Communication with Patients who are Anxious (Home Health Care) - CE/NCPD

ALERT

Acknowledge and address physical and emotional discomforts in a patient who is anxious without emphasizing the physical complaints to the exclusion of the emotional ones. Focus on understanding the patient’s particular anxieties or fears. Provide feedback and assist in problem solving. Create an atmosphere of concern and acceptance.

OVERVIEW

Patients experience anxiety for a variety of reasons. A newly diagnosed illness, life changes due to disabilities, and financial concerns are just a few factors that can cause anxiety. How successfully a patient copes with anxiety depends, in part, on previous experiences, the presence of other stressors, the significance of the event causing the anxiety, and the availability of supportive resources. The health care team member can be a support to the patient and can decrease anxiety through effective communication. Communication methods reviewed in this skill assist the health care team member in helping a patient who is anxious recognize factors causing anxiety and how the patient can cope more effectively. There are four stages of anxiety with corresponding behavioral manifestations: mild, moderate, severe, and panic (Box 1).

SUPPLIES

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EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Teach the patient, family, and caregivers to identify possible sources of anxiety, such as illness, physical deficits, knowledge deficits, or other known stressors. This gives the patient awareness of anxiety and increases the patient’s sense of control.
• Engage the patient, family, and caregivers in selecting specific methods of coping with anxiety.
• When teaching the patient, family, and caregivers, remember that those who are under stress may require repeated explanations.
• Encourage questions and answer them as they arise.

STRATEGIES

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient, family, and caregivers.
3. Verify the correct patient using two identifiers.
4. Explain the strategies to the patient, family, and caregivers, and ensure that the patient agrees to treatment.
5. Verify the practitioner’s order and assess the patient for pain.
6. Assess for physical, behavioral, and verbal cues that indicate that the patient is anxious, such as dry mouth, sweating, altered tone of voice, elevated pulse and respiratory rates, difficulty concentrating, irritability, wringing of hands, and complaints of fear, worry, or sleeplessness.^{undefined#ref1">1}
7. Assess for possible factors causing the patient anxiety, such as pain, dyspnea, recent disabling conditions, fatigue, financial worries, and an uncertain prognosis.
8. Assess for factors influencing communication with the patient, such as the presence of other people, previous experiences with home health personnel, pain, or discomfort.
9. Discuss the possible causes of the patient’s anxiety with the family and caregivers.
10. Recognize own anxiety level and remain calm (breathe slowly and deeply). Be aware of nonverbal cues that indicate own anxiety such as body language, posture, and speech cadence.
11. Make the physical environment as quiet and calm as possible and allow ample personal space.
12. Provide a brief, simple introduction and explain the purpose of the home visit.
13. Use appropriate nonverbal behaviors, such as maintaining a relaxed and calm posture, and active listening skills.

    Rationale: Appropriate nonverbal behaviors express interest and help to alleviate anxiety.

14. Use appropriate verbal techniques that are clear and concise to respond to a patient who is anxious. Use brief statements that acknowledge the patient’s current feeling state, such as “It seems to me that you are anxious” or “I notice that you seem anxious.”

    Rationale: Appropriate techniques and statements provide reassurance and prevent further escalation of anxiety.

15. Provide necessary comfort measures.

    Rationale: Pain and discomfort heighten anxiety.

16. Help the patient learn coping strategies, such as progressive relaxation, slow deep-breathing exercises, and guided imagery. Be aware of physical deficits and disabilities.
    1. Progressive relaxation (often combined with guided imagery and breathing exercises): Teach the patient to tighten and relax various muscle groups.
    2. Deep-breathing exercises: Teach the patient to focus on slow, deep, even breaths.
    3. Guided imagery: Teach the patient to focus on pleasant images to replace negative or stressful feelings. Guided imagery may be self-directed or led by a health care team member or a recording.²
17. Observe for the continued presence of physical signs and symptoms or behaviors that reflect anxiety.
18. Discuss ways to cope with anxiety with the patient.

    Rationale: Discussing ways to cope with anxiety allows the health care team member to measure the patient’s ability to assume more health-promoting behavior.

19. Evaluate the patient’s ability to discuss factors causing anxiety.

    Rationale: Evaluating the patient’s ability to discuss factors causing anxiety allows the health care team member to recognize and focus on areas of concern.

20. Assess pain, treat if necessary, and reassess.
21. Remove PPE and perform hand hygiene.
22. Document the strategies in the patient’s record.

EXPECTED OUTCOMES

• Patient incorporates strategies for coping with anxiety.
• Source of anxiety is identified and resolved.
• Health care team member’s interaction with patient reduces patient’s anxiety.
• Patient incorporates strategies for problem solving.
• Patient incorporates strategies for decision making.
• Patient focuses attention on discussion regarding concerns.
• Anxiety is decreased.

UNEXPECTED OUTCOMES

• Physical signs and symptoms of anxiety continue.
• Health care team member’s interaction increases the patient’s anxiety.
• Source of anxiety is not resolved.
• Patient displays difficulty in decision making.
• Patient avoids health care team member’s efforts at focusing discussion or is unable to discuss real concerns.
• Anxiety continues to prevent problem solving.
• Anxiety continues to escalate.

DOCUMENTATION

• Cause of patient’s anxiety
• Signs and symptoms of anxiety
• Methods used to relieve anxiety and patient’s response
• Education
• Patient’s progress toward goals
• Assessment of pain, treatment if necessary, and reassessment
• Unexpected outcomes and related interventions

OLDER ADULT CONSIDERATIONS

• Anxiety often goes undiagnosed in older adult patients because it may present differently than it does in younger adults. Symptoms of anxiety in older patients may be expressed as somatic complaints. In addition, tools used to assess for anxiety in younger adults may not be specific for anxiety in older adults.⁵
• Anxiety may affect sensory input needed to maintain balance, placing the older adult with anxiety at a higher risk for falls. In addition, adults with anxiety are more likely to report a fear of falling even if they have not had a fall.⁴
• In older adults, anxiety may develop as a result of a specific event or a general pattern of change, such as an overall decline in health. In addition, major life-changing events can precipitate delayed posttraumatic stress disorder in older adults.³
• Anxiety should be managed based on the patient’s presenting behaviors while considering cognitive or physical impairments.
• Older adults who are socially isolated and have multiple medical problems are more likely to have anxious or depressive symptoms, and they are less likely to seek care for these symptoms.⁵

REFERENCES

1. Andrews, G. and others. (2018). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Australian and New Zealand Journal of Psychiatry, 52(12), 1109-1172. doi:10.1177/0004867418799453 (Level VII)
2. National Institutes of Health (NIH), National Center for Complementary and Integrative Health (NCCIH). (2021). Relaxation techniques: What you need to know. Retrieved November 28, 2023, from https://www.nccih.nih.gov/health/relaxation-techniques-what-you-need-to-know (Level VII)
3. Pless Kaiser, A. and others. (2019). Posttraumatic stress disorder in older adults: A conceptual review. Clinical Gerontologist, 42(4), 359-376. doi:10.1080/07317115.2018.1539801
4. Wetherell, J.L. and others. (2018). Integrated exposure therapy and exercise reduces fear of falling and avoidance in older adults: A randomized pilot study. The American Journal of Geriatric Psychiatry, 26(8), 849-859. doi:10.1016/j.jagp.2018.04.001 (Level II)
5. Witlox, M. and others. (2021). Prevalence of anxiety disorders and subthreshold anxiety throughout later life: Systematic review and meta-analysis. Psychology and Aging, 36(2), 268-287. doi:10.1037/pag0000529 (Level I)

ADDITIONAL READINGS

Grover, S. and others. (2019). Anxiety and somatic symptoms among elderly patients with depression. Asian Journal of Psychiatry, 41, 66-72. doi:10.1016/j.ajp.2018.07.009

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports

Clinical Review: Loraine Fleming, DNP, APRN, PMHNP-BC, PMHCNS-BC

Published: January 2024