9.6 Applying the Nursing Process to Anxiety Disorders and Obsessive-Compulsive Disorder

People with anxiety disorders and OCD rarely require hospitalization unless they are suicidal, although anxiety can occur during hospitalization for other reasons. As a nurse working with individuals with diagnosed anxiety disorders, be aware of your self-reaction. It is not uncommon to have feelings of frustration, especially if you feel as if the symptoms are a matter of choice or under the patient’s control. The patient often acknowledges the fear is unrealistic or exaggerated but continues to engage in avoidant behavior. Recall that avoidant behavior is a symptom, and behavioral changes are accomplished slowly with treatment.^[1] 

It is also important to be aware that hospitalized patients may develop anxiety in association with other medical conditions (i.e., chronic obstructive pulmonary disease [COPD], angina, or hyperthyroidism) or medical procedures. Anxiety is a nursing diagnosis or cue, as well as a component of several disorders. While implementing interventions that address medical conditions, often the nurse must also implement interventions that address associated anxiety.

Recognizing Cues

When assessing patients with anxiety, assess for the symptoms associated with the “fight or flight” stress response including the following^[2]:

• Restlessness
• Altered concentration, attention, or memory
• Diminished ability to learn or problem solve
• Hypervigilance
• Fear
• Irritability or nervousness
• Hand tremors
• Increased perspiration
• Quivering voice
• Increased respiratory rate, heart rate, and blood pressure
• Palpitations
• Weakness
• Abdominal pain, nausea, or diarrhea
• Urinary urgency
• Altered sleep pattern

Determine the patient’s current level of anxiety (mild, moderate, severe, or panic) and assess for risk of suicide or self-harm. Perform a psychosocial assessment and focus on what factors could be contributing to the anxiety. For example, the patient may identify a problem such as a relationship issue, stressful job, or recent traumatic event that could be pertinent to treatment.^[3]

Diagnostic and Lab Work

When assessing for anxiety disorders, the provider will typically order lab work to rule out common medical causes of anxiety, such as hyperthyroidism, hypoglycemia, hypercalcemia, hyperkalemia, hyponatremia, hypoxia or substances. Review and/or monitor the results of these tests as part of the nursing assessment.

Cultural Considerations

Cultural beliefs can affect an individual’s expression of their feelings of anxiety. An example of a culture-mediated response related to anxiety and panic disorder is ataque de nervios (ADN) or “attack of the nerves” that may be exhibited in Hispanic populations. Symptoms of ADNs can vary widely but are typically described as an experience of distress characterized by a general sense of being out of control. The most common symptoms include uncontrollable shouting, attacks of crying, trembling, and heat in the chest rising into the head. Suicidal gestures, seizures, or fainting episodes may be observed. These symptoms are reported to typically occur following a distressing event such as an interpersonal conflict or the death of a loved one.^[4] Discussing the patient’s cultural background may also elicit patient perception of causes as well as specific treatments.

Analyzing Cues, and Generating and Prioritizing Hypotheses

Anxiety is a nursing concern described as “vague, uneasy feeling of discomfort or dread accompanied by an autonomic response; a feeling of apprehension caused by anticipation of danger. It is an alerting sign that warns of impending danger and enables the individual to take measures to deal with the threat.”^[5] The analysis of the situation should include examining what is related to the anxiety. What assessment data are linked to the anxiety?  Does the patient have another condition that is causing the anxiety, for example alcohol withdrawal? What do you, as the nurse think is happening?

As you link the cues, you will consider what nursing action is the highest priority. As with other disorders, safety is the highest priority. Intent to self-injure or harm others needs to be addressed first. Panic level anxiety is also a high priority.

Generating Solutions

The overall goal for anyone experiencing anxiety is to reduce the frequency and intensity of the anxiety symptoms. SMART outcomes are individualized to the patient’s diagnosed conditions, situational factors, and current status. Highest priority cues are suicidal ideation and symptoms of severe anxiety and panic. Planning outcomes in small, attainable steps can help a client gain a sense of control over their anxiety.^[6]

Examples of SMART outcomes include:

• The patient’s vital signs will return to baseline within one hour.

• The patient will identify and verbalize symptoms of anxiety by the end of the shift.

• The patient will verbalize three preferred stress management and coping strategies for managing their anxiety by the end of Week 1.

Taking Actions

The patient should be encouraged to participate, if possible, in planning outcomes and actions tailored to their situation and needs. This will increase the likelihood that the interventions will be successful. Keep in mind that patients with severe anxiety or panic may not be able to participate in planning and rely on the nurse to take a directive role.^[7]

Safety

If a patient is diagnosed with risk for suicide, interventions to maintain their safety receive priority. Review interventions for patients with a risk for suicide in Chapter 2. If a patient’s anxiety continues to escalate and they become agitated, measures must be taken to keep them and others safe. The nurse may find that administering prescribed medications or initiating time in a quiet room reduces suicidal thoughts.

Mild to Moderate Anxiety

The nurse can reduce a patient’s anxiety level and prevent escalation by providing a calm presence in a quiet environment, acknowledging their feelings of distress, and actively listening. Using therapeutic techniques like open-ended questions, distraction, exploring, and seeking clarification can be used to relieve the patient’s feelings of tension and focus on previously successful coping strategies.^[8] Review therapeutic communication techniques in Chapter 4. It may be helpful to encourage the patient to participate in physical activities that may provide relief from tension and increase endorphin levels. For example, the nurse can encourage the mildly anxious patient to walk.^[9]

Severe Anxiety to Panic

A person experiencing severe anxiety to panic is often unable to solve problems or grasp what is going on in the environment. The nurse should remain with a patient experiencing acute, severe, or panic levels of anxiety. Therapeutic communication should focus on helping the patient feel safe. Firm, short, simple statements using a slow, low-pitched voice are helpful.^[10] Encouraging the patient to take three deep diaphragmatic breaths along with the nurse may be helpful.

In addition to keeping the patient and others safe, priority nursing interventions for a patient experiencing severe anxiety focus on the patient’s physical needs, such as fluids to prevent dehydration, blankets for warmth, and rest to prevent exhaustion. If a person continues to constantly move or pace despite interventions, high-calorie finger foods may be offered to maintain their nutrition.^[11]

Lavender oils as aromatherapy have been shown to have a calming effect for patients. Some facilities offer lavender oil saturated pads that the nurse may administer to the patients to sniff. An order from the provider as well as assessing plant allergies are necessary before administration.^[12]

Evaluation

Refer to the individualized SMART outcomes established for each patient when evaluating the effectiveness of interventions in the care plan. In general, evaluation of outcomes with patients with anxiety disorders includes the following questions^[13]:

• Is the patient experiencing a reduced level of anxiety?
• Does the patient recognize their symptoms are related to anxiety?
• Is the patient successfully implementing adaptive coping strategies to manage their anxiety?
• Is the patient adequately performing self-care activities (e.g., hygiene, eating, and elimination)?
• Is the patient able to maintain satisfying interpersonal relationships?
• Is the patient able to successfully function socially, occupationally, or in other important areas of functioning?