I. Understanding Anxiety

Anxiety is a feeling uneasy, worried, or afraid and can be mild to severe. This condition can occur for no apparent reason. Anxiety is an emotional level with the characteristics of the changes in body, mind, and behavior. This condition has a limit at a certain level. Once the level of anxiety reached this limit, then he will stop for a while and then dropped (Dadds et al., 2000; National Institute for Clinical Excellence, 2004). All people can experience anxiety, but if the person is experiencing at the time that was not supposed to and found it difficult to control the anxiety condition was experiencing the person is said to suffer from anxiety disorders (National Institute for Clinical Excellence, 2004).

Anxiety includes three components (Dadds et al., 2000):

1. Physical changes.

These physical changes can vary. However, the most common problems are short of breath, dizziness, heart palpitations, trembling, muscle tension, sweating, numbness, tingling sensation, dry mouth, discomfort in the stomach, and nausea.

2. Mind.

Different types of anxiety associated with different thoughts. The mind is such a fear of crowds or attention was having a heart attack. In essence, the patient feels to be in a dangerous condition.

3 Behavior.

The most common reaction is indicated by the patient anxiety is avoidance. For example, if someone was afraid to be in the crowd then these people will avoid crowded places.
II. Anxiety Symptoms

Forms and symptoms of anxiety disorder among others (American Psychiatric Association, 2005):

- Feelings of panic and fear that too much.

- Disturbance uncontrolled thoughts.

- Disturbed by the memory or painful memories.

- The nightmare that kept recurring.

- Physical symptoms such as nausea, sweating, tingling feeling in the stomach, heart pounding, easily startled, muscle tension, headache, trouble speaking, difficulty in swallowing .
Whereas in children and adolescents are anxious to experience the following symptoms (Dadds et al., 2000):

- Unrealistic, and excessive anxiety.

- The need for continuing to tranquilizers.

- Too worried about the events that have or that will happen.

- Too concerned with everything he does.

- Complaints without obvious cause.

- Lack of rest.

- Tired.

- It's hard to concentrate.

- Irritable.

- It's hard to part with their parents.

- Not like the school.

- Panic attacks.

- Avoidance of a situation.

- Difficult in the social environment.

- Phobia.

- Interference or pressure minds.

III. and Physiology of Anxiety

Until now, the aetiology of anxiety disorder is still unknown. There are various opinions that explain how an anxiety reaction occurs. Some researchers focused on the amygdala are believed to act as a communications hub between the parts of the brain that processes the sensor signals are coming and interpret other parts. The amygdala may provide a signal that there is a threat or danger, and lead to fear or anxiety response (Dickey, 2002; American Psychiatric Association, 2005).

While other studies focus on the hippocampus is a structure of the brain responsible for processing threatening or traumatic stimuli. Hippocampus plays an important role in the brain to help turn information into memory. Another part of the basal ganglia and the striatum contribute to anxierty type of obsessive-compulsive disorder (Dickey, 2002).

Some experts also suggested that the gene also have a role in anxiety . This is what can explain why a person after a trauma or a specific stimulus may suffer from PTSD, while others suffer from PTSD with different stimuli, and also explains why anxiety disorder can be lowered into the family. It is still studied how genes interact and experience that can lead to anxiety disorders (Dickey, 2002; American Psychiatric Association, 2005).

IV. Anxiety Disorder Classification

Anxiety is a manifestation of behavior are classified into two categories: state and trait anxiety.. State anxiety is an episode of acute anxiety that is affected by conditions or circumstances at the time and not be settled. While trait anxiety is an anxiety patterns that are considered character or personal traits (Kiyohara et al., 2004).

The types of anxiety disorder include: panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, phobia, generalized anxiety disorder (Dickey et al., 2002).

1. Panic disorder.

Core symptoms of panic disorder is panic attacks. People with panic attck have feelings of terror that strike suddenly and repeatedly without any prior warning. They can not predict when an attack will occur. And some people experience great anxiety among each episode. They are also worried about when and where the next attack will occur. Sometimes they can suffer agarophobia so try to avoid public places (Dickey et al., 2002; National Institute for Clinical Excellence, 2004).

When there is panic attacks, some of the following symptoms may occur (American Psychiatric Association, 2005):

- Heart palpitations and chest pains.

- Sweating, trembling.

- Shortness of breath and choking sensations arise. Nausea or abdominal pain.

- Head spinning.

- Imagining and disconnection with the people around it.

- Fearing loss of control, "mad", or was dying.

- Numb.

- Feeling cold or hot.

Because of severe symptoms, panic disorder sufferer sometimes think that they suffer a heart attack or other diseases threatening (National Institute for Clinical Excellence, 2004; American Psychiatric Association, 2005).

2. Obsessive-compulsive disorder (OCD).

Obesesi is distracting thoughts and irrational that always comes back. Obsessive-compulsive disorder is a disorder where a person has rituals that he can not control because he was haunted by certain thoughts.

Examples are people who are very scared and do not want any germs that he must always do the procedure too much with a particular sequence. This disorder can be very disturbing their daily activities and social relationships (American Psychiatric Association, 2005; Dickey et al., 2002).

3. Post-traumatic stress disorder (PTSD).

Post-traumatic stress disorder is a debilitating condition that develops due to a frightening event. This condition can occur in people who have survived physical and emotional events are very scary.
People who usually mengalaim PTSD nightmares that kept recurring, memories continue to imagine and very disturbing, or even feel bad that he would naturally happen again if he is in certain situations (American Psychiatric Association, 2005; Dickey et al., 2002 ).

People with PTSD may experience such symptoms (American Psychiatric Association, 2005):

- Numb.

- Sleep disturbance.

- Supervised by a person feels.

- Irritability.
Events that can trigger PTSD is a war for example, violent personal assault, natural disasters, tragedies (eg plane crash), physical or sexual violence as a child, or witnessed others in a severe accident (American Psychiatric Association, 2005).

4. Phobia.

Phobia is a fear that excessive and persistent object, situation, or particular akitivitas. This fear makes the sufferer to avoid things they fear excessive manner. A person diagnosed with phobia if the fear of disturbing their lives and their activities daily. Phobia is divided into three: social phobia, specific phobia, and agoraphobia (American Psychiatric Association, 2005)

- Social phobia.

Social phobia or social anxiety disorder is a fear or anxiety is excessive if someone was in the social environment. They're afraid to feel ashamed or afraid when dipehatikan by many people.

Example of speaking in public. (Dickey et al., 2002; American Psychiatric Association, 2005).

- Specific phobia.

Specific phobia is an excessive fear of something that little or no danger at all. Patients are usually aware that their fear is too much, but they are not able to overcome these fears.

For example fear of flying, or fear of certain animals (Dickey et al., 2002; American Psychiatric Association, 2005).

- Agoraphobia Agoraphobia

Agoraphobia is the fear if they are in a place where people feel there is no way out or help someone else. If this condition is not treated, it will increase in serious condition makes the sufferer even afraid to go out and always try to avoid public places (National Institute for Clinical Excellence, 2004; American Psychiatric Association, 2005).

5. Generalized anxiety disorder (GAD).

Generalized anxiety disorder is an anxiety of excessive, unreasonable, and experienced from day to day. People with GAD experience a severe tension and continuous very disturbing his daily activities.

They constantly feel anxious and unable to control this anxiety. They may experience sleep disturbance, tension or muscle pain, trembling, weakness or headache, can not be calm, anxious and irritable, difficult concentration, and have sleep problems (Dickey et al., 2002; National Institute for Clinical Excellence, 2004).

NURSING PROCES

ASSESSMENT

Since all persons experience anxiety in everyday living nad all perseons seeking health care at least some anxiety re;ated to their need for care, it is essential that the nurse have the ability to make and assessment of anxiety and determine if the anxiety being expressed is healthy or not. One author states,”Recognizing anxiety and assessing its cause are as essential {to nursing care} as monitoring vital signs” (Spear, 1996, p. 41.). Another author cautions that nurses in home care setting will see client with anxiety and the nurses must be in a position to make carefull assessment of that anxiety ( Busch, 1996). In such an assessment, the nurse must be able to determine if the client’s anxiety is a symptom of one of the anxiety is a temporary response to a current stressor.

In making the assessment, the nurse should begin with the observable, physical sign of anxiety-increased pulse, blood pressure, and respiratory rate, a heightened startle response, and “gut symptoms” such as urinary frequency or abdominal distress. Then, the nurse should inquire about the client’s cognitive responses- sense of disorientation, difficulty concentrating, and/or fear of losing control.

NURSING DIAGNOSIS

Several nursing diagnosis are relevant to any of the anxiety disorders, and some are likely to be relevant to one of the specific disorders. The accompanying display list diagnoses and related factors commonly assigned to clients with anxiety disorder. These diagnoses address not the anxiety disorder itself, but the human response to the disorder.

OUTCOME IDENTIFICATION

Nursing care for any of the anxiety disorders must be based on achieving realistic outcomes of care. The nurse will set outcome goals in collaboration with the client and will recognize that it may take weeks for the client to feel a sense of control of his life or months to achieve a day-to-day perceptions of clecreased anxiety. Realistic outcomes might be that the client’s anxiety is clecreased so that he may drive a car on the freeway whithout fear of panic attack or that he may leave the house in the morning at least 2 days without excessive anxiety regarding being out in public.

PLANNING / INTERVENTIONS

The Nurse’s independent role in treating anxiety disorder as to plan interventions aimed at assisting the client to cope with subjective, human responses to the anxiety experienced. The nursing interventions of therapeutic listening, building trust, and establishing a positive nurse client relationship are essential to providing care. The nurse must let the client know that he understands and accepts her symptoms of anxiety as real and important. For example, identifying symptoms of an impending panic attack and administering medications.

EVALUATION

Nursing care should be evaluated in terms of whether or not the expected outcomes were achieved. In anxiety disorder, one cannot expect the client to experience a complete “cure” or remission of the disorder. However, the therapeutic goal should be that the client achieve a level of control over his anxieties and be able to experlance life in a personally satisfying manner. There is obviously a need for the nurse and client to discuss realistic expectations and to determine the client’s and wants in relation to his own illness

CARE PLAN

The story of Wilbur the man experienced the crisis of the West Virginia flood=one can recognize the tragedy of significant disaster. Wilbur is experiencing Post-Traumatic Stress Disorder. One year after the flood experience, he describes guilt, anxiety, sleeplessness, and fear of water/rain. A nurse involved evaluation of those losses in his life that are associated whit the flood, the nurse uncovers that the grief as prolonged, yhat is he has not worked trough the grief he is holding.

Imagine that nurse are giving care to the man, who has come to the facility for treatment. A fictionalized nursing care plan follows.

NURSING DIAGNOSIS 1 :

Post-trauma syndrome related to disaster (flood), as evidenced by flashbacks and nightmares, and verbalization of guilt.

Outcomes	NIC	Nursing Actions	Evaluations
· Wilbur will verbalize an understanding of Post-Traumatic Sterss Disorder (PTSD) · Wilbur will begin to be more involved with his family and community: has anxiety has will decrease over the next 6 months as his interest in other increases	· Crisis intervention · Support system enhancement	· Provide information to Wilbur regarding post traumatic response : the relationship among his fear of rain, sleepless-ness, and anxiety · Assist Wilbur to identify activites he might enjoy to redirect his attentions to the present. · Identify support groups that might be available in Wilbur local area	· Within 1 mont, Wilbur had a good underdtanding of PTSD and could relate the information to his own experience · Wilbur began to enjoy and engage in outdoor activities with old friends, for example, hiking.

NURSING DIAGNOSIS 2

Disfinctional grieving related to actual losses, as evidenced by reliving of past experiences, interference with life functioning, and alterations in sleep habits.

Outcomes	NIC	Nursing Actions	Evaluation
Wilbur will begin the grieving process to identify his losses and work through the emotions of anger and depression.	· Presence · Active listening · Grief work facilitations	· Encourage Wilbur to slowly and gradually discuss his experience in a safe and secure setting. · Assess Wilbur for depression, enxiety, and the potential for self-harm of neglect. · Support Wilbur through the grieving process. · Facilitate creating an environment that would most enable Wibur to heal based on his perspective. · Provide positive feedback for Wilbur’s growth and improvement.	Over time, Wilbur dealt with the severe losses from the flood. He realitez the flood. He realized the normalicy of grieving and how one “sometimes can not make sense of these things”. He kept thinking that he and his whole family would have died had he not gotten up to smoke. When the most intense grieving period had passed, he grinned and commented that evertyboddy thinks smoking is so bad. He believes it saved his life.