Anxiety
General s/s: feelings of apprehension, uneasiness, uncertainty, dread
Criteria: excessive anxiety and worry about several events or activities for MORE THAN 6 MO
Inability to cope w/anxiety
Associated w/3+ symptoms: feeling restless or on edge, easily tired, poor attention span,
irritability, muscle tension, difficulty sleeping
Causes significant distress or impaired ability to work/maintain relationships
NO concurrent substance use or misuse
NO underlying medical cause
NOT explained by another mental health problem
Nursing actions: provide calm environment, decrease environment stimuli and stay with pt
Ask pt to identify what or how they feel
Encourage pt to describe and discuss feelings
Help pt identify causes of feelings if they are having difficulty doing so
Listen to pt expressions of helplessness and hopelessness
Document event, significant information, actions taken and F/U actions, pts response
o Mild: sense of sight/sound increased, perceptual field increased, restlessness, irritability, mild tension
Experienced in everyday life
Motivation, produce growth, enhance creativity, increase learning
Nursing actions: allow expression of feelings, empathy in communication, demonstrate active listening,
help pt identify problems, assist with problem solving, evaluate and explore results, plan
o Moderate: lingers and continues to influence person’s life experience feeling of being overwhelmed and troubled
S/S: increased HR, perspiration, gastric discomfort, urinary urgency, mild tremors, HA
Learning and problem solving still occurs
Nursing actions: offer cool beverage, respect need for personal space, active dialog to share feelings, create
activities for distraction, exploration alternation coping mechanism, help pt focus on here and now
o Severe: person’s stress level has not been reduced, more obvious, negative behavior begins to intrude (somatic
complaints, agitations, anger)
S/S: stimulation of sympathetic nervous system (HA, N, Dizziness, sleep disturbance), increased tremors,
pounding HR, hyperventilation
Learning and problem solving NOT possible
ALL behavior aimed at relieving anxiety
Focus on minute/scattered details
Nursing actions: begin limit setting, make simple and direct statements, describe behavior needed, notify
MD and administer medication, remove other patients from day room, explain consequences of behavior
o Panic: physically and emotionally exhausted from stress, ability to cope and exert self-control virtually non-existent
Dread and terror and impending doom
S/S: loss of rational thought, increased motor activity (pacing, shouting, screaming), withdrawal, impulsive
and erratic behavior, FULL fight or flight mode, gross motor skills at highest level
If Prolonged exhaustion or death
Nursing actions: assess potential for injury to self/others, conduct debriefing of unit community, call for
therapeutic team support, call physician for onsite assessment, conduct debriefings of staff and patient post-
containment
