Question

#1: A 21-year-old woman is being treated for behaviors associated with obsessive-compulsive disorder.

• What information will the nurse base his/her response to the question of managing the patient’s ritualistic behaviors?
• What assessments for comorbid mental health disorders should the nurse perform?

#2: A 49-year-old married woman comes in to see her medical provider complaining of severe sleep difficulty involving initial insomnia, poor appetite, a severe decrease in her energy level (anergia) to the extent that some weeks she calls into work two or more days, and lack of enjoyment in her usual hobbies and interests (anhedonia). She describes her mood as “depressed.” You observe the patient to have a sad, blunted affect; slowed speech; and psychomotor retardation. In exploring the patient’s life stressors, you learn that she has a 19-year-old daughter who is away at college and that 4 months ago, her 17-year-old daughter was killed in a car accident. The patient admits to maladaptive grieving and an irrational fear that something “bad” will happen to her daughter at college. The patient also admits that she is depressed and that she does have some vague suicidal ideation but no specific plan. She feels compelled to watch over her daughter as she feels a degree of guilt that she was not a good mother and that failing contributed to her 17-year-old daughter’s death. She tells you that she has been taking St. John’s wort for the past 2 months but has not thought that it has helped with her depression. The primary provider gives the patient a prescription for citalopram (Celexa). (Learning Objectives 3 and 5)

• Are there any concerns related to her current medication regimen? Please explain why or why not.
• What type of teaching should you expect to provide to this patient?
• What types of focused assessments are indicated in this patient?

Answer 1

1. A) Nursing management of ritual behavior :-

- provide structured schedule of activities including adequate time for completion of rituals.

- gradually begin to limit amount of time allotted for ritual behavior.

- give positive reinforcement for non - ritualistic behavior

- help the patient to learn ways to interrupt obsessive thoughts.

- work with the patient to determine the types of situation that increase anxiety and results in ritual behavior

- do not be judgemental or verbalize disapproval of the behavior

- support the patient efforts to explore the meaning and purpose of the behavior.

B) . The main assessment tool used for detecting any comorbid mental health disorders is Mental Status Examination along with medical history and past experience of any event .

2a) . Yes there are certain concerns regarding the use of celexa . The main reason is it's side effects :-

problems with memory or concentration

headache, drowsiness

dry mouth, increased sweating

numbness or tingling

increased appetite, nausea, diarrhea, gas

fast heartbeats, feeling shaky

sleep problems (insomnia), feeling tired

cold symptoms such as stuffy nose, sneezing, sore throat

Already she has a problem with insomnia , feeling tired etc adding this drug will add on to her problems .

2b). Patient teaching regarding disease condition and drug :-

∙ Instruct patient to take citalopram as directed. Take missed doses as soon as remembered unless almost time for next dose; do not double doses. Do not stop abruptly; may cause anxiety, irritability, high or low mood, feeling restless or changes in sleep habits, headache, sweating, nausea, dizziness, electric shock-like sensations, shaking, and confusion. Advise patient to read the Medication Guide prior to starting therapy and with each refill in case of changes.

∙ May cause drowsiness, dizziness, impaired concentration, and blurred vision. Caution patient to avoid driving and other activities requiring alertness until response to the drug is known.

∙ Instruct patient to notify HCP of all Rx or OTC medications, vitamins, or herbal products being taken and to consult HCP before taking any other Rx, OTC, or herbal products, especially alcohol or other CNS depressants.

∙ Caution patient to change positions slowly to minimize dizziness.

∙ Advise patient, family, and caregivers to look for suicidality, especially during early therapy or dose changes. Notify HCP immediately if thoughts about suicide or dying, attempts to commit suicide, new or worse depression or anxiety, agitation or restlessness, panic attacks, insomnia, new or worse irritability, aggressiveness, acting on dangerous impulses, mania, or other changes in mood or behavior or if symptoms of serotonin syndrome occur.

∙ Advise patient to use sunscreen and wear protective clothing to prevent photosensitivity reactions.

∙ Inform patient that frequent mouth rinses, good oral hygiene, and sugarless gum or candy may minimize dry mouth. If dry mouth persists for more than 2 wk, consult HCP regarding use of saliva substitute.

∙ Instruct female patients to inform HCP if pregnancy is planned or suspected, or if they plan to breast feed. If used during pregnancy should be tapered during third trimester to avoid neontal serotinin syndrome.

∙ Emphasize the importance of follow-up exams to monitor progress.