Halter: Varcarolis' Foundations of Psychiatric Mental Health Nursing, 7th

Edition
Chapter 15: Anxiety and Obsessive-Compulsive Related Disorders

Case Studies and Nursing Care Plans #2: Anxiety with Agoraphobia

Eric, a retired teacher, comes to the mental health clinic on the advice of his physician. He is
accompanied by his wife of 41 years. Eric tells the nurse practitioner, Gen, that he began to have panic
attacks about 5 years ago. In an anxious voice, he describes them as terrifying and like heart
attacks, although he has been reassured by multiple physicians that these events are not heart attacks.
His panic attacks are debilitating; they are accompanied by heart palpitations, sweating, and feelings
of doom. They occur at unexpected times and places. He notes them more acutely when he enters
buildings, buses, or trains. He drives hundreds of miles to avoid crossing bridges, adding hours to his
traveling time when he visits his daughter and grandchildren. He feels that up to now, he has been able
to cope with them; however, lately he has noticed that he has begun to fear attending large gatherings
of people, such as church. Erics visible signs of anxiety increase as he relates his experience of panic
attacks. I feel anxious now. I can feel my heart beginning to race. Im often anxious, even when I
dont have panic attacks. Apprehensively he asks whether the nurse practitioner can help him with his
anxiety, because he doesnt want to stop going to church or on other outings because of his anxiety.

Assessment
Objective Data
History of panic attacks
No diagnosable heart problems
Apprehensive
Heart palpitations and sweating with panic attacks
Anxious mood
Apprehensive

Subjective Data
Terrifying panic attacks
Like a heart attack
Fear of bridges, buses, buildings, and trains
New onset of fear of gatherings of people
Does not want to stop going to church or on other outings because of his anxiety
I feel anxious now.
I can feel my heart beginning to race.

Nurses Personal Perspective

Although concerned about Erics long history of panic attacks, Gen is heartened by his desire to
improve his mental health, his initiative in seeking treatment, and the presence of his supportive wife,
who wants to participate in the therapy. Gen knows that she must address Erics current moderate
anxiety before she can begin helping him decrease his panic attacks.
 Diagnosis
Fear related to perceived threat to biological integrity as manifested by
Fear of bridges, buses, buildings, and trains
Fear of attending large gatherings
Heart palpitations and sweating with panic attacks
Like heart attacks
Inability to recognize situations as harmless
Avoiding bridges negatively affecting relationship with grandchildren.

Panic attacks when exposed to buses, buildings, bridges, trains

Powerlessness related to impaired cognition as manifested by

Request for help
Increased time driving to see grandchildren
Apprehension

Outcomes Identification
Eric will demonstrate less anxiety and verbalize fewer panic attacks and will resume his normal
activities, such as visiting his grandchildren.

Planning
Gen plans to assess Erics mental status thoroughly, because anxiety is often accompanied by
depression. She plans to address his moderate anxiety before concentrating on his panic attacks. After
that, she plans to concentrate on anxiety-relieving methods and client education.

Implementation

Short-Term Goals Intervention Rationale Evaluation

Client will exhibit
fewer and reduced Remain with the Isolation increases Eric appeared
panic symptoms. client during the time clients anxiety. anxious upon his
when clients levels initial visit with the
of anxiety are high. nurse. Later, listening
to the nurses calm
Educate the client Anti-anxiety voice he stated, I
about anti-anxiety medications relieve was afraid to come
medications such as symptoms of anxiety. here, but now I know
benzodiazepines for that I am not the only
acute anxiety. Education necessary person with an
to prevent client from anxiety disorder.
using the medications
improperly (drinking Eric was unable to
alcohol with repeat medication or
medications, or using relaxation technique
heavy machinery information as his
while taking anxiety, although
medications) lowered, was still
 present. The Nurse
Practitioner
prescribed a
benzodiazepine as
well as an SSRI.
Remain calm during
client interactions. Anxiety is catching
and client needs to The nurse gave Eric
feel that he is instructions in
supported and safe. writing to take home
about his disorder,
medications, and
Teach the client to relaxation
recognize signs of techniques.
escalating anxiety. Early recognition
leads to early
Assist client identify intervention.
precipitating events
that increase
likelihood of a panic Client can eliminate
attack. some precipitating
events or prepare for
Encourage client to probable anxiety.
verbalize feelings
related to panic
attacks. Encouraging patient
to verbalize his
feelings increases the
patients
understanding of the
disorder and helps
him to recognize that
Enforce clients self anxiety feelings are
concept and feelings normal and that other
of competence. individuals have
anxiety.

Client will feel

capable of coping
with disorder.

Client will participate Educate patient about These methods help Eric was not able to
in relaxation anxiety relieving to decrease anxiety. demonstrate the
techniques. techniques such as relaxation techniques
exercise, meditation, to the nurse, and
guided imagery, plans were made for
muscle relaxation. Eric to take his anti-
anxiety medications
Ensure that patient Relaxation prior to his next visit.
practice relaxation techniques must be
techniques. practiced to be
 effective during fear
episode.
Teach client and
family about anxiety Client needs support
and agoraphobia. of family to
incorporate
relaxation techniques
into his daily
activities.

Client needs to
understand disorder
to realize that his
feelings are not
abnormal and that
Discuss method of other individuals
systematic experience anxiety
desensitization. and agoraphobia.

Systematic
desensitization is
Give client positive effective method of
support for progress decreasing symptoms
using relaxation of anxiety.
methods or
systematic Increases clients
desensitization. likelihood of success

Evaluation

The client returned consistently to the clinic. I am determined to live the rest of my life without
fearing everything. I want to be the active grandpa. Because of Erics motivation and determination,
his anxiety with agoraphobia symptoms decreased rapidly. Within 9 months, Eric was experiencing
them infrequently and stated, I know what to do now, thanks to the clinic.