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Risk for injury related to mental health illness as evidenced by ritualistic behaviors.

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Assessment and stabilization: Begin by conducting a thorough assessment of the patient's physical and mental health status, including assessing for any acute medical issues related to her compulsive behaviors, such as skin damage from excessive use of bleach. Stabilize any immediate medical concerns, such as providing wound care for her damaged skin. Simultaneously, assess her current mental state, including her level of distress and risk of harm to herself or others.

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A 42-year-old woman who presents to the mental health Emergency Room accompanied by her daughter for an exacerbation of her symptoms of obsessive-compulsive disorder (OCD). The patient engages in ritualistic behaviors, such as compulsive hand washing, checking locked doors, and hoarding cleaning supplies. She finds it difficult to leave her house due to her fear of germs and the need to check and recheck things. She feels overwhelmed by persistent and intrusive thoughts.

She spends several hours each day engaging in these behaviors and lately, has started to use undiluted bleach to clean her hands. The skin on her hands is red, raw, cracked, and dry.

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·         Heart rate: 110 bpm

·         Blood pressure: 90/60 mmHg

·         Respiratory rate: 22 breaths/minute

·         Temperature: 37.5°C

·         Oxygen saturation: 97% on room air

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Situation: A 42-year-old woman with a history of obsessive-compulsive disorder (OCD) is presenting to the mental health ED with exacerbated symptoms. She engages in ritualistic behaviors such as compulsive hand washing, checking locked doors, and hoarding cleaning supplies. Recently, she has been using undiluted bleach to clean her hands, resulting in red, raw, cracked, and dry skin.

Background: The patient has a longstanding history of OCD characterized by intrusive thoughts and compulsive behaviors. She struggles to leave her house due to fear of germs and spends several hours each day engaged in these behaviors, impacting her daily functioning.

Assessment: The patient is experiencing an exacerbation of her OCD symptoms, resulting in severe distress and functional impairment. Her compulsive behaviors are causing significant physical harm, as evidenced by the raw and damaged skin on her hands.

Recommendation:

1. Provide immediate medical attention for the patient's hand injuries, including wound care and assessment for infection.

2. Initiate psychiatric evaluation and treatment to address the exacerbation of OCD symptoms, including medication management and therapy.

3. Collaborate with the patient and her daughter to develop a comprehensive treatment plan that includes coping strategies, exposure therapy, and support resources.

4. Educate the patient and her daughter about the risks associated with using undiluted bleach and provide guidance on safe hygiene practices.

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Ineffective coping related to ritualistic behaviors as evidenced by compulsive hand washing, checking locked doors, and hoarding cleaning supplies.

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Anxiety related to unwanted thoughts as evidenced by extreme fear.

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Provide safety for the patient by removing dangerous objects and providing 1:1 supervision

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Encourage self-help techniques to reduce tension and fears.

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Administer SSRI’s as ordered by the provider.

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We anticipate for the provider to order an SSRI med like Setraline (Zoloft) to help decrease the exacerbations of OCD.

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Collaboration with the healthcare team: Collaborate with the interdisciplinary healthcare team, including psychiatrists, psychologists, social workers, and occupational therapists, to develop a comprehensive treatment plan tailored to the patient's needs. This may involve medication management for her OCD symptoms, psychotherapy, such as cognitive-behavioral therapy (CBT) or exposure and response prevention (ERP), and occupational therapy to address functional impairments related to her OCD symptoms. Ensure clear communication and coordination among team members to provide holistic care for the patient.

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1. Facilitate transition to a higher level of care: Based on the severity of her symptoms and her inability to manage them effectively in the current setting, facilitate the patient's transition to a higher level of care, such as an inpatient psychiatric facility or an intensive outpatient program specializing in the treatment of OCD. Coordinate with the patient's insurance provider and arrange for transportation to the appropriate facility. Provide the patient and her daughter with information and support regarding the transition process, including what to expect during her stay and how to stay connected with her treatment team.

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The patient started collecting cavi wipes and using them to clean her hands. Her physical status has deteriorated and she currently now has open wounds. The patient’s mental status has also deteriorated and she will need to be moved to a unit with a lower nurse-to-patient ratio, such as the ICU.