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Published by chivels

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Published by: chivels on Feb 16, 2010
Copyright:Attribution Non-commercial


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PROBLEM:A 40- year-old woman with a history of multiple admissions isadmitted to the floor. Emma Rice was found wandering downtownincoherent and dishevelled. During the assessment interview,Emma is noted to have a flat affect and is withdrawn. Shereports not seeing her family for five years and cannot rememberwhen she last held a job. There is no history of hallucinatoryor delusional thought content in this recent occurrence. Thestaff knows Emma and knows that during past admissions, she hasresponded to the less expensive haloperidol. After admission,Emma says, “Let me go. Go on, onward, backward (pause) Emmahide, died.” When asked where she lives, Emma slowly responds,“Over there, somewhere, anywhere, nowhere.” Emma’s board andcare operator knows her well and has indicated that a bed isbeing held for Emma.DIAGNOSIS: SchizophreniaSchizophrenia affects thought processes and content,perception, emotion, behaviour and social functioning; however,it affects each individual differently. The degree of impairmentin both the acute or psychotic phase and the chronic or longterm phase varies greatly; thus, so do the needs of and thenursing interventions for each affected client. The nurse mustnot make assumptions about the client’s abilities or limitationsbased solely on the medical diagnosis of schizophrenia.ASSESSMENTS:Name: Emma RiceAge: 40 years old
Areas of strength:
No history of hallucinatory or delusional thought contentin the current occurrence
Responds in less expensive Haloperidol during pastadmissionsProblems of the patient/ signs and symptoms:
She cannot remember when she last held a job
Incoherent and dishevelled
Clang association
Flat affect and withdrawn
1.Risk for suicide
Nursing interventions:
Assess the client for previous suicideattempts by asking questions such as “ Haveyou ever attempted suicide?” or “ Have youever heard voices telling you to hurtyourself?”
Assess history of aggressive behaviour byasking questions such as “What do you dowhen you are angry, frustrated, upset, orscared?”
Note behaviours indicative of intent
Develop therapeutic nurse-clientrelationship. Promotes sense of trust
Encourage expression of feelings and maketime to listen to concerns
Maintain observations of client and checkenvironment for hazards that could be usedto commit suicide, to increase client safety.
2.Self-care Deficit 
Nursing interventions:
Identify degree of patient impairment or functionlevel
Develop plan of care appropriate to patient’ssituation
Assist with rehabilitation program
Determine age or developmental issues affectingability of individual to participate in own care
3. Ineffective health maintenance

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