Therapeutic communication for anxiety

[Mavnurse17, BSN, RN]

I work at the high school level and there are a lot of students with mental health disruptions.  I will be called to a bathroom where a student is having a full-blown panic attack. 

My question is, what do you guys say to students who are having these panic attacks?  I don't know why, but all I can manage to say to them is "it's okay, you're okay, it'll be okay," which I know isn't therapeutic.  I've tried the "name 5 things you can see, 4 things you can hear, 3 things you can touch..." exercise but it has never worked.  Usually they just blank out and ignore me anyway when I do try to say anything meaningful to try and calm them down.  

Anyone have any tips on what I can say/do to help these students?

[BrisketRN, BSN, RN]

We were told to offer guided meditations.  If they have a phone on them they can use that and lie down and do a guided meditation or sometimes just allowing them to listen to music can help.

[KeeperOfTheIceRN, ADN]

I ask them if they want to go outside for a little while. Mental health is not my strong suit by any means, but I'm a huge fan of getting them outside when they reach this point. Especially with the older ones. I've noticed the fresh air, change of scenery, and sun light (even on cloudy days) does wonders for them. If they want to walk, we walk. If they want to sit, we sit. If they want to talk, we talk. But I let them do what they feel they need to, within reason/safety parameters, and I just meet them there. 

I also have this jar that I made with glitter glue, sequins, and water. I'll have them shake it and then watch the glitter and sequins swirl around. I'll ask them to tell me some of the shapes they see (there's unicorns, stars, geometric shapes etc. etc. in the jar). This works best with my middle schoolers though. 

[LikeTheDeadSea, MSN, RN]

Whenever I have the urge to say that "it's okay," I replace it with, "I am here for you and care about you."  Going from personal experience, that is always my favorite thing to hear when I'm in that heightened state of anxiety. 

[GdBSN, RN]

I will get on the floor and do deep breathing exercises with them initially (I feel that getting down on their level helps them relax instead of standing over and looking down to them) Once they are feeling better we will walk around the school or rest in the clinic, which ever they say they want. I will try to re-direct their thinking by asking questions about what they like to do at home, what are their hobbies, do they have animals, etc...

40 minutes ago, LikeTheDeadSea said:

Whenever I have the urge to say that "it's okay," I replace it with, "I am here for you and care about you."  Going from personal experience, that is always my favorite thing to hear when I'm in that heightened state of anxiety. 

I really like this! I am going to try this next time.

[Mavnurse17, BSN, RN]

40 minutes ago, GdBSN said:

I will get on the floor and do deep breathing exercises with them initially (I feel that getting down on their level helps them relax instead of standing over and looking down to them) Once they are feeling better we will walk around the school or rest in the clinic, which ever they say they want. I will try to re-direct their thinking by asking questions about what they like to do at home, what are their hobbies, do they have animals, etc...

Yep, tried all this.  We had an incident in the bathroom last week and the girl was sitting in a chair someone had rolled in for her; I kneeled down next to her and told her to deep breathe-- even demonstrated for her.  She didn't even look at me.  She was in her own world.  I know attacks manifest differently for everyone and it's not uncommon to tunnel like that.  Just makes me feel like my effort is futile.  And after these failed interventions my admin look at me like "okay, what do we do now?" and insist on calling EMS.  

[NutmeggeRN, BSN]

I always bring a pulse ox with me...sometimes they truly believe they cannot breathe and the number can sometimes be reassuring.

[arlingtonnurse]

I tell them 'most important is just to breath' then we'll do deep breathing exercises together.  Even if they don't do it originally I will keep going and they kind of look at me strange then will often give it a go.  It helps me stay calm too.

[guest464345]

My general process, assuming no one's doing anything unsafe:

1. Get the audience out (including unnecessary staff).  Extra people are not good for drama-seekers, and not good for people who are panicked and overstimulated. Only one person should talk to the patient. Don't let people stand/loom over the patient or make comments. Get down to his/her level yourself.
2. Introduce yourself, ask permission to do a quick physical check. Wait to get OK. Listen to lungs/heart and check O2 sats. If everything's OK, verbalize findings "excellent, just need one finger, I'm checking your oxygen. Your brain and body are getting plenty of oxygen. Now I'll check your lungs. You'll feel the stethoscope here. Very good. I know you're short of breath but don't worry, your lungs sound good.  It's OK to slow down your breathing now, I'll keep an eye on you."  (If nothing else, this reassures admin)
3. Give reassurance and two safe choices that  you can offer:  "I'm going to be with you until you feel better. Do you want to rest here, or would you like to get some air in the courtyard?"  No other questions, no longer statements. WAIT for answers longer than you think, you might sit quietly for a what feels like forever.

Other things that I try to remember

• You don't have to fix anything.  If everyone's safe, it's OK.  Panic passes, no matter what you do, so just being there is fine.
• Sometimes I tell kids this! "This terrible feeling is like a big wave, it  can knock you over for a minute, but then little by little it rolls away and leaves you safe on the beach." 
• When they're out of the full blown panic, I'll try techniques folks have mentioned above. If I know they're working on coping skills, I'll offer their preferred strategies: "I'd like to help you use a coping skill, should we try music or breathing?"
• Some kids do better with just decreased stimuli. I have a room in my office with.a recliner and a dim light - I will say, "would it help if you had a quiet, private place to regroup? Yes? Here's a glass of water. I'm right outside if you need me.  I'll check on you in 10 minutes."  (of course this is presuming no self-harm behavior, and that I can discreetly keep an eye on them).  Sometimes I'll ask where their anxiety is (1-10) before and after.
  
  No one teaches us this stuff in nursing school! I just try to project kindness, confidence, and a neutral tone. Practice helps.  You can do it ?

[SchoolNurseK, BSN, RN]

On 5/25/2021 at 12:36 PM, NutmeggeRN said:

I always bring a pulse ox with me...sometimes they truly believe they cannot breathe and the number can sometimes be reassuring.

This is what I always do as well.  I explain that they are getting enough oxygen, they are safe, etc... 

[vintagegal, BSN, DNP, RN, NP]

Guided breathing helps. I’ve worked with a lot of dementia who have anxiety episodes. I sit down with them, hold their hand (once I get permission). Guided breathing. I usually say “I hear you, I am listening “ a lot of times people get anxiety because they feel loss of control, as though nobody hears them or understands. 

[NRSKarenRN, BSN, RN]

All great responses and suggestions ---   bookmarking  to use @ camp position.  Will share with my nurse interns as expect more anxiety this Summer.  Adding pulse ox to my take-to-camp list.