Explanation Of the anxiety, etiology of the anxiety, RELATED CLINICAL CONCERNS,

Etiologi

Theoretical approaches to anxiety are wide ranging. In the biological perspective, anxiety is the
uneasy feeling aroused by a threat or danger and is accompanied by a physiological response. This
response prepares the person for “fight or flight.” The fight response (sympathetic stimulation)
causes changes primarily in the cardiovascular and neuroendocrine systems. During the flight
response (parasympathetic stimulation), which occurs in acute fear states, an effort is made to
conserve body resources. Other evidence suggests a biological basis for anxiety.

In psychoanalytical theory, anxiety represents a person’s struggle with the demands and prohibitions
in his or her environment, including the internal struggle among the person’s instinctual drives (id),
the realistic assessment of the possibility for need fulfillment (ego), and the conscience (superego).
Anxiety is a signal from the ego that an unacceptable drive is pressing for conscious discharge. A
conflict results between the drive, usually of a sexual or aggressive nature, and fear of punishment
or disapproval. Phobias are fears that are disproportionate to the situation and cannot be explained
or reasoned away. The significance and meaning of anxiety depend on the nature of the underlying
conflict.

Interpersonal theorists believe that anxiety arises from experiences in relationships with significant
others (SOs) throughout a person’s development.

Learning and behavioral theorists explain anxiety as the result of a conditioning process in which a
neutral stimulus has come to represent punishment, pain, or fear. The individual learns to reduce
anxiety by avoiding a negative stimulus or by approaching a positive reinforcer. Extinction of
behavior is a process of reducing response strength by nonreinforcement.

RELATED CLINICAL CONCERNS

Anxiety may be caused by many other medical and psychiatric problems such as cardiac and vascular
disorders, sleep disorders, hyperthyroidism, anemia, depression with agitation, dementia, delirium,
hypochondriasis, schizophrenia, mania, and personality disorders. Some medications, caffeine
intoxication, and withdrawal from alcohol or sedatives may cause anxiety. Anxiety can also
contribute to medical illness such as arrhythmias and labile hypertension (Epstein & Hicks, 2005).

ASSESMWNT

Mood and Emotions • Dread, fear, apprehension • Lack of control or self-confidence • Guilt • Anger
• Grief • Sense of imminent catastrophe Thoughts, Beliefs, and Perceptions • Narrowed focus of
attention • Perceptual focus scattered or fixed • Inability to focus on reality Chapter 7 ■ Problems
with Anxiety 65 POSSIBLE NURSES’ REACTIONS • May be apprehensive and even fearful about caring
for patients experiencing severe anxiety or a panic attack. Intense anxiety can be very contagious,
not only to staff members but also to other patients. • May try to determine the cause of patient’s
anxiety and do what is possible to reassure and assist patient to decrease it, then become frustrated
when patient’s anxiety continues. • May find it too strenuous to work with patient for more than a
day at a time if patient’s anxiety does not subside as the nurse thinks it should. • May interpret the
anxiety as a weakness in the patient, who is seen as unable or unwilling to control it or may judge
the anxiety as part of a more serious psychological problem and feel very uncomfortable caring for
these patients. • May prefer to keep patient sedated. • May feel resentment and even hostility
toward anxious patients who require more attention and time than their physical conditions alone
warrant. • May want to avoid family members or SOs who are also quite anxious and make
unreasonable requests in a demanding or complaining manner. Most of these behaviors may be
caused by the families’ own frustration or apprehension in dealing with the patient’s anxiety, and
they are often unaware that their behavior is affecting the staff. 07 Gorman(F)-07 11/5/07 4:52 PM
Page 65 • Inability to learn or remember, forgetfulness • Inability to reason or problem solve •
Difficulty concentrating, lack of awareness of environment • Distorted perceptions Relationships and
Interactions • Withdrawal and isolation, avoidance behaviors • Demanding, complaining, quarreling,
attention-seeking behavior • Defensive, uses denial • Tense, strained relationships; others frustrated
over dealing with patient’s anxiety and maladaptive coping Physical Responses See Table 7–1 for
physical responses to various anxiety levels. Pertinent History • Medical conditions that present with
anxiety as a symptom • Thyroid, pituitary, and adrenocortical disorders • Low hemoglobin •
Hypoglycemia • Impending heart attack • Use if stimulants including crystal meth, cocaine,
amphetamines • Synergistic or idiosyncratic drug reactions • Alcohol or sedative withdrawal •
Cerebrovascular disorders • Sequelae to head injury • Chronic anxiety • Recent loss of loved one,
significant object, work, finances, or self-esteem • Phobic behavior • Recent re-exposure to anxiety-
causing situation • Traumatic experience COLLABORATIVE MANAGEMENT Anxiety disorders are
usually treated with some form of counseling or psychotherapy or pharmacotherapy, either alone or
in combination. The milder forms may be effectively treated with cognitive or behavior therapy
alone, but more severe and persistent symptoms may require pharmacotherapy. 66 Chapter 7 ■
Problems with • Inability to learn or remember, forgetfulness • Inability to reason or problem solve •
Difficulty concentrating, lack of awareness of environment • Distorted perceptions Relationships and
Interactions • Withdrawal and isolation, avoidance behaviors • Demanding, complaining, quarreling,
attention-seeking behavior • Defensive, uses denial • Tense, strained relationships; others frustrated
over dealing with patient’s anxiety and maladaptive coping Physical Responses See Table 7–1 for
physical responses to various anxiety levels. Pertinent History • Medical conditions that present with
anxiety as a symptom • Thyroid, pituitary, and adrenocortical disorders • Low hemoglobin •
Hypoglycemia • Impending heart attack • Use if stimulants including crystal meth, cocaine,
amphetamines • Synergistic or idiosyncratic drug reactions • Alcohol or sedative withdrawal •
Cerebrovascular disorders • Sequelae to head injury • Chronic anxiety • Recent loss of loved one,
significant object, work, finances, or self-esteem • Phobic behavior • Recent re-exposure to anxiety-
causing situation • Traumatic experience.

COLABORATIVE MANAGEMENT

Anxiety disorders are usually treated with some form of counseling or psychotherapy or
pharmacotherapy, either alone or in combination. The milder forms may be effectively treated with
cognitive or behavior therapy alone, but more severe and persistent symptoms may require
pharmacotherapy
NURSING MANAGAMENT

ANXIETY manifested by tension, distress, uncertainty related to threat to health, self-concept and
lifestyle. Patient Outcomes • Demonstrates decreased level of anxiety • Will report feeling less
anxious after using coping strategies • Will use coping strategies effectively when anxiety is
recognized • Demonstrates increased ability to prevent episodes of anxiety by problemsolving
Chapter 7 ■ Problems with Anxiety 67 07 Gorman(F)-07 11/5/07 4:52 PM Page 67 Interventions •
Speak in a calm, quiet voice; convey a sense of confidence and control and a tolerant, understanding
attitude. • Place patient in quiet environment; reduce distracting stimuli (e.g., noise, activity, light). •
Use discretion in conversations with patient and near patient’s room. • Recognize factors that may
stimulate more anxiety. • Reduce demands placed on patient until anxiety is reduced. Provide rest
periods between tests, activities, and visitors. • Provide diversional activity and exercise. Monitor
changes in level of activity. • Allow supportive others (clergy, social workers, volunteers) to visit
patient. Explain tests and equipment to them so they can in turn be more relaxed around patient. •
Provide realistic feedback about patient’s situation; do not give false reassurances. Help patient
understand the anxiety by having him or her name the feeling. • Encourage patient to express
feelings (some crying and anger are appropriate). • Have patient identify what happened just before
the anxiety started and try to identify the causative event. Discuss the possible connection between
the precipitating event and the meaning it has for the patient. • Determine patient’s usual coping
mechanism in similar situations. • Encourage patient to recall and think through similar instances of
anxiety, what alternative behaviors could be used to cope more adaptively. • Attempt to discuss
what patient understands as cause of anxiety or panic once the anxiety level is reduced. • Stay with
patient but do not require explanations for the distress; individuals with severe or panic-level anxiety
may become more agitated by attempts to communicate with them. • Provide measures to relieve
anxiety (e.g., warm bath, back rub, walk). Discuss other techniques for reducing anxiety (relaxation
exercises, stress-reduction techniques) when patient is calmer and more rested. Encourage slow,
deep breathing if patient is hyperventilating; breathing with patient to set pattern may be helpful. •
Assist patient in learning and problem solving when anxiety is diminished enough to allow
concentration. • Evaluate need for antianxiety medications; anxiolytics can be very effective in
relieving panic; if none have been ordered, consult with physician for pharmacologic therapy. •
Assess for potential injury or violence to self or others. 68 Chapter 7 ■ Problems with Anxiety 07
Gorman(F)-07 11/5/07 4:52 PM Page 68 • Give feedback about patient’s current coping ability;
reinforce any attempts to cope adaptively. • Refer patients with recurrent anxiety and maladaptive
coping mechanisms for further psychiatric/psychological evaluation and treatment. • For patients
with panic-level anxiety: • Take patient to a quiet area with minimal stimuli. • Administer anxiolytics
as needed (ask what medications patient has used in past) • Remain with patient through the attack.
• Give patient clear, honest feedback (“You are having a panic attack; I will stay with you”).

PATEIENT AND FAMILLY EDUCATION

PATIENT AND FAMILY EDUCATION • Teach patient and family or SO anxiety-reducing exercises such
as muscle relaxation, guided imagery, music, or other activities for distraction. • Discuss with patient
and family or SO the causes and treatment of patient’s anxiety. • Review possible negative short-
term and long-term effects of anxiety on physical and mental health. • If patient is using antianxiety
medications, review the need to monitor their use and potential problems when overused or
discontinued without weaning. • Educate on the use of appropriate medications to treat paralyzing
symptoms such as OCD
ANGGER?.

Anger is a normal human emotion. It can result from frustration, fear, or rejection. When handled
appropriately, anger can help people resolve conflicts and make decisions. It can energize us into
action. It can also contribute to physical and emotional distress if handled in a destructive manner.
Expressing anger directly can be uncomfortable. However, denying it, suppressing it, or expressing it
inappropriately tends to lead to more negative outcomes. The inappropriate expression of anger
may be threatening to oneself and others (HarperJaques & Reimer, 2005).

ETIOLOGI

Biological theories of anger focus mainly on neurotransmitters, such as dopamine, norepinephrine,

and serotonin. The balance of these and other brain chemicals seem to influence or even aggravate
response to anger and stress. Actual physical changes in the brain have been noted in aggressive
behavior (Watson, 2006).

Psychological theories look at the various dynamics and learned responses that cause anger. Anger
occurs as a result of a buildup of frustration.

Sociocultural factors also play an important role in the way an individual expresses anger

Women are often socialized to deal with anger differently from men. They may tend to displace or
suppress angry feelings and attempt to give in and compromise rather than deal with the conflict
directly (Hollinworth, Clark, Harland, Johnson, & Partington, 2005). This behavior can lead to passive-
aggressive responses or resentment that may eventually become destructive. Such repression can
also be detrimental and lead to misunderstanding when dealing with male colleagues.

CLINICAL CONCERN

Medical conditions, such as chronic illness or loss of body function, may strain one’s coping abilities
and lead to an uncharacteristic display of anger Some conditions, including some brain tumors and
different forms of dementia, may also directly contribute to inappropriate expressions of anger
because of their influence on brain function. Emerson-Rose (2005) has found evidence that negative
emotional states contribute to cardiovascular disease.

ASSESMENT

Mood and Emotions • Annoyance, discomfort, frustration, continuous state of tension • May be
quick to anger, then let it go or take time to “stew” before expressing anger • Guilt • Powerlessness
• Vulnerability, easily offended • Defensive response to criticism • Passive-aggressive emotional
response, possibly including being sullen, yet denying any concerns, or inappropriate cheerfulness
for the situation Thoughts, Beliefs, and Perceptions • May believe that anger is normal and can be
expressed without hurting others • May take responsibility appropriately without blaming others •
May be angry at others but still care for them • May lack ability to express true feelings • May fear
loss of love if anger is expressed directly • May fear emotional or physical abandonment if anger is
expressed • May feel a sense of power when angry Relationships and Interactions • May
communicate concerns clearly to avoid additional misunderstanding • May avoid other hostile or
angry persons • May be catered to by others who fear patient’s anger Physical Responses • Fight-or-
flight response during confrontations, possibly including rapid pulse, increased blood pressure, rapid
breathing, muscle tension, sweating, or intense feelings of wanting to attack or run • Episodes of
headaches, depression, sleep alterations, pain, or gastrointestinal symptoms associated with
repressed anger

NURSING MANGEMENT

NURSING MANAGEMENT ANXIETY evidenced by tension, distress, uncertainty, restlessness, or

displeasure related to threat to self-concept, frustration, or unconscious conflict. Patient Outcomes
• Verbalizes concerns and frustrations directly at an appropriate time • Demonstrates reduced
tension including lowered voice and more appropriate anger response • Demonstrates problem-
solving skills when faced with frustration • Demonstrates behaviors to calm self when faced with
frustration Interventions • Use therapeutic communication techniques including open-ended
questions, appropriate eye contact, and supportive gestures to encourage patient to vent feelings
and concerns. Avoid providing solutions before the patient has a chance to relieve tension. • Listen
with concern without being patronizing or condescending. Phrases such as “Tell me what happened
next” or “That really sounds frustrating” allow the patient to feel accepted and understood. Avoid
phrases that escalate feelings of powerlessness, such as “Calm down” or “It can’t be that bad.” • If
needed, direct the patient to a more private setting to express his or her feelings. Having others view
the demonstration of anger can make it more difficult to back down and contribute to escalation of
hostility or aggression. • When the tension of the situation is reduced, focus on identifying the
source of anger and validating the problem. Explore options on how to deal with the problem more
constructively. Ask the patient which methods he or she has used successfully in the past when
dealing with frustration. Teach problem-solving skills. Assist the patient to identify and use more
effective coping mechanisms. • Teach tension-reducing techniques, such as deep breathing,
counting to 10, walking away, and talking to self about remaining in control. • Encourage the patient
to express angry feelings toward the appropriate person. Role-playing before the confrontation may
help the patient choose effective strategies. Chapter 8 ■ Problems with Anger 79 08 Gorman(F)-08
11/5/07 4:54 PM Page 79 • Recognize that an angry outburst may result from an accumulation of
multiple stressors that causes the patient to overreact. • If the patient is justifiably angry because of
something you have done or not done, accept appropriate responsibility. Work with the patient or
colleagues to resolve the problem. Accepting and validating the patient’s feelings sends the message
that you value his or her viewpoint. • Encourage children to vent frustration by redirecting their
activity, such as hitting a pillow or engaging in exercise.

PATIENT AND FAMILLY

PATIENT AND FAMILY EDUCATION • Teach assertiveness skills by role-modeling appropriate

responses and helping the patient practice these skills. • Review with the patient frequently
encountered frustrations, and explain that giving up control of the outcome may be the most
effective strategy for dealing with them. • Review potential negative health effects of inappropriate
anger expression. • If the patient is using antianxiety medications, review the need to monitor their
use and avoid using them in place of trying to resolve the cause of anger. • Review with
patient/family what has helped in the past.
PAIN?

Pain is a universal experience occurring in all age groups and is the most frequent reason why people
seek health care. It is also the most feared symptom (Daudet, 2002). Much progress has been made
over the last decade in understanding pain mechanisms and the epidemiology of pain. The subject is
important for all clinicians because the frequency and perhaps the severity of pain may increase now
that progress in medical science has increased survival through old age and chronic illness, and now
affects more people than ever before.

ETOLOGI

The Gate Control theory, originally proposed in 1965 by Melzack and Wall, suggests that pain occurs
when smaller diameter type A nerve fibers and very small diameter type C fibers are stimulated.
These afferent, or sensory, fibers penetrate the dorsal horn of the spinal cord and end in the
substantia gelatinosa

A number of neurotransmitters have been discovered that are found to contribute to the carrying of
the pain impulse. These include glutamate and substance P. A number of drugs are being
investigated that inhibit binding of excitatory amino acids such as glutamate that normally binds to
N-methyl-Daspartate (NMDA)

The multiple opioid receptor theory recognizes that not all opioids work the same way and some
cannot be switched back and forth without adverse consequences. There are at least three types of
opioid receptor sites in the spinal column. Each type binds somewhat differently with different types
of opioids

Gender and social and cultural factors also affect the pain response by influencing how the individual
interprets pain and how he or she responds. emotionally. Through family, social, and cultural values
and attitudes, the patient learns which types of pain responses are appropriate within his or her
group.

CLINICAL CONCERNS

Chronic pain is a significant health problem. For example, 10% to 15% of adults in the United States
are estimated to have some form of disability from back pain (Borsook, McPeek, & Lebel 1996). One
in five Americans suffer from chronic pain (Sternberg, 2005). In addition to disrupting employment,
chronic pain can contribute to family problems and social isolation.

The physiological and psychological risks associated with untreated pain are greatest in frail patients
with other illnesses, such as heart or lung disease; those undergoing major surgical procedures; and
very young or very old patients. Untreated pain can contribute to complications because the patient
is unable to cough or deep breathe or get adequate rest or nutrition