Stress-related anxiety disorders

Acute stress disorder (ASD) occurs within 1 month after exposure to an event
that involves actual or threatened harm or death to the self, significant others, or
other persons nearby, and in which the patient responds with fear, helplessness,
or horror. The individual must exhibit at least three dissociative symptoms during
or after the traumatic event: a sense of numbing, detachment, or an absence of
emotional response; reduced awareness of surroundings (dazed state); and
derealization, depersonalization, or amnesia for important aspects of the
traumatic event. This disorder lasts for 2 days to 4 weeks.
Posttraumatic stress disorder (PTSD) affects individuals who have
experienced traumatic events in a similar manner as the individual with ASD but
the symptoms last for 1 to 3 months (acute) or more than 3 months (chronic). The
onset of symptoms may also occur more than 6 months after the trauma.
After the traumatic event, the individual typically experiences anxiety
characterized by elevated autonomic responses (rapid pulse, increased blood
pressure, and increased respiratory rate), cognitive impairment, and altered
memory function. The individual persistently reexperiences the traumatic event
through intrusive and unwanted thoughts or nightmares and tries to cope by
suppressing emotional responsiveness. These behaviors are characteristic
symptoms of PTSD.
Pathophysiology
Recent research shows that severe psychological and physical trauma can cause
alterations in the neurobiological response to stress, even several years after the
original exposure or insult. These long-standing alterations may contribute to a
number of complaints and symptoms that are commonly experienced by
individuals with ASD or PTSD.
Neurobiological studies provide evidence for at least two relatively
consistent neurobiological alterations in chronic PTSD. Findings from
psychophysiologic, hormonal, receptor-binding, and I.V. challenge studies have
demonstrated repeatedly that reminders of the original trauma provoke
hyperresponsiveness of the sympathetic nervous system in individuals with
PTSD.
 Additionally, findings of hypothyroid-pituitary-adrenal (HPA) axis
alterations in PTSD suggest increased responsiveness of this system. Low
baseline cortisol, along with heightened response to exogenous dexamethasone,
is consistent with an HPA axis that is extremely sensitive to the stress-mediated
hormones. These neurobiological findings are consistent with a behavioral
sensitization model of PTSD. Behavioral sensitization produces an increased
magnitude of response following repeated presentation of a particular stimulus
such as a traumatic event.
Complications
Substance abuse or dependence
Engaging in high-risk behaviors
Social isolation
Withdrawal from the family
Violent behavior
Suicide

Assessment (only potential abnormalities listed)

NURSING HISTORY BY FUNCTIONAL HEALTH PATTERN
Health perception and management
Extreme concern about "going crazy"
Fear of being confined in a hospital
Extreme concern about general health
Exaggerated worry about daily life circumstances
Worry about medication compliance, follow-up visits, and inability to follow
through
Inability to control feelings
Numerous somatic complaints, with or without diagnostic validation
Overuse or underuse of health care system to ease anxiety symptoms
Nutrition and metabolism
Concern about eating behaviors, such as using food to suppress feelings
Concern about weight fluctuations
Inattentiveness to dental problems
Changes in appetite, including anorexia and binges
Elimination
Concern about gastrointestinal system disturbances, such as pain, flatulence,
diarrhea, nausea, constipation, vomiting, and intestinal bleeding
 Frequent urination
Concern about increased sweating or cold and clammy skin
Activity and exercise
Agitation and restlessness
Concern about fluctuations in energy and activity level
Decreasing interest and participation in leisure or social activities
Trembling
Concern about being easily fatigued
Difficulty accomplishing normal daily activities
Concern about any limitations and restrictions of activity caused by disease or
condition
Withdrawn or apathetic behavior
Sleep and rest
Feeling fatigued after sleep
Dreams or nightmares of traumatic event
Sleep disturbances, such as falling asleep but not staying asleep or awakening
early in the morning
Use or dependence on sleep aids, such as alcohol, benzodiazepines, or
hypnotics
Concern about use or abuse of sleep aids
Cognition and perception
Memory impairment
Difficulty concentrating
Acute or chronic pain
Difficulty learning
Difficulty understanding and reacting to external stimuli
Worry about inability to think clearly
Distorted perceptions
Self-perception and self-concept
Anxiety or feelings of inadequacy
Feeling detached or estranged from others
Feelings of having no control over life
Concern about being indecisive and dependent
Perception of self as being highly anxious
Perception of self as being incompetent and powerless
 Concerns about body image, self-esteem, and self-worth
Roles and relationships
Concern about inability to maintain relationships with loved ones
Inability to maintain consistent or rewarding employment
Concern about feeling alone and not being involved in the community
Intense concern about relationships with family and friends
Rumination about engaging in social situations with friends, fellow employees,
or family
Concern about the lack of response to or support of lifestyle changes from
family and friends
Concern about a distressful work situation
Concern about how community members and neighbors may respond to the
disease or condition
Sexuality and reproduction
Decrease in sexual desire
Difficulties with sexual performance or satisfaction
Dissatisfaction with sexual relations
Difficulty with intimacy
Concern about involvement in high-risk sexual behavior, such as unprotected
sex or promiscuity
Concern about involvement with high-risk partners, including I.V. drug users,
homosexual or bisexual partners, and strangers
Coping and stress management
Feeling tense most of the time
Flashbacks or recurrences of traumatic event can progress to illusions and
hallucinations (in severe presentation)
Significant number of stressful events during the last year
Inability to cope
Feelings of "going crazy"
Pervasive muscle tension
Constant irritability, feeling on edge or keyed up
Constant shakiness, trembling, or twitching
Concern about experiencing an exaggerated startle response (hypervigilance)
Denial of clearly manifested anxiety
 Inability to identify persons or measures that alleviate rather than exacerbate
the condition
Belief that significant lifestyle changes are contributing to feeling out of control
Values and beliefs
Inability to achieve goals in life
Desire to increase or decrease involvement in spirituality or religion
Concern about impaired ability to believe in anything or anyone
Disbelief about present situation
PHYSICAL EXAMINATION
Mental status and behavior
Anger to rage
Anxiety at or around the time of year that the traumatic event occurred
Feeling constricted
Diminished interest in life activities or work
Feeling detached or estranged
Sleep-induced hypnagogic hallucinations (such as might occur when a war
veteran falls asleep and reexperiences a bombing incident)
Hypnopompic hallucinations, or dreams that continue after waking (such as
those that make an ex-hostage continue to feel as if he's being held hostage
after awaking from a dream about the experience)
Nightmares
Recurrent dreams about the traumatic event
Illusions of being back in the traumatic situation (such as might occur when a
veteran hears a car backfire and thinks he's back in combat)
Intrusive thoughts of the traumatic event
General numbing of emotional responsiveness
Self-hatred
Significant irritability
Social withdrawal
Substance abuse or dependence
Sudden acting or feeling as if the traumatic event were recurring
Survivor guilt
Feeling keyed up or on edge
Inability to concentrate
Blank mind
Respiratory
Hyperventilation
Increased respiratory rate
Shortness of breath
Smothering sensation
Choking sensation
Cardiovascular
Excessive perspiration
Increased heart rate
Cold, clammy skin
Elevated blood pressure
Hot and cold flashes
Palpitations
Tingling sensation
Gastrointestinal
Abdominal distress
Diarrhea
Nausea
Gastric ulcers
Dry mouth
Vomiting
Difficulty swallowing
Neurologic
Headaches
Hyperalertness
Hypervigilance
Memory impairment
Inability to fall asleep or to remain asleep
Startle reactions
Tremors or tics
Dilated pupils
Dizziness or faintness
Light-headedness
Paresthesia
Restlessness
Musculoskeletal
Muscle aches, pains, or soreness
Muscle tension
Restlessness
Trembling
Fatigue
Shakiness
Twitching
Renal and urinary
Frequent urination

Nursing care plan

Nursing diagnosis Nursing priorities
Posttrauma syndrome related to the subjective Assess the traumatic event and degree of patient
experience of an overwhelming traumatic event anxiety to determine the seriousness of the
perceived threat.
Powerlessness related to feelings of helplessness Help the patient regain control over feelings and
and overwhelming anxiety and inadequate problem- behaviors.
solving and coping skills
Insomnia related to recurrent nightmares, dreams of Help the patient establish a restful environment
personal death, or fear of reexperiencing the to increase hours of refreshing sleep.
traumatic event
Chronic low self-esteem related to the traumatic Help enhance the patient's self-esteem.
experience
Spiritual distress related to the patient's perception Help the patient manage personal fears.
of the world as threatening after the traumatic event
Other potential nursing diagnoses: Fear related to flashbacks and nightmares Ineffective role
performance related to disruption of thought processes and coping from severe anxiety

Posttrauma syndrome related to the subjective

experience of an overwhelming traumatic event
EXPECTED OUTCOME
As the treatment progresses, the patient will report that intrusive thoughts and
memories produce less anxiety and will demonstrate appropriate lifestyle
changes.
Suggested NOC Outcomes
Anxiety level; Anxiety self-control; Coping; Fear level; Stress level; Suicide self-
restraint
NURSING INTERVENTIONS
Intervention type Intervention Rationale
Independent Observe for and identify any Physical injuries can occur during
 physical injury to the patient.
Independent Identify the patient's symptoms
(such as numbness, headache,
nausea, palpitations, or chest
tightness) and ensure that they
are anxiety-related and not the
products of a physiologic
condition.
Independent Identify any physical effects of the
traumatic event on the patient.
Such effects might include
disfigurement, chronic physical
conditions, and disabilities.
Independent Identify and document the
patient's psychological responses
(such as shock, anger, panic,
bewilderment, and confusion) and
emotional changes. Observe for
emotional instability evidenced by
crying, alternating calm and
agitation, hysteria, and
statements of self-blame or
disbelief concerning the event.
Independent Identify the patient's cultural
beliefs and ethnic background.
Independent Determine the degree of
disorganization in the patient's
thinking and coping.
Collaborative Observe for verbal and nonverbal
expressions of survivor guilt (self-
blame or guilt over having
survived the traumatic event) and
for signs of increasing anxiety.
Independent Assess for suicidal thoughts or
plans and initiate precautions as
needed.
Independent Teach the patient measures to
decrease anxiety, such as
relaxation techniques and
journaling.
Independent Teach the patient about the
disorder, treatment options, and
support services available.
a traumatic event as well as during
a recurrence of that event.
Anxiety-related symptoms must be
differentiated from medical
symptoms so that appropriate
treatment can be instituted.
Sequelae from the traumatic event
may significantly interfere with
normal daily functioning. They also
may serve as constant reminders
of the event.
The behavioral range following a
traumatic event is naturally broad;
however, such responses must be
managed or they will become
repetitive and chronic.
Knowing the patient's cultural
beliefs and ethnic background can
help the nurse better understand
responses to both the event and
treatment. For example, a male
patient whose culture emphasizes
macho behavior may have
particular difficulty coping with a
frightening experience that caused
him to run away or hide for self-
protection and survival.
Evaluating the patient's thinking
and coping abilities helps the
nurse determine the degree of
intervention necessary during
hospitalization, crises, follow-up
care, and support group therapy.
Self-blame, guilt, and increasing
anxiety indicate a decreased
coping ability.
This degree of anxiety and
disturbing sensations increases
the risk of suicide, so assessment
must be made regularly and
precautions initiated promptly
when needed.
Substituting new actions when
stressed can increase sense of
self-control and increase coping
skills.
Repairing any knowledge deficit
about the disease helps increase
the patient's self-esteem and
reduce guilt feelings.
 [Additional individualized
interventions:]
Suggested NIC Interventions
Anxiety reduction; Coping enhancement; Counseling; Suicide prevention
Powerlessness related to feelings of helplessness and
overwhelming anxiety and inadequate problem-solving
and coping skills
EXPECTED OUTCOME
As treatment progresses, the patient will express a sense of control over the
present situation and will become actively involved in the decision-making
processes concerning present and future treatment.
Suggested NOC Outcomes
Anxiety level; Anxiety self-control; Decision-making; Health beliefs: Perceived
control; Health beliefs: Perceived resources
NURSING INTERVENTIONS
Intervention type Intervention
Independent Assess the patient's pre-event
coping abilities and degree of
success with these skills and
abilities.
Independent Explore cultural and religious
beliefs that may support helpless
behavior as well as those that
might be used to support the
patient.
Independent Collaborate with the patient to
establish realistic, achievable
goals for an effective care plan.
Independent Identifying stressors that
contribute to or trigger feelings of
powerlessness can enhance
patient self-confidence and
self-control.
Independent Teach the patient strategies to
diffuse intense stress and
escalating anxiety. Rehearse the
strategies with the patient.
Rationale
Acknowledging any past success
that the patient has had in dealing
with the condition fosters self-
confidence and self-control. It also
reminds the patient that other
behavior exists.
Cultural and religious beliefs need
to be examined in terms of the
rigidity, shame, guilt, and sense of
powerlessness they can instill.
Understanding the influence of
such beliefs can enable the patient
to see that feelings have certain
foundations and that they aren't
beyond control. Positive cultural
and religious beliefs, such as
those that promote self-control
and self-determination, can help
the patient regain a sense of
control.
Involvement in the care plan can
enhance the patient's sense of
control.
Identifying stressors that
contribute to or trigger feelings of
powerlessness can enhance
patient self-confidence and
self-control.
Strategies such as deep
breathing, using thought-stopping
techniques to interrupt irrational
thinking, counting to refocus
energy, and reviewing the situation

Independent Encourage the patient to
participate in group
psychotherapy and self-help
support groups; possibly consider
a therapist educated in Eye
Movement Desensitization
Reprocessing techniques.
[Additional individualized
interventions]
Suggested NIC Interventions
Anxiety reduction; Cognitive restructuring; Self-esteem enhancement; Self-
responsibility facilitation; Teaching: Individual
Insomnia related to recurrent nightmares, dreams of
personal death, or fear of reexperiencing the traumatic
event
EXPECTED OUTCOME
As treatment progresses, the patient will identify and utilize focused sleep
hygiene measures to reduce sleep pattern disturbance.
Suggested NOC Outcomes
Anxiety self-control; Sleep; Stress level
NURSING INTERVENTIONS
Intervention type Intervention
Independent Gather information from the
patient, loved ones, or family
members to assess the patient's
usual sleep pattern and any
changes in that pattern that have
occurred since the traumatic
event.
Independent Assess the patient's usual sleep-
related behaviors, such as time of
retiring and rising, bedtime rituals,
alcohol and sleep aid use, and
caffeine intake before bedtime.
Independent Teach the patient effective sleep
measures, such as retiring and
with a staff or family member or
friend provide alternative coping
methods for feelings of
powerlessness and can increase
the patient's sense of
self-management.
Participating in such groups
enables the patient to learn and
share new coping strategies with
peers who have experienced
similar traumatic events and
reactions.
Rationale
Both subjective and objective
information can help the nurse
assess the patient's specific sleep
disturbance and focus
interventions.
Knowing when the patient goes to
bed and arises and usual bedtime
rituals can help the nurse evaluate
potential difficulties. For example,
alcohol and sleep aids interfere
with the rapid-eye-movement
sleep cycle, thereby preventing
refreshing sleep. Coffee, exercise,
or animated conversations before
bed can cause restlessness and
interfere with the normal sleep
cycle.
Taking measures to modify
behaviors and promote sleep can
 rising at regular times, avoiding
naps, and avoiding caffeine and
alcohol in the evening. Encourage
the patient to remain fairly active
during the early evening and not
to spend most of the night on the
couch resting or watching
television.
Independent Arrange a quiet, restful
environment that is not too warm
and that has no direct light.
Independent Encourage the patient to install a
dim night-light in the bedroom.
Independent Help the patient to develop an
individualized relaxation program.
Demonstrate and rehearse such
techniques as self-hypnosis,
imagery, and muscle relaxation.
Collaborative Refer the patient to a support
group concerned with similar
traumatic events.
Collaborative In collaboration with the patient
and doctor, select, administer, and
monitor psychopharmacologic
medications to manage ASD or
PTSD symptoms that are
interfering with patient's sleep-
wake cycle.
[Additional individualized
interventions]
Suggested NIC Interventions
Medication administration; Medication management; Security enhancement;
Sleep enhancement; Therapy group
Chronic low self-esteem related to the traumatic
experience
EXPECTED OUTCOME
As treatment progresses, the patient will identify effective coping strategies to
alleviate negative self-perception and will verbalize positive statements about
successes when coping with increased anxiety levels.
Suggested NOC Outcomes
Hope; Self-esteem
help decrease the patient's anxiety
about sleeplessness.
These measures can facilitate a
sleep-inducing environment.
Should the patient awake quickly
from a nightmare, a night-light
promotes orientation, thereby
reducing overwhelming fear.
These strategies can produce both
physical and mental relaxation,
which may decrease the patient's
anxiety and induce sleep.
Relaxation can reduce the
incidence of nightmares.
Exploring trauma-related
nightmares and fears in a
supportive and understanding
environment can help diminish the
patient's feelings of isolation and
loneliness.
The patient may require short-term
medication to decrease
exhaustion, fatigue, or fear and to
alleviate the symptoms that are
interring with their ability to sleep.
Frequent assessments are
necessary to determine the
therapeutic response to the
medication and assist in adverse
effect management.
NURSING INTERVENTIONS
Intervention type
Independent
Independent
Suggested NIC Interventions
Counseling; Emotional support; Values clarification
Intervention
Discuss with the patient any
experiences related to the
community's response to the
traumatic event.
Explore cultural and social values
that might contribute to the
patient's emotional response and
potential for lowered self-esteem.
[Additional individualized
interventions]
Rationale
Relating these experiences can
give the patient an opportunity to
explore specific events of
prejudicial behavior.
Cultural and social values can
instill a sense of shame related to
certain traumatic events, such as
rape. Helping the patient to
differentiate these views from
personal feelings may enhance
self-esteem.

Spiritual distress related to the patient's perception of the

world as threatening after the traumatic event
EXPECTED OUTCOME
As treatment progresses, the patient and family will report believing that they
will again be safe in their lives and will verbalize an understanding that they
aren't to blame for the traumatic event.
Suggested NOC Outcomes
Hope; Spiritual health; Psychosocial adjustment: Life change
NURSING INTERVENTIONS
Intervention type Intervention
Independent Encourage the patient, loved
ones, and family to express
feelings about the traumatic
event.
Collaborative Collaborate with the patient,
family members, and a religious
counselor to discover the reasons
for the traumatic event.
Independent Discuss support systems
available to both the patient and
his family members.
Independent Determine whether the patient's
spiritual practices are adversely
affecting treatment.
[Additional individualized
interventions]
Rationale
Doing so prevents suppression or
denial of feelings.
Understanding that such events
occur for specific reasons can help
the patient accept that he was not
a random victim, which in turn can
give the patient a more positive
outlook on life.
Knowing that support is available
can make the patient and his
family feel more connected to
others and diminish feelings of
isolation.
Understanding the patient's
spiritual or religious beliefs can
help the nurse determine any
conflict between such beliefs and
treatment.
Suggested NIC Interventions
Hope instillation; Referral; Spiritual growth facilitation; Spiritual support

Teaching checklist
Impact of intrusive thoughts or memories on anxiety level and daily
functioning
Strategies to diminish feelings of powerlessness
Value of participation in the care plan and decision making
Methods that facilitate sleep
Alternative coping skills
Available group, family, or marital support resources
Medication use, dosage, administration schedule, and possible adverse effects
Emergency contact information, including patient behaviors that indicate the
need for immediate assistance