Anxiety, Trauma, and Somatic Disorders Notes

Chapter 15: Anxiety and Obsessive-Compulsive Disorders

  • A nurse should first lower a client's anxiety before teaching alternative coping strategies because severe anxiety narrows perceptual field and impairs learning.
  • Body dysmorphic disorder:
    • Characterized by preoccupation with an imagined defect in appearance.
    • Example: A woman with proportional body features wants surgical reduction of her feet and conceals them in social settings.
  • Social anxiety disorder (social phobia):
    • Severe anxiety or fear provoked by exposure to social or performance situations, fearing negative evaluation by others.
  • Separation anxiety disorder:
    • Developmentally inappropriate levels of concern over being away from a significant other.
  • When a client experiencing moderate anxiety says, “I feel undone,” the nurse should ask for an example to clarify the feeling, as anxiety can scatter thoughts.
  • Prioritize safety for a client experiencing panic because they are at high risk for self-injury due to increased motor activity, distorted perceptions, and disordered thoughts.
  • Nursing diagnosis for a client in panic:
    • Risk for injury (highest priority).
    • Rationale: Increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts.
  • Cognitive restructuring helps clients test automatic thoughts and draw new conclusions (e.g., exploring the likelihood of a house fire with a client who obsessively checks electrical cords).
  • Defense mechanism: Denial involves unconsciously blocking threatening or painful information or feelings.
  • Moderate anxiety:
    • Impairs information grasp and problem-solving ability.
    • Assessment findings: Tremulous voice, respirations 28, pulse 110.
  • Nursing intervention for a client with moderate anxiety preparing for surgery:
    • Present information calmly using simple language.
  • Encouraging a client to talk about their feelings and concerns helps in problem-solving by making concerns less overwhelming.
  • Assessing Generalized Anxiety Disorder:
    • Ask: "Do you find it difficult to control your worrying?"
  • For a client in the emergency department showing disorganized behavior and incoherence:
    • Provide a safe, quiet, non-stimulating environment (e.g., an interview room with minimal furniture).
  • Severe anxiety:
    • Characterized by inability to solve problems and poor grasp of the environment.
    • Somatic symptoms are present.
    • Example: person with nausea, dizziness, tachycardia, and hyperventilation after a car accident.
  • Defense Mechanism: Projection involves attributing one's own unacceptable thoughts or feelings to another.
  • Rationalization involves justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations.
    • Example: A client attributes their success to luck and opportunities instead of their ability.
  • Lorazepam is appropriate as a PRN anxiolytic due to its rapid action.
  • Altruism:
    • Dealing with emotional conflict by meeting the needs of others.
    • Example: A nurse not promoted becomes supportive of the new manager.
  • Compensation is an unconscious process of excelling in one area to make up for deficits in another to raise self-esteem.
    • Example: A person who feels unattractive says, “Although I’m not beautiful, I am smart.”
  • Reaction formation:
    • Keeps unacceptable feelings out of awareness by using the opposite behavior.
    • Example: An individual expresses adoration for a rival they dislike.
  • Rationalization involves making excuses for one’s behavior.
    • Example: An individual blames their sexual dysfunction on their partner being unattractive.
  • Mild Anxiety:
    • May be helpful:
      • Can promote studying and increase awareness.
    • Symptoms:
      • Feel very alert and a little restless.
    • Nursing interventions:
      • Explain that the symptoms result from mild anxiety and discuss the helpful aspects.
  • Rationalization: Justifying unacceptable behavior.
    • Example: A cruel person saying, “That person should not have provoked me.”
  • Nursing intervention for a client experiencing panic:
    • Give simple, neutral, directive instructions to help the client regain control.
  • Positive self-talk (cognitive restructuring):
    • Replaces negative thoughts with positive ones to gain mastery over symptoms.
    • Example: Changing "I can’t leave my apartment" to "I can control my anxiety."
  • Obsessive-compulsive disorder (OCD) is suggested by recurring doubts (obsessive thinking) and the need to check (compulsive behavior).
  • Alprazolam (acute anxiety):
    • Avoid alcoholic beverages because depressant effects of both drugs will be potentiated.
  • Agoraphobia:
    • Patients with agoraphobia generally acknowledge that the behavior is not constructive and that they do not really like it.
    • However, clients will state, are unable to change the behavior.
  • Nursing diagnosis for OCD: Anxiety related to persistent thoughts about bacteria, germs, and dirt as evidenced by inability to control compulsive cleaning.
  • Nursing intervention for ritualistic hand washing:
    • Encourage participation in social activities to improve coping and prevent constant focus on anxiety and symptoms.
  • Intervention for a client experiencing panic:
    • Provide calm, brief, directive communication to help the client gain control.
  • Interventions for a child in a foster home who is apprehensive and overreacts to stimuli:
    • Use a calm manner and low voice.
    • Maintain simplicity in the environment.
    • Explain and reinforce reality to avoid distortions.
  • Health teaching for a client diagnosed with generalized anxiety disorder who begins a new prescription for lorazepam:
    • Caution in use of machinery.
    • The importance of caffeine restriction.
    • Avoidance of alcohol and other sedatives.
  • Assessment questions for a client with possible obsessive-compulsive disorder:
    • Are there others in your family who must do things in a certain way to feel comfortable?
    • Is it difficult to keep certain thoughts out of your awareness?
    • Do you do certain things over and over again?
  • Nursing diagnoses for an adult who is socially withdrawn and hoards:
    • Ineffective home maintenance.
    • Chronic low self-esteem.
    • Risk for injury.

Chapter 16: Trauma, Stressor-Related, and Dissociative Disorders

  • Intervention for PTSD with flashbacks and arousal symptoms:
    • Explain that the physical symptoms are related to the psychological state to instill a sense of hope and decrease powerlessness over the symptoms.
  • Resilience:
    • Positive adaptation or the ability to maintain or regain mental health despite adversity.
    • Example: Parents creating a scholarship fund at their child’s high school after the child dies.
  • Therapeutic response to a man who says, “I can’t live without her … she was my whole life” after the death of his wife:
    • “Her death is a terrible loss for you.”
    • Rationale: A statement that validates a bereaved person’s loss is more helpful than false reassurances and clichés because it signifies understanding.
  • Adjustment disorder symptoms includes guilt, depression, and anger.
  • The nurse builds trust and shows compassion in the face of adjustment disorders. The nurse should show patience and tact while offering sympathy and warmth.
  • Maladaptive Grief: The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings.
  • For a client expressing feelings related to a loss, the nurse's priority intervention is to form a therapeutic alliance and support the client’s expression of feelings.
  • Dissociative fugue state:
    • Relocates and lacks recall of their life before the fugue began.
    • Often fugue states follow traumatic experiences and sometimes involve assuming a new identity.
  • Assessments related to client safety take priority and the nurse must be alert for indicators of risk for self-injury for clients with Dissociative identity disorder.
  • Depersonalization disorder:
    • Persistent or recurrent experience of feeling detached from and outside oneself.
    • Although reality testing is intact, the experience causes significant impairment in social or occupational functioning and causes distress to the individual.
  • For a client with amnesia:
    • Offer simple directions to promote activities of daily living and reduce confusion to help increase feelings of safety and security.
    • Provide a calm, secure, predictable, protective environment.
  • For a client with depersonalization disorder who says, “It’s starting again. I feel as though I’m going to float away,”:
    • Engage the client in a physical activity such as exercise, which assists the client to interrupt the dissociative process.
  • The sympathetic nervous system (fight or flight response) is stimulated in times of stress, while the parasympathetic nervous system is a relaxation response.
  • Flashbacks are common for individuals with PTSD.
  • Co-morbidities for adults with PTSD include depression, anxiety disorders, sleep disorders, and dissociative disorders.
  • Suicide is a high risk among military personnel diagnosed with PTSD.
  • If a solder reports of re-experiencing events it may be a type Flashback.
  • Avoidance:
    • Physiological reactions to reminders of the event that include persistent avoidance of stimuli associated with the trauma results in the individual’s avoiding talking about the event or avoiding activities, people, or places that arouse memories of the trauma.
    • Avoidance is exemplified by a sense of foreshortened future and estrangement.
  • The nurse's best response for a solider experiencing PTSD is PTSD precipitates changes that can lead to divorce. So it is important to provide support to both the veteran and spouse.
  • Dissociative Fugue state:
    • The client frequently relocates and assumes a new identity while not recalling previous identity or places previously inhabited.
  • Chronic and potentially debilitating stress:
    • This parasympathetic response results in the heart rate and respiration slowing down and a decrease in blood pressure.
  • Relaxation techniques promote activity of the parasympathetic nervous system.
  • Etiology to complete this nursing diagnosis should be
    • Cognitive distortions associated with unresolved childhood abuse issues.
  • Acute stress disorder, depersonalization disorder, and PTSD can involve dissociative elements, such as numbing, feeling unreal, and being amnesic for traumatic events.

Chapter 14: Somatic Symptom and Related Disorders

  • Intervention for a client experiencing anxiety associated with a serious medical condition:
    • Emotion centered: “I’m wondering if you are feeling anxious about your illness and being left alone.”
      • Rationale: Focuses on the emotions underlying the behavior rather than the behavior itself.
  • Clients with illness anxiety disorder have fears of serious medical problems, such as cancer or heart disease:
    • These fears persist despite medical evaluations and interfere with daily functioning.
    • There are no complaints of pain.
  • For somatic symptom disorder assess if secondary gains are prominent.
  • Somatic symptom disorders involve expression of stress through bodily symptoms and are not under voluntary control or culture bound.
  • *Factitious disorders are under voluntary control.
  • Questioning the evidence is a cognitive reframing technique.
    • Example Response: “Let’s see if there are any other possible explanations for your vomiting.”
  • Somatic symptom disorders:
    • Commonly associated with complicated reactions to stress.
    • Relaxation can diminish the client’s perceptions of pain and reduce muscle tension.
  • Secondary gains should be assessed. Secondary gains reinforce maladaptive behavior. There may be a history of abuse or doctor shopping, but the question does not assess the associated gains.
  • If client with somatic symptom disorder has decreased preoccupation with symptoms and increased ability to perform activities of daily living the nurses should evaluate the treatment plan as partially successful.
  • Factitious disorder imposed on another is a condition wherein a person intentionally causes or perpetuates the illness of a loved one.
  • Nursing interventions for a patient with Factitious disorder imposed on another:
    • When this disorder is suspected, the child’s life could be at risk.
    • Encourage family members to visit in groups of two or three.
    • Interact with the client frequently during visiting hours.
    • Detailed tracking of visitation and untoward events helps identify any patterns there might be between select visitors and the course of the child’s illness.
  • Assessment findings that suggest the possibility of a factitious disorder, imposed on self-type has:-
    • History of multiple hospitalizations without findings of physical illness
    • History of multiple medical procedures or exploratory surgeries