Level of Anxiety & Interventions
Mild +1
1. Discuss source of anxiety (steps
of learning)
2. Problem Solving
3. Accept anxiety as natural;
tolerates and benefit from it.
Moderate +2
1. Decrease Anxiety – ventilation,
crying, exercise
2. Re-focus attention
3. Relate feelings and behaviors to
anxiety.
4. The use of problem solving
5. Oral medication if needed
Severe +3
1. Decrease anxiety, stimuli and
pressure
2. Use kind, firm, simple directions
3. Use time out (seclusion).
Intramuscular medication if
needed.
Panic +4
1. Guide firmly or physically take
control, IM medication
2. Restraints needed
Psychomotor
 Preparation of body for
constructive action
 Slight muscle tension
 Slight fidgeting
 Energetic
 Good eye contact
 Preparation of body for
protective action
 Moderate muscle tension
 Increase BP, pulse and
respirations.
 Startle reflex
 Slight perspiration
 Difficulty sitting still
 Repeated fidgeting
 Periodic slow pacing
 Increased rate of speech
 Sporadic eye contact
 Preparation of body for
flight or fight
 Extreme muscle tension
 Increased perspiration
 Continuous rapid reflex
responses.
 Loud and/or rapid speech
 Poor eye contact
 Somatic symptoms – sleep
disturbance
 Actual flight, fight or
immobilization
 Suicide Attempt or Violence
 Depletion of body resources,
eyes fixed, hysterical or
mute
 Incoherent
SYMPTOMS
Emotional
 Occasional slight irritability
 Feeling challenged
 Confident
 Use of Adaptive coping mechanism
 Feeling uncomfortable, on edge,
keyed up
 Motivated to decrease anxiety
 Increased irritability
 Decreased confidence
 Use of Palliative coping mechanism
 Extreme discomfort
 Feeling of dread
 Hypersensitivity
 Defensiveness with threats and
demands
 Use of Maladaptive coping
mechanism
 Feeling overwhelmed and out of
control
 Rage
 Desperation
 Feeling of totally drained
 Use of Dysfunctional coping
mechanism
Cognitive
 Alertness
 Awareness of surrounding
 Concentration
 Accurate perception
 Attentiveness
 Logical reasoning and problem solving
 Difficulty concentrating
 Easily distracted, can focus with
assistance
 Circumstantiality
 Tangeniality
 Loose association
 Narrowed perceptions
 Decreased span of attention
 Misperception of stimuli
 Tuning out of stimuli
 Problem
 Distorted perceptions
 Difficulty focusing even with
assistance
 Flight of ideas
 Ineffective reasoning and problem
solving
 Disorientation
 Delusions and hallucinations if
prolonged
 Suicidal/homicidal ideations if
prolonged
 Disorganized perceptions
 Disorganized or irrational reasoning
and problem solving
 Flight of ideas
 Neologisms
 Clang associations
 Word salad
 Out of contact with reality
 Personality disorganization