Nurse's Pocket Guide

Related Factors
Innate origin (e.g., sudden noise, height, pain, loss of physical support);
innate releasers (neurotransmitters); phobic stimulus
Learned response (e.g., conditioning, modeling from or identification
with others)
Unfamiliarity with environmental experience(s)
Separation from support system in potentially stressful situation
(e.g., hospitalization, hospital procedures [/treatments])
Language barrier; sensory impairment
Defining Characteristics
SUBJECTIVE
Report of apprehension; excitement; being scared; alarm; panic;
terror; dread; decreased self-assurance; increased tension; jitteriness
Cognitive: Identifies object of fear; stimulus believed to be a
threat
Physiological: Anorexia; nausea; fatigue; dry mouth; [palpitations]
OBJECTIVE
Cognitive: Diminished productivity/learning ability/problem
solving
Behaviors: Increased alertness; avoidance[/flight]; attack behaviors;
impulsiveness; narrowed focus on the source of the fear)
Physiological: Increased pulse; vomiting; diarrhea; muscle tightness;
increased respiratory rate; dyspnea; increased systolic
blood pressure; pallor; increased perspiration; pupil dilation
Desired Outcomes/Evaluation
Criteria—Client Will:
• Acknowledge and discuss fears, recognizing healthy versus
unhealthy fears.
• Verbalize accurate knowledge of/sense of safety related to current
situation.
• Demonstrate understanding through use of effective coping
behaviors (e.g., problem solving) and resources.
• Display appropriate range of feelings and lessened fear.
Actions/Interventions
NURSING PRIORITY NO. 1.To assess degree of fear and reality of
threat perceived by the client:
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 313
FEAR