NCM 32117L

OBSESSIVE-COMPULSIVE DISORDER
Case Study

Submitted by:
Jareño, Kate Lynn
Matienzo, Mariah Ainna
Ramos, Kyle Anne
BSN – 3

Submitted to:
Dr. Maria Angelica Eugenio
Professor
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TABLE OF CONTENTS

I. Introduction
II. Demographic Data
III. Reason for seeking care/ Chief Complaint
IV. History of Present Illness
V. Family History
VI. Functional Assessment
VII. Review of System
VIII. Anatomy and Physiology
IX. Pathophysiology
X. Diagnostic Evaluation
XI. Drug study
XII. Therapies
XIII. Nursing Care Plan

INTRODUCTION

Obsessive compulsive disorder is an anxiety disorder in which people have unwanted and
repeated thoughts, feelings, ideas, sensations (obsessions), or behaviors that make them driven
to do something (compulsions)and engage in behaviors or mental acts in response to these
thoughts or obsessions.
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Obsessive compulsive disorder (OCD) is a debilitating neuropsychiatric disorder with a lifetime

prevalence of 2 to 3 percent and is estimated to be the 10th leading cause of disability in the
world. People are unable to control either the thoughts or the activities for more than a short
period of time. Obsessive compulsive disorder (OCD) was once thought to be extremely rare,
but recent epidemiological studies have shown it to be the fourth most common psychiatric
disorder (after substance abuse, specific phobias, and major depression). OCD is often a
chronic disorder that produces significant morbidity when not properly diagnosed and treated.
The mainstay of treatment includes cognitive behavioral therapy and medication management.

Obsessive-compulsive disorder (OCD) is a mental illness, with a chronic (long-lasting) state of

anxiety, traps people in a constant cycle of repeated obsessions and compulsions: People with
OCD have repetitive and distressing fears or urges they can’t control. These obsessive thoughts
cause intense anxiety. To control obsessions and anxiety, people with OCD turn to certain
behaviors, rituals or routines. They do so repeatedly. They don’t want to perform these
compulsive behaviors and don’t get pleasure from them. But they feel like they have to follow
along or their anxiety will get worse. Compulsions only help temporarily, though. The
obsessions soon come back, triggering a return to the compulsions. This loop leads to a
constant cycle of anxiety.

Case Report

A 28 year old female got admitted with the complaints of having thoughts of biting male and
female private part, thoughts like brushing using a broomsticks, impulse to throttle her mother
on slit or throat using a saw, feels like there is a blood or feces on her plate of food, irritability
and anger burst, crying spells for 8 months, thoughts to bite soap, and thoughts to bite her
hand.
Her vital signs are BP 120/80mm Hg, pulse 98 beats/ min, respiration 20 breaths/min and
temperature 98.8 deg F. Patient had a previous history of the same complaints and she had
poor drug compliance which made her develop her symptoms. Patient had improved her
condition after her treatment schedule.
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Demographic Data
Name: AKK
Gender: Female
Age: 28 years old
Birthdate: 03/16/1994
Marital Status: Single
Nationality: Filipino
Educational Background: Highschool dropout

Reason for Seeking Care/Chief Complaint

Complaints of having thoughts of biting male and female private part, thoughts like brushing
using a broomsticks, impulse to throttle her mother on slit or throat using a saw, feels like there
is a blood or feces on her plate of food, irritability and anger burst, crying spells for 8 months,
thoughts to bite soap, and thoughts to bite her hand.

History of Present Illness

Patient had a previous history of the same complaints and she had poor drug compliance which
made her develop her symptoms.

Family History
Family history of psychosis and postpartum depression.

FUNCTIONAL ASSESSMENT

A. Health Perception/ Health Maintenance

Patient had a previous history of the same complaints and she had poor drug compliance, which
made her develop her symptoms. Her family brought her to the hospital for consultation and
treatment and she had improved her condition after six sessions of ECT were given.

B. Interpersonal Relationship
She is an introvert person, she isolates herself, she doesn't maintain a good relationship with
her family members and friends.
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C. Personal Habits
Patient AKK had obsessive thoughts and obsessive impulses such as an undoing habit of biting
her hand instead of killing her mother, biting herself,and biting soaps.

D. Self-Esteem/Self-Concept/Self-Perception Pattern
Patient has a fear of failing an exam,going to school, and has low esteem.

E. Activity/Exercise Pattern
She doesn’t usually engage in physical activities or house choirs as part of her daily routine.
According to her family, she isolates herself in her room and when she was admitted to a mental
hospital she did an exercise pattern like yoga and music therapy.

F. Nutrition-Metabolic Pattern
Patient feels like there is blood or feces on her plate of food which makes her lose her appetite
often, instead, she thought of biting soap as her food. She doesn't drink water often.

G. Elimination Pattern
Patient doesn’t have any difficulties in urinating and defecating.

H. Sleep/Rest Pattern
Patient tends to feel restless most of the time, has a poor sleep quality and experiences crying
spells for 8 months.

I. Sexuality/Reproductive
Patient is a 28 year old woman who had her menarche at the age of 13.

J. Environmental Hazard

Upon assessment, a family history of psychosis and postpartum depression was confirmed by
the patient’s family. According to the patient's family, the patient began isolating herself more
frequently after her grandfather died.
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REVIEW OF SYSTEM

SYSTEM FINDINGS

General ● Irritability
● Restless
● Anger burst
● Crying spells for 8 months

Cardiovascular ● Blood pressure: 120/80 mmHg

● Pulse rate: 98 beats / min
● Respiratory rate: 20 breaths / min

Immunologic ● Temperature: 37.1 °C

Nervous System ● Obsessional thoughts:The patient

had obsessive thoughts to
strangulate her mother, biting
herself and biting soaps.
● Obsessional Ruminations: The
patient had focused attention
towards killing her mother and
spitting on others.
● Obsessive impulses: The patient is
impulse to throttle her mother or cut
the throat by using a saw.
● Obsessive slowness present.
○ Lack of concentration and
task completion
○ Impaired social or work
functioning
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ANATOMY AND PHYSIOLOGY

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Anatomy Physiology

Cerebrum It is the largest part of the brain and is composed of right and left
hemispheres.
It performs higher functions like interpreting touch, vision and
hearing, as well as speech, reasoning, emotions, learning, and
fine control of movement.

Cerebellum It is located under the cerebrum. Its function is to coordinate

muscle movements, maintain posture, and balance.

Brainstem It acts as a relay center connecting the cerebrum and cerebellum

to the spinal cord.
It performs many automatic functions such as breathing, heart
rate, body temperature, wake and sleep cycles, digestion,
sneezing, coughing, vomiting, and swallowing.

Hypothalamus is located in the floor of the third ventricle and is the master
control of the autonomic system.

It plays a role in controlling behaviors such as hunger, thirst,

sleep, and sexual response. It also regulates body temperature,
blood pressure, emotions, and secretion of hormones.

This lies in a small pocket of bone at the skull base called the
Pituitary gland sella turcica. The pituitary gland is connected to the hypothalamus
of the brain by the pituitary stalk. Known as the “master gland,” it
controls other endocrine glands in the body. It secretes hormones
that control sexual development, promote bone and muscle
growth, and respond to stress.

Pineal gland It is located behind the third ventricle. It helps regulate the body’s
internal clock and circadian rhythms by secreting melatonin. It has
some role in sexual development.

Thalamus It serves as a relay station for almost all information that comes
and goes to the cortex. It plays a role in pain sensation, attention,
alertness and memory.

Basal ganglia It includes the caudate, putamen and globus pallidus. These
nuclei work with the cerebellum to coordinate fine motions, such
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as fingertip movements.

Limbic system It is the center of our emotions, learning, and memory. Included in
this system are the cingulate gyri, hypothalamus, amygdala
(emotional reactions) and hippocampus (memory).

Anterior cingulate cortex It is the front-most portion of the cingulate cortex and has been
implicated in several complex cognitive functions, such as
empathy, impulse control,emotion, attention allocation, mood
regulation, and decision-making.

Frontal cortex The frontal lobe is part of the brain's cerebral cortex. It is
especially important for planning appropriate behavioral re-
sponses to external and internal stimuli. It functions in close
association with other regions of the brain that make up cerebral
systems specifically designed for individual mental tasks.

Orbitofrontal cortex The orbitofrontal cortex is the area of the prefrontal cortex that sits
just above the orbits (also known as the eye sockets). It is thus
found at the very front of the brain, and has extensive connections
with sensory areas as well as limbic system structures involved in
emotion and memory. It is also involved in the cognitive process
of decision-making.
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PATHOPHYSIOLOGY
Psychological
Hypotheses \
- Cognitive behavioral
model: Emotional
disturbance arising from
dysfunctional beliefs about
situations or stimuli
- Avoidance/Compulsions
maintain maladaptive
beliefs and anxiety
Obsessive- Compulsive Disorder
NON-MODIFIABLE
FACTORS
- Age
- Genetics (27-50%
Biological Hypotheses Genetics hereditary)
- Abnormalities in serotonin • 27-50 % - Presence of other mental
neurotransmission heritability in twin health conditions
- Dysfunction of brain circuits in studies
(Depression, emotional,
the oribito-frontal-subcortical
regions suspected problems)
- Gender (Early onset; Men)
- Traumatic life events
- Stress
MODIFIABLE FACTORS
- Drug & alcohol use
- Marital status
- Employment status

Obsessions Compulsions
Patient attempts to
Unwanted/intrusive thoughts, Urges to perform overt
suppress/neutralize
ideas, images, impulses that behavioral or mental rituals
unwanted
intrude into consciousness to reduce obsessional
anxiety or distress about
feared consequences

Beliefs are usually

Need for order incongruent with Patient may end up
and symmetry the patient’s belief spending majority of Ordering/arranging
system their day performing things, counting
compulsions and rhyming
Guilt and
responsibility
for harm to Anxiety Mental rituals
self or others (praying,
Impairment in
cancelling out bad
daily function
thoughts with good
Unwanted
ones)
ideas about
germs and Checking (stove,
contamination locks), repeating
Complications behaviors to
Unwanted High comorbidity with other mental disorders: prevent bad luck
ideas about Generalized Anxiety Disorder, Major Depression
one’s safety/ Disorder, Bipolar disorder, Bulimia Nervosa,
something bad Asperger’s syndrome, Tourette’s syndrome
will happen High risk of suicidal thoughts and behavior
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Excessive hand-
washing/cleaning

Biting of hands

DIAGNOSTIC EVALUATION

Mental Status Examination

 The patient findings noted such as crying spells,
decreased psychomotor activity, obsessive
thoughts and obsessive impulses. Mood is
appropriate to affect.
 Affect is unpleasurable.
 1st degree True insight is present.

MRI and CT brain scan Brain scan showed enlarged basal ganglia and
changes in the ventricular volume

Positron Emission Tomography

 PET Scan showed increased glucose metabolism
in part of the basal ganglia

 The patient scoring was 24, shows moderate.

Yale-Brown Obsessive Compulsive Scale (Y- Obsessive-compulsive disorder (OCD)
BOCS) is an OCD screening test that can help
determine the severity of your OCD symptoms.

Procedure: Compulsions Checklist and Obsessions

Checklist serve as guides for Y-BOCS. Each checklist
is a 5-item questionnaire with a 0-4 scale for each
response on how frequently the compulsion and
obsession occur. The subtotals for obsession and
compulsion are the sums of items 1-5 and 6-10,
respectively.

Scale (Y-BOCS) Scoring and interpretation

Score ranges from 0-40:

● 0-20 sub case of OCD

● 21-30 moderate OCD
● 31-40 severe OCD
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Reference:
 https://iocdf.org/wp-content/uploads/2014/08/
Assessment-Tools.pdf
 https://iocdf.org/wp-content/uploads/2016/04/04-Y-
BOCS-w-Checklist.pdf
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MANAGEMENT

Pharmacologic Management

Name of the Drug Classification Dosage Mechanism of Indication and Side effects and Nursing Management
Frequency Action Contraindication Adverse Effects

Fluvoxamine Selective 50 mg PO hs This medication I: Treat obsessive- SE: Nausea, Assessment

Maleate tablets serotonin administered as works by helping to compulsive disorder vomiting,
(Luvox) reuptake a single daily restore the balance (OCD). It helps drowsiness, Hypersensitivity to
inhibitors (SSRIs) dose of /increases decrease dizziness, loss of fluvoxamine; lactation;
Antidepressant serotonin in the persistent/unwanted appetite, trouble impaired hepatic
brain, a natural thoughts sleeping, function; suicidal
substance in the (obsessions) and weakness, and tendencies; seizures;
brain that helps urges to perform sweating. mania; CV disease;
maintain mental repeated tasks labor and delivery;
balance. (compulsions such AE: headache, pregnancy
as hand-washing, tremor, ssess the client’s
counting, checking) palpitations, personal and family
that interfere with anxiety, fainting, history
daily living. black stools,
hematemesis, Weight; vital signs; skin
CI: seizures, eye rash; lesions; reflexes,
Hypersensitivity. Not pain/swelling/redn affect; bowel sounds;
to be used with ess, widened peripheral perfusion;
thioridazine, pupils, vision LFTs, renal function
terfenadine, changes tests.
astemizole,
cisapride, pimozide, Interventions
aloestron, tizanidine.
Lactation. Give lower or less
frequent doses in elderly
Pregnancy, patients and with hepatic
Serotonin syndrome, or renal impairment.
seizures, liver
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problems, increased BLACK BOX WARNING:

risk of bleeding, Establish suicide
manic behavior, precautions for severely
tobacco smoker depressed patients,
children, and
adolescents. Limit
quantity of tablets
dispensed.

Administer drug at
bedtime. If the dose
exceeds 100 mg, divide
the dose and administer
the largest dose at
bedtime.

Monitor patient for

therapeutic response for
up to 4–7 days before
increasing dose.

Monitor patient for

serotonin hypertension
syndrome, elevated
fever, severe anxiety,
rigidity.

WARNING: When
discontinuing the drug,
taper dose by 50 mg/day
every 5–7 days.

Teaching points

Take this drug at

bedtime; if a large dose
NCM 32117L

is needed, the dose may

be divided but take the
largest dose at bedtime.

Do not stop taking this

drug abruptly; it should
be discontinued slowly.

You may experience

these side effects:
Dizziness, drowsiness,
nervousness, insomnia
(avoid driving or
performing tasks that
needs alertness),
nausea, vomiting, weight
loss (eat frequent small
meals), sexual
dysfunction (reversible).

Report rash, mania,

seizures, severe weight
loss.

This medication can

increase the effects of
caffeine. Avoid drinking
large amounts of
beverages containing
caffeine (coffee, tea,
colas) or eating large
amounts of chocolate or
taking nonprescription
products that contain
caffeine.
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Diazepam (Valium) Benzodiazepine 2-10 mg PO q6- Diazepam appears I: Management of SE: drowsiness, Assessment
Anxiolytics 12hr to act on areas of anxiety disorders or tiredness,
the limbic system, for short-term relief muscle weakness, History: Hypersensitivity
2-10 mg IV/IM thalamus, and of symptoms of and to benzodiazepines;
q6-12hr; no hypothalamus, anxiety. loss of psychoses, acute
more than 30 inducing anxiolytic coordination, narrow-angle glaucoma,
mg/8 hours effects. Valium does not help nausea shock, coma, acute
Benzodiazepine treat OCD. Instead, it alcoholic intoxication;
drugs including may provide AE: elderly or debilitated
diazepam increase temporary relief and Psychological and patients; impaired liver
the inhibitory reduce symptoms physical or renal function;
processes (GABA) until proper treatment dependence with pregnancy, lactation
in the cerebral is sought. Valium can withdrawal
cortex. offer short-term relief syndrome; fatigue, Physical: Weight; skin
from many anxious drowsiness, color, lesions;
feelings but has a sedation, ataxia, orientation, affect,
high potential for vertigo, confusion, reflexes, sensory nerve
abuse and addiction. depression, GI function, ophthalmologic
disturbances, examination; P, BP; R,
CI: Hypersensitivity; changes in adventitious sounds;
preexisting CNS salivation, bowel sounds, normal
depression or coma, amnesia, jaundice, output, liver evaluation;
respiratory paradoxical normal output; LFTs,
depression; acute excitation, renal function tests, CBC
pulmonary elevated liver
insufficiency or sleep enzyme values; Interventions
apnoea; severe muscle weakness,
hepatic impairment; visual WARNING: Do not
acute narrow angle disturbances, administer intra-
glaucoma; children < headache, slurring arterially; may produce
6 mth; pregnancy of speech and arteriospasm, gangrene.
and lactation. dysarthria; mental
changes; Change from IV therapy
incontinence, to oral therapy as soon
constipation; as possible.
hypotension,
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tachycardia; Do not use small veins

changes in libido; (dorsum of hand or
pain and wrist) for IV injection
thrombophloebitis .
at Inj site (IV). Reduce dose of opioid
analgesics with IV
Potentially Fatal: diazepam; dose should
Respiratory and be reduced by at least
CNS depression; one-third or eliminated.
coma.
Carefully monitor P, BP,
respiration during IV
administration.

WARNING: Maintain
patients receiving
parenteral
benzodiazepines in bed
for 3 hr; do not permit
ambulatory patients to
operate a vehicle
following an injection.

Monitor liver and renal

function, CBC during
long-term therapy.
Taper dosage gradually
after long-term therapy.

Discuss risk of fetal

abnormalities with
patients desiring to
become pregnant.

Teaching points
NCM 32117L

Take this drug exactly as

prescribed. Do not stop
taking this drug (long-
term therapy,
antiepileptic therapy)
without consulting your
health care provider.

Caregiver should learn

to assess seizures,
administer rectal form,
and monitor patient.

Use of barrier
contraceptives is
advised while using this
drug; if you become or
wish to become
pregnant, consult with
your health care
provider.

You may experience

these side effects:
Drowsiness, dizziness
(may lessen; avoid
driving or engaging in
other dangerous
activities); GI upset (take
drug with food); dreams,
difficulty concentrating,
fatigue, nervousness,
crying (reversible).

Report severe dizziness,

weakness, drowsiness
 NCM 32117L

that persists, rash or

skin lesions, palpitations,
swelling of the ankles,
visual or hearing
disturbances, difficulty
voiding.

Lamotrigine Antiepileptic, 75 mg/day PO Stabilizes neuronal I: Lamotrigine is SE: Blurred vision, Assessment:
(Lamictal) Mood stabilizer membranes by indicated to treat double vision,
inhibiting sodium epilepsy. It can also nausea, vomiting, History: Hypersensitivity;
transport help prevent low photosensitivity, kidney or liver disease;
mood (depression) in clumsiness, heart problems;
It delays the time adults unsteadiness, depression, suicidal
between mood dizziness, or thoughts or actions;
changes and CI: Meningitis not d/t drowsiness pregnancy, lactation,
manic or an infection; anemia; taking birth control pills
depressive states decreased blood AE: Fainting,
by decreasing the platelets; liver and fast/slow/irregular/ Assess mental status;
intensity of kidney problems pounding seizures
irregular electrical heartbeat, easy or
activity in the brain. unusual Monitor daytime
It also binds and bruising/bleeding, drowsiness, depression,
weakly inhibits stiff neck, vision or other changes in
several other problems, loss of thoughts and behavior.
signaling receptors coordination, Repeated or excessive
in the brain, muscle symptoms may require
including those to pain/tenderness/w change in dose or
which dopamine eakness, signs of medication.
and serotonin kidney problems
normally bind. By (such as change in Interventions:
inhibiting these the amount of
receptors, urine),serious skin Monitor liver and kidney
signaling in the rashes, multi- function.
brain is “tuned organ
down,” or reduced, hypersensitivity, Monitor for serious skin
which can also changes in mood reactions
NCM 32117L

decrease seizure or behavior

activity. Causes photosensitivity;
use care if administering
UV treatments. Advise
patient to avoid direct
sunlight and use
sunscreens and
protective clothing.

Teaching points:

This drug can be taken

with or without food.

Take this drug at the

time(s) recommended by
your doctor.

You can cut or crush the

chewable and regular
oral tablets. You should
not crush or cut the
extended-release or
orally disintegrating
tablets.

Do not discontinue
abruptly without the
doctor’s order.

In case of emergency,
wear or carry medical
identification to let others
know you use seizure
medication.
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Advise patient about the

risk of daytime
drowsiness and
decreased attention and
mental focus.Avoid
doing activities that
require alertness.

Report any new or

worsening symptoms to
your doctor, such as:
mood or behavior
changes, depression,
anxiety, or if you feel
agitated, hostile,
restless, hyperactive
(mentally or physically),
or have thoughts about
suicide or hurting
yourself.

Aripiprazole (Abilify) Second 10 mg/day PO Aripiprazole is an I: Abllify is used SE: Dizziness; Assessment
generation antipsychotic drug alone or with a mood drowsiness;
antipsychotic that is both stabilizer medicine to Nausea, vomiting; Assess for the
(SGA) or Atypical dopamine and treat a wide variety of tiredness; blurred mentioned cautions and
antipsychotic. serotonin receptor mental/mood vision; weight contraindications (e.g.
blocker used to disorders. gain; constipation; drug allergies, CNS
treat disorders headache; trouble depression, CV
associated with CI. Hypersensitivity; sleeping disorders, glaucoma,
problems in diabetes;overweight; respiratory depression,
thought process. low WBC count; AE: Fainting; etc.) to prevent any
confusion; CHF; mental/mood untoward complications.
Aripiprazole can Orthostatic changes
decrease hypotension; (increased anxiety, Perform a thorough
hallucinations and pregnancy; lactation; depression,suicida physical assessment
improve active alcoholism; l thoughts); trouble (other medications
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concentration.It PUD; CNS swallowing; taken, CNS, skin,

balances depression; restlessness(espe respirations, and
dopamine and immunosuppression cially in the legs); laboratory tests like
serotonin to tremor; muscle thyroid, liver, and renal
improve thinking, spasm; trouble functions tests and
mood, and controlling certain complete blood count or
behavior. urges; seizures; CBC) to establish
sleep apnea. baseline data before
drug therapy begins, to
determine effectiveness
of therapy, and to
evaluate for occurrence
of any adverse effects
associated with drug
therapy.

Intervention

Monitor cardiovascular
status. Assess for and
report orthostatic
hypotension.

Monitor body
temperature in situations
likely to elevate core
temperature
.
Monitor for and report
signs of tardive
dyskinesia.

Monitor for and

immediately report S&S
of neuroleptic malignant
syndrome (NMS)
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Lab tests: Monitor

periodically Hct & Hgb.
Monitor periodically
blood glucose. Monitor
for elevated CPK and
myoglobinuria if NMS is
suspected.
Intervention

Teaching points

Carefully monitor blood

glucose levels if diabetic.

Do not drive or engage

in other potentially
hazardous activities until
reaction to drug is
known.

Avoid situations where

you are likely to become
overheated or
dehydrated.

Notify physician if you

become pregnant or
intend to become
pregnant while taking
this drug.

Do not breast feed while

taking this drug.
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Therapies

ElectroConvulsive Therapy  6 sessions of ECT were given.

Thought Stopping techniques  Thought stopping technique has been taught to the patient. She used to practice daily

Relaxation techniques  Deep breathing techniques have been taught.

Supportive therapies  Supportive therapy given such as Yoga and Music therapy.

Counseling  Individual and family counseling given.

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NURSING CARE PLAN

Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Expected Outcomes

SUBJECTIVE DATA: SHORT TERM INDEPENDENT SHORT TERM

Anxiety related to
“May habit talaga siya na unmet needs (unable After 8 hours of Establish relationships Anything about which After 8 hours of nursing
maghugas ng kamay at to complete nursing intervention, through use of the client feels intervention, the patient
gumagamit ng alcohol compulsions) as the patient will empathy, warmth, and anxious will serve to will be able to verbalize
para iwas sakit daw. Pero evidenced by verbalize respect. Demonstrate increase the understanding of
yung habit niya na persistent fear of understanding of interest in clients as a ritualistic behaviors. significance of ritualistic
maghugas ng kamay ay acquiring germs by significance of person through Establishing trust behaviors and
mas nagiging madalas touching things and ritualistic behaviors attending behaviors. provides support and relationship to anxiety
kada minuto ganon tapos overemphasis on and relationship to communicates that
bago niya hawakan ang cleanliness anxiety the nurse accepts LONG TERM
isang bagay, iniisprayan the client as a person
niya ng alcohol kahit pa LONG TERM with the right to self- The patient will be able to
kaming pamilya niya determination. demonstrate the ability to
iniisprayan niya. Kapag cope effectively with
pinagsabihan naman The patient will Use a relaxed manner
demonstrate the Any attempts to stressful situations
magagalit siya or di kaya with the client; keep decrease stress will without resorting to
sisigaw at magdadabog” ability to cope the environment calm.
effectively with help the client to feel obsessive thoughts or
as verbalized by the less anxious. compulsive behaviors two
patient’s mother. stressful situations
without resorting to weeks after the nursing
obsessive thoughts Stress management intervention.
OBJECTIVE DATA Assist client to learn techniques can be
or compulsive stress management
behaviors two used, instead of
(eg. Thought-stopping, ritualistic behavior to
- Overemphasis on weeks after the relaxation exercise,
cleanliness (frequent nursing intervention break habitual
imagery)
hand-washing and
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spraying of alcohol)
- Skin damage from patterns.
excessive washing Give positive
- Fear of acquiring reinforcement for non-
germs/infections when The approach will
compulsive behavior. prevent the client
touching random things Help significant
- Aggressiveness when from obtaining
other(s) learn the secondary gains
unable to complete value of not focusing
compulsions (shouting) from the maladaptive
on ritualistic behaviors. behaviors.
- BP: 130/80 mmHg

Encourage client to
explore the meaning This exploration
and purpose of provides an
behaviors; to describe opportunity to begin
the feelings when the to understand the
behaviors occur, process and gain
intensify, or are control over the
interrelated. obsessive-
compulsive
sequence.
Recognizing
precipitating factors
allows clients to
interrupt escalating
anxiety.
Include pt control and
the problem solving Allowing pt choice
skills in order to provide a measure of
develop individualized control and serves to
strategies that the pt increase feelings of
can use to minimize self-worth.
anxiety.

Discuss home
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situation, include
family/SO as Returning to
appropriate. Involve in unchanged home
discharge plan. (If environment
hospitalized) Increases risk that
client will resume
compulsive
DEPENDENT behaviors.

Administer
medications as
indicated (e.g. Help balance
fluvoxamine (Luvox) serotonin levels,
decreasing feelings
of anxiety, reducing
need for ritualistic
behavior(s), and
allowing client to
learn of other
methods of stress
reduction.
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Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Expected Outcomes

ACTUAL: SHORT TERM INDEPENDENT SHORT TERM

SUBJECTIVE DATA
“ayaw ko makipagusap sa
mga tao dahil di ko sila
kailangan atsaka hindi rin
naman nila ako
maiintindihan” as
verbalized by the patient.
OBJECTIVE DATA:
Impaired social Client will Ascertain patient Assess causative Client will be able to
interaction related to communicate with perception regarding and contributing communicate with others,
disinterest with verbal others, for example, sense of social factors. for example, respond
communication as respond verbally to isolation. verbally to question(s)
evidenced by verbal question(s) asked by asked by the staff within 8
reports of disinterest in the staff within 8 Establish therapeutic To promote trust and hours of nursing
communicating hours of nursing nurse and patient allow patient to feel intervention
intervention relationship. free to discuss
sensitive matters. LONG TERM

● Poor interpersonal LONG TERM Introduce patient to To provide role The patient will be able to
relationships those with similar models, encourage re-establish and/or
(Unable to make The patient will re- shared interest and problem solving and maintain relationship and
eye contact) establish and/or other supportive possibly making a and a social life and
● verbalizing/ maintain relationship people. friends that will relive participate in activities at
exhibiting and a and a social patient sense of a level of ability and
discomfort around life and participate in isolation. desire within 72 hours of
others (appears activities at a level of nursing intervention
upset or agitated ability and desire Promote participation To alleviate
when others come within 72 hours of in recreational, conditions
too close in contact nursing intervention special interest contributing to
or try to engage activities in setting patient sense of
her in an activity that patient views as isolation.
● Self-isolation (deep safe.
boredom and
general lack of Assess factors in Patient may
interest) patient life that may withdraw and fail to
 NCM 32117L

● Social withdrawal contribute to sense of seek out friends who

(Avoids people and helplessness. may have been in
activities she her life previously
usually enjoy) and had negative
● Uncommunicative interactions with.

Assess patient feeling To assess causative

about self-sense of and contributing
ability to control factors.
situation and sense of
hope.

Teach the client social The client may lack

skills, such as social skills and
approaching another confidence in social
person for an interactions; this
interaction, may contribute to
appropriate the client’s
conversation topics, depression
and active listening. and social isolation.
Encourage her to
practice these
skills with staff
members and other
clients, and give the
client feedback
regarding interactions.

Encourage the client The client may have

to identify been depressed and
relationships, social, withdrawn for
or recreational some time and have
situations that have lost interest in
been positive in the people or activities
past. that provided
pleasure in the past.
NCM 32117L

COLLABORATIVE

Encourage the client The client to pursue

to pursue past past relationships,
relationships, personal interests,
personal interests, hobbies, or
hobbies, or recreational
recreational activities activities that were
that were positive in the past
positive in the past or or that may appeal
that may appeal to the to the client.
client. Consultation Consultation with a
with a recreational recreational
therapist may be therapist may be
indicated. indicated.
 NCM 32117L
Assessment
SUBJECTIVE DATA
“Noong namatay ang lolo
niya, ilang linggo rin siya
hindi kumikibo, walang
gana kumain at
nagkukulong sa kwarto.
Mahahalata mo minsan
na wala siyang tulog
tapos makikita mo na lang
na umiiyak siya lalo na
kapag nakikita ang picture
ng kanyang lolo” as
verbalized by the patient’s
parents
OBJECTIVE DATA
- emotional outbursts,
irritability, mood swings
- restlessness
- fatigue
- inadequate/disturbed
sleep pattern
- inability to perform daily
life roles and
responsibilities
Nursing Diagnosis Planning Nursing Intervention Rationale Expected Outcomes
Ineffective coping SHORT TERM INDEPENDENT SHORT TERM
related to loss of family
member as evidenced The client will talk As the client’s anxiety The client may need The client will be able to
by verbal reports of with staff and identify decreases and as a to learn ways to talk with staff and
difficulty coping stresses, anxieties, trust relationship manage anxiety so he identify stresses,
and conflicts within 8 builds, talk with the or she can deal with it anxieties, and conflicts
hours of nursing client about his or her directly. This will within 8 hours of nursing
intervention. thoughts and behavior increase the client’s intervention.
and the client’s confidence in
LONG TERM feelings about them. managing anxiety and
Help the client identify other feelings LONG TERM
The client will alternative methods
demonstrate for dealing with The client will be able
improved coping anxiety. demonstrate improved
techniques and coping techniques and
alternative ways of Convey honest Your presence and alternative ways of
dealing with stress, interest in and interest in the client dealing with stress,
anxiety, and life concern for the client. convey your anxiety, and life
situations after a (Do not flatter the acceptance of the situations after a week
week of intervention. client or be otherwise client. Clients do not of intervention.
dishonest.) benefit from flattery or
undue praise, but
genuine praise that
the client has earned
can foster self-
esteem.
Observe the client’s
eating, drinking, and The client may be
elimination patterns, unaware of physical
and assist the client needs or may ignore
NCM 32117L

as necessary. feelings of hunger,

thirst, the urge to
defecate, and so
Forth.

Assess and monitor Limiting noise and

the client’s sleep other stimuli will
patterns, and prepare encourage rest and
her for bedtime by sleep. Comfort
decreasing stimuli measures and sleep
and providing comfort medications will
measures or enhance the client’s
medications. ability to relax and
sleep.

You may need to The client’s thoughts

allow extra time, or or ritualistic behaviors
the client may need to may interfere
be verbally directed to with or lengthen the
accomplish activities time necessary to
of daily living perform tasks.
(personal hygiene,
preparation for sleep,
and so forth).

Encourage the client Gradually reducing

to try to gradually the frequency of
decrease the compulsive behaviors
frequency of will help diminish the
compulsive behaviors. client’s anxiety and
Work with the client encourage
to identify a baseline success.
frequency and keep a
record of the
decrease.
NCM 32117L

COLLABORATIVE

Teach the client and The client and family

family or significant or significant others
others about the may have little or
client’s illness, no knowledge about
treatment, or these.
medications, if any.

Encourage the client Clients often

to participate in experience long-term
follow-up therapy, difficulties in dealing
if indicated. Help the with obsessive
client identify thoughts.
supportive resources
in the community or
on the internet.
NCM 32117L

Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Expected Outcomes

Risk for Suicide related SHORT TERM INDEPENDENT SHORT TERM

to obsessional thoughts
and/or behavior The patient will Determine the Physical safety of the The patient will be able
identify alternative appropriate level of client is a priority. to identify alternative
ways of dealing with suicide precautions ways of dealing with
stress and emotional for the client. Institute stress and emotional
problems, and was these precautions problems, and will be
safe and free from immediately on safe and free from injury
injury throughout admission by nursing throughout
hospitalization after or physician order. hospitalization the shift
the shift.
Assess the client’s The client’s suicidal LONG TERM
LONG TERM suicidal potential, and potential varies; the
evaluare the level of risk may increase The patient will be able
The patient will suicide precautions at or decrease at any to demonstrate use of
demonstrate use of least daily time. alternative ways of
alternative ways of dealing with stress and
dealing with stress emotional problems a
and emotional In your initial Information on past week after the nursing
problems a week assessment, note any suicide attempts, intervention
after the nursing previous suicide ideation, and family
intervention attempts and history is important in
methods, as well as assessing suicide
family history of risk. The client
mental may be using suicidal
illness or suicide. behavior as a
Obtain this manipulation or to
information in a obtain secondary
matter-of-fact gain. It is important to
manner; do not minimize
NCM 32117L

discuss at length or reinforcement given to

dwell on details these behaviors.

Ask the client if he or Suicide risk increases

she has a plan for when the client has a
suicide. Attempt to plan, especially
ascertain how one that is feasible or
detailed and feasible lethal
the plan is.

Explain suicide The client’s

precautions to the determination to
client commit suicide may
lead
him or her to use
even common objects
in self-destructive
ways

Be especially alert to The client is a

sharp objects and participant in his or
other potentially her care. Suicide
dangerous items precautions
demonstrate your
caring and concern
for the client.

If the client is Physical safety of the

attempting to harm client is a priority.
himself or herself, it
may
be necessary to
restrain the client or to
place him or her
in seclusion with no
objects that can be
NCM 32117L

used to self-inflict
injury (electric outlets,
silverware, and even
bed clothing).

Observe, record, and Risk of suicide

report any changes in increases when mood
the client’s or behavior suddenly
mood changes. Remember:
As depression
decreases, the client
may have the energy
to carry out a plan for
suicide.

Be alert to the The client may

possibility of the client accumulate
saving up his or her medication to use in a
medications or suicide attempt. The
obtaining medications client may manipulate
or dangerous objects or otherwise use other
from other clients or clients or visitors to
visitors. You may obtain medications or
need to check the other dangerous
client’s mouth after items.
medication
administration or use
liquid medications to
ensure that they are
ingested.

Encourage and Self-destructive

support the client’s behavior can be seen
expression of anger. as the result of anger
(Remember: Do not turned inward. Verbal
take the anger expression of anger
NCM 32117L

personally.) Help the can help to

client deal with the externalize these
fear of expressing feelings.
anger and related
feelings.

COLLABORATIVE

Know the The client at high risk

whereabouts of the for suicidal behavior
client at all times. needs close
Designate a specific supervision.
staff person to be Designating
responsible for the responsibility for
client at all times. If observation of
this person must the client to a specific
leave the unit for any person minimizes the
reason, information possibility that the
and responsibility client will have
regarding supervision inadequate
of the client must be supervision.
transferred to another
staff person.

Referral to the facility Discussing spiritual

chaplain, clergy, or issues with an advisor
other spiritual who shares his
resource person may or her belief system
be indicated. may be more
comfortable for the
client and may
enhance trust and
alleviate guilt
NCM 32117L

Involve the client as Participation in

much as possible in planning his or her
planning his or her care can help to
own treatment. increase the client’s
sense of responsibility
and control.

Examine with the The client’s significant

client his or her home others may be
environment and reinforcing the client’s
relationships outside suicidal behavior, or
the hospital. the suicidal behavior
may be a
symptom of a problem
involving others in the
client’s li
NCM 32117L

Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Expected Outcomes

Risk for other-directed SHORT TERM INDEPENDENT Physical safety of the SHORT TERM
violence related to client and others is a
aggressiveness when The patient will Provide a safe priority. The client The patient will be able
unable to complete demonstrate environment. may use many to demonstrate
compulsions decreased common items and decreased restlessness,
restlessness, environmental agitation, and hostility
agitation, and situations in a within 8 hours of nursing
hostility within 8 destructive manner. intervention
hours of nursing
intervention Consistency and
structure can
LONG TERM Provide a consistent, reassure the client. LONG TERM
structured The client must know
The patient is free of environment. Let the what is expected The patient will be free
threatened or actual client know what is before he or she can of threatened or actual
aggression toward expected of him or work toward meeting aggression toward self
self or others and her. Set goals with the those expectations. or others and will
expresses feelings of client as soon as express feelings of
anger or frustration possible. Ventilation of feelings anger or frustration
verbally in a safe may help relieve verbally in a safe
manner after two Encourage the client anxiety, anger, and manner after two weeks
weeks of nursing to verbalize feelings so forth. of nursing intervention.
intervention. such as anxiety
and anger. Explore
ways to relieve
tension with the client
as soon as possible. Physical activity can
diminish tension and
Encourage hyperactivity in a
supervised physical healthy, non-
activity destructive manner.
NCM 32117L

DEPENDENT

Administer PRN Medications can help

medications the client regain self-
judiciously, as control but should not
indicated, preferably be used to control the
before the client’s client’s behavior for
behavior becomes the staff’s
destructive. convenience or as a
substitute for working
with the client’s
problems.