Nursing diagnosis: Anxiety/Fear related to Situational crisis, Threat of death, change in health status, Physiological factors, hypermetabolic state
Possibly evidenced by
Increased tension, helplessness
Apprehension, uncertainty, worry, sense of impending doom
Sympathetic stimulation; restlessness, focus on self
Desired Outcomes/Evaluation Criteria—Client Will
Verbalize awareness of feelings and healthy ways to deal with them.
Report anxiety is reduced to a manageable level.
Nursing intervention with rationale:
1. Evaluate anxiety level, noting client’s perception of situation and verbal and nonverbal responses. Encourage free expression of emotions.
Rationale: Apprehension may be escalated by severe pain, severity of illness, urgency of diagnostic procedures, and possibility of surgery.
2. Review physiological factors present, such as sepsis or toxins related to infection, medications, and metabolic imbalances
Rationale: These factors are present in seriously ill client and can cause or contribute to anxiety.
3. Provide ongoing information regarding disease process and anticipated treatment.
Rationale: Knowing what to expect can reduce anxiety for both client and significant other (SO). Also, ongoing review helps to identify those factors adding to anxiety that could be changed—client getting more uninterrupted sleep or adding or deleting medications.
4. Provide presence. Acknowledge anxiety and fear. Do not deny or reassure client that everything will be all right. Be accurate and factual in providing information. Correct misconceptions about disease process and possible treatments.
Rationale: Affirms client’s value as a human being in need of assistance in dealing with a serious health threat; helps client and SO identify and deal with reality.
5. Schedule adequate rest and uninterrupted periods for sleep.
Rationale: Limits fatigue, conserves energy, and can enhance coping ability.
6. Provide comfort measures: family presence, quiet environment, soft music, back rub, and Therapeutic Touch (TT).
Rationale: Promotes relaxation and enhances ability to deal with situation.