Question

Stress & Coping Case Study

Penny, age 61 years, was admitted to the behavioral health center for short-term inpatient treatment following medical evaluation for chest pain, shortness of breath, and experiencing a racing heart rate after a myocardial infarction (MI) workup with a negative stress test ruled out an MI. She was prescribed Wellbutrin and Xanax by her PCP for anxiety attacks and discharged with a prescription to an outpatient therapist to help her cope with her anxiety. It has been identified that Penny has several stressors currently: she is working two full-time jobs to help cover the costs of her older brother’s long-term facility care to manage his worsening dementia. Before the admission, Penny had been attempting to care for her brother at home, but found that he required more care and supervision than she was able to provide. She feels tremendous guilt that she had to place her brother in a facility. Additionally, her brother has not managed the transition from home to the long-term care facility well, and there have been several incidents of behavioral problems, which have resulted in the administrator of the long-term care facility notifying Penny that they may not be able to continue to provide care for her brother.

Penny began having difficulty focusing at work and was spoken to by her supervisor about her forgetfulness. She became restless and irritable and described periods of apprehension and helplessness to her therapist. Her anxiety attacks have worsened over the past 2 weeks, and she now has difficulty leaving her house. When Penny does leave the house, she often experiences an attack where she feels unsafe, has difficulty prioritizing and making decisions, and feels like running home, where she is “safe.” It was decided to readmit Penny for stabilization of her current symptoms.

Upon entering Penny’s room to complete the admission paperwork, the nurse finds Penny crying, pacing back and forth, and wringing her hands. She repeats over and over, “I just don’t know what to do. I need to get out of here.”

1. What nursing diagnosis would the nurse apply to this patient with the above history and behavior?
2. Which level of anxiety is Penny currently experiencing?
3. What nursing interventions should be immediately implemented by the nurse?

Expert Answer

Answer 1

Stress can be defined as a feeling of mental tension due to challenges or demands one is facing. This mainly stems up due problems in life. Coping involves resisting the stress factors so as to overcome the challenges. In elderly people, stress can be overwhelming and may be difficult to cope with compared to others. It can lead to extreme sadness, depression, etc.

a. In the case mentioned, Penny was admitted to behavioral health center with complaints of chest pain, shortness of breath, and a racing heart rate.

Nursing diagnosis for Penny would be:

Anxiety

She is struggling with anxiety as a result of her stressful double full-time job. Some of the symptoms include:

• Affective symptom: Irritability
• Cognitive symptom: Difficulty in focusing on work
• Behavioral symptom: Restlessness.
• Physiological symptom: Increased heart rate, shortness of breath.

Pain

As a result of anxiety attack she is also experiencing acute chest pain

Depression

Penny is depressed due to the guilt that she is not able to care for her brother who is struggling in the long-term care facility.

Low self esteem

She is lacking confidence in herself and feels unsafe. Hence, she is finding it difficult to leave her house. She also has difficulty in prioritizing and making her own decisions.

b. The patient has increased activity of autonomic nervous system (hyperventilation and heart rate), elevated vital signs, muscle tension, chest pain, etc. She is also experiencing nervousness, restlessness, feeling unsafe, lack of ability to focus, desire to avoid things, performing certain actions again and again, severe sweating, etc.

From all these symptoms, it can be established that Penny is suffering from severe anxiety.

c. Nursing interventions which can be implemented by the nurse include:

• Be calm and supportive.
• When under anxiety attack a simple massage or backrub can help to reduce anxiety.
• Try to hold hands or use verbalization technique to show support and encourage the patient to clarify any questions, concerns, or needs.
• Make the patient aware of the reason for anxiety. Acknowledge the patient’s feeling and communicate the acceptance of the feelings.
• Communicate with the patient in a peaceful manner and listen to her patiently. Do not interfere or argue with her. This can make the patient feel safe and secure with the nurse taking care of her.
• Encourage the patient to express her feelings, any pain or discomfort she is experiencing.
• Be empathetic while reassuring the patient regarding her anxiety issues.
• Talk positively to the patient and encourage her to think and talk positively about the situation.
• Help the patient to cope with the situation by using anxiety reducing skills like meditation, relaxation techniques, positive self-statements, etc.
• Provide anti-anxiety medications and educate the patient regarding it and importance of taking it regularly.
• Use guided imagery like fantasizing about a beautiful place can help overcome the stress.
• Listening to slow soothing music is also helpful to reduce anxiety.