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I.

INTRODUCTION
a. Bio data of patient
 Name: Reeta rani w/o Shri Mukund lal
 Age: 46 years
 Gender: Female
 Religion: Hindu
 Address: Ladoka mandi, Fazilka
 Education: 10th
 Occupation: Housewife
 Marital status: Unmarried
 Languages known: Hindi, English, Punjabi
 Monthly income: 15000/-
 Date of Admission: 3/12/18
 CRF: PFDGG1001060816
 Mobile no. : 09780216560
 Diagnosis: Obsessive compulsive disorder
 Reason for admission : Treatment and evaluation purpose
 Informant:
 Patient
 Reliability of Informant: reliable
b. Significance/relevance to the concept:
OCD is a disorder that has a neurobiological basis. It equally affects men, women, and children
of all races, ethnicities and socioeconomic backgrounds. In the India, the point prevalence of
OCD is 0.8. And according to the World Health Organization, OCD is one of the top 20 causes
of illness-related disability, worldwide, for individuals between 15 and 44 years of age.

c. B a c k g r o u n d k n o w l e d g e :

• Definition : Obsessive–compulsive disorder (OCD) is a mental disorder where people feel the
need to check things repeatedly, perform certain routines repeatedly (called "rituals"), or
have certain thoughts repeatedly (called "obsessions"). People are unable to control either the
thoughts or the activities for more than a short period of time. Common activities include hand
washing, counting of things, and checking to see if a door is locked.
• Clinical manifestation:
People may experience:

 Behavioural: compulsive behaviour, agitation, compulsive hoarding, hypervigilance,


impulsivity, meaningless repetition of own words, repetitive movements, ritualistic
behaviour, social isolation, or persistent repetition of words or actions
 Mood: anxiety, apprehension, guilt, or panic attack
 Psychological: depression, fear, or repeatedly going over thoughts

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 Also common: food aversion or nightmares

Causes: The cause of obsessive-compulsive disorder isn't fully understood. Main theories
include:

o Biology. OCD may be a result of changes in your body's own natural chemistry or brain
functions.

o Genetics. OCD may have a genetic component, but specific genes have yet to be
identified.

o Environment. Some environmental factors such as infections are suggested as a trigger


for OCD, but more research is needed.

Prognosis
The prognosis of this condition is good, with most cases improving within a year of diagnosis.
The minority of cases will developing a long-term course of the illness, fluctuating and persisting
with time. When severe, the condition can last for many years, and may be more resistant to
treatment than less severe forms of the disease.

Complications: Problems resulting from OCD may include, among others:

Health issues, such as contact dermatitis from frequent hand-washing

Inability to attend work, school or social activities

Troubled relationships

Overall poor quality of life

Suicidal thoughts and behavior

NURSE CENTERED

Objectives

Upon completion of the case study, participants should be able to:

1. Demonstrate transfer of knowledge of obsessive compulsive disorder pathophysiology,


assessment, and treatment planning to a case situation.
2. Develop a multimodal treatment plan for a patient with obsessive compulsive disorder
according to their prognosis.
3. Illustrate responsible therapy prescribing.
4. Understand complications of obsessive compulsive disorder.
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HISTORY OF PATIENT

1. Bio data of patient


 Name: Reeta rani w/o Shri Mukund lal
 Age: 46 years
 Gender: Female
 Religion: Hindu
 Address: Ladoka mandi, Fazilka
 Education: 10th
 Occupation: Housewife
 Marital status: Unmarried
 Languages known: Hindi, English, Punjabi
 Monthly income: 15000/-
 Date of Admission: 3/12/18
 CRF: PFDGG1001060816
 Mobile no. : 09780216560
 Diagnosis: Obsessive compulsive disorder
 Reason for admission : Treatment and evaluation purpose
 Informant:
 Patient
 Reliability of Informant: reliable

2. CHIEF COMPLAINTS:
According to records:
 Obsessions of symmetry
 Sadness
 Obsession for frequent hand washing X 20 years
 Hopelessness
 Loss of concentration
 Disturbed sleep pattern
 Decreased sleep
 Irritability
 Generalized body ache
 Constipation

3. HISTORY OF PRESENT ILLNESS:


 Duration : 20 years
 Mode of onset: Chronic
 Course of illness: Continuous
 Predisposing factors : conflicts with family and husband
 Aggravating factors : Loneliness in the home

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4. PAST HEALTH HISTORY
 Medical history:
 No H/O hypertension, Diabetes mellitus , Asthma, or any other medical illness.
 No h/o neurological disorders
 No h/o convulsions
 No h/o unconsciousness
 No h/o HIV, visceral disorders
 H/o hypertension from last 10 years
 Surgical history: Not available
 Psychiatric history :
H/o OCD * 20 years
h/o decreased interest in work
h/o crying spells
h/o suicidal thoughts
o Hospitalization : In AIIMS , New Delhi , PGI , Chandigarh and from Rajasthan
also
o Nature of treatment : Drug therapy and ECT
o Improvement : Not significantly

5. FAMILY HISTORY
Sr Members Relation with Education occupation Health status
.no Patient
1 Mukund lal Husband Graduate Businessman Good

2 Reeta rani Patient Matric Housewife Ill

3 Aditya Son Graduate Private job Good

4 Kusum Daughter Undergraduate Student Good

Type of family : Nuclear

Birth order : 2nd in order

Psychiatry history: H/o OCD in elder sister , H/o OCD in aunt

No h/o substance abuse in family

Medical history: No significant history

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Surgical history: No significant history

Current housing conditions :

i. Home circumstances: conflicts with family


ii. Per capita income : 3750 rs. per month
iii. Socioeconomic status : Middle class family
iv. Head of the family : Husband
v. Current attitude of family members towards illness : Cooperative from son and
daughter but not satisfactory from husband
vi. Communication pattern in family : not satisfactory
vii. Cultural and religious view : Hindu religion
viii. Ethnicity : Punjabi
ix. Social support systems available : From relatives

FAMILY TREE

Father mother

Sister husband patient brother brother brother brother

Son daughter

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6. PERSONAL HISTORY
a) BIRTH & DEVELOPMENT
 Antenatal period:
o Any febrile illness : no history
o Physical illness : no history
o Medications / drugs use : no
o Trauma to abdomen : no
o Immunization : no history available
 Natal period:
o Birth : full term
o Wanted : yes
o Type of delivery : normal vaginal delivery
o Birth cry : immediate
o Birth defects : no
o Postnatal complications : no
b) CHILDHOOD HISTORY :
o Primary caregiver : mother
o Feeding : breast feed
o Age at weaning : 1 year
o Developmental milestones : normal
o Age and ease of toilet training : 2 and half years
o Behavioural and emotional problems :
i. Thumb sucking : YES
ii. Temper tantrums : NO
iii. Tics and head banging : NO
iv. Night terror : YES
v. Fears : YES
vi. Bed wetting : YES
vii. Nail biting : YES
viii. Stuttering : NO
ix. Enuresis: NO
x. Encopresis: NO
xi. Somnambulism : NO
c) EDUCATIONAL HISTORY :
o Age at beginning of formal education : 5 years
o Age of finishing formal education : 17 years
o Relationship with peers and teachers : fear from teachers
o School phobia : yes
o Truancy , non attendance : no
o Learning disabilities : present in mathematics

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o Reason for termination of studies : Family issues
o Bullying at school : no
d) PLAY HISTORY :
o Games played : indoor games with sister and cousin sisters
o Relationship with mates : good

e) ADOLESCENCE:
Emotional problems during adolescence :
o Running away from home : NO
o Delinquency : NO
o Smoking : NO
o Drug abuse : NO
o Any other : NO SIGNIFICANT HISTORY AVAILABLE
f) PUBERTY:
o Age at appearance of secondary sexual characteristics : 15 YEARS
o Anxiety related to puberty changes : YES
o Age at menarche : 16 YEARS
o Reaction to menarche : ANXIOUS
o Regularities of menstrual cycle : REGULAR
o Abnormalities : NO
g) OBSTETRICAL HISTORY :
o Any abnormalities associated with delivery / puerperium/ pregnancy : No
o Number of children : 2
o Termination of pregnancy : with delivery of live baby
h) OCCUPATIONAL HISTORY :
o Age at starting work : 8 YEARS
o Jobs : HOME MAKING
o Reasons for change : NO CHANGE IN THE JOB
o Current job satisfaction : NO INTEREST IN WORK
i) SEXUAL HISTORY :
o Type of marriage : ARRANGE
o Duration of marriage : 22 YEARS
o Interpersonal relationship with in laws: UNSATISFACTORY
o Relationship with husband : CONFLICTS
o Relationship with children : CONFLICTS
j) SUBSTANCE ABUSE: No significant history
k) PRE-MORBID PERSONALITY
i. Interpersonal relationships:
o Interpersonal relationships with family : unsatisfactory
o Interpersonal relationships with friends : Good

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o Type of personality : introverted
o Making social relationships : Not good
ii. Use of leisure time :
o Hobbies : Cooking , stitching
o Interests : listening music
o Intellectual activities : no
o Energetic : no
o Sedentary : yes
iii. Predominant mood :
o Pessimistic
o Prone to anxiety
o Despondant
o Reaction to stressful events : anxious
iv. Attitude towards self and others :
o Self confidence level : low
o Self criticism : yes
o Self consciousness : yes
o Thoughts for others : thoughtful
o Self appraisal of activities : less
o General attitude towards others : sympathetic , loving and caring
v. Attitude to work and responsibilities
o Decision making : less
o Acceptance of responsibility : no acceptance
o Flexibility : no
o Foresight : impaired
o Religious beliefs : faith in god
o Fantasy life : wants a happy life
o Day dreams : no
vi. Habits :
o Eating pattern : irregular
o Elimination : irregular
o Sleep : irregular
o Use of drugs / tobacco / alcohol: no
 VITAL SIGNS

s. no. Vital signs Normal value Patient value Remarks


1 Temperature 98.6 F 98 F Normal
2 Pulse 72-100/min 82/min Normal
3 Respiration 20-24/ min 24/min Normal
4 B.P 120/80mm hg 140/90mm hg Prehypertension

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INVESTIGATION

Investigations Normal Values Patient’s Values Remarks


Bilirubin
 Total 0.0-0.2 mg / dl 0.25 mg /dl Normal
 Direct 0.2-1.2 mg / dl 0.10 mg/dl Normal

SGOT 40 U/L 38 U/L Normal


SGPT 40 U/L 43 U/L Normal
Total protein 3.5-5.3 g/dl 6.9 g/dl Normal
Albumin 3.5-5.3 g/dl 4.0 g/dl Normal
Random sugar 80-120 mg/dl 116mg/dl Normal
Urea 15-45 mg/dl 21 mg/dl Normal
Creatinine 0.6-1.3 mg/dl 0.64 mg /dl Normal
Uric acid 3.5-7.2 mg /dl 4.9 mg/dl Normal
Sodium 135-158 mmol/dl 142 mmol/dl Normal
Potassium 3.8-5.6 mmol/dl 4.5 mmol/dl Normal
Calcium 1.1 – 1.3 mmol/dl 1.2 mmol/dl Normal

MEDICATION

Name the drugs Composition Dosage Route Frequency Action


Tab. Stalopam Escitalopram + 10 mg+0.5 Oral TDS Antidepressant
plus Clonazepam mg + anti anxiety

Tab. Amigold Amisulpride 100 mg Oral OD Antipsychotic

Tab. Sertex Sertraline hydrochloride 100mg Oral OD Analgesic

Tab. Erides ER Desvenlafaxine 50 . mg Oral BD Antidepressant

Nursing care provided to patient

Day 1 1) Rapport established with the patient.


2) Vital signs are monitored.
3) Administration of medication.

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4) Patient is involved in activities like painting,
Day 2 1) Co-operation of patient gained.
2) Establishment of good IPR with Patient.
3) Assessment regarding personal hygiene done.
4) History collection is done including biodata, illness and other all
aspects.
5) Preparation of nursing care plan according to patient’s needs.
Day 3 1) Patient is involved in activities like carom board, painting
2) Mental status examination is conducted.
3) Play therapy is given to patient.
4) Patient is assisted in self care activities.

MENTAL STATUS EXAMINATION

I. APPEARANCE

1. GROOMING AND DRESS

Inference:
Patient is wearing appropriate dress which is according to the place and season. Hair
are also combed. She is not well groomed

2. HYGIENE

Inference:
Hygienic condition of the patient is poor. Patient takes bath after 7 days and also
changes her clothes. Nails are unclean.

3. PHYSIQUE

Inference:
Patient has normal body physique

4. POSTURE

Inference:
Patient is having an open posture.

5. FACIAL EXPRESSIONS

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Inference:
Facial expressions of the patient are anxious . They are appropriate according to the
talk of the patient.

6. LEVEL OF EYE CONTACT

Inference:
Patient maintains eye-to-eye contact throughout the conversation.

7. RAPPORT
N: Good morning
P: Good morning Ma’am
N:Main M.Sc Psychiatric Nursing ki student hoon. Aaj main aapse kuch baatein
karunga, jo aapke ilaj aur meri sahayeta karenge. Kya aap mujhse baat karoge?
P: yes
Inference:
A good rapport is maintained with the patient. She took part in the conversation well
and responded to all the questions asked to her.

II. MOTOR ACTIVITY

Inference:
Patient is able to sit still. Her psychomotor activity is decreased . Unusual gestures or
mannerisms are not present.

III. SPEECH

Inference:
Patient spoke in Hindi language. Rate of speech is normal and in normal tone.
IV. EMOTIONS

1. MOOD
N: Kaise ho ap ?
P: bus thik hoon.
Inference:
Patient ‘s mood is good.

2. AFFECT

Inference:

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Patient’s emotional response is appropriate.

V. THOUGHT

1. FORMATION LEVEL

N: Aap kis vajah se yahan par admit ho?


P: Mujhe baar baar haath dhone ki adat hai
Inference:
Normal formation level

2. CONTENT LEVEL

N: Kya aap ko kabhi aisa lagta hai ki log aapke bare mein baat kar rahe hain yaa na
apko marna chahte hain.
P: (Smiling) nahi. Mujhe aisa nhi lagta.
N: Kya aapko kisi cheez se dar lagta hai.
P: Nahi mujhe kisi cheez se dar nahi lagta.

Inference:
Delusions, phobias etc. are absent.

3. PROGRESSION LEVEL

N: Kya koi khayal aapke mun mein baar-baar aata hai.


P: hanji baar baar maan mein ek hi khyal ate hai
Inference:
Progression level of thought is impaired.

VI. PERCEPTION

N: Kya aapko kabhi koi ajeeb aawazein sunai deti hain?


P: Nahi , aisa kuch bhi hota tha .
N: Kya kabhi aisa lagta hai ki aapko koi cheez dikhayi deti hai, jo koi aur nahi dekh
sakta.
P: Nahi aisa bhi kuch nahi tha
Inference:
Patient is not having any kind of visual and auditory kind of hallucinations.
Perception in patient is intact.

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VII. SENSORIUM AND COGNITIVE ABILITY

1. LEVEL OF ALERTNESS/CONSCIOUSNESS

Inference:
Patient is alert and conscious. She is actively listening to all the questions and is also
giving appropriate answers.

2. ORIENTATION
N: Aap yahan kab se hai?
P: 03 decemeber se hun.
N: Aap kahan ke rehne wale ho?
P: Main fazilka ki rehne wali hu
N: Aaj kaunsa din hai?
P: Friday.
N: Aap is waqt kahan pe ho?
P: GGS hospital psychiatry ward mein hu
Inference:
Patient is fully oriented with person, place and time.

3. MEMORY

a) Immediate memory

N: Main jo 5 no. bolu use dhyan se sunna aur phir batana:


4,21,5,2
P: 4, 21, 5, 2
Inference:
Immediate memory of the patient is intact.

b) Recent memory

N: What had you taken in your breakfast?


P: Bread, milk, egg.
N: How many times you are taking meal in a day?
P: 3 times
Inference:
Patient’s recent memory is also intact.

c) Remote memory

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N: what is your date of birth?
P: 23 July 1973
N: Aap is hospital mein konsi date ko aye the?
P: 03 december ko
Inference:
Patient’s remote memory is intact.

4. CONCENTRATION AND ATTENTION

N: Ek sawal hai isse solve karo: 90 - 17 =?


P: 73
N: 1 se 20 tak counting karo.
P: 1, 2, 3, 4, 5

Inference:
Patient is having loss of concentration and attention.

5. INFORMATION AND INTELLIGENCE

N: Bharat ka Pradhan mantra kon hai?


P: pta nahi
N: India ki capital kya hai?
P: New delhi

Inference:
Patient general information level is less .

6. ABSTRACT THINKING

N: orange aur ball mein kya antar hai?


P: Ball se hum game khelte hai, aur saantr amai khati hoon (with smiling face).
Inference:
Abstract thinking of the patient is good.

7. JUDGMENT

a) Social

N: Aagar aapke aas-pados mein kabhi aag lag jaye toh aap kya karoge?

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P: Mai aag ko bujhane ki koshish karoongi.

Inference:
Patient has logical social judgment.

b) Personal

N: Agar aapko 100 ka note sadak par girahua mile toh aap kya karoge?
P: agar kana hua to mai apne paas rakhloongi.

Inference:
Personal judgment of the patient is appropriate.

VIII. INSIGHT

N: Aapko kya lagta hai ki aapko koi mansik ya sharirik bimari hai?
P: Hanji mujhe meri problem ke bare mein pta hai , ab main isko thik karna chahti hu
Inference:
Patient is having grade V insight as she accepts her illness.

IX. GENERAL ATTITUDE

Inference:
General attitude of the patient is normal and appropriate. Patient is very co-operative.

X. SPECIAL POINTS

N: Aaj subah nashta kiya aapne?


P: Haan kiya tha.
N: Bukh theekh se lagti hai?
P: nhi
N: Neend theek se aati hai?
P: nhi .
N: Kabji kabaz vagerah ki takliph toh nahi?
P: hanji hai .

Inference:
Patient’s appetite, bowel, bladder and sleep pattern is disturbed

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XI. PSYCHOSOCIAL FACTORS

1. STRESSORS

N: Aapko kisi baat se koi pareshaani hai.


P: Nhi mujhe koi pareshani nhi hai. Bas ab main thik hona chahti hu

Inference:
she is worried about her future

2. COPING SKILLS

N: Aap apni tension door karne ke liye kya karte ho?


P: kujh nhi karti

Inference:
Her coping skills are not accurate

3. RELATIONSHIPS

N: Kya aapke dost hain?


P: Ji haan.
N: Kya aapko who aache lagte hain?
P: Jihaan, woh mere kafi ache dost hain. Main sabhi ki both help krti hoon.
N: Kya aap apne gharke sabhi logon se pyar karte hain?
P: haan . par who meri baat ko nhi smjhte

Inference
Patient has good relationship with his friends and but has conflicts in the family .

4. SOCIO CULTURAL

N: Kya aap ko kabhi aisa lagta haiki is samaaj ke asool sakht hai aur aap unhe
badalna chahtehain?
P: Nahi aisa kuch bhi nahi hai
Inference
Patient follows the rules of society.
5. SPIRITUAL
N: Kya aap pooja krte ho?
P: Haan! Kabhi kabhi

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Inference:
Patient is spiritual and believes in god.
SUMMARY : In MSE , it has been found that patient ‘s personal hygiene is not maintained .
Psychomotor activity is decreased . but thought and speech are normal . There are no
hallucinations and delusions . Patient is sad and affect is congruent. Grade V insight is present .
General attitude is good and patient is cooperative.

NEUROLOGICAL EXAMINATION:

LEVEL OF CONCIOUSNESS:

 Alertness: patient is alert and response immediately & appropriately to all verbal
commands.
 Lethargic: patient does not feel drowsy.

GLASGOW COMA SCALE:

RESPONSE TYPES POINTS PATIENTS


VALUE
Best eye opening response  Spontaneously 4 4
 To speech 3
 To pain 2
 No response 1
Best motor response  Obeys verbal command 6 6
 Localizes pain
 Flexion- withdrawal 5
 Flexion- abduction 4
 Extension 3
 No response 2
1

Best verbal response  Oriented to time, place, 5 5


person
 Confused conversation 4
 Speech inappropriate
 In comprehensive 3
 No respose
2
1
Total score 15 15

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ASSESSMENT OF CEREBRAL FUNCTIONS:

 Agnosia : absent as patient can recognize the common objects


 Apraxia: absent as patient can carry out some skilled activities
 Aphasia: absent; patient can communicate.
 Finger to finger test: normal
 Finger to nose test: normal
 Romberg test: positive as patient can maintain his balance.
 Tandom walking test: positive patient can walk in straight line.

CRANIAL NERVE EXAMINATION:

 CN I, (Olfactory nerve): patient have the CN I functioning as he smelled and identified


the fruit orange by closing his eyes.
 CNII,(Optic nerve) : inspection of the eyes was done and no obvious abnormalities was
found.
 CN III (occulomotor) CN IV(trochlear),CN VI(abducens) : normal control eye movement
in all six cardinal, IOP was normal,
 CN V(trigeminal nerve):corneal reflexes are observed and it was normal.
 CN VII(facial nerve): no any presence of facial palsy, and had normal taste sensation.
 CN VIII(vestibulo-cochlear nerve): normal auditory acuity and maintain a normal range
of balance. But patient have deviated range of motion.
 CN XII(hypoglossal nerve): there is no deviation from midline.

REFLEX TESTING:

A). SUPERFICIAL REFLEXES:

Abdominal Reflex-Lightly stroking the skin on an abdominal quadrant normally contract the
abdominal muscle, moving the umbilicus towards the stimulated side.

 Present.

Planter reflex- Scratching the foot’s outer aspect of the planter surface from the heel towards
the toes normally contracts or flexes the toes in patients older than 2 years of age.

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 Present.

Corneal reflex- Gently touching the cornea with a wisp of cotton causes blinking.

 Present.

Pharyngeal reflex- Depress the tongue with a tongue blade and have the patient say “ahh” or
yawn. Uvula and soft palate should rise. Gag reflex should be present and the voice should sound
smooth.

 Present.

B).DEEP TENDON REFLEXES:

Biceps Reflex (C5 – C6): Support the forearm on the examiners forearm. Place your thumb on
the bicep tendon (located in the front of the bend of the elbow; midline to the anticubital fossa).
Tap on your thumb to stimulate a response.

 Present.

Triceps Reflex (C7-C8): Have the individual bend their elbow while pointing their arm
downward at 90 degrees. Support the upper arm so that the arm hangs loosely and “goes dead”.
Tap on the triceps tendon located just above the elbow bend (funny bone).

 Present.

Brachioradialis Reflex (C5-C6): Hold the person’s thumb so that the forearm relaxes. Strike
the forearm about 2-3 cm above the radial styloid process (located along the thumb side of the
wrist, about 2-3 cm above the round bone at the bend of the wrist). Normally, the forearm with
flex and supinate.

 Present.

Quadriceps Reflex (Knee jerk) L2 – L4: Allow the lower legs to dangle freely. Place one hand
on the quadriceps. Strike just below the knee cap. The lower leg normally will extend and the
quadriceps will contract.

If the patient is supine: Stand on one side of the bed. Place the examiners forearm under the
thigh closest to the examiner, lifting the leg up. Reach under the thigh and place the hand on the
thigh of the opposite leg, just above the knee cap. Tap the knee closest to the examiner, (the one
that has been lifted up with the examiners forearm).

 Present.

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Achilles Reflex (ankle jerks) L5 – S2: Flex the knee and externally rotate the hip. Dorsiflex the
foot and strike the Achilles tendon of the heel. In conscious patients, kneeling on a chair can
help to relax the foot.

Heel Lift While the patient is supine, bend the knee and support the leg under the thigh. Have
the leg “go dead”. Briskly jerk the leg to lift the heel of the bed. Normally, the leg will remain
relaxed and the heel will slide upward; increased tone will cause the heel and leg to stiffen and
lift off the bed.

 Present.

Babinski Response: Dorsiflexion of the great toe with fanning of remaining toes is a positive
Babinski response. This indicates upper motor neuron disease.

 Present.

Reflex responses: 0 no response 1+ diminished, low normal 2+ average, normal 3+ brisker than
normal 4+ very brisk, hyperactive

Lower motor neuron disease is associated with 0 or 1+, upper motor neuron disease is associated
with 3+ or 4+.

 Patient`s reflex were normal

REFLEXES Biceps Triceps Supinator Knee Ankle Plantar Abdominal


Right +2 +2 + + + + +
Left +2 +2 + + + + +

MINI MENTAL STATUS EXAMINATION:

COMPONENT DESCRIPTION PATIENT POINTS


SCORE
I. ORIENTATION
 What is the year? 1 1
 Season? 1 1
 Date? 1 1
 Day? 1 1
1 1
 Month?
1 1
 Which state you live?
1 1
 Country?
1 1
 Town/city?
1 1
 Hospital name?
1 1

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 Floor ?
II. ATTENTION AND CALCULATION:
 Count 1-10 forward 5 5
 Count 1-10 backward
 Add 5+10= 15
 Subtract 5-2= 3
 Spell word SUMMER.

III. REGISTRATION
 Name three objects : register, cup, book 3 3
IV. RECALL:
 Register, cup book 3 3
V. LANGUAGE
 What is this ( patient was shown a book and he 2 2
gave right answer)?
 Patient was shown a wrist watch and time was
asked?
 Ask the person to repeat the following 1 1
 Command: take the pencil and draw a circle 3 3
 Fold the paper into four halves. 1 1
 write a sentence of your choice 1 1
 Copy: patient was asked to draw the following 1 1
shape and she drawed it

Shapes:

Total score: 30 30

VITAL SIGNS:

Vitals sign Patient value Normal value Remarks


1. Temp. 98.6 F 98.6 F Normal
2. Pulse 86/min 70-80/min increased
3. Respiration 20/min 24/min Normal
4. BP 130/80mmhg Normal

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PROCESS RECORDING

BIO –DATA OF THE PATIENT

 NAME OF THE PATIENT: Reeta rani


 AGE : 46 years
 SEX : female
 MARITAL STATUS : married
 EDUCATION : 10th
 OCCUPATION : homemaker
 MOTHER TONGUE : Hindi, Punjabi
 ADDRESS : ladoka mandi , Fazilka
 WARD : psychiatry ward , GGS hospital , Faridkot
 TIME TAKEN : 15 min
 DIAGNOSIS : obsessive compulsive disorder

BRIEF HISTORY OF PATIENT:

Patient was admitted to psychiatry ward , GGS hospital , Faridkot with the chief complaints of

According to records:
 Obsessions of symmetry
 Sadness
 Obsession for frequent hand washing X 20 years
 Hopelessness
 Loss of concentration
 Disturbed sleep pattern
 Decreased sleep
 Irritability
 Generalized body ache
 Constipation
PROCESS RECORDING

Objectives for the patient:

1. To establish rapport and therapeutic IPR.


2. To socialize effectively.
3. To ventilate his feelings.
4. To identify the problems.
5. To learn healthy coping mechanisms.

Objectives for the nurse:

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1. To develop adequate communication skill.
2. To develop confidence in maintaining therapeutic relationship.
3. To develop skill in acknowledging the problems of the patient.
4. To assist the patient in dealing with his personal problems.
5. To assist the patient in developing positive coping mechanisms.
6. To procure skill in evaluating the pre-set objectives in order to assess the effectiveness of
therapeutic IPR.
7. To judge self in dealing with anxiety, fear and sentiments while progressing through the
therapeutic IPR.

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S. Particip Conversation Therapeutic Inference Communica
no ants techniques tion
1. Nurse Good Morning Giving Initiation of Verbal
recognition communicatio
Patient Good Morning ! n
2. Nurse Kya mai aapse baat kar sakti hoo? Giving Initiation of Verbal
recognition communicatio
Patient Hanji n
3. Nurse Ap thik ho ? Exploring Maintain eye Verbal
to eye contact
Patient Hanji thik hu
4. Nurse Aap yahan pe kyu aye the? Questioning Responding Verbal
spontaneously
Patient Mujhe baar baar haath dhone ki adat hai
. mai tang aa chuki hu
5. Nurse Aapko kitne din ho gye yahan pe aye Linking Answer Verbal
hue? adequately
Patient Mujhe yahan aye huye 7 din hogye hai
6. Nurse Apko je problem kab se hai ? Theme Answer Verbal
identification
adequately &
made
Patient Mujhe je problem pichle 20 saal se hai eye to
… maine bhut ilaaj karwaya par ab tak eye
thik nhi huyi contact.
7. Nurse Aapko yahan pe kon le kar aya? Open general Answers Verbal
lead adequately
Patient Muje yahan pe meri family leke ayi hai
8. Nurse Iske ilawa ap koi koi auar takleef toh Questioning Answers Verbal
nhi hai ? adequately

Patient Mera mann bhut udas rehta hai .. ab


main tang aa chuki hu .. meri wajah se
sab takleef mein hai
9. Nurse Apke ghar mein kounkoun hai ? Questioning Answers Verbal
adequately.

Patient Mere ghar mein mere pati aur 2 baache


hain
10. Nurse Ap ghar mein kya karte ho ? Restating Maintains eye Verbal
to eye contact
Patient Mera gharmein koi bhi kaam karne ka
mann nhi krta ..mere ghar ka sra kaam
meri beti karti hai

24
11. Nurse Apko koi tension toh nhi hai Reinforcing Answered Verbal
the patient sadly
Patient Nhi ghar mein sab thik hai offering
general lead
12. Nurse Apko aur kya takleef hain ? Asking divert Answers Verbal
question adequately
Patient Ab toh problem itni badh chuki hain ki
paani ka glass bhi uthakr nhi pee sakti
… who bhi pados mein kisi ko bulana
padhta hai
13. Nurse Ap ghar mein ladhayi karte ho ? Giving broad Answers Verbal
opening a
Patient Nhi mai kabhi kisi se nhi ladhta . meri d
ghar aur bahr dono jagah banti hai e
q
u
a
t
e
l
y
14. Nurse Apke parivaar mein kisi aur ko yeh Encouraging Answers Verbal
takleef thi description of adequately
Patient Hanji meri badi behn ko yeh takleef thought
hain
15. Nurse Apka kya karne ka mann karta hain Encouraging Answers Verbal
ventilation of adequately
Patient Mera kujh bhi karne ka mann nhi karta. feelings.
Bas apna kamm bhi kisi aur se karwana
padhta hai…
16. Nurse Apne kabhi isko thik karne ki koshish Divert Answers sadly Verbal
ki hai ? questioning
Patient Hanji , par iska fark nhi pada kabhi….. about his
feelings
17. Nurse Apko nhi lgta ise apke ghar walon ko Encouraging Answers Verbal
preshani ho rhi hai? description of adequately
Patient Han… isliye toh mai chahti hu ki mai thought
thik ho jayu……
18. Nurse Koi baat nhi apko kisi baat ki tension Encouraging Answers Verbal
nhi leni apne ? description of adequately
Patient Hanji … thought
19. Nurse Aapko yahan a k kuch farak mehsoos Divert Answers Verbal
huya hai? questioning adequately

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Patient Hanji pehle se bhut fark lag raha hai .. about his
bas thoda body mein pain hota hai .. par thinking
baki sab thik hai process
20. Nurse Theek hai. Aap ab aise hi apne aap ko Linking with Answers Verbal
sudharne k liye effort krna aur haath reality adequately
done ke bare mein bilkul nhi sochna
Patient Ji han.. ab uske ke bare mein bilkul nhi
sochungi….
21. Nurse Psychoeducation: Suggestion Linking and Verbal
 Aap samay se dwai liya kijiye ta accepting my
k aap thik ho jaye fir aap ghar ja suggestion
payenge.
 Apna dhyan apni family ki taraf
lagaiye
 Roj exercise kijiye
 jab bhi haath done ka mann kare
toh … baith jana hai bas
 khud uthke glass se paani peene
ki koshish karni hai
 Roj nahayea kijiye, ache se
khana khayea kijiye aur sari
counselling aur treatment
procedure mein saath dijiye

Patient Thik hai ji


Nurse Chaliye aaj k liye hum itni hi baat Informing Behave Verbal
krenge, abhi aap apne saath vale dosto k and normally and
saath baatein kijiye, aapke saath baat terminating termination of
krke mujhe bhut acha lga. Mujhse baat the interview the interview is
krne k liye thank you. Ok bye. done in normal
way and is
accepted by
Patient Thik hai beta the patient.

PHYSICAL EXAMINATION :
General survey :
Height : 5’5”
Weight : 60 kg.
Body makeup: Normal
Communication pattern : conscious
Skin :
o Color - Brown

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o Turgor - Poor
o Bruises- Absent
o State of hydration – Dehydrated
Eyes:
 Sclera - Yellowish
 Pupils – contracted
Respiratory : Normal
Vital signs:
 Heart rate – 100 beats/ minute
 Temperature – 98 F
 Blood pressure- 140/90 mm hg.
 Capillary refill – 4 seconds
 Respiratory rate – 22 breathes/ minute
Body position / alignment :
 Alignment – appropriate
Mental acuity :
Oriented , coherent , appropriately responsive
Sensory / Motor restrictions :
 Amputation : Absent
 Deformity : Absent
 Paresis: Absent
 Paralysis: Absent
 Fracture : Absent
 Gait : Normal
 Hearing disorders: Absent
 Speech : slurred
Emotional status:
Euphoric : Absent
Depressed : present
Apprehensive : Absent
Angry/ Hostile : Absent
Others : drowsy look , anxious
Medically imposed restrictions :
No
Other health related patterns :
Fatigue : Present
Restlessness : Absent
Weakness : Present
Insomnia : Absent
Coughing : Absent
Dyspnea : Absent
Dizziness : Absent
Pain: Present

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Environment
Room temperature : Normal , adequate
Lightning : adequate
Safety :
Violations of medical asepsis: Absent
Violations of safety measures: Absent
Activities of daily living :
Feeding – able to perform
Dressing – not able to perform
Combing – not able to perform
Brushing –able to perform
Bathing – not able to perform
Transferring – not able to perform

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DESCRIPTION
OF
DISEASE

29
OBSESSIVE COMPULSIVE DISORDER
Definition :

 An anxiety disorder characterized by recurrent, persistent obsessions or compulsions.


Obsessions are the intrusive ideas, thoughts, or images that are experienced as
senseless or repugnant. Compulsions are repetitive and seemingly purposeful behavior
which the individual generally recognizes as senseless and from which the individual
does not derive pleasure although it may provide a release from tension.
 Disorder characterized by recurrent obsessions or compulsions that may interfere with
the individual's daily functioning or serve as a source of distress.

Common Obsessions in OCD

Contamination Unwanted Sexual Thoughts

 Body fluids (examples urine feces)  Forbidden or perverse sexual


 Germs/disease (examples herpes HIV) thoughts or images
 Environmental contaminants (examples: asbestos  Forbidden or perverse sexual
radiation) impulses about others
 Household chemicals (examples cleaners solvents)  Obsessions about homosexuality
 Dirt  Sexual obsessions that involve
children or incest
Losing Control  Obsessions about aggressive sexual
behavior towards others
 Fear of acting on an impulse to harm oneself
 Fear of acting on an impulse to harm others Religious Obsessions (Scrupulosity)
 Fear of violent or horrific images in one’s mind
 Fear of blurting out obscenities or insults  Concern with offending God, or
 Fear of stealing things concern about blasphemy
 Excessive concern with right/wrong
Harm or morality

 Fear of being responsible for something terrible Other Obsessions


happening (examples: fire burglary)
 Fear of harming others because of not being careful  Concern with getting a physical
enough (example: dropping something on the illness or disease (not by
ground that might cause someone to slip and hurt contamination, e.g. cancer)
him/herself)  Superstitious ideas about
lucky/unlucky numbers certain
Obsessions Related to Perfectionism colors

 Concern about evenness or exactness


 Concern with a need to know or remember
 Fear of losing or forgetting important information
when throwing something out
 Inability to decide whether to keep or to discard
things
 Fear of losing things

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Common Compulsions in OCD

Washing and Cleaning:

o Washing hands excessively or in a certain way

o Excessive showering, bathing, tooth brushing,


grooming or toilet routines

o Cleaning household items or other objects


excessively

o Doing other things to prevent or remove contact


with contaminants

Checking:

o Checking that you did not/will not harm others


o Checking that you did not/will not harm yourself
o Checking that nothing terrible happened
o Checking that you did not make a mistake
o Checking some parts of your physical condition or
body

Repeating:

 Rereading or rewriting

 Repeating routine activities (examples: going in or


out doors, getting up or down from chairs)

 Repeating body movements (example: tapping,


touching, blinking)

 Repeating activities in "multiples" (examples: doing a


task three times because three is a "good," "right,"
"safe" number)

Mental Compulsions:

 Mental review of events to prevent harm (to oneself,


others, to prevent terrible consequences)

 Praying to prevent harm (to oneself, others, to prevent


terrible consequences)

 Counting while performing a task to end on a "good,"


"right," or "safe" number

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 "Cancelling" or "Undoing" (example: replacing a
"bad" word with a "good" word to cancel it out)

Other Compulsions:

 Collecting items that results in significant clutter in


the home (also called hoarding)

 Putting things in order or arranging things until it


"feels right"

 Telling, asking, or confessing to get reassurance

 Avoiding situations that might trigger your obsession.

Classification: : According to ICD 10

F42: Obsessive-compulsive disorder


Obsessional thoughts are ideas, images, or impulses that enter the patient’s mind again and
again in a stereotyped form. They are almost invariably distressing and the patient often tries,
unsuccessfully, to resist them. They are, however, recognized as his or her own thoughts,
even though they are involuntary and often repugnant.

Compulsive acts or rituals are stereotyped behaviours that are repeated again and again.
They are not inherently enjoyable, nor do they result in the completion of inherently useful
tasks. Their function is to prevent some objectively unlikely event, often involving harm to or
caused by the patient, which he or she fears might otherwise occur.

Usually, this behaviour is recognized by the patient as pointless or ineffectual and repeated
attempts are made to resist. Anxiety is almost invariably present. If compulsive acts are
resisted the anxiety gets worse.

F42.0 Predominantly obsessional thoughts or ruminations


These may take the form of ideas, mental images, or impulses to act, which are nearly always
distressing to the subject. Sometimes the ideas are an indecisive, endless consideration of
alternatives, associated with an inability to make trivial but necessary decisions in day-to-day
living.

F42.1 Predominantly compulsive acts [obsessional rituals]


The majority of compulsive acts are concerned with cleaning (particularly hand washing),
repeated checking to ensure that a potentially dangerous situation has not been allowed to
develop, or orderliness and tidiness.

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F42.2 Mixed obsessional thoughts and acts
F42.8 Other obsessive-compulsive disorders
F42.9 Obsessive-compulsive disorder, unspecified

EPIDEMIOLOGY

The prevalence of OCD estimated in the general population are between 0.5 to 1
percent. About 10 percent of patient with neurotic disorder suffer from OCD and 1 percent
are among the psychiatric outpatient population. Minor obsessive compulsive symptoms may
be present in up to 17 percent of the population. Studies from United States of America
(USA) suggest that 2 to 3 percent of the population may suffer from it at sometime at their
lives.

The overall prevalence of OCD is equal in males and females, although the disorder
more commonly presents in males in childhood or adolescence and in females in their
twenties. Childhood-onset OCD is more common in males and more likely to be comorbid
with attention deficit hyperactivity disorder (ADHD) and Tourette disorder.

Two thirds of individuals have an age of onset in the early 20s, before 25s years, with
the mean age of about 22 years. It can even begin in childhood with peak age of onset of 10
to 14 years old. Those with checking rituals have earlier mean age of onset of 18 years,
compared to other groups with mean age of 27 years. The course tends to be chronic with
exacerbation.

OCD appears to have a similar prevalence in different races and ethnicities, although
specific pathological preoccupations may vary with culture and religion.

PROGNOSIS

Obsessive compulsive disorder can now be effectively treated in up to 70% of cases.


The prognosis tends to be worse the more reasonable the preoccupation, for example
checking that the house is looked before leaving home has poorer prognosis than pointless
rituals such as walking between the cracks in the pavement.

Other than that the outcome is worse when individuals do not realize their obsessions
and or compulsions are not reality based. Although up to 25 percent of patient may refuse
cognitive behavioral therapy, those who complete it show a 50 to 80 percent reduction in
OCD symptoms after 12 to 20 sessions

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AETIOLOGY

o Genetic Factors

Twin studies have consistently found a significantly higher concordance rate for monozygotic
twins than for dizygotic twins. Family studies of these patients have shown that 35% of the
first degree relatives of obsessive-compulsive disorder patients are also affected with the
disorder.

o Biochemical Influences

A number of studies suggest that the neurotransmitter serotonin (5-HT) may be abnormal in
individuals with obsessive-compulsive disorder.

o Psychoanalytic Theory

The psychoanalytic concept (Freud) views patients with obsessive-compulsive disorder


(OCD) as having regressed to developmentally earlier stages of the infantile superego, whose
harsh exacting punitive characteristics now reappear as part of the psychopathology. Freud
also proposed that regression to the pre oedipal anal sadistic phase combined with the use of
specific ego defence mechanisms like isolation, undoing, displacement and reaction
formation, may lead to OCD.

o Behavior Theory

This theory explains obsessions as a conditioned stimulus to anxiety. Compulsions have been
described as learned behavior that decreases the anxiety associated with obsessions. This
decrease in anxiety positively reinforces the compulsive acts and they become stable learned
behavior. This theory is more useful for treatment purposes.

DYNAMICS OF OBSESSIVE COMPULSIVE DISORDER

34
TYPES OF OBSESSIVE COMPULSIVE DISORDER
The types of OCD are:
o Checking: This is a need to repeatedly check something for harm, leaks, damage, or
fire. Checking can include repeatedly monitoring taps, alarms, car doors, house lights,
or other appliances. It can also apply to "checking people." Some people with OCD
diagnose illnesses they feel that they and the people close to them might have. This
checking can occur hundreds of times and often for hours, regardless of any
commitments the individual may have.
o Contamination or mental contamination: This occurs when a person with OCD
feels a constant and overbearing need to wash and obsesses that objects they touch are
contaminated. The fear is that the individual or the object may become contaminated
or ill unless repeated cleaning takes place. It can lead excessive tooth brushing, over

35
cleaning certain rooms in the house, such as the bathroom or kitchen, and avoiding
large crowds for fear of contracting germs.
o Hoarding: This is the inability to throw away used or useless possessions.
o Rumination: Ruminating involves an extended and unfocused obsessive train of
thought that focuses on wide-ranging, broad, and often philosophical topics, such as
what happens after death or the beginning of the universe.
o Intrusive thoughts: These are often violent, horrific, obsessional thoughts that often
involve hurting a loved one violently or sexually. They are not produced out of choice
and can cause the person with OCD severe distress. Because of this distress, they are
unlikely to follow through on these thoughts.
o Symmetry and orderliness: A person with OCD may also obsess about objects being
lined up to avoid discomfort or harm. They may adjust the books on their shelf
repeatedly so that they are all straight and perfectly lined up, for example. While these
are not the only types of OCD, obsessions and compulsions will generally fall into
these categories.

CLINICAL FEATURES

Obsessional thoughts These are words, ideas and , beliefs that intrude forcibly into the
patient's mind. They are usually unpleasant and shocking to the patient and may be obscene
or blasphemous.

o Obsessional images : These are vividly imagined scenes, often of a violent or


disgusting kind involving abnormal sexual practices.
o Obsessional ruminations: These involve internal debates in which arguments for
and against even the simplest everyday actions are reviewed endlessly.
o Obsessional doubts: These may concern actions that may not have been completed
adequately. The obsession often implies some danger such as forgetting to turn off the
stove or not locking a door. It may be followed by a compulsive act such as the person
making multiple trips back into the house to check if the stove has been turned off.
Sometimes these may take the form of doubting the very fundamentals of beliefs,
such as, doubting the existence of God and so on.
o Obsessional impulses : These are urges to perform acts usually of a violent or
embarrassing kind, such as injuring a child, shouting in church etc.
o Obsessional rituals: These may include both mental activities such as counting
repeatedly in a special way or repeating a certain form of words, and repeated but
senseless behaviours such as washing hands 20 or more times a day. Sometimes such
compulsive acts may be preceded by obsessional thoughts; for example, repeated

36
hand washing may be preceded by thoughts of contamination. These patients usually
believe that the contamination is spread from object to object or person to person even
by slight contact and may literally rub the skin off their hands by excessive hand
washing.
DIAGNOSIS

OCD is classified in the Diagnostic and Statistical Manual of Mental Disorders,


Fourth Edition, Text Revision (DSM-IV-TR) as an anxiety disorder.[1 ]It is characterized by
distressing intrusive obsessive thoughts and/or repetitive compulsive actions (which may be
physical or mental acts) that are clinically significant. The specific DSM-IV-TR criteria for
OCD are as follows:

A. The individual expresses either obsessions or compulsions.


1. Obsessions as define by (1), (2), (3) and (4):

1. Recurrent and persistent thoughts, impulses, or images are experienced at


some time during the disturbance as intrusive and inappropriate and cause
marked anxiety and distress. Those with this disorder recognize the craziness
of these unwanted thoughts (such as fears of hurting their children) and would
not act on them, but the thoughts are very disturbing and difficult to tell others
about.
2. The thoughts, impulses, or images are not simply excessive worries about real-
life problems.
3. The person attempts to suppress or ignore such thoughts, impulses, or images
or to neutralize them with some other thought or action.
4. The person recognizes that the obsessional thoughts, impulses, or images are a
product of his/her own mind (not imposed from without, as in thought
insertion).

2. Compulsions are defined by the following 2 criteria:


1. The person performs repetitive behaviors (eg, hand washing, ordering,
checking) or mental acts (eg, praying, counting, repeating words silently) in
response to an obsession or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing distress or
preventing some dreaded event or situation; however, these behaviors or

37
mental acts either are not connected in a realistic way with what they are
meant to neutralize or prevent or they are clearly excessive.
B. At some point during the course of the disorder, the person recognizes that the
obsessions or compulsions are excessive or unreasonable. This does not apply to
children.
C. The obsessions or compulsions cause marked distress; are time consuming (take >1
h/d); or significantly interfere with the person's normal routine, occupational or
academic functioning, or usual social activities or relationships.
D. If another Axis I disorder is present, the content of the obsessions or compulsions is
not restricted to it, such as preoccupation with food and weight in the presence of an
eating disorder, hair pulling in the presence of trichotillomania, concern with
appearance in body dysmorphic disorder, preoccupation with drugs in substance use
disorder, preoccupation with having a serious illness in hypochondriasis,
preoccupation with sexual urges in paraphilia, or guilty ruminations in the presence of
major depressive disorder.
E. The disorder is not due to the direct physiologic effects of a substance or a general
medical condition.

Specify if : The additional "with poor insight" is made if, for most of the current episode,
the person does not recognize that the symptoms are excessive or unreasonable.

TREATMENT OF OBSESSIVE COMPULSIVE DISORDER

PSYCHOTHERAPY

38
There are two types of psychotherapy that can be done to OCD patient. The first one
is the psychoanalytic psychotherapy. This type of psychotherapy is used in certain patients
who are psychologically oriented especially those with anankastic personality. Secondly, is
the supportive psychotherapy which is an important adjunct to other modes of treatment.
Supportive psychotherapy is also needed by the family members.

BEHAVIOR AND COGNITIVE BEHAVIORAL THERAPY

Behavior modification is an effective mode of therapy with a success rate as high as


80% especially for the compulsive acts. It is customary these days to combine the cognitive
behavioral therapy with behavior therapy. This involves graded self exposure and self
imposed response prevention of ‘undoing’ of obsession through compulsions, and / or
cognitive therapy. The techniques that often used are thought stopping, response prevention,
systematic desensitization and modeling.

DRUG TREATMENTS

i. Benzodiazepines
For example alprazolam and clonazepam, but they have limited role in
controlling anxiety as adjuncts and should be used very sparingly.
ii. Antidepressant
Some patients may improve dramatically with specific serotonin reuptake
inhibitors (SSRI)
 Clomipramine (75-300mg/day), non specific serotonin reuptake
inhibitors (SRI), was the first drug used effectively in the treatment of
OCD. The response is better in the presence of depressive symptoms,
but many patients with pure OCD also improve substantially.
 Fluoxetine (20-80mg/day), is a good alternative to clomipramine and
often preferred these days for its better side effects profile.
 Fluvoxamine (50-200mg/day), marketed as specific anti-obsessional
SSRI drug, while paroxetine (20-40mg/day), and setraline (50-
200mg/day) are also effective in some patients.
iii. Antipsychotics
These are occasionally used in low doses in the treatment of severe, disabling
anxiety. Some example are haloperidol, risperidone, olanzepine, aripiprazole
and pimazole.

39
iv. Buspirone
Has also been used beneficially as adjuncts for augmentation of SSRI, in some
patient.
Electroconvulsive Therapy (ECT)

In the presence of severe depression with OCD, ECT may be needed. ECT is
particularly indicated when there is a risk of suicide and/or when there is a poor response to
the other modes of treatment. However ECT is not the treatment of first choice in OCD.

Psychosurgery

In severe, intractable, chronic and incapacitating cases, where all other treatments
have failed, streotactic site specific brain surgery has been reported to be successful. This has
included the used of radioactive yttrium implants and more recently, non invasive proton,
electron and X-ray techniques. Anterior cigulotomy, capsulotomy and limbic leucotomy have
also been found to be effective in 25-30 percent of such cases. All involve the separation of
the frontal cortex from deep limbic structures. Sadly, psychosurgery only available as a
treatment choice at a very few centers’ throughout the world.

NURSING CARE PLAN

NURSING ASSESSMENT

 Vital signs are monitored.


 On MSE, it is found that patient shows depressive and decreased psychomotor
activity.
 Nutritional status of patient is assessed.
 Low self esteem in patient
 Collection of detailed history.
 Personal hygiene is assessed.

NURSING DIAGNOSIS

 Ineffective individual coping related to underdeveloped ego, punitive superego,


avoidance learning, possible biochemical changes, evidenced by ritualistic behavior
or obsessive thoughts.
 Altered role performance related to the need to perform rituals, evidenced by inability
to fulfill usual patterns of responsibility.

40
 Chronic low self esteem related to lack of positive feedback evidenced by inability to
tolerate being alone.

Short Term Goals:-

 To improve coping mechanisms of patient .


 To enhance role performance in family .
 To promote coping skills.
 To promote the self esteem.
 To make patient self dependent.

Long Term Goals:-

 To rehabilitate the patient.


 To prevent further complications.
 To assist the patient in early recovery.

41
DIAGNOSIS EXPECTED PLANNING IMPLEMENTATION RATIONALE EVALUATION
OUTCOME
Ineffective Patient will (a) Work with (a) Patient is 1) Recognition is the Client has
individual coping demonstrate patient to encouraged to first step in teaching started coping
related to ability to cope determine types of determine types of the patient to with the
underdeveloped
effectively situations that situations that increase interrupt escalating ritualistic
ego, punitive
without increase anxiety anxiety and result in anxiety. Sudden and behaviors and
superego,
avoidance
resorting to and result in ritualistic behaviors. complete elimination trying to control
learning, possible obsessive ritualistic (b) Patient is of all avenues for obsessions.
biochemical compulsive behaviors. encouraged for dependency would
changes, behaviors. (b) Initially meet independence and give create intense anxiety
evidenced by the patient's positive reinforcement on the part of the
ritualistic dependency for independent patient.
behavior or needs. Encourage behaviors. 2) Positive
obsessive independence and (c) patient is allowed reinforcement
thoughts. give positive plenty of time for enhances self-esteem
reinforcement for rituals. and encourages
independent (d) Supporting repetition of desired
behaviors. patient's efforts to behaviors.
(c) In the explore the meaning 3) Denying patient
beginning of and purpose of the this activity may
treatment, allow behavior. precipitate panic
plenty of time for (e) Providing structured anxiety.
rituals. Do not be schedule of activities Patient may be
judgmental or for patient, including unaware of the
verbalize adequate time for relationship between
disapproval of the completion of rituals. emotional problems

42
behavior. (f) Limit is set to time and compulsive
(d) Support allotted for ritualistic behaviors.
patient's efforts to behavior as patient 4) Recognition is
explore the becomes more involved important before
meaning and in unit activities. change can occur.
purpose of the (g) Positive Structure provides a
behavior. reinforcement for non feeling of security for
(e) Provide ritualistic behaviors is the anxious patient.
structured given 5) Anxiety is
schedule of (h) Patient is minimized when
activities for encouraged to learn patient is able to
patient, including ways of interrupting replace ritualistic
adequate time for obsessive thoughts and behaviors with more
completion of ritualistic behavior with adaptive ones.
rituals. techniques such as 6) Positive
(f) Gradually thought stopping, reinforcement
begin to limit relaxation and exercise. encourages repetition
amount of time of desired behaviors.
allotted for These activities help
ritualistic behavior in interruption of
as patient obsessive thoughts.
becomes more
involved in unit
activities.
(g) Give positive
reinforcement for
non ritualistic

43
behaviors.
(h) Help patient
learn ways of
interrupting
obsessive thoughts
and ritualistic
behavior with
techniques such as
thought stopping,
relaxation and
exercise.

Altered role Patient will be a) Determine a) Determining patient's This is important Patient is able to
performance able to resume patient's previous previous role within the assessment data for resume role-

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related to the role-related role within the family and the extent to formulating an related
need to perform responsibilities. family and the which this role is altered appropriate plan of responsibilities in
rituals, evidenced extent to which this by the illness. Identify care. family .
by inability to role is altered by the roles of other family Identifying specific
fulfill usual illness. Identify members. stressors, as well as
patterns of roles of other b) Encouraging patient to adaptive and
responsibility. family members. discuss conflicts evident maladaptive responses
b) Encourage within the family system. within the system, is
patient to discuss Identify how patient and necessary before
conflicts evident other family members assistance can be
within the family have responded to this provided in an effort to
system. Identify conflict. facilitate change.
how patient and (c) Exploration of Planning and rehearsal
other family available options for of potential role
members have changes or adjustments transitions can reduce
responded to this in role is done. Practice anxiety.
conflict. through role play. Positive reinforcement
(c) Explore d) To Patient positive enhances self-esteem
available options reinforcement for ability and promotes repetition
for changes or to resume role of desired behaviors.
adjustments in role. responsibilities by
Practice through decreasing need for
role play. ritualistic behaviors is
d) Give patient lots given .
of positive
reinforcement for
ability to resume
role responsibilities
by decreasing need

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for ritualistic
behaviors.
Chronic low self Client will a) Assess the a) Client has very low a) Assessment Client’s self
esteem related demonstrate self self esteem. provides the esteem is
to lack of increased self concept of b) Psychological baseline data. enhanced . so
positive esteem and client. support is provided to b) It will enhance that she is able
feedback perception of b) Provide client. the self esteem to do her work
evidenced by himself as a psychologi c) Inaccuracies in self of client. by her own and
inability to worthwhile cal support perception are c) Client may not she don’t need
tolerate being person to client. discussed with client. see positive to depend on
alone. c) Discuss d) Client is motivated aspects of self others.
inaccuracie to enlist the that others see.
s in self weaknesses and d) It will help the
perception strengths client develop
with client. e) Positive feedback is internal self
d) Instruct the provided to client, worth.
client to when she has explored e) It will help the
prepare a her feelings. client to learn
list of new coping
weaknesses behaviour.
and
strengths.
e) Provide
positive
feedback to
client.

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DISCHARGE PLAN

Patient not yet discharged and receiving treatments.


HEALTH EDUCATION
1) PERSONAL HYGIENE:
 Patient is taught about importance of personal hygiene of patient.
 She is advised to perform her self care activities independently.
 She is asked to perform hygiene practices daily.
2) DIET:
 Patient is taught about the importance of balanced diet.
 She is taught about foods that are contraindicated during taking particular medications.
3) EXERCISES:
 She is taught perform active and passive exercises.
 She is asked to assist patient to carry out activities of daily life.
4) ENVIRONMENT:-
 Environment should be calm and safe for the patient.
 Attendant is asked to remove all the hazardous objects.
5) MEDICATIONS:-
 Patient is advised to take medication regularly.
 Patient is advised to inform immediately whenever any unusual symptoms appears.
 She is advised not to discontinue medicine by their own.
SUMMARY

I have taken the client with ' OBSESSIVE COMPULSIVE DISORDER ’ named Reeta rani for
my case study . The aim of the study is to demonstrate transfer of knowledge of cancer
esophagus pathophysiology, assessment, and treatment planning to case situation. I interacted
with the client and the family to understand the predisposing factors and causes of the disease .
The patient is 46 years old and has previous history of OCD about 20 years ago . The patient has
problems of washing hands frequently conflicts with the family , lack of personal hygiene . A
clear and logical case description ensuring essential elements of the history , current care and
outcome of the patient about OCD are discussed and provided .

RECAPTUALIZATION

Upon completion of the case study, the researcher is able in :

1. Demonstrating transfer of knowledge of OCD pathophysiology, assessment, and


treatment planning to carcinoma esophagus
2. Developing a multimodal treatment plan for a patient with OCD patients according to
their staging
3. Illustrating responsible therapy prescribing
4. Understanding complications of OCD

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Bibliography:
 Ahuja Niraj. A short Textbook of Psychiatry. 7th ed. Jaypee Brothers.
 Lalitha K. Mental Health and Psychiatric Nursing.1st ed. VMG Book House.
 Sadock BJ, sadock VA. Kaplan &Sadock’s Synopsis of psychiatry. 10th ed. Lippincott.
 Mary CT. Psychiatric Mental Health Nursing. 4th ed. F.A. Davis.

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