9.8 Spotlight Application

Melissa is a 20-year-old nursing student who visits her primary care provider for a refill on her birth control pills. During the admission assessment, Melissa shares with the intake nurse that her “anxiety has gotten much worse” during nursing school. She states, “I always feel tired, but I can’t sit down and relax. I feel like there is always more studying that I should be doing for my classes. Even though I’m tired at night, I don’t sleep well and wake up frequently throughout the night. If I can’t go back to sleep, I turn on my computer and study. I have also been getting headaches every day, and I think it is from being on the computer so much. My boyfriend keeps asking me why I am so crabby. Lately I have had a lot of test anxiety, and sometimes my mind goes blank during an exam even though I have memorized all of the material.”

The primary care provider diagnoses Melissa with Generalized Anxiety Disorder and encourages her to attend a local support group with other people experiencing anxiety. A beta-blocker is prescribed on an “as needed” basis for before exams or other types of performance assessments, and a referral is made to a psychotherapist for cognitive behavioral therapy.  Melissa is encouraged to follow up with her primary health care provider in two weeks for evaluation of her progress.

1. What priority assessment data should the nurse collect at this time? (Assessment/Recognizing Cues)

The frequency, duration and triggers of her anxiety; including how her anxiety affects her daily life, academic performance and relationship with others. The number of hours Melissa sleeps at night, the quality of her sleep and how often she wakes up during the night. Further assessment of Melissa’s headaches, including frequency, severity, location and possible triggers. Coping mechanisms that Melissa has tried to use to manage her stress. Signs of fatigue or nutritional imbalances. Presence of support system. Signs and symptoms associated with the “flight or fight” stress response. The levels of anxiety Melissa has been experiencing (mild, moderate, severe or panic). Screening tools, such as the Severity Measure for Generalized Anxiety Disorder. Lab work to assess for physiological causes of Melissa’s anxiety. Cultural beliefs that may affect Melissa’s perception of anxiety or treatment options.

2. Based on the assessment data provided, which nursing diagnoses would be appropriate at this time? (Diagnosis/Analyzing Cues)

•       Anxiety r/t academic demands
•       Disturbed sleep pattern r/t anxiety
•       Chronic pain r/t excessive screen use
•       Impaired social interaction r/t irritability
•       Ineffective coping r/t inability to manage anxiety

3. Provide a sample of expected outcomes that would be appropriate for Melissa. (Outcome Identification/Generate Solutions)

•       Melissa will report a decrease in anxiety symptoms within two weeks.
•       Melissa will sleep 6-8 hours per night without frequent awakenings within two weeks.
•       Melissa will experience a reduction in headache frequency and severity within two weeks.
•       Melissa will maintain healthy relationships by managing her irritability within two weeks.
•       Melissa will list three different stress management techniques prior to leaving the clinic.

4. What nursing interventions would be appropriate for this client? (Planning & Implementation/Generate Solutions & Take Action)

•       Use therapeutic communication techniques such as actively listening, providing a calm environment and validating Melissa’s feelings.
•       Teach Melissa how create a realistic study schedule that balances study time with self-care activities.
•       Provide Melissa with resources on stress management techniques such as exercise, guided imagery, journaling or practicing mindfulness.
•       Encourage Melissa to limit screen time before bed and avoid studying in bed to help improve quality of sleep.
•       Provide education on how a well-balanced diet can improve anxiety and overall wellbeing.
•       Reinforce the importance of support groups and following through with psychotherapy referral.
•       Teach Melissa to recognize the early signs of anxiety so it can be managed effectively.
•       Educate Melissa on her prescribed beta-blocker, including proper timing and potential side effects.
•       Encourage Melissa to avoid caffeine as this can exacerbate anxiety as well as interfere with sleep.

5. How would you evaluate if Melissa’s outcomes were met? (Evaluation/Evaluate Outcomes)

Every time the nurse interacts with Melissa, outcomes should be evaluated. Continued assessment of Melissa’s anxiety levels, sleep patterns, headaches, relationship status and ability to apply stress management techniques will help the nurse determine if outcomes are met, partially met, or not met. If outcomes are partially met or not met, the nurse may need to continue monitoring Melissa’s progress or the care plan may need revision.