The purpose of this course is to provide the Nursing Assist with the tools to recognize different types of anxiety as well as symptoms, provide methods for communicating with an anxiety patient and when and what should be report to the nurse.
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.
Mary is driving home from work when a van suddenly pulls out front of her. She pulls the car over and notices that she is shaking, she feels nauseous and her head is spinning. She takes a few moments to gather herself and then drives home. She recalls the events to her husband with no physical effect. She is just glad she is home.
Janet is also driving home from work when a car pulls out in front of her. Janet slams on the brakes, stopped the car in the middle of the road and starts to cry hysterically. She feels nauseous, her head is spinning, and she is shaking uncontrollably. She cannot calm down. Another driver stops to help her and notices how visibly upset she is. They move the car off to the side of the road and call her husband to come and get her. Janet is still shaking, crying, and very upset hours later and even into the next day.
Mary suffers from anxiety, but it is short-lived. She is able to go on with her daily activities without repercussions or reliving the events. Janet on the other hand is not able to do so. Janet suffers from a diagnosis of anxiety.
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.
Generalized anxiety disorder features unrealistic and exaggerated worry about everyday events (Halter, 2014). For example, going grocery shopping or needing food, the person will worry excessively about how they will get food and what food they will get. The worry consumes them and is uncontrollable. The thoughts interfere with their daily life. This worry that they cannot control the situation leads to restlessness, feelings of being on edge, easily fatigued, difficulty concentrating, irritability, and even sleep disturbances (Sadock & Sadock, 2014). This patient may appear fidgety and constantly asking questions about a common occurrence or restating how they will manage an activity.
This person experiences intense apprehension, fear and even terror. This is often associated with feelings of impending doom and intense physical discomforts. Panic attacks have an unpredictable onset and there are usually no stimuli (Sadock & Sadock, 2014). The person is not able to function during the panic attack and show signs of severe anxiety. These symptoms may include chest pain, shortness of breath, rapid heart rate, numbness and tingling in hands, dizziness, and the person may state they are losing control or feeling like they will die (Halter, 2014; Sadock & Sadock, 2014). Panic attacks can last from a few minutes or longer. They can occur multiple times throughout the day. Often, people will avoid places were panic attacks have occurred.
A phobia is a persistent, irrational fear of a specific object, activity, or situation that causes the person to avoid that object, activity, or situation (Sadock & Sadock, 2014).& Several types of phobias exist including specific phobias, social phobias and agoraphobias.
Specific phobias are seen as anxiety or fear provoked by a specific object or situation that is real or imagined (Sadock & Sadock, 2014). These phobias are very common and usually do not cause much difficulty as long as the person is able to avoid the spirit object or situation.& The person recognizes that the fear is exaggerated or irrational; however, they avoid the object or situation anyway. An example may be a fear of spiders.& The person may avoid corners or places where spiders might be.
Social phobias or social anxiety is seen as anxiety or fear provoked by exposure to a social or performance situation (Sadock & Sadock, 2014).& An example may be public speaking or eating in a public place.& People with social phobia tend to experience an overwhelming anxiety when faced in a situation such as eating in public.& The person may fear possible embarrassment or ridicule from others. They may feel that they are being laughed at or made fun of or even loosing control of their bowels. The person may become anxious hours or days before the event. The person will avoid the activity.& A decrease in daily activities may be seen.
Agoraphobia is the fear of being alone in an open public place where escape may be difficult (Sadock & Sadock, 2014).& This can include being alone outside or at home, traveling in a car or bus arriving in an elevator.& Intense, excessive anxiety may be seen in this person.& The person will avoid these places and activities that may restrict their daily activities.
Overall signs and symptoms of anxiety may include feeling like they have a lump in their throat, butterflies in the stomach, feeling like their heart is going to jump out of their chest, feeling like they're going to have a heart attack, rapid pulse, rapid breathing, increased blood pressure, rapid speech, voice changes, dry mouth, sweating, nausea, diarrhea, or short attention span, difficulty following directions, difficulty sleeping, or loss of appetite.& These symptoms are vast.& It is important to observe the patient and the environment to understand if anxiety in any form is occurring.& Looking for triggers or behaviors is equally important.
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):
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.
Sally is a patient of yours today. The report you receive from the nurse says she is a little upset today. Her family visited her last night and now she cannot stop talking about when she eats. As you enter the room you notice that she is looking around the room, wringing her hands, she is mumbling to herself and appears upset. You enter her room smiling and asking how you can help her today “You seem upset” you state. Sally continues to wring her hands and looks even more upset.
“I have to leave. I have to get dinner ready. They will be here soon.” Sally tells you. Her face appears stressed and she begins to get up to pace.
“Ok Sally, let’s go into the other room and talk…”
Before you can finish, Sally picks up a hairbrush and throws it at you. She starts yelling that she has to leave now and you can’t keep her prisoner here anymore.
What do you do?
First, make sure you are near the door with an anxious or already agitated patient. Remember that anxiety can lead to agitation quickly such as with Sally. Talk slowly and calmly. Although it may be difficult to stay calm in such a situation as this, it is important that Sally sees you calm and collected. Remaining quiet and not making sudden moves will help Sally calm down too. Never argue or tell her she is wrong. If you can reach for the call light do so and get someone in the room with you. If you must leave the room to get help, make sure Sally is safe. Notify the nurse how you found Sally and what happened. If this is happening in Sally’s home, get another family member to stand close by to help calm Sally or use distraction until you can get a hold of the nurse. Also remember that she had visitors last night. Perhaps that is a trigger. Consider the following:
These are questions you should ask as you are in the room with Sally. The answers will provide the nurse and yourself with ideas on how to proceed to help Sally calm down.
Once Sally is calm, suggest a distraction such as folding clothes or walking the halls. You may suggest she wash up or get dressed or even get something to eat. Sally may prefer to stay in a quiet location rather than with others. Be sure to check on her frequently to make sure she does not begin to get anxious again. Develop a strategy with the nurse to anticipate Sally’s anxiety and calm her before it gets out of hand.
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).
This course is applicable for the following professions:
Certified Nursing Assistant (CNA), Home Health Aid (HHA)
CPD: Practice Effectively, CPD: Prioritize People, Geriatrics, Psychiatric