Obsessive compulsive disorder

Obsessive compulsive disorder (OCD) is characterized by unwanted, recurrent,

intrusive thoughts or images (obsessions), which the person tries to alleviate
through repetitive behaviors or mental acts (compulsions). The compulsions are
meant to reduce the anxiety or prevent some dreaded event from happening.
Obsessions and compulsions may be simple or complex and ritualized.
Compulsions include both overt behaviors, such as hand washing, and mental
acts, such as praying or counting. OCD may cause significant distress and may
severely impair occupational and social functioning. Compulsive behaviors can
also endanger health and safety. For example, severe dermatitis or a skin
infection may result from compulsive hand washing.
For most patients, the disorder takes a fluctuating course, with exacerbations
linked to stressful events. Many OCD sufferers also have major depressive
disorder, panic disorder, social phobia, specific phobia, eating disorders,
substance abuse, or personality disorders.
Pathophysiology
Genetic, biological, and psychological factors may be involved in OCD
development. OCD tends to run in families and biological evidence is also
strong. Magnetic resonance imaging and computed tomography scanning show
enlarged basal ganglia in some OCD patients. Positron-emission tomography
scans found increased glucose metabolism in a particular part of the basal
ganglia. Anatomic-physiologic disturbances in brain areas involved in learning or
acquiring and maintaining habits and skills may also be involved in OCD.
Freudian psychoanalysts view OCD as the result of conflict between the ego
and the id (the unconscious part of the psyche that gives rise to instinctual
impulses): Impulses that are repugnant to the ego are controlled by unconscious
defense mechanisms. Behaviorists, on the other hand, see OCD as a conditioned
response to anxiety-provoking events. In their view, linking anxiety with a
neutral object or event causes obsessional preoccupation.
Complications
Aggressive behavior toward the self or others
Depression
Skin breakdown or infection from obsessive
Assessment (only potential abnormalities listed)
NURSING HISTORY BY FUNCTIONAL HEALTH PATTERN
Health perception and management
Extreme concern about diet, germs, and disease
Concern about or evidence of inadequate attention to health care needs
Extreme concern about general health
Exaggerated worry about daily life circumstances
Worry about medication compliance, follow-up visits, and inability to follow
through
Fear of "going crazy"
Inability to control feelings
Numerous somatic complaints, with or without diagnostic validation
Overuse or underuse of health care system to ease anxiety symptoms
Nutrition and metabolism
Weight loss resulting from fear of contaminated food or ritualistic behaviors
that interfere with meal time and eating ability
Weight gain resulting from compulsive eating
Worry about eating behaviors, such as using food to calm or soothe self
Changes in appetite, including anorexia and binges
Elimination
Constipation resulting from fear of contacting excrement
Concern about gastrointestinal system disturbances, such as pain, flatulence,
diarrhea, nausea, constipation, vomiting, and intestinal bleeding
Frequent urination
Concern about increased sweating or cold and clammy skin
Activity and exercise
Concern about compulsive behavior interfering with personal, occupational,
scholastic, and social functioning
Restlessness or trembling
Concern about being easily fatigued
Difficulty in accomplishing normal daily activities
Concern about inability to participate in and enjoy leisure activities
Concern about limitations and restrictions of activity caused by disease or
condition
Withdrawn or apathetic behavior
Sleep and rest
Decreased sleep resulting from obsessive thoughts or impulses
Inability to relax because of constant activity resulting from an inability to
prevent intrusive obsessive thoughts or impulses
Concern about falling or staying asleep and nightmares
Feeling fatigued after sleep
Concern about use or abuse of sleep aids, such as alcohol, benzodiazepines, and
hypnotics
Cognition and perception
Concern about the disturbing nature of obsessions
Awareness of illogical thoughts and behavior and of the inability to control
them
Self-destructive or aggressive ideas or impulses
Difficulty concentrating
Difficulty understanding and reacting to external stimuli
Worry about inability to think clearly
Distorted perceptions
Self-perception and self-concept
Low self-esteem and feelings of powerlessness resulting from the inability to
control thoughts and behavior
Feelings of worthlessness secondary to feeling unclean
Concern about inability to meet expectations
Concern about being indecisive and dependent
Perception of self as being highly anxious
Perception of self as being incompetent
Concerns about body image
Roles and relationships
Disturbance in interpersonal relationships
Diminished ability to meet occupational, functional, interpersonal, or parental
expectations
Intense concern about relationships with family and friends
Rumination about engaging in social situations with friends, fellow employees,
or family
Concern about the lack of response to or support of lifestyle changes from
family and friends
 Concern about a distressful work situation
Concern about how community members and neighbors may respond to the
disease and associated behaviors
Sexuality and reproduction
Fear of intimate contact with others resulting from fear of contamination and
disease
Sexual dysfunction
Compulsive or ritualistic sexual activity, such as compulsive masturbation,
excessive fascination with pornography, or use of others as sex objects
Dissatisfaction with sexual relations
Difficulty with intimacy
Concern about involvement in high-risk sexual behavior, such as unprotected
sex or promiscuity
Concern about involvement with high-risk partners, including I.V. drug users,
homosexual or bisexual partners, and strangers
Coping and stress management
Feeling overwhelmed
Avoiding social situations
Concern about increasing frequency and duration of compulsive behaviors
Pervasive muscle tension
Constant irritability, feeling on edge or keyed up
Constant shakiness, trembling, or twitching
Concern about experiencing an exaggerated startle response (hypervigilance)
Denial of clearly manifest anxiety
Inability to identify those persons or measures that alleviate rather than
exacerbate the condition
Belief that significant lifestyle changes are contributing to feeling out of control
Values and beliefs
Fear of condemnation
Feelings of powerlessness, hopelessness, or unworthiness
Concern that the condition is punishment for sin or previous acts
Overreliance on or identification with religious themes associated with
ritualistic behavior
Desire to increase or decrease involvement in spirituality or religion
Concern about impaired ability to believe in anything or anyone
 Disbelief about present situation
PHYSICAL EXAMINATION
Mental status and behavior
Feeling keyed up or on edge
Inability to concentrate
Irritability
Blank mind
Integumentary
Skin irritation from constant washing
Respiratory
Increased respiratory rate
Shortness of breath
Smothering sensation
Choking sensation
Cardiovascular
Cold, clammy skin
Elevated blood pressure
Hot and cold flashes
Increased heart rate
Palpitations
Sweating
Tingling
Gastrointestinal
Dry mouth
Abdominal distress
Nausea
Vomiting
Diarrhea
Difficulty swallowing
Neurologic
Dilated pupils
Dizziness or faintness
Light-headedness
Paresthesia
Restlessness
Inability to fall asleep or to stay asleep
Musculoskeletal
Increased fatigue
Muscle aches, pains, or soreness
Muscle tension
Restlessness
Shakiness
Trembling
Twitching
Renal and urinary
Frequent urination

Nursing care plan

Nursing diagnosis Nursing priorities
Ineffective coping related to checking and Help the patient gradually decrease ritualistic
rechecking actions or other ritualistic behaviors behavior and learn alternative strategies for coping
with stress and anxiety.
Risk for impaired skin integrity related to ritualistic Help the patient maintain intact skin to prevent
behaviors involving cleaning, such as hand washing, infection.
scrubbing, teeth brushing, and showering
Interrupted family processes related to inability to Facilitate the family's participation in a therapy
express feelings and develop intimate relationships program.
Other potential nursing diagnoses: Anxiety related to underlying mental disorder and inability to express
feelings Impaired verbal communication related to psychiatric disturbance Deficient diversional activity
related to fear of going outside the home or other comfort settings Risk for caregiver role strain related to
severity of patient's illness and effect on daily activities and schedules

Ineffective coping related to checking and rechecking

actions or other ritualistic behaviors
EXPECTED OUTCOME
As the treatment progresses, the patient will demonstrate a steady replacement of
ritualistic behaviors with alternative coping strategies for anxiety and stress.
Suggested NOC Outcomes
Anxiety self-control; Coping; Impulse self-control
NURSING INTERVENTIONS
Intervention type Intervention Rationale
Independent Assess the degree of interference As the involvement level
with daily functions by increases, the patient typically has
determining how much time the less time to devote to normal daily
patient spends on compulsive functions. A patient exhibiting
behaviors. Involvement of 1 hour severe or extreme involvement is
or less a day on such behavior is unable to use adaptive
considered mild interference; 1 to problem-solving skills.
3 hours per day, moderate; 3 to 5
 hours per day, severe; and almost
constant involvement, extreme.
Independent As part of the structured care,
provide the patient with time for
rituals and compulsive behaviors
without focusing attention on
them. As the patient's anxiety
abates, gradually decrease the
time allowed for these behaviors.
Independent Encourage the patient to verbalize
feelings and to discuss the
maladaptive or disruptive nature
of the behavior.
Collaborative Have the patient collaborate with
team to develop the care plan and
set realistic goals and
expectations.
Collaborative Establish behavioral contracts in
which the patient agrees to refrain
from certain behaviors in
exchange for certain rewards.
(For example, if the patient
decreases the number of hand
washings after meals from 50 to
40 times, the patient is rewarded
with a predetermined
reinforcement.)
Independent Provide realistic, alternative
coping methods, such as social
interaction, occupational therapy,
diversionary activities, relaxation,
and self-help support groups.
Independent Respond positively when the
patient makes productive
behavioral adaptations to cope
with anxiety.
Independent Gradually begin to set limits on
the frequency and duration of
compulsive behaviors.
Independent Encourage the patient to talk
about the cause of and need for
the compulsive behavior. Also
encourage the patient to describe
feelings just before and during
such behavior.
Independent Collaborate with the patient to
develop a set of positive coping
cards to be kept for emergency
use.
Allowing time for the patient's
compulsive behaviors can
decrease anxiety, thereby
decreasing the need for rituals and
compulsions. Furthermore,
acknowledging the patient's
feelings and fears helps establish
a trusting nurse-patient
relationship.
A frank discussion about the
condition and feelings can help the
patient develop a more realistic
perspective about the behavior.
Such discussion also fosters trust
between the nurse and patient.
Such participation can increase
the patient's self-esteem and
sense of control while decreasing
anxiety and frustration.
Positive reinforcements for
nonritualistic behaviors enhance
the patient's self-esteem and
encourage the continuation of
those behaviors.
Success with new behaviors and
coping methods can increase self-
esteem, decrease feelings of
powerlessness, provide structure,
and reinforce behavioral change.
Self-help support groups provide
both support and the opportunity
for the patient to talk about fears.
Reinforcing the successful use of
new behaviors increases the
patient's self-esteem and feelings
of control.
Reducing the time allowed for
compulsive behaviors can give the
patient a sense that treatment is
progressing. Furthermore, limiting
such behaviors decreases the
potential for patient injury.
As the patient's understanding of
the behavior, its causes, and
personal feelings about it become
clearer, the patient will be better
able to choose more appropriate
adaptive behaviors.
The patient's ability to cope with
OCD symptoms during a crisis
may be enhanced with preset
messages that are written and
specific for the patient. This can
 assist patients in refocusing on
what they are able to do rather
than on the OCD symptoms and
feelings of inadequacy.
[Additional individualized
interventions]
Suggested NIC Interventions
Anxiety reduction; Coping enhancement; Counseling; Impulse control training;
Teaching: Individual

Risk for impaired skin integrity related to ritualistic

behaviors involving cleaning, such as hand washing,
scrubbing, teeth brushing, and showering
EXPECTED OUTCOME
As the treatment progresses, the patient will demonstrate evidence of intact,
uninfected skin.
Suggested NOC Outcomes
Infection severity; Risk control; Tissue integrity: Skin and mucous membranes
NURSING INTERVENTIONS
Intervention type Intervention Rationale
Independent Assess the patient's skin integrity Assessment is necessary to
and mucous membranes of the ensure that the patient's behaviors
mouth (if compulsion involves aren't compromising the
teeth brushing). integumentary system.
Independent Encourage the patient to use only Using a mild soap and skin cream
a mild soap and skin cream, or or mild toothpaste without
mild toothpaste without abrasive abrasive mouthwashes can
mouthwashes during ritualistic prevent or minimize trauma to the
behaviors involving cleaning. integumentary system until the
patient can alter the compulsive
behavior.
[Additional individualized
interventions]
Suggested NIC Interventions
Skin surveillance; Teaching: Individual

Interrupted family processes related to inability to

express feelings and develop intimate relationships
EXPECTED OUTCOME
As the treatment progresses, the patient and family will report understanding of
the illness and corresponding treatment.
Suggested NOC Outcomes
Family coping; Family functioning; Family support during treatment; Social
interaction skills
NURSING INTERVENTIONS
Intervention type Intervention
Independent Collaborate with family members
to define and clarify their
relationships with one another.
Independent Help family members to identify
their feelings and to understand
the importance of sharing those
feelings with each other.
Independent Teach family members
assertiveness techniques, and
rehearse these techniques with
them.
Independent Teach the patient and family
about obsessive-compulsive
behavior and ways the family can
assist the patient, such as through
use of relaxation and behavioral
modification.
Collaborative Instruct the patient and family
about psychopharmacologic
interventions utilized to treat
individuals with OCD.
[Additional individualized
interventions]
Suggested NIC Interventions
Assertiveness training; Family integrity promotion; Family therapy; Teaching:
Disease process; Teaching: Prescribed medication
Teaching checklist
Recognition of obsessive-compulsive symptoms
Use of alternative coping methods
Methods to reduce intrusive thoughts
Ways to increase social skills within and outside the family unit
Location and services of aftercare options
Measures to maintain patient's skin integrity
Medication use, dosage, administration schedule, and possible adverse effects
Rationale
Making the patient and family
more aware of how families
function can enable them to
continually evaluate and, if
necessary, redefine their
relationships.
Families that are aware of and
able to openly exchange emotions
function more positively. Clearly
expressing and communicating
feelings also enhances family
functioning.
Family members need to assume
responsibility for their own
thoughts, feelings, and actions
rather than blame others.
Adequate information about OCD
enables the family to better
understand the patient's condition
and behavior. By reinforcing
patient relaxation, using
behavioral contracts, helping the
patient recognize anxious
behavior, and praising appropriate
coping strategies, family members
can enhance the patient's
self-esteem and feelings of
control.
Knowledge of medication usage,
effects, dosage, administration ,
interactions, and adverse effects
enhances safe use.
 Communication skills to effect improvements in family relationships
Contact information for emergency services in case of deterioration or suicidal
or homicidal impulses