Introduction:

Working in a mixed Admission Ward for the last three years we regularly noticed that

anxiety is very often present in most of the newly admitted residents. The purpose of this

study is to give an overview regarding the levels of anxiety and the physiological and

psychological responses to anxiety and describe how I as a nurse can contribute to the

reduction of anxiety of residents in our setting. However, it shall be compared with studies

carried out and referred later in the text.

Losses of loved ones, loss of property and belongings, and loss of independence as a result of

physical and mental decline, are some of the major elements that contribute to the challenge

of aging. The change of ones habitual living conditions in favor of institutionalized living in a

residential home is for an old person usually connected with many difficulties. Anxiety is

expressed in different ways and may be associated with one or more of the following risk

factors (Doraiswamy 2001).

• Female gender

• Physical debilitation

• Depression

• Hearing/vision loss

• Memory loss

• Loss of friends/family

• Changes in living arrangements (e.g., recent admission)

Levels of Anxiety:
Mild: Attentive, alert, perceptive to verity of stimuli; an effective problem solving.

Moderate: Perceptual filed narrows; responds to direction and support.

Severe: A perceptual field narrows; stimuli distorted; focus is on scattered detailed.

Panic: Sensory ability and attention reduced so that only objects of anxiety are noticed.

The Physiological Responses to Anxiety:

Mild: Tension of needs motivates behavior and is adaptive to variety of internal and external

stimuli.

Moderate: Some symptoms mentioned above may be present.

Severe: Alarm stage changes intensify, and stage of resistance may progress to stage of

exhaustion.

Panic: Severe symptoms of exhaustion stage may be ignored.

The Psychological Responses to Anxiety:

Mild: No intense feelings; self concepts not threatened. Use ago adaptive mechanisms

minimal, and flexible behaviors appropriate to situation.

Moderate: Selective inattention and focus on stimuli that do not add to anxiety. Use any

adaptive mechanism to protect feelings and meanings of behaviour, impatient, irritability,

forgetful, demanding, crying and anger.

Severe: Self- concept threatened; sense of helpless and mood changes. Behavior erratic or

inappropriate and can be aware of inappropriate behavior but is unable to improve.

Panic: May becomes immobilized, assumes fetal position, or become mute, or may be

unresponsive to directions and needs protection.

Men are more likely to channel anxiety into aggressive behavior while women are more

likely to channel anxiety into depressive behavior (Mills et al 1988).

Definition of Anxiety:

Anxiety is defined as a response to a perceived threat and is associated with a vague,

unpleasant uneasiness (Clark, 1992).

Most of the residents are admitted directly from home; others are admitted from other

institutions and others are transferred directly from the acute general hospital. An aged person

finds himself in a new environment he will be naturally anxious about keeping in touch with

the family, friend and hobbies. Wilson Barnett (1979) suggested that the first 24 hours

following admission where the client had the highest stress levels, a proper nursing

assessment can directly affect the length of time it takes to help the client adopt to his new

environment. The nurse is in the most important position to help the new client to diminish

the anxiety of finding himself in an institution and to adjust to his present situation. This can

be done effectively by implement the three phases of the caring relationship according to the

resident’s needs that are orientation, working and termination phase.

Orientation Phase:
A strange environment and a new routine can be extremely disorientating the client’s

thoughts leaving little time or inclination for pursuit of activities and interests. As a nursing

action for the older adult, being present requires knowing and being comfortable with oneself

and connecting with the person through affirmation, valuing, vulnerability, empathy, serenity,

and silence ( Stanley 2002). On admission the first nursing intervention is to introduce

oneself by name, and discuss the reason for move or change. Any questions that may be

asked should be answered as completely and honestly as possible. Attempting to shield the

aged person from often harsh reality is likely to result in anger and loss of trust so the nurse

should help the aged person identify the benefits that will come with the change and avoid

making personal or negative comments about the move.

Within each person there are cultural patterns which provides the roles and directions for

daily living, all beliefs, values and behavior are rooted in one’s culture. Many interests and

hobbies of the elderly people have been with them since their younger days so it is important

to elicit the views of the resident when trying to establish his quality of life.

Assessing Anxiety:

Patients should be assessed for anxiety. Assessment of worry is significant when planning

nursing care (Fakouri and Lyon 1996). The most important thing before assessing and

planning an intervention is to talk to both the client and his relatives and try to build a helping

relationship based on trust, respect and acceptance. Trust and identification are the most

relevant components of nursing commitment in identifying the anxiety level of the new

client. So then it will be more appropriate to reach out goal in reducing the client’s level of

anxiety.
Assessment is the most important skill in practice with older people. The medical doctor

normally will do an assessment to assess for dementia, delirium, depression and other

common disorders of later life. The nurse should be present and listen to what the resident

had to say during the assessment this can help the nurse to gain more inside of the client.

Psychologists can play a unique role in this process of determine the mental condition of the

resident. Diagnosis of the major disorders of late life depends to a considerable extent on

evaluation of behavior and cognition. The starting point for any assessment is to put the client

at easy and to establish rapport. Through an evaluation the members of the health care team

should monitor the client’s anxiety, providing reassurance when needed and conducting the

assessment in a supportive way.

Different perspectives could be used to investigate the extent of anxiety the client is

experience, its correlation with other demographic and health variables, and for testing the

effectiveness of therapeutic approaches. The most common formal assessment of

psychological and physical functioning required of a nurse is that keeping precise records of

some aspects of behavior. The formal recording of baseline data allows precise effects of any

intervention to be determined. The skill of asking questions appropriately is essential if a

client needs are to be assessed accurately, in order to assess a clients need and to

communicate effectively it is essential that the nurse have the appropriate skills.

Working Phase:

During this phase the nurse must demonstrate acceptance of client’s behavior. Establish

rapport (interpersonal harmony characterized by understanding and respect). Provide

opportunity for resident to begin develop trust (active listening, empathy,

consistency). Both must recognizes and differentiate what types of problems are

subject to intervention. Nurse must inform client when desired goals are beyond the
 nurse’s domain of expertise or the duration of the interaction. Both the nurse and the

client affect each other.

To implement any interventions the nurse needs to work closely with other members of the

multidisciplinary team such as social workers, occupational therapists and

physiotherapist so any planning would be directed according to the client’s needs.

Multidisciplinary characterised by each discipline within the team working towards

discipline-related goal. Team members work within the boundaries of their

professional practice; progress is formal discussed at team meeting, effective

communication is considered vital in order to plan realistic goals to be achieved by

the client.

Empathetic Listening:
Empathy is entering another person’s experience to perceive it accurately, while maintaining

objectivity. To give empathy the nurse need to gain inside of the client and imagine oneself

in the situation of the client so then the nurse will be able to understand more better the

client’s experiences. The nurse must give client time, opportunity and ability to explain

himself. Listen to the client with intent to understand, without diminishing the client’s

feelings or immediately giving advice. Understand the cause of the client’s unusual attitude or

behavior. Respect the client’s values, opinion’s needs and ethno cultural beliefs. Integrate

these elements into the care plan with the client’s help. Care giver is a companion, who

shares freely but does not impose. Tschudin(1992). Both listening and assertive skills are

required to undertake this role.

Therapeutic Interventions:

The nurse must establish a working relationship with client through continuity of care. An

ongoing relationship establishes trust, reduces the feeling of isolation, and may facilitate
coping. Opportunities should be provided for the client to express concerns, fears, feelings,

and expectations. Verbalization of actual or perceived threats can help reduce anxiety.

Encourage patient to identify own strengths and abilities. Fostering awareness can expedite

use of these strengths. Occupational Therapy classes can help the client in this way. Residents

who are not coping well may need more guidance initially. During crises, patients may not be

able to recognize their strengths. The nurse must encourage the client to seek information that

increases coping skills.

Residents who are coping ineffectively have reduced ability to assimilate information. The

nurse must provide information to the resident wants and needs and pay attention not to

provide more information than the resident can handle. The resident must be encouraged to

set realistic goals. This can helps the resident to gain control over the situation. Guiding the

resident to view the situation in smaller parts may make the problem more manageable.

Assist the client to problem solve in a constructive manner. Discourage decision making

when under severe stress.

Assess level of understanding and readiness to learn needed lifestyle changes. Appropriate

problem solving requires accurate information and understanding of options. Often patients

who are ineffectively coping are unable to hear or assimilate needed information. Assess

decision-making and problem-solving abilities. Patients may feel that the threat is greater

than their resources to handle it and feel a loss of control over solving the threat or problem.

The nurse can assist the client with his problem of being among unfamiliar environment by

introducing him to other clients who will be present throughout each day, and they can assist

to give the new client a feeling of ‘belonging', indeed other aged persons can be a great

support and source of information to new clients (Rowden and Jones 1993).
Spiritual Needs and Support:

‘Every hospital patient has the right to receive spiritual and moral assistance in accordance

with his o her religious belief ‘(Patients’ Charter-Malta 2001, no. 01. 04 p6)

The nurse has to try and to provide holistic care to the residents to help them acquire new

behaviors that are important to the resident’s well being and that are required to adjust to

aging and their situation. Spirituality enables the person to experiencing self growth through

life events and mission in life (Burkhardt 1994). For the older adult, finding the meaning of

critical life can be a challenging, process wherein the nurse can have significant influence.

There are numerous benefits for the older adult to enhance, their prayer beliefs and practices

so then the older adults will enhance his trust, self-worth and hope. Research on nurses and

health careers identified the nursing interventions in spiritual care such as, referral to

chaplains or other professionals, prayer, active listening, facilitation of clients’ thoughts all

are nursing interventions that can help the client meet his spiritual needs which can help in

reducing his level of anxiety Halm et al (2000). All or part of these interventions can help the

elderly client to meet his spiritual needs and to encourage him to build up again his self-

esteem. Factors that facilitate motivation in one individual, may not work as effectively for

another person, Loeb, O’Neill, & Gueldner, (2001).

Entertainment Service:
This section provide, the daily supply of local news papers to the institution and organize

weekly theatre plays and culture activities such as playing bingo, masses in chapels outside

the residence etc. Residents should be encouraged to use this service as it serves as a tool to

increase their self esteem and keep them in touch with the outside environment.

Empowerment through Wellness:

Individual behavior is notoriously hard to change. It may be that the best way to ensure

change is through creating a positive, healthy environment, in which helpers communicate a

sincere belief in the capability of individuals to assume responsibility for their own total well-

being. Such an environment is inherently empowering. Positive, healthy lifestyle choices can

enhance the quality of life across the lifespan beginning whenever they are implemented.

Wellness is essentially an empowering philosophy which has a goal of helping individuals

identify areas of their lives over which they have control, and assisting them to make healthy

lifestyle choices which enhance their physical and emotional well being, as well as their

continued ability to make even more healthy choices.

Mental Health and Aging:

Most persons cope with changes in their lives as they grow older with little disruption of

functioning. At the same time, it is fairly well documented that mental health

concerns increase with advancing age. Older persons experience many stresses, crises,

and losses, in addition to the need to cope with devalued status and they are more

prone to depression. The nurse must encourage patient’s participation in self-care to

the extend possible to reduce patient’s felling of hopelessness The nurse should

evaluate any symptoms that the patient may have through communication with the

client as he will feel helplessness so then any consultations needed, will be addressed

by his doctor.

Treating Stress by Massage:

When the body is stressed it must work harder than usual to remain balanced. Convectional

relaxation methods such as drinking and smoking are over used in order for person to relax.

Some people have to learn how to relax and having a massage is one way of allowing the

person to know what it feels like to be relaxed, as tension is removed.

Relaxation Techniques:

Medical research across the world is beginning to awaken to the possibility that regular

practice of meditation; relaxation and visualization techniques can help to reduce the stress

hormones in our blood that influence our long-term health and well-being.

Benefits of Progressive Relaxation:

This relaxation technique has proven effective in helping people relax and dose not requires

any special equipment and has been shown to have both physiological and psychological

benefits.

Physiological Effects: Multiple researchers have found that progressive relaxation is

effective in treating tension headaches Cox et al & Haynes et al (1997).

Psychological Effects: Progressive relaxation has been demonstrated to have wide

ranging effects upon psychological well-being, as well as upon behavioral changes. For

example, mediators have been found to be less anxious. Even more significant than this,

however the finding is that anxiety can be decreased by teaching people to meditate Miller et

al (1995) & Rubin (1996).

Termination Phase:

Termination ends when the goals are met. It may be difficult both for the nurse and the client.

In this case it is very important that the nurse must prepare the client and his family for the

termination phase early in the communication process.

Conclusion:
Normal changes that occur with aging are the result of complex interactions among genetics,

biological systems, and physical and social environments. Disease complicates a person's

ability to adapt and maintain functional health (the ability to carry out the usual and desired

daily activities). Mental or physical decline in older adults often may not be directly related

to the aging process but may result from the absence of supportive care and services

that could prevent disease and help maintain the older adult's ability to function.

The aims to provide care while safeguarding and promoting the welfare of older adults. The

aims and duties of this service are focused on medical and nursing care, physiotherapy and

occupational therapy, dental and ophthalmic care and podology and speech therapy and

entertainment service. It is imperative that the employer employ more qualified persons in

psychology and alternative therapists, so then the residents will have more services that can

assist them in reducing their anxiety levels.

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