Nursing care for patient with obsessive compulsive disorder

Nursing care for patient with obsessive compulsive disorder and anxiety disorder including CBT items. Prepared by: Mr. Osama Emad

y t e i x n a r o f s r e a d c r g o n s i i s r d u N

Assessment: Mental state examination Past psychiatric history. Past medical history, laboratory investigation Past family history.

Nursing Diagnoses Anxiety Powerlessness Ineffective verbal communication Self-esteem disturbance Impaired social interaction Risk for injury Sleep pattern disturbances

Nursing Priorities Assist client to recognize onset of anxiety. Explore the meaning and purpose of the behavior with the client. Assist client to limit ritualistic behaviors. Help client learn alternative responses to stress. Encourage family participation in therapy program.

Goals Anxiety decreased to a manageable level. Ritualistic behaviors managed/minimized. Environmental and interpersonal stress decreased. Client/family involved in support group/community programs.

Interventions: Establish and maintain a trusting relationship by listening to the client; displaying warmth, answering questions directly, offering unconditional acceptance; being available and respecting the client’s use of personal space. Be aware and in control of own feelings; explore the cause of own anxiety and use this understanding therapeutically, The nurse’s anxiety can be communicated to the client, which only adds to the client’s sense of terror.

>> Promote positive health behaviors, including medication compliance (if appropriate) and healthy lifestyle choices (for example, diet, exercise, not smoking). Promote the person’s engagement with their social and support network. Learn to identify the signs and symptoms of anxiety and panic, including triggers. Helping people to recognize the symptoms is also the first step in teaching them selfmanagement techniques.

>> Observe for increasing anxiety. Assume a calm manner, decrease environmental stimulation, and Provide for client’s safety. Take care with potentially hazardous activities. Monitor recovery, compliance with medication and general physical health (including nutrition, weight, blood pressure etc. ). Provide education on possible side effects to any medication (if appropriate). Assist client/family to recognize and modify situations that cause anxiety when precipitating factor can be identified.

>> Determine/discuss use of alcohol and other drugs. May be used to reduce anxiety/avoid panic attacks and can lead to abuse. Explore things that may lower fear level and keep it manageable (e. g. use of singing while dressing, practicing positive self-talk while in a fearful situation). Helps client to achieve physical and mental relaxation as the anxiety becomes less uncomfortable.

>> Use desensitization approach, e. g. : Systematic desensitization (gradual systematic exposure of the client to the feared situation under controlled conditions) allows the client to begin to overcome the fear, become desensitized to the fear. Note: Implosion or flooding (continuous, rapid presentation of the phobic stimulus) may show quicker results than systematic desensitization, but relapse is more common or client may become terrified and withdraw from therapy. Expose client to a predetermined list of anxietyprovoking stimuli rated in hierarchy from the least frightening to the most frightening. Experiencing fear in progressively more challenging but attainable steps allows client to realize that dangerous consequences will not occur. Helps extinguish conditioned avoidance response.

Counselling and psychological therapies Various approaches may be used in combination. These can include cognitive behavior therapy (CBT), desensitization and problem-solving strategies. The approach will be tailored to the individual and type of anxiety, including: Psycho-education about anxiety, including information about signs and symptoms of anxiety. Monitoring for early signs of relapse is important, and early intervention may prevent full-blown symptoms returning. Regular revision of management techniques may also be helpful. Behavioral techniques to help the person control the physical effects of anxiety (for example, breathing and relaxation). A basic technique to control hyperventilation is a simple breathing and relaxation exercise. Breathing in deeply (using the abdominal muscles) to a count of five, holding the breath for five and then breathing out to a count of five saying the word ‘relax’. This reduces hyperventilation and relieves some of the physical symptoms. (desensitization or flooding).

CBT techniques help the person learn to challenge the catastrophic thoughts that may be exacerbating or maintaining the fear. People learn to identify the links between activating events (A), the consequent feelings (C) and the thoughts or behaviours (B) that emerge between A and C. If a person changes the unhelpful thinking or behavior at B, as demonstrated in the example below, a more positive outcome can be expected.

The basic premise of cognitive behavioral therapy is that our thoughts—not external events—affect the way we feel. In other words, it’s not the situation you’re in that determines how you feel, but your perception of the situation.

Thought challenging Thought challenging—also known as cognitive restructuring—is a process in which you challenge the negative thinking patterns that contribute to your anxiety, replacing them with more positive, realistic thoughts. This involves three steps: Identifying your negative thoughts. Challenging your negative thoughts. Replacing negative thoughts with realistic thoughts.

Other Psychosocial Therapies Family Therapy – this is directed toward education and support for the whole family of the patient. Group therapy.

Exposure therapy for anxiety *Systematic desensitization Rather than facing your biggest fear right away, which can be traumatizing, exposure therapy usually starts with a situation that’s only mildly threatening and works up from there. This step-by-step approach is called systematic desensitization. Systematic desensitization allows you to gradually challenge your fears, build confidence, and master skills for controlling panic. systematic desensitization involves three parts: Learning relaxation skills. First, your therapist will teach you a relaxation technique, such as progressive muscle relaxation or deep breathing. You’ll practice in therapy and on your own at home. Once you start confronting your fears, you’ll use this relaxation technique to reduce your physical anxiety response (such as trembling and hyperventilating) and encourage relaxation.

Creating a step-by-step list. Next, you’ll create a list of 10 to 20 scary situations that progress toward your final goal. For example, if you final goal is to overcome your fear of flying, you might start by looking at photos of planes and end with taking an actual flight. Each step should be as specific as possible, with a clear, measurable objective. Facing a fear of flying Step 1: Look at photos of planes. Step 2: Watch a video of a plane in flight. Step 3: Watch real planes take off. Step 4: Book a plane ticket. Step 5: Pack for your flight. Step 6: Drive to the airport. Step 7: Check in for your flight. Step 8: Wait for boarding. Step 9: Get on the plane. Step 10: Take the flight. Working through the steps. Under the guidance of your therapist, you’ll then begin to work through the list. The goal is to stay in each scary situation until your fears subside. That way, you’ll learn that the feelings won’t hurt you and they do go away. Every time the anxiety gets too intense, you will switch to the relaxation technique you learned. Once you’re relaxed again, you can turn your attention back to the situation. In this way, you will work through the steps until you’re able to complete each one without feeling overly distressed.

Nursing Interventions for OCD. (nursing care). Establish trust relationship through use of empathy, warmth, and respect. Demonstrate interest in client as a person through use of attending behaviors. Acknowledge behavior without focusing attention on it. Verbalize empathy toward client’s experience rather than disapproval or criticism. Better to say, "I see you undress 3 times every morning. That must be tiring for you, ” rather than “Try to dress only 1 time today. ” Use a relaxed manner with the client; keep the environment calm. Encourage to express the feeling in order to decrease anxiety.

Assist client to learn stress management, (e. g. , thought-stopping, relaxation exercises, imagery). Because Stress-management techniques can be used, instead of ritualistic behaviors, to break habitual pattern. Identify what the client perceives as relaxing (e. g. , warm bath, music). Engage in constructive activities such as quiet games that require concentration, as well as arts and crafts such as needlework, woodworking, ceramics, and painting. Work with client to develop appropriate coping skills. Encourage participation in a regular exercise program. Because Exercise therapy can help relieve anxiety. Give positive reinforcement for noncompulsive behavior. Avoid reinforcing compulsive behavior.

Limit the amount of time allotted for the performance of rituals. Encourage client to gradually decrease this time. Provides initial control of maladaptive behaviors until client can enforce own limits and substitute more adaptive response(s) to stress. Limit, but do not interrupt, the compulsive acts. Encourage client to explore the meaning and purpose of behaviors; to describe the feelings when the behaviors occur, and to examine the precipitating factors to the performance of the rituals. Help the client to assess how the compulsive behavior affect his functioning. Encourage the client to identify situations that produce anxiety and precipitate obsessive compulsive behavior

Discuss home situation, include family/SO as appropriate. Involve in discharge plan. Returning to unchanged home environment Increases risk that client will resume compulsive behaviors. Risk associated with the use of alcohol and drug abuse, Instruct the patient to compliance with prescribed medications.

Cognitive-Behavioural Therapy for OCD. Exposure and response prevention (EX/RP). The mostly widely practiced behavior therapy for OCD is called exposure and response prevention (ERP). The "exposure" part of this treatment involves direct or imagined controlled exposure to objects or situations that trigger obsessions that arouse anxiety. Over time, exposure to obsessional cues leads to less and less anxiety. Eventually, exposure to the obsessional cue arouses little anxiety at all. This process of getting "used to" obsessional cues is called "habituation. " The "response" in "response prevention" refers to the ritual behaviours that people with OCD engage in to reduce anxiety. In ERP treatment, patients learn to resist the compulsion to perform rituals and are eventually able to stop engaging in these behaviours.

How does ERP work? Before starting ERP treatment, patients make a list, or what is termed a "hierarchy" of situations that provoke obsessional fears. For example, a person with fears of contamination might create a list of obsessional cues that looks like this: touching garbage using the toilet shaking hands. Treatment starts with exposure to situations that cause mild to moderate anxiety, and as the patient habituates to these situations, he or she gradually works up to situations that cause greater anxiety. The time it takes to progress in treatment depends on the patient's ability to tolerate anxiety and to resist compulsive behaviours.

Exposure tasks are usually first performed with therapist assisting. These sessions generally take between 45 minutes and three hours. Patients are also asked to practice exposure tasks between sessions for two to three hours per day. In some cases, direct, or "in vivo, " exposure to the obsessional fears is not possible in therapist's office. If, for example, a patient were being treated for an obsession about causing an accident while driving, therapist would have to practice what is called "imaginal" exposure. Imaginal exposure involves exposing the person to situations that trigger obsessions by imagining different scenes.

The main goal during both in vivo and imaginal exposure is for the person to stay in contact with the obsessional trigger without engaging in ritual behaviours. For example, if the person who fears contamination responds to the anxiety by engaging in hand-washing or cleaning rituals, he or she would be required to increasingly resist such activities - first for hours, and then days following an exposure task. The therapy continues in this manner until the patient is able to abstain from ritual activities altogether. To mark progress during exposure tasks with therapist and in homework, patients are trained to be experts in rating their own anxiety levels. Once they have made progress in treatment, participants are encouraged to continue using the ERP techniques they have learned, and to apply them to new situations as they arise. A typical course of ERP treatment is between 14 and 16 weeks.

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