Care of the Patient with Anxiety

Anxiety is a daily experience and normal. It can be described as a short-term, mild to moderate feeling that is a response to or a particular stressor. Anxiety also has physical expressions such as quick heavy breathing, nausea, or shaking to name a few.

Anxiety becomes abnormal or a diagnosis when the response is greater than the actual risk or situation justifies; the response continues the time of the event; there is impaired function of all daily activities; and there may be physical effects (Hives, nausea or diarrhea). It is important to note that often anxiety leads to agitation.

Anxiety is the most common psychiatric disorder in the United States today. It affects more than 40 million Americans over the age of 18 (Anxiety and Depression Society of America, 2015). There is a ratio of 2:1 higher in women than in men. Treatment of anxiety costs over $22 billion each year (Anxiety and Depression Society of America, 2015). Research indicates that there are several factors involved in anxiety including genetics, environment, development, and psychological states.

Disorders of anxiety are particularly present in the older population. It is estimated that 4-10% of older adults suffer from anxiety (Calleo & Stanley, 2008). The diagnosis symptoms are often masked by physical complaints that tend to be focused on more. The highest number of anxious patients is seen in homebound and nursing home patients. Approximately 40% of these patients suffer from symptoms of anxiety due to disabilities or chronic diseases (Calleo & Stanley, 2008). Also, patients who suffer from dementia are very likely to suffer from anxiety as well.

Several types of anxiety exist in the Diagnostic and Statistical Manual 5, which is used to diagnose mental health disorders.  This article will cover an overview of anxiety including generalized anxiety, phobias and panic attacks. 

Defense mechanisms are automatic unconscious reactions that block unpleasant threatening feelings (Whitbourne, 2011). Use of defense mechanisms is normal to protect people from anxiety, maintain self-image, block feelings, conflicts, and memories. Using defense mechanisms can help people adjust to the environment or be adaptive (Whitbourne, 2011). However, these mechanisms become a problem or maladaptive when they keep people from facing reality. The individual using them does not always acknowledge defense mechanisms (Halter, 2014). Most people use several defense mechanisms but not always at the same level or at the same time. In order to evaluate whether a defense mechanism is adaptive or maladaptive, it will be important to observe for frequency, intensity, and duration.

Some examples of defense mechanisms are as follows (Halter, 2014; Whitbourne, 2011):

Compensation - used to cover up shortcomings related to perceived deficiencies and to protect the mind from recognizing them. For example, an adaptive use of compensation is a person becoming assertive and dressing himself or herself even though they feel they make poor clothing choices. An example of a maladaptive use of compensation is when a person with low self-esteem throws objects to relieve the discomfort.

Denial-Refusal to accept facts, or an uncomfortable event in order to make thoughts and feelings not exist. For example, an alcoholic will deny they have a problem with alcohol even though they have been arrested several times for driving drunk.

Displacement - the transference of one emotion toward a particular person, object or situation onto something else. For example a patient maybe angry with the nurse when his spouse fails to visit.

Projection- Unpleasant or unacceptable characteristics of one’s own self are unconsciously given to another person, situation or object. For example, a woman is really angry at herself for missing deadlines at work, comes home and yells at her husband.

Dissociation- A separation of emotions and thoughts. Typically this person will loose track of time and can loose their self -image. An example is an adult who was abused during childhood, disconnects from reality and mentally goes to a different place when stressed.

There are several other defense mechanisms that people use to decrease the feelings of anxiety. Understanding how and why defense mechanisms are used will help the caregiver to assist the patient in coping with anxiety.

Helping a person who is upset, anxious, or agitated may include the following (Acello & Hegner, 2015):

• Attempt to identify and eliminate the stressor.
• Do not argue or confront the person.
• Make sure the environment is safe for them.
• Assign the patient a brief task or activity to distract them.
• Watch for injuries.
• Prevent the patient from becoming exhausted.
• Get the nurse if panic or severe anxiety is present.

If the patient is becoming anxious, try to help them gain control by using distraction or giving them something else to do. Help them to identify coping strategies that they have used in the past to calm down (Halter, 2014). Use communication techniques such as asking open-ended questions, giving broad opening statements, and exploring and seeking clarification of the situation. It is important to remain calm and recognize that the person is in distress. The ability to listen is also important.

For severe or panic -level anxiety, the nurse should be involved as the patient may not know what is happening and may not be able to follow directions well (Acello & Hegner, 2015). However, the patient experiencing severe or panic level of anxiety is out of control and they need to know they are safe. Use short simple sentences and remain with the person when possible (Halter, 2014). It is also important to maintain their physical needs such as fluid and rest to prevent exhaustion when they are calm. The person may be moved to a quieter environment with minimal stimulation. The nurse may also give medications to help lessen the anxiety.

There are certain behaviors that need to be reported immediately to the nurse. Anytime the patient is in an unsafe environment or at risk for injury should be reported immediately.

If the patient is unable to focus on the environment, they appear paralyzed with fear, are not able to communicate, they begin to hallucinate or have delusions, or are blocking out the environment or events around them, the nurse should be notified immediately (Acello & Hegner, 2015; Halter, 2014). It is, however, important that someone stay with the patient or keep an eye on the patient until the nurse arrives.

Also, if the patient can describe a feeling of dread, confusion, a sense of impending doom, physical complaints, hyperventilation, rapid heartbeat, loud, rapid speech or if they begin to threaten or make demands upon anyone, the nurse should also be notified (Sadock & Sadock, 2014; Halter, 2014). The patient may also be observed to be hyperactive or in flight mode, have dilated pupils, jumbled words, severe shakiness, sleeplessness or agitation (American Psychiatric Association, 2013). Be sure to stay clear of the patient unless they appear to be at a risk of falling or injuring themselves. Do not allow yourself to be in harm's way.

Watch for signs that the patient is becoming agitated. Express your willingness to help and listen to their feelings and concerns. Approach the patient calmly and in a nonthreatening manner however, maintain your personal space. Your eyes should be on the same level as the patient to decrease intimidation. Always leave yourself an escape routes in case the patient does become out of control. If the patient becomes verbally abusive, do not take the verbal abuse personally. Use open-ended statements and questions rather than challenging statements such as what's wrong with you. Avoid threatening, accusatory or challenging statements. Instead, try to find out what is behind the aggressive behavior. Ask the patient if they want to go to a quieter place. Pay close attention to the environment. For example, is there a lot of activity around the patient that might be agitating them and causing their anxiety? If the patient becomes agitated, which may be seen by an appropriate speech words or activity or even disorientation, the nurse should intervene (Halter, 2014).

One of the most important interventions for anxious patient is to remain calm (Acello & Hegner, 2015). If the patient can see how to calm the caregiver is, they may become calmer themselves. It is also important to stay with the patient, speak slowly and calmly as this conveys calmness and promote security.

If the patient is given medication for anxiety, be sure to watch for side effects. Side effects can include drowsiness, lack of energy, slow reflexes, slurred speech, confusion, disorientation, and depression (Halter, 2014). If any of these signs are noticed, report them to the nurse immediately.

Working with a patient who suffers from anxiety can be difficult. You may experience feelings of anger or frustration. Understanding or using empathy is important as well as having patience. If you feel yourself getting frustrated or angry, remember not to transfer those feelings to the patient (Halter, 2014). Instead, find another health care professional to talk to and try to come up with alternative ways of working with the patient. One way is to keep things simple. Small reachable goals will help you and the patient feel less overwhelmed. 

Remember that everyone gets anxious at one time or another. It is when the anxiety does not allow the person to continue with their normal daily activities that it becomes a chronic problem. It is important to remembering to stay calm and have a plan to get help when needed. Try to recall the events that take place during the anxious episode as well as what might have occurred before. There might be triggers to report to the nurse and adjustments that can be made in the patient environment. In the case of a panic attack, which usually does not have a trigger, it is important to stay with the patient until they calm down. Talk slowly and calmly. Try to get the patient to focus on you or their own breathing until the nurse arrives or you get further instructions. Following these simple steps will help the patient overcome the anxious moment.

Acello, B., & Hegner, B. (2015).Nursing assistant: A nursing process approach. Cengage Learning.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Washington, DC: American Psychiatric Association.

Anxiety and Depression Society of America. (2015). Facts & statistics | anxiety and depression association of America, ADAA. Retrieved January 25, 2016, (Visit Source).

Calleo, J., & Stanley, M. A. (2008, July 1). Anxiety disorders in later life. Retrieved January 25, 2016, (Visit Source)

Halter, Margaret J. Varcarolis' (2014). Foundations of psychiatric mental health nursing: A clinical approach. 7th ed. St. Louis, Mo.: Elsevier.

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014).Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry. United States: Lippincott Williams and Wilkins.

Whitbourne, S. K. (2011, October 22). The essential guide to defense mechanisms. Retrieved January 25, 2016 (Visit Source).