Nursing Care of Clients with:  Anxiety Disorders  OCD  Dissociative disorders  Post traumatic Stress Disorder  Somatic symptom associated disorders

Associated Nursing Diagnosis Panic anxiety Fear Post-traumatic Syndrome Grieving Powerlessness Social Isolation Ineffective Coping Ineffective Role Performance Disturbed Body Image Chronic pain Fear of serious illness Disturbed Sensory Perception Disturbed Thought process

Nursing Diagnosis: Panic Anxiety Panic Anxiety Related to: real or perceived threat to biological integrity or self-concept Evidenced by: Any or all of the physical symptoms identified by the DSM-IV-TR

Desired outcome are 3 levels Acute phase of anxiety; ◦ The client will be free from self inflicted harm ◦ The client will experience decrease anxiety symptoms Stabilization phase of therapy: ◦ Client will begin to learn to verbalization of their feelings, ◦ The client will understand their own stress response, and try new methods for anxiety reduction

Desired outcome are 3 levels Community phase: ◦ The client will develop adaptive methods for coping with stress, ◦ The client will use support system, ◦ The client will demonstrate adequate social and occupational functioning

Nursing Care of patient during Panic attack (acute phase) Have calm nonthreatening attitude while caring for the client (anxiety is easily transmitted between people) Stay with the patient, supporting and reassuring the client that he/she is not going to die. Loosen tight cloths. Direct the patient to inhale and exhale slowly - do it with him/her if necessary.

Acute panic attack Help patient to breathe into a paper bag to increase co2 concentration and decrease acidosis. Use short, simple, sentences and firm directing voice to provide external control. Move patient to a smaller area to decrease stimuli. Give anti-anxiety drugs if prescribed (PRN).

Acute panic attack Stay with the client and offer reassurance of safety & security Use simple wards & messages, spoken calmly & clearly, to explain any procedure Help patient verbalize and name the experience كيف شاعر الآن؟ هل أنت مضطرب؟ ماذا ممكن أن تعمل لترتاح أكثر؟

Acute panic attack As the patient relaxes encourage his/her to recall and describe what happened immediately before the attack. Connect feeling of anxiety with relief behavior. Recall similar situations. Assess for risk of self-harm (suicide) Use stress management techniques

Nursing Interventions: Panic Anxiety Decrease environmental stimuli (dim light, decrease number of people, simple décor,…) Develop one-to-one sessions to discuss ways to decrease level of anxiety: ◦ Help client recognize precipitating factors ◦ Help client recognize early signs ◦ Teach client ways to interrupt escalation of signs (progressive relaxation, breathing exercises, or physical exercises…)

Nursing Diagnosis: Fear Fear Related to: ◦ Thought of causing embarrassment to self in front of others, being in a place from which one is unable to escape, or specific stimuli Evidenced by: ◦ Behavior directed toward avoidance of the feared object or situation

Outcome Criteria: Fear Short term Goal: ◦ Verbalize feelings of fear and discomfort ◦ Respond to relaxation techniques with decreased anxiety ◦ Effectively decrease own anxiety level ◦ Decrease avoidance behaviors ◦ Manage the anxiety response effectively Long Term Goal: ◦ The client will be able to function in the presence of phobic object or situation without experiencing a panic attack

Nursing Interventions: Fear Reassure client of his/her safety Allow the client to express feelings openly. Teach the client and family or significant others about phobic reactions. Dispel any myths. Reassure the client that he or she can learn to decrease the anxiety and gain control over the anxiety attacks

Nursing Interventions: Fear Reassure the client that he or she will not be forced to confront the phobic situation until prepared to do so Instruct the client in progressive relaxation techniques. These include deep breathing, focusing on specific muscles to decrease tenseness, and imagining. Encourage the client to practice relaxation until he or she is comfortable and successful.

Nursing Interventions: Fear Explain systematic desensitization thoroughly to the client. (the gradual exposure to the feared object) Reassure the client that you will allow him or her as much time as needed at each step.

Nursing Interventions: Fear Have the client develop a hierarchy of situations that relate to the phobia. Begin with the least anxiety-producing situation. Have the client use progressive relaxation in that situation until he or she is able to decrease the anxiety. If the client becomes excessively anxious or begins to feel out of control, return to the former step with which the client was comfortable and successful.

Nursing Interventions: Fear Give positive feedback for the client's efforts at each step. Avoid equating success only with mastery of the entire process. Discuss the previously identified avoidance behaviors with client to determine if there is a corresponding decrease as client progress in systematic desensitization

Nursing care of a client with Post- traumatic Disorder

Nursing Diagnosis: Post-trauma Syndrome Post-trauma Syndrome Related to: ◦ Distressing event considered to be outside the range of usual human experience Evidenced by: ◦ Flashbacks, intrusive recollections, nightmares, psychological numbness related to the event, dissociation, or amnesia.

Outcome Criteria: Post-trauma Syndrome Short Term Goals: ◦ Client will begin a healthy grief resolution, initiating the process of psychological healing (within time frame specific to individual). Long Term Goal: ◦ The client will integrate the traumatic experience into his or her persona, renew significant relationships, and establish meaningful goals for the future.

Post-trauma Syndrome Assign the same staff as often as possible Stay with client during periods of flashbacks and nightmares Encourage the client to talk about the trauma at his or her own pace Discuss coping strategies used in response to the trauma Assist the individual to try to comprehend the trauma if possible

Nursing Interventions: Post-trauma Syndrome Stay with client during periods of flashbacks and nightmares. Offer reassurance of safety and security and that these symptoms are not uncommon following a trauma of the magnitude he or she has experienced. Obtain accurate history from significant others about the trauma and the client’s specific response.

Nursing Interventions: Post-trauma Syndrome Provide a nonthreatening, private environment, and include a significant other if the client wishes. Acknowledge and validate client’s feelings as they are expressed. Discuss coping strategies used in response to the trauma, as well as those used during stressful situations in the past.

Nursing Interventions: Post-trauma Syndrome Determine those that have been most helpful, and discuss alternative strategies for the future. Include available support systems, including religious and cultural influences. Identify maladaptive coping strategies (e.g., substance use, psychosomatic responses) and practice more adaptive coping strategies for possible future post-trauma responses.

Nursing Interventions: Post-trauma Syndrome Discuss feelings of vulnerability and the individual’s “place” in the world following the trauma. As tolerated, encourage the client to share his or her feelings and experiences in group therapy, in a support group related to post- trauma, or with other clients informally

Nursing Diagnosis: Complicated Grieving Complicated Grieving Related to: ◦ Loss of self as perceived prior to the trauma or other actual/perceived losses incurred during/following the event. Evidenced by: ◦ Irritability and explosiveness, self- destructiveness, substance abuse, verbalization of survival guilt or guilt about behavior required for survival

Outcome Criteria: Complicated Grieving Short Term Goals: ◦ Client will verbalize feelings (guilt, anger, self- blame, hopelessness) associated with the trauma. Long Term Goal: ◦ Client will demonstrate progress in dealing with stages of grief and will verbalize a sense of optimism and hope for the future.

Nursing Interventions: Complicated Grieving Acknowledge feelings of guilt or self-blame that client may express. Assess stage of grief in which the client is fixed. Discuss normalcy of feelings and behaviors related to stages of grief. Assess impact of the trauma on client’s ability to resume regular activities of daily living. Consider employment, marital relationship, and sleep patterns.

Nursing Interventions: Complicated Grieving Assess for self-destructive ideas and behavior. Assess for maladaptive coping strategies, such as substance abuse. Identify available community resources from which the individual may seek assistance if problems with complicated grieving persist.

Nursing Diagnosis: Social Isolation Social Isolation Related to: ◦ Fear of being in a place from which escape is not possible Evidenced by: ◦ Staying alone, refusing to leave room or home

Outcome Criteria: Social Isolation Short Term Goals: ◦ The client will willingly attend therapy activities by trusted support person for 1 week Long Term Goals: ◦ Client will spend time voluntarily with staff members in group activities by discharge

Nursing Interventions: Social Isolation Develop trust relationship through: ◦ Conveying acceptance and regard ◦ Being honest and keeping promises ◦ Making brief frequent contacts Attend group activities with client to provide emotional security for client Give space and avoid touch Administer PRN tranquilizers Discuss with client signs of increased anxiety and techniques to interrupt it (relaxation …) Give positive reinforcement for voluntary interaction with others

Nursing Care of a client with OCD

Nursing Diagnosis: Ineffective Coping Ineffective Coping Related to: ◦ Underdeveloped ego, punitive superego, avoidance learning, biochemical changes (OCD) ◦ Repressed anxiety, unmet dependency needs (Somatoform disorder) ◦ Severe psychosocial stressors or substance abuse and repressed severe anxiety (Dissociative disorder)

Nursing Diagnosis: Ineffective Coping Ineffective coping Evidenced by: ◦ Ritualistic behavior, obsessive thoughts (OCD) ◦ Verbalization of numerous physical complaints, self centered, presence of physical symptoms with no path-physiology (somatic disorders) ◦ Sudden travel away from home with inability to recall previous identity (dissociative disorders)

Outcome Criteria: Ineffective coping Short Term Goals: ◦ Client will decrease participation in ritualistic behavior by half within 1 week ◦ Client will verbalize understanding of correlation between physical symptoms or dissociative behavior & anxiety or stressful psychosocial stress ◦ Client will verbalize more adaptive ways of coping in stressful situations than resorting to dissociation or physical complaint or symptoms

Outcome Criteria: Ineffective coping Long Term Goals: ◦ Client will demonstrate the use of healthy coping strategies without resorting to previous unhealthy coping

Nursing Intervention: Ineffective coping Develop trust relationship through communicating acceptance, understanding, respect …. Reassure the client for safety & security by your presence Accept client’s behavior (physical complaint) & do not deny client’s feelings Give space and allow ritualistic behavior of complaint at the beginning of treatment without judgment

Nursing Intervention: Ineffective coping Initially meet the client’s dependency needs as required, & encourage independence & give positive rewards for independent behavior Identify factors or stressors that precipitate severe anxiety Support client & help him/her to verbalize & explore meaning & purpose the exhibited behavior (OCD, dissociative or physical complaint)

Nursing Intervention: Ineffective coping Provide structured schedule to divert from the unwanted behavior (ritualistic or physical complaint) – allow some time for ritualistic behavior then decrease the allocated time for it gradually- Explain that new physical complaint will be referred to the physician with no further attention Help client to learn ways to interrupt unhealthy behaviors (ritualistic, complaining of physical symptoms)

Nursing Intervention: Ineffective coping Discuss possible alternative coping strategies to use in response to stress – relaxation, exercise…- Give positive reinforcement for use of healthy coping strategies Help client identify ways of getting recognitions from others without resorting to physical symptoms Identify community resources for support to prevent unhealthy coping behaviors from reoccurring

Nursing Diagnosis: Ineffective Role Performance Ineffective Role Performance Related to: ◦ Need to perform rituals Evidenced by: ◦ Inability to fulfill usual patterns of responsibility

Outcome Criteria: Ineffective Role Performance Short Term Goal: ◦ Client will verbalize understanding that rituals interfere with role performance in order to decrease anxiety Long Term Goal ◦ Client will be able to resume role related responsibilities by discharge

Nursing Interventions: Ineffective Role Performance Assess extent of role alteration by exploring client’s role and other family members’ roles Discuss client & family members perception of the role and determine if it is realistic Encourage the client to discuss conflict within family system in order to produce change in family system if needed ◦ Identify specific stressors ◦ Identify adaptive or maladaptive responses of both client & family members

Nursing Interventions: Ineffective Role Performance Explore available options for changes or adjustments in role Plan & rehearse through role play, of potential role transition this will help to decrease anxiety Encourage the participation of family members who are directly involved in planning and helping client to work through the changes Give the client positive reinforcement for ability to resume role responsibilities

Nursing Diagnosis: Disturbed Body Image Disturbed Body Image Related to: ◦ Repressed anxiety Evidenced by: ◦ Preoccupation with imagined or real defect, verbalizations that are out of proportion to any actual physical abnormality that may exist, numerous visits to dermatologists to seek help

Outcome Criteria: Disturbed Body Image Short Term Goal: ◦ Client will verbalize understanding that changes in bodily structure or function is exaggerated (specific time) Long Term Goal: ◦ Client will verbalize perception of own body that is realistic to actual structure or function by discharge

Nursing Interventions: Disturbed Body Image Assess client’s perception of his/her body image, keep in mind that body image is real for the client Help client to see that his/her body image is distorted and exaggerated recognition is necessary before accepting reality Encourage verbalization of fears & anxieties associated with life situations-verbalization help the client to come to term with unresolved issues Discuss alternative coping strategies Involve client in activities that reinforce positive self image –to develop self satisfaction based on accomplishments

Nursing care of a client with Somatic Disorders

Nursing Diagnosis: Chronic Pain Chronic Pain Related to: ◦ Repressed anxiety & learned maladaptive coping skills Evidenced by: ◦ Verbal complaints of pain with no patho- physiology, excessive use of analgesics

Outcome Criteria: Chronic Pain Short Term Goals: ◦ Client will verbalize relief from pain ◦ Client will verbalize understanding of the relationship between pain & psychological problem Long Term Goal: ◦ Client will demonstrate the ability to cope with life situations with decreased experience of pain responses

Nursing Interventions: Chronic Pain Monitor physician on going assessment & lab reports Accept the reality of the pain to the client Observe & record the onset, precipitating factors, duration & intensity of the pain Provide prescribed pain medication Provide comfort measures such as back rub, warm bath, hot pads that will meet the secondary gains from being in pain

Nursing Interventions: Chronic Pain Offer attention when client is not complaining of pain Identify activities that helps to distract the client’s attention from complaints Encourage verbalization of feelings by ◦ Exploring meaning of pain ◦ Connecting between pain & anxiety ◦ Identify situations that cause anxiety

Nursing Interventions: Chronic Pain Encourage client to identify new health coping strategies with stress Explore ways to intervene with pain (so that it will not become disabling) such as deep breathing, imagery, relaxation Provide positive reinforcement for times when client is not focusing on pain

Nursing Diagnosis: Fear (of having a serious illness) Fear (of having a serious illness) Related to: ◦ Past experience with life threatening illness of self or significant others Evidenced by: ◦ Preoccupation with & unrealistic interpretation of bodily signs & sensations

Outcome Criteria: Fear (of having a serious illness Short Term Goal: ◦ Client will verbalize that fear is associated with bodily sensation are irrational Long Term Goal: ◦ Client will interpret bodily sensation correctly

Nursing intervention: Fear (of having a serious illness) Monitor physician’s ongoing assessment & lab reports Refer to physician if new complaint occur Assess gain or met needs by fear of illness Assess precipitating factors, onset, duration & intensity of fear & level of anxiety Allocate specific time to discuss physical symptoms (start with a certain length of session then decrease the allocated time gradually) ◦ Verbalize feelings instead of converting it to physical symptoms ◦ Do not provide positive reinforcement to expressing of feelings physically Teach the client coping strategies that will be helpful to decrease levels of anxiety such as deep breathing, relaxation, exercise

Nursing care of a client with Dissociative Disorders

Nursing Diagnosis: Disturbed Thought Process Disturbed Thought Process Related to: ◦ Severe psychological stress & repression of anxiety Evidenced by: ◦ Loss of memory

Outcome Criteria: Disturbed Thought Process Short Term Goals: ◦ The client will verbalize understanding that loss of memory is related to stressful situation ◦ Client will discuss the stressful situation Long Term Goal: ◦ The client will  Recover deficit in memory  Develop more adaptive coping strategies to deal with stress

Nursing Interventions: Disturbed Thought Process Obtain information from family about the client’s likes & dislikes, important people, activities Do not provide the client with excessive information about his/her past Expose client to pleasant experiences similar to ones in his/her past to stimulate memory Discuss underlying feeling of stressful situations & how to deal with it Assist client in identifying conflicts, identify solutions & follow up on carrying out the resolution

Nursing Diagnosis: Disturbed Sensory Perception (visual/kinesthetic) Disturbed Sensory Perception (visual/kinesthetic) Related to: ◦ Repressed severe anxiety & psychological stress Evidenced by: ◦ Loss or alteration in physical functioning with no physical pathology (conversion); alteration in the perception of the self or the environment (depersonalization)

Outcome Criteria: Disturbed Sensory Perception Short Term Goal: ◦ Client will verbalize understanding of emotional problems as a contributing factor to the alteration in physical functioning ◦ Client will verbalize adaptive ways of coping Long Term Goal: ◦ Client will recover from lost or altered function ◦ Client will demonstrate the ability to perceive stimuli correctly ◦ Client will maintain a sense of reality during stressful situations

Nursing Interventions: Disturbed Sensory Perception Monitor physician’s on going assessment & lab reports Identify primary & secondary gains from physical symptoms (dependency, attention, protection from experiencing stress) Provide support & encouragement during times of depersonalization to lessen fear & anxiety Explain the depersonalization (conversion) behavior & the purpose it serves Explain the relationship between severe anxiety and depersonalization (conversion)

Nursing Interventions: Disturbed Sensory Perception Do not focus on disability & encourage client to become more independent Discuss painful experiences by exploring past experiences and possible painful situations such as trauma, losses..etc. Encourage client to deal with underlying feelings associated with the stressful situation Teach client more health ways of responding to stress through role play Give positive reinforcement for identification or demonstration of more healthy coping skills that will help in enhancing self esteem