Bethlehem University

Faculty of Nursing and Health Science

Psychiatric Nursing

NURS 342

Psychiatric Case Study

Prepared by: moath zaiter.
Submitted to: Mr. Hussin Awawddah.

Spring 2021

Student name: moath zaiter .

Date:20/2/2021.
Date of admission : 16 /2/2021 . (‫ واحضره من خالل سيارة اسعاف‬, ‫) الذي احضر المريض الى المشفى اخاه‬.
Ward : acute ward ( ‫) قسم ادخال رجال‬.

1- Demographics / general information :

Patient’s initials: E.S.S.
Age : 43 years .
Gender : male .
Place of residence : Ramallah \ the village of Taybeh .
Number of children : no .
Marital status : Unmarried , and the patient did not enter into any love relationship .
Educational level: twelfth grade (‫)توجيهي‬. After twelfth grade , he took a course in
programming and accounting .
Occupation : he worked in the UAE in the field of accounting in banks. He worked for
nearly 10 years and then returned to Palestine.( ‫وقال المريض انه ال يوجد سبب للعودة اال ان المريض‬
‫) فضل ان يكمل حياته في الوطن ومع عائلته‬. , and when he returned to Palestine , he worked in the
profession of electricity and in scheduling accounts for his brother،s work .The patient
continued to work until symptoms of the disease began.
Socioeconomic status : the patient lives in Ramallah \ the village of Taybeh with two
brothers and a sister in one house , and the patient is not married , and the patient says that
his relationship with his brothers , sister, relatives and neighbors is good , and the patient
said that their financial condition is (‫)متوسط‬. The patient also likes to sit at home with the
family and does not like to interact a lot with people .
Alcohol use ( no).
Tobacco use (yes ). The patient smokes ten to fifteen cigarettes a day ,before entering the
hospital .
Caffeine use (yes) .the patient drinks tea and coffee .
Substance abuse ( no ).

2- Chief complaint ( patient،s problem or reason for current admission in patient،s own
words):
‫المريض بحكي سبب دخوله لمستشفى االمراض العقلية بحس بدخول الشياطيين الى جسدي وبسمع اصوات غريبة من‬
‫ الناس سرقوا عقلي وبعطوني‬, ‫انا بحكي عن الناس‬, ‫ ويقول المريض انا مش نفسي‬, ) ‫ هللا‬, ‫ بنات‬, ‫قبل الناس (شباب‬
 ‫ وكل شخص بحاول يتحكم‬, ‫ وبحكي المريض انه شبكوا جهاز في مخه وبحطوا شخص وبصير شخص اخر‬, ‫االفكار‬
‫ في وفي تصرفاتي وفي حكيي (كالمي ) ويقول المريض انه مسيحي وهو مسلم‬.

3- History of current illness (previous admissions / include current and previous

symptoms ) :
The patient says that he symptoms of the disease began to appear about three months ago ,
and he had never entered the hospital for any reason whatsoever , and these symptoms
affect the patient for the first time , and the appearance of these symptoms was not
accompanied by any event or any problem , and these symptoms began to hear strange ,
unnatural sounds .

4- Family history ( mental disorders , type and treatment if known ) :

Free.

5- Recent losses / stressors as reported / predisposing and precipitating factors :

Recent losses : the patient suffers from loss of life , the first of which is the death of his
mother at the age of eighteen , then his failure in the twelfth grade due to the death of his
mother , as well as the death of his father at the age of thirty , where his father died while
outside the country and did not see him .
Stressors as reported : the patient said that he faced many pressures in his life , including
economic pressures , as he says that their financial condition is moderates , but he suffers
from poverty because he is unable to marry and his inability to marry is social pressures and
also his travel outside the country due to the lack of work is considered economic and
political pressures due to the occupation .
Predisposing factors : there are several factors , including the death of his mother , the
death of his father , poverty , also the death of his father while he was outside the country ,
he failed in the twelfth grade , and being away from the family because of work .
Precipitating factors : several factors , including the persistence of poverty and the
patient،s inability to marry .
Note : the patient says that he has a twin son and their birth was normal , and his
childhood , school stage and adolescence were beautiful and he did not pass any problems , and his
mother and father were on good terms with each other, and his relationship with his brothers and
sister was good , and the parents did not differentiate between them , and he said that he did not
enter the hospital in his life for whatever reason he had friends throughout his life . the patient has a
calm personality .

6- Medical and surgical history :

Free .
7- General state of health , sleep and nutrition :
General state of health : male pt . 43 years old. the pt is in good health as he dos not
perform any previous operation, and the pt cooperates with the medical team , and the pt
has a calm personality , and the pt cooperates with me during the interview , the pt has a
healthy body and does not suffer from any physical disabilities , the pt was active . But the
pt suffers from delusion and hallucinations .
Sleep: the patient،s sleep pattern before the symptoms appeared , he slept once a day about
8 to 9 hours in the evening , and after the symptoms appeared , he slept a lot , as he used to
spend most of his time sleeping so that he did not hear those annoying sounds , but in the
hospital he slept according to the department system .
Nutrition: before and after the onset of symptoms , the pt was eating breakfast , lunch and
dinner at home , currently , the pt is in the hospital eating breakfast , lunch and dinner . the
most preferred meal for the pt is grape leaves .
8- Mental status exam (MSE) :
A- Appearance :

Manner of dress : The patient's clothes were clean and consistent in color .

Cleanliness : The patient does not care about hygiene . He told me that he had a week not

showering and also the patient’s feet were dirty.

Posture : The patient's gait was normal, as he did not suffer from any problems or any movement

disabilities.

Facial expressions : I asked the patient whether he was happy or not, and his answer was yes,

happy, and it became clear to me that he was happy through the features of his face.

Eye contact : The patient eye contact is good , this was clear to me through the interview.

Identifying features ( tattoos , marks , scars ) : patient has a scar in the shoulder because giving

vaccine . ( no tattoos and marks ).

Apparent age versus actual age : It seems to me from the patient’s appearance that his

appearance is younger than his age.

B- Speech: The patient's speech and voice in terms of volume, quality and speed were

normal, and the letter exits were sound, clear and natural and there were no problems.

Quality: The patient's quality of speech (normal ) has coherent , congruent , live ,

reliable. no atypical , no slurring , no stammer , no dispirited , no repetitive , no

spontaneous and no monotonous.

Quantity: The patient's quantity of speech (normal ) has adequate . No voluminous, no

scarce, no pressured.

Rate: The patient's rate of speech (normal) . No slow and rapid.

Volume: The patient's volume of speech (normal ) has audible . No loud and soft .

C- Motor activity : The patient's movement are normal and active , as he does not have

any movement problems. NO ( calm , hyperactive , psychomotor retardation ,

lethargic , tense , tics , restless , rigid , agitated grimaces , tremors , unusual gestures ,

catatonic , fidgeting , akathisia ) .

D- Interaction during interview: The patient was cooperated , relaxed, and interactive

with me during the interview. Pt has interested , relaxed , cooperative and friendly . pt

no uncomfortable , no bored , no hostile , no seductive , no guarded , no uncooperative ,

no irritable , no domineering , no submissive , no apathetic , no defensive , no

suspicious .

E- Mood ( patient,s subjective way of explaining emotion / feelings ) : The patient's

mood is good and the patient told me he was happy. Patient no Euthymic , no Don't

know , no Sad , no Fearful , no Hopeless , no Euphoric , no Anxious , no Angry , no

 Depressed, no Irritable, no Guilty , no Worried , no Tired , no Labile no Mixed

(anxious and depressed).

F- Affect (patiet،s display of emotion / feelings ) : There is a correlation between the

patient's inner feeling (mood), where he told me that he was happy, and it turned out

that he was happy through the features of the patient's face, where he appeared on his

face as happy. patient has appropriate and congruent with mood .Patient has no

constricted , no Inappropriate to thought content , no Blunted , no Flat , no Expansive ,

no Incongruent with mood.

G- Perceptions: patient has hallucinations : auditory and tactile . no has visual , gustatory

and olfactory hallucinations . pt no has illusions , no depersonalization , pt no has

derealization . auditory hallucinations ( ‫يسمع المريض اصوات مثل صوت هللا و صوت شب و صوت‬

‫) بنت‬. Tictile hallucinations ( ‫) احساس المريض بدخول الجن الى جسده‬.

H- Thought process : patient has normal thought process .But sometimes the patient

hesitate before answering the question . patient has no Circumstantial, no Flight of

ideas , no Looseness of assaciation , no Neologism, no Clanging , no Perseveration ,

noTangential , no Word salad , no Echolalia no Thought blocking.

I- Thought content : the patient has religous delusions , thought insertion , thought

withdrawal and control delusions . patient has no Somatic , no Grandiose , no

Paranoid , no Persecution , no Jealousy , no Erotomanic , no ideas of reference , no

magical thinking , no Nihilistic , no Thought broadcasting. Religious delusions (

‫) المريض بحكي انا مسيحي وهو مسلم‬. thought insertion ( ‫بحكي انه الناس زرعوا في جهاز واعطوا‬

‫) افكارهم‬. Thought withdrawal ( ‫ ) المريض بحكي انه الناس اخذوا افكاره‬. control delusion (

‫ ) المريض بحكي في حدا مسيطر على افكاره بس ما بعرف مين‬.

Obsessions / compulsions: ( no ) .

Phobias : ( no ) .
J- Risk assessment :

Suicidal ideation or intent: (describe past or present attempts or thoughts of self –

harm specific plans) : The patient never thought about suicide.

Homicidal ideation or intent: ( describe past or present acts or thoughts of hurting

anyone ):The patient never thought of homicidal or harming anyone.

K- Judgment (patient،s judgment based on hypothetical situations ) : patient has good

judgment . pt no has poor judgment . good judgment ( ‫قلت للمريض اذا اشتعلت نار في‬

L- ‫القسم الذي انت فيه في المشفى ماذا تفعل قال اهرب عن مكان الحريق واذا لم استطع الهروب احاول ان اطفا‬

‫) الحريق‬.

M- Insight ( patient،s understanding of the illness / treatment ) :

Patient has no insight ( .‫الن المريض يقول انا غير مريض وعقلي سليم وال حاجة الخذ الدواء مع انه يقول‬

‫( ( في نفس الوقت ان االفكار التي يسمعها غير طبيعية‬pt no good and poor insight ).

N- Cognition :

Level of consciousness : patient has alert , no confused , no sedated , no lethargic, and

no stuporous . ( ‫) كان المريض منتبه معي اثناء المقابلة‬.

Orientation : patient has orientation for person , place , and time .( ‫المريض قال اسمه واسمي‬

‫(وقال لي انه موجود في مشفى االمراض العقلية في بيت لحم وقال لي الوقت حاليا الصبح والساعة عشرة صباحا‬

Memory : patient has good memory .

Remote memory : intact ( ‫) قال لي المريض عن مرحلة الطفولة والمدرسة‬.

Recent memory : intact ( ‫) قال لي المريض ان اخاه هو الذي احضره الى المشفى‬.

Immediate : intact ( ‫) سالت المريض العصر ماذا كان فطورك في الصباح وذكر الفطور كامال‬.

Abstract thought : intact ( ‫قلت للمريض مثل عصفور في اليد وال عشرة عصافير على الشجرة قال لي‬

‫) المريض شغلة وحدة تكون معي احسن من عشرة اشياء او اكثر مش معي‬.

Level of concentration , attention and calculation ): yes . pt has good concentration ,

attention and calculation. ( ‫حيث كان المريض مننبه معي اثناء المقابلة ومركز ايضا حيث كنت عندما‬

25 ‫ ومن ناحية الحساب جيد حيث طلبت منه حل مسالة خمسة في خمسة كم قال‬, ‫)اساله عن شيئ يجيبني عنه‬.
I. IX- Differential Diagnosis/Impression (Psychiatric Dx./Mental Disorders):
Patient undifferentiated schizophrenia .
As manifested by the following MSE :
1- Control of delusions : ( thought insertion , thought withdrawal ,)
2- Religious delusions .
3- patient has hallucinations : auditory and tactile .

X- nursing care plan (3-4 nursing diagnosis and interventions ) :

Nursing Planning Interventions Rational Evaluation
diagnosis
1- Lack of short term goal 1- Encouraging 1- to maintain on going .
hygiene related Encouraging the patient to personal
to the patient to wash the legs, hygiene.
undifferentiated adhere to feet and face 2- to improve
schizophrenia hygiene, at the with soap and the
manifested by hospital . water before and psychological
feet dirty. after sleep. state and enjoy
2- Encouraging good health.
long term goal the patient to 3- So that the
Encouraging shower twice a patient stays
the patient to week. clean and smells
adhere to 3- Change beautiful.
hygiene clothes after 4- to keep the
at the home . showering. teeth clean and
4- Encouraging smell beautiful
the patient to and prevent
clean his teeth. them from
5- Encouraging decay.
the patient to 5- to maintain
wash hands with hygiene and
soap and water prevent disease
before and after transmission.
eating.
2- Lack of Short term goal 1- Provide 1- to educate the On going .
knowledge Educating the patient patient and
related to patient about knowledge about convince him of
undifferentiated the disease and the disease. his illness.
schizophrenia encouraging the 2- Encouraging 2- Enhancing the
manifested by patient to take the patient to patient's
the patient no medicine at the accept the confidence that
insight for hospital . disease by he will
disease and instilling hope overcome the
treatment. Long term goal and optimism in disease and
The patient's the patient. return to his
adaptation to 3- Educating the normal life.
the disease and patient about the 3- to improve
the obligation necessity of the patient's
to take the adherence to condition and
medication at medication. not relapse
the home . 4- Encouraging again.
the patient to fill 4- So that the
his spare time, patient
sit with family, overcomes these
friends and undifferentiated
relatives, and schizophrenia
stay away from and that the
the things that disease does not
bother him. overcome the
patient.
3-Lack of Short term goal 1-Encouraging 1/2/3 On going .
patient Encouraging the patient to So that the
interaction with the patient to mix with the patient
patients related interact with other patients . overcomes the
to patients 2-Encouraging disease, fills his
undifferentiated At the hospital. the patient to spare time,
schizophrenia make friends in returns to his
manifested by Long term goal the hospital and normal life and
The patient Encouraging outside the does not relapse
remains alone the patient to hospital. again.
and does not interact with 3- Encouraging
talk to anyone. people and the patient to do
form the things he
relationships. loves, such as
At the home . going to the
mosque.
XI- Management :
Pharmacotherapy (list drugs and attach details about each drug, including trade & generic name,
classification, mechanism of action, indication for use, side effects, nursing implications) :
Trade Generic Classification Mechanism of action Indication Side effects Nursing
name name for use implications

Zyprex Olanzapine atypical The exact mechanism treatment of Drowsiness, Monitor

diabetics for
a 5mg antipsychotic of manic or dizziness
loss of
by 2 , s action of olanzapine is mixed dry mouth, glycemic
control ,
subling not known. It may constipation
episodes monitor V/S .
work by blocking , increased Monitor for
ual . associated seizures .
receptors for several appetite,
with bipolar
neurotransmitters ( It or weight
I disorder
binds to alpha-1, gain may
,schizophre
dopamine, histamine occur .
H-1, and serotonin.). 
nia and
control
delusion
disease.
Electroconvulisive therapy (ECT) – indication :

The patient did not undergo for ECT.

Indication : ECT used for patients depression and schizophrenia .

Psychotherapy ( explain about one recommended psychotherapy model) :

It is not applied in the hospital.

The advanced practice psychiatric-mental health nurse uses individual, group, and family

psychotherapy, and other therapeutic treatments to assist clients in preventing mental illness and

disability, treating mental health disorders, and improving mental health status and functional

abilities.

XII- Discharge Plan (METHOD approach: Medication, Environment, Treatment, Health

teaching, Outpatient follow-up, Diet) :

1- Medication : Encouraging the patient and emphasizing him to adhere to taking the

medicine at the appropriate times, and educating the patient about the medicine, and if the

patient feels that symptoms usually have him despite taking the medicine, he must go to the

hospital or any psychiatrist in the area . teaching the pt about drugs :

Do not drive or engage in potentially hazardous activities until response to drug is known;
drug increases risk of orthostatic hypotension and cognitive impairment.

Learn common adverse effects and possible drug interactions.

Avoid alcohol and do not take additional medications without informing physician.

Do not become overheated; avoid conditions leading to dehydration.

2- Treatment: As we mentioned previously, adhere to medication. If the patient feels

symptoms are returning, he must see a psychiatrist or hospital, and periodically go to the
psychiatrist, social worker and occupational therapy in order to ensure the patient’s safety.

3- Environment: Encouraging the patient to join the community, return to his work, do the
work he loves, go out with friends, fill in free time, encourage the patient to sit with the
 family, and not feel inferior due to illness. And provide a calm atmosphere for sleep and
sleep in the evening.

4- Health teaching outpatient follow – up and diet :

Encouraging the patient as he was previously committed to breakfast, lunch and dinner,
exercising such as walking, reducing smoking or abstaining from smoking, going out to
nature and refraining from places that lead to psychological exhaustion for the patient. As
we mentioned previously, adhere to the medication, review the doctor and specialists when
needed, and periodically, and merge with others.

XIII- References :

1- Patient.

2- Patient profile.

3- Medical teem.

4-

http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/O003.htm

l.