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S: Situation

The patient is a 42-year-old Hispanic female who presented to the mental health Emergency Room with exacerbated OCD symptoms. The patient’s daughter reports her mother has been engaging in ritualistic behaviors like compulsive hand washing, checking locked doors, and hoarding cleaning supplies. Her mother does not want to leave the house due to her fear of germs and the need to check and recheck things. She feels overwhelmed by persistent and intrusive thoughts.

B: Background

The patient has a history of obsessive-compulsive disorder (OCD). The patient has not been compliant with her prescribed medication. The patient reports feeling overwhelmed by persistent, intrusive thoughts that compel her to clean constantly to eliminate germs and repeatedly check for cleanliness. The patient’s daughter reported her mother's recent use of undiluted bleach on her hands, causing her skin damage.

A: Assessment

Upon physical examination, patients’ hands show red, raw, cracked, dry, skin damage. The patient is positive for intrusive thoughts and compulsions. The patient is at risk for self-injury behaviors. The last set of vitals

Vital signs:

Heart rate: 110 bpm

Blood pressure: 90/60 mmHg

Respiratory rate: 22 breaths/minute

Temperature: 37.5°C

Oxygen saturation: 97% on room air

R: Recommendation

Initiate psychiatric evaluation.

Implement cognitive-behavioral therapy with a focus on exposure and response prevention.

Provide skin care treatment to prevent infection and promote healing.

Monitor vital signs closely.

Educate the patient and family about OCD management.

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Electrolyte Imbalance and Dehydration:

Due to her vital signs, she has tachycardia and hypotension which could be signs of dehydration due to inadequate fluid intake due to her obsessive compulsive disorder

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The patient's compulsive hand washing with bleach has caused significant harm to her skin, resulting in damage that makes it more susceptible to infections.

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Impairment in daily functioning: The patient finds it difficult to leave her house due to her fear of germs and her need to double-check everything, which impacts her ability to work, interact with others, and perform daily activities.

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Fluid Replacement:

Encourage Fluid Intake if patient is able to

drink.

Administer isotonic IV Fuids as prescribed, such as Lactated Ringer’s or Normal Saline Solution.

Rationale: Electrolyte imbalances impair bodily functions so it is imperative to replace these electrolytes with fluids.

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Altered skin integrity:

Patient will cover damage parts on the skin with bandages and transparent covers. Patient will also use non skin degrading products to keep the site damage clean such as soap and water.

Rationale:

It is important to keep the damaged skin from bleach covered to prevent further damage to the skin and to reduce outside elements irritating or causing infection to the skin. Using a transparent cover will also allow the nurse to evaluate the sight for infection without removing it. Also it is important to clean the damaged skin with non skin degrading and non irritant products such as non irritant soap and water. Preventing infection is important to prevent permanent damage or even death.

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Implementation of Behavioral Strategies:

We will teach and implement behavioral strategies such as structured routines and scheduling of activities to help the patient manage anxiety and perform daily tasks.

Rationale: Behavioral strategies like exposure and response prevention (ERP) can help and also gradually desensitize the patient to triggers and reduce ritualistic behaviors, thereby improving daily functioning. (CBT) cognative behavioral therapy as well to help understand the patients rationalize and understand their thought process.

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I anticipate that the provider will order IV fluids to be pushed. This is due to the patient having tachycardia and hypotension. The patient may not have been intaking fluids appropriately due to their obsessive-compulsive disorder.

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Despite our best efforts, the patient has gone into shock due to their dehydration. We will need to transfer to a higher level of care.

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First, we would want to continuously monitor vital signs to ensure the patient responds to treatment and does not get worse. We can pass these vitals on to the next care team so they can know what actions to take.

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If needed, we would administer oxygen and airway support. If the patient is not getting enough oxygen, it can cause damage to their organs and make them sicker. We would continuously monitor respiratory status.

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We would closely monitor the patient's fluid status, including their input and output. This ensures that we are not causing fluid volume overload and that the patient is getting the correct amount of fluids.