NURSING HISTORY AND ASSESSMENT
Stephanie is a 34-year-old mother of a 7-year-old girl named April. Stephanie’s husband, Chris, brought her to the emergency department when she began complaining of chest pain and shortness of breath. Diagnostic testing ruled out cardiac problems, and Stephanie was referred for psychiatric evaluation. Chris was present at the admission interview. He explained to the nurse that Stephanie has become increasingly “nervous and high-strung” over the past few years. Four years ago, April, then 3 years old, was attending nursery school 2 days a week. April came down with a very severe case of influenza that developed into pneumonia. She was hospitalized, and her prognosis was questionable for a short while, although she eventually made a complete recovery. Since that time, however, Stephanie has been extremely anxious about her family’s health. She is fastidious about housekeeping and scrubs her floors three times a week. She launders the bedclothes daily and uses bleach on all the countertops and door handles several times a day. She washes the woodwork twice a week. She washes her hands incessantly, and they are red and noticeably chapped. Chris explained that Stephanie becomes very upset if she is not able to perform all of her cleaning chores according to her self-assigned schedule. This afternoon, April came home from school with a note from the teacher saying that a child in April’s class had been diagnosed with a case of meningitis. Chris told the nurse, “Stephanie just lost it. She got all upset and started crying and had trouble breathing. Then she got those pains in her chest. That’s when I brought her to the hospital.” Stephanie is admitted to the psychiatric unit with a diagnosis of Obsessive-Compulsive Disorder. The physician orders alprazolam 0.5 mg tid and paroxetine 20 mg every morning.
The night nurse finds her up at 2 a.m. scrubbing the shower with a hand towel. She refuses to sleep in the bed, stating that it must certainly be contaminated. When the day nurse makes morning rounds, she finds Stephanie in the bathroom washing her hands.
NURSING DIAGNOSES AND OUTCOME
IDENTIFICATION
From the assessment data, the nurse develops the following nursing diagnoses for Stephanie:
1. Panic anxiety related to perceived threat to biological integrity evidenced by chest pain and shortness of breath.
a. Short-Term Goal: Client will be able to relax with effects of medication.
b. Long-Term Goal: Client will be able to maintain anxiety at manageable level.
2. Ineffective coping related to panic anxiety and weak ego strength evidenced by compulsive cleaning and washing hands.
a. Short-Term Goal: Client will reduce amount of time performing rituals within 3 days.
b. Long-Term Goal: Client will demonstrate ability to cope effectively without resorting to ritualistic behavior.
PLANNING AND IMPLEMENTATION
PANIC ANXIETY
The following nursing interventions have been identified for
Stephanie:
1. Stay with Stephanie and reassure her that she is safe and
that she is not going to die.
2. Maintain a calm, nonthreatening manner.
3. Speak very clearly and calmly, and use simple words and messages.
4. Keep the lights low, the noise level down as much as possible, and as few people in her environment as is necessary.
5. Administer the alprazolam and paroxetine as ordered by the physician. Monitor for effectiveness and side effects.
6. After several days, when the anxiety has subsided, discuss with Stephane the causes that precipitated this attack.
7. Teach her the signs that indicate her anxiety level is rising.
8. Teach strategies that she may employ to interrupt the escalation of the anxiety. She may choose which is best for her: relaxation exercises, physical exercise, meditation.
INEFFECTIVE COPING
The following nursing interventions have been identified for
Stephanie:
1. Initially, allow Stephanie all the time she needs to wash her hands, straighten up her room, change her own sheets, and so on. To deny her these rituals would result in panic anxiety.
2. Initiate discussions with Stephanie about her behavior. She ultimately must come to understand that these rituals are her way of keeping her anxiety under control.
3. Within a couple of days, begin to limit the amount of time
Stephanie may spend on her rituals. Assign her to groups and activities that take up her time and distract her from her obsessions.
4. Explore with Stephanie the types of situations that cause her anxiety to rise. Help her to correlate these times of increased anxiety to initiation of the ritualistic behavior.
5. Help her with problem-solving and with making decisions about more adaptive ways to respond to situations that cause her anxiety to rise.
6. Explore her fears surrounding the health of her daughter.
Help her to recognize which fears are legitimate and which are irrational.
7. Discuss possible activities in which she may participate that may distract from obsessions about contamination.
Make suggestions, and encourage her to follow through.
Examples may include enrollment in classes at the local community college, volunteer work at the local hospital, or part-time employment.
8. Explain to her that she will likely be discharged from the hospital with a prescription for paroxetine. Teach her about the medication, how it should be taken, possible side effects, and what to report to the physician.
9. Suggest that she may benefit from attendance in an anxiety disorder support group. If she is interested, help locate one that would be convenient and appropriate for her.
