Stress and Anxiety Nursing Care Management

Every patient you meet carries some level of anxiety, and your read on which level tells you how to approach them. Mild anxiety sharpens focus. Panic shuts the brain down. The same intervention that grounds a moderately anxious patient is useless on someone in panic, so you assess the level first and match your response to it.

Stress is the brain's reaction to any demand, usually triggered by change, positive or negative, real or perceived. Anxiety is the psychological and physiological state of unease, worry, or apprehension. It is a normal response to a perceived threat, but when it runs excessive or prolonged it becomes a condition that interferes with daily functioning.

Anxiety Levels and Effects

Anxiety runs along a spectrum, and each level looks different at the bedside.

Mild

The patient knows something is off and pays attention to it. Sensory stimulation increases, which actually sharpens focus for learning. It rarely threatens coping ability and can motivate the person to try new things and take risks. They are alert, aware of the environment, and motivated to deal with problems. Behaviorally: can't sit still, fine tremors, a little impatient.

Moderate

The patient grows nervous or agitated. Perception narrows and concentration increases. They feel fearful or uneasy but can still function, though the voice may quiver or change pitch. Behaviorally: uncomfortable, shaken, sensitive.

Severe

The patient believes there is a threat. They feel very agitated, confused, and inadequate. Perception is reduced and anxiety blocks effective functioning. They either avoid the anxiety or get overwhelmed by it, with increased pulse and respirations, dizziness, tingling, and headache.

Panic

Concentration is disrupted and behavior disintegrates.

Causes of Stress and Anxiety

Stressors fall into three groups. Psychobiological stressors attack the integrity of the body (injuries). Psychological stressors include various forms of trauma. Psychosocial stressors come from interaction with people and show up physically (sweating, high blood pressure, rapid heartbeat).

Anxiety-Related Disorders

When anxiety stops being useful, real illness sets in. Anxiety disorders are the most common psychiatric disorders. They share excessive fear (the emotional response to a real or perceived imminent threat) and anxiety with related behavioral disturbances. They often appear together but differ in the objects or situations that trigger them, and the fear runs excessive and persistent well beyond what is developmentally appropriate.

Generalized Anxiety Disorder (GAD)

Persistent, overwhelming, uncontrollable anxiety out of proportion to the trigger. It emerges slowly and tends to be chronic. Usual onset is the early 20s, and it affects 3% of the population.

Panic Disorder

Anxiety in its most severe form: recurrent, unexpected panic attacks bringing intense apprehension and a sense of impending doom, often changing the patient's behavior.

Obsessive-Compulsive Disorder (OCD)

Unwanted, recurrent, intrusive thoughts or images (obsessions) that the person tries to relieve through repetitive behaviors or mental acts (compulsions). The obsession drives anxiety; the compulsion is meant to reduce it or prevent some dreaded event. Compulsions are typically overt: hand washing, counting, praying.

Phobic Disorder

Social phobia centers on anxieties about speaking or eating in public or using public restrooms, with deep concern that others will spot the anxiety symptoms (sweating, blushing) or judge the person as weak. Specific phobias split into five subtypes: natural environment, animal, blood-injection-injury, situational, and other.

Post-traumatic Stress Disorder (PTSD)

Persistent, recurrent images and memories of a serious traumatic event the person experienced or witnessed, impairing the ability to function.

Causes of Anxiety-Related Disorders

• Genetic. Some anxiety disorders (panic disorder, OCD, GAD) run in families. Research is looking at defective genes that regulate the neurotransmitters serotonin and dopamine.
• Biochemical. A biological vulnerability to stress.
• Neuroanatomic. MRI and other neuroimaging show brain atrophy, underdeveloped frontal and temporal lobes, amygdala abnormalities (fear, memory, and emotion regulation), and hippocampal changes (emotion and memory storage).
• Other. Traumatic events, medical conditions, and gender (women are at higher risk than men). Add marital separation or divorce, a history of childhood physical or sexual abuse, and low socioeconomic status.

Medical Management

Stressed and anxious patients benefit from social supports, psychotherapy, cognitive or behavioral therapy, pharmacotherapy, and supportive counseling.

Nursing Management

Nursing Assessment

• Assess the anxiety level. Review familial and physiological factors (genetic depressive factors), psychiatric illness, and active medical conditions (thyroid problems, metabolic imbalances). Monitor vital signs.
• Describe feelings, expressed and displayed. Interview and observe behaviors.
• Gauge awareness and ability to recognize and express feelings.
• Note any related substance use.

Nursing Diagnosis

Anxiety related to unconscious conflict about essential goals and values, threat to self-concept, positive or negative self-talk, or physiological factors (hyperthyroidism, pulmonary embolism, dysrhythmias).

Planning and Goals

Set the treatment plan with individual responsibility for activities, and a teaching plan.

Nursing Interventions

• Help the patient identify feelings and start working the problem. Build a therapeutic relationship. Be available to listen and talk. Help the patient develop awareness of their verbal and nonverbal behaviors. Clarify the meaning of feelings and actions by giving feedback and checking your read against theirs. Above all, acknowledge the anxiety and fear. With children, be truthful and never bribe.
• Promote wellness. Help the patient find new ways to cope with disabling anxiety. Review the events, thoughts, and feelings that preceded the attack. List helpful resources and people. Build skills like catching negative thoughts, saying "Stop," and substituting a positive thought.

Evaluation

Track patient involvement and the patient's response to interventions, teaching, and actions performed.

Discharge and Home Care Guidelines

Instruct the patient and family on relaxation techniques (deep breathing, imagery, music therapy), maintaining the positive coping strategies they learned, avoiding triggers, stress management techniques, and strict adherence to the medication (if prescribed) and therapy schedule.