Nursing Care Plan: OCD PDF

11/16/23, 11:26 AM Realizeit for Student Nursing Care Plan: OCD Nursing Diagnosis Ineffective Coping: Inability to form a valid appraisal of stressor, inadequate choices of practiced responses, and/or inability to use available resources Assessment Data Ambivalence regarding decisions or choices...

11/16/23, 11:26 AM Realizeit for Student Nursing Care Plan: OCD Nursing Diagnosis Ineffective Coping: Inability to form a valid appraisal of stressor, inadequate choices of practiced responses, and/or inability to use available resources Assessment Data Ambivalence regarding decisions or choices Disturbances in normal functioning due to obsessive thoughts or compulsive behaviors (loss of job, loss of/or alienation of family members, etc.) Inability to tolerate deviations from standards Rumination Low self-esteem Feelings of worthlessness Lack of insight Difficulty or slowness completing daily living activities because of ritualistic behavior Expected Outcomes Immediate The client will: Talk with staff and identify stresses, anxieties, and conflicts within 2 to 3 days. Verbalize realistic self-evaluation; for example, make a list of strengths and abilities and review list with staff within 3 to 4 days. Establish adequate nutrition, hydration, and elimination within 4 to 5 days. Establish a balance of rest, sleep, and activity; for example, sleep at least 4 hours per night. Stabilization The client will: Identify alternative methods of dealing with stress and anxiety. Complete daily routine without staff assistance or prompting by a specified date. Verbalize knowledge of illness, treatment plan, and safe use of medications, if any. Community The client will Demonstrate a decrease in obsessive thoughts or ritualistic behaviors to a level at which the client can function independently. Demonstrate alternative ways of dealing with stress, anxiety, and life situations. Maintain adequate physiological functioning, including activity, sleep, and rest. Follow through with continued therapy if needed; for example, identify a therapist and make a follow-up appointment before discharge. Implementation Nursing Interventions Rationale Observe the client’s eating, drinking, and elimination patterns, and assist the The client may be unaware of physical needs or may ignore feelings client as necessary. of hunger, thirst, or the urge to defecate, and so forth. Assess and monitor the client’s sleep patterns, and prepare him or her for bedtime by decreasing stimuli and providing comfort measures or medication. You may need to allow extra time, or the client may need to be verbally directed to accomplish activities of daily living (personal hygiene, preparation for sleep, and so forth). Limiting noise and other stimuli will encourage rest and sleep. Comfort measures and sleep medications will enhance the client’s ability to relax and sleep. The client’s thoughts or ritualistic behaviors may interfere with or lengthen the time necessary to perform tasks. Encourage the client to try to gradually decrease the frequency of compulsive Gradually reducing the frequency of compulsive behaviors will behaviors. Work with the client to identify a baseline frequency and keep a diminish the client’s anxiety and encourage success. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPHV… 1/7 11/16/23, 11:26 AM Realizeit for Student record of the decrease. As the client’s anxiety decreases and as a trust relationship builds, talk with the The client may need to learn ways to manage anxiety so that he or she client about his or her thoughts and behavior and the client’s feelings about can deal with it directly. This will increase the client’s confidence in them. Help the client identify alternative methods for dealing with anxiety. managing anxiety and other feelings. Convey honest interest in and concern for the client. Do not flatter or be otherwise dishonest. client. Clients do not benefit from flattery or undue praise, but genuine praise that the client has earned can foster self-esteem. Provide opportunities for the client to participate in activities that are easily accomplished or enjoyed by the client; support the client for participation. Teach the client social skills, such as appropriate conversation topics and active listening. Encourage him or her to practice these skills with staff members and other clients, and give the client feedback regarding interactions. Teach the client and family or significant others about the client’s illness, treatment, or medications, if Your presence and interest in the client convey your acceptance of the any.* The client may be limited in his or her ability to deal with complex activities or in relating to others. Activities that the client can accomplish and enjoy can enhance self-esteem. The client may feel embarrassed by his or her OCD behaviors and may have had limited social contact. He or she may have limited social skills and confidence, which may contribute to the client’s anxiety. The client and family or significant others may have little or no knowledge about these. Encourage the client to participate in follow-up therapy, if indicated. Help the Clients often experience long-term difficulties in dealing with client identify supportive resources in the community or on the internet.* obsessive thoughts. *Collaborative interventions. Adapted from Schultz, J. M., & Videbeck, S. L. (2013). Lippincott’s manual of psychiatric nursing care plans (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Application of the Nursing Process Assessment Box 15.1 presents the Yale-Brown Obsessive–Compulsive Scale. The nurse can use this tool along with the following detailed discussion to guide his or her assessment of the client with OCD. BOX 15.1Yale-Brown Obsessive–Compulsive Scale For each item, circle the number identifying the response that best characterizes the patient. 1. Time occupied by obsessive thoughts - How much of your time is occupied by obsessive thoughts? - How frequently do the obsessive thoughts occur? 0 Not at all 1 Mild (<1 hour/day) or occasional (intrusion occurring no more than eight times a day) 2 Moderate (1–3 hours/day) or frequent (intrusion occurring more than eight times a day, but most of the hours of the day are free of obsessions) https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPHV… 2/7 11/16/23, 11:26 AM Realizeit for Student 3 Severe (>3 and up to 8 hours/day) or very frequent (intrusion occurring more than eight times a day and occurring during most of the hours of the day) 4 Extreme (>8 hours/day) or near-consistent intrusion (too numerous to count and an hour rarely passes without several obsessions occurring) 2. Interference due to obsessive thoughts - How much do your obsessive thoughts interfere with your social or work (or role) functioning? - Is there anything that you don’t do because of them? 0 None 1 Mild: slight interference with social or occupational activities, but overall performance not impaired 2 Moderate: definite interference with social or occupational performance, but still manageable 3 Severe: causes substantial impairment in social or occupational performance 4 Extreme: incapacitating 3. Distress associated with obsessive thoughts - How much distress do your obsessive thoughts cause you? 0 None 1 Mild, infrequent, and not too disturbing 2 Moderate, frequent, and disturbing but still manageable 3 Severe, very frequent, and very disturbing 4 Extreme, near constant, and disabling distress 4. Resistance against obsessions - How much of an effort do you make to resist the obsessive thoughts? - How often do you try to disregard or turn your attention away from these thoughts as they enter your mind? 0 Makes an effort to always resist, or symptoms so minimal doesn’t need to actively resist 1 Tries to resist most of the time 2 Makes some effort to resist 3 Yields to all obsessions without attempting to control them, but does so with some reluctance 4 Completely and willingly yields to all obsessions 5. Degree of control over obsessive thoughts - How much control do you have over your obsessive thoughts? - How successful are you in stopping or diverting your obsessive thinking? 0 Complete control 1 Much control: usually able to stop or divert obsessions with some effort and concentration 2 Moderate control: sometimes able to stop or divert obsessions 3 Little control: rarely successful in stopping obsessions 4 No control: experienced as completely involuntary, rarely able to even momentarily divert thinking 6. Time spent performing compulsive behaviors - How much time do you spend performing compulsive behaviors? - How frequently do you perform compulsions? https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPHV… 3/7 11/16/23, 11:26 AM Realizeit for Student 0 Not at all 1 Mild (<1 hour/day performing compulsions) or occasional (performance of compulsions occurring no more than eight times a day) 2 Moderate (1–3 hours/day performing compulsions) or frequent (performance of compulsions occurring more than eight times a day, but most of the hours o 3 Severe (>3 and up to 8 hours/day performing compulsions) or very frequent (performance of compulsions occurring more than eight times a day and occurr 4 Extreme (>8 hours/day performing compulsions) or near-consistent performance of compulsions (too numerous to count and an hour rarely passes without 7. Interference due to compulsive behaviors - How much do your compulsive behaviors interfere with your social or work (or role) functioning? Is there anything that you don’t do because of the compulsion 0 None 1 Mild: slight interference with social or occupational activities, but overall performance not impaired 2 Moderate: definite interference with social or occupational performance, but still manageable 3 Severe: causes substantial impairment in social or occupational performance 4 Extreme: incapacitating 8. Distress associated with compulsive behavior - How would you feel if prevented from performing your compulsions? - How anxious would you become? How anxious do you get while performing compulsions until you are satisfied they are completed? 0 Not at all 1 Mild: only slightly anxious if compulsions prevented or only slightly anxious during performance of compulsions 2 Moderate: reports that anxiety would mount, but remains manageable if compulsions prevented or that anxiety increases, but remains manageable during pe 3 Severe: prominent and very disturbing increase in anxiety if compulsions interrupted or prominent and very disturbing increases in anxiety during performa 4 Extreme: incapacitating anxiety from any intervention aimed at modifying activity or incapacitating anxiety during performance of compulsions 9. Resistance against compulsions - How much of an effort do you make to resist the compulsions? 0 Makes an effort to always resist, or symptoms so minimal doesn’t need to actively resist 1 Tries to resist most of the time 2 Makes some effort to resist 3 Yields to all compulsions without attempting to control them, but does so with some reluctance 4 Completely and willingly yields to all compulsions 10. Degree of control over compulsive behavior 0 Complete control 1 Much control: experiences pressure to perform the behavior but usually able to exercise voluntary control over it 2 Moderate control: strong pressure to perform behavior; can control it only with difficulty 3 Little control: very strong drive to perform behavior; must be carried to completion; can only delay with difficulty 4 No control: drive to perform behavior experienced as completely involuntary Reprinted with permission from Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., … & Charney, D. S. (1989). The Yale-Brown Obsessive–Compulsive Scale: I: Development, use, and reliability. Archives of General Psychiatry, 46, 1006. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPHV… 4/7 11/16/23, 11:26 AM Realizeit for Student History The client usually seeks treatment only when obsessions become too overwhelming or when compulsions interfere with daily life (e.g., going to work, cooking meals, or participating in leisure activities with family or friends) or both. Clients are hospitalized only when they have become completely unable to carry out their daily routines. Most treatment is outpatient. The client often reports that rituals began many years before; some begin as early as childhood. The more responsibility the client has as he or she gets older, the more the rituals interfere with the ability to fulfill those responsibilities. General Appearance and Motor Behavior The nurse assesses the client’s appearance and behavior. Clients with OCD often seem tense, anxious, worried, and fretful. They may have difficulty relating symptoms because of embarrassment. Their overall appearance is unremarkable; nothing observable seems to be “out of the ordinary.” The exception is the client who is almost immobilized by his or her thoughts and the resulting anxiety. Mood and Affect During assessment of mood and affect, clients report ongoing overwhelming feelings of anxiety in response to the obsessive thoughts, images, or urges. They may look sad and anxious. Thought Processes and Content The nurse explores the client’s thought processes and content. Many clients describe the obsessions as arising from nowhere during the middle of normal activities. The harder the client tries to stop the thought or image, the more intense it becomes. The client describes how these obsessions are not what he or she wants to think about and that he or she would never willingly have such ideas or images. Assessment reveals intact intellectual functioning. The client may describe difficulty concentrating or paying attention when obsessions are strong. There is no impairment of memory or sensory functioning. Judgment and Insight The nurse examines the client’s judgment and insight. The client recognizes that the obsessions are irrational, but he or she cannot stop them. He or she can make sound judgments (e.g., “I know the house is safe”), but cannot act on them. The client still engages in ritualistic behavior when the anxiety becomes overwhelming. Self-Concept During exploration of self-concept, the client voices concern that he or she is “going crazy.” Feelings of powerlessness to control the obsessions or compulsions contribute to low self-esteem. The client may believe that if he or she were “stronger” or had more willpower, he or she could possibly control these thoughts and behaviors. Roles and Relationships It is important for the nurse to assess the effects of OCD on the client’s roles and relationships. As the time spent performing rituals increases, the client’s ability to fulfill life roles successfully decreases. Relationships also suffer as family and friends tire of the repetitive behavior, and the client is less available to them as he or she is more consumed with anxiety and ritualistic behavior. Physiological and Self-Care Considerations The nurse examines the effects of OCD on physiology and self-care. As with other anxiety disorders, clients with OCD may have trouble sleeping. Performing rituals may take time away from sleep, or anxiety may interfere with the ability to go to sleep and wake refreshed. Clients may also report a loss of appetite or unwanted weight loss. In severe cases, personal hygiene may suffer because the client cannot complete the needed tasks. Data Analysis Depending on the particular obsession and its accompanying compulsions, clients have varying symptoms. Nursing diagnoses can include the following: Anxiety Ineffective coping Fatigue Situational low self-esteem Impaired skin integrity (if scrubbing or washing rituals) https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPHV… 5/7 11/16/23, 11:26 AM Realizeit for Student Outcome Identification Outcomes for clients with OCD include the following: The client will complete daily routine activities within a realistic time frame. The client will demonstrate effective use of relaxation techniques. The client will discuss feelings with another person. The client will demonstrate effective use of behavioral therapy techniques. The client will spend less time performing rituals. Intervention Using Therapeutic Communication Offering support and encouragement to the client is important to help him or her manage anxiety responses. The nurse can validate the overwhelming feelings the client experiences while indicating the belief that the client can make needed changes and regain a sense of control. The nurse encourages the client to talk about the feelings and describe them in as much detail as the client can tolerate. Because many clients try to hide their rituals and keep obsessions secret, discussing these thoughts, behaviors, and resulting feelings with the nurse is an important step. Doing so can begin to relieve some of the “burden” the client has been keeping to him or herself. Teaching Relaxation and Behavioral Techniques The nurse can teach the client about relaxation techniques such as deep breathing, progressive muscle relaxation, and guided imagery. This intervention should take place when the client’s anxiety is low so he or she can learn more effectively. Initially, the nurse can demonstrate and practice the techniques with the client. Then, the nurse encourages the client to practice these techniques until he or she is comfortable doing them alone. When the client has mastered relaxation techniques, he or she can begin to use them when anxiety increases. In addition to decreasing anxiety, the client gains an increased sense of control that can lead to improved self-esteem. To manage anxiety and ritualistic behaviors, a baseline of frequency and duration is necessary. The client can keep a diary to chronicle situations that trigger obsessions, the intensity of the anxiety, the time spent performing rituals, and the avoidance behaviors. This record provides a clear picture for both client and nurse. The client then can begin to use exposure and response prevention behavioral techniques. Initially, the client can decrease the time he or she spends performing the ritual or delay performing the ritual while experiencing anxiety. Eventually, the client can eliminate the ritualistic response or decrease it significantly to the point that interference with daily life is minimal. Clients can use relaxation techniques to assist them in managing and tolerating the anxiety they are experiencing. It is important to note that the client must be willing to engage in exposure and response prevention. These are not techniques that can be forced on the client. Completing a Daily Routine To accomplish tasks efficiently, the client initially may need additional time to allow for rituals. For example, if breakfast is at 8 AM and the client has a 45minute ritual before eating, the nurse must plan that time into the client’s schedule. It is important for the nurse not to interrupt or to attempt to stop the ritual because doing so will escalate the client’s anxiety dramatically. Again, the client must be willing to make changes in his or her behavior. The nurse and client can agree on a plan to limit the time spent performing rituals. They may decide to limit the morning ritual to 40 minutes, then to 35 minutes, and so forth, taking care to decrease this time gradually at a rate the client can tolerate. When the client has completed the ritual or the time allotted has passed, the client then must engage in the expected activity. This may cause anxiety and is a time when the client can use relaxation and stress reduction techniques. At home, the client can continue to follow a daily routine or written schedule that helps him or her to stay on task and accomplish activities and responsibilities. NURSING INTERVENTIONS For OCD Offer encouragement, support, and compassion. Be clear with the client that you believe he or she can change. Encourage the client to talk about feelings, obsessions, and rituals in detail. Gradually decrease time for the client to carry out ritualistic behaviors. Assist the client in using exposure and response prevention behavioral techniques. Encourage the client to use techniques to manage and tolerate anxiety responses. Assist the client in completing daily routine and activities within agreed-upon time limits. Encourage the client to develop and follow a written schedule with specified times and activities. CLIENT AND FAMILY EDUCATION For OCD https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPHV… 6/7 11/16/23, 11:26 AM Realizeit for Student For Clients Teach about OCD. Review the importance of talking openly about obsessions, compulsions, and anxiety. Emphasize medication compliance as an important part of treatment. Discuss necessary behavioral techniques for managing anxiety and decreasing prominence of obsessions. Tolerating anxiety is uncomfortable but not harmful to health or well-being. For Families Avoid giving advice such as, “Just think of something else.” Avoid trying to fix the problem; that never works. Be patient with your family member’s discomfort. Monitor your own anxiety level, and take a break from the situation if you need to. Providing Client and Family Education It is important for both the client and family to learn about OCD. They are often relieved to find the client is not “going crazy” and that the obsessions are unwanted, rather than a reflection of any “dark side” to the client’s personality. Helping the client and family talk openly about the obsessions, anxiety, and rituals eliminates the client’s need to keep these things secret and to carry the guilty burden alone. Family members can also give the client needed emotional support when they are fully informed. Teaching about the importance of medication compliance to combat OCD is essential. The client may need to try different medications until his or her response is satisfactory. The chances for improved OCD symptoms are enhanced when the client takes medication and uses behavioral techniques. Try Its Discuss important teaching components for the family of a client diagnosed with obsessive–compulsive disorder (OCD). For client diagnosed with OCD, develop a teaching plan emphasizing safety issues. Review OCD involves recurrent, persistent, intrusive, and unwanted thoughts, images, or impulses (obsessions) and ritualistic or repetitive behaviors or mental acts (compulsions) carried out to eliminate the obsessions or to neutralize anxiety. Rituals or compulsions may include checking, counting, washing, scrubbing, praying, chanting, touching, rubbing, ordering, or other repetitive behaviors. OCD can start in childhood and often lasts into adulthood. OCD is a chronic progressive disease. Symptoms wax and wane over time, increasing during periods of stress. Disorders related to OCD include dermatillomania, trichotillomania, onychophagia, kleptomania, oniomania, BDD, body identity disorder, and hoarding. Etiology of OCD is not specifically known but includes genetic influences and environmental experiences. OCD is universal across countries with some variation in symptoms. Treatment includes medications, SSRIs, and behavioral therapy, specifically exposure and response prevention. Effective nursing interventions include therapeutic communication, teaching relaxation and behavioral techniques, following a daily routine, and client and family education about OCD and its treatment. Onset of OCD after age 50 is rare. The incidence of hoarding increases with age. Practicing anxiety management and behavioral techniques daily is important for positive long-term outcomes. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IXP1mimyVQOPOHLAvYAjZdL7GFyh%2bBfe9WR6sPHV… 7/7