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134 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

TABLE 7.1 Clinical indicators of anxiety

Physiological Behavioural Psychological/cognitive Social
● ↑ heart rate ● Restlessness ● Confusion ● Seeking reassurance
● ↑ blood pressure ● Agitation ● Anger ● Need for attention/
● Chest pain ● Sleeplessness ● Negative thinking companionship
● ↑ respiratory rate ● Hypervigilance ● Verbalisation of anxiety ● Limiting interaction
● Shortness of breath ● Fighting ventilator ● Facial expression
● Altered O 2 saturation ● Uncooperative ● Inability to retain and process
● Coughing/choking feeling ● Rapid speech information
● ↑ diaphoresis ● Difficulty verbalising
● Pallor ● Distrustful/suspicious
● Cold and clammy ● Desire to leave stressful area
● Dry mouth
● Pain
● Headache
● Nausea and vomiting
● Swallowing difficulty

response, mediated by the hypothalamic-pituitary- The relationship between a patient’s self report of anxiety
adrenal (HPA) axis, regulates this activity. Physiological and clinician assessment of anxiety has been inconsistent.
changes occur to multiple body systems, with the most When chart reviews were undertaken to determine the
relevant including inhibition of salivation and tearing, relationship between clinicians’ routinely documented
constriction of blood vessels, increased heart rate, relax- anxiety and patient self-report of anxiety, no relationship
5
ation of airways, increased secretion of epinephrine and was found. In contrast, when clinicians were prompted
norepinephrine as well as increased glucose production, to assess anxiety in intensive care patients their rating of
8
which all contribute to the range of clinical indicators the severity of anxiety did have moderate correlation with
outlined in Table 7.1. These physiological manifestations patients’ self report of anxiety. 7
illustrate the importance of early identification, active
reduction and minimisation of anxiety in critically ill A number of self-reporting scales exist to measure anxiety
patients. (Table 7.2). These scales require cognitive interpretation
and an ability to communicate responses, which presents
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Clinical indicators of anxiety are broad and relate to four challenges to many critically ill patients. In addition,
major categories including physiological, behavioural, some of these scales have up to 21 items, making them
psychological/cognitive and social (Table 7.1). 9,10 both time-consuming and unmanageable for regular use
in the critical care setting. Patients with visual and audi-
Appropriate recognition of anxiety is important as there
is beginning evidence that the physiological effects of tory impairments will require additional assistance, such
anxiety can have important effects on outcomes for criti- as larger print, hearing aids or glasses in order to com-
cal care patients. Many of the clinical signs listed in Table plete the forms.
7.1, for example, increased blood pressure and respira- The visual analogue scale–anxiety (VAS–A) is fast and
tory rate, are likely to lead to poorer outcomes for the simple to complete as it is a single-item measure. It has
critically ill patient. In addition, in acute myocardial been evaluated against a recognised anxiety scale (SAI)
infarction patients, in-hospital complications such as with 200 mechanically ventilated patients. The VAS–A
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recurrent ischaemia, infarction and significant arrhyth- comprises a 100-millimetre vertical line, with the bottom
mias were significantly higher in patients with high levels marker labelled ‘not anxious at all’ and the top marker
of anxiety compared to those with low levels of anxiety. 11 labelled ‘the most anxious I have ever been’. Patients were
able to successfully mark, or indicate, their present level
ANXIETY ASSESSMENT of anxiety.
The importance of anxiety assessment with the aim of The Faces Anxiety Scale, another single-item scale that has
reducing or preventing the adverse effects it produces, is recently been developed by a group of Australian research-
supported by the literature. However, recognition and ers, has five possible responses to assess anxiety (see Figure
interpretation of anxiety is complex, particularly when 7.1). Initial testing with small numbers of critically ill
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signs and symptoms are masked by critical illness, the patients indicates that the self-reporting single-item scale
effect of medications and/or mechanical ventilation. appears to accurately detect a patient’s anxiety. 20,21
Further, alterations in levels of biochemical markers such
as cortisol and catecholamines that are frequently associ-
ated with anxiety may also be attributed to physiological ANXIETY MANAGEMENT
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stress. Thus, anxiety rating scales are advocated and Critical care nurses recognise that anxiety is
may offer benefits not found with unstructured clinical detrimental to patients and that anxiety management is
22
assessment. important. Although pharmacological interventions