Disorder: GENERAL ANXIETY DISORDER

Factors: PREDISPOSING

 Sex
Women are diagnosed with GAD twice as often as men. It may be tied to hormones, cultural expectations, and more willingness to visit
doctors and talk about their anxiety.
 Family History
Anxiety disorders may run in families. The risk of GAD may be higher if there is a family history of anxiety or mood disorders.
 Substance Abuse
Smoking, alcohol, and drug use can increase the risk of GAD.
 Medical Conditions
People with chronic illnesses have a greater risk of GAD.

Neurochemical/biological alternation:
Abnormalities in the GABA (Gamma-Aminobutyric Acid), an inhibitory neurotransmitter, which means that it weakens or slows down signals.
Because of its inhibitory function, GABA plays an important role in anxiety. When nerve signals fire too quickly and carry anxiety-inducing signals,
GABA acts to slow the signals down, reducing overwhelming feelings of anxiety.

PRECIPITATING:

 History of Stressful Life Events

 Traumatic event, (physical or emotional)
 Poor or oppressed.
 Childhood abuse or neglect; exposure to parental abuse or drug use or physical discipline.
 Divorce, separation, or being widowed

Assessment:
Mental Status Assessment Adaptive Functioning Theories
General Appearance Conceptual Psychosexual/ Freud
Facial Expression: Sad or Depressed, Communication - Speech, language, Oral - tension and gratification
Pale/Reddened vocabulary and listening Anal - Control
Posture: Upright Functional Academics - academic skills in Phallic - Genital (Elektra & Oedipus complex)
Gait: Normal basic reading, writing, Latency - Social activities
Dressed: Appropriately dress mathematics Genital - True intimacy
Grooming/hygiene: Well Groomed/Clean Self-Direction - independence and Psychosocial/ Erickson
Odor: No presence/ Alcohol/ Cigarette smoke completing task Trust vs Mistrust - Drive and hope
Eye contact: Poor eye contact (lacks) Social Autonomy vs Shame/Doubt - Self-control &
Motor Behavior Social Skills - Interact socially and get along will power
Spasms with others Initiative vs Guilt - Direction & Purpose
Speech Leisure - planning leisure and recreational Industry vs Inferiority - Methods &
Rate: Rapid/Slow activities Competence
Volume: Soft/ mumbled Practical Life Skills Identity vs Role Confusion - Devotion &
Quantity: Paucity/ Muteness Self-care - dressing, bathing, toileting, Fidelity
Quality: Pressured speech/ monotonous grooming, hygiene Intimacy vs Isolation - Affiliation & Love
Emotional State Home/School Living - basic care of a home or Generativity vs Stagnation - Productivity &
Inappropriate living setting Care
Anxiety/ Panic attack Community Use - functioning in the Ego Integrity vs Despair - Wisdom
Perception community, including use Cognitive/ Piaget
None of community resources Sensorimotor (0-2) - Use language
Thinking Health and Safety - Skills needed for Pre-operational (2-7) - Understand
None protection of health relationships
Attitudes Work - holding a part-time or full-time job in Concrete operation (7-11) - Socialized and
Cooperative a work setting logical
Withdrawal Formal Operation (11-above) - Think
Fearful scientifically and solve complex problems
Defense Mechanisms Moral/Kohlberg
Regression PRECONVENTIONAL LEVEL
Stage 1: Punishment and Obedience
Orientation
Stage 2: Instrumental Relativist Orientation
 CONVENTIONAL LEVEL
Stage 3: Good-Boy-Nice-Girl Orientation
Stage 4: Society-Maintaining Orientation

POST CONVENTIONAL LEVEL

Stage 5: Social Contract Reorientation
Stage 6: Universal Ethical Principle
Orientation
Hierarchy of needs/Maslow
SELF ACTUALIZATION - Fulfillment of unique
potential
SELF ESTEEM - Self-esteem and respect;
prestige
LOVE AND BELONGING - Giving and receiving
affection; companionship; group
identification
SAFETY - Avoiding harm; security; and
physical safety
PHYSIOLOGIC NEEDS - Biological needs for
oxygen, water, food, sleep, sex

Nursing Diagnosis:

1. Anxiety r/t real or perceived threat to physical integrity or self-concept AEB extraneous movements, uneasiness

2. Ineffective coping r/t level of anxiety AEB verbalization of inability to cope

3. Impaired social interaction r/t misinterpretation of internal or external stimuli AEB discomfort in social situations

Planning: Priority
  The client will be verbalized ways to intervene in escalating anxiety within 1 week
 Client will be able to recognize symptoms of onset of anxiety and intervene before reaching the panic stage by time of discharge from
treatment

Psychopharma:

 Anxiolytics (Benzodiazepines)
- Prolonged use may lead to dependency and abuse
- They appear to increase the effectiveness of GABA
- Driving should be avoided until tolerance develops
- These drugs should not be stopped abruptly
 Buspirone (BuSpar),
- Causes no sedation thus makes it less attractive for abuse
- Because it does not induce an immediate calming effect it should not be used as a prn medication for anxiety
- Because of its high cost and slow onset of action, buspirone is not widely prescribed
 tricyclic antidepressants
 SSRI or Selective serotonin reuptake inhibitors,

Nursing Considerations

- Do not leave the patient until the drug is swallowed.

- Do not permit the patient to go to the bathroom to take the medication.
- Do not allow one patient to carry medicine to another.
- Always address the patient by name and make certain identification.
- Give fresh water after all medications. – If it is necessary to leave the patient to get water or assistance, do not leave the tray within the
reach of the patient or unsupervised. Do not take the tray within reach of disturbed or delirious patients.
- Do not force oral medication because of the danger of aspiration.

Therapy
Cognitive therapy – Helps patients understand how automatic thoughts and false beliefs/distortions lead to exaggerated emotional responses,
such as anxiety, and can lead to secondary behavioral consequences.

Behavioral therapy – Involves sequentially greater exposure of the patient to anxiety-provoking stimuli; over time, the patient becomes
desensitized to the experience.

Diet – Caffeine containing products, such as coffee, tea, and colas, should be discontinued.

PNCP

Cues/Clues Psychiatric Psychodynamics Planning Therapeutic Rationale Evaluation

Nursing Diagnosis (Rationale) Approach
Subjective Anxiety r/t real or Schematic Client will Assess the Hildegard E. Client was able to
Objective perceived threat Diagram verbalize ways to patient’s level of Peplau described verbalize ways to
to physical intervene in anxiety. 4 levels of anxiety: intervene in
integrity or self- escalating anxiety mild, moderate, escalating anxiety
concept AEB within 1 week. severe and panic. within 1 week.
extraneous
movements, Client will be able Acknowledgment Client was able to
uneasiness to recognize Recognize of the patient’s recognize
symptoms of awareness of the feelings validates symptoms of
onset of anxiety patient’s anxiety. the feelings and onset of anxiety
and intervene communicates and intervene
before reaching acceptance of before reaching
the panic stage those feelings. the panic stage by
by time of time of discharge
discharge from from treatment.
treatment. Awareness of the
Familiarize environment
patient with the promotes comfort
environment and and may decrease
new experiences anxiety
or people as experienced by
needed. the patient.
 Talking or
Reinforce otherwise
patient’s personal expressing
reaction to or feelings
expression of sometimes
pain, discomfort, reduces anxiety.
or threats to well-
being

Anxiety may
Lessen sensory intensify to a
stimuli by keeping panic state with
a quiet and excessive
peaceful conversation,
environment noise, and
equipment
around the
patient

Recognition and
exploration of
Recommend factors leading to
patient to keep a or reducing
log of episodes of anxious feelings
anxiety are important
steps in
developing
alternative
responses.

Discovering new
coping methods
Assist the patient provides the
in developing patient with a
new anxiety- variety of ways to
reducing skills manage anxiety.

Short-term use of
antianxiety
Instruct the medications can
patient in the enhance patient
appropriate use coping and reduce
of antianxiety physiological
medications. manifestations of
anxiety.