Nursing Care Plan for Generalized Anxiety Disorder

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Pathophysiology

While everyone worries about things from time to time, clients with Generalized Anxiety Disorder worry about things more than what seems to be appropriate. Clients may have anxiety or worry about situations or events, or even just day-to-day activities. The level of worry may range from mild to severe and may make it difficult to carry out routine activities. This condition is common in middle and high school aged children as well as adults and can lead to physical manifestations such as abdominal pain and headaches. Clients may realize and have probably been told by others that they worry too much, but they are unable to relax.

Etiology

 

Diagnostic Criteria:

 

  • Excessive anxiety and worry, most days for at least 6 months
  • Individual finds it difficult to control the worry
  • Difficulty functioning in social or occupational areas
  • Not caused by a substance (drug abuse, medication, alcohol) or some other medication condition (hyperthyroidism)
  • Cannot be more accurately diagnosed by another condition (ie., social phobia, PTSD, somatic symptom disorder, etc.)
  • Symptoms present most days in the past 6 months: (adult: 3+ symptoms; child: 1 symptom)
    • Restlessness
    • Easily fatigued
    • Difficulty concentrating / mind goes blank
    • Irritability
    • Muscle tension
    • Sleep disturbance (too little or too much)

Desired Outcome

Client will be free from injury. Client will develop more effective coping techniques. Client will learn how to manage worry and fears optimally.

Generalized Anxiety Disorder Nursing Care Plan

Subjective Data:

  • Persistent worry
  • Overthinking plans and worst-case solutions
  • Indecisiveness
  • Difficulty sleeping
  • Perceiving situations as threatening
  • Inability to relax
  • Difficulty concentrating
  • Fatigue
  • Abdominal pain
  • Headaches
  • Chest pain or tightness
  • Shortness of breath

Objective Data:

  • Muscle tension
  • Sweating
  • Vomiting
  • Diarrhea

Nursing Interventions and Rationales

  • Assess vitals

 

Determine baseline for effectiveness of interventions and to rule out other medical conditions such as hypertension or fever.

 

  • Obtain 12-lead EKG

 

Get an EKG to rule out cardiac etiology of symptoms. “Anxiety attacks” or “panic attacks” from GAD may mimic the symptoms of a coronary event with chest pain or tightness and shortness of breath.

 

  • Determine if client is having homicidal or suicidal ideations

 

Maintain safety for client and others around them

 

  • Establish trust with the client
    • Listen to their concerns
    • Avoid giving immediate suggestions
    • Be respectful of client’s space

 

Especially when a client has a high level of anxiety, establishing trust can help the client calm down and make treatment more effective.

Never say “calm down” or “just relax”, it’s not that easy.

 

  • Maintain a calm and comforting demeanor while working with client

 

Clients often have the feeling of being out of control. Being around someone who is calm and in control of the present situation may help the client feel safer and more at ease.

 

  • Be present
    • Stay with the client during levels of high anxiety or “panic attacks”

 

The presence of someone the client trusts provides positive encouragement to handle situations. Being present also helps ensure the client’s safety.

 

  • Provide opportunities for client to assist with decision making, but avoid decisions that may require concentrated thought or may be life-changing

 

Allowing the client to help make minor decisions can help them regain control of their emotions. For example, start with giving them a choice between music therapy or guided imagery.

 

  • Use desensitization approaches carefully
    • Systematically  expose client to small stressors to develop coping techniques
    • Pair each situation with a positive or calming affect (relaxation or exercise)

 

Desensitization helps the client take control of worry or fears. Start small with safe situations and work up to those that cause higher anxiety.

Many times this is coordinated by a psychiatric/mental health provider.

 

  • Administer medications appropriately (benzodiazepines)

 

Medications can be a quick response to high stress or anxiety and help calm the client during therapy or desensitization. Monitor for signs of addiction or withdrawal.

 

  • Avoid allowing personal thoughts, feelings or anxiety to interfere with care

 

Anxiety is somewhat contagious and contributing your own emotions can make a client’s symptoms and worry more exacerbated.

 


References

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Video Transcript

All right. Let’s work through an example Nursing Care Plan that’s really specific to kind of mental health. And so specifically we’re going to talk about anxiety. So when we talk about this hypothetical patient, please know that a patient with anxiety is also probably going to have a ton of other issues going on. They might actually have something that’s more medical than, than mental health related, but right now we’re really just gonna focus specifically on the anxiety and how we can help this patient manage what’s going on in their world. So most of what you’re going to see is going to be subjective. So you have this patient with anxiety, they’ve got persistent worry, they’re always worried about something.  Things seem to be overwhelming. They’re overthinking things. They might be thinking, worst case scenario all the time, it’s really not a fun way to live, guys.  

Some objective data might be insomnia. You might notice your patient’s awake all night long. They’re not sleeping at all.  we might see someone who’s indecisive and I’m going to put this kind of right in between because it could be reported in decisiveness or you could notice it yourself, right?  they may have some muscle tension or even that tension can turn into pain or headaches, right? Just depending on what’s going on with that patient. they’re going to be fatigued because this is really, like I said, it’s kind of not a fun way to live.  They’re going to have difficulty concentrating. They’re going to have poor focus, poor concentration. And then the big thing here is you have a huge risk for a couple of problems. One being panic attacks or anxiety attacks, and those can really start presenting physically. You’re going to present with chest pain. You’re going to present with palpitations.

All of the, the mental anxiety that’s going on starts to present physically in your body. So that’s when you start getting these panic or anxiety attacks. And the other risks that we have that’s major is for any kind of self harm or possibly even suicidal ideations, especially when you start to get very overwhelmed with life.  This becomes a risk for sure. So just remember, anxiety patients tend to be very overwhelmed with everything that’s going on. They tend to have trouble coping and concentrating, tend to have trouble dealing with stressful situations. So we’re going to take all of our data. Like I said, we’re focusing specifically on what’s related to anxiety,  and to figure out what our problems are. So our major problem for this patient is they’re really struggling with their mood. They’re struggling to manage their emotions, they’re struggling to manage their thoughts.

And that of course can be distressing for this patient.  They may need to improve their coping skills when something stressful happens. They might need to be able to say, hey, I know how to handle this now.  another problem we have is the physical symptoms. Remember, anxiety can manifest physically, whether it’s chest pain, palpitations, shortness of breath, they might end up with a headache. That muscle tension, that manifestation has physical symptoms, is definitely a problem. And then of course, a huge problem is that risk for self harm. We don’t want them to hurt themselves in any, any, any way. And so when we think about a priority for a patient with anxiety, what is our number one concern? I was their number one concern is the physical risk to this patient. And so I’m just going to say safety. Safety is my number one concern.

We can deal with their mood and emotions after that. But my number one focus is going to be making sure that this patient doesn’t hurt themselves and that they’re physically safe. So ask her how questions again, how do we know it was a problem? This is where we just data link. We go back to our data and we say this piece of data says that this is a problem. So then how are we going to address it? What kinds of things are we going to do for this patient? Well, we said safety was number one, right? So why don’t we first just assess for self harm or suicidal ideations. We need to assess, we need to ask those questions. Be Very straightforward with your questions. Have you had any thoughts of hurting yourself or anyone else? It’s so important that we’re very clear when we asked this question because we need to get a straight answer from the patient and if they do, we need to put them on suicide precautions or self harm precautions.

Whatever your facility does, we need to keep them safe. The other thing we want to assess is any of their physical symptoms.  to make sure that we can rule out any other problems. So we might get a 12 lead to rule out their chest pain. We might, evaluate their back pain or their headache for something else. Right? We want to rule out anything other than anxiety as a source of the problem. Probably going to give some meds, some antianxiety medications as ordered. Religious helps decrease those leveling of anxiety. And we always want to make sure we stay with them. So if they’re starting to have these panic attacks, if they’re starting to really struggle with anxiety, stay with the patient to make sure we keep them safe. And then also we start to look at things like establishing trust. We start to look at helping them express their concerns and their emotions, we might even assist them in helping identify some coping strategies, right?

So coping looks so different for everybody that we can’t just educate, you know, it’s not just educate, right? It’s not just, hey, here’s a, here’s a list of possible things in my work. We actually need to help them talk through it and help them identify what is going to work for them. So how do I know it worked? Right? We go back to our data, we say, well, how did I know it was a problem? My patient told me they were anxious. So decreased reports of anxiety, right? They’re going to say, my anxiety is much better. I feel much better now.  we also know we want to keep the patients safe and free from injury or harm. And I think because we’re really wanting to help them identify these coping strategies, we could probably have them verbalize or choose some coping strategies they’re going to use.

So we wanna make sure that they are  reporting that their anxiety is better, that they’re safe and free from injury and that they’re talking through how they’re going to handle this anxiety. That makes sense. So let’s translate that into some high level priority concepts here. We gotta be concise to communicate what the problems are. So number one problem, we said safety, we’ve got to keep them from injury, we’ve got to make sure they’re not physically unsafe. And then I would say at that point we can start looking at their mood or their emotions. They’re an effect. Make sure we’re addressing the actual anxiety itself. And then I think start looking at coping strategies. So protect them from harm, address the current issues and then worry about future issues. Does that make sense in terms of prioritizing these? So keep them safe, address what’s currently going on and help them decide how they’re going to deal if it happens again.

All right so now lets transcribe, let’s get this on paper. So we set our top priorities where safety, mood and affect and coping. So this is just where we link all of our data together. We’re connect connecting the dots between our data, our interventions and rationales and our expected outcomes. So how do we know that safety was a concern? Well, we know that this patient might have these physical symptoms, these panic attacks, and when you get in that mode where your chest starts to hurt, you feel like the world is closing in on you, you really never know what’s going to happen at that point. So that’s a problem. We know they possibly have suicidal or self harm ideations and they possibly have that insomnia. Insomnia can definitely, a lack of sleep can definitely cause a lot of problems for this patient. So what are we going to do?

Well, we’re going to rule out other sources of these symptoms, right? So we might get a 12 lead. We’re going to assess those ideations and possibly implement suicide precautions if necessary. Again, we’re trying to ensure that these symptoms aren’t cardiac in nature or that there’s not any other source of those physical symptoms. And then of course we want to prevent self injury. And if necessary, you could possibly administer meds, uh, for insomnia specifically so that we can try to increase the ability for them to sleep. So overall, the expected outcome here is based on what our original goal was, right? Which is just to keep that patient safe and free from injury, free from any complications of some of these physical symptoms. So now that we’ve addressed their safety, we can start addressing their current emotional needs. So they have this persistent worry, this trouble concentrating.

They’re probably fatigued and they’re definitely overwhelmed. So what kinds of things can we do to address their current emotional state? We can absolutely give anxiolytics or anti anxiety medications. We establish trust and rapport with them. We provide an opportunity for them to express their emotions and express their feelings. So the goal here is that we would improve their overall symptoms and decrease their levels of anxiety by establishing trust so that they don’t get so overwhelmed when they have those conversations. So ultimately the goal here is just that the patient order report decreased levels of anxiety. They’re going to tell me I’m feeling a little better. I’m not feeling so anxious.  I’m having an easier time concentrating and feeling less overwhelmed. We just want those symptoms to be decreased. So now let’s look at coping. Remember coping. We’re kind of thinking future, right? We’re thinking how are they going to handle this if it happens again?

So how do we know that they might have an issue coping? Well, maybe they’re always thinking, worst case scenario, when something comes up, they’re thinking though this is the worst thing that could possibly happen, it’s probably going to happen. They’re having trouble deciding, so how are they going to, how are they going to go about their life if they can’t make decisions? Right? And they’re just overthinking everything. So what can we do for this patient who’s really having trouble coping? Well, we can stay with them when anxiety is really high. And again, assist them to identify coping strategies that will work for them. So again, all we’re trying to do here and the reason we’re doing these things is to try to help that patient cope with those stressful situations. So my biggest goal here is going to be to have this patient verbalize the coping strategies that they’re going to use in the future.

I had a patient once who was so concerned that two wasn’t going to be allowed to go home until she was happy go lucky and had no problems. And I told her, I said, nobody’s expecting you to feel wonderful right now and be perfectly happy right now, but what we want to know is that you’re going to be able to cope in a healthy way in the future. She had actually come in with some self harm and so I said, nobody expects you to feel wonderful. They just expect you to tell us how you’re going to safely manage when this happens again. Okay? So I love this idea of helping them identify what’s gonna work for them. All right, so let’s just review our five step process. We always collect all of our information first. That’s our assessment data. We take that information and analyze it and choose what’s relevant, choose what tells us there’s a problem and figure out what our priorities are.

Then we ask those how questions so that we can actually plan our interventions and figure out what we would be looking for. Get that into your concise terms so that you can easily, quickly communicate what the problems are for your patient and then get it on paper, whatever form you want to use, whatever template you want to use, if you’re documenting it into an electronic medical record, either way, just put on paper what your plan is for your patient. So I hope this was helpful to work through a care plan for a patient with anxiety. Again, this is an isolated care plan for a hypothetical patient who only has anxiety, right? So I’m sure there’s plenty of other things that they may have going on. So remember to look at the big picture,  and choose priorities as a whole holistically for your patient. Make sure you check out the rest of the examples in this course, as well as our whole nursing care plan library. Now go out and be our best selves today, guys. And as always, happy nursing.

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