APPLICATION OF THE NURSING PROCESS: PANIC DISORDER
The nurse can use this tool along with the following detailed discussion to guide his or her assessment of the client with panic disorder.
The client usually seeks treatment for panic disorder after he or she has experienced several panic attacks. The cli-ent may report, “I feel like I’m going crazy. I thought I was having a heart attack, but the doctor says it’s anxiety.” Usually, the client cannot identify any trigger for these events.
The nurse assesses the client’s general appearance and motor behavior. The client may appear entirely “normal” or may have signs of anxiety if he or she is apprehensive about having a panic attack in the next few moments. If the client is anxious, speech may increase in rate, pitch, and volume, and he or she may have difficulty sitting in a chair. Automatisms––which are automatic, unconscious mannerisms––may be apparent. Examples include tapping fingers, jingling keys, or twisting hair. Automatisms are geared toward anxiety relief and increase in frequency and intensity with the client’s anxiety level.
Assessment of mood and affect may reveal that the client is anxious, worried, tense, depressed, serious, or sad. When discussing the panic attacks, the client may be tearful. He or she may express anger at himself or herself for being “unable to control myself.” Most clients are distressed about the intrusion of anxiety attacks in their lives. During a panic attack, the client may describe feelings of being disconnected from himself or herself ( depersonalization) or sensing that things are not real (derealization).
During a panic attack, the client is overwhelmed, believing that he or she is dying, losing control, or “going insane.” The client may even consider suicide. Thoughts are disorganized, and the client loses the ability to think rationally. At othertimes, the client may be consumed with worry about when the next panic attack will occur or how to deal with it.
During a panic attack, the client may become confused and disoriented. He or she cannot take in environmental cues and respond appropriately. These functions are restored to normal after the panic attack subsides.
Judgment is suspended during panic attacks; in an effort to escape, the person can run out of a building and intothe street in front of a speeding car before the ability to assess safety has returned. Insight into panic disorder occurs only after the client has been educated about the disorder. Even then, clients initially believe they are help-less and have no control over their anxiety attacks.
It is important for the nurse to assess self-concept in cli-ents with panic disorder. These clients often make self-blaming statements such as “I can’t believe I’m so weak and out of control” or “I used to be a happy, well-adjusted person.” They may evaluate themselves negatively in all aspects of their lives. They may find themselves con-sumed with worry about impending attacks and may be unable to do many things they did before having panic attacks.
Because of the intense anticipation of having another panic attack, the person may report alterations in his or her social, occupational, or family life. The person typically avoids people, places, and events associated with previous panic attacks. For example, the person may no longer ride the bus if he or she has had a panic attack on a bus. Although avoiding these objects does not stop the panic attacks, the person’s sense of helplessness is so great that he or she may take even more restrictive measures to avoid them, such as quitting work and remaining at home.
The client often reports problems with sleeping and eating. The anxiety of apprehension between panic attacks may interfere with adequate, restful sleep even though the per-son may spend hours in bed. Clients may experience loss of appetite or eat constantly in an attempt to ease the anxiety.
The following nursing diagnoses may apply to the client with panic disorder:
· Risk for Injury
· Situational Low Self-Esteem (Panic Attacks)
· Ineffective Coping
· Ineffective Role Performance
· Disturbed Sleep Pattern
Outcomes for clients with panic disorders include the following:
· The client will be free from injury.
· The client will verbalize feelings.
· The client will demonstrate use of effective coping mechanisms.
· The client will demonstrate effective use of methods to manage anxiety response.
· The client will verbalize a sense of personal control.
· The client will reestablish adequate nutritional intake.
The client will sleep at least 6 hours per night.
During a panic attack, the nurse’s first concern is to pro-vide a safe environment and to ensure the client’s privacy. If the environment is overstimulating, the client should move to a less stimulating place. A quiet place reduces anxiety and provides privacy for the client.
The nurse remains with the client to help calm him or her down and to assess client behaviors and concerns. After getting the client’s attention, the nurse uses a sooth-ing, calm voice and gives brief directions to assure the cli-ent that he or she is safe:
“John, look around. It’s safe, and I’m here with you. Nothing is going to happen. Take a deep breath.”
Reassurances and a calm demeanor can help to reduce anxiety. When the client feels out of control, the nurse can let the client know that the nurse is in control until the client regains self-control.
Clients with anxiety disorders can collaborate with the nurse in the assessment and planning of their care; thus, rapport between nurse and client is important. Communi-cation should be simple and calm because the client with severe anxiety cannot pay attention to lengthy messages and may pace to release energy. The nurse can walk with the client who feels unable to sit and talk. The nurse should evaluate carefully the use of touch because clients with high anxiety may interpret touch by a stranger as a threat and pull away abruptly.
As the client’s anxiety diminishes, cognition begins to return. When anxiety has subsided to a manageable level, the nurse uses open-ended communication techniques to discuss the experience:
Nurse: “It seems your anxiety is subsiding. Is that correct?” or “Can you share with me what it was like a few minutes ago?”
At this point, the client can discuss his or her emotional responses to physiologic processes and behaviors and can try to regain a sense of control.
The nurse can teach the client relaxation techniques to use when he or she is experiencing stress or anxiety. Deep breath-ing is simple; anyone can do it. Guided imagery and progres-sive relaxation are methods to relax taut muscles: Guided imagery involves imagining a safe, enjoyable place to relax. In progressive relaxation, the person progressively tightens, holds, and then relaxes muscle groups while letting tension flow from the body through rhythmic breathing. Cognitive restructuring techniques (discussed earlier in text) also may help the client to manage his or her anxiety response.
For any of these techniques, it is important for the cli-ent to learn and to practice them when he or she is rela-tively calm. When adept at these techniques, the client is more likely to use them successfully during panic attacks or periods of increased anxiety. Clients are likely to believe that self-control is returning when using these techniques helps them to manage anxiety. When clients believe they can manage the panic attack, they spend less time worry-ing about and anticipating the next one, which reduces their overall anxiety level.
Client and family education is of primary importance when working with clients who have anxiety disorders. The client learns ways to manage stress and to cope with reactions to stress and stress-provoking situations. With education about the efficacy of combined psychotherapy and medication and the effects of the prescribed medica-tion, the client can become the chief treatment manager of the anxiety disorder. It is important for the nurse to edu-cate the client and family members about the physiology of anxiety and the merits of using combined psychother-apy and drug management. Such a combined treatment approach along with stress reduction techniques can help the client to manage these drastic reactions and allow him or her to gain a sense of self-control. The nurse should help the client to understand that these therapies and drugs do not “cure” the disorder but are methods to help him or her to control and manage it. Client and family education regarding medications should include the rec-ommended dosage and dosage regimen, expected effects, side effects and how to handle them, and substances that have a synergistic or antagonistic effect with the drug.
The nurse encourages the client to exercise regularly. Routine exercise helps to metabolize adrenaline, reduces panic reactions, and increases production of endorphins; all these activities increase feelings of well-being.
Evaluation of the plan of care must be individualized. Ongoing assessment provides data to determine whether the client’s outcomes were achieved. The client’s perception of the success of treatment also plays a part in evaluation. Even if all outcomes are achieved, the nurse must ask if the client is comfortable or satisfied with the quality of life.
Evaluation of the treatment of panic disorder is based on the following:
· Does the client understand the prescribed medication regimen, and is he or she committed to adhering to it?
· Have the client’s episodes of anxiety decreased in fre-quency or intensity?
· Does the client understand various coping methods and when to use them?
· Does the client believe that his or her quality of life is satisfactory?