APPLICATION OF THE NURSING PROCESS: OBSESSIVE-COMPULSIVE DISORDER
The nurse can use this tool along with the following detailed discussion to guide his or her assessment of the client with OCD.
The client usually seeks treatment only when obsessions become too overwhelming or when compulsions interfere with daily life (e.g., going to work, cooking meals, or par-ticipating in leisure activities with family or friends) or both. Clients are hospitalized only when they have become completely unable to carry out their daily routines. Most treatment is outpatient. The client often reports that ritu-als began many years before; some begin as early as child-hood. The more responsibility the client has as he or she gets older, the more the rituals interfere with the ability to fulfill those responsibilities.
General Appearance and Motor Behavior
The nurse assesses the client’s appearance and behavior. Clients with OCD often seem tense, anxious, worried, and fretful. They may have difficulty relating symptoms because of embarrassment. Their overall appearance is unremark-able; that is, nothing observable seems to be “out of the ordinary.” The exception is the client who is almost immo-bilized by his or her thoughts and the resulting anxiety.
Mood and Affect
During assessment of mood and affect, clients report ongo-ing, overwhelming feelings of anxiety in response to the obsessive thoughts, images, or urges. They may look sad and anxious.
Thought Processes and Content
The nurse explores the client’s thought processes and con-tent. Many clients describe the obsessions as arising from nowhere during the middle of normal activities. The harder the client tries to stop the thought or image, the more intense it becomes. The client describes how these obses-sions are not what he or she wants to think about and that he or she would never willingly have such ideas or images.
Assessment reveals intact intellectual functioning. The client may describe difficulty concentrating or paying attention when obsessions are strong. There is no impair-ment of memory or sensory functioning.
Judgment and Insight
The nurse examines the client’s judgment and insight. The client recognizes that the obsessions are irrational, but he or she cannot stop them. He or she can make sound judg-ments (e.g., “I know the house is safe”) but cannot act on them. The client still engages in ritualistic behavior when the anxiety becomes overwhelming.
During exploration of self-concept, the client voices con-cern that he or she is “going crazy.” Feelings of powerless-ness to control the obsessions or compulsions contribute to low self-esteem. The client may believe that if he or she were “stronger” or had more will power, he or she could possibly control these thoughts and behaviors.
Roles and Relationships
It is important for the nurse to assess the effects of OCD on the client’s roles and relationships. As the time spent per-forming rituals increases, the client’s ability to fulfill life roles successfully decreases. Relationships also suffer as family and friends tire of the repetitive behavior, and the client is less available to them as he or she is more con-sumed with anxiety and ritualistic behavior.
Physiologic and Self-Care Considerations
The nurse examines the effects of OCD on physiology and self-care. As with other anxiety disorders, clients with OCD may have trouble sleeping. Performing rituals may take time away from sleep, or anxiety may interfere with the ability to go to sleep and wake refreshed. Clients also may report a loss of appetite or unwanted weight loss. In severe cases, personal hygiene may suffer because the cli-ent cannot complete needed tasks.
Depending on the particular obsession and its accompany-ing compulsions, clients have varying symptoms. Nursing diagnoses can include the following:
· Ineffective Coping
· Situational Low Self-Esteem
· Impaired Skin Integrity (If Scrubbing or Washing Rituals)
Outcomes for clients with OCD include the following:
· The client will complete daily routine activities within a realistic time frame.
· The client will demonstrate effective use of relaxation techniques.
· The client will discuss feelings with another person.
· The client will demonstrate effective use of behavior therapy techniques.
· The client will spend less time performing rituals.
Using Therapeutic Communication
Offering support and encouragement to the client is impor-tant to help him or her manage anxiety responses. The nurse can validate the overwhelming feelings the client experiences while indicating the belief that the client can make needed changes and regain a sense of control. The nurse encourages the client to talk about the feelings and to describe them in as much detail as the client can toler-ate. Because many clients try to hide their rituals and to keep obsessions secret, discussing these thoughts, behav-iors, and resulting feelings with the nurse is an important step. Doing so can begin to relieve some of the “burden” the client has been keeping to himself or herself.
Teaching Relaxation and Behavioral Techniques
The nurse can teach the client about relaxation tech-niques such as deep breathing, progressive muscle relaxation, and guided imagery. This intervention should take place when the client’s anxiety is low so he or she can learn more effectively. Initially, the nurse can demonstrate and practice the techniques with the cli-ent. Then, the nurse encourages the client to practice these techniques until he or she is comfortable doing them alone. When the client has mastered relaxation techniques, he or she can begin to use them when anxi-ety increases. In addition to decreasing anxiety, the client gains an increased sense of control that can lead to improved self-esteem.
To manage anxiety and ritualistic behaviors, a base-line of frequency and duration is necessary. The client can keep a diary to chronicle situations that trigger obses-sions, the intensity of the anxiety, the time spent perform-ing rituals, and the avoidance behaviors. This record pro-vides a clear picture for both client and nurse. The client then can begin to use exposure and response prevention behavioral techniques. Initially, the client can decrease the time he or she spends performing the ritual or delay performing the ritual while experiencing anxiety. Eventu-ally, the client can eliminate the ritualistic response or decrease it significantly to the point that interference with daily life is minimal. Clients can use relaxation techniques to assist them in managing and tolerating the anxiety they are experiencing.
It is important to note that the client must be willing to engage in exposure and response prevention. These are not techniques that can be forced on the client.
Completing a Daily Routine
To accomplish tasks efficiently, the client initially may need additional time to allow for rituals. For example, if breakfast is at 8:00 AM and the client has a 45-minute rit-ual before eating, the nurse must plan that time into the client’s schedule. It is important for the nurse not to inter-rupt or to attempt to stop the ritual because doing so will escalate the client’s anxiety dramatically. Again, the client must be willing to make changes in his or her behavior. The nurse and client can agree on a plan to limit the time spent performing rituals. They may decide to limit the morning ritual to 40 minutes, then to 35 minutes, and so forth, taking care to decrease this time gradually at a rate the client can tolerate. When the client has completed the ritual or the time allotted has passed, the client then must engage in the expected activity. This may cause anxiety and is a time when the client can use relaxation and stress reduction techniques. At home, the client can continue to follow a daily routine or written schedule that helps him or her to stay on tasks and accomplish activities and responsibilities.
Providing Client and Family Education
It is important for both the client and the family to learn about OCD. They often are relieved to find the client is not “going crazy” and that the obsessions are unwanted, rather than a reflection of any “dark side” to the client’s personality. Helping the client and family to talk openly about the obsessions, anxiety, and rituals eliminates the client’s need to keep these things secret and to carry the guilty burden alone. Family members also can better give the client needed emotional support when they are fully informed.
Teaching about the importance of medication compli-ance to combat OCD is essential. The client may need to try different medications until his or her response is satis-factory. The chances for improved OCD symptoms are enhanced when the client takes medication and uses behavioral techniques.
Treatment has been effective when OCD symptoms no longer interfere with the client’s ability to carry out respon-sibilities. When obsessions occur, the client manages resulting anxiety without engaging in complicated or time-consuming rituals. He or she reports regained control over his or her life and the ability to tolerate and manage anxi-ety with minimal disruption.