Nursing Care Plans For Obsessive–Compulsive Disorder

Nursing Care Plans For Patient With Obsessive–Compulsive Disorder

Obsessive–Compulsive Disorder

This disorder is characterized by involuntary recurring thoughts or images that the individual is unable to ignore and by recurring impulse to perform a seemingly purposeless activity. These obsessions and compulsions serve to prevent extreme anxiety on the part of the individual.

Patients with obsessive-compulsive disorder are prone to abuse alcohol, anxiolytics, or other substances in an attempt to relieve their anxiety. In addition, other anxiety disorders and major depression commonly coexist with obsessive-compulsive disorder. Obsessive-compulsive disorder is typically a chronic condition with remissions and flare-ups. Mild forms of the disorder are relatively common in the population at large.

Causes

The cause of obsessive-compulsive disorder is unknown. Some studies suggest the possibility of brain lesions, but the most useful research and clinical studies base an explanation on psychological theories. Several studies have shown brain abnormalities, such as decreased caudal size and decreased white matter, but results are inconsistent and remain under investigation. In addition, major depression, organic brain syndrome, and schizophrenia may contribute to the onset of obsessive-compulsive disorder.

Assessment Nursing Care Plans For Obsessive Compulsive Disorder

The psychiatric history of a patient with this disorder may reveal the presence of obsessive thoughts, words, or mental images that persistently and involuntarily invade the consciousness. Common obsessions include thoughts of violence (such as stabbing, shooting, maiming, or hitting), thoughts of contamination (images of dirt, germs, or stool), repetitive doubts and worries about a tragic event, and repeating or counting images, words, or objects in the environment. The patient recognizes that the obsessions are a product of his own mind and that they interfere with normal daily activities but feels powerless to stop them.

The patient's history may also reveal the presence of compulsions irrational and recurring impulses to repeat a certain behavior. Common compulsions include repetitive touching, sometimes combined with counting; doing and undoing (for instance, opening and closing doors or rearranging things); washing (especially hands); and checking (to be sure no tragedy has occurred since the last time he checked). In all cases, obsessive-compulsive behaviors and activities consume more than 1 hour of the patient's time per day. The activities are done to alleviate anxiety triggered by the patient's core fear.

During the assessment interview, determine the patient's personality type. The obsessional personality usually is rigid and conscientious and has great aspirations. He exhibits a formal, reserved manner, with precise and careful movements and posture; he takes responsibility seriously and finds decision-making difficult. He lacks creativity and the ability to find alternate solutions to his problems.Also evaluate the impact of obsessive-compulsive phenomena on the patient's normal routine. He'll typically report moderate to severe impairment of social and occupational functioning.

Diagnoses Nursing Care Plans For Obsessive Compulsive Disorder

• Anxiety
• Chronic low self-esteem
• Fear
• Ineffective coping
• Ineffective role performance
• Impaired social interaction
• Risk for injury
• Social isolation

Key outcomes Nursing Care Plans For Obsessive–Compulsive Disorder

• The patient will express feelings of anxiety as they occur.
• The patient will develop self-esteem.
• The patient will express fears and concerns.
• The patient will demonstrate effective social interaction skills.
• The patient will cope with stress without excessive obsessive-compulsive behavior.
• The patient will reduce the amount of time spent each day on obsessing and ritualizing.
• Ritualistic behavior won't produce harmful effects.
• The patient will maintain family and peer relationships
• Client is able to maintain anxiety at level in which problemsolving can be accomplished.
• Client is able to verbalize signs and symptoms of escalating anxiety.
• Client is able to demonstrate techniques for interrupting the progression of anxiety to the panic level.

Interventions Nursing Care Plans For Obsessive–Compulsive Disorder

• Approach the patient unhurriedly.
• Provide an accepting atmosphere; don't show shock, amusement, or criticism of the ritualistic behavior.
• Allow the patient time to carry out the ritualistic behavior (unless it's dangerous) until he can be distracted into some other activity. Blocking this behavior raises anxiety to an intolerable level.
• Keep the patient's physical health in mind. For example, compulsive hand washing may cause skin breakdown, and rituals or preoccupations may cause inadequate food and fluid intake and exhaustion. Provide for basic needs, such as rest, nutrition, and grooming, if the patient becomes involved in ritualistic thoughts and behaviors to the point of self-neglect.
• Let the patient know you're aware of his behavior. For example, you might say, I noticed you've made your bed three times today; that must be very tiring for you. Help the patient explore feelings associated with the behavior. For example, ask him, What do you think about while you are performing your chores?
• Make reasonable demands, and set reasonable limits; make their purpose clear. Avoid creating situations that increase frustration and provoke anger, which may interfere with treatment.
• Explore patterns leading to the behavior or recurring problems.
• Listen attentively, offering feedback.
• Encourage the use of appropriate defense mechanisms to relieve loneliness and isolation.
• Engage the patient in activities to create positive accomplishments and raise his self-esteem and confidence.
• Encourage active diversional resources, such as whistling or humming a tune, to divert attention from the unwanted thoughts and to promote a pleasurable experience.
• Assist the patient with new ways to solve problems and to develop more effective coping skills by setting limits on unacceptable behavior (for example, by limiting the number of times per day he may indulge in obsessive behavior). Gradually shorten the time allowed. Help him focus on other feelings or problems for the remainder of the time.
• Identify insight and improved behavior (reduced compulsive behavior and fewer obsessive thoughts). Evaluate behavioral changes by your own and the patient's reports.
• Identify disturbing topics of conversation that reflect underlying anxiety or terror.
• Observe when interventions don't work; reevaluate and recommend alternative strategies.
• Monitor effects of pharmacologic therapy.

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Nursing Care Plans For Delusional Disorders

Nursing Care Plans For Patient With Delusional Disorders

DELUSIONAL DISORDERS

According to the DSM-IV-TR, delusional disorders are characterized by false beliefs with a plausible basis in reality. Formerly referred to as paranoid disorders, delusional disorders are known to involve erotomanic, grandiose, jealous, or somatic themes as well as persecutory delusions. Some patients experience several types of delusions; other patients experience unspecified delusions that have no dominant theme.

Delusional disorders commonly begin in middle or late adulthood, usually between ages 40 and 55, but they can occur at a younger age. These uncommon illnesses affect less than 1% of the population; the incidence is about equal in males and women. Typically chronic, these disorders often interfere with social and marital relationships but seldom impair intellectual or occupational functioning significantly.

Causes

Delusional disorders of later life strongly suggest a hereditary predisposition. At least one study has linked the development of delusional disorders to inferiority feelings in the family. Some researchers suggest that delusional disorders are the product of specific early childhood experiences with an authoritarian family structure. Others hold that anyone with a sensitive personality is particularly vulnerable to developing a delusional disorder.

Certain medical conditions are known to exaggerate the risks of delusional disorders: head injury, chronic alcoholism, deafness, and aging. Predisposing factors linked to aging include isolation, lack of stimulating interpersonal relationships, physical illness, and diminished hearing and vision. In addition, severe stress (such as a move to a foreign country) may precipitate a delusional disorder.

Assessment Nursing Care Plans For Delusional Disorders

The psychiatric history of a delusional patient may be unremarkable, aside from behavior related to his delusions. He's likely to report problems with social and marital relationships, including depressive symptoms or sexual dysfunction. In fact, about one-third of delusional patients are widowed, divorced, or separated at the time of first admission. Others describe a life marked by social isolation or hostility. Such patients may deny feeling lonely, relentlessly criticizing or placing unreasonable demands on others.

Also watch for nonverbal cues, indicating suspiciousness or mistrust, such as excessive vigilance or obvious apprehension on entering the room. During questions, the patient may listen intently, reacting defensively to imagined slights or insults. He may sit at the edge of his seat or fold his arms as if to shield himself. If he carries papers or money, he may clutch them firmly.

Diagnostic Nursing Care Plans For Delusional Disorders
Psychiatric examination confirms the presence of the following diagnostic criteria in the DSM-IV-TR:

1. Nonbizarre delusions of at least 1 month's duration are present, involving real-life situations, such as being followed, poisoned, infected, loved at a distance, or deceived by one's spouse or lover.
2.  Auditory or visual hallucinations, if present, aren't prominent.
3. Apart from the delusion or its ramifications, behavior isn't obviously odd or bizarre, and the patient isn't markedly impaired functionally. 
4. If a major depressive or manic syndrome has been present during the delusional disturbance, the total duration of all episodes of the mood syndrome has been brief relative to the total duration of the delusional disturbance.
5. The patient has never met diagnostic criteria for schizophrenia (presence of characteristic psychotic symptoms in the active phase for at least 1 week), and it can't be established that an organic factor initiated and maintained the disturbance.
6. In addition, blood and urine tests, psychological tests, and a neurologic evaluation rule out organic causes of the delusions, such as amphetamine-induced psychoses and Alzheimer's disease. Endocrine function tests are performed to rule out hyperadrenalism, pernicious anemia, and thyroid disorders such as “myxedemic madness

Treatment

Effective treatment of delusional disorders, consisting of a combination of drug therapy and psychotherapy, must correct the behavior and mood disturbances that result from the patient's mistaken belief system. Treatment may also include mobilizing a support system for the isolated, aged patient.

Drug treatment with antipsychotic agents is similar to that used in schizophrenic disorders. Antipsychotics appear to work by blocking postsynaptic dopamine receptors. These drugs reduce the incidence of psychotic symptoms, such as hallucinations and delusions, and relieve anxiety and agitation. Other psychiatric drugs, such as antidepressants and anxiolytics, may be prescribed to control associated symptoms.

High-potency antipsychotics include fluphenazine, haloperidol, thiothixene, and trifluoperazine. Loxapine, molindone, and perphenazine are intermediate in potency, and chlorpromazine and thioridazine are low-potency agents. Haloperidol and fluphenazine are depot formulations that are implanted I.M. to release the drug gradually over a 30-day period, improving compliance.

Clozapine, which differs chemically from other antipsychotic drugs, may be prescribed for severely ill patients who fail to respond to standard neuroleptic treatment. This agent effectively controls a wider range of psychotic symptoms without the usual adverse effects.

However, clozapine can cause drowsiness, sedation, excessive salivation, tachycardia, dizziness, and seizures, as well as agranulocytosis, a potentially fatal blood disorder characterized by a low white blood cell count and pronounced neutropenia. Routine blood monitoring is essential to detect the estimated 1% to 2% of all patients taking clozapine who develop agranulocytosis. If caught in the early stages, the disorder is reversible.

Diagnoses that may occur in Nursing Care Plans For Delusional Disorders

1. Anxiety
2. Disabled family coping
3. Disturbed personal identity
4. Disturbed sensory perception (visual, auditory)
5. Disturbed thought processes
6. Fear
7. Imbalanced nutrition: Less than body requirements
8. Impaired home maintenance
9. Impaired social interaction
10. Ineffective coping
11. Powerlessness
12. Risk for injury
13. Risk for other-directed violence
14. Risk for self-directed violence
15. Social isolation

Key outcomes Nursing Care Plans For Delusional Disorders

• The patient will consider alternative interpretations of a situation without becoming hostile or anxious.
• The patient and his family will participate in care and prescribed therapies.
• The patient will identify internal and external factors that trigger delusional episodes.
• The patient will maintain functioning to the fullest extent possible within the limitations of his visual or auditory impairment.
• The patient will remain oriented to person, place, time, and situation.
• The patient will express all fears and concerns.
• The patient will show no signs of malnutrition.
• The patient will recognize symptoms and comply with medication regimen.
• The patient will demonstrate effective social interaction skills in both one-on-one and group settings.
• The patient will demonstrate adaptive coping behaviors.
• The patient will identify and perform activities that decrease delusions.
• The patient will remain free from injury.
• The patient won't harm others.
• The patient won't harm self.
• The patient will maintain family and peer relationships.

Interventions Nursing Care Plans For Delusional Disorders

• In dealing with the patient, be direct, straightforward, and dependable. Whenever possible, elicit his feedback. Move slowly, with a matter-of-fact manner, and respond without anger or defensiveness to his hostile remarks.
• Accept the patient's delusional system. Don't attempt to argue with him about what's real.
• Respect the patient's privacy and space needs. Avoid touching him unnecessarily.
• Take steps to reduce social isolation, if the patient allows. Gradually increase social contacts after he has become comfortable with the staff.
• Watch for refusal of medication or food, resulting from the patient's irrational fear of poisoning.
• Monitor the patient carefully for adverse effects of neuroleptic drugs: drug-induced parkinsonism, acute dystonia, akathisia, tardive dyskinesia, and malignant neuroleptic syndrome.

Patient teaching Nursing Care Plans For  Delusional Disorders

• If the patient is taking clozapine, stress the importance of returning weekly to the hospital or outpatient setting to have his blood monitored.
• Emphasize the importance of complying with the prescribed medication treatment. Instruct the patient to report any adverse effects instead of stopping the drug. If he's taking a slow-release formulation, be sure he understands when to return to the physician for his next dose.
• Involve family members in treatment. Teach them how to recognize an impending relapse, and suggest ways to manage symptoms. These include tension, nervousness, insomnia, decreased concentration ability, and loss of interest.

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Nursing Care Plans For Schizophrenia

Nursing Care Plans For Patient With Schizophrenia

Schizophrenia is characterized by disturbances (for at least 6 months) in thought content and form, perception, affect, language, social activity, sense of self, volition, interpersonal relationships, and psychomotor behavior. The DSM-IV-TR recognizes catatonic, paranoid, disorganized, residual, and undifferentiated schizophrenia.

Schizophrenia affects approximately 0.85% of individuals worldwide, with a lifetime prevalence of 1% to 1.5%. Onset of symptoms usually occurs during late adolescence and has an insidious onset and poor outcome. It can progress to social withdrawal, perceptual distortions, chronic delusions, and hallucinations
This disorder produces varying degrees of impairment. As many as one-third of schizophrenic patients have just one psychotic episode and no more after that. Some patients have no disability between periods of exacerbation; other patients need continuous institutional care. The prognosis worsens with each acute episode


Causes For Schizophrenia
Schizophrenia may result from a combination of genetic, biological, cultural, and psychological factors with genetic and environmental insults most associated. For example, some evidence supports a genetic predisposition to this disorder. Close relatives of schizophrenic patients are up to 50 times more likely to develop schizophrenia; the closer the degree of biological relatedness, the higher the risk.

The most widely accepted biochemical hypothesis holds that schizophrenia results from excessive activity at dopaminergic synapses. Other neurotransmitter alterations may also contribute to schizophrenic symptoms.

Numerous psychological and sociocultural causes, such as disturbed family and interpersonal patterns, also have been proposed as possible causes. Schizophrenia has a higher incidence among lower socioeconomic groups, possibly related to downward social drift or lack of upward socioeconomic mobility, and to high stress levels, possibly induced by poverty, social failure, illness, and inadequate social resources. Gestational and birth complications, such as Rh factor incompatibility, prenatal exposure to influenza during the second trimester, and prenatal nutritional deficiencies, have been associated.



Complications For Schizophrenia
Because of disordered thought processes, the schizophrenic patient often neglects personal hygiene or ignores health needs. As a result, the patient has a shorter life expectancy than the general population. Ten percent of schizophrenic patients commit suicide.


Assessment Nursing Care Plans For Schizophrenia
Schizophrenia is associated with a wide variety of abnormal behaviors; therefore, assessment findings vary greatly, depending on both the type and phase of the illness. The individual may exhibit a decreased emotional expression, impaired concentration, and decreased social functioning, loss of function, or anhedonia. Individuals with these particular symptoms (present in one-third of the schizophrenic population) are associated with poor response to drug treatment and poor outcome.

Although behaviors and functional deficiencies can vary widely among patients and even in the same patient at different times, watch for the following characteristic signs and symptoms during the assessment interview:

1. ambivalence coexisting strong positive and negative feelings, leading to emotional conflict
2. apathy
3. clang associations words that rhyme or sound alike used in an illogical, nonsensical manner; for instance, It's the rain, train, pain.
4. concrete thinking inability to form or understand abstract thoughts
5. delusions false ideas or beliefs accepted as real by the patient. Delusions of grandeur, persecution, and reference (distorted belief regarding the relation between events and one's self; for example, a belief that television programs address the patient on a personal level) are common in schizophrenia. Also common are feelings of being controlled, somatic illness, and depersonalization.
6. echolalia meaningless repetition of words or phrases
7. echopraxia involuntary repetition of movements observed in others
8. flight of ideas rapid succession of incomplete and poorly connected ideas
9. hallucinations false sensory perceptions with no basis in reality. Usually visual or auditory, hallucinations may also be olfactory (smell), gustatory (taste), or tactile (touch).
10. illusions—false sensory perceptions with some basis in reality; for example, a car backfiring might be mistaken for a gunshot.
11. loose associations not connected or related by logic or rationality
12. magical thinking belief that thoughts or wishes can control other people or events
13. neologisms bizarre words that have meaning only for the patient
14. poor interpersonal relationships
15. regression return to an earlier developmental stage
16. thought blocking sudden interruption in the patient's train of thought
17. withdrawal disinterest in objects, people, or surroundings
18. word salad illogical word groupings; for example, She had a star, barn, plant. It's the extreme form of loose associations.

Diagnostic criteria Nursing Care Plans For Schizophrenia

Complete physical and psychiatric examinations rule out an organic cause of schizophrenic symptoms such as an amphetamine-induced psychosis. Diagnosis rests on fulfilling the criteria in the DSM-IV-TR.

Several tests, including brain imaging studies, tissue studies, functional and metabolic studies, and psychological tests, can be helpful in the diagnosis of schizophrenia

Treatment For Schizophrenia

In schizophrenia, treatment focuses on meeting both the physical and psychosocial needs of the patient based on his previous level of adjustment and his response to medical and nursing interventions. Treatment typically includes a combination of drug therapy, long-term psychotherapy for the patient and his family, vocational counseling, and the use of community resources

The primary treatment (for more than 30 years), antipsychotic drugs (sometimes called neuroleptic drugs) appear to work by blocking postsynaptic dopamine receptors. These antipsychotic drugs reduce the incidence of psychotic symptoms, such as hallucinations and delusions, as well as relieve anxiety and agitation. Other psychiatric drugs, such as antidepressants and anxiolytics, may also be prescribed to control associated signs and symptoms.

Some antipsychotic drugs cause numerous adverse reactions, several of which are irreversible. Most experts admit that patients who are withdrawn, isolated, or apathetic show little improvement after this drug treatment.

High-potency antipsychotics include fluphenazine, haloperidol, thiothixene, and trifluoperazine. Loxapine, molindone, and perphenazine are intermediate in potency, and chlorpromazine and thioridazine are low in potency. Haloperidol and fluphenazine are depot formulations that are implanted I.M. to provide gradual release over a 30-day period, thus improving compliance.

Risperidone (Risperdal), ziprasidone (Geodon), and olanzapine (Zyprexa) are atypical antipsychotic agents used to treat both the positive and negative symptoms of schizophrenia. A newer drug, aripiprazole (Abilify), is a dopamine system stabilizer that also shows promise in treating both the positive and negative symptoms of schizophrenia. Clozapine, which differs chemically from other antipsychotic drugs, may be prescribed for severely ill patients who fail to respond to standard treatment. This agent effectively controls a wider range of signs and symptoms without the usual adverse effects. However, clozapine can cause drowsiness, sedation, excessive salivation, hyperglycemia, tachycardia, dizziness, seizures, and agranulocytosis, a potentially fatal blood disorder characterized by a low white blood cell count and pronounced neutropenia.

Routine blood monitoring is essential to detect the estimated 1% to 2% of all patients taking clozapine who develop agranulocytosis. If the disorder is caught in the early stages, agranulocytosis is reversible.

Clinicians disagree about the effectiveness of psychotherapy in treating schizophrenia. Although a patient who has experienced a single acute psychotic episode may respond, psychotherapy is often futile in a patient with a long history of chronic disease. Nonetheless, some physicians use it as an adjunct to reduce loneliness, isolation, and withdrawal and enhance productivity.

Other studies suggest that psycho-education and social skills training are a more productive approach for the chronic schizophrenic. Besides improving understanding of the disorder, these methods teach the patient and his family coping strategies, effective communication techniques, and social skills such as grocery shopping.

Because schizophrenia is so disruptive to the family, all members may require psychotherapy. Family therapy can reduce guilt and disappointment as well as improve acceptance of the patient and his bizarre behavior.

Diagnoses Nursing Care Plans For Schizophrenia

• Anxiety
• Bathing or hygiene self-care deficit
• Disabled family coping
• Disturbed body image
• Disturbed personal identity
• Disturbed sensory perception (auditory, visual, kinesthetic)
• Disturbed sleep pattern
• Disturbed thought processes
• Dressing or grooming self-care deficit
• Fear
• Hopelessness
• Imbalanced nutrition: Less than body requirements
• Impaired home maintenance
• Impaired social interaction
• Impaired verbal communication
• Ineffective coping
• Ineffective role performance
• Powerlessness
• Risk for injury
• Risk for other-directed violence
• Risk for self-directed violence
• Social isolation

Key outcomes Nursing Care Plans For Schizophrenia

1. The patient will consider an alternative interpretation of a situation without becoming unduly hostile or anxious.
2. The patient will perform bathing and hygiene activities to the fullest extent possible.
3. The patient's family will demonstrate adaptive coping behaviors.
4. The patient will verbalize positive feelings about self.
5. The patient will identify internal and external factors that trigger delusional episodes.
6. The patient will maintain maximum functioning within the limits of his auditory, visual, or kinesthetic impairment.
7. The patient will resume appropriate rest and activity patterns.
8. The patient will identify and perform activities that decrease delusions.
9. The patient will perform dressing and grooming activities to the fullest extent possible.
10. The patient will express fears and concerns.
11. The patient and his family will participate in care and prescribed therapies.
12. The patient will remain free from signs of malnutrition.
13. The patient will develop effective coping behaviors.
14. The patient will maintain usual roles and responsibilities to the fullest extent possible.
15. The patient will recognize symptoms and comply with medication regimen.
16. The patient will demonstrate effective social interaction skills in both one-on-one and group settings.
17. The patient will express his needs.
18. The patient will gradually join in self-care and the decision-making process.
19. The patient will remain free from injury.
20. The patient won't harm others.
21. The patient won't harm self or others.
22. The patient will maintain family and peer relationships.

Interventions Nursing Care Plans For Schizophrenia

1. Assess the patient's ability to carry out the activities of daily living, paying special attention to his nutritional status. Monitor his weight if he isn't eating. If he thinks that his food is poisoned, allow him to fix his own food when possible, or offer him foods in closed containers that he can open. If you give liquid medication in a unit-dose container, allow the patient to open the container.
2. Maintain a safe environment, minimizing stimuli. Administer medication to decrease symptoms and anxiety. Use physical restraints according to your facility's policy to ensure the patient's safety and that of others.
3. Adopt an accepting and consistent approach with the patient. Don't avoid or overwhelm him. Keep in mind that short, repeated contacts are best until trust has been established.
4. Avoid promoting dependence. Meet the patient's needs, but only do for the patient what he can't do for himself.
5. Reward positive behavior to help the patient improve his level of functioning.
6. Engage the patient in reality-oriented activities that involve human contact: inpatient social skills training groups, outpatient day care, and sheltered workshops. Provide reality-based explanations for distorted body images or hypochondriacal complaints. Clarify private language, autistic inventions, or neologisms, explaining to the patient that what he says isn't understood by others. If necessary, set limits on inappropriate behavior.
7. If the patient is hallucinating, explore the content of the hallucinations. If he has auditory hallucinations, determine if they're command hallucinations that place the patient or others at risk. Tell the patient you don't hear the voices but you know they're real to him. Avoid arguing about the hallucinations; if possible, change the subject.
8. Don't tease or joke with the patient. Choose words and phrases that are unambiguous and clearly understood. For instance, a patient who's told, That procedure will be done on the floor, may become frightened, thinking he is being told to lie down on the floor.
9. Don't touch the patient without telling him first exactly what you're going to do. For example, clearly explain to him, I'm going to put this cuff on your arm so I can take your blood pressure. If necessary, postpone procedures that require physical contact with facility personnel until the patient is less suspicious or agitated.
10. Remember, institutionalization may produce new symptoms and handicaps in the patient that aren't part of his diagnosed illness, so evaluate symptoms carefully.
11. Mobilize community resources to provide a support system for the patient and reduce his vulnerability to stress. Ongoing support is essential to his mastery of social skills.
12. Encourage compliance with the medication regimen to prevent relapse. Also monitor the patient carefully for adverse effects of drug therapy, including drug-induced parkinsonism, acute dystonia, akathisia, tardive dyskinesia, and malignant neuroleptic syndrome. Make sure you document and report such effects promptly.

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