-
Mild +1 (Signs)
- psychomotor:
- Slight muscle tension
- Slight fidgeting
- Energetic
- Good eye contact
- Emotional:
- Occasional slight irritability
- feeling challenged
- confident (use of adaptive coping mechanisms)
- Cognitive:
- alertness
- awareness of surroundings
- concentration
- accurate perceptions
- attentiveness
- logical reasoning and problem solving skills
-
Mild +1 (Interventions)
- discuss source of anxiety
- problem solve
- accept anxiety as natural and benefit from it
-
Moderate +2 (signs)
- Psychomotor:
- Moderate muscle tension
- increased blood pressure, pulse, and respitations
- startle reflex
- slight perspitation
- difficulty sitting still
- repeated fidgeting
- periodic slow pacing
- increased rate of speech
- sporadic eye contact
- Emotional:
- Feeling uncomfortable, on edge, keyed up
- motivated to decrease anxiety
- increased irritability
- decreased confidence (use of palliative coping mechanisms)
- Cognitive:
- Difficulty in concentrating
- easily distracted, can focus with assistance
- circumstantiality
- tangenitality
- loose associations
- narrowed perceptions
- deceased attention span
- misperception of stimuli
- problem solving and reasoning skills with effort or assistance
-
Moderate +2 (interventions)
- decrease anxiety, ventilation, crying, exercise, relaxation techniques
- refocus attention: relate feelings and behaviors to anxiety then use problem solving techniques
- give oral medications if needed
-
Severe +3 (signs)
- Psychomotor:
- increased perspitation
- continuous and rapid pacing
- reflex responses
- loud or rapid speech or both
- poor eye contact
- somatic
- Emotional:
- Extreme discomfort
- feeling of dread
- hypersensitivity
- defensiveness with threats and demand (use of maladaptive coping mechanisms)
- Cognative:
- distorted perceptions
- difficulty focusing, even with assistance
- flight of ideas
- ineffective reasoning and problem-solving
- disorientation
- delusions and hallucinations if prolonged
- suicidal or homicidal ideations if prolonged
-
Severe +3 (interventions)
- decrease anxiety, stimuli and pressure
- use kind, firm, simple directions
- use time out, (seclusion)
- give Intramuscular medications if needed
-
Panic +4 (signs)
- suicide attempts or violence
- depletion of body resources
- eyes fixed
- hysterical or mute
- incoherent
- feeling overwhelmed out of control
- rage
- desperation
- feeling totally drained (Use of dysfunctional coping mechanisms)
- disorganized perceptions
- irrational reasoning and problem solving
- neologisms
- clang associations
- word salad
- out of contact with reality
- peronality disorganization
-
Severe +4 (inteventions)
- Guide firmly, or physically take control
- give intramuscular medication
- order restraints, if needed
|
|
