Course:

Clinical Teaching and Assessment

Topic:

Nursing care of the patient with an anxiety disorder

Level of participants:

Third year Bscn Nursing Students

Number of Participants:

15

Date:

April 3rd, 2012

Time:

10:30 am

Duration:

45 minutes

Venue:

Inservice Education Department

Methodology:

Lecture/Discussion/Demonstration

Learning Theory:

Ausubel: Emphasized the use of advance organizers which

he said was different from overviews and summaries. His use of an advance organizer acted as a
bridge the chasm between learning material and existing related ideas. The advanced organizer
used, sought to bridge new knowledge with what was known (sometimes what is Known is
uncertain and not concrete). Though he specified that his theory applied only to reception
learning in schools, it was utilized because it introduced the topic and aided the sequence of the
information to be imparted. (Ormrod & Rice, 2003). Rogers: Dealt with the adult learner, he
posited that learning is student centered and personalized and the educators role is that of a
facilitator. Affective and cognitive needs are central and the goal is to develop self-actualized
persons in a cooperative, supportive environment. (Quinn, 2006). Bruner: Believed that learners
were not blank slates but bought past experiences to a new situation, he also stated that new
information was linked to prior knowledge, thus mental representations are subjective. Bruners
Discovery learning is an inquiry-based, constructivist learning theory that takes place in problem
solving situations where the learner draws on his or her own past experience and existing
knowledge to discover facts and relationships and new truths to be learned. (Quinn, 2006).

Students interact with the world by exploring and manipulating objects, wrestling with questions
and controversies, or performing experiments. As a result, students may be more likely to
remember concepts and knowledge discovered on their own (in contrast to a transmissionist
model). (Quinn, 2006). Models that are based upon discovery learning model include: guided
discovery, problem-based learning, simulation-based learning, case-based learning, incidental
learning, among others. The advantages of this theory are: it encourages active engagement,
promotes motivation, a tailored learning experience, and promotes autonomy, responsibility,
independence, the development of creativity and problem solving skills. (Quinn, 2006)
Aim of Activity:

The purpose of this activity is to educate student nurses on

Nursing management of the client experiencing anxiety
disorders

Resources:

Registered nurse, Laptop computer, multimedia and white

board

Scientific Principle:

Homeostasis: The concept of homeostasis is widely used in n

physiology and psychology. This is the tendency to maintain
and restore certain steady states or conditions of the organism.
(The Merriam-Websters Dictionary, 2012).

Specific Objectives:

At the end of 45 mins interactive session students should be

able to:

1. Define the terms anxiety, anxiety disorders

According to Frisch & Frisch, 2006
2. State the four stages of anxiety
3. Describe the major six subtypes of anxiety
4. Discuss the nursing management for clients with anxiety
disorders
Evaluation:

Formative and Summative. Questions will be asked before and

after each objective and followed by a test at the end.

.
References:

Ackley, B & Ladwig. (2010). Nursing diagnosis handbook: A guide to planning care
Amsterdam: Elsevier/Mosby
Badger, J. (1994, May). Calming the anxious patient. Am J Nurs. 94(5): 46-50 Retrieved on
March 22nd, 2012 from http://www.ncbi.nlm.nih.gov/pubmed/7909404
Evans, M & Rubio, P. (1994) Music: a diversionary therapy. Todays OR Nurse.16: 17-22
Fishel, A. (1998) Nursing management of anxiety and panic. Nursing ClinicNorth America; 33:
1, 135-151.
Frisch, N, C & Frisch, Lawrence E. (2006). Psychiatric mental health nursing
Colorado Springs, Colorado: Thomson Delmar Learning.
Garvin, B., Huston, G & Baker, C. (1992). Information used by nurses to prepare patients for a
stressful event. Applied Nursing Research 5(4):158-163.10.

Olson, M & Sneed, N (1995, March-April). Anxiety and therapeutic touch. Issues Ment Health

Nurs. 16(2): 97-108.

Ormrod, J & Rice, F. (2003). Lifespan development and learning. Boston MA: Pearson
Publishing.
Peplau, H. (1963). A working defnition of anxiety. In S. Burd & M. Marshall,
some clinical approaches to psychiatric nursing. New York: Macmillan
Quinn, F. (2006). The principles and practice of nurse education. London: Stanley Thornes
Rose, S., Conn, V & Rodeman, B. (1994). Anxiety and self-care following myocardial
infarction. Issues in Mental Health Nursing, 15:433-444.
The Merriam-Websters Dictionary (2012). Homeostasis. Retrieved on March 15th, 2012 from
http://www.merriam-webster.com/medical/homeostasis

OBJECTIVES
Ice breaker

CONTENTS

TEACHERS
OBJECTIVES

LEARNERS
OBJECTIVES

EVALUATION

Oh...i dont suppose you will understand! Its not

that I am afraid of any dangerif a thief were to
come into my room I would attempt to kill him
without turning a hair. I am not afraid of ghost,
and the supernaturalI am not afraid of the
dead..I am afraid of myself!....my heart is

Define the terms

going biff, baff, biff and my palms are so sweaty..

Frisch & Frisch, (2006) defines anxiety as a state

Teacher will ask

Students will attempt

Students will

anxiety, anxiety

where in a person feels a strong sense of dread,

students to attempt

to define the terms

correctly define

disorder

frequently accompanied by physical symptoms of

to define the terms

anxiety, anxiety

the terms

increased heart, respiratory and blood pressure

anxiety, anxiety

disorder in their own

anxiety, anxiety

rates without having a specific source or reason

disorder their own

words

disorder using at

for the emotions.

words

least two key

Anxiety disorder: This is the experience of severe

anxiety to the point where it interferes with a

words from each

Teacher will define

Students will listen

term such as: a

personal ability to function in daily life (Frisch et

the terms anxiety,

attentively and follow

state where in a

al 2006)

anxiety disorder

on screen as the

person feels a

according to the

definition of anxiety,

strong sense of

content with the aid

anxiety disorder is

dread

of PowerPoint

read.

accompanied by

presentation

physical
symptoms with a

Teacher will ask two

Two students seated at

reason for the

individuals seated at

the back of the class

emotions; severe

the back of the class

will define the terms

anxiety to the

to define the terms

anxiety, anxiety

point where it

anxiety, anxiety

disorder using at least

interferes with a

disorder according

two key words such

personal ability

to the content

as: a state where in a

to function in

person feels a strong

daily life

sense of dread
accompanied by

physical symptoms
with a reason for the
emotions; Severe
anxiety to the point
where it interferes
with a personal ability
to function in daily
State the four stages

The four stages of anxiety according to (Frisch et

Teacher will ask

life
Four students will role

Student will

of anxiety

al, 2006) are:

four students to role

play one stage each

correctly state

play one stage each

for after reading a

the four stages of

day to day living, individual has an alert

for anxiety

card given by

anxiety

perceptual field, this can motivate

subsequent to

Teacher.

learning, for example anxiety felt when

reading a card given

missing the bus

by teacher

1. Mild: This is where there is the tension of

2. Moderate: Focus is on immediate

concerns; perceptual field is narrowed;

Teacher will State
individuals exhibits selective inattention.

Students will sit, listen

For example anxiety felt when taking an

the four stages of

and follow attentively

anxiety using

on PowerPoint as the

PowerPoint

four stages of anxiety

presentation

are stated.

car accident
4. Panic: A sense of awe, dread and/or

Teacher will ask two

Two students on the

intense terror; individual looses self

students on the right

right and two students

control; there is a disorganization of the

and two students on

on the left will state

personality. Example anxiety felt when

the left to state one

one stage each for

experiencing an earthquake and being

stage each for

anxiety according to

unable to cope ()

anxiety according to

the content
Students seated in the

Students will be

exam.
3. Severe: Focus is on the specific detail;
perceptual field is greatly reduced.
Example anxiety felt when witnessing a

Describe the six

Frisch et al, (2006) posits the major subtypes of

the content
Teacher will ask

major subtypes of

anxiety disorders as the following:

students seated in

middle of class will

able to describe

anxiety disorders

Generalized anxiety disorder: Anxiety is

the middle to make

attempt to state the six

the six major

focused on a variety of events or activities,

an attempt in stating

major

subtypes of

evidenced by restlessness, fatigue difficulty in

the six major

subtypes of anxiety

anxiety disorders

concentrating, sleep disturbance and so on

subtypes of anxiety

Panic disorder: Discrete episodes of intense

disorders

disorder

anxiety that begin abruptly and reach a peak

within 10 minutes, evidenced by palpitations,

Teacher will

Students will listen

sweating, trembling, SOB, chest pain, fear of

describe the six

and follow on

losing control, fear of dying.

major subtypes for

PowerPoint as the six

Agoraphobia: Acute anxiety in crowds; fear of

anxiety disorders

major subtypes for

being alone; fear in any physical activity where

using PowerPoint

anxiety disorders are

the individual may have trouble escaping,

presentation

described.

losing control that results in either refraining

Teacher will ask

Students seated in the

from going out or avoiding situations that may

students seated in

second row will

bring about anxiety. (Frisch, et al, 2006).

the second row to

describe the six major

Phobia: Persistent, excessive or unreasonable

describe the six

subtypes of anxiety

fear of a specific object or situation. For example

major subtypes of

disorders according to

elevators, airplanes, dogs, spiders and so on,

anxiety disorders

the content

evidenced by fear that interferes with lifes

according to the

evidenced by an intense feeling of anxiety of

activities.

content

Obsessive compulsive disorder: Occurrence of

recurrent thoughts, images and or impulses that
are intrusive are inappropriate and leads to
anxiety, for example an individual who keeps on
washing his hands over and over although are
clean, he wishes to stop, but there is unable to
stop the repetitive behaviour.
Post traumatic stress disorder: Occurs after a
significant life threatening event, there is the
experience of anxiety symptoms in which the
event is reexperienced through recollections.
(Frisch et al, 2006).
Discuss at least four

Psychotherapy, pharmacology and combination

Teacher will ask the

Class will form two

Student will be

nursing intervention

therapy play a major role in the treatment of

class to form two

groups, each will give

able to Discuss

measures for anxiety

anxiety disorders, psychotherapy generally fall

groups, each will

a reason why nursing

at least four

disorders

into two categories. Insight- based treatments and

give a reason why

diagnoses written on

nursing

Behavioural treatments.

nursing diagnoses

white board are

intervention

NURSING DIAGNOSES

written on white

appropriate to a client

measures for

-Anxiety related to a subjective sense of

board are

with an anxiety

anxiety disorders

uneasiness and tension

appropriate to a

disorder, students will

-Fear related to specific object (Fear of heights)

client with an

also give two

-Disturbed sleep pattern related to anxiety of

anxiety disorder,

interventions along

being alone, fear of the dark, or flashback

they will also give

with rationales

associated with post-traumatic stress

two interventions

-Social isolation related places that are felt to be

with rationales

unsafe
-Interrupted family process related to family

Teacher will discuss

Students will sit and

adjustment regarding obsession and

the nursing

listen attentively as the

compulsions/phobic behaviours of one of their

management

nursing management

members

measures for anxiety

measures for anxiety

-Powerlessness related lack of control of ones

disorders according

disorders are

own thoughts and behaviours

to the content using

discussed using the aid

-Post-trauma syndrome related to anxiety

PowerPoint

of PowerPoint

following a significant life threatening event.

presentation

presentation

cope with significant losses following a

Teacher will ask two

Two students seated in

significant life threatening event.

students seated in

the fourth row will

(Ackley & Ladwig, 2010)

the fourth row to

identify one nursing

INTERVENTIONS AND RATIONALES

identify one nursing

intervention each for

-Use presence, touch (with permission),

intervention each

anxiety disorder

verbalization, and demeanor to remind clients

for anxiety disorder

according to the

that they are not alone and to encourage

according to the

content.

expression or clarification of needs, concerns,

content

-Dysfunctional grieving related to an inability to

unknowns, and questions. Being supportive and

approachable encourages communication (Olson,
Sneed, 1995).

If the situational response is rational, use

empathy to encourage client to interpret the

anxiety symptoms as normal-anxiety is a normal

response to actual or perceived danger (Peplau,
1963).

- Assess client's level of anxiety and physical

reactions to anxiety (e.g., tachycardia, tachypnea,
nonverbal expressions of anxiety). Validate
observations by asking client, "Are you feeling
anxious now?"- anxiety is a highly
individualized, normal physical and
psychological response to internal or external life
events (Badger, 1994)
-Accept

client's defenses; do not confront, argue,

or debate. If defenses are not threatened, the

client may feel safe enough to look at behavior
(Rose, Conn & Rodeman, 1994).
-Explore coping skills previously used by client

to relieve anxiety; reinforce these skills and

explore other outlets-Methods of coping with
anxiety that have been successful in the past are
likely to be helpful again. Listening to clients and
helping them to sort through their fears and
expectations encourages them to take charge of
their lives (Fishel, 1998)
-Explain

all activities, procedures, and issues that

involve the client; use nonmedical terms and

calm, slow speech. Do this in advance of
procedures when possible, and validate client's
understanding-with preadmission patient
education, patients experience less anxiety and
emotional distress and have increased coping
skills because they know what to expect (Review,
2000)- uncertainty and lack of predictability
contribute to anxiety (Garvin, Huston, Baker,

1992).
-Provide clients with a means to listen to music of
their choice. Provide a quiet place and encourage
clients to listen for 20 minutes. Music is a simple,
inexpensive, esthetically pleasing means of
alleviating anxiety. When allowed to participate
in decision-making regarding their care, patients
can regain a partial sense of control. As patient
advocates, nurses should take advantage of the
therapeutic effect of music by incorporating it
into their plan of care (Evans, Rubio, 1994).

Test
Questions
1. Define the terms anxiety, anxiety disorders according to Frisch & Frisch, 2006
2. State the four stages of anxiety
3. State three of the major subtypes of anxiety

4. Name three nursing interventions for clients with anxiety disorders

Answers
1. Frisch & Frisch, (2006) defines anxiety as a state where in a person feels a strong sense of dread, frequently accompanied by
physical symptoms of increased heart, respiratory and blood pressure rates without having a specific source or reason for the
emotions.
Anxiety disorder: This is the experience of severe anxiety to the point where it interferes with a personal ability to function in daily
life (Frisch et al 2006)
2. Mild: This is where there is the tension of day to day living, individual has an alert perceptual field, this can motivate learning,

for example anxiety felt when missing the bus

Moderate: Focus is on immediate concerns; perceptual field is narrowed; individuals exhibits selective inattention. For
example anxiety felt when taking an exam.
Severe: Focus is on the specific detail; perceptual field is greatly reduced. Example anxiety felt when witnessing a car accident
Panic: A sense of awe, dread and/or intense terror; individual looses self control; there is a disorganization of the personality.
Example anxiety felt when experiencing an earthquake and being unable to cope

3. Generalized anxiety disorder: Anxiety is focused on a variety of events or activities, evidenced by restlessness, fatigue
difficulty in concentrating, sleep disturbance and so on
Panic disorder: Discrete episodes of intense anxiety that begin abruptly and reach a peak within 10 minutes, evidenced by
palpitations, sweating, trembling, SOB, chest pain, fear of losing control, fear of dying.
Agoraphobia: Acute anxiety in crowds; fear of being alone; fear in any physical activity where the individual may have
trouble escaping, e (Frisch, et al, 2006).
Phobia: Persistent, excessive or unreasonable fear of a specific object or situation.
Obsessive compulsive disorder: Occurrence of recurrent thoughts, images and or impulses that are intrusive are inappropriate
and leads to anxiety.
Post traumatic stress disorder: Occurs after a significant life threatening event, there is the experience of anxiety symptoms
4.

in which the event is reexperienced through recollections. (Frisch et al, 2006).

Use presence, touch (with permission), verbalization, and demeanor to remind clients that they are not alone and to encourage
expression or clarification of needs, concerns, unknowns, and questions. Being supportive and approachable encourages

communication (Olson, Sneed, 1995).

If the situational response is rational, use empathy to encourage client to interpret the anxiety symptoms as normal-anxiety is a
normal response to actual or perceived danger (Peplau, 1963).

Assess client's level of anxiety and physical reactions to anxiety (e.g., tachycardia, tachypnea, nonverbal expressions of
anxiety). Validate observations by asking client, "Are you feeling anxious now?"- anxiety is a highly individualized, normal

physical and psychological response to internal or external life events (Badger, 1994)
-Accept

client's defenses; do not confront, argue, or debate. If defenses are not threatened, the client may feel safe enough to look at

behavior (Rose, Conn & Rodeman, 1994).

-Explore coping skills previously used by client to relieve anxiety; reinforce these skills and explore other outlets-Methods of coping
with anxiety that have been successful in the past are likely to be helpful again. Listening to clients and helping them to sort through
their fears and expectations encourages them to take charge of their lives (Fishel, 1998)
-Explain

all activities, procedures, and issues that involve the client; use nonmedical terms and calm, slow speech. Do this in advance

of procedures when possible, and validate client's understanding-with preadmission patient education, patients experience less anxiety
and emotional distress and have increased coping skills because they know what to expect (Review, 2000)- uncertainty and lack of
predictability contribute to anxiety (Garvin, Huston, Baker, 1992).
-Provide clients with a means to listen to music of their choice. Provide a quiet place and encourage clients to listen for 20 minutes.
Music is a simple, inexpensive, esthetically pleasing means of alleviating anxiety. When allowed to participate in decision-making
regarding their care, patients can regain a partial sense of control. As patient advocates, nurses should take advantage of the
therapeutic effect of music by incorporating it into their plan of care (Evans, Rubio, 1994).

SUMMARY: The Client with anxiety disorder

Nursing care of the client with an anxiety disorder was presented on April 3rd, 2012 at the In-service Education Department Bellevue
Hospital. The purpose of the teaching session was to educate senior nursing students from Northern Caribbean University (NCU) and
University of Technology (UTECH) on the nursing management of patients with anxiety disorder. The teaching methodologies used
were lecture discussion and demonstration
The learning theories used were: Ausubel who served to break the ice, introduce and sequence the topic, since it was his theory that
spoke about the use of an advance organizer in teaching. Rogers: who posited that for the adult, learning is student centered and
personalized and that the educator act as a facilitator; Bruner: who posited that learners were not blank slate, but brought their past
experiences to this learning situation. The students were on the units at Bellevue Hospital and at Ward 21 University Hospital of the
West Indies and had seen patients with the disorders or had some form of anxiety themselves or had seen some family member with
the disorders, thus they were excited with the topic and gave full participation.
The scientific principle of homeostasis was utilized since it looked at the tendency of the organism to maintain and restore certain
steady states.

The session was evaluated using a formative and summative evaluation method, which is questions were asked before and after each
objective followed by a test at the end.
At the end of the 45mins interactive session students were able to:
1. Define the terms anxiety, anxiety disorders according to Frisch & Frisch, 2006
2. State the four stages of anxiety
3. Describe the major six subtypes of anxiety
4. Discuss the nursing management for clients with anxiety disorders