NURSING DIAGNOSIS FOR AXIETY

Nama Kelompok :

Gustiana Satra Dewi 1614301041

Risa Hairun Nisyah 1614301042

Linda Safitri 1614301043

Iis Komang Reni 1614301044

Rizqo Aditya Utama 1614301045

Mega Meilisa Manara 1614301046

Aprilia Cahyaningrum 1614301047

Anggun Karunia Putri 1614301048

Marhamah 1614301049

Ikhsan Aji Dwi Wibowo 1614301050

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN KEMENKES TANJUNG KARANG

JURUSAN KEPERAWATAN TANJUNG KARANG

PRODI D.IV KEPERAWATAN TANJUNG KARANG

TAHUN AKADEMIK 2016/2017

  Definitions:

a five-part systematic decision-making method focusing on identifying and treating responses

of individuals or groups to actual or potential alterations in health. Includes assessment, nursing
diagnosis, planning, implementation, and evaluation. The first phase of the nursing process is
assessment, which consists of data collection by such means as interviewing, physical
examination, and observation. It requires collection of both objective and subjective data. The
second phase is nursing diagnosis, a clinical judgment about individual, family, or community
nursing responses to actual or potential health problems/life processes. Provides the basis for
selection of nursing intervention to achieve outcomes for which the nurse is accountable
(NANDA, 1990). The third phase is planning, which requires establishment of outcome criteria
for the client's care. The fourth phase is implementation (intervention). This phase involves
demonstrating those activities that will be provided to and with the client to allow achievement
of the expected outcomes of care. Evaluation is the fifth and final phase of the nursing process. It
requires comparison of client's current state with the stated expected outcomes and results in
revision of the plan of care to enhance progress toward the stated outcomes.

Anxiety Definition : A vague, uneasy feeling of discomfort or dread accompanied by an

autonomic response, with the source often nonspecific or unknown to the individual; a feeling of
apprehension caused by anticipation of danger. It is an altering signal that warns of impending
danger and enables the individual to take measures to deal with threat.

 Nursing Interventions and Rationales

1. Assess client’s level of anxiety and physical reactions to anxiety (e.g., tachycardia,
tachypnea, nonverbal expressions of anxiety). Validate observations by asking client, “Are you
feeling anxious now?”
Anxiety is a highly individualized, normal physical and psychological response to internal or
external life events (Badger, 1994).
2. Use presence, touch (with permission), verbalization, and demeanor to remind clients that
they are not alone and to encourage expression or clarification of needs, concerns, unknowns,
and questions.
Being supportive and approachable encourages communication (Olson, Sneed, 1995).
3. Accept client’s defenses; do not confront, argue, or debate.
If defenses are not threatened, the client may feel safe enough to look at behavior (Rose, Conn,
Rodeman, 1994).
4. Allow and reinforce client’s personal reaction to or expression of pain, discomfort, or threats
to well-being (e.g., talking, crying, walking, other physical or nonverbal expressions).
Talking or otherwise expressing feelings sometimes reduces anxiety (Johnson, 1972).
5. Help client identify precipitants of anxiety that may indicate interventions.
Gaining insight enables the client to reevaluate the threat or identify new ways to deal with it
(Damrosch, 1991).
6. If the situational response is rational, use empathy to encourage client to interpret the anxiety
symptoms as normal.
Anxiety is a normal response to actual or perceived danger (Peplau, 1963).
7. If irrational thoughts or fears are present, offer client accurate information and encourage
him or her to talk about the meaning of the events contributing to the anxiety.
This study shows that during diagnosis and management of cancer, highlighting the importance
of the meaning of events to an individual is an important factor in making people anxious.
Acknowledgment of this meaning may help to reduce anxiety (Stark, House, 2000).
8. Encourage the client to use positive self-talk such as “Anxiety won’t kill me,” “I can do this
one step at a time,” “Right now I need to breathe and stretch,” “I don’t have to be perfect.”
Cognitive therapies focus on changing behaviors and feelings by changing thoughts. Replacing
negative self-statements with positive self-statements helps to decrease anxiety (Fishel, 1998).
9. Avoid excessive reassurance; this may reinforce undue worry.
Reassurance is not helpful for the anxious individual (Garvin, Huston, Baker, 1992).
10. Intervene when possible to remove sources of anxiety.
Anxiety is a normal response to actual or perceived danger; if the threat is removed, the
response will stop.
11. Explain all activities, procedures, and issues that involve the client; use nonmedical terms
and calm, slow speech. Do this in advance of procedures when possible, and validate client’s
understanding.
With preadmission patient education, patients experience less anxiety and emotional distress
and have increased coping skills because they know what to expect (Review, 2000).
Uncertainty and lack of predictability contribute to anxiety (Garvin, Huston, Baker, 1992).
12. Explore coping skills previously used by client to relieve anxiety; reinforce these skills and
explore other outlets.
Methods of coping with anxiety that have been successful in the past are likely to be helpful
again. Listening to clients and helping them to sort through their fears and expectations
encourages them to take charge of their lives (Fishel, 1998).
13. Provide backrubs for clients to decrease anxiety.
In one study the dependent variable, anxiety, was measured prior to back massage, immediately
following, and 10 minutes later on four consecutive evenings. There was a statistically
significant difference in the mean anxiety (STAI) score between the back massage group and
the no intervention group (Fraser, Kerr, 1993). In a discussion of the results of a systematic
review of 22 articles examining the effect of massage on relaxation, comfort, and sleep, the
most consistent effect of massage was reduction in anxiety. Out of 10 original research studies,
8 reported thatmassage significantly decreased anxiety or perception of tension (Richards,
Gibson, Overton-McCoy, 2000).
14. Provide massage before procedures to decrease anxiety.
In one study parents performed massage on their hospitalized preschoolers and school-age
children before venous puncture. The results obtained indicate that massage had a significant
effect on nonverbal reactions, especially those related to muscular relaxation (Garcia, Horta,
Farias, 1997).
15. Use therapeutic touch and healing touch techniques.
Various techniques that involve intention to heal, laying on of hands, clearing the energy field
surrounding the body, and transfer of healing energy from the environment through the healer
to the subject can reduce anxiety (Fishel, 1998). In a recent study, anxiety was significantly
reduced in a therapeutic touch placebo condition. Healing touch may be one of the most useful
nursing interventions available to reduce anxiety (Gagne and Toye in Fishel, 1998).
16. Provide clients with a means to listen to music of their choice. Provide a quiet place and
encourage clients to listen for 20 minutes.
Music is a simple, inexpensive, esthetically pleasing means of alleviating anxiety. When
allowed to participate in decision-making regarding their care, patients can regain a partial
sense of control. As patient advocates, nurses should take advantage of the therapeutic effect of
music by incorporating it into their plan of care (Evans, Rubio, 1994). Immediately and 1 hour
after listening to music for 20 minutes in a quiet environment, reductions in heart rate,
respiratory rate, and myocardial oxygen demand were significantly greater in the experimental
group of patients with myocardial infarction than in the control group (White, 1999).
17. For the client experiencing preoperative anxiety, provide music of their choice for listening.
A study indicates that music combined with preoperative instruction can be more beneficial
than preoperative instruction alone for reducing the anxiety of ambulatory surgery patients.
Patients who listened to their choice of music before surgery in addition to receiving
preoperative instruction had significantly lower heart rates than patients in the control group
who received only preoperative instruction (Augustin, Hains, 1996).
18. Animal-assisted therapy (AAT) can be incorporated into the care of perioperative patients.
A study of perioperative clients has shown that interacting with animals reduces blood pressure
and cholesterol, decreases anxiety, and improves a person’s sense of well-being ( Miller,
Ingram, 2000).
19. Rule out withdrawal from alcohol, sedatives, or smoking as the cause of anxiety.
Withdrawal from these substances is characterized by anxiety (Badger, 1994).
20. Identify and limit, discontinue, or be aware of the use of any stimulants such as caffeine,
nicotine, theophylline, terbutaline sulfate, amphetamines, and cocaine.
Many substances cause or potentiate anxiety symptoms.
  Geriatric
1. Monitor client for depression. Use appropriate interventions and referrals.
Anxiety often accompanies or masks depression in elderly adults.
2. Provide a protective and safe environment. Use consistent caregivers and maintain the
accustomed environmental structure.
Elderly clients tend to have more perceptual impairments and adapt to changes with more
difficulty than younger clients, especially during illness (Halm, Alpen, 1993).
3. Observe for adverse changes if antianxiety drugs are taken.
Age renders clients more sensitive to both the clinical and toxic effects of many agents.
4. Provide a quiet environment with diversion.
Excessive noise increases anxiety; involvement in a quiet activity can be soothing to the
elderly.

 Multicultural

1. Assess for the presence of culture-bound anxiety states.

The context in which anxiety is experienced, its meaning, and responses to it are culturally
mediated. The following culture-bound syndromes are related to anxiety: Susto-Latin America,
Nervios-Latin America, Dhat-Asia, Koro-Southeast Asia, Kayak angst-Eskimo, Taijin
kyousho-Japan, Nervous breakdown-African Americans (Kavanagh, 1999; Charron, 1998).
2. Assess for the influence of cultural beliefs, norms, and values on the client’s perspective of a
stressful situation.
What the client considers stressful may be based on cultural perceptions (Leininger, 1996).
3. In the culturally diverse client identify how anxiety is manifested.
Anxiety is manifested differently from culture to culture through cognitive to somatic
symptoms (Charron, 1998).
4. Acknowledge that value conflicts from acculturation stresses may contribute to increased
anxiety.
Challenges to traditional beliefs and values are anxiety provoking (Charron, 1998).

 Client/Family Teaching

1. Teach client and family the symptoms of anxiety.

If client and family can identify anxious responses, they can intervene earlier than otherwise
(Reider, 1994). Information is empowering and reduces anxiety (Fishel, 1998).
2. Because intensive care unit (ICU) stays are increasingly shorter, provide written teaching
information that is readily available to clients when they are transferred out.
Time constraints have become a barrier to effective teaching. A pamphlet (available in Spanish
and English) has been developed to ease the move for patients, families, and critical care and
medical nurses from a medical ICU (MICU) to a general floor. Reading this pamphlet has
helped to reduce symptoms of anxiety (Maillet, Pata, Grossman, 1993).