7 Anxiety and Panic Disorders Nursing Care Plans

Fear

Fear is an automatic neurophysiological state of alarm characterized by a fight or flight response to a cognitive appraisal of present or imminent danger (Chand & Marwaha, 2022). Clients with anxiety disorders experience fear as a nursing diagnosis related to phobic stimulus and physiological symptoms and mental behaviors because their bodies and minds react in a heightened state of arousal in response to perceived threats or triggers. This can lead to avoidance behaviors and physical symptoms such as sweating and trembling, which can further exacerbate their anxiety. 

Nursing Diagnosis

• Fear

May be related to

• Phobic stimulus
• Physiological symptoms, and mental/cognitive behaviors indicative of panic

Possibly evidenced by

• Feelings of paranoia
• Apprehensions; agitation
• Excessive sweating, increased heart rate

Desired Outcomes

• The client will be able to discuss phobic objects or situations with the nurse.
• The client will be able to function in presence of a phobic object or situation without experiencing panic anxiety by the time of discharge from treatment.

Nursing Assessment and Rationales

1. Determine the type of the client’s fear by thorough, rational questioning and active listening.
Active listening and thorough questioning promote trust and rapport between the client and the nurse. This, in turn, can encourage clients to be more open and honest about symptoms and feelings, which can lead to more effective treatment and improved outcomes. Anxiety is linked to fear and manifests as a future-oriented mood state that consists of a complex cognitive, affective, physiological, and behavioral response system associated with preparation for the anticipated events or circumstances perceived as threatening (Chand & Marwaha, 2022).

2. Explore the client’s perception of a threat to physical integrity or a threat to self-concept.
It is important to understand the client’s perception of the phobic object or situation to assist with the desensitization process. Triggers of panic can include injury, illness, interpersonal conflict or loss, use of cannabis, use of stimulants (caffeine, decongestants, cocaine), certain settings such as stores and public transportation, use of sertraline, and the SSRI discontinuation syndrome (Bhatt & Bienenfeld, 2019).

Nursing Interventions and Rationales

1. Present and discuss the reality of the situation with the client to recognize aspects that can be changed and those that cannot.
The client must accept the reality of the situation before the work of reducing the fear can progress. Anxiety disorders often involve excessive and persistent worry about future events or past experiences, which can lead to a sense of disconnection from the present moment. Additionally, clients with anxiety disorder tend to ruminate, focusing on negative thoughts and worrying about things that may or may not happen in the future.

2. Reassure the client of his safety and security.
At panic-level anxiety, the client may fear for their own life. Reassure and calm the client. Untreated panic attacks can subside spontaneously within 20 to 30 minutes, especially with reassurance and a calming environment (Bhatt & Bienenfeld, 2019).

3. Suggest that the client substitute positive thoughts for negative ones.
Emotion is connected to thought, and changing to a more positive thought can decrease the level of anxiety experienced. This also gives the client an alternative way of looking at the problem. By accepting these emotions, the client can learn to regulate their emotional responses and develop more effective coping strategies.

4. Include the client in making decisions related to the selection of alternative coping strategies.
Allowing the client choices provides a measure of control and serves to increase feelings of self-worth. This sense of control can reduce anxiety symptoms, as clients feel more empowered and better able to manage their anxiety. Additionally, when the client is involved in decision-making, healthcare providers can personalize treatment plans to meet the client’s unique needs, resulting in effective treatment.

5. Encourage the client to explore underlying feelings that may be contributing to irrational fears. Helping the client to understand how facing these feelings, rather than suppressing them, can result in more adaptive coping abilities.
Verbalization of feelings in a non-threatening environment may help the client come to terms with unresolved issues. The nurse may give the client a broad opening during conversations. Therapeutic communication is often most effective when clients direct the flow of the conversation and decide what to talk about. To that end, giving the client a broad opening such as “What’s on your mind today?” or “What would you like to talk about?” can be a good way to allow the client an opportunity to discuss their feelings (Rivier University, 2023).

6. Discuss the process of thinking about the feared object/situation before it occurs.
Anticipation of a future phobic reaction allows the client to deal with the physical manifestations of fear. Exposure can take several forms including imaginal, in vivo, and interoceptive. In vivo exposure involves a gradual approach to places, objects, people, or situations that were previously avoided although they are safe. Interoceptive exposure involves deliberately inducing physical sensations the client fears are indicative of a panic attack (Kaczkurkin & Foa, 2022).

7. Encourage the client to share seemingly unnatural fears and feelings with others, especially the nurse therapist.
Clients are often reluctant to share feelings for fear of ridicule and may have repeatedly been told to ignore feelings. Once the client begins to acknowledge and talk about these fears, it becomes apparent that the feelings are manageable. The client may be more likely to open up about their fears if they feel comfortable and safe with their nurse therapist. It is essential to establish a trusting relationship by being empathetic, non-judgmental, and validating their experiences.

8. Encourage to stop, wait, and not rush out of feared situations as soon as experienced. Support the use of relaxation exercises.
The client fears disorganization and loss of control of body and mind when exposed to the fear-producing stimulus. This fear leads to an avoidance response, and reality is never tested. If the client waits out the beginnings of anxiety and decreases it with relaxation exercises, then she or he may be ready to continue confronting the fear.

9. Explore things that may lower fear level and keep it manageable (e.g. singing while dressing, repeating a mantra, practicing positive self-talk while in a fearful situation).
This provides the client with a sense of control over the fear. It also distracts the client so that fear is not focused on and is allowed to escalate. Distraction techniques are often used along with other coping mechanisms. The client may try to control their breathing, use entertainment such as reading or watching TV, engage in a relaxation technique, or participate in a creative pursuit (Star, 2020).

10. Use a desensitization approach:

• 10.1. Systematic desensitization
  Systematic desensitization (gradual systematic exposure of the client to the feared situation under controlled conditions) allows the client to begin to overcome the fear and become desensitized to the fear. Note: Implosion or flooding (continuous, rapid presentation of the phobic stimulus) may show quicker results than systematic desensitization, but relapse is more common, or the client may become terrified and withdraw from therapy.
• 10.2. Expose the client to a predetermined list of anxiety-provoking stimuli rated in a hierarchy from the least frightening to the most frightening.
  Experiencing fear in progressively more challenging but attainable steps allows the client to realize that dangerous consequences will not occur. This helps extinguish conditioned avoidance responses. Systematic desensitization begins with imaginary exposure to feared situations. The client uses their anxiety hierarchy to break down the feared situation into manageable components (Ankrom, 2020).
• 10.3. Pair each anxiety-producing stimulus (e.g. standing in an elevator) with the arousal of another effect of an opposite quality (e.g. relaxation, exercise, biofeedback) strong enough to suppress anxiety.
  This helps the client to achieve physical and mental relaxation as the anxiety becomes less uncomfortable. For example, the client may stand in the checkout line, which could be their highest fear response. Then the client starts to focus on the action that causes the least amount of distress and then works their way up (Ankrom, 2020).
• 10.4. Help the client to learn how to use these techniques when confronting an actual and anxiety-provoking situation. Provide practice sessions (e.g.role-play) to deal with the phobic reactions in real-life situations.
  The client needs a continued confrontation to gain control over fear. Practice helps the body become accustomed to the feeling of relaxation, enabling the individual to handle feared objects/situations. This technique is based on the principles of classical conditioning and the premise that what has been learned can be unlearned (Ankrom, 2020).

11. Encourage the client to set increasingly more difficult goals.
This develops confidence and movement toward improved functioning and independence. Systematic desensitization usually starts with the client imagining themselves in a progression of fearful situations and using relaxation strategies that compete with anxiety. Once successfully managed, the client may use the technique in real-life situations (Ankrom, 2020).

12. Administer benzodiazepines as indicated; watch out for any adverse side effects.
Biological factors may be involved in phobic/panic reactions, and these medications (particularly Xanax) produce a rapid calming effect and may help the client change behavior by keeping anxiety low during learning and desensitization sessions. The risk of addiction to benzodiazepines should be carefully considered before use in anxiety disorders. Benzodiazepines should not be used in clients with a prior history of alcohol or other drug abuse (Bhatt & Bienenfeld, 2019).

13. Administer anti-anxiety agents as prescribed.
Buspirone is a nonsedating antipsychotic drug unrelated to benzodiazepines, barbiturates, and other sedative-hypnotics. This is a novel antianxiety agent that is comparable with benzodiazepines in reducing symptoms of anxiety. Buspirone also has fewer cognitive and psychomotor adverse effects, which makes it preferable in older adults. Major limitations include a lack of anti-panic activity and reduced anxiolytic effects in clients recently withdrawn from benzodiazepines (Bhatt & Bienenfeld, 2019). 

14. Administer beta-blockers as indicated.
Beta-blockers control the physical symptoms of anxiety such as rapid heart rate, a trembling voice, sweating, dizziness, and shaky hands. They are most helpful for phobias, particularly social phobias (Chand & Marwaha, 2022).

15. Provide information about cranial electrotherapy stimulators (CES).
In 2019, the FDA approved CES for the treatment of anxiety, depression, and insomnia. The prescription device delivers micro pulses of electrical current across the brain, which in clinical trials led to a reduction in anxiety levels, insomnia, and depressed mood. It is the first CES integrated into noise-canceling, Bluetooth-enabled headphones, and the first CES managed through an app (Bhatt & Bienenfeld, 2019).