GENERALIZED

ANXIETY DISORDER
C

By: Mary Kenui

Patient Information
Identifying data: 15 yo F admitted 01/12/16 (LOS 31 days)
Legal status: MH5A
DSM diagnosis
I-Generalized Anxiety Disorder & Major Depressive Disorder
II-nonverbal learning disability
III-Postural Orthostatic Tachycardic Syndrome (POTS) & migraines
IV-Problems with primary support group, problems r/t the social environment & educational
problems
V-GAF 45

Reason for admission: + SI/HI after stopping medications in Oct. 2015 for diagnosed
mental illnesses; transferred from Queens Medical Center ER
Financial data: Tricare (Department of Defense healthcare program)

Tricare Coverage
What is not covered?

What is covered?

Acute Inpatient Psychiatric Care

Applied Behavior Analysis

Eating Disorder Treatment

Family Therapy

Partial Hospitalization

Psychological Testing

Psychotherapy

Residential Treatment Facility Care

Substance Abuse Treatment

Telemental Health Services

Aversion therapy
Behavioral health care services and supplies related solely to obesity and/or weight
reduction
Bioenergetic therapy
Biofeedback for psychosomatic conditions
Carbon dioxide therapy
Counseling services, such as nutritional counseling, stress management, marital therapy,
or
lifestyle modifications
Custodial nursing care
Diagnostic admissions
Educational programs
Environmental ecological treatments
Experimental procedures
Filial therapy
Guided imagery
Hemodialysis for schizophrenia
Intensive outpatient treatment program
Marathon therapy
Megavitamin or orthomolecular therapy
Narcotherapy with LSD
Primal therapy
Psychosurgery
Rolfing
Sedative action electrostimulation therapy
Sexual dysfunction therapy
Telephone counseling
Therapy for developmental disorders such as dyslexia, developmental mathematics
disorders, developmental language disorders, and developmental articulation disorders
Training analysis
Transcendental meditation
Z therapy

Patients Description of Problem

Ability to function severely impaired due to Postural Orthostatic
Tachycardic Syndrome, mental health illnesses & nonverbal learning
disability
Inability to control emotions
Restlessness
Fatigue
Sleep issues
Difficulty concentrating
Limited in exercise/sports
Enjoys swimming & reading
Online schooling
Inability to socialize easily/comfortably & build lasting, meaningful
peer relationships
Low self esteem
Im confined by my health issues which play a part in my other
issues (referring to her GAD & MDD diagnosis) .

Ethnicity/Spiritual Concerns &

Implications

Ethnicity: Patient does not associate with any specific ethnicity or culture.
Religion: Patient states she is spiritual but does not associate with any specific
religion.
Implications
No real sense of self
Increased risk for negative behavior (substance abuse, depression, suicide, etc.)

Spirituality = protective factor

Strengths & Limitations

Strengths
Intelligent
Creative/artistic
Friendly/personable
Easy to get along
with

Limitations
Health
Mental &
physical
Low self
esteem/self hate
Pessimism
Lack of coping skills

Medications & Labs

Fluoxetine 10 mg PO QAM
Drug class-SSRI; antidepressant, Total 24 hr dose-10 mg/day. Recommended range-10 mg/day
which may be increased to 20 mg/day after 2 weeks; additional increases may be made after
several more weeks with range of 20-60 mg/day, low dose, current SE-none

Propranolol 40 mg PO BID (hold for SBP<100 or DBP<60)

Drug class-Beta blocker, Total 24 hr dose-80 mg/day, Recommended range-20 mg 4 times daily or
80 mg/day as sustained release capsule; may be increased as needed up to 240 mg/day, low dose,
current SE-none

Melatonin 6 mg PO QPM PRN for insomnia

Drug class-hormone supplement; insomnia, Total 24 hr dose-6 mg/day, Recommended range-0.050.15 mg/kg (patient weighs 134 which is 60.9 kg so range is 3.0-9.1 mg), medium dose, current SEnone

Buproprion 150 mg PO QAM

Drug class-Aminoketone; antidepressant, Total 24 hr dose-150 mg/day, Recommended range-200400 mg/day, low dose, current SE-none
No abnormal labs currently. Buproprion levels need to be checked to verify therapeutic effects due to
low dosage. Blood levels should be above 860 ng/mL to be therapeutic.

Mental Status Assessment

Alert and oriented x 3, well nourished, medium build, dressed
in age appropriate clothing, appears specified age, good
personal hygiene and grooming AEB clean/neat appearance
and wet hair indicating AM shower, maintains eye contact
appropriately, speech is clear and spontaneous, friendly and
cooperative, thought process is linear, logical and goal
directed, no evidence of hallucinations, delusions, or illusions,
denies suicidal or homicidal ideations, full range affect and
euthymic mood, intact short and long term memory, no hx of
substance abuse or dependence, fair insight and judgement
AEB ability to state current problems and medication
compliance since admittance, does isolate herself in her room
during free time, patients psychosocial developmental stage
is identity vs role confusion (important events include social
relationships), she is friendly and easy going which are assets
but her anxiety, depression, and self-esteem limit her ability
to build peer relationships

Treatment Plan/DC Plan/Community Resources

Stabilize mood
Depression
Anxiety

Eliminate SI & HI ideations

Safety

Medication compliance
Education & SE
Inform physician if patient feels meds arent working

Community resources: Anxiety and Depression Association of America (ADAA), Hawaii Families
As Allies, TIFFE, and Catholic Charities Hawaii

Standardized Assessment Tools Used

TM33
Score of 1 = No precautions for suicide

Coppersmith Self-Esteem Inventory

Score of 5 = Moderately low self-esteem

Symptoms Compared to DSM-4 Criteria

All of the below features must be present in order to make a proper diagnosis of GAD
Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months,
about a number of events or activities (such as work or school performance)
The person finds it difficult to control the worry;
The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some
symptoms present for more days than not for the past 6 months). Note: only one item required in children
Restlessness, feeling keyed up or on edge.
Being easily fatigued
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbance

The focus of the anxiety is and worry is not confined to features of an Axis I disorder;
The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social,
occupational, or other areas of functioning;
The disturbance is not due to the direct physiological effects of a substance or general medical condition and
does not occur exclusively during a mood disorder, a psychotic disorder or a pervasive developmental
disorder;

Nursing Priority #1
Diagnosis: Risk for suicide r/t unstable mood (anxiety & depression) AEB history of
self harm and history of positive suicidal and homicidal ideations
Priority #1 because we need to ensure patient safety to self and others
Goals: patient agrees to inform staff upon impulse to self harm and agrees to treatment
plan to reduce risk for suicidal behavior by end of shift and is reflected in no new injuries to
self (short term goal); patient is compliant with medications with no self-harm acts and
denies thoughts of suicide before discharge as measured by a score of 0-1 on TM33
P: patient at risk for self-harm and suicide
E: patient has hx of self-harm (scratches herself) and has hx of thoughts of hurting herself
and her parents
S: patient agrees to inform staff with feelings to self harm or upon suicidal/homicidal ideations
& continues medication compliance to stabilize mood

Care Plan #1

Intervention & Frequency

Scientific Rationale
(In complete sentences!)
(Reference in APA format, including
page number)
Interview the patient to assess the
Gulanick and Myers (2014) state
potential for self harm and suicide q thatPeople who are suicidal are
every 24hrs. Utilize TM33.
often ambivalent about wanting to

end their lives. Patients

contemplating suicide may exhibit

verbal and behavioral cues about

their intent to end their life (p.
186).
Develop a verbal or written contract Gulanick and Myers (2014) state
stating that the patient will not act
that A written or verbal agreement
on impulse to do self harm. Review
establishes permission to discuss
and update the contract as needed the subject, makes a commitment
daily.
not to act impulse, and defines a

plan of action in case impulse

occurs (p. 187).
Instruct the patient in the
Gulanick and Myers (2014) state
appropriate use of medications to
that Drug therapy may help the
facilitate her ability to cope and the patient manage underlying health
importance of continued medication problems such as depression (p.
compliance daily.
188).

Evaluation
TM33 score of 1, which is no precautions for
suicide. Patient states she has no feelings or
thoughts to self harm.

Patient agrees to inform staff if feeling

unsafe or has positive suicidal/homicidal
ideations.

Patient able to state medications and their

therapeutic effects; she continues
medication compliance.

Nursing Priority #2
Diagnosis: Anxiety r/t academic performance and social situations/interactions with peers AEB
insomnia, restlessness, difficulty concentrating, muscle tension, irritability, feelings of
inadequacy and helplessness, and increased BP, pulse and respirations
Priority #2 because patients unstable mood interferes/impairs her ability to function
Goals: patient describes a reduction in the level of anxiety by end of shift and is reflected by normal BP,
pulse, and respirations (short term goal); patient uses effective coping mechanisms and maintains a
desired level of function before discharge which is reflected by the patients ability to sleep through the
night without medication, improvement in academic performance, building of peer relationships on the
unit, and the Hamilton Anxiety Rating Scale with a score <17
P: patient suffers from anxiety that interferes/impairs her ability to function
E: irritable, restless, poor academic performance, feelings of inadequacy and helplessness, and limited
social/peer relationships
S: educate patient on effective coping mechanisms, the use of relaxation techniques such as breathing to
decrease anxiety, and the importance of medication compliance to control anxiety/stabilize mood

Care Plan #2

Intervention & Frequency

Assess the patients level of anxiety q
every shift.

Assist the patient in developing new

anxiety-reducing skills (e.g. relaxation,
deep breathing, positive visualization,
and reassuring self-statements)
weekly.
Instruct the patient in the appropriate
use of antianxiety medications and
importance of medication compliance
daily.

Scientific Rationale
(In complete sentences!)
(Reference in APA format, including
page number)
Gulanick and Myers (2014) state that
The patient with mild anxiety will
have minimal or no physiological
symptoms of anxiety. Vital signs will be
within normal ranges. The patient will
appear calm but may report feelings of
nervousness (p. 17).
Gulanick and Myers (2014) state that
Learning to identify a problem and to
evaluate the alternatives to resolve
that problem helps the patient cope
(p. 18).
Gulanick and Myers (2014) state that
Short-term use of antianxiety
medications can enhance patient
coping and reduce physiological
manifestations of anxiety (p. 18).

Evaluation
Patient anxiety level appears mild AEB normal
VS and calm demeanor.

Patient interested in learning new anxietyreducing skills. Discussed positive self-talk as

one way to cope. She currently reads and swims
to reduce stress and cope with her anxiety.
Patient nods understanding of the importance of
medication compliance to control anxiety.

Nursing Priority #3
Diagnosis: Ineffective coping r/t lack of coping skills and inadequate level of confidence
in ability to cope AEB insomnia, fatigue, poor concentration, and destructive behavior
towards self
Priority #3 because her lack of coping skills affects her mood and associated behavior
Goals: patient lists and describes learned coping skills by end of shift and is measured by no acts
of destructive behavior towards herself (short term goal); patient describes positive results from
new behaviors before discharge and is reflected via Cope Inventory (long term goal)
P: patient unable to cope successfully with underlying chronic health condition, mental illnesses
that impair her ability to function, and daily stress
E: poor sleep habits, fatigue, poor concentration, and history of self harm and thoughts of
suicide/homicide
S: educate patient on effective coping skills and teach patient the use of relaxation, exercise, and
diversional activities as methods to cope with stress

Care Plan #3

Intervention & Frequency

Assess for specific stressors daily.

Evaluate resources and support systems

available to the patient.

Instruct the patient about the need for

adequate rest and a balanced diet
weekly.

Scientific Rationale
(In complete sentences!)
(Reference in APA format, including
page number)
Gulanick and Myers (2014) state that
Accurate appraisal can facilitate
development of appropriate coping
strategies. They go on to say that
Persistent stressors may exhaust the
patients ability to maintain effective
coping (p. 54).
Gulanick and Myers (2014) state that
Patients may have support in one
setting, but lack sufficient support for
effective coping in the home setting (p.
54).
Gulanick and Myers (2014) state that
Inadequate diet and fatigue can
themselves be stressors and limit
effective coping (p. 55).

Evaluation
Daily peer interactions and required school type
setting involved on the residential adolescent unit
are possible daily stressors for the patient AEB
patient staying in room and not socializing with
other patients on unit during free time.
Patients main support system consists of her
parents and siblings. She has family therapy and
psychotherapy available to her from her Tricare
insurance. Coming from a military family, she has
the support of the military community as well.
Patient sleeping well currently with a good
appetite. She has Melatonin 6 mg PO at bedtime
PRN prescribed for insomnia but has not needed to
take it recently.

Evidence Based Journal Article

Breathing retraining in anxiety and panic disorder
Birch (2015) states in the Australian Nursing and Midwifery Journal that hyperventilation or over
breathing is often a key component in anxiety and panic disorders, and also in the condition known as
dysfunctional breathing/hyperventilation syndrome.
The article examined the role of breathing retraining in anxiety and panic disorder and provided a case
study on the subject.
Female 17 year old student was enrolled in a breathing retraining program using the Buteyko Method (developed in
Russia in 1950s utilizing the Bohr effect). The program consisted of 5 consecutive daily sessions of 90 minutes
duration where the subject paused her breathing intermittently to increase her CO2. Kate had been diagnosed with
hyperventilation syndrome and anxiety at a major hospital 6 months prior to enrollment. She found the symptoms
distressing and they were making study difficult and affecting her quality of life.
Results: On day 5 of the course, the patient stated she was feeling better, sleeping well, and symptoms of her
diagnosis were decreasing. At the follow up review, the patient stated she was no longer experiencing fatigue,
panic attacks, anxiety or migraines and she reported that she had been able to exercise without feeling short of
breath. In addition, all of the symptoms associated with hyperventilation (SOB, paresthesia, dyspnea and
dizziness) had ceased.
Mary Birch is an RN and a breathing retraining consultant based in Melbourne. She has conducted breathing
retraining programs based on the Buteyko Method since 1999.

Patient & Implications of Care

Blended family
Sexual abuse from older sibling at 5 years old

Does not associate with a specific culture; doesnt consider anyone place home
Military and therefore has never had a stable living environment
Lived in Germany for 4 years prior to current move to Hawaii; lived in Hawaii a total of 4 years from 3 separate moves

Military families tend to undergo a lot more stress than your typical family
Deployment

Physical and mental health issues combined with lack of coping skills, poor self image, and lack of
communication with her parents facilitated admission to Kahi Mohala
CBT: Patient thinks that her medications arent working and that no medications can help her physical and mental
disorders which generates feelings of helplessness, hopelessness and depression so she hurts herself and stops taking
her medication. Patient also thinks she will never overcome her learning disability, thinks she isnt good enough, and
that finishing schoolwork is impossible which causes her to feel overwhelmed, anxious and depressed so she isolates
herself and avoids stressful activities or events (such as schoolwork or social situations).

Patient plan of care is relevant, reasonable, obtainable and measurable

Patient could benefit from other treatments such as biofeedback for her POTS which is made worse by her
GAD & MDD, hypnosis, counseling services for stress management, and enrolling in a breathing retraining
program (but none of this is covered by Tricare)

What Makes YOU

Biological

Spirituality

Psychological

Life Experience

Psycho-social

Fear
Desires

Cultural
Generational

Big Picture
This patient must continue her current medications since they help
stabilize mood
Inform her parents and physician if she feels they arent working or is
experiencing SEs
Communicate with her parents and notify them if she is feeling the
need to hurt herself or is having thoughts of suicide or homicide
Learn and effectively utilize coping mechanisms to deal with daily
stress
Continue family therapy and CBT
Gain a positive self-image which is reflected in a Coppersmith SelfEsteem Inventory
Utilize resources available to her in the community and that are
available to her through Tricare (psychotherapy)
Per Erikson she is in the psychosocial development stage of identity
vs role confusion
Needs to examine her identity and find out who she is
Socialize and build peer relationships

References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV (4th ed.).
Washington, DC: Author.
Birch, M. (2015). Breathing retraining in anxiety and panic disorder. Australian Nursing and Midwifery Journal, 23(4),
31.
Gulanick, M., & Myers, J.L. (2014). Nursing care plans-diagnoses, interventions, and outcomes (8th ed.).
Philadelphia, PA: Elsevier Mosby.

THE END