Module 3

CASE ANALYSIS #1

SITUATION #1:

Profile

Betty, a 50-year-old woman, came to this country with her parents when she was 7 years old. The family
members worked as migrant farm workers until they had enough money to open a restaurant. Betty
married young. She and her husband worked in the family restaurant and eventually bought it from the
parents. They raised seven children, all grown and living on their own. Betty and her husband live in a
mobile home close to the restaurant. She does not work in the family restaurant anymore because she
worries excessively about doing a poor job. Betty no longer goes out if she can help it. She stays at home
worrying about how she looks, what people think or say, the weather or road conditions, and many
other things. Betty is not sleeping at night and keeps her husband awake when she roams the house.
She keeps her clothing and belongings in perfect order while claiming she is doing a poor job of it. She
does not prepare large family dinners anymore, though she still cooks the daily meals; one daughter has
taken over the family dinners. This daughter has become concerned about Betty being isolated at home
and worrying excessively and calls the community mental health center for an appointment for Betty.

Case

Betty presents at the community mental health center accompanied by her husband, her children and
their spouses, several grandchildren, and a few cousins. When Betty’s name is called and she is told that
the nurse is ready to see her, she frowns and says: “What will I say? I don’t know what to say. I think my
slip is showing. My hem isn’t straight.” Betty says she wants her whole family to go in to see the nurse
with her. The nurse notices that Betty is extremely well groomed and dressed in spite of concerns she
has been voicing about her appearance. Before the psychiatric nurse inter-views Betty alone, she hears
from the daughter that Betty “worries all the time” and although she has always been known to be a
worrier, the worrying has become worse over the past six or eight months. The husband shares that his
wife is keeping him awake at night with her inability to get to sleep or stay asleep. The nurse interviews
Betty alone. The nurse notices that Betty casts her eyes downward, speaks in a soft voice, does not
smile, and seems restless as she taps her foot on the floor, drums her fingers on the table, and seems on
the verge of getting out of her chair. Themes in the interview include: being tired, getting tired easily,
not being able to concentrate, not getting work done, trouble sleeping, worrying about whether her
husband loves her anymore and whether she and her husband have enough money, and not having the
energy to attend to the housework or her clothing. The nurse has the impression that Betty’s anxiety
floats from one worry to another. There is no convincing Betty that she looks all right. Any attempt to
convince her that she need not worry about something in particular leads to a different worry before
coming back to the earlier worry. The community mental health psychiatrist examines Betty and, after a
thorough physical examination and lab studies, finds nothing to explain her fatigue and difficulty
sleeping other than anxiety. Betty produces her medicine bottles and says she is currently taking only
vitamins, hormone replacement, and calcium. The psychiatrist asks the nurse to contact Betty’s family
health care provider to get information on any medical or psychiatric conditions he is treating her for;
the report comes back that she has no medical diagnoses and the family health care provider thinks she
suffers from anxiety. The psychiatrist prescribes buspirone (BuSpar) for Betty.

Two weeks later, during a home visit to Betty, the nurse learns, with some probing, that Betty is upset
with her husband for loaning all their savings to the daughter and her husband to build a new home,
while they continue to live in an older mobile home. At the end of the nurse’s home visit, Betty’s
daughter arrives and tells the nurse that she wonders if Betty is making any progress. Betty also worries
she is not getting better and asks the nurse about taking some herbal medicines containing Kava and
Passaflora that her sister got from a folk healer; her sister wants to take her to see the folk healer and
have her do a ritual to cure the evil eye that was placed on Betty and made her sick.

NURSING DIAGNOSIS: FEAR

RELATED TO: Causing embarrassment to self in front of others, being in a place from which one is
unable to escape.

EVIDENCED BY: Behavior directed toward avoidance of the feared situation

OUTCOME CRITERIA NURSING INTERVENTION RATIONALE

Short-Term Goal: 1. Reassure client that he or she 1. At the panic level of anxiety,
 Client will discuss the is safe. client may fear for his or her
phobic object or own life.
situation with the 2. Explore client’s perception of 2. It is important to understand
health-care provider the threat to physical integrity client’s perception of the phobic
within 3 hours. or threat to self-concept. object or situation to assist with
the desensitization process.

3. Discuss reality of the 3. Client must accept the reality

Long-Term Goal: situation with client to
 By time of discharge recognize aspects that can
from treatment, client be changed and those that
will be able to function cannot.
in presence of phobic
object or situation 4. Include client in making
without experiencing decisions related to selection of
panic anxiety. alternative coping strategies.
(e.g., client may
choose either to avoid the
phobic stimulus or to attempt to
eliminate the
fear associated with it.)
of the situation (aspects that
cannot change) before the work
of reducing the fear can
progress.
4. Allowing the client choices
provides a measure of control
and serves to increase feelings
of self-worth.

5. If client elects to work on 5. Fear is decreased as the

elimination of physical and
 the fear, techniques of
desensitization or implosion
therapy may be employed.
psychological sensations
diminish in response to
repeated exposure to the
phobic stimulus under
nonthreatening conditions.

6. Encourage client to explore 6. Exploring underlying feelings

underlying feelings that may be may help the client to confront
contributing to irrational fears, unresolved conflicts and
and to face them rather than develop more adaptive coping
suppress them. abilities.

DTR #1

DRUG/ ROUTE CLASSIFICATION INDICATION/ SIDE EFFECTS/ NURSING

/ MECHANISM CONTRAINDICATIO ADVERSE RESPONSIBILITIES
OF ACTION N EFFECTS
GENERIC NAME: Anxiolytics INDICATION: Dizziness, BEFORE:
BUSPIRONE ANXIETY drowsiness,  Warn pt. to
DISORDERS headache, avoid
PREGNANCY numbness, hazardous
BRAND NAME: CATEGORY: fatigue, anger, activities that
BUSPAR B CONTRAINDICATION excitement, require
: confusion, light- alertness and
ROUTE OF  In patients headedness, good
ADMINISTRATION ACTION: hypersensitive nervousness, coordination
: May inhibit to drug and sweating until effects
P.O neural firing and within 14 days of drug are
reduced of MAO ADVERSE known.
serotonin inhibitor EFFECTS:  Tell pt. to
turnover in therapy. Non-specific avoid use of
cortical,  Is not chest pain, alcohol
amygdaloid and recommended blurred vision, during
septohippocamp for patients aches and therapy.
al tissue. with severe pains of  Advise pt. to
hepatic renal musculoskeleta take
impairment. l, depression, consistently;
stomach upset. that is,
always with
or always
without food.
 Assess pt. if
allergic to
drug.
  Assess pt. if
have taken
an MAO
inhibitor in
past 14days.
 Observe 15
rights of
medication
administratio
n.
 Monitor v/s
for baseline.

DURING:
 Take drug
exactly as
prescribed.
Avoid OTC
and alcohol
unless
consulted to
healthcare
provider.

AFTER:
 Report any
side effects.
 Monitor vital
signs.

REFERENCE:
NURSING DRUG
HANDBOOK
By: Wolters Kluwer
 PSYCHOTHERAPY PLAN/ MANAGEMENT

I. PROMOTING CLIENT’S SAFETY

 Safe expression of feelings and emotions

II. HELPING CLIENT TO COPE AND CONTROL EMOTIONS

 Identifying feelings
 Journal entries
 Moderating emotional responses
 Decreasing impulsivity

III. PROVIDE COMFORT MEASURES

 Calm or quiet environment

IV. COGNITIVE THERAPY

 Homework assignments
 Provide an experimental, problem-solving approach to overcoming long-held anxieties

V. SYSTEMATIC DESENSITIZATION

 Training in relaxation techniques

VI. TO PROMOTE WELLNESS

 Assist in developing skills

 Awareness of negative thoughts, saying “stop”, and substituting a positive thought.