Care of the Patient with Obsessive-Compulsive Disorder

People have regular routines and rituals that are a part of everyday life. People get up, brush their teeth, comb their hair, and get dressed every day. It does not bother them if they get rushed and do not have time to brush their teeth. For a person with obsessive-compulsive disorder (OCD), who has strict morning rituals, being rushed so that they do not have time to brush their teeth one morning upsets them, or they may not be able to skip brushing their teeth no matter how urgently they need to leave.

People with OCD have rituals and routines that do not have a purpose and can be harmful. People with OCD have uncontrollable thoughts called obsessions.These obsessions cause the person to have behaviors they repeat called compulsions (Staff, 2024). Obsessive thoughts are unwanted and uncontrollable. Worries and concerns are called anxiety.

Many people with OCD live everyday lives. Some have changed their way of life. These changes are modifications. Modifications let the person remain independent and functional. Compulsive acts are very time-consuming. If it is very severe, the person may be unable to work or care for themselves.

Common obsessions are germs, dirt, fear of making mistakes, religion, harming others, or sexual thoughts. The compulsions may be cleaning, handwashing, checking and rechecking tasks, counting, arranging and rearranging things, or repeating words. OCD can interfere with relationships and everyday activities. A person with OCD may also have other mental health problems like anxiety or mood disorders.

Most people with OCD are aware that their obsession and compulsions do not make sense, but they cannot stop. Sometimes, the person is frustrated or embarrassed about their compulsive acts (OCD: A Fact Sheet, 2024).

For example, Mrs. K has a strict routine and becomes upset when it is interrupted or blocked. She walks the same path every day to meals and activities. One day, on her way to breakfast, the hall was closed due to a water leak. To get to breakfast, Mrs. K had to go down another hall. She was so upset that she could not go. Instead, she walked back to her room and paced the rest of the day. She knew her friends would miss her at breakfast. She knew people would discuss why she did not go down the other hall. Mrs. K. knew it was not reasonable to refuse to walk down the other hall. However, she could not do it. All of this adds to her anxiety.

The signs of OCD are different for different people. People obsess over different things. Compulsions may occur with everyday rituals for some people. Other people may only have a compulsion that occurs only in certain situations that do not happen often. Severe compulsions can take up so much time that a person cannot take care of themselves. Other compulsions may be so mild that most people do not notice. The signs may be there for a while and then go away for a while(OCD: A Fact Sheet, 2024). A compulsion may not be a behavior that you can see. It may be a rumination.

People occasionally spend a lot of time thinking about a problem to decide what to do. When that thinking takes too much time, happens too often, and is negative, it is a rumination. Rumination does not solve the problem. It does not relieve the person’s distress or make them feel better. The person just cannot stop thinking about it (Scott, 2022). People ruminate over things that are frustrating, threatening, or insulting. Rumination may be about past events, religion, philosophy, or self-worth. It makes the person appear distracted or preoccupied. Instead of doing something that needs to be done, the person sits there and thinks.

Approach the patient/residents with OCD with understanding and patience. Accept their anxiety, rituals, and compulsions without judgment. Encourage the patient/resident to discuss their anxiety or behavior if they want to. Allow patients/residents with OCD to act out their compulsion as long as it is safe. Never argue with them about their compulsion.

Follow the patient/resident’s care plan. Those with OCD need help to manage their obsession, compulsions, and anxiety. Socialization and group participation are important to keeping patients/residents active and functional. However, the patient/resident with OCD may not be able to participate. OCD patients/residents may have problems with relationships and have increased anxiety when other people interrupt their rituals. On the other hand, socialization may distract the patient/resident from thinking about their obsession.

The plan may include how to prevent things that trigger their obsession and compulsions. Triggers are those things that make the obsessions and compulsions start or get worse. The plan may include boundaries to prevent the patient/resident from being triggered. For example, if shaking hands triggers the patient/resident to start washing their hands for 20 minutes, the plan may reduce social situations where people shake hands. There may be a plan that includes moving them to an area that is quiet with fewer people if they become agitated.

Report changes in behaviors like you would for any patient/resident. Additionally, report aggressive or violent obsessions and compulsions—particularly thoughts of self-harm, harm to others, panic, or increasing agitation. Also, report if the patient/resident starts talking about hopelessness.

Things that need to be reported may be found in what the patient/resident says. Another way is to watch their behavior. Agitation is an emotional response of excitement or restlessness (Mulkey & Munro, 2021). Agitation is shown by restlessness, pacing, wringing their hands, a movement that is more abrupt or jerky, or shouting (Tucker et al., 2020). Agitation can turn into aggression quickly, so you need to report it quickly.

Aggression is showing readiness to attack or confront others. Sometimes, it is called hostility or violent attitudes or acts. So, you must respond to the patient/resident calmly and respectfully. If you show agitation or aggression toward the patient/resident, it will quickly become a bad situation (Tucker et al., 2020).

Mr. J has been assigned as one of your patients/residents today. In the report, you are told he has been acting oddly since being admitted yesterday. You are told he likes to count things and gets agitated when he is not allowed to finish counting. As you knock on the open door, you notice he has his finger in the air, moving it as though he is counting something. Mr. J does not respond. You notice he has not washed recently, his clothes are stained, and he has not eaten anything from his breakfast tray. You knock again and say, “Hello, Mr. J. My name is Mary, and I will be your CNA today. Can I get you something else to eat?” Mr. J stopped what he was doing and turned to you. Angrily, he yells, “No, get out now! Get out!” Mr. J picks up the cup of juice and throws it at you. What do you do?

First, check the environment and make sure that Mr. J is safe and not a danger to himself. Next, find the nurse and report your observations. You ask the nurse, “Should I have allowed Mr. J to continue counting? What if it took all day?” The nurse tells you that Mr. J suffers from OCD. She tells you that patience and communication are important when working with Mr. J.

You and the nurse discuss the plan of care for Mr. J. Upon your reminding the nurse that Mr. J needs to wash and get on some clean clothes, she suggests that you try giving Mr. J a washcloth if he will not move into the bathroom to wash. Ask him to wash his face with five strokes and his arms and legs with five strokes each. Since he threw something at you, it is a good idea to keep the tub of water away from him. You can rinse the washcloth when needed.

The first plan is to try some distraction. Since Mr. J likes to count, see if he will go to the common room where there are puzzle pieces for him to count. He may want to count the steps to the common room, and that is ok. Perhaps if he calms down, he can attend a group today where he can concentrate on something else.

You feel that this is a good plan and start working with Mr. J. You understand his disorder better and feel you can work with Mr. J to get him to the common room, where he can calm down and participate in the groups.

Patients/residents with OCD have obsessive thoughts and compulsions. They try to relieve obsessive thoughts by doing a compulsion act. Although the act may or may not temporarily relieve the obsessive thoughts, it is essential, as a caregiver, to understand and be patient/resident with the patient/resident. The patient/resident is aware of their obsessions and compulsions. They may be ashamed or frustrated. There is a care plan in place that may limit compulsions. Be sure to follow the plan and watch for agitation or harmful thoughts to report to the nurse.

• Mulkey, M., & Munro, C. (2021). Calming the agitated patient/resident: Providing strategies to support clinicians. Medsurg Nurs., 30(1), 9–13.
• OCD: A fact sheet. (2024). Department of Psychiatry, College of Medicine, University of Florida. Visit Source.
• Scott, E. (2022). What is rumination? How rumination differs from emotional processing. VeryWell Mind. Visit Source.
• Staff. (2024). Obsessive-Compulsive Disorder (OCD). Mayo Clinic. Visit Source.
• Tucker, J., Whitehead, L., Palamaro, P., Rosman, j, & Seaman, K. (2020). Recognition and management of agitation in acute mental health services: A qualitative evaluation of staff perceptions. BMC Nursing, p. 106. Visit Source.