Fear as the nursing diagnosis in surgical patient

Introduction

Illness and especially the hospitalization associated with it is a difficult life situation for most patients and can be accompanied by intense negative experiences associated with emotions that are unfavorable for the organism (Jandová, 2003). Any disease has an adverse effect on a person's psyche. The disease changes the usual way of life, restricts a person in his usual habits for a shorter or longer period of time, reduces performance in the profession or makes it impossible, often disrupts or changes interpersonal relationships. The disease requires a certain degree of adaptation to a new situation, coping with adverse, often painful manifestations, places increased demands on the individual in suddenly changed conditions (Čechová et al., 2001).

During the hospitalization of a surgical patient, and especially when surgical therapy is indicated, the possibilities and ways of reducing fear come to the fore, as hospitalization is usually a relatively new kind of experience for patients. Many things change - not only in the patient (in his body), but also in his psyche, or even in his spiritual life (Křivohlavý, 2002). From the nursing point of view, Fear comes to the fore as a nursing diagnosis in surgical patients, or in patients undergoing surgical therapy.

A nursing diagnosis is a clinical conclusion about the responses of an individual, a family, a community to current or potential health problems or a life process. It forms the basis for selecting nursing activities to achieve the results for which the nurse is responsible. NANDA International deals with the development and standardization of nursing diagnostic terminology. The development of diagnostic terminology initiated by NANDA-I resulted in the creation of an international classification system of nursing diagnoses (NANDA Taxonomy I, NANDA Taxonomy II) (Boledovičová, Vörösová, 2009 In: Žiaková et al., 2009, p. 100; Kozierová et al., 2004; Marečková, Jarošová, 2005; Marečková, 2006; Mastilikova, 2014; Tóthová, 2014; Vörösová et al., 2015).

According to the Decree of the Ministry of Health of the Slovak Republic no. 306/2005 Coll. of June 30, 2005, which establishes the list of nursing diagnoses, is nursing, or nursing diagnosis defined as "a clinical conclusion about a current or potential need, nursing problem, or condition of a person, family, or community that affects health and requires intervention specific to a nurse or midwife. A nursing problem is any condition or situation in which a person requires assistance in consolidating, supporting, maintaining, or regaining health, or in ensuring a peaceful death." The nursing diagnosis of Fear is included in the List of Nursing Diagnoses in the Appendix to Decree No. 306/2005 Coll. in the group of diagnoses P 100 – 119 Mental states and processes under code P 111.

NANDA International (Herdman, Kamitsuru, 2014) classifies the nursing diagnosis Fear with code 00148 in the 9th domain: Coping with stress - resistance to stress and in the 2nd class within the mentioned domain: Response to coping with stress. This class is intended for nursing diagnoses, which are the standard names for nursing problems in the field of managing stress related to the human environment. NANDA International defines Nursing Diagnosis 00148 Fear as a response to a perceived threat that is consciously recognized as dangerous. NANDA International presents standardized names of nursing diagnoses with numerical code and their definitions, while offering an overview of the defining features, associated and risk factors of the diagnoses. Based on their presence, it is possible to confirm the occurrence of a specific nursing diagnosis in the patient and establish a diagnostic conclusion (Marečková et al., 2012).

The nursing diagnosis of Fear was included in the list of NANDA nursing diagnoses as early as 1973 (Kim, 1982 In Zeleníková et al., 2011). It was divided into two main categories: functional and non-functional fear, with levels of mild, average, severe, panic. In 1980, two categories were removed from the list of NANDA nursing diagnoses, and the separate diagnosis Fear remained included in the classification system until the present (Zeleníková et al., 2011).

A precise and documentable nursing diagnostic conclusion is the basis for a decision on appropriate nursing interventions, which is implemented for the patient by a team of nursing professionals in cooperation with a team of other health professionals. Primary sources on the issue of nursing diagnostics are published at two-year intervals by the Wiley-Blackwell publishing house under the title "NANDA - International Nursing Diagnoses: Definitions & Classification" (Marečková et al., 2012).

Determinants of the nursing diagnosis 00148 Fear according to NANDA International, taxonomy II are divided into general, cognitive, behavioral and physical. Among the general defining characters, or defining characteristics include a premonition that something is going to happen, a decrease in self-confidence, irritability, a feeling of dread, fear, panic, horror, warnings, increased blood pressure, increased tension, nervousness, muscle tension, nausea, paleness, dilated pupils, vomiting. Cognitive determinants include reduced ability to learn, reduced ability to solve problems, reduced productivity, identification of a fear-inducing object, presence of a stimulus that the patient considers a threat. Behaviorally determining signs are attack and escape behavior, narrowed focus of attention on the source of fear, impulsivity, increased vigilance. Among the physical determining signs are loss of appetite, changed physiological response (e.g. increased blood pressure, accelerated pulse rate, accelerated respiratory rate, etc.), diarrhea, dry mouth, shortness of breath, exhaustion, excessive sweating (Herdman, Kamitsuru, 2014; Marečková, 2006).

Related factors of nursing diagnosis 00148 Fear are instinctive reactions to external stimuli (e.g. unexpected sound, height), language barrier, learned response (e.g. to external conditions), phobia-inducing stimuli, sensory disorders (e.g. visual, auditory), separation from support system, unfamiliar environment and new experiences (Herdman, Kamitsuru, 2014; Marečková, 2006).

When recognizing the current nursing diagnosis 00148 Fear, the nurse proceeds in 4 steps. In the 1st step, it assesses the presence of determining characters. If at least one determining feature is found, the presence of related factors will be assessed in the 2nd step. If the patient detects a combination of one of the determining signs and one of the related factors, in the 3rd step it proceeds to the verification and considers whether the patient is really in a situation defined by the definition: Fear is a person's reaction to a threat that he perceives as dangerous. If the verification result is positive, in the 4th step the nurse records the presence of fear in the patient's nursing documentation (Marečková, 2006).

According to Šlaisová (2016), fear can be diagnosed by observing the patient (frightened facial expression, crying, shaking, sweating, paleness, quiet speech, etc.) and an interview, the aim of which is to find out the cause and intensity of fear, the level of awareness of the patient, his attitudes and expectations. Questionnaires and assessment scales can also be used in the diagnosis of fear.

The characteristics and use of evaluation and measurement tools in the assessment of fear and anxiety in a patient during surgical therapy can be found primarily in foreign professional literature, while these evaluation tools are primarily oriented towards anxiety (anxiety, or preoperative anxiety). Janíková, Zeleníková (2013) state that the majority of measurement tools and scales for assessing fear and anxiety are available in the original - most often English language. When translating a specific tool from the original language, it is necessary to respect the standard procedure of translating the original version, which represents the process of linguistic validation. This process consists of several phases, the content of which is determined by the recommendations of a specific organization or the author. The first necessary step is usually to obtain the consent of the author of the measuring instrument to translate it.

The STAI questionnaire (Spielberger's State-Trait Anxiety Inventory), which is considered the gold standard, is most often used to assess preoperative fear and anxiety. It is a 40-item self-assessment tool that contains 2 separate scales – 20 items of the first scale measure the state of anxiety and 20 items of the second scale measure anxious personality traits. The total score is from 20 to 80, with the higher the score, the higher the degree of anxiety (Janíková, Zeleníková, 2013). Other standardized instruments useful in assessing fear and anxiety in the surgical patient include:

  • VAS (Visual Analogue Scale) – it is a 100 mm segment that represents a scale from 0 to 100, with 0 on the left side representing no anxiety and 100 on the right side representing the greatest possible anxiety.
  • HADS (The Hospital Anxiety and Depression Scale) – a 14-item questionnaire for determining anxiety and depression.
  • GAS (Graphic Anxiety Scale) – a simple one-item linear scale on which the patient evaluates the level of anxiety, while individual points on the scale include the following statements: calm, mildly anxious, moderately anxious, very anxious, extremely anxious.
  • APAIS (The Amsterdam Preoperative Anxiety and Information Scale) – Amsterdam scale of preoperative anxiety and need for information containing 6 items (4 items related to fear of anesthesia and fear of surgery and 2 items related to need for information), within which the patient evaluates on a Likert scale from 1 to 5, where 1 means - not at all and 5 means - very much.
  • BAI (The Beck Anxiety Inventory) – is a 21-item inventory that describes subjective symptoms, somatic symptoms, and anxiety symptoms related to panic.
  • HARS (The Hamilton Anxiety Rating Scale) – The Hamilton Anxiety Rating Scale is a 14-item scale used to rate the severity of anxiety symptoms and the patient rates each item on a 5-point scale.
  • Anxiety level scale 1211 – a selected set from the NOC (Nursing Outcomes Classification) forms a list of 31 defining indicators, the intensity of which is assessed by the nurse on a Likert scale from 1 – severe to 5 – none (Janíková, Zeleníková, 2013; Vörösová, 2015 In: Hlinková, Nemcová et al., 2015).

Other scales include SFQ (The Surgical Fear Questionnaire), ASSQ (Anxiety Specific to Surgery Questionnaire), COSS (The Coping with Surgical Stress Scale), MAACL (Multiple Affect Adjective Check List) (Badner et al., 1990; Bailey, 2010; Janíková, Zeleníková, 2013; Krohne et al., 2000; Mitchell, 2003; Sigdel, 2015; Theunissen et al., 2014; Vörösová, 2015 In: Hlinková, Nemcová et al., 2015).

Among the expected results or evaluation criteria in the nursing diagnosis Fear of surgical performance according to Doenges et al. (2010) include:

  • the patient admits his feelings and looks for suitable ways of dealing with them,
  • the patient appears relaxed and is able to rest or sleep adequately,
  • the patient behaves in such a way that his fear is reduced to a manageable level,
  • the patient demonstrates the ability to perform the requirements resulting from the therapeutic procedure.

Doenges, Moorhouse (2001) include the following nursing interventions for the nursing diagnosis of Fear: a) assess the degree of fear and the reality of the threat felt by the patient:

  • find out how the patient and his support persons perceive what is happening and how it affects their lives,
  • notice the degree of influence by fear (e.g. "stiffened by fear", inability to engage in necessary activities),
  • compare verbal and non-verbal responses and assess whether they match and whether there is a wrong view of the situation,
  • look for signs of denial or depression,
  • detect possible sensory disorders (e.g. hearing impairment) that have an impact on sensory perception and interpretation of the environment,
  • notice to what extent the patient is focused and what he focuses his attention on,
  • analyze subjective experiences described by the patient (they may be delusions or hallucinations),
  • be attentive and always carefully examine whether there is a threat of violent behavior,
  • examine the basic physiological parameters (physiological response) to the situation,
  • assess family dynamics (focusing on nursing diagnoses: Inability of the family to cope with the burden, Threatening coping with the burden by the family, Disturbed family life).

b) help the patient and his support persons to cope with fear, or deal with the situation:

  • be close to the patient or ensure that someone is always with him (the feeling of abandonment can exacerbate fear),
  • actively listen to the patient (verbalization of his concerns),
  • provide oral and written information; speak in simple sentences and specific terms; facilitate the understanding and memorization of information,
  • recognize the normality of fear, pain, despair and allow the patient to adequately express feelings,
  • give the patient the opportunity to ask questions and answer them honestly; not to argue with how the patient perceives the situation; limit conflicts, because fear has a negative impact on rational thinking,
  • support the patient in controlling himself as much as possible and accepting that he is not able to do so in certain things,
  • encourage the patient to contact peers who have successfully gone through a similar fearful situation (this creates a role model and the patient willingly believes someone who has experienced something similar).

c) lead the patient to develop his own answers when solving problems:

  • recognize the usefulness of fear in taking care of your person,
  • make it clear that the patient is the one responsible for the solution (support him by making the nurse's help available); strengthen the patient's sense of control over things,
  • determine internal and external sources of help (e.g. awareness of the situation, use of skills proven in the past, use of social support),
  • explain the necessary procedures to the patient at such a level that he is able to understand and implement them (a lot of information can confuse him),
  • as appropriate, explain the relationship between the disease and the symptoms,
  • check the use of anti-anxiety medications and emphasize the necessity of taking them exactly as prescribed.

d) focus on health promotion (teaching/instructions before discharge):

  • support the planning of the steps to be taken,
  • teach the patient relaxation, visualization and similar techniques,
  • encourage the patient and help him to prepare an exercise program, within his possibilities, that provides a healthy outlet for the energy created by fear and promotes relaxation,
  • respond appropriately to any sensory impairment (e.g. speak clearly and distinctly, use touch),
  • recommend support groups or public organizations as indicated, or provide additional assistance according to individual needs.

Doenges et al. (2010) specify nursing interventions for a patient with a nursing diagnosis of Fear of surgery:

  • carry out pre-operative patient education, including repetition of procedures in the pre-operative period,
  • demonstrate and discuss with the patient routine procedures and processes that can be a source of fear for the patient (e.g. administration of sedatives the evening before surgery, premedication, operating room environment, monitoring aids during surgery and anesthesia, etc.),
  • to assure the patient about the effects of anesthesia and about blocking the view of the surgical field with a surgical drape in the case of local or regional anesthesia,
  • to identify the presence of fear of a possible postponement of the operative performance,
  • validate the source of fear,
  • provide accurate and understandable information,
  • actively listen and observe the patient (verbalization of fear, feeling of helplessness, possible changes due to the operation, etc.),
  • ensure the transfer of the patient to the operating room accompanied by a medical professional, prevent confusion of the patient and check the patient's signed informed consent to surgical therapy,
  • prevent an unnecessarily long stay of the patient in the operating room before the operation,
  • participate in the cooperation of the surgeon, anesthesiologist, nurses, clergy, clinical psychologist,
  • if necessary, discuss the postponement of the surgical procedure with the operator, or attending physician, patient and his family.

Čáp, Holmanová (2008 In: Tomagová, Bóriková et al., 2008) recommend the following effective strategies for patients with fear, which should be supported:

  • support for hope in one's own strength,
  • venting emotions through conversation,
  • actively seeking help from others,
  • division of the problem situation into parts and their gradual solution,
  • problem solving in a heuristic way: trial and error,
  • the ability to recognize signs of fatigue and disorganization,
  • willingness to change oneself,
  • cope with accepting problems.

When dealing with fear as a nursing diagnosis, it is necessary to apply an appropriate psychological approach in the care of patients during surgical therapy, which Zacharová and Šimíčková-Čížková (2011) include:

  • knowledge of a person's premorbid personality,
  • creating relationships between the doctor and the patient, especially in connection with the surgical performance,
  • knowledge of the stages the patient goes through in post-traumatic conditions and complicated treatment,
  • a comprehensive assessment of the state of health with regard to the patient's psyche,
  • individual approach to the patient, especially in preoperative preparation and postoperative care,
  • elimination of fear and anxiety associated with surgery,
  • explanation of the course and stages of pain in connection with professional performance,
  • enabling patient contact with support persons,
  • preparing the patient for new changed living conditions or a changed lifestyle,
  • appropriate communication between the patient and medical staff,
  • early education about treatment options and options,
  • cooperation with a psychologist or psychiatrist.

When providing nursing care to a patient in the perioperative period, nurses must take into account that the life needs of a surgical patient change during hospitalization. The specific form of the needs of a sick person depends on the nature of the disease, on the patient's personality and on the social conditions in which he lives (Zacharová et al., 2007).

Bártlová (2003 In: Zacharová et al., 2007) divides human needs into needs that do not change due to illness, needs that are modified by illness, and needs that arise with illness. Knowledge about basic human needs forms the theoretical basis for the application of the nursing process. When treating the patient, the nurse must always keep in mind that she is working with a person whose mood, experience and behavior are influenced by the satisfaction of biological, psychological, social and spiritual needs (Zacharová et al., 2007).

An important part in solving the nursing diagnosis of Fear in a surgical patient is also the implementation of nursing visits. Nursing visits take place with the participation of nurses as well as other healthcare workers (e.g. nutritionist, dietitian, physiotherapist) at the patient's bedside. They are designed to identify and ensure the patient's nursing needs – nutrition, excretion, physical and psychological well-being, etc. (Krišková et al., 2006).

The main goals of an individual nursing visit are:

  • communicate about the nursing needs (problems) of the patient,
  • assess and, if necessary, treat wounds and invasive entrances (peripheral intravenous cannula, permanent urinary catheter, etc.),
  • give an instruction about upcoming examinations,
  • teach the patient some treatment procedures (e.g. insulin application),
  • listen to the patient's problems, reduce anxiety and fear of further treatment procedures or examinations,
  • dispel the patient's fears with suitable employment,
  • plan continuity of nursing care and satisfaction of needs (Krišková et al., 2006).

The content focus of a nursing visit at surgical workplaces concerns the area of ​​basic nursing care (hygiene, feeding, voiding), psychological and social needs of patients, ensuring their safety and specialized nursing care (Vomela et al., 1998).

From the point of view of experiencing fear and the effect of stressogenic factors on the surgical patient and their elimination, the focus of the nursing visit according to Magerčiaková (2011) is as follows:

  • assessment of the presence or expectation of a stressful situation (e.g. expectation of surgery, difficult or painful examination, discharge of a lonely geriatric patient, presence of pain, etc.),
  • reassessment of manifestations of fear - patient behavior, psychological state, etc. - way of dealing with stress,
  • assessment and planning of nursing interventions to reduce the patient's fear,
  • assessment of the need for cooperation of the nursing staff with the patient's support persons, clinical psychologist, social worker, physiotherapist, or other workers in the elimination of stress, or reduction of fear in the patient,
  • suggestions for modifying the patient's environment in terms of fear reduction,
  • communication and education of the patient in order to eliminate stressogenic factors.

Experiencing fear in a surgical patient can persist even in the postoperative period, and even in the period when the patient is discharged to the home environment or transferred to another inpatient ward or to another medical or social facility. That is why care must include discharge planning, or transfer of the patient. Discharge planning is the process of creating a care plan for a patient who is being transferred from one setting to another (Richards, Edwards, 2004). The importance of early discharge planning must not be underestimated, as the average length of hospitalization has decreased rapidly thanks to technological progress, financial issues and contractual requirements of health insurance companies (Magerčiaková, 2011). Dismissal planning should consider the following components:

  • Patients and their families or partners must be informed of the conditions of discharge.
  • The patient's discharge should be planned in such a way as to promote self-sufficiency or, where necessary, provide assistance in meeting needs.
  • Involvement of a multidisciplinary team (attending doctor, nurse, physiotherapist, etc.).
  • Physical, psychological, social, cultural, spiritual and economic needs of the patient. - The degree of support required after the discharge of the patient in terms of a safe and healthy environment.
  • Planning who will take care of the patient.
  • Consideration of the specific care needs of patients who live alone, are frail or elderly, have a serious diagnosis, are chronically ill and will return to the hospital for further treatment, are incapacitated, have a learning disability, mental illness or dementia, are minors, have limited financial resources, are homeless or live in inadequate housing conditions, speak another language, must have aids or special equipment at home, have spent a very long time in hospital.
  • Consideration of the need to provide care through a home nursing or nursing care agency, therefore a social worker should also be involved in planning the patient's discharge (Richards, Edwards, 2004).

When planning and subsequent implementation of the discharge or transfer of a surgical patient, it is necessary to write out a nursing (nursing) discharge note, or translation report. This report must include facts that are important for ensuring the continuity of nursing, or healthcare and patient education. The report should also include interventions related to, or contributing to the reduction of fear in the patient (Magerčiaková, 2011).

One very important aspect of patient care during surgical therapy should be care for their psychological needs and interest in psychological survival, because every surgical procedure, either radical or mutilating, or minimally invasive, represents for the patient an intervention not only in his somatic, but also in his psychological, social and spiritual side. Nurses from surgical departments are usually the first and only human support available to the patient in the perioperative period, as they are in contact with the patient most often. The patient perceives the nurse as a person providing support and understanding, an intermediary between the doctor and the patient, an object that reduces tension between the doctor and the patient, a member of the medical team that strengthens the patient's trust in the treatment process, a calming element that takes care of the patient's emotional state (Zacharová, Šmíčková-Čížková, 2011).

The nursing care provided by nurses also has an impact on the reduction of fear in surgical patients. The consistent and responsible application of individual phases of the nursing process in clinical practice at surgical workplaces has the effect that the determination of the nursing diagnosis of Fear is made on the basis of a thorough assessment of a specific patient. Only on the basis of an exhaustive database of data about the patient and his individual characteristics can effectively be planned and subsequently implemented nursing interventions to solve this nursing problem.

Authors: PhDr. Mgr. Mariana Magerčiaková, PhD. Department of Nursing, Faculty of Health Sciences, Catholic University in Ružomberok PhDr. Iveta Kurová Surgical Clinic, Central Military Hospital SNP Ružomberok – FN Literature

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