Nursing process for a patient with needle phobia: a case study

to report a clinical case of needle phobia which culminated in cardiac arrest and describe the outcome of a care plan based on fear and anxiety diagnoses, using the Roy adaptation model as the framework.

Methods:

case study conducted in a chemotherapy outpatient unit in Rio de Janeiro. Care was guided by the nursing process and the use of instruments to assess the venous network, anxiety and fear.

Results:

the Roy adaptation model enabled proposing nursing interventions that allowed the study subject to adapt to the external and internal stimuli triggered by vasovagal syndrome. The instruments indicated the choice of an adequate semi-implanted venous access device and led to improved levels of anxiety and fear.

Final Considerations:

after carrying out the nursing activities, anxiety was reduced, and the patient achieved greater control over fear.

Descriptors:
Phobic Disorder; Intravenous Infusions; Nursing Care; Catheters; Anxiety

Tool	Score	Interpretation	Score	Interpretation
Tool		Before		After
Beck Anxiety Inventory (BAI)	23	Moderate degree of anxiety	8	Low degree of anxiety
Hospital Anxiety and Depression Scale (Anxiety subscale)	7	Improbable anxiety profile	4	Improbable anxiety profile

Focal	Contextual	Residual
Exposure to procedures with needles	Use of tobacco, psychoactive substances, presence of the nurse and environments that do not offer safety (with smell of antiseptics, chemotherapy room and laboratory).	Traumatic events in childhood, fear of not being able to control one's emotions, fear of not completing the chemotherapy.

Nursing interventions (NIC) ⁽¹⁰10 Bulechek GM, Butcher HK, Dochterman JM, Wagner CM. NIC - Classificação das intervenções de enfermagem. 6ª ed. Rio de Janeiro: Elsevier; 2016. ⁾	Nursing activities
Control of central venous access device	Indicate early on a central venous access device, based on individual characteristics and the proposed chemotherapy protocol. The Adult Venous Assessment Tool (VAT) and Deciding on Intravenous Access (DIVA) were applied for the purpose of decision making ⁽¹⁶16 Wells S. Venous access in oncology and haematology patients: part two. Nurs Stand. 2008;23(1):35-42. doi: 10.7748/ns2008.09.23.1.35.c6652 https://doi.org/10.7748/ns2008.09.23.1.3... ⁾.
	Provide information related to the device (type, indication, function and precautions with the device).
	Clarify the short-, mid- and long-term risks and benefits of catheters.
	Check that the patient understands the purpose, care and maintenance of the semi-implanted catheter.
Reduction of anxiety and fear	Help the patient identify situations that precipitate anxiety and fear.
	Identify other situations that cause panic and anxiety, such as differential diagnosis ⁽⁴4 Marrs JA. Stress, fears, and phobias: the impact of anxiety. Clin J Oncol Nursing. 2006;10(3):319-22. doi: 10.1188/06.CJON.319-322 https://doi.org/10.1188/06.CJON.319-322... ^,²⁰20 McGrandles A, Duffy T. Assessment and treatment of patients with anxiety. Nurs Stand. 2012;26(35):48-57. doi: http://dx.doi.org/10.7748/ns2012.05.26.35.48.c9082 http://dx.doi.org/10.7748/ns2012.05.26.3... ⁾ of needle phobia.
	Apply specific scales for assessing levels of anxiety ⁽¹⁰10 Bulechek GM, Butcher HK, Dochterman JM, Wagner CM. NIC - Classificação das intervenções de enfermagem. 6ª ed. Rio de Janeiro: Elsevier; 2016. ⁾, fear and depression, before, during and after chemotherapy. The Beck Anxiety Inventory ⁽¹²12 Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988;56(6):893-7. doi: 10.1037/0022-006X.56.6.893 https://doi.org/10.1037/0022-006X.56.6.8... ^-¹³13 Cunha JA. Manual da versão em português das Escalas Beck. São Paulo: Casa do Psicólogo; 2001. ⁾ and Hospital Anxiety and Depression Scale (anxiety subscale) ⁽¹⁴14 Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361-70. doi: 10.1111/j.1600-0447.1983.tb09716.x https://doi.org/10.1111/j.1600-0447.1983... ^-¹⁵15 Botega NJ, Bio MR, Zomignani MA, Garcia Jr C, Pereira WAB. Transtornos do humor em enfermaria de clínica médica e validação de escala de medida (HAD) de ansiedade e depressão. Rev Saúde Pública. 1995;29(5):355-63. doi: 10.1590/S0034-89101995000500004 https://doi.org/10.1590/S0034-8910199500... ⁾ were applied.
	Teach slow breathing exercises to promote relaxation ⁽⁴4 Marrs JA. Stress, fears, and phobias: the impact of anxiety. Clin J Oncol Nursing. 2006;10(3):319-22. doi: 10.1188/06.CJON.319-322 https://doi.org/10.1188/06.CJON.319-322... ⁾. Reduction of carbon dioxide blood levels, triggered by hyperventilation, should be avoided. This results in cerebral vascular constriction, reduced availability of oxygen and syncope symptoms. In addition, blood pressure levels may also be high due to the intervention ⁽²¹21 Kowalsky JM, Conatser R, Ritz T, France CR. Effects of respiratory and applied muscle tensing interventions on responses to a simulated blood draw among individuals with high needle fear. J Behav Med. 2018;41(6):771-83. doi: 10.1007/s10865-018-9925-8 https://doi.org/10.1007/s10865-018-9925-... ⁾.
	Instruct the patient to avoid medications and substances such as alcohol, caffeine and stimulants of the central nervous system, since they can aggravate the symptoms of anxiety and/or phobia ⁽⁴4 Marrs JA. Stress, fears, and phobias: the impact of anxiety. Clin J Oncol Nursing. 2006;10(3):319-22. doi: 10.1188/06.CJON.319-322 https://doi.org/10.1188/06.CJON.319-322... ⁾.
	Assess verbal and non-verbal signs of anxiety ⁽¹⁰10 Bulechek GM, Butcher HK, Dochterman JM, Wagner CM. NIC - Classificação das intervenções de enfermagem. 6ª ed. Rio de Janeiro: Elsevier; 2016. ⁾, fear and potential psychological complications associated with intravenous insertion.
	Refer to a mental health specialist when necessary, since certain interventions are beyond the technical, ethical and legal competencies of nurses, in order for the patient to receive psychotherapeutic and clinical treatment for phobia and mood disorders ⁽⁴4 Marrs JA. Stress, fears, and phobias: the impact of anxiety. Clin J Oncol Nursing. 2006;10(3):319-22. doi: 10.1188/06.CJON.319-322 https://doi.org/10.1188/06.CJON.319-322... ^,²⁰20 McGrandles A, Duffy T. Assessment and treatment of patients with anxiety. Nurs Stand. 2012;26(35):48-57. doi: http://dx.doi.org/10.7748/ns2012.05.26.35.48.c9082 http://dx.doi.org/10.7748/ns2012.05.26.3... ⁾.
	Recognize panic attack risk factors in the nursing record, such as low weight, start of treatment, younger age, fear of fainting, concerns about health risks, fear of "being afraid", treatment with anxiolytics or antidepressants, smoking and use of illicit substances ⁽²²22 Miedziun P, Czabała JC. Stress Management Techniques. Arch Psychiatry Psychother. 2015;17(4):23-31. doi: 10.12740/APP/61082 https://doi.org/10.12740/APP/61082... ⁾.
Counseling	Educate the patient about the disorder ⁽⁴4 Marrs JA. Stress, fears, and phobias: the impact of anxiety. Clin J Oncol Nursing. 2006;10(3):319-22. doi: 10.1188/06.CJON.319-322 https://doi.org/10.1188/06.CJON.319-322... ^,²⁰20 McGrandles A, Duffy T. Assessment and treatment of patients with anxiety. Nurs Stand. 2012;26(35):48-57. doi: http://dx.doi.org/10.7748/ns2012.05.26.35.48.c9082 http://dx.doi.org/10.7748/ns2012.05.26.3... ⁾, supplying factual information as necessary and appropriate ⁽¹⁰10 Bulechek GM, Butcher HK, Dochterman JM, Wagner CM. NIC - Classificação das intervenções de enfermagem. 6ª ed. Rio de Janeiro: Elsevier; 2016. ⁾. Teach the patient to replace thoughts that increase fear, such as "expecting to faint" with others that promote self-confidence, such as: "whatever goes up (fear), comes down".
Distraction	Encourage the individual to choose distraction techniques, such as listening to music, deep breathing exercises and recalling positive events ⁽⁴4 Marrs JA. Stress, fears, and phobias: the impact of anxiety. Clin J Oncol Nursing. 2006;10(3):319-22. doi: 10.1188/06.CJON.319-322 https://doi.org/10.1188/06.CJON.319-322... ^,¹⁰10 Bulechek GM, Butcher HK, Dochterman JM, Wagner CM. NIC - Classificação das intervenções de enfermagem. 6ª ed. Rio de Janeiro: Elsevier; 2016. ^,²³23 Sampaio F, Sequeira C, Canut MTL. Intervenções psicoterapêuticas de enfermagem NIC na prática clínica em Portugal: um estudo descritivo. Rev Port Enferm Saúde Mental. 2016;16:11-8. doi: 10.19131/rpesm.0152 https://doi.org/10.19131/rpesm.0152... ⁾.
Promotion of cerebral perfusion	Provide instruction in the muscle tension technique, which is the application of repeated isometric tension in the muscles of the legs, buttocks, abdomen or trunk during other invasive procedures or those with needles. The intervention prevents and alleviates presyncope and syncope symptoms. This leads to an improvement in cerebral blood flow, oxygenation, cardiac output and blood pressure. This technique diverts peripheral blood from large muscles to central circulation ⁽²¹21 Kowalsky JM, Conatser R, Ritz T, France CR. Effects of respiratory and applied muscle tensing interventions on responses to a simulated blood draw among individuals with high needle fear. J Behav Med. 2018;41(6):771-83. doi: 10.1007/s10865-018-9925-8 https://doi.org/10.1007/s10865-018-9925-... ⁾.

Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br

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[1] Corresponding author: Angelo Braga Mendonça. E-mail: angeloprimax@gmail.com