Nurse's Pocket Guide

ANXIETY
Parasympathetic
Urinary urgency; decreased blood pressure/pulse
Desired Outcomes/Evaluation
Criteria—Client Will:
• Appear relaxed and report anxiety is reduced to a manageable
level.
• Verbalize awareness of feelings of anxiety.
• Identify healthy ways to deal with and express anxiety.
• Demonstrate problem-solving skills.
• Use resources/support systems effectively.
Actions/Interventions
NURSING PRIORITY NO.1.To assess level of anxiety:
• Review familial/physiological factors, such as genetic depressive
factors; psychiatric illness; active medical conditions (e.g.,
thyroid problems, metabolic imbalances, cardiopulmonary
disease, anemia, or dysrhythmias); recent/ongoing stressors
(e.g., family member illness/death, spousal conflict/abuse, or
loss of job). These factors can cause/exacerbate anxiety/
anxiety disorders.
• Determine current prescribed medications and recent drug
history of prescribed or OTC medications (e.g., steroids,
thyroid preparations, weight loss pills, or caffeine). These
medications can heighten feelings/sense of anxiety.
• Identify client’s perception of the threat represented by the
situation.
• Monitor vital signs (e.g., rapid or irregular pulse, rapid
breathing/hyperventilation, changes in blood pressure,
diaphorsesis, tremors, or restlessness) to identify physical
responses associated with both medical and emotional
conditions.
• Observe behaviors, which can point to the client’s level of
anxiety:
Mild
Alert; more aware of environment; attention focused on environment
and immediate events
Restless; irritable; wakeful; reports of insomnia
Motivated to deal with existing problems in this state
Moderate
Perception narrower; concentration increased; able to ignore
distractions in dealing with problem(s)
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
90 Cultural Collaborative Community/Home Care