt to different situations. Nurses, because of their unique status in interaction with family members of clients, can adopt constructive measures to help these families (Batsikoura et al., 2021).
Provide referrals for support resources.
Finding a support system is important when struggling with anxiety. There are a variety of support resources available, both in-person options and online, that can help the client and their families. A community of people who not only understand but can offer tips and suggestions for helpful coping strategies can be valuable (Meek, 2021).
Help identify areas of life situations that the client can control.
The client’s emotional condition prevents his ability to solve problems. Support is required to perceive the benefits and consequences of available alternatives. The client’s locus of control may determine how much effort people will put in, and how long they will persevere when coping with stressful situations. The stronger the internal locus of control, the more active the efforts to cope (Wen Li & Miller, 2020).
Help the client identify areas of life situation that are not within his ability to control; encourage verbalization of these feelings.
This helps deal with unresolved issues and accept what cannot be changed. Locus of control refers to an individual’s perception of what or who controls the things that happen to them. People with an internal locus of control believe that they are in control of their future and can change a given situation. People with an external locus of control believe their lives are controlled and determined by factors outside their control (Wen Li & Miller, 2020).
Note behaviors indicative of hopelessness.
Listen for statements of despair, such as “they don’t care” or “It won’t make any difference”. These behaviors indicate the client’s ability to manage life changes. A client with panic disorder may have moods described as similar to anxiety and their speech may reflect anxiety or urgency (Bhatt & Bienenfeld, 2019).
Determine the degree of life and locus of control.
Life mastery helps determine success in adjusting to the health condition. The locus of control relates to the ability to manage outcomes related to the disease process. An external locus of control would benefit from positive affirmation.
Have the client take as much responsibility for their self-care practices.
Providing clients with choices and responsibility will increase their feelings of control. Self-efficacy refers to an individual’s belief in his or her ability to perform given tasks and reach goals. A self-efficacious person is high in self-motivation, remains persistent during hard times, copes with challenges well, and responds well to negative situations. Self-efficacy may thus serve as a means of developing effective coping (Wen Li & Miller, 2020).
Help the client set realistic goals.
Unrealistic goals set the client up for failure and reinforce feelings of powerlessness. Many people challenged with anxiety lead full, productive, and joyful lives. The key is for the client to take time to learn what strategies work well for them, stay connected with others, and remain positive (Meek, 2021).
Identify ways and instances in which the client can achieve and encourage participation in these activities; provide positive reinforcement for participation.
Positive reinforcement enhances self-esteem and encourages the repetition of positive behaviors. The goal of both positive and negative reinforcement is to increase the likelihood that a behavior will occur again in the future. The difference is in how each accomplishes this. Positive reinforcement adds something to strengthen behavior, while negative reinforcement removes something (Cherry, 2023).
Incorporate the client’s daily routine into the home care schedule or hospital stay, as possible.
Routines maintain a sense of control, self-determination, and independence. Having a routine can provide a sense of predictability and stability in daily life, which can reduce anxiety. Knowing what to expect and having a sense of control over the environment can create a sense of safety and security, which is soothing for individuals with anxiety.
Discuss needs openly and facilitate actions to meet identified needs.
Open discussion empowers the client. It also helps deal with manipulative behaviors. Discussing needs can help the client develop a better understanding of their own emotional, psychological, and physical needs. This awareness can help the client recognize when their needs are not being met, which can trigger anxiety. The open discussion also gives the client a voice and helps them assert their preferences and priorities as appropriate.
Discuss plans for the future and include family members in the planning.
Planning promotes a sense of control and hope. Family members should also receive information about the effect of anxiety disorders on mood, behavior, and relationships. Family members can assist in care by reinforcing the need for medical treatment and supervision. Family members may also assist by providing a collaborative resource for monitoring the severity of the client’s anxiety symptoms and response to treatment interventions (Bhatt & Bienenfeld, 2019).
Identify the extent of social isolation.
Studies described that social functioning levels remain impaired for up to 18 months following remission from panic disorder. This impaired social functioning following remission can be the result of residual cognitive affective symptoms or ‘social scarring’. However, such impaired social functioning can also be reflective of a vulnerability toward the development of affective disorders (Saris et al., 2017).
Assess for signs of depression.
Although impairment of social functioning seemed generally more prominent in depressive disorders than in anxiety disorders, the largest effect sizes were found in clients with comorbid anxiety and depression. Loneliness increases the risk of depression. Clients with anxiety disorders have a lower quality of life, especially in the areas of social interactions and subjective well-being. An estimated 50 to 70% of the clients’ anxiety and depression tend to co-occur, most likely as a result of common underlying pathophysiological processes (Saris et al., 2017).
Convey an accepting and positive attitude by making brief, frequent contacts.
An accepting attitude increases feelings of self-worth and facilitates trust. A study showed that loneliness was the strongest contributor to diminished physical health in comparison with network size, frequency of contact, and quality of the social network. Findings in another study show that the absence of close friends and relatives are associated with an increased risk of clinical anxiety and depression (Saris et al., 2017).
Show unconditional positive regard.
This conveys your belief in the client as a worthwhile individual. Findings in studies suggest the importance of providing positive regard to one’s clients; affirming clients may serve many valuable functions and, at a minimum, “sets the stage” for other mutative interventions (Farber et al., 2018).
Be with the client to offer support during group activities that may be frightening or difficult for him or her.
The presence of a trusted individual provides emotional security for the client. A meta-analysis of client adherence to medical treatment found greater structural, functional, and quality measures of social connection were associated with better adherence, with the strongest effect on social support (Donovan & Blazer, 2020).
Be honest, and empathetic and keep all promises.
Honesty and dependability promote a trusting relationship. In clinical settings, empathy is an essential personality trait for healthcare professionals that involves professional behavior focused on what the client and their family expect from the caring staff. The client’s positive outcomes are directly influenced by the ability of professionals to develop positive relationships to provide quality and safe care and even influence the outcome of the illness (Ayuso-Murillo et al., 2020).
Be cautious with touch. Allow the client extra space and an avenue for exit if he becomes too anxious.
A person with panic-level anxiety may perceive touch as a threatening gesture. The nurse may use therapeutic communication techniques such as silence and active listening while supporting the client. At times, it’s useful not to speak at all. Deliberate silence can give both the nurse and the client an opportunity to think through and process what comes next in the conversation. It gives the nurse and client the time and space they need to broach a new topic. The nurse should always let the client break the silence (Rivier University, 2023).
Administer tranquilizing medications as ordered; monitor adverse side effects.
Short-term use of antianxiety medications helps to reduce the level of anxiety in most individuals. Buspirone is a nonsedating antipsychotic drug unrelated to benzodiazepines, barbiturates, and other sedative-hypnotics. It has been found to be comparable with benzodiazepines in reducing symptoms of anxiety in double-blind placebo-controlled clinical trials and has fewer sedative or withdrawal adverse effects than benzodiazepines (Bhatt & Bienenfeld, 2019).
Discuss with the client the signs of increasing anxiety and techniques for interrupting the response such as breathing exercises, thought-stopping, relaxation, and meditation.
Maladaptive behaviors are manifested during times of increased anxiety. There are varied practices of mindfulness that can help with anxiety. Using techniques like mindfulness, prayer, and deep breathing can help slow down the anxious processing of thoughts and emotions. By slowing down, the client may learn to be more present rather than hyper-focused on trying to anticipate and prepare for the future, which is what anxiety makes us focus on, even when there are no threats present (Meek, 2021).
Give recognition and positive reinforcement for the client’s voluntary interaction with others.
Positive reinforcement enhances self-esteem and encourages the repetition of acceptable behaviors. Positive reinforcement is commonly used as part of behavior modification, an intervention that focuses on reducing or eliminating maladaptive behaviors. Positive reinforcement is most effective when it occurs immediately after the behavior. Reinforcement should be presented enthusiastically and should occur frequently (Cherry, 2023).
Ensure that the client’s assistive aids function appropriately, such as hearing aids and eyeglasses.
Indirect interventions for social isolation in older adults tend to address underlying conditions or risk factors such as hearing aids or cochlear implants to mitigate the impact of hearing loss in social isolation (Donovan & Blazer, 2020).
Provide referrals to support groups and community resources.
Social isolation may also be addressed indirectly by providing resources or support for clients who have recently relocated or who are bereaved. Social prescribing is a common practice in which practitioners help clients access nonclinical sources of support within the community. This may be through facilitating client engagement in voluntary organizations and community groups broadly or by facilitating specific referrals to community organizations which directly address social isolation (Donovan & Blazer, 2020).
Reinforce information about psychotherapy.
Psychotherapeutic approaches to reduce social isolation have included cognitive behavioral therapy and mindfulness-based approaches, with some studies showing efficacy for reducing loneliness and improving social interactions. Research suggests that lonely individuals interpret social interactions more negatively and are more likely to perceive social threats compared to those who are not lonely. These cognitive-emotional biases may lead to a cycle of worsening withdrawal and loneliness (Donovan & Blazer, 2020).
Due to the impact of anxiety disorders, patients may experience a lack of engagement in self-care activities. The overwhelming worry and preoccupation with anxiety-related concerns can make it challenging for individuals to prioritize their own well-being, resulting in neglect of basic self-care practices such as exercise, proper nutrition, adequate rest, and engaging in activities that bring joy or relaxation. This lack of self-care activities can further contribute to the cycle of anxiety and hinder the development of healthy coping strategies.
Keep strict records of food and fluid intake.
This is for an accurate nutritional assessment. Caffeine-containing products, such as coffee, tea, and colas, should be discontinued or decreased to a reasonable level. Over-the-counter preparations and herbal remedies should be reviewed with special caution because ephedrine and other herbal compounds may precipitate or exacerbate anxiety symptoms (Bhatt & Bienenfeld, 2019).
Assess the client’s ability to self-manage.
Prior research has highlighted that there is a complex interaction between anxiety and depressive disorders and the use of self-management skills. Research has shown that the ability of clients with anxiety and depressive disorders to perform self-management skills is influenced by the level of their symptoms and that more severe anxiety disorders lead to a decrease in self-management activities (Huang & Zhang, 2021).
Urge the client to perform normal ADLs to his level of ability.
Successful performance of independent activities enhances self-esteem. Self-management strategies, which require the daily adoption of various behaviors to manage an illness, appear to be particularly appropriate in dealing with depression and anxiety. Many strategies can be taken from the original daily-life-oriented list presented by researchers, indicating that many mental health self-management strategies can be applied at work and more generally in everyday life (Meunier et al., 2019).
Encourage independence. Intervene when the client is unable to perform.
The safety and comfort of the client are nursing priorities. The client may self-manage their disorder by seeking support from professionals and important others, maintaining a healthy lifestyle and engaging in activities, or taking control and staying focused on their recovery (Huang & Zhang, 2021).
Offer recognition and positive reinforcement for independent accomplishments.
Positive reinforcement enhances self-esteem and encourages the repetition of desired behaviors. Positive reinforcement is the addition of a positive outcome to strengthen behaviors. A shorter time between a behavior and positive reinforcement makes a stronger connection, therefore, the reinforcement should be delivered quickly (Cherry, 2023).
Show the client how to perform activities with which he is having difficulty.
During high anxiety levels, the client may require simple, concrete demonstrations of activities that would be performed without difficulty under normal conditions. When first teaching a new behavior, the nurse would likely use a continuous reinforcement schedule where positive reinforcement is delivered every single time the behavior occurs. Using this technique can have a powerful influence on how strong a response is and how often it occurs (Cherry, 2023).
Offer nutritious snacks and fluids between meals.
The client may be unable to tolerate large amounts of food and mealtimes and may therefore require additional nourishment. There is evidence that certain dietary patterns may influence the development and progression of anxiety disorders. The diets associated with lower anxiety include “healthy” diet patterns, the Mediterranean diet, traditional diets, the anti-inflammatory diet, and diets with increased variety. All of these diet patterns share common elements such as an emphasis on vegetables, fruit, limited sugar, refined grains, and greater consumption of minimally processed foods (Aucoin et al., 2021).
Promote exercise and physical activities.
Exercise and physical activities could be used as a first-line, low-intensity intervention for mild to moderate mood and anxiety disorders, along with other self-management strategies. Both aerobic and anaerobic activities are effective, therefore the choice should be based on the client’s preference. In terms of duration and frequency, sessions should last for at least 30 minutes three times a week (Pelletier et al., 2017).
Assist clients in choosing self-care activities that they can perform within their abilities.
Self-care is the most common strategy and is identified as most helpful, as exercise, formal and informal relaxation, and taking medication are generally encouraged by healthcare professionals and viewed as good ways to support physical and mental health. They are also largely free or low-cost and do not require a large investment of time or effort (Shepardson et al., 2017).
Patient education for individuals with anxiety disorders involves providing information and resources to help better understand their condition, its symptoms, and potential triggers. It also involves educating patients about available treatment options, including therapy techniques, medication management, and self-help strategies. Empowering patients with knowledge about their condition equips them with tools to manage their anxiety, develop coping skills, and make informed decisions.
Assess for nausea, headache, nervousness, insomnia, agitation, and sexual dysfunction.
These are the common adverse effects of SSRIs. Treatment should be started at low doses and increased gradually as the client tolerates it. The longer half-life of fluoxetine minimizes the risk and severity of SSRI withdrawal that can occur when clients exhaust or abruptly discontinue their SSRI. Periodic reassessment of the client is essential to determine the need for continued treatment (Bhatt & Bienenfeld, 2019).
Assess for fatigue, drowsiness, and cognitive impairments.
These are common side effects of benzodiazepines. Chronic benzodiazepine use may be associated with tolerance, withdrawal, and treatment-emergent anxiety. The risk of addiction with benzodiazepines should be carefully considered before use in anxiety disorders (Bhatt & Bienenfeld, 2019).
Assess the client’s and family members’ understanding of anxiety disorders.
Even though anxiety disorders are the most common mental disorders in older adults, there has been scant attention paid to some major issues regarding anxiety disorders. Family members should receive information about the effect of anxiety disorders on mood, behavior, and relationships. Family members can assist in care by reinforcing the need for medical treatment and supervision (Bhatt & Bienenfeld, 2019).
Assess for possible barriers to learning about and accepting treatment for anxiety disorders.
One of the barriers associated with mental illness is social stigma. Several socio-cultural factors were previously found to be associated with clients choosing not to seek treatment or diagnosis for mental disorders, including social taboo, extreme shame, family stigma, as well as self-stigma. Another reason for the low diagnosis of mental health disorders could be the lack of awareness of mental health conditions among non-mental health professionals (Yu et al., 2018).
Utilize psychometric tools in assessing the client’s experiences in relation to stress and other mental health-related factors.
Ecological momentary assessment (EMA) involves repeated measurement of momentary experiences naturalistically and in real-time. It has been used to assess stress, behavior, and other physical and mental health-related constructs. EMA appears well-suited to examine anxiety symptomatology. EMA avoids reporting biases such as recency and severity effects, “telescoping”, and difficulties with estimation. These types of assessments can also capture diurnal variations in symptoms (Lenze & Wetherell, 2022).
Explain the physiologic action of SSRI in relieving anxiety.
Anxiety disorders are caused by a neuropsychiatric disorder that responds to the medication. Fluoxetine can be used, especially if panic disorders occur with depression; however, clients may poorly tolerate it initially because it may increase anxiety, except at very low starting doses. Fluoxetine has a long half-life, making it a good choice for marginally compliant clients. It alters the metabolism of cytochrome P-450 2D6-cleared agents (Bhatt & Bienenfeld, 2019).
Reinforce that a gradual tapering is necessary when a benzodiazepine is discontinued.
Abrupt discontinuation can cause a recurrence of anxiety. Benzodiazepines can be reasonably used as an initial adjunct while SSRIs are titrated to an effective dose, and they can be tapered over 4 to 12 weeks while the SSRI is continued. Clonazepam has become a favored replacement because it has a longer half-life and empirically elicits fewer withdrawal reactions upon discontinuation (Bhatt & Bienenfeld, 2019).
Encourage the client and family members to engage in educational programs about mental health.
Mental health resources can be limited and unevenly distributed, especially in rural areas. Most of the resources may be distributed only at the provincial or municipal levels with a lack of resources at community levels. There is a need for mental health education campaigns to both educate for earlier recognition of problems as well as provide better support for mental health services (Yu et al., 2018).
Promote smoking cessation and decreased alcohol intake.
Significant factors that were most highly associated with a generalized anxiety disorder (GAD) were excessive drinking and current or former smoking, according to a study. GAD was found to be associated with excessive alcohol consumption in another epidemiological study (Yu et al., 2018). Data from the Centers for Disease Control and Prevention showed that 30% of clients with mild anxiety and 45% of people with severe anxiety use tobacco. Acute withdrawal symptoms from nicotine can mimic anxiety, creating a perpetual loop feeding into itself (Christensen, 2021).
Provide information about self-help guides for mental health concerns.
Bibliotherapy, or guided self-help, has long been a low-cost and widely available alternative to a full-scale psychotherapy protocol. Such self-help guides exist using CBT, Acceptance and Commitment Therapy, or mindfulness models; they can be used as a first step in, or complement to, formal psychotherapy or pharmacotherapy approaches. A recent study of late-life anxiety and depression prevention used a stepped-care approach, in which the first intervention was bibliotherapy, was effective at preventing anxiety and depressive episodes (Lenze & Wetherell, 2022).
Refer to reliable internet sources for educational purposes.
Internet-based self-help may be another increasingly available, low-cost psychotherapy option. Organizations such as the Anxiety Disorders Association of America and the Geriatric Mental Health Foundation offer psychoeducational help for late-life anxiety disorders online (Lenze & Wetherell, 2022).
Monitor the effects of benzodiazepines among older adult clients with anxiety disorders.
Benzodiazepines are still commonly used for geriatric anxiety. In older adults, these medications are associated with falls, disability, and cognitive impairment decline. The risks occur at doses lower than the usual efficacious dose of these medications for anxiety disorders. They should consider short-term adjuncts to treatment, with long-term use only as a last resort (Bhatt & Bienenfeld, 2019).
Emphasize the importance of follow-up consultations.
Follow-up includes interviewing clients for any concerns about perceived side effects. Clients often seem to perceive side effects and symptoms that predate the start of medication and are clearly a component of the disorder. In anxiety, adherence issues stem from vigilance to perceived side effects and subsequent catastrophizing. If such an issue is noted, immediate contact will reassure the client that they are being monitored closely by experts and that the medication is not causing some sort of severe or worsening problem (Lenze & Wetherell, 2022).
Encourage family members to ask questions.
Family involvement can help with adherence. Nevertheless, most clients will have additional concerns after the medication is prescribed, especially before and just after they take the first dose. State to clients and families that it is natural to have questions, and encourage them to call, providing 24-hour contact information (Lenze & Wetherell, 2022).
Evaluate the effects of maintenance treatment and relay to the client and their families.
Since anxiety is chronic, treatment will usually need to be long-term, maintenance medication and/or booster psychotherapy sessions. As the client has already overcome any fears or initial side effects, maintenance pharmacotherapy requires less frequent oversight though continued monitoring of clinical changes, side effects, and changes in co-prescribed medications is necessary (Lenze & Wetherell, 2022).
Common medications prescribed for anxiety include selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, and buspirone. These medications work to regulate neurotransmitter levels in the brain, alleviate anxiety symptoms, and restore a sense of calmness. Other medications such as beta blockers can play a role in managing certain physical symptoms of anxiety such as increase heart rate and palpitations.
Selective serotonin reuptake inhibitors (SSRIs):
These medications work by increasing the levels of serotonin, a neurotransmitter involved in regulating mood, in the brain.
Citalopram (Celexa): Primarily used for depression but also prescribed off-label for anxiety disorders, such as panic disorder, GAD, and social anxiety disorder.
Benzodiazepines
Biological factors may be involved in phobic/panic reactions, and these medications (particularly Xanax) produce a rapid calming effect and may help the client change behavior by keeping anxiety low during learning and desensitization sessions. The risk of addiction to benzodiazepines should be carefully considered before use in anxiety disorders. Benzodiazepines should not be used in clients with a prior history of alcohol or other drug abuse (Bhatt & Bienenfeld, 2019).
Anxiolytics
Buspirone is a nonsedating antipsychotic drug unrelated to benzodiazepines, barbiturates, and other sedative-hypnotics. This is a novel antianxiety agent that is comparable with benzodiazepines in reducing symptoms of anxiety. Buspirone also has fewer cognitive and psychomotor adverse effects, which makes it preferable in older adults. Major limitations include a lack of anti-panic activity and reduced anxiolytic effects in clients recently withdrawn from benzodiazepines (Bhatt & Bienenfeld, 2019).
Beta-blockers
Beta-blockers control the physical symptoms of anxiety such as rapid heart rate, a trembling voice, sweating, dizziness, and shaky hands. They are most helpful for phobias, particularly social phobias (Chand & Marwaha, 2022).
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Matt Vera, a registered nurse since 2009, leverages his experiences as a former student struggling with complex nursing topics to help aspiring nurses as a full-time writer and editor for Nurseslabs, simplifying the learning process, breaking down complicated subjects, and finding innovative ways to assist students in reaching their full potential as future healthcare providers.
Are nurses eligible to give mandala coloring activities to inpatients and college students for anxiety and stress Reply
Zanita Glenda PlagaI just came over this, though this has been asked 3 years ago yet. Yes, I would say it can help them. I had my students do their own mandala and they commented that doing it has helped them with their stress and anxieties especially during this lockdown and pandemic. Reply
