Anxiety is the uncomfortable feeling of dread that occurs in response to extreme or prolonged periods of stress (Smeltzer and Bare, 2000). It is commonly ranked as mild, moderate, severe, or panic. It is believed that a mild amount of anxiety is a normal part of the human being and that mild anxiety is necessary to change and develop new ways of coping with stress. Anxiety is a reaction to an internal threat, such as an unacceptable impulse or a repressed thought that is straining to reach a conscious level or a real, threatened, or imagined threat to the patient’s self-esteem. Overwhelming anxiety can result in a generalized anxiety disorder (GAD) – uncontrollable, unrealistic worry that is persistent. Risk Factors/Incidence Onset is usually before age 20, and the patient usually has a history of childhood fears. It’s equally common in men and women. More than 80% of patients with GAD suffer from major depression, arrhythmias, or social phobia (Smeltzer and Bare, 2000). Physiological Process/Etiology of the Disease or Condition Anxiety can indicate a primary psychiatric condition, be related to a primary medical disease, or be related to a medication adverse effect. In GAD, an alteration in benzodiazepine receptor regulation is thought to occur (Smeltzer and Bare, 2000). Serotonin abnormalities also appear to play a part in anxiety (Smeltzer and Bare, 2000). Increased serotonin levels have been associated with obsessive compulsive disorders.
Psychoanalytical theory says that anxiety is a conflict between the id and the superego, which was repressed in early development but which emerges again in adulthood (Smeltzer and Bare, 2000). Biological theory looks at this situation differently. Biological theories consider the sympathoadrenal responses to stress and observe the blood vessels constrict because epinephrine and norepinephrine have been release (Smeltzer and Bare, 2000). Blood pressure rises. If the body adapts to the stress, hormone levels adjust to compensate for epinephrine-norepinephrine release, and the body functions return to homeostasis(Smeltzer and Bare, 2000). If the body does not adapt to the stress, the immune system is challenged, lymph nodes swell, and risk for physical illness increases (Smeltzer and Bare, 2000).
Signs & Symptoms
The patient admits to worrying excessively about minor matters, with life-disturbing effects. Physical examination of the patient with GAD may reveal symptoms of muscle tension, including trembling, muscle aches and spasms, headaches, and an inability to relax. Autonomic signs and symptoms include shortness of breath, tachycardia, and sweating, and abdominal complaints are rare. The patient may startle easily and complain of feeling apprehensive, fearful, or angry and of having difficulty sleeping, eating, or concentrating. Other signs and symptoms may be a feeling of restlessness or feeling “on edge”, shaking, palpitations, dry mouth, nausea or vomiting, hot flashes, chills, polyuria, and difficulty swallowing.
When the patient’s symptoms match the following criteria documented in the DSM-IV, the diagnosis of GAD is confirmed:
* The patient has an unrealistic or excessive anxiety and worry about two or more events or activities for 6 months, during which he has been bothered most days by these concerns.
*The patient finds it difficult to control the worry.
*The focus of the anxiety and worry doesn’t have the features of an Axis disorder.
*The disturbance doesn’t occur only during the course of a mood disorder, psychotic disorder, or pervasive development disorder; nor is it due to direct physiologic effects of a substance ( drug abuse or medication) or a general medical condition (such as hyperthyroidism).
*Anxiety and worry are linked with three or more of the following symptoms present over the past 6 months (only one is required in a child): -restlessness or feeling keyed up or on edge -being easily fatigued -difficulty concentrating or mind going blank -irritability -muscle tension -sleep disturbance.
*The anxiety, worry, or symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning. Because anxiety is the central feature of other mental disorders, psychiatric evaluation is necessary to rule out phobias, obsessive-compulsive disorders, depression, and acute schizophrenia.
Treatment is individualized for the patient and may include one or more of the following: psychopharmacology, individual psychotherapy, group therapy, systematic desensitization hypnosis, imagery, relaxation exercises, and biofeedback (Smeltzer and Bare, 2000). Drug treatment and psychotherapy is most effective in treating a patient with this disorder. Complete symptomatic relief is rare, however. The benzodiazepine antianxiety drugs relieve anxiety but should only be prescribed for 4 to 6 weeks because of the potential for abuse (Smeltzer and Bare, 2000). Buspirone, an antianxiety drug, causes less sedation and less risk of physical and psychological dependence than the benzodiazepine (Smeltzer and Bare, 2000). However, it takes several weeks to take effect. Psychotherapy can help the patient identify and deal with the cause of anxiety, anticipate his reactions, and plan effective response strategies to deal with the anxiety. The patient may learn relaxation techniques, such as deep breathing, progressive muscle relaxation, focused relaxation, and visualization (Smeltzer and Bare, 2000). Complications Anxiety can impair social or occupational functioning; effects can range from mild to severe and incapacitating. GAD patients often abuse substances. Alcohol or sedative and hypnotic abuse is common.
Assessment: Head to toe nursing assessment to identify the signs and symptoms of the disease and potential presence of complications described above. Areas of focus: psychological status (on edge, easily startled, sad, fatigue easily, fearful, angry, mood, any changes in behavior, altered thought processes, including patient’s explanation of problem, onset, duration, participating events, past coping, present coping, insight, motivation to change, anxiety level (+1,+2,+3,+4),Current stressors, results of mental status examination, and personal abilities, talents, and strengths, ect.), nutritional status ( nausea, vomiting, intake, output, IBW, weight loss, weight gain, anorexia, ect.), immune status (fatigue, malaise, vague underlying complaints, delayed healing, ect.), respiratory status (vital signs, SOB, ect.), skin status (rash, lesions, ect.), cardiovascular status (tachycardia, palpitations, rapid pulse, ect.). History of panic symptoms (choking feeling in throat, hyperventilation, light-headedness, dizziness, and other physical signs and symptoms of anxiety). Medication history (response, effectiveness, and adverse effects), sociologic status, including support systems, hobbies, interests, work history, family makeup, family roles, family coping mechanisms, lifestyle, ect.
*Anxiety related to unexpected panic attacks
* Decisional conflict (excessive worry) related to anxiety level
* Impaired social interaction related to embarrassment and shame associated with symptoms
* altered thought process related to inability to function Interventions: Interventions include the assessments identified above and may also include the following: Establish relationship with unconditional positive regard and respect (Miller, 1992) Competently maintain universal precautions Maintain strict confidentiality Administer medications as prescribed by MD Refer to appropriate agencies (related to health, finances, support groups,, ect.) Active listening/allow time for expression of feelings (empowerment)
Teaching (Medication actions and their adverse effects, relaxation techniques, ect.) Stay with patient when he is anxious, and encourage him to discuss his feelings, reduce environmental stimuli, and remain calm. Help patient develop effective coping mechanisms to manage his anxiety Suggest activities that distract patient from anxiety.
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