Today I am working as a registered nurse at a specialty hospital for behavioral health clients. I am preparing to meet with a newly admitted client, F.A., whom has been medically diagnosed with social anxiety disorder. Social anxiety disorder, also known as social phobia “is a chronic anxiety disorder marked by fear and excessive self-consciousness in public” (Schub & March, 2018). I know from reading her chart that F.A. is a 47-year-old Caucasian female client who lives alone at her home in the country.
Introduction
Delving into F.A.’s intake paperwork I find that she has voluntarily admitted herself for therapeutic milieu. She has stated that in the last few years it is increasingly difficult to do things that were once mundane parts of life, such as go to the grocery store. “I pull into the parking lot and I look around at all the people and my heart just begins to pound.” F.A. is quoted as saying. “But what am I supposed to do? I cannot let my poor cats starve because I am afraid to go in public. I always feel that everyone is judging me, and when I go up to the checkout stand I notice that the cashier says hello to the person in front of me and then just rings up my items without greeting me. Takes my money and goes on to the next person in line.
I notice she tells them hello, too, but not me. I feel like I am constantly being stared at and judged. I just hurry as fast as I can to get my shopping done and get out of there to get home.” According to the National Institute of Mental Health, a misinterpretation of the behaviors and actions of other people is a major factor in social anxiety (Social Anxiety Disorder: More Than Just Shyness, n.d.). I read on to see that F.A. began to work nights about a year ago because overnights she is basically alone and has no interaction with people on her shift at an assisted living facility. She has been divorced for 8 years and has two adult daughters that have urged her to seek more in-depth care for this disorder. No history of physical violence or past or present substance abuse issues were disclosed.
Medications and Interventions
The only recent interventions for this client have been via the pharmacological route. F.A. has been prescribed Venlafaxine, a serotonin-norepinephrine reuptake inhibitor which she has taken for almost 5 years along with lorazepam, an anti-anxiety medication. Last year her youngest daughter graduated from college. Because of her racing and pounding heart symptoms around large groups of people, her practitioner prescribed atenolol, a beta-blocker, so that she could attend the ceremony. Beta-blockers particularly atenolol and propranolol may be prescribed to complement therapy for social anxiety but must be done so “off-label” (Brown, 2018). F.A.’s eldest daughter, a registered nurse, is expecting her first baby in the next few months. Through a series of meetings at her mother’s residence, she convinces her mother to begin inpatient treatment. I read on in her intake information that in the past cognitive behavioral therapy and counseling through a private psychology practice have been unsuccessful. F.A. continues to take venlafaxine and lorazepam, but states “they help my symptoms; therefore, it is easier just to stay home.”
Personal Thoughts, Cognitive Concerns and Possible Interventions
As I conclude acquainting myself with F.A. by thoroughly scouring her chart, I can empathize with her situation. In a world where social media is prevalent and suggests women should all look and act a certain way it is no wonder that she feels like everyone is judging her. I can also personally attest how women over the age of 25 are almost shunned and discarded as used goods. In my personal opinion there is so much hate and violence today that no individual is safe. Turn on the television or the computer and people are arguing, name calling, shaming each other. This trend is quite disturbing and is one I feel will not be slowing in the future. After meeting personally with F.A., I believe that cognitively she has exhibited impaired judgment.
She stated in our meeting that she often would wait until she was completely out of food for a few days before entertaining the thought of a shopping trip. She claims that now her youngest daughter does her grocery shopping for her, so she does not have to leave home. Learning this information, F.A. seems to have tendencies for agoraphobia as well. According to the Mayo Clinic, agoraphobia is an anxiety disorder that “may be so overwhelming that you may feel unable to leave your own home” (Agoraphobia, 2017). As a nurse, collaborating with her provider to advocate for a possible change in medications may be an option for intervention as well as continued outpatient cognitive behavioral therapy (CBT). According to Harvard University, 12-16 weekly sessions of CBT can help those suffering from social anxiety disorder to “change the way they think about and behave in certain situations that terrify them (Treating social anxiety disorder, 2010).
Care Plan: Diagnoses and Interventions and Outcomes
I felt in this situation, the priority diagnosis was “anxiety related to unconscious conflict about essential values” (Ludwig & Ackley, 2011 p.187). This is evidenced by the fear and physical symptoms the patient incurs while in public, or quite frankly just by leaving her house. Nursing interventions would be: assessment of client’s anxiety level and physical reactions to anxiety (Ladwig & Ackley, 2011 p.187), use empathy to promote F.A.’s interpretation of anxiety symptoms as normal, if rational (Ladwig & Ackley, 2011 p.187) and describe any activities that would involve the client using non-medical verbiage utilizing calm and slow speech. Our specific, measurable, attainable, realistic and timely (S.M.A.R.T.) goals/outcomes are that the client will: identify and verbalize symptoms of anxiety (Ladwig & Ackley, 2011 p. 187) within one week. By the end of week 3 the client will identify, verbalize and demonstrate techniques to control anxiety (Ladwig & Ackley, 2011 p. 187). Finally, the client will demonstrate some ability to reassure herself by date of her discharge in approximately 6 weeks.
Second highest priority diagnosis would be chronic low self-esteem related to social anxiety (psychiatric) disorder as evidenced by the client’s subjective data that she perceives she is always being negatively judged by others (Ladwig & Ackley p.644). Interventions for this diagnosis: actively listen to and respect the client (Ladwig and Ackley p.645). Assess the client’s strengths and coping abilities and provide opportunities for their expression and recognition (Ladwig & Ackley, 2011 p.645). Demonstrate and promote effective communication techniques; spend time with the client (Ladwig & Ackley, 2011 p.645). Our S.M.A.R.T. goals are as follows: the client will verbalize increased self-acceptance through positive self-statements (Ladwig & Ackley, 2011 p.645) in one week. The client will identify and work on achievable small goals (Ladwig & Ackley, 2011 p.645) in week 3, and upon discharge client will demonstrate improved ability to interact with others (Ladwig & Ackley, 2011 p.645)
Lastly, ineffective coping related to inadequate level of perception of control, as evidenced by the client’s inability to cope with being in public or away from home. Interventions: Assist the client to set realistic goals and identify personal skills and knowledge (Ladwig & Ackley, 2011 p.302). Observe for contributing factors for ineffective coping such as lack of support and poor self-concept (Ladwig & Ackley, 2011 p.302) and discuss changes with the client before making them (Ladwig & Ackley, 2011 p.303). S.M.A.R.T. goals/outcomes: client will use effective coping strategies (Ladwig & Ackley, 2011 p.302) within 1 week, report decrease in physical symptoms caused by stress (Ladwig & Ackley, 2011 p.302) by end of week 3, and at discharge client will report increase in psychological comfort (Ladwig & Ackley, 2011 p.302). As a staff nurse my intentions are to meet with this client and evaluate progress weekly. If necessary plan of care will be re-designed to meet any new or changing data assessed.
Resources for the patient and Educational Tool
Evidenced based practice tells us that exercise is good to combat social anxiety and my favorite complimentary therapies to recommend to clients are yoga and tai chi. These two ancient practices are shown by research to reduce blood pressure, stress and anxiety as well as give your energy levels a boost and increase your well-being (Cuncic & Gans, 2018). Anything that will get a person moving tends to have an overall positive outcome not just physically, but psychologically as well (Cuncic & Gans, 2018).
In my research for educational tools, which was dismally unsuccessful, I also came across an article about using smartphone apps to help curb anxiety of all types. This to me is worth mentioning. “Insight Timer” is a free app for iphone or Android that features over 4,000 guided meditations (Newman, 2017). Others that are highly recommended are “Stop, Breathe and Think” and “Omvana” (Newman, 2017). Even your exercise tracking device comes with a “breathe” setting to promote mindfulness and reduce stress. Stress is everywhere, and in this world, I would only predict an increase. However, with the proper techniques and interventions stress can likely be managed to promote a good quality of life.
