Essay on Anxiety
Anxiety is the body’s first response to a potential threat to something "essential to one’s existence and security" (Stuart, G. and Sundeen, S. 1987), producing a heightened state of awareness and preparing the body for action. This assignment will focus on the experience of anxiety of an 89-year-old gentleman who, in order to maintain confidentiality (NMC 2002), will be referred to as Frank. It will also look at the physiological effects of anxiety, ie. hypertension, tachycardia and cold, clammy skin, and consider a number of nursing interventions.
Until recently, Frank lived at home with his wife Iris, 87, and their daughter Susan, 68, their the main carer. For the past eight years Frank has been suffering from vascular dementia. Lately his behaviour has become very confused and his daughter can no longer offer him the care that he needs. He is currently receiving 'permanent respite' at the home where I am on placement until a place becomes available in full time nursing care. He is often very anxious and will be observed crying, wringing his hands and repeating "Where's my mother? I love my mother". His mother died when he was 12. He often appears to hallucinate that she is near-by and becomes distressed when his attempts to reach out to her are in vain.
When the brain perceives a threat, it sends a signal from the medulla oblongata to the adrenal medulla via the sympathetic branch of the autonomic nervous system, releasing noradrenaline and adrenaline. These hormones cause physiological effects known as the fight or flight response.They include increased heart rate, raised blood pressure, dilation of vessels in the skeletal muscle, dilation of the bronchi and pupils, and the release of glucose into the blood.
Observable physiological changes include the following:
· Hypertension. Blood pressure is generated by cardiac output, which is affected by the rate and force of heart contractions and resistance to the flow of blood through the vessels. As a result of adrenaline secretion by the adrenal medulla, heart rate and stroke volume increase, due to increased myocardial contractility, and peripheral resistance increases due to vasoconstriction. The effect of this is a rise in arterial blood pressure. Another factor affecting blood pressure is the release of adrenocorticotrophic hormone (ACTH) by the anterior pituitary gland. This causes the adrenal cortex to reabsorb water and sodium ions, increasing blood volume and raising blood pressure.
· Tachycardia. The cardiovascular centre, situated in the medulla, raises heart rate via the autonomic nervous system by stimulation of sympathetic nerves with the release of adrenaline and noradrenaline. This is the body's attempt to increase cardiac output in readiness for action so that the vital organs receive an adequate supply of oxygen and nutrients, and waste products, carbon dioxide and heat are removed.
· Cold, clammy skin. The skin feels clammy due to an increase in perspiration. This occurs to stop the body overheating while in action and makes the skin harder to grab if caught by a predator (TAPIR 2002). Peripheral blood vessels are constricted, taking blood away from areas like the fingers and toes, making them cold to the touch. This is to prevent bleeding to death if we are gravely injured. Instead blood is sent to the heart, central nervous system and muscle. This is crucial preparation for fight or flight.
Teasdale (1995) suggests that nurses are well placed to assess levels of anxiety and to help patients to cope. Assessment can be carried out by careful interviews with the client and their family or carer. If a person is unable to give much detail about their feelings, a review of an average day can provide information about what raises anxiety and how they cope. (Wattis, J. and Martin, C. 1994). According to Maslow (1970), anxiety will result if our needs are not met.
In the case of people with organic dementia, "psychological defenses that previously kept anxiety at bay may have been weakened, and in some cases, collapsed completely" (Kitwood, T. 2001).
Attempts to communicate needs are likely to be observed as "behaviour easily labeled as difficult or disruptive" (Goudie F. and Stokes G. 1989). It is therefore important to "seek to understand the message, and to engage with the need that is not being met" (Kitwood T. 2001). Counselling skills including reflective listening, exploration, warmth and acceptance were suggested by Rogers (1951) as a way for professional carers to empathise with the hidden meaning and feelings lying behind confused verbal and behavioral expressions.
During the first week that I was working with Frank, I noticed a sharp deterioration in his condition, making it extremely difficult to communicate with him. I suspected that this might be the result of an 'acute confusional state' . Whilst assisting Frank to use the toilet, I noticed that his urine had a strong odour and dark colour. Previous experience led me to suspect that Frank might have a urinary tract infection, which urinalysis confirmed. I also suspected that Frank might be constipated. I spoke to his GP, who prescribed Lactulose and a course of antibiotics, which acted quickly to relieve the exacerbation of Frank's anxiety and confusion.
In an attempt to develop a therapeutic relationship with Frank, I considered the recommendations of Jones, G (1996) who noted the effectiveness of touch as it "can reassure the impaired person that there is someone there, even if their thoughts wander". I was careful to use Frank's preferred name, as "… it is a useful way to gain the client's attention and respect" (Phair and Good 1998). I took Frank into the 'quiet room' and made sure that we would not be disturbed, as recommended by Arnold (1995) and followed the suggestions of Egan, G (1994) regarding active listening, which include sitting squarely with an open posture, leaning slightly forward, making appropriate eye contact and relaxing. I made an effort to explain things to him in a way that he could understand. Asking open questions provoked limited response so I made careful use of closed and leading questions, frequently repeating and clarifying what Frank said to avoid misunderstandings. Goldsmith, M. (1996) suggests that it is possible to gain insight into "the views and preferences, the mood and sense of well-being of people with dementia through art, music and different forms of touch". In Frank's case the most obvious change in his behaviour and facial expression occurred when we listened to music together. He appeared very calm and relaxed, showing no signs of anxiety, and started tapping his hands on the arm of the chair, grinning and humming along to the music.
In this situation, it can be seen that an effective nursing intervention requires a combination of many skills. It involves effective use of communication skills and an 'attitude' towards the client of empathy, genuineness and unconditional positive regard (Rogers 1951). Morris (1999) describes such an undertaking as having a 'tool box' of skills, which should be applied appropriately to the job in hand. Nursing skills such as counselling and giving information are useful tools as are a number of complementary therapies, including relaxation techniques, aromatherapy, reflexology and acupuncture, although these "must be discussed with the team as part of the therapeutic process and the client must consent to their use" (NMC 2002).
Until recently, Frank lived at home with his wife Iris, 87, and their daughter Susan, 68, their the main carer. For the past eight years Frank has been suffering from vascular dementia. Lately his behaviour has become very confused and his daughter can no longer offer him the care that he needs. He is currently receiving 'permanent respite' at the home where I am on placement until a place becomes available in full time nursing care. He is often very anxious and will be observed crying, wringing his hands and repeating "Where's my mother? I love my mother". His mother died when he was 12. He often appears to hallucinate that she is near-by and becomes distressed when his attempts to reach out to her are in vain.
When the brain perceives a threat, it sends a signal from the medulla oblongata to the adrenal medulla via the sympathetic branch of the autonomic nervous system, releasing noradrenaline and adrenaline. These hormones cause physiological effects known as the fight or flight response.They include increased heart rate, raised blood pressure, dilation of vessels in the skeletal muscle, dilation of the bronchi and pupils, and the release of glucose into the blood.
Observable physiological changes include the following:
· Hypertension. Blood pressure is generated by cardiac output, which is affected by the rate and force of heart contractions and resistance to the flow of blood through the vessels. As a result of adrenaline secretion by the adrenal medulla, heart rate and stroke volume increase, due to increased myocardial contractility, and peripheral resistance increases due to vasoconstriction. The effect of this is a rise in arterial blood pressure. Another factor affecting blood pressure is the release of adrenocorticotrophic hormone (ACTH) by the anterior pituitary gland. This causes the adrenal cortex to reabsorb water and sodium ions, increasing blood volume and raising blood pressure.
· Tachycardia. The cardiovascular centre, situated in the medulla, raises heart rate via the autonomic nervous system by stimulation of sympathetic nerves with the release of adrenaline and noradrenaline. This is the body's attempt to increase cardiac output in readiness for action so that the vital organs receive an adequate supply of oxygen and nutrients, and waste products, carbon dioxide and heat are removed.
· Cold, clammy skin. The skin feels clammy due to an increase in perspiration. This occurs to stop the body overheating while in action and makes the skin harder to grab if caught by a predator (TAPIR 2002). Peripheral blood vessels are constricted, taking blood away from areas like the fingers and toes, making them cold to the touch. This is to prevent bleeding to death if we are gravely injured. Instead blood is sent to the heart, central nervous system and muscle. This is crucial preparation for fight or flight.
Teasdale (1995) suggests that nurses are well placed to assess levels of anxiety and to help patients to cope. Assessment can be carried out by careful interviews with the client and their family or carer. If a person is unable to give much detail about their feelings, a review of an average day can provide information about what raises anxiety and how they cope. (Wattis, J. and Martin, C. 1994). According to Maslow (1970), anxiety will result if our needs are not met.
In the case of people with organic dementia, "psychological defenses that previously kept anxiety at bay may have been weakened, and in some cases, collapsed completely" (Kitwood, T. 2001).
Attempts to communicate needs are likely to be observed as "behaviour easily labeled as difficult or disruptive" (Goudie F. and Stokes G. 1989). It is therefore important to "seek to understand the message, and to engage with the need that is not being met" (Kitwood T. 2001). Counselling skills including reflective listening, exploration, warmth and acceptance were suggested by Rogers (1951) as a way for professional carers to empathise with the hidden meaning and feelings lying behind confused verbal and behavioral expressions.
During the first week that I was working with Frank, I noticed a sharp deterioration in his condition, making it extremely difficult to communicate with him. I suspected that this might be the result of an 'acute confusional state' . Whilst assisting Frank to use the toilet, I noticed that his urine had a strong odour and dark colour. Previous experience led me to suspect that Frank might have a urinary tract infection, which urinalysis confirmed. I also suspected that Frank might be constipated. I spoke to his GP, who prescribed Lactulose and a course of antibiotics, which acted quickly to relieve the exacerbation of Frank's anxiety and confusion.
In an attempt to develop a therapeutic relationship with Frank, I considered the recommendations of Jones, G (1996) who noted the effectiveness of touch as it "can reassure the impaired person that there is someone there, even if their thoughts wander". I was careful to use Frank's preferred name, as "… it is a useful way to gain the client's attention and respect" (Phair and Good 1998). I took Frank into the 'quiet room' and made sure that we would not be disturbed, as recommended by Arnold (1995) and followed the suggestions of Egan, G (1994) regarding active listening, which include sitting squarely with an open posture, leaning slightly forward, making appropriate eye contact and relaxing. I made an effort to explain things to him in a way that he could understand. Asking open questions provoked limited response so I made careful use of closed and leading questions, frequently repeating and clarifying what Frank said to avoid misunderstandings. Goldsmith, M. (1996) suggests that it is possible to gain insight into "the views and preferences, the mood and sense of well-being of people with dementia through art, music and different forms of touch". In Frank's case the most obvious change in his behaviour and facial expression occurred when we listened to music together. He appeared very calm and relaxed, showing no signs of anxiety, and started tapping his hands on the arm of the chair, grinning and humming along to the music.
In this situation, it can be seen that an effective nursing intervention requires a combination of many skills. It involves effective use of communication skills and an 'attitude' towards the client of empathy, genuineness and unconditional positive regard (Rogers 1951). Morris (1999) describes such an undertaking as having a 'tool box' of skills, which should be applied appropriately to the job in hand. Nursing skills such as counselling and giving information are useful tools as are a number of complementary therapies, including relaxation techniques, aromatherapy, reflexology and acupuncture, although these "must be discussed with the team as part of the therapeutic process and the client must consent to their use" (NMC 2002).
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