Defining Characteristics
Anxiety is an emotion and a subjective individual experience. It is an energy and therefore cannot be observed directly. A nurse inferes that a patient is anxious besed on certain behaviors. The nurse needs to validate this with the patient. Also, anxiety is an emotion without a specific object. It is provoked by the unknown and precedes all new job, or giving birth to a child.
Anxiety is a situation that marked by fear feel that espoused by somatik's sign that declare for hiperaktifitas's happening otonom's nervous system. Anxiety is phenomena that don't frequent one specific be found and oft constitutes a normal emotion (kusuma w, 1997).

Anxiety is respond to a threat that its unknown source, internal, vaguely or conflict (Kaplan, Sadock, 1997).

Anxiety theory
Anxiety constitutes a response to fraught situation pressure. Stress can be defined as a threat perception to an expectation that triggers alarm. Its result is working for behaviour (Rawlins, at al, 1993).
a. Psikodinamik's theory
b. Behavioural theory
c. Interpersonal's theory
d. Biological theory
e. Cognitive family

Predisposisi's factors
Anxiety is a prime factor in the development of the personality and formation of individual character traits. Because of its importance, various theories of the origin of anxiety have been developed.
Each change in life or life scene that can evoke stress situation called by stresor. Stress that experienced by someone can evoke anxiety, or anxiety constitutes manifestasi direct of life stress and so hand in glove bearing it by patterns life (Wibisono, 1990).
A variety factor predisposisi who can evoke anxiety (Roan, 1989) which is genetic factor, organic factor and psychology factor. On patient who will trip operation, predisposisi's factor anxiety that really influential is psychological factor, particularly uncertainty about procedure and operate for that will be tripped.

Levels of Anxiety
Pepelau identified four of anxiety and described their effect on the individual:
1. Mild anxiety is associated with the tension of day. To-day living. During this stage the person is alert and the perceptual field is increased. The person sees, hears, and grasps more than previously.
2. Moderate anxiety, in wich the person focuses only on immediate concerns, involves the narrowing of the perceptual field as the person sees, heras and grasps less.
3. Severe anxiety is marked by a significant reduction in the parceptual field.the person tends the focus on a specific detail and not think about anything else.
4. Panic is a associated with awe, dread, and terror this stage details are blown out of proportion. Because of a complete loss of control, the person unable to do things even with direction.
Symptom of Anxiety
Patient that experience anxiety usually have typical and subdivided phenomenas in a few phase, which is:
a. Phase 1
Situation is physical as it were on phase reacts warning, therefore body unlimbers to berkelahi (fight), or flight (run at full speed). On this phase body feels not delicate consequent of increasing secretion adrenalin hormone and nor is adrenalin.
Therefore, therefore phenomena marks sense anxiety can as perceive convulsively at muscle and exhaustion, particularly at chest muscles, jugular and back. In its preparation for fight, causing muscle wills be stiffer and accordingly will evoke ache and spasme at chest muscle, jugular and back. Stress of agonis's group and antagonist will evoke tremor and quiver that easily gets to be seen on fingers (Wilkie, 1985). On this phase anxiety constitutes step-up mechanism of nervous system that reminds we that system its function nerve begins mengolah's baffled ala aught information is right (Asdie, 1988).
b. Phase 2 (two)
Over and above clinical phenomena as on phase one, as perturbed as, muscle stress, sleeping trouble and belly complaint, patient also beginning can't control its emotion and no motifasi self (Wilkie, 1985).
c. Phase 3
Phase anxiety situation one and two that doesn't be settled whereas stresor just make a abode continued, patient will fall into phase anxiety three. In contrast to phenomena which appear on phase one and two one are easily at its bearing identification with stress, anxiety phenomena on phase three by and large as changed as deep behavioral and not usually in evidence bearing it with stress. On phase three it can appear phenomenas as: intoleransi by stimulates sensoris, tolerance ability loss to something earlier one have that it can tolerir, trouble reacts to something that glimpses most see as personality trouble (Asdie, 1988).

The Nursing Process

Assessment

Phobic Disorders

Behaviour Assessment Affective Assessment Cognitive Assessment Social Assessment
What situation or objects do you try to avoid in life?

Describe wthat you do to avoid these situations or objects.

Are you social or work activities limited to a prescribed geographic area?

How often and in what circumstance are you able to leave home? What are you greatest fears in life?

Do you fear others laughing are you? Being humiliated?
Being abandoned by others?
Being alone in an unfamiliar situation?

What feeling do you experience when you are confronted with the situation or object that you fear?

What else happens to you at this time?
To what degree do you fear having future panic attacks?

Do you dislike being controlled by your fears?

What does the future look like for you?

Describe how family living patterns have changed around you fears.

Under what circumstances are you able to socialize wih friends?

Obsessive Compulsive Disorder

Behaviour Assessment Affective Assessment Cognitive Assessment Social Assessment
What kinds of objects or situation do you feel a need to check or recheck frequently?

How much time during a day do you spend on checking activities?

Desribe any movements you are forced to repeat.

What kinds of things do you count, silently or our loud? Describe how you experience the feeling of anxiety.


Describe the qualities you like about your self.

How much support do you need from others to cope with life?
How hepless and dependent on others do you feel? Who is able to support you in avoiding your feared situations or objects?


What happens to you when you feel out of control in situation?

Describe situations in which you feel close to and warm with your family members.

In what ways do you feel dependent on your family?

Describe your relationships with significant others.

How do these others relate to you?

What are your greatest fears in life? Describe the qualities you like about your self. Describe the qualities you do not like about your self.

What are you thoughts about you compulsive bahaviour?

Would you like to decrease the need for your compulsive behavior?

How much time a day do you spend doubting what you have done?

What are the fears you worry about every day? In what way do habits or thoughts get in the way of work? Social life? Personal life?

Nursing Diagnosis
Anxiety, mild, related to threat to self concept due to far of being out of control.

Outcome Identification
Goals such as “decrease anxiety” and “minimize anxiety” lack specific behaviors and evaluation criteria. These goals therefore are not particularly useful in guiding nursing care and evaluating its effectiveness. The expected outcome for patients with maladaptive anxiety responses is :
The patient will demonstrate adaptive ways of coping with sress. Short term goals can then break this down into readily attainable steps. This allows the patient and nurse to see progress even if the ultimate goal still appears distant.
When the nursing diagnosis describes the patient’s anxiety at the server or panic levels, the highest- priority short-term goals should address lowering the anxiety level. Only after this has been achieved can additional progress be made. The reduced level of anxiety should be evident in a reduction of behaviours associated with the severe or panic levels. Following are examples of short-term goals for a particular patient.
After 4 days Mr. Lones will :
1. Attend and remain seated during all meetings.
2. Participate at least three times during each meeting.
3. Discuss one topic for a minimum of 10 minutes when meeting with his nurse.
4. Attend all occupational therapy sessions.
5. Sleep a minimum of 6 hours a night.
When these goals are met, the nurse can assume and validate that the patient’s level of anxiety has been reduced. The nurse may then develop new short- term goals directed toward insight or relaxation therapy.

Planning
The main goal of the nurse working with anxious patients is not to free them totally from anxiety. Patients need to develop the capacity to tolerate mild anxiety and to use it consciously and constructively. In this way the self will become stronger and more integrated. As they learn from these experiences, they will move on in teheir development. Patients must also be convinced that the values to be gained in moving ahead are greater than those to be gained by escape. Anxiety can be considered a war between the therat and the values individuals identify with their existences. Maladaptive behavior means that the strunggle is won by the threat. The constructive approach to anxiety means that the strunggle is won by the person’s values. Thus a general nursing goal is to help patients develop sound values. This does not mean that patients assume the nurse’s values. Rather, the nurse work with patients to sort out their own values.
Anxiety can also be an important factor in the patient’s decision to seek treatment. Since anxiety is undesirable, the individual will seek ways to reduce it. If the patient’s coping mechanism or symptom does not minimize anxiety, the motivation for treatment will be increased. Conversely, anxiety about the therapeutic process can delay or prevent the individual from seeking treatment.
The patient should actively participate in planning treatment strategies. If the patient is actively involved in identifying relevant stressors and planning possible solutions, the success of the implementation phase will be maximized. Patients in extreme anxiety initially will not be able to participate in the problem solving process. However, as soon as their anxiety is reduced, the nurse should encourage their involvement. This will also reinforce that they are responsible for their own growth and personal development.

Implementation
Severe and Panic Levels of Anxiaety

Establishing a trusing relationship. The patient with severe o panic levels of anxiety may be hospitalized. To produce this patient’s level of anxiety, most nursing actions are supportive and protective. Initially nurses need to establish an open, trusting relationship. Nurses should actively listen to patients and encourage them to discuses their feeling of anxiety, hostility,guilt, and frustation. Nurses should answer patient’s questions directly and offer unconditional acceptance of them. Nurses should remain available and respect use of personal space. A 6-floot distance in a small room may create the optium condition for openness and discussion of fears.
The more this distance is increased or decreased, the more anxious the patient may become.

Self- awareness. Nurses feeling are of particular importance when working with highly anxious patients. They may find themselves being unsympathetic, impatient, and frustrated. These are common feeling of reciprocal anxiety that nurses should be awere of and accept. If nurses are alert to the development ao anxiety in themselves, they can learn from it and use it therapeutically. For example, it may indicate some important emotional issue that the patient is unable to identity and verbalize, or it may reflect a conflict within the nurses that is interfering with the ability to be therapeutic. Nurses should therefore be alert to the signs of anxiety in themselves, accept them, and attempt to explore their cause. The nurse may ask the following questions:
• What is threatening me?
• Is this patient a source of reflected esteem for me?
• Have I failed ti live up to what I imagine is the patient’s ideal?
• Am I comparing myself to a peer or another health professional?
• Is the pateint’s are conflict one that I have not resolved in myself?
• Is my anxiety related to something that will or mayhappen in the future?is my patient’s conflict really one my own that I am projecting?
If nurses deny theirr own anxiety, it can have detrimental effects on the nurse-patient relationship. Because of their own anxiety. Nurses may be unable to differentiate between levels of anxiety in others. They may also transfer their feals and frustations to patients, thus compounding their problem. Finally, nurses who are anxious will arouse defenses in other patients and staff that will severely interfere with their therapeutic usefulness.
Clinical situations or patient problems raise yaour anxiety as a nurse
• Protecting the patient
• Modifying the environment
• Encouraging activity
• Medication

Evaluation
Evaluation is an ongoing process engaged in by the nurse ang patient that is part of each phase of the nursing process. Even before beginning to formulate the nursing diagnosis, the nurse should ask: “Did I critically observe my patient’s physiological and psychomotor behaviors? Did I listen to my patient’s subjective description of experience? Did I fail to see the relationships between my patient’s expressed hostility or guilt and underlying anxity? Did I assess intellectual and social functioning?” After collecting the data, the nurse should analyze it. Was I able to identify the precipitating stressor for the patient? What was the patient’s perception of the threat? How was this influenced by physical health, past experiences, and present feelings and needs? Did I correctly identify the patient’s level of anxiety and validate it?
When using the criteria of adequacy, effectiveness appropriateness, efficiency, and flexibility in evaluating the nursing goals and actions, the following question can be raised.
• Were the planning, implementation, and evaluation mutual?
• Were goals and actions adequate in number and sufficiently specific to minimize the patient’s level of anxiety?
• Were maladaptive responses reduced?
• Were new adaptive coping responses learned?
• Was the care plan reasonable in terms of time, energy, and expense?
• Was the nurse accepting of the patient and able to monitor personal anxiety throughout the relation ship?
Answering these questions enables the nurse to review the total care provided. The nurse will also identify personal strengths and limitations in working with the anxious patient. Plans may then be made for over coming the areas of limitation and further improving nursing care.



References

D. barry Patricia,1997. Mental health & mental illness, philadelphia newyork :

LippincottFontainate, Karen Lee.1999. Mental health nursing. 4 thred. Menlo park, California : Addison Wesley

Frinch Noreen Cavan & Lowrence E Frisch. 2006. Psychiatric mental health nursing. Third edition, Colorado Springs, Colorado : Thomson Delmar Learning

Wiscorz Stuart & Shandra J Sundeen. 1995, Principles and practice of Psychiatric nursing. Fifth edition. United states of america. Mosby. Year book. Inc

Kaplan, Sadock, B.1995 Comprehensive Text Book Of Psyshiatry. 6 th ed, Vol 1. Marland: William & Wilkins