Scientific Basis:
The emotional response of the patient during illness is of extreme importance. The mind-body-spirit connection is well established; it is known, for example, that when a physiological response occurs, there is a corresponding psychological response.
A common reaction to stress is anxiety, a state of mental uneasiness, apprehension, dread, or foreboding or a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationship.
An actual or perceived threat to life, health, self-esteem, or role cause anxiety. Fear is the response to known factors. Questions arise as to whether the individual will survive of be able to continue previous life-style. Individuals feel anxious whenever they are threatened, whether the threat is perceived or actual. High levels of anxiety however, can be overwhelm the person and impair the ability to think and function. As the severity of the anxiety increases, the person is less able to function; thereby it threatens his health status and condition.
DeLaune and Ladner, 2002; Berman, et al, 2008
Intervention and Rationale
I: Note palpitations, elevated pulse/respiratory rate.
R: Changes in vital signs may suggest the degree of anxiety patient is experiencing or reflect the impact of physiological factors, e.g., endocrine imbalances, medications.
I: Acknowledge fear/anxieties. Validate observations with patient, e.g., “You seem to be afraid.”
R: Feelings are real, and it is helpful to bring them out in the open so they can be discussed and dealt with.
I: Assess degree/reality of threat to client and level of anxiety (e.g., mild, moderate, severe) by observing behavior such as clenched hands, wide eyes, startle response, furrowed brow, clinging to family/staff, or physical/verbal lashing out.
R: Individual responses can vary according to cultural beliefs/traditions and culturally learned patterns. Distorted perceptions of the situation may magnify feelings.
I: Note narrowed focus of attention (e.g., client concentrates on one thing at a time).
R: Narrowed focus usually reflects extreme fear/panic.
I: Observe speech content, vocabulary, and communication patterns, e.g., rapid/slow, pressured speech; words commonly used, repetition, use of humor/laughter, swearing.
R: Provides clues about such factors as the level of anxiety, ability to comprehend what is currently happening, cognition difficulties, and possible language differences.
I: Assess severity of pain when present. Delay gathering of information if pain is severe.
R: Severe pain and anxiety leave little energy for thinking and other activities.
I: Orient to environment and new experiences or people as needed.
R: Orientation and awareness of the surroundings promotes comforts and may decrease anxiety.
I: Identify client’s/SO’s perception(s) of the situation
R: Regardless of the reality of the situation, perception affects how each individual deals with the illness/stress.
I: Acknowledge reality of the situation as client sees it, without challenging the belief.
R: Client may need to deny reality until ready to deal with it. It is not helpful to force client to face facts.
I: Evaluate coping/defense mechanisms being used to deal with the perceived or real threat.
R: May be dealing well with the situation at the moment; e.g., denial and regression may be helpful coping mechanisms for a time. However, continued use of such mechanisms diverts energy client needs for healing, and problems need to be dealt with at some point in time.
I: Review coping mechanisms used in the past, e.g., problem-solving skills, recognizing/asking for help.
R: Provides opportunity to build on resources client/SO may have used successfully.
I: Assist client to use the energy of anxiety for coping with the situation when possible.
R: Moderate anxiety heightens awareness and can help motivate client to focus on dealing with problems.
I: Maintain frequent contact with client/SO. Be available for listening and talking as needed.
R: Establishes rapport, promotes expression of feelings, and helps client and SO look at realities of the illness/treatment without confronting issues they are not ready to deal with.
I: Acknowledge feelings as expressed (e.g., use of Active-
Listening, reflection). If actions are unacceptable, take necessary steps to control/deal with behavior. (Refer to ND: Violence, risk for.)
R: Often acknowledging feelings enables client to deal more appropriately with situation. May need chemical/physical control for brief periods.
I: Identify ways in which client can get help when needed, including telephone numbers of contact persons.
R: Provides assurance that staff/resources are available for assistance/support.
I: Stay with or arrange to have someone stay with client as indicated.
R: Continuous support may help client regain internal locus of control and reduce anxiety/fear to a manageable level.
I: Provide accurate information as appropriate and when requested by client/SO. Answer questions freely and honestly and in language that is understandable by all. Repeat information as necessary; correct misconceptions.
R: Complex and/or anxiety-provoking information can be given in manageable amounts over an extended period. As opportunities arise and facts are given, individuals will accept what they are ready for. Note: Words/phrases may have different meanings for each individual; therefore, clarification is necessary to ensure understanding.
I: Avoid empty reassurances, with statements of “everything will be all right.” Instead, provide specific information: e.g., “Your heart rate is regular, your pain is being easily controlled, and that is what we want”
R: It is not possible for the nurse to know how the specific situation will be resolved, and false reassurances may be interpreted as lack of understanding or honesty, further isolating client. Sharing observations used in assessing condition/prognosis provides opportunity for client/SO to feel reassured.
I: Note expressions of concern/anger about treatment or staff.
R: Anxiety about self and outcome may be masked by comments or angry outbursts directed at therapy/caregivers.
I: Ask client/SO to identify what he or she can/cannot do about what is happening.
R: Assists in identifying areas in which control can be exercised and those in which control is not possible.
I: Provide as much order and predictability as possible in scheduling care/activities, visitors.
R: Helps client anticipate and prepare for difficult treatments/movements, as well as look forward to pleasant occurrences.
I: Instruct in ways to use positive self-talk, e.g., “I can manage this pain for now”
R: Internal dialogue is often negative. When this is shared out loud, client becomes aware and can be directed in the use of positive self-talk, which can help reduce anxiety.
I: Encourage client to develop regular exercise/activity program.
R: Helpful in reducing level of anxiety; has been shown to raise endorphin levels to enhance sense of well-being.
I: Encourage/instruct in guided imagery/relaxation techniques; e.g., imaging a pleasant place, use of music/tapes, deep-breathing, meditation, and mindfulness.
R: Promotes release of endorphins and aids in developing internal locus of control, reducing anxiety. May enhance coping skills, allowing body to go about its work of healing. Note: Mindfulness is a method of being in the here and now, concentrating on what is happening in the moment.
I: Provide touch, Therapeutic Touch, massage, and other adjunctive therapies as indicated.
R: Aids in meeting basic human need, decreasing sense of isolation, and assisting client to feel less anxious. Note: Therapeutic Touch requires the nurse to have specific knowledge and experience to use the hands to correct energy field disturbances by redirecting human energies to help or heal.
I: Use simple language and brief statements when instructing about self care measure, diagnostic or surgical procedures.
R: When experiencing moderate to severe anxiety, the patient may be unable to comprehend anything more than simple, clear, and brief instructions.
I: Refer to social service or other appropriate agency for assistance. Have case manage and social worker discuss modifications of medical aid if client is eligible for these resources.
R: Often client is not aware of the resources available providing current information about individual courage/ limitations and other possible sources of support will assist with adjustment to situation.
Gulanick, 2007; Doenges, et al, 2006; Kruse, et al, 2003
The emotional response of the patient during illness is of extreme importance. The mind-body-spirit connection is well established; it is known, for example, that when a physiological response occurs, there is a corresponding psychological response.
A common reaction to stress is anxiety, a state of mental uneasiness, apprehension, dread, or foreboding or a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationship.
An actual or perceived threat to life, health, self-esteem, or role cause anxiety. Fear is the response to known factors. Questions arise as to whether the individual will survive of be able to continue previous life-style. Individuals feel anxious whenever they are threatened, whether the threat is perceived or actual. High levels of anxiety however, can be overwhelm the person and impair the ability to think and function. As the severity of the anxiety increases, the person is less able to function; thereby it threatens his health status and condition.
DeLaune and Ladner, 2002; Berman, et al, 2008
Intervention and Rationale
I: Note palpitations, elevated pulse/respiratory rate.
R: Changes in vital signs may suggest the degree of anxiety patient is experiencing or reflect the impact of physiological factors, e.g., endocrine imbalances, medications.
I: Acknowledge fear/anxieties. Validate observations with patient, e.g., “You seem to be afraid.”
R: Feelings are real, and it is helpful to bring them out in the open so they can be discussed and dealt with.
I: Assess degree/reality of threat to client and level of anxiety (e.g., mild, moderate, severe) by observing behavior such as clenched hands, wide eyes, startle response, furrowed brow, clinging to family/staff, or physical/verbal lashing out.
R: Individual responses can vary according to cultural beliefs/traditions and culturally learned patterns. Distorted perceptions of the situation may magnify feelings.
I: Note narrowed focus of attention (e.g., client concentrates on one thing at a time).
R: Narrowed focus usually reflects extreme fear/panic.
I: Observe speech content, vocabulary, and communication patterns, e.g., rapid/slow, pressured speech; words commonly used, repetition, use of humor/laughter, swearing.
R: Provides clues about such factors as the level of anxiety, ability to comprehend what is currently happening, cognition difficulties, and possible language differences.
I: Assess severity of pain when present. Delay gathering of information if pain is severe.
R: Severe pain and anxiety leave little energy for thinking and other activities.
I: Orient to environment and new experiences or people as needed.
R: Orientation and awareness of the surroundings promotes comforts and may decrease anxiety.
I: Identify client’s/SO’s perception(s) of the situation
R: Regardless of the reality of the situation, perception affects how each individual deals with the illness/stress.
I: Acknowledge reality of the situation as client sees it, without challenging the belief.
R: Client may need to deny reality until ready to deal with it. It is not helpful to force client to face facts.
I: Evaluate coping/defense mechanisms being used to deal with the perceived or real threat.
R: May be dealing well with the situation at the moment; e.g., denial and regression may be helpful coping mechanisms for a time. However, continued use of such mechanisms diverts energy client needs for healing, and problems need to be dealt with at some point in time.
I: Review coping mechanisms used in the past, e.g., problem-solving skills, recognizing/asking for help.
R: Provides opportunity to build on resources client/SO may have used successfully.
I: Assist client to use the energy of anxiety for coping with the situation when possible.
R: Moderate anxiety heightens awareness and can help motivate client to focus on dealing with problems.
I: Maintain frequent contact with client/SO. Be available for listening and talking as needed.
R: Establishes rapport, promotes expression of feelings, and helps client and SO look at realities of the illness/treatment without confronting issues they are not ready to deal with.
I: Acknowledge feelings as expressed (e.g., use of Active-
Listening, reflection). If actions are unacceptable, take necessary steps to control/deal with behavior. (Refer to ND: Violence, risk for.)
R: Often acknowledging feelings enables client to deal more appropriately with situation. May need chemical/physical control for brief periods.
I: Identify ways in which client can get help when needed, including telephone numbers of contact persons.
R: Provides assurance that staff/resources are available for assistance/support.
I: Stay with or arrange to have someone stay with client as indicated.
R: Continuous support may help client regain internal locus of control and reduce anxiety/fear to a manageable level.
I: Provide accurate information as appropriate and when requested by client/SO. Answer questions freely and honestly and in language that is understandable by all. Repeat information as necessary; correct misconceptions.
R: Complex and/or anxiety-provoking information can be given in manageable amounts over an extended period. As opportunities arise and facts are given, individuals will accept what they are ready for. Note: Words/phrases may have different meanings for each individual; therefore, clarification is necessary to ensure understanding.
I: Avoid empty reassurances, with statements of “everything will be all right.” Instead, provide specific information: e.g., “Your heart rate is regular, your pain is being easily controlled, and that is what we want”
R: It is not possible for the nurse to know how the specific situation will be resolved, and false reassurances may be interpreted as lack of understanding or honesty, further isolating client. Sharing observations used in assessing condition/prognosis provides opportunity for client/SO to feel reassured.
I: Note expressions of concern/anger about treatment or staff.
R: Anxiety about self and outcome may be masked by comments or angry outbursts directed at therapy/caregivers.
I: Ask client/SO to identify what he or she can/cannot do about what is happening.
R: Assists in identifying areas in which control can be exercised and those in which control is not possible.
I: Provide as much order and predictability as possible in scheduling care/activities, visitors.
R: Helps client anticipate and prepare for difficult treatments/movements, as well as look forward to pleasant occurrences.
I: Instruct in ways to use positive self-talk, e.g., “I can manage this pain for now”
R: Internal dialogue is often negative. When this is shared out loud, client becomes aware and can be directed in the use of positive self-talk, which can help reduce anxiety.
I: Encourage client to develop regular exercise/activity program.
R: Helpful in reducing level of anxiety; has been shown to raise endorphin levels to enhance sense of well-being.
I: Encourage/instruct in guided imagery/relaxation techniques; e.g., imaging a pleasant place, use of music/tapes, deep-breathing, meditation, and mindfulness.
R: Promotes release of endorphins and aids in developing internal locus of control, reducing anxiety. May enhance coping skills, allowing body to go about its work of healing. Note: Mindfulness is a method of being in the here and now, concentrating on what is happening in the moment.
I: Provide touch, Therapeutic Touch, massage, and other adjunctive therapies as indicated.
R: Aids in meeting basic human need, decreasing sense of isolation, and assisting client to feel less anxious. Note: Therapeutic Touch requires the nurse to have specific knowledge and experience to use the hands to correct energy field disturbances by redirecting human energies to help or heal.
I: Use simple language and brief statements when instructing about self care measure, diagnostic or surgical procedures.
R: When experiencing moderate to severe anxiety, the patient may be unable to comprehend anything more than simple, clear, and brief instructions.
I: Refer to social service or other appropriate agency for assistance. Have case manage and social worker discuss modifications of medical aid if client is eligible for these resources.
R: Often client is not aware of the resources available providing current information about individual courage/ limitations and other possible sources of support will assist with adjustment to situation.
Gulanick, 2007; Doenges, et al, 2006; Kruse, et al, 2003
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