Anxiety/PTSD/Panic PPT

What is anxiety?

A subjectively distressful experience activated by the perception of threat, which has both a potential psychological and physiological etiology and expression

Levels of Anxiety & Nursing Implications: Mild Anxiety

Looks like:

• Increased alertness

• Heightened perception

• Improved problem-solving

Nursing Implications:

• Use as a teaching opportunity

• Encourage verbalization and goal setting

Levels of Anxiety & Nursing Implications: Moderate Anxiety

Looks like:

• Narrowed focus

• Selective inattention

• Tension, shakiness, GI discomfort

Nursing Implications:

• Give short, clear directions

• Help patient focus and refocus

• Encourage deep breathing or calming techniques

Levels of Anxiety & Nursing Implications: Severe Anxiety

Looks like:

• Greatly reduced perceptual field

• Trouble thinking clearly

• Sense of doom, hyperventilation, trembling

Nursing Implications:

• Stay with patient

• Speak calmly, slowly

• Reduce environmental stimuli

• Focus on safety and physical needs

Levels of Anxiety & Nursing Implications: Panic Anxiety

Looks like:

• Unable to focus

• Feeling out of control or detached from reality

• Possible hallucinations or impulsive behavior

Nursing Implications:

• Ensure safety first

• Use calm, simple communication

• May require medications or hospitalization

• Avoid touch or overloading with information

Best Nursing Response to Crying/Stressed Clients

• Stay present – don’t walk away

• Offer tissues and say, “It’s okay to cry”

• Use calm, supportive tone

• Say: “I’m here with you,” or “Would you like to talk about what’s upsetting you?”

How Nurses Can Decrease Anxiety

• Provide a calm, quiet environment

• Use short, clear sentences

• Offer reassurance without false promises

• Teach breathing or grounding techniques

• Help the client identify triggers and coping strategies

• Encourage verbalization of feelings

Therapeutic Responses During Crisis or Anxiety

• “You’re safe here.”

• “Let’s take this one step at a time.”

• “Tell me what you’re feeling right now.”

• “What has helped you in the past when you’ve felt this way?”

• Use active listening (nodding, eye contact, repeating key phrases)

• Avoid judgment, minimizing, or giving too much advice

Defense Mechanisms - Why do we use them?

• Defense mechanisms are unconscious psychological strategies used to protect ourselves from anxiety, stress, or internal conflict.

• They can be adaptive (healthy) or maladaptive (harmful if overused).

Common Defense Mechanisms - Denial

• Definition: Refusing to accept reality or facts.

• Example: A woman diagnosed with cancer continues to plan a long vacation next year.

Common Defense Mechanisms - Rationalization

• Definition: Justifying behaviors or feelings with logical-sounding excuses.

• Example: A student blames the teacher for failing a test, saying the questions were unfair.

Common Defense Mechanisms - Regression

• Definition: Reverting to an earlier developmental stage.

• Example: A child starts bed-wetting again after a new sibling is born.

Common Defense Mechanisms - Intellectualization

• Definition: Using logic and reasoning to avoid emotional stress.

• Example: A person diagnosed with a terminal illness focuses solely on research and statistics instead of dealing with their emotions.

Defense mechanisms

• Repression: Unconsciously blocking unpleasant feelings or experiences.

• Projection: Attributing one's own unacceptable thoughts or feelings to others.

• Displacement: Redirecting emotions from a threatening target to a safer one.

• Sublimation: Channeling unacceptable impulses into socially acceptable activities.

• Reaction Formation: Behaving in a way that's opposite to one's true feelings.

• Suppression: Consciously choosing to delay paying attention to a thought or emotion.

• Undoing: Attempting to take back unconscious behavior or thoughts that are unacceptable or hurtful.

• Identification: Adopting the characteristics of someone else to deal with a situation.

• Compensation: Overachieving in one area to compensate for failures in another.

• Conversion: Expressing emotional conflicts through physical symptoms.

Patients use defense mechanisms to help deal with their anxiety! 

Psychobiological Interventions for Anxiety

• Behavioral therapies and counseling

• Family intervention/family therapy, Group therapy

• Cognitive and behavioral therapy

• Prolonged exposure therapy

• Mindfulness/Relaxation/Breathing Techniques

  • help calm the body and mind, making them effective tools for managing anxiety, stress, and emotional distress

• Peer support

• Nutrition – no caffeine, food coloring, monosodium glutamate

• Exercise

Anxiety Disorders

• Distinct from normal anxiety

• Interfere with ability to function in daily life

• This module will focus on Panic Disorder & PTSD

• Medical Causes of Anxiety (e.g. heart disease, addiction, tumors that produce “fight or flight” hormones, etc.)

Panic Disorder

• Episodes of intense anxiety (intense terror, apprehension, fear)

• Characterized by recurrent panic attacks

• Symptoms: Abrupt onset, peak in 10 min

• Patients often visit ED

What should be included in the Assessment of patient with history of panic attack?

• Event or situation causing stress or crisis

• Subjective experience e.g.  “What does this loss mean to you?”

• Level of anxiety (on scale of 0-10)

• Suicidal ideation - is it present?

• Coping style and strengths (adaptive or maladaptive coping?)

• Support available

Assessing for Suicidal Ideation

What Might a Client Say? Direct Statements:

• “I want to die.”

• “I’m thinking about killing myself.”

• “I’ve thought about ways to end it.”

Indirect Statements:

• “I can’t do this anymore.”

• “Everyone would be better off without me.”

• “What’s the point in living?”

• “Soon, this won’t matter.”

• Giving away possessions or saying goodbye

🧠 Nursing Action:

• Ask directly: “Are you thinking about hurting yourself?”

• Assess plan, means, and intent

• Ensure safety (remove means, stay with patient, notify provider)

• Follow facility protocol for suicide precautions

Assessment for a Patient with a History of Panic Attacks

Assess for safety and suicidality.

• “Are you feeling like you want to harm yourself?”

• Rule out medical causes (e.g., cardiac, respiratory)

4 or > symptoms = Panic Attack

• Palpitations

• Pounding heart

• Increased heart rate

• Diaphoresis

• Nausea & vomiting

• Trembling

• Paresthesia (Feeling of burning, prickling)

• Feelings of choking

• Chills

• Hot flashes

• SOB

• Smothering sensation

• Fear of dying

• Derealization (alteration in the experience or perception of the external world so that it seems unreal)

• Chest pain

• Depersonalization (periods of feeling detached or disconnected from one's body and thoughts)

• Fear of losing control or going crazy

• Dizziness

Acute Nursing Care for a Patient Experiencing a Panic Attack

• During acute panic attack, attempt to minimize stimuli and remain calm and quiet

• Stay with the client; reassure client that you will not leave them alone

• Client is unable to concentrate on learning new information during a panic attack

• Although sometimes medications are used during a panic attack, trying the least restrictive measure first (e.g. stay with the client, remain quiet and calm) often works and should be tried prior to medicating the client. 

• If staying with the client and providing a calming, reassuring presence is not effective and the client becomes severely distressed or the feelings of panic continue to escalate, a PRN dose of a benzodiazepine may be administered

Nursing Interventions for Acute Panic Attack

• Stay with the patient: Offer a calm, reassuring presence to prevent feelings of isolation.

• Maintain a quiet environment: Reduce noise, dim lights, and limit the number of people in the room to minimize stimuli.

• Use simple, clear communication: Speak in short sentences and a gentle tone to avoid overwhelming the patient.

• Encourage slow, deep breathing: Guide the patient to take deep breaths to help reduce hyperventilation and promote relaxation.

• Avoid teaching or decision-making: Recognize that the patient is unable to process new information during a panic attack; defer education until the patient is calm.

• Ensure safety: Assess for any risk of self-harm and remove potential hazards from the environment.

Long Term: Nursing care for a client with Panic Disorder is aimed at

• Recognizing symptoms of onset of anxiety and intervening before reaching panic stage (oftentimes cognitive behavioral therapy helps with this)

• Developing a balanced life and nourishing one’s spirit

Post-Traumatic Stress Disorder

• Follows exposure to extreme traumatic stressor (personal physical threat/trauma or witnessing another)

• Re-experience of significant, life-threatening event

• Increased incidence with previous hx of abuse or trauma

Symptoms of PTSD

• Hallucinations, flashbacks, illusions

• Recurrent, intrusive recollection of the event(s)

• Avoidance of stimuli associated with the trauma, such as avoiding people, inability to show feelings, not wanting to talk about the event(s)

• Sleep disturbances - recurring nightmares associated with the traumatic event; insomnia; sleepwalking

• Increased arousal - irritability, anger, trouble concentrating, heightened startle response

• Detachment from relationships / interpersonal problems

• Destructive behavior, such as suicidal thoughts or thoughts of harming others

Notes

Suicidal patient may not always say, “I’m thinking of killing myself” or “I want to die.”  They may say, “I don’t understand why it wasn’t me who died.” or “I don’t see any reason to go on.”  or “Life just doesn’t seem to have any meaning anymore.”  etc.  You need to recognize these types of suicidal ideation.

Hyperarousal/ Hypervigilance

Startles easily, insomnia, fear, anxiety, panic, irritability

Intrusion –nightmares, Hallucinatory-like flashbacks

Avoidance, numbing

Impairment of social functioning is common for those suffering from PTSD.

Acute nursing care of the client with PTSD is aimed at:

• Helping client to focus on the present - use structured interview

• Provide safety and comfort during crisis period - quietly remain with client - provide safety for other clients and staff

• Assess for suicide risk (client might not always say “I’m feeling like killing myself.”  They might say, “A lot of my friends died, and I don’t know why it wasn’t me.” or “I don’t deserve to be here when so many others died,” etc.

• Assess for comorbid substance abuse

  Long Term GOALS:

• Use therapeutic communication to help patient express feelings of anxiety / validate and acknowledge feelings

• Client participation in decision-making related to care

Restraint of these clients (physical and chemical) should be avoided if at all possible (only used as a very last resort!)  Restraint itself has many risks, and can also be traumatic to clients

Goals of Crisis Intervention

• Psychological resolution of  immediate crisis –Deal with “here & now”

• Restoration to the level of functioning before the crisis period.

• Once past crisis, improvement in functioning above the pre-crisis level

What do you do when the patient with PTSD is experiencing a mental health crisis? 

1. Ensure Safety

   • Remove harmful objects from the area

   • Assess for suicidal or homicidal ideation

   • Stay with the patient—do not leave them alone

2. Remain Calm and Grounding

   • Speak slowly and in a low, reassuring voice

   • Orient the patient: “You are safe. I’m here with you.”

   • Use grounding techniques (e.g., “Can you name five things you see?”)

3. Reduce Stimuli

   • Move to a quiet, low-stimulation environment

   • Dim lights, reduce noise, limit number of people

4. Do NOT Force Discussion of Trauma

   • Avoid probing questions or asking about the event

   • Allow the patient to express emotions only if they initiate

5. Use Non-Threatening Body Language

   • Maintain personal space

   • Avoid sudden movements or touch unless necessary

6. Document and Notify

   • Document behaviors, interventions, and patient response

   • Notify mental health provider or follow crisis protocol

🧠 Key Point (Varcarolis): PTSD crises may involve flashbacks, dissociation, panic, or rage. Focus on safety, reorientation, and support—not processing the trauma in that moment.

 Long Term Goals Nursing Care PTSD Continued

• Help client identify relaxation techniques to help with pain, anxiety, sleeping problems, tension

• Instill hope for future (but don’t give false reassurance)

• Assist client in identifying maladaptive defense mechanisms that interfere w recovery

• Postpone health teaching until acute anxiety subsides!

How can we tell if relaxation techniques are working?  We should see improved ability to concentrate, decreased blood pressure and heart rate, a decrease in insomnia, and decreased muscle tension.

Recap: Important Assessments PTSD

• Patient safety (Is patient depressed or suicidal?  Is there a distinct plan?)

• Physiological integrity (Is patient’s condition causing him/ her to neglect physical health?  Nutrition? Sleep?)

• Functional ability - is condition affecting patient’s ability to perform job, parent, etc?

• Important further screenings

Remember, the nurse cannot DIAGNOSE a medical condition, but they can screen and refer patients for further diagnosis and treatment.  They can also perform nursing interventions.

Evidence Based Treatment PTSD (Nonpharmacologic)

• Prolonged Exposure (usually w phobias)

• Eye Movement Desensitization and Reprocessing (EMDR)

• Cognitive Behavioral/Processing  Therapy

What do you understand about pharmacological management of panic disorder?

✅ First-Line Treatment:

• SSRIs (Selective Serotonin Reuptake Inhibitors)

  • Examples: Paroxetine, Sertraline, Fluoxetine

  • Reduce frequency and intensity of panic attacks

  • Start low and titrate slowly to avoid increasing anxiety

⚠ Second-Line or Adjunct:

• SNRIs (e.g., Venlafaxine) – also effective

• Benzodiazepines (short-term only)

  • Examples: Lorazepam, Clonazepam

  • Used for acute relief of severe symptoms

  • Risk of dependence/sedation – avoid long-term use

🧠 Other Options:

• Buspirone – less sedating, not habit-forming, but not effective for acute panic

• Beta-blockers (e.g., Propranolol) – helpful for physical symptoms (e.g., tachycardia)

🔄 Important Notes:

• Meds take 2–4 weeks to start working

• Combine with CBT or therapy for best outcomes

• Monitor for side effects and suicidal ideation when starting antidepressants

Pharmacology for Anxiety Disorders

• Antidepressants

  • SSRIs (e.g. fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil)

• SSRIs are first-line (long term) treatment for panic disorder!

• Anti anxiety meds/anxiolytics – may be useful during acute panic attack but are not used as long term treatment for panic disorder.

  • Benzodiazepines (e.g. alprazolam, lorazepam, diazepam) - quick acting, indicated for short term (crisis) use - long term use may lead to dependence, potential for withdrawal syndrome if stopped abruptly, and development of cognitive impairment.  Also, if used with opioids, potentiates resp. depression!

  • Atypical anxiolytic/ non barbiturate anxiolytics e.g. Buspirone

If a client is having an acute panic attack and nonpharmacologic methods (such as quietly staying with the client and reducing stimuli) don’t work to help the client calm down, or the client is at risk of hurting themself or others during the attack, then a short acting medication such as a Benzo will be used to help calm the client quickly.