OUR LADY OF FATIMA UNIVERSITY

120 MacArthur Highway, Valenzuela, 1440 Metro Manila

COLLEGE OF NURSING

“General Anxiety Disorder : A Case Study”

A Clinic Case Study Presented to the Faculty of College of Nursing

Our Lady of Fatima University

Valenzuela City Campus

In Partial Fulfillment of the Requirements in NCMB 317

Related Learning Experience

For the Degree of Bachelor of Science in Nursing

Clinical Instructor:

Mrs. Aida Bautista MAN, RN

Mrs. Caroline Sandiego MAN, RN

Submitted by: GROUP 5 3Y2-1A

Leader: Torres, Jolina Mae DG.

Members:

Galacia, Alexis

Guevarra, Mary Grace

Hilario, Adrianne Elisha

Quiaot, Regina

Ramirez, Raquel

Salvador, Carmelito

Vergara, Charo
I. OBJECTIVES

General Objectives:
The purpose of this case study is to broaden and develop every nursing student’s knowledge, attitude, and
skills and application of different nursing processes and management of the patient with General Anxiety Disorder.
In addition to providing accurate nursing measure and appropriate nursing responsibilities needed to apply based on
the patient demand for care

Specific Objectives:
• Describe General Anxiety Disorder and discuss the incidence and prevalence rate, risk factors, signs and symptoms,
treatment, and management.
• Discuss the psychopathology of General Anxiety Disorder.
• Set measurable and achievable short-and long-range goals
• Establish appropriate nursing diagnosis based from the assessment data gathered.
• Provide proper interventions to meet the health needs of the client.
• Determine the indications, contraindications, side effects, and nursing responsibilities of the medications
administered for the patient condition
• Develop an effective nursing care plan in which the client may benefit.
• Provide health teaching to patient with General Anxiety Disorder.
II. INTRODUCTION

Anxiety Disorder is one of the most common mental health concerns globally. These are diagnosed when
anxiety is no longer functions as a signal of danger or a motivation for needed change but becomes chronic and
permeates major portion of the person’s life, resulting in maladaptive behaviors and emotional disability. In
addition, these are the most prevalent psychiatric disorders which have high comorbidity between anxiety and
depressive disorders, which render complex treatment (Thibaut, 2017). Furthermore, anxiety is a condition where
considered as a response to both internal and external stimulus. Normally, it is considered accustomed emotion
when it is suitable to the situation and dissipates when it is resolved. However, the chronic significant distress may
result to impair holistic physiologic and psychologic functioning.
According to the National Statistics Office (2010) the Philippines has small-scale of epidemiological
evidence on mental disorder. However, there are available data which there is 14% of 1.4 million Filipinos with
disabilities were identified to have mental disorder. In addition, it is identified that mental illness is the third most
prevalent form of morbidity, in which there is accounted findings, 88 cases of mental health problems were reported
for every 100,000 population (DOH,2005). With the vast number of prevalence rate of people living with anxiety
and anxiety disorder, this data shows, Philippines made to have the third highest rate of mental health problems in
the Western Pacific Region (Martinez,2020). Moreover, suicide rates are pegged at 3.2 per 100,000 population with
numbers possibly higher due to underreporting or misclassification of suicide cases as ‘undetermined deaths.
The most prominent anxiety disorder is social anxiety disorder, which has an early onset by age 11 years
in about half of those diagnosed, and by age 20 years in about 80% of those diagnosed, and is a risk factor for
subsequent depressive illness and drug abuse. There is accounted and recorded prevalence of anxiety disorders
globally, which varies from 2.5 to 7 percent by each country. Furthermore, an estimated 284 million people
experienced an anxiety disorder in 2017, making it the most prevalent mental health or neurodevelopmental
disorder. Around 63 percent (179 million) were female, relative to 105 million males (Ritchie and Roser, 2018).
With the Generalized Anxiety Disorder, risk factors and precipitating factors have been identified but
there is no singular cause that could potentially trigger the development of generalized anxiety disorder. Some of the
common factors includes genetic predisposition, neurotransmission, family history, social influence and traumatic
experiences. Furthermore, the onset of clinical course of this type of disorder are extremely variabl
 A. PATIENT PROFILE

NAME: Mrs. Xenia

GENDER: Female
AGE: 45y/o
BIRTHDAY: Sept. 2,1972
NATIONALITY: Filipino
RELIGION: Catholic
ADDRESS: Makati City
CHIEF COMPLAINT: Constant worrying, insomnia and fatigue
ADMITTING General Anxiety Disorder
DIAGNOSIS:

HISTORY OF PRESENT • Two months prior to admission Mrs. Xenia 45 year old a
ILLNESS university professor, continued to be tortured by persistent
feelings of anxiety and worry associated with insomnia,
irritability, tension, and fatigue. Over the years, her
friends and family chided her for "worrying too much,"
and she reported difficulty controlling her anxiety over
her financial situation, job security, and her children's
safety, despite evidence that none of these were
problematic. Her husband reported that he found her
persistent anxiety and ongoing need for reassurance
"exhausting" and that he noticed himself withdrawing
from her, which led to significant tension between them.
The high quality of her work at the university was
recognized and she was well-compensated financially, yet she
continued to worry about her performance and was, in fact,
passed over for promotion to team leader because, as one of
her annual reviews stated, her "constant anxiety makes
everyone else too nervous."
PAST MEDICAL HISTORY • (+) History of anxiety and recurrent depressive symptoms
• Fears of dark and lightning
 • Persistent fear of insects, particularly cockroaches
• Experienced her first major depressive episode following a
break-up with a boyfriend.
SOCIAL AND FAMILY • Working in a university
HISTORY • Married with 2 children
• Developed a postpartum depression after giving birth that
lasted almost a year and for which she didn't seek
treatment.
• She reported that childhood was "generally happy"
• There was no history of physical or sexual abuse.
• She noted that her mother and father were both
"nervous" people, and though never formally diagnosed
and treated, her maternal grandmother had a history of
depression.
 B. MENTAL STATUS ASSESSMENT

ASSESSMENT AREA PATIENT’S ASSESSMENT

A –Appearance and Behavior The patient is an overweight woman and has a height of
162cm. She was wearing a slipper and observed to have
good grooming and personal hygiene. She has a shoulder
level hair and mole on the left side of her cheek. The
patient was cooperative during interview. She was
responsive to queries but provide limited information to
questions asked and seemed tensioned.
T –Thought Contents and Process The patient was dealing with the feelings of anxiety
and worry associated with insomnia, irritability,
tension, and fatigue. Her friends claimed that she’s
worrying too much and reported difficulty controlling
her anxiety over her financial situation, job security,
and her children's safety, despite evidence that none
of these were problematic. She kept on mouthing
“Nakakapagod ang trabaho ko”, “Hindi nila alam kung
anong ginagawa ko para sa kanila”, “Natatakot ako,
kinakabahan ako”, “Wala na akong pera, ubos na pera
ko”.
O -Orientation The patient is oriented to the 3 spheres: place, person and
time. She was able to state that she is currently in a
psychiatric institution. She was oriented to person as she
can recall the name of her student. She is also oriented to
time as he can state the time and the date of the day.
M -Memory The patient can recall further and recent memories. Can
recall past events of her life and able remember recent
events. When asked what she ate today she replied
“sinigang na baboy” spontaneously. When asked what is
his birthday and important past events of his life, she can
narrate.
I –Intellectual Functions The patient was very attentive during the NPI (nurse-
 patient interaction). She can follow simple instructions,
identify objects and can repeat sentences. She can also
do simple math problems and can identify different
objects.
C –Cognitive Functions The patient has poor judgment and decision making.
When asked “Paano kapag nakakita ka ng sampung libo,
anong gagawin mo?” she answered “Ibubulsa ko
kaagad” Abstract reasoning seemed good. When asked
“Pag binato ka ng bato?” She answered “Batuhin mo ng
tinapay”.
III. PSYCHOPATHOLOGY
 IV. DRUG STUDY
DRUG ACTION INDICATION/ CONTRAINDICATION SIDE EFFECTS NURSING
RATIONALE CONSIDERATION
Generic name: It increases Diazepam belongs to Contraindicated includes None side effect • Maintain patients
Diazepam neuronal a class of drugs -Hypersensitivity seen on the patient receiving
membrane known as - Pre-existing CNS benzodiazepines in
Brand name: permeability to benzodiazepines. It is depression or coma WOF for possible bed for 3 hours.
Valium chloride ions by used for the - Respiratory depression side effects: • Do not use small
binding to mmanagement of - Acute pulmonary veins (dorsum of
stereospecific anxiety disorders or insufficiency or sleep CNS: hand or wrist) for
Therapeutic class:
benzodiazepine for short-term relief apnea Headache, anxiety, IV injection.
Anxiolytics
receptors on the of symptoms of • Monitor liver and
- Severe hepatic pain, fatigue,
postsynaptic anxiety impairment insomnia and renal function,
Pharmacologic drug: GABA neuron CBC during long-
Benzodiazepines - Acute narrow angle drowsiness
within the CNS and term therapy.
glaucoma CV: Bradycardia,
enhancing the • Monitor EEG in
- Pregnancy and lactation tachycardia, CV
Dose: GABA inhibitory DRUG patients treated for
collapse,
5-10 mg effects resulting in RATIONALE status epilepticus,
hypertension and
hyperpolarization It works by seizures may recur
hypotension
Route: and stabilization. increasing the levels after initial
GI:
IV of a calming control.
Nausea and
chemical in the brain. • Observed patient
vomiting &
Frequency: This drug is given to closely and
abdominal pain,
May repeat in 3 to 4 make the patient feel monitor vital signs
GU:
hours if needed. drowsy, and relieve when diazepam is
Urine retention given.
anxiety,
HEMATOLOGIC: • Observed
Neutropenia necessary
HEPATIC: preventive
jaundice precautions for
SKIN: suicidal tendencies
rash that may be
present in anxiety
 states
accompanied by
depression.
• Monitored I&O
ratio, including
urinary and bowel
elimination.
• Monitor liver and
renal function,
CBC during long-
term therapy.
 DRUG ACTION INDICATION / CONTRAINDICATION SIDE EFFECTS NURSING
RATIONALE CONSIDERATION
Generic name: Fluoxetine It belongs to a class -Hypersensitivity to None side effect seen • Monitored for
Fluoxetine thought to be of medications called fluoxetine or any on the patient worsening of
linked to drugs selective serotonin component in its depression or
Brand name: inhibition of CNS reuptake inhibitors formulation WOF for possible expression of
Prozac neuronal uptake (SSRIs). side effects: suicidal.
of serotonin. -Use of monoamine Ideations.
Therapeutic class: DRUG oxidase CNS: Headache, • Notify physician
Antidepressants RATIONALE inhibitors (MAOI) used to nervousness, anxiety, of any rash;
Used to treat treat psychiatric disorders insomnia, drowsiness, possible sign of
generalized anxiety (clinicians should avoid fatigue, tremor, a serious group
Pharmacologic
disorder. This drug is initiating fluoxetine dizziness of adverse
class:
given to the patient within two weeks of effects.
SSRIs( selective
to decrease anxiety discontinuing the MAOI) CV: • Supervised
serotonin reuptake
symptoms and feel Palpitations and hot patients closely
inhibitors)
more relaxed and -Never initiate of flashes who are high
less anxious fluoxetine in a patient GI: suicide risks;
Dose: . receiving linezolid. Do especially during
20 mg/day Abdominal pain, dry
not give fluoxetine with mouth and vomiting. initial therapy.
pimozide, thioridazine, or • Watched for
Route: tamoxifen. Use with weight change
Oral SKIN:
caution in those with a during therapy
history of seizures. Rash, diaphoresis,
pruritus, sweating, • Used
Frequency: antihistamines or
hypersensitivity
O.D topical
reactions
corticosteroid to
treat rasher and
pruritus.
• Monitored I&O
ratio, including
urinary and
bowel
elimination.
 DRUG MECHANISM INDICATION & CONTRAINDIICATIO SIDE EFFECTS NURSING
OF ACTION RATIONALE N CONSIDERATION
Generic name: May block Used alone or with Contraindicated to patient None side effect seen • Assist patient with
Lamotrigine voltage-sensitive other medications to hypersensitivity to on the patient ambulation if
sodium channels, prevent and control lamotrigine. dizziness, ataxia
Brand name: stabilizing seizures. It may also WOF for possible occurs.
Lamictal neuronal be used to help side effects: • Assess for visual
membranes, prevent the extreme abnormalities,
Therapeutic class: Regulating mood swings of headache
Anticonvulsant presynaptic bipolar disorder in • Dizziness • Monitor for suicidal
transmitter adults. • Headache ideation, depression,
Pharmacologic release of • Diplopia behavioural changes
class: excitatory amino • Nausea • Take medication
Phenyltriazine acids. • Blurred vision only as prescribed,
• drowsiness do not abruptly
NOTE: Past discontinue
medication used for medication after
5 years on an as long- term therapy
needed basis during • Avoid drinking
periods of increased alcohol.
anxiety.
 DRUG MECHANISM INDICATION & CONTRAINDIICATION SIDE EFFECTS NURSING
OF ACTION RATIONALE CONSIDERATION
Generic name: Exact mechanism Used to treat Contraindicated to patients Nausea and Light • Assist with
Buspirone of action anxiety disorders or hypersensitivity to headedness are the ambulation if
unknown. Binds in the short-term buspirone. side effect drowsiness, dizziness
Brand name: to serotonin, treatment of observed in the occur.
Buspar DOPamine at symptoms of patient in the • Avoid tasks that
presynaptic anxiety. It works by couple of months require alertness,
Therapeutic class: neurotransmitter changing the while taking this motor skills until
Antianxiety receptors in amounts of certain drugs response to drug is
CNS. natural substances established.
Pharmacologic in the brain. The common side • Avoid alcohol and
class: effects are: grapefruit products.
Nonbarbiturate • Dizziness • Evaluate for
• Drowsiness therapeutic response:
NOTE: Past • headache calm facial
medication took expression, decreased
couple of months restlessness, and
mental status.
 V. NURSING CARE PLAN

ASSESSMENT NURSING BACKGROUND GOAL OF CARE NURSING RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE INTERVENTION
Subjective data: Anxiety related to Short term goal: Independent: Independent: Short term
perceived threat to goal:
Predisposition to Anxiety:
“Nag-aalala ako self-concept and Imbalance and/or abnormal functioning of norepinephrine, After 1 week of 1. Maintained a 1. To develop
kasi baka hindi biologic integrity serotonin, dopamine, and gamma- aminobutyric (GABA) nursing intervention calm, feeling of After 1 week
maganda ang as evidenced by the patient be able to: nonthreatening security in of nursing
performance ko sa worry associated Hippocampus and Cingulate Gyrus
abnormally process threat
• Lessen anxiety and manner while presence of intervention
trabaho at baka with insomnia, will appear relax working with calm staff patient’s
may mangyaring irritability, tension, Amydala maladaptive activate fear • Able to sleep and client person anxiety was
response
masama sa mga fatigue, and visual rest appropriately lessened,
magulang ko” as perceptions of • Verbalize ways to 2. Established and 2. Therapeutic appear relaxed,
verbalized by the traumatic event intervene in maintain a trusting skills need able to sleep
Activation of hypothalamus- Activation of autonomic nervous
patient pituitary- adrenal cortex axis system and adrenal medulla escalating anxiety relationship by to be and rest
• Respond to listening to the directed appropriately
Objective data: Cortisol release Epinephrine release relaxation client, answering toward and verbalized
techniques with a questions directly, putting the ways to
• Worry decreased anxiety and respecting the client at intervene in
associated Stress hormones interact with brain and level client’s use of ease, escalating
with body in various complicated mechanisms. personal space because the anxiety. Thus,
insomnia Long term goal: nurse who the goal was
• Irritability Anxiety
is a stranger met
• Tension After 1 month of may pose a
• Fatigue nursing intervention threat to the Long term
• Visual the patient will be able highly goal:
perceptions to: anxious
of traumatic • Recognize client After 1 month
event symptoms of onset of nursing
of anxiety 3. Used simple 3. In an intervention
And intervene words and brief intensely the patient was
before reaching anxious able to
panic stage by time messages, spoken situation, recognize
of discharge calmly and clearly client is symptoms of
From treatment unable to onset of
comprehend anxiety
anything and intervene
but the most before
elementary reaching panic
communicat stage by time
ion of discharge
from treatment
4. Remained with 4. The client’s
the client at all safety is
times when levels utmost
of anxiety are high priority. A
and reassure client highly
of his or her safety anxious
and security client
should not
be left alone
as his
anxiety will
escalate

5. Kept immediate 5. Anxious

surroundings low behavior
in stimuli by escalates by
moving into a external
quiet area with stimuli. A
minimal stimuli smaller or
secluded
area
enhances a
sense of
 security as
compared to
a large area
which can
make the
client feel
lost and
panicked

6.Taught signs and 6. So the client

symptoms of can start
escalating anxiety, using
and ways to relaxation
interrupt its techniques;
progression gives the
client
confidence
in having
control over
his anxiety

7. Avoided asking 7. The client

or forcing the may not
client to make make sound
choices and
appropriate
decisions or
may unable
to make
decisions at
all
8. Observed for 8. Early
increasing anxiety detection
and
intervention
facilitate
modifying
client’s
behavior

9. Encouraged the 9. Relaxation

client’s exercises
participation in are effective
relaxation nonchemica
exercises such as l ways to
deep breathing, reduce
progressive muscle anxiety
relaxation, and
guided imagery

Dependent: Dependent:

1. Administered 1. To help
Diazepam 5-10 relieve
mg prn as anxiety
prescribed by the
physician
 ASSESSMENT NURSING BACKGROUND GOAL OF CARE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE

SUBJECTIVE DATA: “Sleep SHORT TERM INDEPENDENT After 1 hour of nursing

Predisposition to Anxiety:
Deprivation Imbalance and/or abnormal functioning of norepinephrine,
After 1 hour of 1. Create an intervention the client
“Hindi ako nursing atmosphere to 1. Trust is an abled to
related to serotonin, dopamine, and gamma- aminobutyric (GABA)
nakakapagkatulog ng intervention the facilitate trust. essential first
persistent
maayos ilang araw na client will be step in the The patient is calm
worrying as Hippocampus and Cingulate Gyrus
sa dami ng aking iniisip abnormally process threat able to therapeutic and stop worrying as
evidenced by
”- as verbalized by the relationship evidenced by staying
lack of energy,
patient Amydala maladaptive activate fear The patient will and lying at her bed
dark circles response
calm and stop
OBJECTIVE DATA under the eyes worrying 2. Encourage
and verbal 2. Open
verbalization of Verbalize plan that
• Stunned report of expression of
Activation of hypothalamus- Activation of autonomic nervous Verbalize plan feelings, perceptions, provides adequate
difficulty of pituitary- adrenal cortex axis system and adrenal medulla feelings
• looked paler that provides and fears.
facilitates
time for sleep as
sleeping “ adequate time evidenced by “pipilitin
• sadder Cortisol release for sleep identification of kong wag
Epinephrine release
specific emotions magsaydong mag isip
• skin displayed Identify actions such as anger or isp ng makatulog at
wrinkles that can be helplessness, makapagpahinga ako”
Stress hormones interact with brain and
taken to ensure distorted
• Dark circles body in various complicated mechanisms.
adequate sleep perceptions, and Identify actions that
under the eyes
Anxiety time unrealistic fears. can be taken to ensure
• Lack of energy adequate sleep time
3. Obtain a sleep 3. To determine as evidenced by
Sense of foreboding or
• Problems with apprehension history to identify the what specific reducing things at the
concentration specific personal and factor or bed side and plan to
and memory environmental factors situation that have at least 8 hours
\Sleep
that may be depriving of sleep in a day, and
Deprivation
eliminating high in
• Verbal reports Clients of the amount cause difficulty to caffeine beverages
of difficulty of sleep needed for sleep intake
falling asleep optimal functioning.
✓ Goal was MET

4. Assess the amount

4. To determine
of sleep obtained each
the patient’s
night compared with
length of time
the amount of sleep
that she sleep
needed.

5. Encourage the client

to calm and have a rest 5. To promote
and keep environment comfort and rest
quiet
6. Stress
6. Encourage him to interferes with a
eliminate stressful person’s ability to
situations before relax, rest, and
bedtime sleep

7. Monitor bedtime 7. Milk and

food and beverage protein foods
intake for items that contain
facilitate or interfere tryptophan, a
with sleep precursor of
serotonin, which
is thought to
induce and
maintain sleep.
Stimulants should
 be avoided
because they
inhibit sleep.
8. Assist her to use
coping responses that
have been successful in 8. Feelings of
the past. safety and
security increase
when an
individual
identifies
previously
successful ways
of dealing with
anxiety-
DEPENDENT provoking or
fearful situations
Administer the
medication as ordered

- Diazepam

used to treat
anxiety and may
induce
- Fluoxetine drowsiness and
help get to sleep

to treat
depression and
anxiety
VI. RECOMMENDATION

Medication:
• Strict compliance with the prescribed medications:
✓ Diazepam 5-10mg oral PRN
✓ Fluoxetine 10mg oral OD
Educate the patient and caregiver about the common side effect of the drugs and the different
medication precaution of each drugs.
Environment and Exercise:
• Provide a calm and quiet room to reduce the stimuli, and allowing the patient to have
adequate rest periods to maintain regular sleeping pattern.
• Instruct patient to do walking, jogging, dancing, yoga or meditation.
• Teach patient how to do deep breathing exercise.
Treatment:
• Pharmacologic Treatment:
✓ Antidepressants and Anxiolytic drugs as needed and prescribed.
• Social Network and Support
✓ Cognitive Behavioral Therapy
✓ Relaxation training
✓ Group Therapy
Health Teachings:
For patient and relatives/Guardians:
• Instruct patient to make strict sleeping schedule or sleeping habits, avoid to take naps at
day time
• Advise patient strategies to initiate sleeping by listening calm music, turn off all the
electronics, and avoid stimuli that hinder her to sleep
• Instruct to have adequate sleep of 7-8 hours a day
• Learn ways and activities to cope with anxiety and worry, use diversional activities.
• Encourage client to keep a daily journal to become aware of what triggers anxiety.
• Encourage the patient to have social interaction. Talk to someone like spouse, significant
other, friend, child or doctor to express her feelings.
 • Encourage the family to recognize and acknowledge the client’s emotions, and always be
available to the client.
• Educate the family with regards to the nature of the disorder and what to expect from the
client. Also, avoid or not to argue with the patient.
• Educate the family with regards to the importance of being compliant to prescribed
medications, follow-up check-ups.
Out-patient:
Remind patient and family that frequent check-ups are important for health status monitoring, to
improve her condition and maintain optimum balance of wellness

Diet:
• Do not eat or drink foods and drinks that contains caffeine.
• Have high intake of fluids
• Eat food that are complex carbohydrates, protein, vitamin D, vegetable, and fruits
• Eat chocolate -pure, dark chocolate without milks and sugars. Reduces the stress
hormone, cortisol, and improves your mood
• Avoid or limit fast food, fried food, processed food, or foods with a high salt content
• Limit or avoid alcohol
Spiritual:

Encourage patient to remain at inner peace and pray often to promote good emotional condition
REFERENCES

Filipino help-seeking for mental health problems and associated barriers and facilitators: a systematic
review | SpringerLink

Mental Health - Our World in Data

Mental health services in the Philippines (nih.gov)

Anxiety disorders: a review of current literature (nih.gov)