Table 1. Common signs of acute anxiety
• Feelings of fear or dread
• Trembling, restlessness, and muscle tension
• Rapid heart rate
• Light-headedness or dizziness
• Cold hands/feet
• Shortness of breath
As mentioned earlier carols primary source of socialisation when at home comes from spending time with her daughter. NIMH (2000) suggests that the family is of great importance in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive without helping to perpetuate the person's symptoms. If the family tends to trivialize the disorder or demand improvement without treatment, the affected person will suffer. Therefore some degree of involvement is required from the daughter. This was not done and in future, consideration will be given to educating carers. Another part of the assessment process involved utilizing other quantitative tools, such as Beck's Depression inventory (BDI), Beck's Anxiety Inventory (BAI) and Beck's Suicide Scale (BSS) (See Appendix C). These were chosen in the hope of aiding the identification of care priorities. This was not good enough alone as collaboration with the client or 'the expert' (Rogers 1989) is an essential component in attaining an accurate assessment of need. (Ward 1985, Beck et al 1993). Therefore I chose to confer with the client over what aspect she felt was most important, what I felt was, and what the rating scales suggested. Beck et al (1993) would affirm this approach, as emphasis in their view should be on collaboration from the outset suggesting that it enables the client to maintain their own care. Both Carol and myself evaluated the results of the BDI, BAI and BSS. The results indicated a moderate score for depression of (32 out of 63). The suicide score was low (14 out of 42) and the BAI indicated that her severe symptoms of anxiety included fear of losing control and fear of dying and discomfort in the abdomen. Although simple in their appearance these tools served to allow a quick, simple, structured way of quantitative assessment. It allowed progress to be at a faster pace in visually constructing what are the areas of most need. The depression was being controlled through an anti-depressant regime and the noises and voices were being treated with anti-psychotic medication. The assessment indicated several strengths and needs to assist clarification they will be listed below. To help clarify the main strengths and needs from the assessment I will list them below.
. Anxiety (Moderate-Severe with Panic at times).
2. Relationship issues, regarding ability to form them.
3. Physical responses to anxiety, including blurred vision, dizziness, restlessness, abdominal discomfort, sleep disturbance and general aches and pains.
It was decided collaboratively with nurse-patient and members of the multi disciplinary team (MDT) that the decision to focus on anxiety was an appropriate one. As the Nursing Assessment had indicated that anxiety was a key factor in carols current condition. This will be the focus of discussion when considering the planning of care.
Beck et al (1993) see care planning as a definite guide to nurse-client interactions. Dyer et al (1995) view it as a written plan of action designed to help deliver quality patient care. It is a natural progression from assessment and analysis yet its effectiveness relies heavily on the accuracy of the preceding assessments. Dyer et al (1995) suggest that its benefit includes continuity of care and communication between members of the team and the patient knows what current thinking is. Sentiments shared by Ritter (1989). As explained above the emphasis was on the symptoms of anxiety. Following the identification of a need or a problem, thoughts turned to a solution. As mentioned the planning/prioritising of care must be a collaborative decision. Within MDT meetings attended by the consultant, SHO, primary nurse, Carols CPN and myself. The directions of provisions were agreed. The way to use the provisions was a decision for the nursing team involved in Carols care. Goals were set. Unfortunately Carol did not attend these meetings, as it was the consultant's decision not to invite her. Doenges et al (1995) would argue that all health disciplines as well as family/client involvement is pertinent. It first raises the question of whether the goals can be valid and realistic as the UKCC (1998) state that to meet complex needs of clients, teamwork is required. It raises ethical questions, regarding client autonomy. The UKCC (1998) state again the nurse has a responsibility to promote client independence including discussion with the client on their proposed treatment of care. On reflection it could be viewed as a failure on my part as I did not express any concerns I had regarding carols absence. An issue requiring consideration in future practices. Finally the ethical issue of informed consent deserves consideration. The client must be informed (UKCC 1998) in order to consent. If Carol was excluded from weekly MDT meetings then surely this action undermines the concept. The issue here may have been time. With many clients on each ward the MDT has an allocated amount of time in which to discuss care. Working on the presumption that if nurses could relay what is said to the patient, then that would be acceptable. Is this information then open to misinterpretation consequently leading to the client being given the wrong information? If so the accuracy of the care delivered could be reduced.
The agreed care priority in Carol's case was the control of her anxiety and its effects. Therefore a strategy of anxiety management was required. In accordance with the holistic framework, Collaboration was again a key to this. (Beck et al 1993). If a strategy had any chance of working it must be realistic and that means maximum client involvement. Therefore a meeting took place between Carol and myself, the purpose of which was to plan an intervention strategy.
The chosen strategy comes from Internet resources. It is a self-help pack (Appendix D), for anxiety disorders, chosen for its simple format. It covers a broad spectrum of complaints following a logical path, with the key objective being the empowerment of the client (Doenges et al 1995), allowing more adaptive coping mechanisms to be discovered and utilised. The change from maladaptive/adaptive coping can restore any lost self-confidence and self-esteem. (Lyttle 1991). The pack allows for self-discovery in the client. The pack is underpinned with theoretical ideas lent from behaviour and Cognitive therapy. Behavioural therapy focuses on changing specific actions and uses several techniques to decreases or stop unwanted behavior. For example, one technique trains patients in diaphragmatic breathing, a special breathing exercise involving slow, deep breaths to reduce anxiety. This is necessary because people who are anxious often hyperventilate, taking rapid shallow breaths that can trigger rapid heartbeat, lightheadedness, and other symptoms (Hallam 1994) as in carols case. Another technique, exposure therapy gradually exposes patients to what frightens them and helps them cope with their fears (NIMH 2000), yet the benefit of this is questioned, as the trigger for her anxiety is unclear. Like behavioural therapy, cognitive-behavioural therapy teaches patients to react differently to the situations and bodily sensations that trigger these anxiety symptoms (Lyttle 1991). However, patients also learn to understand how their thinking patterns contribute to their symptoms and how to change their thoughts so that symptoms are less likely to occur (Carpento 1999). This awareness of thinking patterns is combined with exposure and other behavioural techniques to help people confront their feared situations (Hallam 1994). In carols case, she becomes light-headed during a panic attack and fears she is going to lose control. This can be helped with the following example of the approach used in cognitive-behavioural therapy. In this case it could involve getting carol to spin around in a circle until she becomes dizzy. When she becomes alarmed and starts thinking, "I'm going to lose control or die to replace that thought with a more appropriate one, such as "It's just a little dizziness? I can handle it." The aim is not to eliminate anxiety but to educate her on ways of coping with it and increase her awareness of the symptoms, while hopefully developing a more rationalised perception of events this was made clear to carol at that time. Explanation of what is expected from the intervention including both parties took place and feedback was given to the MDT. The rationale for choice, the objectives, and carols feelings regarding this, were included. Evaluation of its effectiveness took the form of verbal in our regular meetings. The BDI, BSS, BAI will be repeated after a two week so that comparison with baseline observations recorded initially can be carried out. It was seen in the pen picture that carol is easily distracted; therefore I would check the availability of more private rooms in a more appropriate environment so that carol can feel less anxious through a low stimulus environment. A final point is that the support of existing coping strategies are important, as until new ones are developed removing these would only serve to increase carols symptoms of anxiety. An intervention plan can be found in Appendix E.
Results and Evaluation
Evaluation according to Beck et al (1993) can be broken down into several criteria. Adequacy: The self-help pack allowed carol to gain new skills and insight into her anxiety enabling her to begin to manage it more effectively. If we use of her PRN medication as an indicator of the severity of her symptoms and observational techniques to view symptomatic evidence then it can be concluded that in carols case some relief of symptoms were evident. Appropriateness: Carol agreed on the goals set and was able to participate immediately in this approach. The self-help pack appeared relevant, although on further exploration carol felt it concentrated too much on understanding body systems and not on techniques for anxiety management. Effectiveness: There was evidence of a reduction in the regularity of the symptoms of anxiety. This shown when the BAI is reassessed as her fear of losing control reduced from severe to moderate. Her use of PRN medication was less regular and she stated that she felt slightly better equipped to deal with these feelings especially when out on home leave indicating some self learning. Efficiency: It can be seen that the self-help pack allowed for some moderation of carols symptoms of anxiety. Although every effort was made to support carol others did not offer her the same level of support? Dismissive attitudes toward carols complaint could be seen throughout the nursing team. A factor identified by O'Toole (1995) as being prevalent in these cases. Throughout nursing literature collaboration is named as a key factor in the accuracy of evaluation (Ward 1985, Ritter 1989, and Beck et al 1993). This aids the in the teaching and learning process within nursing care, allowing growth to occur in the individual as well as in the nurses own capacity to deliver effective care. Therefore both carol and myself evaluated the whole process, helpful in allowing a more critical appraisal of the intervention to take place, as it could be argued that my ability to criticise my own actions could be biased. This also created the perfect opportunity for collaborative re-assessment to take place.
The study allows the reader to observe the theoretical aspects of the nursing process and the practical implications of it. It shows that there is a need to assess the whole person in order to gain an understanding of their perceptual world. Family involvement was shown to be important as well as collaboration with the client and between all agencies and members of the MDT. It illustrates the need for student nurses and qualified staff alike to gain knowledge of effective tools that can be helpful in assessment and diagnosis. E.g. HIS and Beck's inventory tools. It moves on to suggest that a plan of care is dependent on the accuracy of the assessment. The more accurate the assessment, the more effective the plan of care is. It emphasises the need for ethical awareness. Allowing the nurse to predict problems. Interventions with anxiety related disorders vary but all seem to have elements of cognitive and behavioural theory within them. The self-help pack can be useful in respecting autonomy but the choice must be appropriate for client needs. Finally evaluation is seen as having four components. The care delivered must be assessed for adequacy, appropriateness, effectiveness and efficiency. Helping in the teaching and learning aspects of nurse-client relationships.