CASE STUDY

OBSESSIVE-
COMPULSIV
DISORDER E

Jhuna Fherise S. Mangana, RN

 ASSESSMENT
 NAME : F.S.M.
 AGE : 24
 GENDER : Male
 MARITAL STATUS : Single
 ADDRESS : Tagbilaran City
 RELIGION : Pentecostal
 EDUCATION : College Graduate
 OCCUPATION : Nurse
 PAST HEALTH HISTORY
 He had his first consultation with Dr. Costales, a psychiatrist last 2018 and was diagnosed of
having OCD.
 “It all started when I got my first job after passing the board exam as a professional nurse. I felt
my heart was pounding loudly (palpitations)and I felt that I was catching my breath during one of
my duty days. Maybe because it was my first job, I was still adjusting myself that I’m not anymore
a nursing student.”
 “I had episodes of insomnia at home and would find myself wide awake early in the morning due
to palpitations and breathlessness, thus sought me for professional help.”
 “I also do my handwashing up to elbow for about 15 minutes. I was afraid that germs would try to
eat me.”
 “I was prescribed with a medication to help me calm down: (Xanor ½ tablet HS).”
 PAST HEALTH HISTORY
 Also, certain relaxation techniques were also advised.
 “I just took the prescribed medication for about 2 weeks then
I stopped taking them for I am feeling better”.
 “I resigned from my first job to take time for myself to totally
recover”.
 PRESENT HEALTH HISTORY
 CHIEF COMPLAINT – palpitation and breathlessness
 Just last August 2020, I decided to go back to work and then this happened:
 “sige ko ug palpitate, on and off”, as verbalized by client
 “mokalit rapod maglisod ko ug ginhawa”, as verbalized by client
 “If I do something, I feel like I should do it again, I do perform some activities for many
times.”
 “Doubtful ko usahay if sakto ba akong gipanghimo ug kung unsa akong future.”
 “I think that if people get to know about my condition they may mock at me so I keep myself
isolated at times.”
 “samot na karong tuiga na nay COVID sige rako ug panghunaw kay maconscious ko”.
 “mobalik pd usahay akong insomnia magabie pero akoa rang giampo sa Ginoo tanan”.
 PRESENT HEALTH HISTORY
 Client was apparently alright 1 year ago.
 Some family disturbance was also there due to his father’s second
marriage.
 He was feeling stressed in his work. He used to have palpitations and
breathlessness whenever he got stressed.
 He had excessive sweating during these kind of episodes.
 Later, he keeps himself away from his friends because he thinks that
they may mock at him.
 He starts suspecting in everything. He had repeated thoughts of
contamination of hands so he washes his hand.
 According to his friends and family members:
 He is checking everything for twice or more
 Sometimes he sits alone and he always become anxious without him
knowing.
 If we advice him, he always ask questions frequently related to that matter.
 They also see him sometimes walking like in square shape ( He stops at the
point of changing direction while walking then walk straight.)
 He has some particular position for particular work, if he don’t do that
work according to his position he became anxious.
 He thinks that if he write something in other papers his knowledge may go
away.
 MOOD
 Subjective:
N: Kumusta man ka?
C: Okay ra pero kulbaan ko usahay.
N: Nganong kulbaan mn ka?
C: Daghan kog gihunahuna labi na akong future kung mag-ingani raba ko.
 Objective:
 He is looking anxious.

AFFECT
Quality : Slightly Dysphoric
Fluctuation : Elevated
Range : Broad
Appropriateness : Appropriate
Congruency : Congruent
 THOUGHT

 Stream
N: How much nimo ka-love imong mama?
C: She is like my best friend, love nako siya kaayo.
 Form
N: Unsay imong ginabuhat kung mastress ka?
C: Kung mastress ko magpray ko pero nay times na magsige ug balik-balik sa akong mind ang
problema mao magpalpitate pd kog kalit.
 Content
N: Nganong magsigi man kag butang ug alcohol or magsige ug panghunaw?
C: Kay basin daghan nang kagaw ningtapot sa akong kamot, makatakod palang kosa uban akoy
makaingon masakit sila.
 INFERENCE OF THOUGHT
 Thought stream is normal, goal-directed, no thought block,
circumstantiality, flight of ideas o stereotyping.
 Form is well-structured, understandable, no loosening of
association is seen.
 Client gets obsessions about his hygiene and checks everything and
compulsions about performing some acts in even times.
 Content: Ideas of persecution are present.
 PERCEPTION
 Hallucinations:
N: Naay uban taw makadungog ug lain-lain na tingog and visualize things kung mag-inusara
unya siya ray makadungog. Nakasuway naka ana?
C: Wala ko kasuway ug ingana.
 Illusion:
N: Kanang nakasuway napod ka anang pagkita nimo sa usa ka butang lahi sa pagtanaw sa
uban? Parhas anang moingon nga nakakita ug has pero pisi ra diay to.
C: Wala pod ko kasuway pa ana .
 Derealization:
N: Nakafeel or nakasuway pod ka anang parehas sa salida na imohang soul ninggawas sa
imong lawas unya ikaw gatan.aw la sa lawas nimo gahigda?
C: hahaha, wala papod uy!
 HEAD TO TOE ASSESSMENT
GENERAL CONDITION
STATE OF AWARENESS Interrupted sleep, consciously answers when
asked. Fully oriented to time, place and person
SIGNS OF DISTRESS, PAIN AND Looks anxious while sharing his story and
ANXIETY signs of sleepiness noted
GAIT AND POSTURE Able to stand freely without the use of any
assistive device.
BODY MOVEMENT Always checking the time; has a mannerism of
cracking his knuckles
HYGIENE/ GROOMING / ODOR Performs hygienic task independently. Always
putting an alcohol on his hands.
SPEECH Verbally responsive.
MOOD AND AFFECT Slightly dysphoric.
PERCEPTION Absence of hallucination and illusion
GORDON’S FUNCTIONAL HEALTH ASSESSMENT
 HEALTH PERCEPTION-HEALTH
MANAGEMENT
 Perceives his present condition (OCD) as a temporary feeling
whenever he feels stressed or anxious at times. He thought
that he is already well and has been fully recovered since it
was 2 years ago when he had last experienced these kind of
symptoms.
 For now, he is doing those relaxation techniques that were
advised by the psychiatrist and he considers taking a
medication the least option available when he will not be
relieved by those relaxation or diversional activities first.
 NUTRITIONAL- METABOLIC PATTERN
 He eats 3 times a day with snacks in between whenever he feels hungry. He eats
more than the usual amount of food whenever he feels stressed.
 He follows what the doctor advised him to avoid eating foods with high- sugar
content including chocolates and drinking caffeinated drinks such as colas
including teas.
 He has no known food allergies.

ELIMINATION PATTERN

 Bowel movement- at least once a day

 Urinates at least 5 times a day more or less
 ACTIVITY- EXERCISE PATTERN
 Gets to exercise at least twice a week if he doesn’t feels lazy at times.
 He is good at table tennis and he plays at least once a week , mostly during
weekends.
 Most of his vacant time is spent at home just doing anything that he likes to
do; preferably watching movies on Netflix and playing online games.
 He drives a motorcycle but sometimes he preferred not to as to be safe
whenever he encounters palpitations and shortness of breath
 “I also do my handwashing up to elbow for about 15 minutes. I was afraid
that germs would try to eat me”.

SEXUALITY- REPRODUCTION
 He claims that he is not sexually active.
 SLEEP- REST PATTERN
 He admits having difficulty sleeping at night and sleep is being interrupted
when palpitation attacks during sleep.
 Most days, he doesn’t get to sleep straight for 8 hours , approximately just 5
hours a day.
 Listening to music while lying down helps him gets to sleep.
 Keeps on yawning while talking.

SENSORY- PERCEPTUAL PATTERN

 He is coherent and is oriented to date and time.
 He is not using any assistive devices such as eyeglasses or hearing aid.
 COGNITIVE PATTERN
 He is coherent and is oriented to place, date and time.
 He can recall what he was doing for the past days and even week.
 He understands what the psychiatrist told him before if he feels the same way again.
 He consults others before making a permanent decision.

ROLE- RELATIONSHIP PATTERN

 He is the 3rd in rank along with his siblings in the family.
 An older brother to his 2 younger brothers and a younger brother to his 2 older sisters.
 He is still dependent to his parents since he has no stable job yet.
 At his present job, he does his responsibilities as a nurse but for the fact that he is still
adjusting he asks his senior nurse first before doing any procedure.
 SELF- PERCEPTION- SELF- CONCEPT
 Perceives self on a positive side but sometimes he gets stressed when he is pressured at
work. He stated that he is confident in himself as a nurse but there are times that he gets
to be doubtful if he is doing the right thing because he is starting all-over again.

COPING – STRESS TOLERANCE

 Sometimes when he could not handle stress, he cries whenever he faces some big
problems.
 He also talks to some of his close friends in church whenever he has a problem and
seldom use certain diversional activities such as watching movies and eating.
 He prays to God specially when he could not understand what he is feeling.
 VALUE- BELIEF PATTERN
 He is a Pentecostal. He attends Sunday church services regularly and
has a strong faith in God.
 He believes in only one God and that everything happens for a reason.
 “We are only living in a temporary world full of sufferings and
challenges.”
GENOGRAM
 DM HPN
CCC
HPN CCC Alzheimer’s Disease

HPN

Heart Disease/ Postpartum Depression

DM

BLUE
Asthma CLIENT BABY
 OBSESSIVE- COMPULSIVE DISORDER
 Represented by a diverse group of symptoms that include intrusive thoughts,
rituals, preoccupations, and compulsions.

 these recurrent obsessions or compulsions cause severe distress to the person. The
obsessions or compulsions are time-consuming and interfere significantly with
the person’s normal routine, occupational functioning, usual social activities, or
relationships. A patient with OCD may have an obsession, a compulsion, or both.
 OCD TYPES AND SYMPTOMS

OCD comes in many forms, but most cases fall into at least one of four
general categories:
 Checking- such as locks, alarm systems, ovens, or light switches, or
thinking you have a medical condition like pregnancy  or schizophrenia.
 Contamination- a fear of things that might be dirty or a compulsion to
clean. Mental contamination involves feeling like you’ve been treated
like dirt.
 Symmetry and ordering- the need to have things lined up in a certain
way
 Ruminations and intrusive thoughts- an obsession with a line of
thought. Some of these thoughts might be violent or disturbing.
 Obsessions and Compulsions

Many people who have OCD know that their thoughts and habits don’t make sense. They
don’t do them because they enjoy them, but because they can’t quit. And if they stop, they feel so
bad that they start again.
Obsessive thoughts can include:
 Worries about yourself or other people getting hurt
 Constant awareness of blinking, breathing, or other body sensations
 Suspicion that a partner is unfaithful, with no reason to believe it
Compulsive habits can include:
 Doing tasks in a specific order every time or a certain “good” number of times
 Needing to count things, like steps or bottles
 Fear of touching doorknobs, using public toilets, or shaking hands
ANATOMY AND PHYSIOLOGY
 BRAIN (BASAL GANGLIA)

 A brain region commonly associated with OCD is the basal ganglia.

The basal ganglia is a collection of structures underneath the cortex,
the largest part of the brain. 
 a group of structures found deep within the cerebral hemispheres. The
structures generally included in the basal ganglia are the caudate,
putamen, and globus pallidus in the cerebrum, the substantia nigra in
the midbrain, and the subthalamic nucleus in the diencephalon.
 best-known for their role in movement.
 Direct/Indirect Model
 when a movement is desired, a signal to initiate the movement is sent from the cortex to the basal
ganglia, typically arriving at the caudate or putamen (which are referred to collectively as the
striatum). Then, the signal follows a circuit in the basal ganglia known as the direct pathway, which
leads to the silencing of neurons in the globus pallidus and substantia nigra. This frees the thalamus
from the inhibitory effects of the basal ganglia and allows movement to occur.

 Indirect pathway- a circuit within the basal ganglia involves the subthalamic nucleus and leads to the
increased suppression of unwanted movements. It is thought that a balance between activity in these
two pathways may facilitate smooth movement.
 The basal ganglia, however, are also thought to have roles in habitual behavior, emotion, and
cognition. Thus, in addition to movement disorders, the basal ganglia are also being investigated in
attempts to understand disorders like Tourette's syndrome, schizophrenia, and obsessive-compulsive
disorder.
 ETIOLOGICAL FACTOR
 NEUROTRANSMITTERS
Serotonergic System
dysregulation of serotonin is involved in the symptom formation of obsessions
and compulsions in the disorder.
 NEUROIMMUNOLOGY
some studies show that there’s a positive link between streptococcal infection and
OCD. Group A hemolytic streptococcal infection can cause rheumatic fever, and 10-
30% of the patients develop Sydenham’s chorea and show obsessive-compulsive
symptoms.
 GENETICS
 TREATMENT

 COGNITIVE- BEHAVIORAL THERAPY

 PHARMACOTHERAPY
 PSYCHOSURGERY
 DEEP BRAIN STIMULATION
 COGNITIVE- BEHAVIORAL THERAPY

 Goals: promotion of self-awareness and emotional intelligence by teaching clients to “read” their
emotions and distinguish healthy from unhealthy feelings. Helping clients understand how
distorted perceptions and thoughts contribute to painful feelings.

 Most effective type of CBT:  Exposure and Response Prevention (ERP)

SALT technique:
 S-top and focus on what is happening.
 A-sk the OCD what it is trying to do for you right now.
 L-isten to what it’s trying to do for you (such as trying to make you feel safe or in control).
 T-hink of three ways you could feel safer or more in control outside of the OCD, and write them
down.
 PHARMACOTHERAPY
 SSRI’S (Selective Serotonin Reuptake Inhibitor)
-- antidepressants
ex: Clomipramine- inhibits the reuptake of serotonin and norepinephrine

 Sodium Valproate
 antipsychotics

PSYCHOSURGERY
DEEP BRAIN STIMULATION
 NURSING MANAGEMENT
 How Should Nurses Act Around OCD Patients?
1)    Try to keep them at low stress levels, especially at the start of OCD treatment.
2)    Make sure that you set rigid rules for the patient's behavior and see to it that they are
enforced consistently.
3)    Encourage them to comply with behavior therapies and medication.
4)    While it is a common instinct of OCD patients to seek for reassurance so as to reduce
anxiety, do not allow them to indulge this habit.
5)    Try to avoid comparing them with others, with or without OCD, as those with an
OCD may already suffer from a low self-esteem.
6)    Be encouraging and supportive, and help the patient set reachable goals in dealing
with OCD.
NURSING CARE
PLAN
 NURSING EXPECTED
ASSESSMENT PLANNING INTERVENTION RATIONALE
DIAGNOSIS OUTCOME
Subjective Cues: Anxiety related to After 2 days of 1. Establish relationship Anything about which Goal met. After 2 days of
 “I also do my unconscious conflict interaction with the through use of empathy, the client feels anxious interaction with the
handwashing up to about essential values client, he will be able to warmth, and respect. will serve to increase the client, he was able to
elbow for about 15 and goals of life as verbalize understanding ritualistic behaviors. verbalize understanding
minutes. I was afraid evidenced by repetitive of significance of 2. Demonstrate interest of significance of
that germs would try action (handwashing and ritualistic behaviors and in client as a person -Establishing trust ritualistic behaviors and
to eat me.” checking) and recurring relationship to anxiety. through use of attending provides support and relationship to anxiety.
thoughts (germs). He will also be able to behaviors. communicates that the Also client was able to
 “Doubtful ko usahay
cope effectively with   nurse accepts the client demonstrate ability to
if sakto ba akong stressful situations.   as a person with the right cope effectively with
gipanghimo ug kung   to self-determination. stressful situations
unsa akong future.”     without resorting to
3. Acknowledge -Lack of attention to obsessive thoughts or
Objective Cues: behavior without ritualistic behaviors can compulsive behaviors.
 Worried facial focusing on it. Verbalize diminish them. As
expression empathy toward client’s anxiety is reduced, the
 Noticeable dark experience need for behaviors is reduced.
circles under the rather than disapproval Reflecting the client’s
eyes or criticism. feelings may reduce the
 Always putting   intensity of the ritualistic
alcohol while behavior.
interviewing  
4. Use a relaxed manner -Any attempts to
  with the decrease stress will help
the client to
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EXPECTED OUTCOME

client; keep the feel less anxious,

environment calm. which may reduce
the intensity of the
ritualistic
behaviors.

5. Assist client to Stress-management

learn stress techniques can be
management, (e.g. used, instead of
thought-stopping, ritualistic
relaxation behaviors, to break
exercises, habitual pattern.
imagery).

 
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EXPECTED OUTCOME

6. Identify what the -Planned activities

client perceive as allow the client less
relaxing (e.g. music, time for compulsive
time for warm bath), behavior, and distract
Engage in constructive him in a manner that
activities such as quiet allows creativity and
games that require positive feedback.
concentration, as well
as arts and crafts such
as needlework,
painting.
 
7. Encourage
participation in a
regular exercise
program. -Exercise therapy can
help relieve anxiety.
Exercise does not need
to be aerobic or
intensive to achieve the
desired effect.
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EXPECTED OUTCOME

8. Assist client to find -Encourages client to

ways to set limits on problem-solve ways
own behaviors. At the to limit own
same time allow behaviors while
adequate behaviors recognizing that
during the daily behaviors cannot be
routine for the stopped by others.
ritual/s.  
  -This exploration
  provides an
9. Encourage client to opportunity to begin
explore the meaning to understand the
and purpose of process and gain
behaviors; to describe control over the
the feelings when the obsessive-compulsive
behaviors occur, sequence.
intensify, or are
interrelated.
 ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EXPECTED OUTCOME

Subjective Cue: Disturbed sleeping After 2 days of 1. Determine patterns of -Each individual has Goal met. After 2 days of
“mobalik pd usahay pattern related to interaction with the sleep in the past in a different patterns of interaction with the
akong insomnia magabie anxiety as evidenced client, he will be able normal environment: sleep. It also provides a client, he was able to
pero akoa rang giampo amount, bedtime baseline data for verbalize adequate
sa Ginoo tanan”. by palpitations and to obtain adequate routines, depth, length, evaluating means to amount of sleep at least
noticeable dark amounts of sleep as positions, aids, and other improve the patient’s 7-8 hours of sleep.
Objective Cues: circles under the eyes evidenced by rested interfering factors. sleep.
 Keeps on yawning appearance,  
while talking verbalization of 2. Educate the patient on
 Noticeable dark feeling rested, and the proper food and fluid
circles under the improvement in sleep intake such as avoiding -Having full meals just
eyes heavy meals, alcohol, before bedtime may
 HR- 115 bpm pattern. caffeine, or smoking produce gastrointestinal
before bedtime. upset and hinder sleep
  onset. Coffee, tea,
chocolate, and colas
which contain caffeine
stimulate the nervous
system. This may
interfere with the
patient’s ability to relax
and fall asleep. Alcohol
produces drowsiness and
may facilitate the onset
of sleep but interferes
with REM sleep.
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION
3. Encourage daytime
physical activities but instruct
the client to avoid strenuous
activities before bedtime.
4. Instruct client to follow a
consistent daily schedule for
rest and sleep.
 
5. Introduce relaxing activities
such as warm bath, calm
music, reading a book, and
relaxation exercises before
bedtime.
6. Suggest an environment
conducive to rest or sleep.
RATIONALE EXPECTED OUTCOME
Stress may be reduced by
therapeutic activities and
may promote sleep.
However, strenuous activities
may lead to fatigue and may
cause insomnia.
-Consistent schedules
facilitate regulation of
circadian rhythm and
decrease the energy needed
for adaption to changes.
-these activities provide
relaxation and distraction to
prepare mind and body for
sleep.
- A lot of people sleep better
in cool, dark, quiet
environment.
 ASSESSMENT
Subjective Cues:
“Doubtful ko usahay if
sakto ba akong
gipanghimo ug kung
unsa akong future.”
“I think that if people get
to know about my
condition they may
mock at me so I keep
myself isolated at
times.”
Objective Cues:
 Worried facial
expression
 Sweating
 Palpitations
 breathlessness
NURSING DIAGNOSIS PLANNING INTERVENTION
Altered role performance After 2 days of 1.Determine client’s role
related to psychological interaction with the within family and extent to
which illness-related
stress as evidenced by client, he will be able to
thoughts and actions affect
client’s verbalization of identify certain stressors role relationships.
doubt and presence of and maintain role-
anxiety. related responsibilities. 2.Discuss client’s perception
of role, how obsessive-
compulsive behaviors affect
role, and whether perceptions
are realistic.
3.Identify conflicts that exist
within the family system and
specific relationships that are
affected.
Encourage family members
to begin to discuss identified
problem areas.
4. Encourage participation
by all family members’
problem-solving process and
plans for change.
RATIONALE EXPECTED OUTCOME
-Identify areas of concern Goal partially met. After
and provide accurate 2 days of interaction
information to formulate plan
with the client, he was
of care.
  able to identify certain
stressors but is still on
-Client may deny extent of the process of assuming
effect that behaviors have on his role-related
daily activities. responsibilities.
 
 
 
-Knowing what stressor as
well as what adaptive and
maladaptive responses are
occurring helps individuals
begin the process of positive
change.
- Likelihood of positive
change increases when
family system is involved in
resolution of situations
arising from client’s
ritualistic behaviors.
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EXPECTED OUTCOME

5. Provide positive -Enhances self-

reinforcement for esteem and
movement toward promotes repetition
resuming role desired behaviors.
responsibilities and
decreasing
ritualistic
behaviors.
 ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EXPECTED OUTCOME
Subjective Cues: Risk for impaired After 2 days of 1.Assess changes in skin -Repetitive behaviors, Goal met. After 2 days of
“I also do my skin/tissue integrity interaction with the or tissue. such as hand washing interaction with the
handwashing up to related to repetitive client, he will be able to   with detergents or client, he was able to
elbow for about 15 behaviors for cleansing identify risk factors and   cleaning with caustic identify risk factors and
minutes. I was afraid that such as hand washing. engage in behaviors or   substances can damage verbalize understanding
germs would try to eat techniques to prevent   the skin and underlying of the techniques to
me.” skin/tissue breakdown.   tissues. prevent skin/tissue
“If I do something, I feel     breakdown.
like I should do it again,    
I do perform some    
activities for many   -Helps to minimize
times.” 2.Encourage use of mild tissue trauma until other
“samot na karong tuiga soap and hand creams to forms of therapy reduce
na nay COVID sige rako decrease repetitive damaging behaviors.
ug panghunaw kay behaviors.  
maconscious ko”.    
   
     
Objective Cue:   -Protects skin and tissues
    in the presence of
 Always putting 3.Discuss measures constant hand washing
alcohol while client can take use of caustic
interviewing during/after cleaning substances.
behaviors.
OCD TESTIMONIALS
CASE STUDY

OBSESSIVE-
COMPULSIV
DISORDER E

Jhuna Fherise S. Mangana, RN