Case study - Generalized anxiety disorder: Nursing

Nurse Becca works in a family practice clinic and is caring for Holly, a 32-year-old who presents with anxiety. After settling Holly in the room, Nurse Becca goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Holly’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.  

First, Nurse Becca recognizes important cues, including Holly’s vital signs which are temperature 98.6 F or 37 C, heart rate 88 beats per minute, respiratory rate 19 breaths per minute, and blood pressure 136/75 mmHg. Nurse Becca notes that Holly appears restless and is biting her nails. She gathers more information about Holly’s symptoms. 
 

Nurse Becca: Hi Holly, tell me how you’re feeling. 

Holly: Well, I’m feeling really overwhelmed lately. I’m worried about so many things. And I’m having trouble concentrating at work.  
  Nurse Becca: That sounds difficult. How are you sleeping? 

Holly: I only sleep a few hours each night, I can’t stop thinking about things.  
  Nurse Becca: When did your symptoms start? 
  Holly: Around seven months ago right after I moved and started my new job. 

Next, Nurse Becca administers the Generalized Anxiety Disorder 7-item screening tool, or GAD-7, and notes Holly has a score of 12 out of 21, which is consistent with moderate anxiety. 

Nurse Becca then analyzes these cues. She reviews the electronic health record, or EHR, and notes that Holly has no previous history of mental health disorders. She reports her assessment findings to the health care provider who diagnoses Holly with generalized anxiety disorder, or GAD.  

Nurse Becca remembers that one of the main features of GAD is excessive worry; and although the exact cause of GAD isn’t known, but it’s thought to be caused by an imbalance of the neurotransmitters, where serotonin system activity is low and noradrenergic system activity is elevated. This leads to symptoms of restlessness, difficulty concentrating, and impaired sleep. It can be brought on by stressful events or life changes, like moving and starting a new job. Nurse Becca recognizes that Holly needs effective management of her anxiety. 

Now, using the information she's gathered, Nurse Becca develops a priority hypothesis of ineffective coping. 

Then, Nurse Becca generates solutions to address Holly’s ineffective coping, including pharmacological and nonpharmacological interventions; and she establishes the expected outcome that after intervening, Holly will adopt two effective coping strategies by her follow up appointment.