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Obsessive-Compulsive Disorder Nursing Care Plan (NCP)

An obsession is an intrusive/inappropriate repetitive thought, impulse, or image that the individual recognizes as a product of his or her own mind but is unable to control. A compulsion is a repetitive urge that the individual feels driven to perform and cannot resist without great difficulty (severe anxiety). Most common obsessions are repetitive thoughts about contamination, repeated doubts, a need to have things in a specific order, aggressive or horrific impulses, or sexual imagery. The individual usually attempts to ignore or suppress such thoughts or to neutralize them with some other thought or action (compulsion). You may refer to this link to further understand about obesity: http://www.enurse-careplan.com/2010/10/nursing-care-plan-ncp-obsessive.html

DSM-IV
300.3 Obsessive-compulsive disorder

ETIOLOGICAL THEORIES
Psychodynamics
Freud placed origin for obsessive-compulsive characteristics in the anal stage of development. The child is mastering bowel and bladder control at this developmental stage and derives pleasure from controlling his or her own body and indirectly the actions of others.

Erikson’s comparable stage for this disorder is autonomy versus shame and doubt. The child learns that to be neat and tidy and to handle bodily wastes properly gains parental approval and to be messy brings criticism and rejection.

The obsessional character develops the art of the need to obtain approval by being excessively tidy and controlled. Frequently the parents’ standards are too high for the child to meet, and the child continually is frustrated in attempts to please parents.

The defensive mechanisms used in obsessive-compulsive behaviors are unconscious attempts by the client to protect the self from internal anxiety. The greater the anxiety, the more time and energy will be tied up in the completion of the client’s rituals. First, the client uses regression, a return to earlier methods of handling anxiety. Second, the obsessive thoughts are either devoid of feeling or are attached to anxiety. Thus, isolation is used. Third, the client’s overt attitude toward others is usually the opposite of the unconscious feelings. Thus, reaction formation is being used. Last, compulsive rituals are a symbolic way of undoing or resolving the underlying conflict.

Biological
Although biological and neurophysiological influences in the etiology of anxiety disorders have been investigated, no relationship has yet been established. The mind-body connection is well accepted, but it is difficult to establish whether the biological changes cause anxiety or the emotional state causes physiological manifestations. However, recent findings suggest that neurobiological disturbances may play a role in obsessive-compulsive disorder, with physiological and biochemical factors also playing significant roles.

Family Dynamics
The individual exhibiting dysfunctional behavior is seen as the representation of family system problems. The “identified patient” (IP) is carrying the problems of the other members of the family, which are seen as the result of the interrelationships (disequilibrium) between family members rather than as isolated individual problems. Multiple factors contribute to anxiety disorders.

NURSING PRIORITIES
1. Assist client to recognize onset of anxiety.
2. Explore the meaning and purpose of the behavior with the client.
3. Assist client to limit ritualistic behaviors.
4. Help client learn alternative responses to stress.
5. Encourage family participation in therapy program.

DISCHARGE GOALS
1. Anxiety decreased to a manageable level.
2. Ritualistic behaviors managed/minimized.
3. Environmental and interpersonal stress decreased.
4. Client/family involved in support group/community programs.
5. Plan in place to meet needs after discharge.

Nursing diagnosis for Obsessive-Compulsive Disorder: Severe Anxiety may be related to Earlier life conflicts (may be reflected in the nature of the repetitive actions and recurring thoughts) and possibly evidenced by Repetitive action (e.g., hand-washing); Recurring thoughts (e.g., dirt and germs); and Decreased social and role functioning.

Desired Outcomes:

1. Verbalize understanding of significance of ritualistic behaviors and relationship to anxiety.
2. Demonstrate ability to cope effectively with stressful situations without resorting to obsessive thoughts or compulsive behaviors.

Nursing intervention with rationale:
1. Establish relationship through use of empathy, warmth, and respect. Demonstrate interest in client as a person through use of attending behaviors.
Rationale: Anything about which the client feels anxious will serve to increase the ritualistic behaviors. Establishing trust provides support and communicates that the nurse accepts the client as a person with the right to self-determination.

2. Acknowledge behavior without focusing attention on it. Verbalize empathy toward client’s experience rather than disapproval or criticism. Better to say, “I see you undress 3 times every morning. That must be tiring for you,” rather than “Try to dress only 1 time today.”
Rationale: Lack of attention to ritualistic behaviors can diminish them. As anxiety is reduced, the need for the behaviors is reduced. Reflecting the client’s feelings may reduce the intensity of the ritualistic behavior.

3. Use a relaxed manner with the client; keep the environment calm.
Rationale: Any attempts to decrease stress will help the client to feel less anxious, which may reduce the intensity of the ritualistic behaviors.

4. Assist client to learn stress management, (e.g., thought-stopping, relaxation exercises, imagery).
Rationale: Stress-management techniques can be used, instead of ritualistic behaviors, to break habitual pattern.

5. Identify what the client perceives as relaxing (e.g., warm bath, music). Engage in constructive activities such as quiet games that require concentration, as well as arts and crafts such as needlework, woodworking, ceramics, and painting.
Rationale: Planned activities allow the client less time for compulsive behavior and distract her or him in a manner that allows creativity and positive feedback.

6. Encourage participation in a regular exercise program.
Rationale: Exercise therapy can help relieve anxiety. Note: Exercise does not need to be aerobic or intensive to achieve the desired effect.

7. Encourage client to explore the meaning and purpose of behaviors; to describe the feelings when the behaviors occur, intensify, or are interrelated; and to examine the precipitating factors to the performance of the rituals.
Rationale: This exploration provides an opportunity to begin to understand the process and gain control over the obsessive-compulsive sequence. When opportunity for ritualistic behavior does not occur, the client fears that something bad will happen. Recognizing precipitating factors allows client to interrupt escalating anxiety.

8. Discuss home situation, include family/SO as appropriate. Involve in discharge plan.
Rationale: Returning to unchanged home environment increases risk that client will resume compulsive behaviors.

9. Administer medications as indicated, e.g.:
Fluvoxamine (Luvox), clomipramine (Anafranil), fluoxetine (Prozac)
Rationale: These drugs help balance serotonin levels, decreasing feelings of anxiety, reducing need for ritualistic behavior(s), and allowing client to learn of other methods of stress reduction. Note: Luvox is classified as a selective serotonin reuptake inhibitor and has fewer side effects than tricyclics.

10. Administer Buspirone (BuSpar) and lithium (Eskalith) as indicated.
Rationale: Clients who are refractory to antidepressants may require combination therapy (e.g., buspirone and fluoxetine or lithium and clomipramine).
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