Nursing diagnosis: anxiety related to threat to self-concept—change of body image; scarring, loss of body part, sexual attractiveness, threat of death—extent of disease, impact on others; uncertainty of prognosis; denial of own mortality, situational crisis
Possibly evidenced by
Increased tension, apprehension, feelings of helplessness, inadequacy
Decreased self-assurance, powerlessness
Self-focus, restlessness, sympathetic stimulation, crying, aggression, withdrawal
Expressed concerns regarding actual or anticipated changes in life
Desired Outcomes/Evaluation Criteria—Client Will
Demonstrate appropriate range of feelings regarding possibility of death or increasing hope related to prognosis.
Acknowledge acceptance of health status.
Communicate thoughts and feelings utilizing available support systems such as family, spiritual leaders, and other resources.
Demonstrate coping behaviors that reduce anxiety.
Nursing intervention with rationale:
1. Ascertain what information client has about diagnosis, expected surgical intervention, and future therapies. Note presence of denial or extreme anxiety.
Rationale: Provides knowledge base for the nurse to enable reinforcement of needed information, helps identify client with high anxiety, or a low capacity for information processing, and need for special attention. Note: Denial may be useful as a coping method intially; however, extreme anxiety needs to be dealt with immediately.
2. Explain purpose and preparation for diagnostic tests or procedures.
Rationale: Promotes clear understanding of procedures and what is happening, increases feelings of control, and lessens anxiety and fear of the unkown.
3. Provide an atmosphere of concern and anticipatory guidance and privacy for client and family.
Rationale: Facilitates therapeutic communication, active-listening, and expression of underlying unresolved issues. Privacy is needed to encourage open discussion related to feelings of anticipated loss and other concerns.
4. Encourage questions and provide time for expression of fears.
Rationale: Provides opportunity to identify and clarify misconceptions and offer emotional support.
5. Offer relaxation techniques such as back massage, guided imagery, and use of touch, if culturally acceptable.
Rationale: Encourages verbalization of feelings when client is relaxed, thus reducing anxiety and fear.
6. Explore previously used coping mechanisms as perceived by the client.
Rationale: Reinforces effective coping mechanisms previously used for coping in a new situation.
7. Explore spiritual support as a resource.
Rationale: Provides calmness and peace in times of uncertainty.
8. Rationale: Discuss role of rehabilitation after surgery and use of community resources.
Rationale: Promotes support systems in place in the rehabilitation process as an essential component of therapy intended to meet physical, social, emotional, and vocational needs so that client can achieve the best possible level of physical and emotional functioning.