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Anxiety Assessment

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Anxiety Assessment

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Anxiety Assessment

Anxiety-bag Assess-man
Picmonic
Anxiety is one of a few psychological responses to stress. Each patient can exhibit different feelings or behaviors when under stress. However, the feeling of apprehension and the feeling of uncertainty are the main characteristics. Typically, patients can manage anxiety and move on, but in some cases anxiety can become problematic where it start interfering with the ability to meet basic needs. Knowing the different levels of anxiety is important when planning interventions to treat the anxiety.
10 KEY FACTS
MILD
Increased Alertness
Up-arrow Alerting-alarm

At first, the body's response to anxiety is known as the "fight or flight" response. The hypothalamic-pituitary-adrenal (HPA) system is activated. These glands release cortisol and catecholamines ("adrenaline") to heighten the body's senses.

Heightened Perception
Heightened Perception-of-door

As anxiety continues to escalate, the body starts becoming overwhelmed by the HPA system, and patients display a heightened perception of their environment. Some patients will exhibit the “flight” response and become restless. This restlessness can manifest as constantly moving around in bed, trying to climb out of bed, and pacing.

MODERATE
Perception Narrowed
Narrowed Perception-of-hallway

The ability of these patients to problem-solve diminishes. Patients will need assistance with completing tasks and staying focused.

Short Attention Span
Shorts with Attention Span

The attention span also diminishes. Patients are easily distracted but start focusing on specific details.

Shaking
Shaking

Restlessness advances into shaking and muscular tension. The body is unable to relax, and the patient may start becoming disoriented.

SEVERE
Ineffective Problem Solving
Inability to Solve Problem-cube

The ability to problem solve comes to a halt, and the patient can have problems completing even the simplest tasks. The inability to problem solve leads the patient to either focus repeatedly on one detail or multiple details.

Automatic Behavior
Automatic-robot

Automatic behavior and thoughts are aimed at reducing or relieving anxiety. Irrational and unrealistic thoughts "flash" in the anxious person's mind, such as, "I can't cope with this," or "I'm not going make it."

Hyperventilation
Hiker-vent

In response to the overproduction of catecholamines, breathing becomes more rapid, and CO2 will be blown off. This response leads to a hyperventilation state with symptoms of numbness and tingling in the extremities, lightheadedness, and dizziness (early signs of respiratory alkalosis).

PANIC
Hallucinations
Halloween-hallucination

Patients can experience hallucinations or delusions. These patients need to be approached with caution, as their reaction to an intervention is unknown. Nursing care should be supportive and protective.

Inability to Function or Communicate
Inability to Communicate on Malfunctioning-telephone

In the highest state of anxiety, patients become withdrawn, and the patient behavior can be “wild.” Patients have a feeling of terror and may think they are “going crazy.”

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