The client will discuss a phobic object or situation with the nurse or therapist within 5 days.
Long term Goals
The client will be able to function in presence of a phobic object or situation without experiencing panic anxiety by the time of discharge from treatment.
Interventions
Rationales
Reassure the client of his or her safety and security.
At a panic level of anxiety, the client may fear for their own life.
Explore client’s perception of threat to physical integrity or threat to self-concept.
It is important to understand the client’s perception of the phobic object or situation in order to assist with the desensitization process.
Discuss reality of the situation with client in order to recognize aspects that can be changed and those that cannot.
The client must accept the reality of the situation (aspects that cannot change) before the work of reducing the fear can progress.
Include the client in making decisions related to the selection of alternative coping strategies. (Example: Client may choose
either to avoid the phobic stimulus or attempt to eliminate
the fear associated with it.)
Allowing the client choices provides a measure of control and serves to increase feelings of self-worth.
If the client elects to work on the elimination of the fear, techniques of desensitization may be employed.
This is a systematic plan of behavior modification, designed to expose the individual gradually to the situation or object (either in reality or through fantasizing) until the fear is no longer experienced.
This is also sometimes accomplished through implosion therapy, in which the individual is “flooded” with stimuli related to the phobic situation or object (rather than in gradual steps) until anxiety is no longer experienced in
relation to the object or situation.
Fear is decreased as the
physical and psychological sensations diminish in response to repeated exposure to the phobic stimulus under nonthreatening conditions.
Encourage the client to explore underlying feelings that may be contributing to irrational fears. Help client to understand how facing these feelings, rather than suppressing them,
can result in more adaptive coping abilities.
Verbalization of
feelings in a nonthreatening environment may help the client come to terms with unresolved issues.
3. Nursing Diagnosis
Ineffective coping
related to
Underdeveloped ego; punitive superego
Fear of failure
Situational crises
Maturational crises
Personal vulnerability
Inadequate support systems
Unmet dependency needs
evidenced by
Ritualistic behavior
Obsessive thoughts
Inability to meet basic needs
Inability to meet role expectations
Inadequate problem solving
Alteration in societal participation
Goals
Short term Goal
Within 1 week, the client will decrease participation in ritualistic behavior by half
Long term Goal
By the time of discharge from treatment, the client will demonstrate an ability to cope effectively without resorting to obsessive-compulsive behaviors or increased dependency.
Interventions
Rationales
Assess client’s level of anxiety. Try to determine the types of situations that increase anxiety and result in ritualistic behaviors.
Recognition of precipitating factors is the first step in teaching the client to interrupt the escalating anxiety.
Initially meet client’s dependency needs as required. Encourage independence and give positive reinforcement for independent behaviors.
Sudden and complete elimination of all avenues for dependency would create intense anxiety on the
part of the client. Positive reinforcement enhances self-esteem and encourages the repetition of desired behaviors.
At the beginning of treatment allow plenty of time for rituals. Do not be judgmental or verbalize disapproval of the behavior.
To deny the client this activity may precipitate a panic level of anxiety.
Support client’s efforts to explore the meaning and purpose of the behavior
The client may be unaware of the relationship between emotional problems and compulsive behaviors.
Recognition is important before change can occur.
Provide a structured schedule of activities for the client, including adequate time for completion of rituals.
The structure provides a feeling of security for the anxious client.
Gradually begin to limit the amount of time allotted for ritualistic behavior as the client becomes more involved in unit activities.
Anxiety is minimized when the client is able to replace ritualistic behaviors with more adaptive ones.
Give positive reinforcement for nonritualistic behaviors.
Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors
Encourage recognition of situations that provoke obsessive thoughts or ritualistic behaviors. Explain ways of interrupting these thoughts and patterns of behavior (e.g., thought-stopping techniques, relaxation techniques, physical exercise, or other constructive activity with which the client feels comfortable).
4. Nursing Diagnosis
Powelessness
related to
Lifestyle of helplessness
Fear of disapproval from others
Unmet dependency needs
Lack of positive feedback
Consistent negative feedback
Evidenced by
Verbal expressions of having no control (e.g., over self-care, situation, outcome)
Nonparticipation in care or decision-making
Expression of doubt regarding role performance when opportunities are provided.
Reluctance to express true feelings
Apathy
Dependence on others may result in irritability, resentment, anger, and guilt
Passivity
Goal
Short term Goal
The client will participate in decision-making regarding his own care within 5 days.
Long term goal
The client will be able to effectively problem-solve ways to take control of his or her life situation by discharge, thereby decreasing feelings of powerlessness.
Interventions
Rationales
Allow client to take as much responsibility as possible for own self-care practices.
For e.g.
a. Include the client in setting the goals of care he or she wishes to achieve.
b. Allow the client to establish his own schedule for self-care activities.
c. Provide the client with privacy as need is determined.
d. Provide positive feedback for decisions made. Respect the client’s right to make those decisions independently, and refrain from attempting to influence him or her toward those that may seem more logical.
Providing client with choices will increase his or her feelings of control.
Help client set realistic goals.
Unrealistic goals set the client up for failure and reinforce feelings of powerlessness.
Help identify areas of life situation that client can control.
Client’s emotional condition interferes with his or her ability to solve problems. Assistance is required to perceive the benefits and consequences of available alternatives accurately.
Help client identify areas of life situation that are not within his or her ability to control. Encourage verbalization of feelings related to this inability.
In an effort to deal with
unresolved issues and accept what cannot be changed.
Identify ways in which the client can achieve. Encourage participation in these activities, and provide positive reinforcement for participation, as well as for achievement.
Positive reinforcement enhances self-esteem and encourages the repetition of desirable behaviors.
5. Nursing Diagnosis
Social isolation
related to
Panic level of anxiety
Past experiences of difficulty in interactions with others
Need to engage in ritualistic behavior in order to keep anxiety under control
Preoccupation with own thoughts; repetitive, meaningless action
Expression of feelings of rejection or of aloneness imposed by others
Experiences feelings of differences from others
Insecurity in public
Goals
Short tem goal
The client will willingly attend therapy activities accompanied by a trusted support person within 1 week.
Long term goal
The client will voluntarily spend time with other clients and staff members in group activities by the time of discharge from treatment.
Interventions
Rationales
Convey an accepting attitude by making brief, frequent contacts.
An accepting attitude increases feelings of self-worth and facilitates trust.
Show unconditional positive regard.
This conveys your belief in the client as a worthwhile human being
Be with the client to offer support during group activities that may be frightening or difficult for him or her.
The presence of a trusted individual provides emotional security for the client.
Be honest and keep all promises.
Honesty and dependability promote a trusting relationship.
Be cautious with touch. Allow client extra space and an avenue for exit if he or she becomes too anxious.
A person in panic anxiety may perceive touch as a threatening gesture.
Administer tranquilizing medications as ordered by the physician. Monitor for effectiveness and for adverse side effects.
Short-term use of antianxiety medications, such as diazepam, chlordiazepoxide, or alprazolam, helps to reduce the level of
anxiety in most individuals, thereby facilitating interactions with others.
Discuss with the client the signs of increasing anxiety and techniques for interrupting the response (e.g., relaxation exercises, thought
stopping).
Maladaptive behaviors, such as withdrawal and suspiciousness, are manifested during times of increased anxiety.
Give recognition and positive reinforcement for the client’s voluntary interactions with others.
Positive reinforcement enhances self-esteem and encourages repetition of acceptable behaviors.
