Identification data :

Name of the patient - Rajesh Sahu

Age / sex - 55yrs / male

Ward - psychiatric ward

D.O.A - 7 /6/2020

Diagnosis - O.C.D.

Address - Raipur

Brought by - brother

Legal history - no any legal history of the patient

Socio- economic data

Marital status – married

Occupation - farmer

Education - 12th

Religion - Hindu

Social - Moderate

Identification data of informant :

Name of the informant - Rakesh Sahu

Age/ sex - 52 yrs

Relationship with patient - brother

Reliability and adequency – information is reliable and adequate.

Chief complaints
Patient point of view :

 Mai har waqt guilty feel karta hu

 Mujhe doubt rehta hai ki maine kuch kaam adhure kiye hai , mai unko bar bar check karta
hu
 Mujhe dar lagta hai mai kahi kisi ki nukhsan na paucha du .

Relative point of view

 Repeadly doing same work for continuously 7 8 times. X 4 month

 Aggression in behaviour x 4 month
 Confused while taking x 4months

History of present illness

 Onset - insidious
 Progress . – deteriorating
 Course - fluctuating
 Precipitating factor - no
 No h/o head injury .
 h/o occasional substance ( alcohol ,cannabis , tobacco).

Past history ( health history )

 past medical history - patient has no history of thyrodism , HTN , diabetes mellitus
 past surgical history - patient had not undergone any surgery in the past .
 past psychiatric history - patient was not having any psychiatric illness , suddently
behaviours changes are occurring back few days

Family history :

 medical history - father having HTN

 surgical history - not significant
 psychiatric history - not significant
 size of family - small
 type of family - nuclear
 Family genome

Rajesh sahu rajini sahu

55 yrs

Reetu sahu 28 yrs

Family History

Sl. Family Age Education Occupatio Health Realtionship Age at Mode

No member n status with patient death of
death
01 Rajesh 55 yrs 12th Farmer Poor Self - -
sahu
02 Rajini 52yrs 10th House wife Good Wife - -
sahu
03 Reetu 28 yrs Pg Teacher Good daughter - -
sahu

Personal history –

1. INFANCY :
 Patient was born with normal vaginal delivery
 Normal development milestone
 Patient was breastfed by her mother

2. CHILDHOOD :
 behavior was good during childhood
 there were good relations with father, mother and friends .
 bed wetting was stopped after 4 yrs.

3. ADOLESENCE:
 Patient had good relations with the teacher and friends .
 Patient had interest in sport .

4. ADULTHOOD :
 Patient continued his study till 12th.
 The relationship become worsen at this stage with the society.
 No any illness in this phase.

5. SEXUAL / MARITAL HISTORY :

 Patient is married
 in back few months no relations:hip formed .

6. SOCIO ECONOMIC HISTORY :

* SELF : patient used to study well , did his job well , was optimist about life.

 SOCIAL RELATIONS : he has good relations with negihbour , family members and
relatives and had many friends .
 INTELLECTUAL ACTIVITY : he has average academic performances and completed
his gradution.
 MOOD : mood of the patient sometimes cheerful , confused.
 LEISURE TIE ACTIVTIES : patient likes to watch cricket ,and listening songs.
 HABIT : patient are well adjusted in family.

VITALS SIGN :

VITAL SIGN PATIENTS NORMAL REMARKS

VALUES VALUES
Temperature 98 f 98.6 Normal
Pulse 78 60 – 100 Normal
Respiration 24 b/min 16 -24 b/ min Normal
Bood pressure 110/60mmHG 120/80 Normal

LAB INVESTIGATIONS.:

SI LAB TESTS PATIENTS NORMAL REMARKS

NO VALUE VALUES
1. Urea 26gm/dl 10-40mg /dl Normal
2 Fasting blood 95mg/dl 60- 150 mg/dl Normal
sugar
3. Creatinine 0.9 0.6 – 1.0 mg /dl Normal
 4. SGOT 43 units 4 - 40 units Normal
5. SGPT 35 unit 4 – 40 units Normal

6. Serum 4.8 meq /L 3.5 -5.5 meq /L Normal.

potassium
7. Serum sodium 147.2 meq /L 135 – 148 meq /L Normal
8. Total protein 7.2 g/ dl 5.5 – 7.5 g/dl Normal
9 Albumin 5.3 g/dl 3.5 – 5.5 g/dl Normal
10 Globulin 3.1 g/dl 2.3 – 3.6 g/dl Normal
11 Bilirubin 0.7 mg /dl 0.2 -1.0 mg /dl Normal
12. Cholestoral 155 mg /dl 150-200 mg /dl Normal
13. HDL 20 mg / dl 30- 35 mg / dl Normal

Physical examination :

General appearances - adequately groomed , kept untidy

Consciousness - conscious

Height - 5’5

Weight - 60kg

Hygiene - maintained

Body build - moderate

Color complexion - fair

Skin : skin color is whitish . lesion is absent . no pigmentation on face

Hair : black hair , thin , no dandruff ,no alopecia .course body hairs.

Nails : short , rounded, without cracking , beds pale.

Eyes : vision is normal

Ears : auricles symmetric , no lesions and tenderness over tragus , no tenderness or

discharge .

Nose and sinuses : no nasal flaring , lesion , tenderness or discharge . mucosa pink or moist .

Mouth and Pharynx :

 Lips : pinkish color

  Gum color : pallor
 Tongue : clean and pallor in presence , taste buds are present
 Tonsils : normal
 Lymph nodes : normal

Neck : symmetric , no mass or sweeling , full range of motion of cervical

spine .thyroid isthmus is soft . jugular vein distension is absent . there is absence of enlargement
of lymph nodes and thyroids glands.

Thorax and lungs : asthemic built , breathing is quiet , unlabored , without use of
asscessory muscle , RR is 24 / min , regular . thorax is symmetric , no tenderness or masses felt.
Thorax expansion is equal . on auscultation , resonance sound is heard.

Abdomen : no striae , vascular bruits present , digestion is normal , bowel sound

is present in all quadrants.

Rectum : stool regularly passed and brown in color .

SYSTEMIC EXAMINATION :

 Cardiovascular system : murmur sound not present

- ECG : E.C.G. normal
- BLOOD PRESSURE : 110/60 mmHG
- S1 S2 interval : normal .

 Respiratory system
- Breathing pattern - normal
- Breathing rate - 24 breath / min
- Characteristic - regular
- Cough - absent .
- Hemoptysis - absent

 Gastro intestinal system

- Bowel sound - normal
- Bowel pattern - normal

 Genitourinary system
- Urination - normal
- Burning and micturition - absent
- Bladder distention - absent
- Perineal area - clean .
  Musculo skeleton system
- Muscle tone - reduced
- Muscle strength - reduced .

 Integumentary system :
- Skin color - pallor
- Moisture - warmth and dryness
- Lesion or brusing - absent
- Temperature of skin – 98 f.

MENTAL STATUS EXAMINATION

 General appearances and behaviour :

- Appearance – fair
- Facial expression - anxious
- Level of grooming - normal
- Level of cleanliness - inadequate
- Level of consciousness - drosy
- Mode of entry - came willingly
- Behavior - normal
- Co operativesness - less than so
- Eye to eye contact - improper
- Psychomotor activity - decreased
- Rapport - difficult
- Gesturing - normal
- Posturing - normal
- Other movements - normal
- Other catatonic phenomena - waxy flexibility
- Conversation and dissociative sign - possession state .
- Compulsive acts or rituals - absent
- Hallucinatory behavior - absent

 Speech
- Initiation - speaks when to speak
- Reaction - shortened
- Rate - normal
- Productivity - pressured
- Volume - high
- Tone - monotonous
 - Stream - circumstantial
- Coherence - incoherent
- Other - rhyming

 Mood and affect

- Predominant mood state - depressed
- Appropriateness - inappropriate

 Thoughts
- Stream - retated thinking
- Form ( flow thought disorder ) – circumstantiality
- Delusion - no
- Thought alienation phenomena - confused
- Obsessional compulsive phenomenon – present

 Perception
- Illusion - absent
- Hallucination - absent
- Jamais vu - absent

 Cognitive function ( neuropsychiatric assessment )

- Consciousness - conscious
- Orientation - oriented.

- Nurse - hii
- Patient - hello
- Nurse - smiling , how r u .,
- Patient - fine

a.nurse : Do you feel a need to confess of seek reassurance on something you said or
did.

Patent : never

b. nurse : Do you collect ‘useless’ objects , or inspect the trash before it get thrown out
to see if you missed something.
 Patient : often , I find myself bringing home seemingly useless material.

c. nurse : are you concerned about being contaminatedby germs , chemicals or

disease
patient : very often , I clean my household excessively

d. nurse : do you excessively worry about things likes fires, car accidents , or your
house getting flooded
patient : yes, I have no control over my thoughts.

e. nurse : do you examine your body for sign of illness .

patient often , I try to remember events in details or make mental lists to prevent
unpleasant consequences .

 Insight
- Insight - poor
Diagnostic formulation – obsessive compulsive disorder

PROCESS RECORDING :

Time - 30 min

Date - 17/6/2020

Places - interview room of male psychiatric ward.

Objectives - to

- Maintain rapport

- Obtain psychiatric history

- Make the patient ventilate feelings

- Improve communication skills.

Process recording :
 Nurse response Patient response Techniques Interference

Verbal Non Verbal Verbal Non Verbal

Hi,Good Smiling Good Looks up Focusing Patient looks

Morning ,Looking at Morning words, Voice anxious
Rajesh Sahu the patient Sister monotonous
Rajesh How Keeps eye I’m good Having smile Listening Have no
are you? contact on face interest

Had you Smiling Yes Confused Listening Little

breakfast. expression confused
what to
express
What are you Observing I’m Disturb Looking Focusing Patient
thinking for? from down looking sad
uncontrolled
thoughts
How are you Keeps eye Same Looking Listening Tangentially
feeling contact downward present

OBSESSIVE COMPULSIVE DISORDER

INTRODUCTION : OCD is an anxiety disorder that 1 – 3 %of the general population suffers
from . There is an equal distribution of males and females that suffers from obsessive
compulsive disorder .

DEFINITION
  OBESSIONS :
Obsession are recurrent and persistent thoughts , impulses or images that cause
distressing emotions such as anxiety or disgust . these intrusive thoughts cannot be settled
by logic or reasoning
- Typical obsession include excessive concern about contamination or harm , the
need for symmetry or exactness ,or for bidden sexual or religious thoughts .

 Compulsions :
Compulsions are repetitive behavior or mental acts that a persons feels driven to
performed in response to an obsession .the behaviorare aimed at preventing or reducing
distress or a feared situation
- Although the compulsion may bring some relief to the worry , the obsession returns
and the cycle .
- Some of the common compulsion include cleaning , repeating , checking and
arranging , mental compulsion etc.

DEFINITION OF OCD
Obessive – compulsive disorder is a common , chronic and long lasting disorder in
which a person has uncontrollable , reoccurring thoughts ( obsession ) and behavior
( compulsive ) that he or she feels the urge to repeat over and over

CAUSES OF THE DISORDER :

 Biological factors
- People with a first degree relative ( parents and sibling ) with OCD have a 5 times
greater risk of having the illness.
- Identical twins have more chances of developing OCD as compared to dizygotics
twins.
 Neuroanatomical factors
- There is evidence of abnormal brain structure and activity in patients with OCD .

- The abnormalities are found in the pathway linking the lobes ( responsible for
judgement ) with the basal ganglia ( which are part of the system frontal for
planning behavior ).
- Serotonin deficiency – OCD suffers have too little serotonin for their nerve cells to
communicate effectively .

 Psychoanalytical theory :
- Individual with OCD have weak ,under developed egos .
 - Clients with OCD are regressed to developmentally earlier stages of the infantile
superego , whose harsh , punitive characteristics , which now reappear as a part of
psychopathology .

 Behavior theory :
- This theory explains obsessions as a conditioned stimulus to anxiety.
- Compulsion have been described as learned behaviour that decrease the anxiety
associated with obsessions.
- This decrease in anxiety positively reinforces the compulsive acts and they become
stable learned behavior.

CLASSIFICATION OF OCD

F42 obsessive compulsive disorder

F42.0 predominantly obsessive thoughts or rumination
F42.1 predominately compulsive acts
F42.2 mixed obsessional thoughts and acts
F 42.8 other obsessive compulsive disorder
F42.9 obsessive compulsive disorder , unspecified.

CLINICAL FEATURES

IN BOOK IN PATIENT
1. Obessional thoughts : PRESENT
Words , ideas and beliefs that
intrude forcibly into the
patient’s mind. They are
usually unpleasant and
shocking to the patient and
may be obsence or
blasphemous.
2. Obsessional rumination : PRESENT
These involve internal debates
in which arguments for and
against even the simplest
everyday actions are revised
endlessly.
3. Obsessional image :
These are vividly imagined PRESENT
scenes , often of a violent or
disgusting kind involving
abnormal sexual practices.
 4. Obsessional impulses : these PRESENT
are urges to performs acts
,usually of a violent or
embrassing kind , such as
injuring a child , shouting in
chruch

PSYCHOPATHOLOGY
SYMPTOMS -

IN BOOK IN PATIENT
 Contamination symptoms : Present
Worries about germs , feelings of
disgust hand-washing and cleaning

 Unacceptable / tam-boo thoughts : Present

Ruminating , mental review ,
reassurance , checking

 Doubt and harm : Present

Worries about accidental harm ,
repeated checking for safety

 Symmetry and arranging : Absent

evening up, feeling of ‘just right ‘
touching / tapping , repeating

DIAGNOSTIC EVALUATION –

IN BOOK IN PATIENT
 MSE  MSE
 Psychiatric history  Psychiatric history
 Investigation  Investigation
 CT Scan  Blood test
 MRI
 Blood test rule out any deficiency or
excess
TREATMENT –

SL DRUG DOS ROUT ACTION SIDE EFFECT NURSING

N E E RESPONSIBILITY
O
1 FLUOXETIN 20 Oral It is an anti May lead to vivid  Arrange for
E mg depressant dreams , dizziness , lower or less
of the trouble sleeping frequent
selective doses in
serotonin elderly
reuptake patient and
inhibitor patient with
class .Is hepatic or
used to treat renal
depression , impairment
bulimia  Administer
condition drug in
,premenstru morning
al syndrome  Monitor the
patient for
responseto
therapy for
upto 4 wks
before
increasing
dose.

2 SERTRALIN 50 Oral It is the Increase the risk oh  Patient
E mg medicine hyponatremia and should
used for the impairement of monitored
treatment of cognitive / motor closely for
the major function . changes in
depressive behavior ,
disorder in clinical
adults. worsening
and sucidial
thinking
3 Citalopram 20 Oral Potentiates  Treatment Have monitoring for
mg serotonergic of E.C.G changes.
activity in depression ,
the cns by particularly Possible increased
inhibiting effective in bleeding with
neuronal major warfarin .
reuptake of depression .
serotonin ,
resulting in
 anti
depressant
effects with
little effect
on nor
epinephrine
or
dopamine
reuptake.

NURSING MANAGEMENT

 Assessment of history :
- Collection of physical , psychological and social data
- Know the impact of obsession and compulsion on physical functioning , mood self
esteem and normal coping ability.
- Identify defense mechanism use , thought content for suicide , ability to function ,
and social support system available.

 Assessment tool :

Several structured interview tool are used to diagnose the personality disorder.
The Minnesota multiphasic personality inventory ( mmpi ) is the best known
standardized test for evaluating personality.

 Nursing diagnosis

a. Severe anxiety related to obsessional thoughts and impulses as evidenced by

repetitive actions and decreased social functioning .

b. Ineffective individual coping related to under developed ego , punitive super ego ,
avoidances learning , possible biochemical changes as evidenced by realistic
behavior.

c. Altered role performance related to the need to perform rituals , as evidenced by

inability to fulfill usual patterns of responsibility.

d. Impaired verbal communication related to lack of interest.

 e. Social isolation related to lack of faith on others.

 Nursing goals and planning :

- Demonstrate ability to cope effectively with stressfull situation without resorting to

obsessive thoughts or compulsive behavior .
- Demonstrate ability to cope effectively without resorting to obsessive compulsive
behavior
- Provide a safe calm environment to decrease environmental stimuli .
- Teaching basic living kill promoting a responsible behavior.

 Nursing intervention

- Established relationship through use of empathy , warmth and respect

- Verbalize empathy towards clients experiences rather than disapproval or critisims .
- Work with patient to identify the situations that increases anxiety and result in
compulsive acts .
- Encouraging independences in patient and give positive reinforcement for
independent behavior.
- Determine patients previous role within family and the extent to which this role is
impaired by the illness.
- Encourage the patient to discuss conflicts evident within the family system. Identify
the response of the patient and family member.

 Nursing evaluation
- Identifies stressors and demonstrate normal heart rate , respiration , sleep pattern
and subjective feeling of anxiety.
- Demonstrate improved concentration and thoughts process through the improved
ability to focus , think and solve problems.
- Reports increased participations and enjoyments in family and community related
events.
- Reports going to work , keeps appointments.
- Uses coping strategies in situation that are anxiety provoking
- Does not injured self or others.
Assessment Nursing Goal Planning Implementation Rationale Evaluation
diagnosis

Subjective Social Short term To Provide a safe Client Uses coping

data : isolational goal: Encourage calm respond to strategies in
My patients related to the the patient environment to noises and situation
‘s brother avoidance To improve to discuss decrease crowding that are
complain behavior or communicatio conflicts environmental with anxiety
that ‘ his related to n with people. evident stimuli. agitation , provoking
brother is embrassessmen within the anxiety and
not getting t and shame Long term goal family Assess if the increased Patient will
socalize associated with : system. medication inability to seek out
with other symptoms. Help the Identify reached concentrate supportive
people ‘. patient to the therapeutic on out side social
identify response levels. events. contacts.
specific cause of the
and situations patient Structures Helps client Patient will
Objective that produces and family planned a brief to develop a use
data : anxiety that member. interaction and sense of appropriate
On inhibits social activities with safety in a social skills
observation interaction. the clients on non in
I found one by one threatening interactions.
that , patient basis. environment
involvement Patient will
towards the Client feels maintain an
grouping is safe and interaction
less. competent with
in a another
graduated client while
hierarch of doing an
interaction activity.
Assessment Nursing Goal Planning Implementation Rationale Evaluation
diagnosis

Risk of To Assess the Assessed the Improved the Patient

Subjective injury improve in level of family quality time anxiety levels
data : related to the coping coping members with family reduces .
My client said compulsive mechanism ability . current levels of members and
that he is behaviour and will be knowledge minimizes the
worrying able to Assist him about the isolations
about the learn new in realizing disease and
continuous adaptive that the education used Isolation
thought techniques compulsive to treat the minimize.
occuring in acts are disease . Developed
the mind time family skills .
something consuming Patient
hurting to Family needs Provided cognitive
others must to supportive thinking
To teach addressed to psychotherap increases .
new stabilized the y and also Thoughts of
Objective data adaptation family units cognitive hurting others
: skills in Meets family behavioural reduceds
On dealing with members therapy
observation I ritualistic needfor
found that , behaviour information . Coping
patient staying mechanism
isolated and Teach develops in
mild confused. various Provided safe patients.
relaxation zone where he
therapy to can get relaxed
relax and and feel better
reduced the
level of
anxiety