Rationale

"Insanity is doing the same thing over and over again, but expecting different results,” Rita Mae Brown said. Schizophrenia is most likely not a single disease of the brain but a heterogeneous disorder with some common features, including thought disturbances and preoccupation with frightening inner experiences like delusions and hallucinations, affect disturbances like flat or inappropriate affect, and behavioral or social disturbances such as unpredictable, bizarre behavior or social isolation (Kaplan & Sadock, 1996). The word schizophrenia originally referred to a “splitting off” of one’s thoughts from one’s emotions. Thus, the word has become confused in the public’s mind with “split personality” or “multiple personality”. A more accurate interpretation of Schizophrenia is a “disconnected mind”. Such disconnection involves a lack of coherence in mental functioning, in which “thinking, feeling, perceiving, behaving, and experiencing operate without the normal linkages that make mental life comprehensible and effective (Nasrallah & Smeltzer, 2003). Currently, the DSM-IV-TR identifies five subtypes of schizophrenia: 1) paranoid, 2) disorganized, 3) catatonic, 4) undifferentiated, and 5) residual. One percent of the population develops schizophrenia. Ninety-five percent suffer a lifetime, 33% of all homeless Americans suffer from it, 50% experience serious side effects from medications and 10% kill themselves. Approximately 2.2 million American adults and 697, 543 Filipinos suffer from Schizophrenia. Although the prevalence rate and symptom presentation for schizophrenia are fairly constant worldwide, inner city residents, those from lower socioeconomic classes, and individuals who experience prenatal difficulties (Bachmann et al, 2005; Opler et al. 2004; Sadock and Sadock, 2003) are more likely to be affected (American Psychiatric Association [APA], 2001). This analysis is done not only for the purpose of merely passing a requirement in NCM 105 – RLE. It is conducted in the light of extracting new and important facts for the enhancement of new knowledge in the nursing practice, education, and research. This case analysis may enhance the care to a client, and so may develop a more clientcentered method in providing care. Assessment of client needs with schizophrenia may be further enhanced the next time it is done. The students’ ability to perform mental

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health status exam and rendering of interventions will be sharpened and critical thinking is utilized. Nursing care plans may also be improved in which the client is the greater focus, especially in the enhancement of the therapeutic approach and milieu management. This case analysis served as the practicing ground for nursing students. When the time they become professional nurse researchers, they can extract ideas and experience from this study. The researchers involved in the analysis believe that research is an unending process, and that it involves commitment to scientific, medical, and nursing discovery. The innovation of research must never stop, and must continue to scour the globe for new findings and knowledge to improve the life of humanity. Optimal health of the client should always be the top-rung of research, and that is why this case study was conducted.

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Goal and Objectives

Main Objectives:
In the 3 weeks of our Psychiatric Nursing experience in New Day Recovery Center, the researchers aim to perform a systematic way of analysis about Schizophrenia, Paranoid Type which would enable each of us, student nurses, to enhance our knowledge regarding the patient’s condition, diagnosis, and the different tests and therapies he underwent, develop skills in the care for such disease and nourish good attitude in interacting with the client.

Specific Objectives:
At the end of our Psychiatric Nursing rotation, we will be able to specifically: a. establish rapport with the client; b. set a contract which contains the roles and responsibilities of the nurse and the patient, and the purpose of the relationship; c. inform the client of the conditions of contract termination; d. obtain essential information about the patient to serve as a tool for the study; e. explain a little about schizophrenia, its prevalence internationally and nationally, and the significance of this study to nursing education, nursing research and nursing practice f. present the client’s personal data; g. discuss the brief history of the client in terms of his disease; h. present the initial mental status examination; i. j. write progress notes in each interaction; identify the series of diagnostic procedures undergone by the patient with its corresponding rationales, actual results, significance or interpretations and nursing implications; k. discuss the medical and therapeutic management or therapies of the disease;

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l.

create drug studies about the patient’s treatment regimen with their detailed information relevant to her condition, which includes the classification, suggested and ordered dose, action, indication, contraindication, side effects, drug interactions and nursing responsibilities;

m. formulate 5 nursing care plans for each identified actual and potential needs of the patient and;

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Personal Data
Name: Mr. A Current Age: 45 years old Gender: Male Status: Single Citizenship: Filipino Birthday: November 6, 1965 Address: Ecoland, Davao City Birthplace: North Cotabato Occupation: None Religion: Roman Catholic Responsible Party: Mrs. C.A. (mother) Re-admission: 2nd (Category) Admitting Date: December 5, 2004 Admitting Time: 11:10 am Admitted: Walk In Admitting Age: 39 years old Physician: Dr. Aneze M. Babista, M.D., N.Y.R.N., D.P.C.S.M. Family: Father – Mr. E.A (78 yrs old) – retired Mother – Mrs. C.A. (76 yrs old) – housekeeper Siblings: 1. L.C. (48 yrs old) – clerk 2. E.A (46 yrs old) – teacher 3. R.A. (44 yrs old) – self-employed 4. J.C. (42 yrs old) 5. W.A. (37 yrs old)

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Brief History
Mr. A was born via normal spontaneous vaginal delivery by a hilot or a midwife on November 6, 1965. He was reported to be an average preschool kid. When he was 7 years old, he was brought to the doctor due to convulsion. During his adolescence, he was an average student as well. He’d select his barkadas or friends, and drinks with them occasionally. He had good interpersonal relationship with the people around him. For college, he took a vocational course in Automotive Diesel Mechanic. Since birth, he had no girlfriends. Hypertension is the only nonpsychiatric disease found in both paternal and maternal lineage. He had no known allergies in foods. On January 28, 2004, the patient told his father that he was feeling something unexplainable on his head but his father did not give much attention. Days after, difficulty of falling asleep was noted. His family approached him and talked to him. They thought that he was only having some emotional problem related to his personal life and experiences. Days passed, difficulty of falling asleep persisted. Some changes in behavior such as not taking a bath and not dressing properly were observed by the family. Because they were unfamiliar with the symptoms, the family got mad at him for they thought that he was just being lazy and stubborn. He was then confined at Davao Mental Hospital after his family observed the mentioned symptoms above plus talking to himself and laughing alone. He became violent too, that he was able to punch his mother on her face. He started throwing away things as well, and he would refuse taking his medications. He had active delusion of persecution. Then 2 days after discharge from Davao Mental Hospital, on December 5, 2004, he was admitted at NDRC due to same behavior and symptoms. He arrived at the NDRC poorly groomed with sad facial expression. During MSE, warm quality of interaction was noted. He was cooperative throughout the interview. Looseness of association was present and blunted affect was observed. Visual hallucination was apparent. He said that he could see a group of people around even though it was only the nurse present. There was also impaired orientation to place and person.

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Mental Status Examination

Mental Status Examination

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This assessment was conducted on December 11, 2010, on the initial contact of the nurse and the client.

I. -

PRE-EXAMINATION: The 45 year old client appears weak or scrawny. He was wearing a gray shirt, blue pair of shorts, and blue slippers. He looks fine with his age. He is cleanly dressed, well shaved and has short hair cut.

A. General Appearance

B. General Mobility Posture and Gait

-

He has a slight slouching or stooping posture. He walks straightly and without any stiffness and rigidity noted.

Activity

-

He has normoactive activity

Facial Expression - He looks suspicious and sad. C. Behaviour - He is friendly and appears interested or attentive in everything you say except when he is overpowered by hallucinatory activities. D. Nurse-Patient Interaction - He is all throughout cooperative. He would answer all the nurse’s questions and even initiate a conversation. But sometimes his answers are too short or are not appropriate to the question. Quality: He is warm.

II. -

STREAM OF TALK

A. Character
He has a deliberate stream of talk. He would give very short answers like, “Pareha gud,” “Ok man,” “O.”

B. Organization of Talk Loose association of words is noted such as, “Sina Gambon, Kambaryo ug Velasco man ‘tong 3 nako nga amigo… Sa gawas, naga-jogging kauban ang

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uban… Magsakay-sakay sa Bachelor, pasahero gud… Muabot mi ug Butuan, Kidapawan… Sila man ang nagpadala sa ako diri sa Babista… “

C. Accessibility Fair : He answers questions but does not open up everything such as” Nurse: Sir, kinsa imong ka-istorya? (after a hallucination) Patient: Wala man. Ikaw gud.

III.

EMOTIONAL STATE & REACTIONS

A. Mood – “Okay ra man.” Anhedonia or absence or loss of interest or pleasure is
seen. The tone of his voice is very low and rough, and he speaks shortly. There is lack of excitement in his voice tone.

B. Affect – He has inappropriate affect. He says he feels okay but he looks sad or
expressionless sometimes. He has a flat affect.

C. Depersonalization and derealization were not present. D. Suicidal Potential – There is no suicidal potential noted. IV. THOUGHT CONTROL

A. Perception
Auditory and visual hallucinations were noted. He would talk or whisper unnecessary and incomprehensible things to himself. He smiles and laughs alone. He said, “Sina Gambon, Kambaryo ug Velasco kay naa sa gawas naga- hulat sa ako. Naga-jogging na sila pirmamente dira. Makit-an nako sila. Gikan pa na sila sa Bachelor ba.” B. Delusions

-

Delusion is also apparent, most specifically the grandiose delusion. “Si Jaworski ang nagtudlo sa ako ug basketball. Narciso. Kaila ka ana niya? Sa Bachelor pud na siya naga-trabaho, sa may Finance. Mangayo unta ko ug tabang sa iya para makasulod sa Bachelor. Gusto pud ko sa may Finance banda. Pero dili man musugot ang Bachelor. Paseminaron sa daw ko nila.”

C. Ideas of Reference are incorrect interpretations of casual incidents and external events as being directed toward the self. It is not observed in Mr. A. D. There are no rumination and preoccupation noted.

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E. Déjà vu and Jamais Vu are not observed as well.

V.

NEUROVEGETATIVE DYSFUNCTION

A. Sleep – The patient has normal sleep as evidenced by his statement, “Okay man
akong tulog.” He also said that it is their routine to sleep at 8 pm and wake up at around 5 the next day.

B. Appetite – As observed, he has increased appetite. C. Diurnal Variation – The patient’s mood pattern during the entire day never
changes. When asked in the morning how he was doing or feeling, he’d answer, “Okay ra man,” in the afternoon, he’d answer the same thing.

D. Weight – not known E. Libido – Libido in its common usage means sexual drive. The client only smiles
and blushes when asked about any relationships with opposite sex in the past. He has no known special relationships with either sexes.

VI.

GENERAL SENSORIUM & INTELLECTUAL STATUS

A. Orientation: He knows what time they sleep and wake up. He knows that he is
inside NDRC/Babista. He knows his name, his co-residents’ names, and his family members’ names.

B. Memory
Remote: “Nagapaparty akong mama sa ako pag-birthday nako.” Recent: “Ang sud-an namo kagabi-i kay gulay.” Immediate: “Unsa gani imong pangalan?” he asked the nurse after a few minutes the nurse introduces herself.

C. Attention Span – His attention span is fair. He would listen to the nurse
attentively but sometimes he’d begin hallucinating again and the conversation or interaction between him and the nurse is disrupted. Sometimes, he’d fall asleep during student nurses’ activities or programs.

D. General Information – He knows his name, his birthday, his birthplace and their
address in Davao City. He also knows that Mintal is found near Calinan. He’s good in calculation simple arithmetic like “8+8=16”. He knows what lumpia wrapper is made of after the student nurses discussed it.

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E. Abstract Thinking Ability
“Nasa tao ang gawa, nasa Diyos ang awa.”

-

Magtrabaho ang tao ug tarong aron makakuwarta. Ang damo kay stock na lang kay wala na may kabayo na mu-kaon.

“Aanhin pa ang damo kung patay na ang kabayo.” The client’s abstract thinking ability is impaired.

F. Judgment and Reasoning “Pag-gawas nako diri, mangita ko ug trabaho para maka-kuwarta,” he answered when asked about the first thing he would do after discharge. “Magdula ug basketball,” he answered when asked about what he is going to do when he sees a ball. His judgment and reasoning is intact.

VII. -

INSIGHT

He has diminished insight as evidenced by:

“Gipadala man ko diri sa Bachelor para mag-seminar. Magdagdag man daw ‘to sila ug unit.” His insight is impaired.

VIII.

SUMMARY OF MENTAL STATUS EXAMINATION

A. There are disturbances in presentation manifested by slight slouching and sad
and suspicious facial expression; stream of talk manifested by deliberate talk, loose association of words and fair accessibility; thought control manifested by hallucinations, delusions; emotional state and reaction manifested by anhedonia and flat affect (inappropriate); neurovegetative dysfunction manifested by increased appetite and decreased libido; general sensorium and intellectual status manifested by fair attention span and impaired abstract thinking ability; and insight.

B. Diagnosis Category – Psychotic C. DSM IV-TR DIAGNOSIS
Axis I – Psychotic (Schizophrenia, Paranoid Type) Axis II – Axis III –

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Axis IV Psychosocial Stressor – Axis V Current GAF – 21-30 Past Year GAF –

Progress Notes

December 10, 2010

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S – “Makauli na ko ani? Gusto na ko mubalik sa Bachelor ba… Ang Bachelor man ang nagdala diri sa ako para mag-seminar.” O – smiles and talks alone frequently, poor eye contact, always looks down, flat affect, walks slowly, unable to perfectly follow exercises, murmurs, increased appetite, shy, refuses to show talent A – Patient is 45 years old, 6 years on treatment at NDRC, with admitting impression of Residual type Schizophrenia P – more one on one interaction - encourage to verbalize feelings - encourage to mingle with others - divert attention when on hallucinating activities - present reality - do not encourage delusion or challenge beliefs December 16, 2010 S – “Si Riden ra gud,” answered by the patient when asked whom he was talking with after caught by the nurse murmuring. - Sa STANFILCO ko nagtrabaho, sa delivery.” O – smiles and talks alone more frequently, delayed reaction to stimulus, can’t execute the exercises well, poor eye contact, aloof, murmurs, increased appetite A – status quo and did share his talent in dancing P – continue to motivate client to share his talent - encourage to express feelings more often - divert attention when hallucinating - present reality - provide activities which can divert his attention - do not challenge his delusion - talk to patient more frequently - encourage to mingle with others January 6, 2011 S – “Basketball ug liga-liga,” the patient said when asked about his first occupation. - “Si Jaworski ang nagtudlo sa ako ug basketball.” - “Wala man koy mabuhat kay dili man ko nila gusto kuha-on. Gusto na dyud ko muuli.”

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- “Kanang kung birthday nako, magpaparty man na siya,” answered by the patient when asked about his mother. O – lesser auditory hallucinations, increased delusional thinking, more expensive of his feelings, talks more frequently with the nurse. A – status quo P – continue one on one interaction - continue to encourage expression of thoughts and feelings - divert attention when hallucinating - present reality - do not challenge delusional thinking January 7, 2011 S – “Wala naman koy ngipon… Gi-injectionan man gud ko ba, unya naligid ko ug naigo ko sa bungbong.” O – smiles and talks less (alone), more open / expressive of his feelings, cooperative, unable to execute properly the exercises, answers questions about general facts correctly, actively sings “Bahay Kubo” during sharing of talents. A – status quo P – continue to encourage patient to cooperate with activities such as sharing of talents and therapeutic activities - give acknowledgment or praises for his achievements on that day - converse with the patient more frequently - divert attention when hallucinating and present reality - do not encourage delusions - speak clearly so that patient can understand instructions January 8, 2011 S – “Kabalo man ko ani kay atong una nagabuhat man mi ani, pero lahi ra nga design,” patient said about the balloon making therapy. O – more focused and attentive to the program or therapy, lesser hallucinatory and delusional activities, cooperative, initiates conversation, sings the song “Anak” during the sharing of talents portion. A – status quo P – encourage to interact with co-residents more frequently

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- praise client for initiating conversation - make the patient occupied with therapeutic communication - teach ways how to prevent hallucinations

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Medical Management

Diagnostic Procedures
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08/10/20 09

Complete Blood Count

The complete blood count (CBC) is one of the most commonly ordered blood tests. The complete blood count is the calculation of the cellular (formed elements) of blood.

Hemoglobin Erythrocyte MCH MCV MCHC Leukocytes Neutrophils Lymphocytes Monocytes Eosinophils Basophils Hematocrit Platelet

135 L 5.07 H 26.7 L 78.3 L 340 9.1 64.6 H 18.9 L 7.5 3.2 0.8 5.07 L 221

Normal Values:
Hemoglobin Erythrocyte MCH MCV MCHC Leukocytes Neutrophils Lymphocytes Monocytes Eosinophils Basophils Hematocrit Platelelt 140-180 4.5-5.0 27-33 80-96 32-36 5-10 0.55-0.65 0.25-0.40 0.02-0.06 0.01-0.05 0.000-0..005 0.40-0.48 150-300

Decreased hemoglobin -indicates anemia. This means that exchange of gases between the alveoli, and the capillary beds are affected. Increased Erythrocyte -indicated that the body tend to cope with the decreased number of hemoglobin, to ensure adequate oxygenation. Low mean corpuscular hemoglobin -MCH is the average mass of hemoglobin per red blood cell in a sample of blood. This indicates that even with increased number of erythrocyte, the body is not having enough oxygen Low mean corpuscular volume -indicates that the client is having microcytic anemia due to low intake of iron rich food. Increased Neutrophils -Also indicates infection. Neutrophils are avid phagocytes at sites of acute infection. Decreased Lymphocytes -Patient is prone to immunosupression since his lymphocytes are small in number. Lymphocytes play an important role in immune response (B and T lymphocytes). Decreased Hematocrit -Hemodilution or there is decreased concentration of RBC in the blood. Plasma volume is increased because of fluid shifting. Decreased hemoglobin

11/09/10

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Hemoglobin Erythrocyte MCH MCV MCHC Leukocytes Neutrophils Lymphocytes Monocytes Eosinophils Basophils Hematocrit Platelet

137 L 4.77 28.8 83 347 5.5 64 32 L 4L

40 213

-indicates anemia. This means that exchange of gases between the alveoli, and the capillary beds are affected. Decreased Lymphocytes -Patient is prone to immunosupression since his lymphocytes are small in number. Lymphocytes play an important role in immune response (B and T lymphocytes). Decreased monocytes - may indicate that there is
an overwhelming bacterial infection.

Nursing Responsibilites: PRETEST: • Explain to the patient the procedure to be done. • Explain to the patient the importance of this test. • Instruct patient to avoid strenuous activities 24 hours before the test because it will cause false positive result of neutrophils and lymphocytes. • Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when it will take place.

• Explain to the patient that he may experience slight discomfort from the tourniquet
and needle puncture. • Inform the patient that he need not restrict food and fluids. DURING THE PROCEDURE: • Make sure that the patient is calm and rested. Exercise, exertion and fear all increases the red blood cell count, stress elevate the tests results temporarily. POSTTEST: • Apply direct pressure to the venipuncture site until bleeding stops.

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• If a hematoma develops at the venipuncture site, apply pressure on the punctured site. • Apply ice pack if bruises appear. When the hemoglobin level is decreased, the nurse should assess abnormal physical responses that include dizziness, pallor and fatigue associated with physical activity

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Psychological Test Evaluation
The purpose of evaluation is to determine what is happening in the individual's psychological life that may be blocking their ability to behave (or feel) in a more appropriate and constructive manner. Testing cannot necessarily pinpoint the precise cause of the disturbance, especially if it is a complex emotional issue, but it will give a number of clues that can help the parent, siblings, family and the professional guide the client in the right direction. Psychological test administered

Test
Basic inventory

Definition

Date administered

Personality The Basic Personality Inventory (BPI) is Dec. 31 2004 an innovative, multiphasic personality assessment clinical and intended normal for use with to populations

identify sources of maladjustment and personal strengths. The BPI can be used with both adolescents and adults, and is completed in half the time of other measures. The BPI measures twelve (12) distinct psychological traits. Scale names were chosen to avoid potentially inaccurate diagnostic construct labels while emphasizing of dimensions

psychopathology. The BPI makes use of sophisticated procedures to minimize susceptibility to the social desirability response bias. It is sensitive to the tendency to describe oneself in favorable ("fake-good") and unfavorable ("fake-bad") terms. The easy reading level makes it suitable for a variety of

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Draw a person test

populations. Children are asked to draw a man, a Dec. 28 2004 woman, and themselves. No further instructions are given and the child is free to make the drawing in whichever way he/she would like. There is no right or wrong type of drawing, although the child must make a drawing of a whole person each time - i.e. head to feet, not just the face. The test has no time limit; however, children rarely take longer than about 10 or 15 minutes to complete all three drawings. Harris's book (1963) provides scoring scales which are used to examine and score the child's drawings. The test is completely noninvasive and non-threatening to children, which is part of its appeal. To evaluate intelligence, the test administrator uses the Draw-a-Person: QSS (Quantitative Scoring System). This system analyzes fourteen different aspects of the drawings (such as specific body parts and clothing) for various criteria, including presence or absence, detail, and proportion. In all, there are 64 scoring items for each drawing. A separate standard score is recorded for each drawing, and a total score for all three. The use of a nonverbal, nonthreatening task to evaluate intelligence is intended to eliminate possible sources of bias by reducing variables like primary

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language, verbal skills, communication disabilities, and sensitivity to working under pressure. However, test results can be influenced by previous drawing experience, a factor that may account for the tendency of middle-class children to score higher on this test than lowerclass children, who often have fewer opportunities to draw. To assess the test-taker for emotional problems, the administrator uses the Draw-a-Person: SPED (Screening Procedure for Emotional Disturbance) to score the drawings. This system is composed of two types of criteria. For the first type, eight dimensions of each drawing are evaluated against norms for the child's age group. For the second type, 47 different items are considered for each drawing. The purpose of the test is to assist professionals children's cognitive in inferring developmental

levels with little or no influence of other factors such as language barriers or special needs. Any other uses of the test are merely projective and are not endorsed by the first creator. House-Tree Person The house-tree-person test (HTP) is a Dec. 28 2004 projective personality test, a type of exam in which the test taker responds to or provides ambiguous, abstract, or unstructured stimuli (often in the form of

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pictures or drawings). In the HTP, the test taker is asked to draw houses, trees, and persons, and these drawings provide a measure of self-perceptions and attitudes. As with other projective tests, it has flexible and subjective administration and interpretation. The HTP can be given to anyone over the age of three. Because it requires test takers to draw pictures, it is often used with children and adolescents. It is also often used with individuals suspected of having brain damage or other neurological impairment. The test takes an average of 150 minutes to complete; it may take less time with normally functioning adults and much more time with neurologically impaired individuals. During the first phase of the test, test takers are asked to use a crayon to draw pictures, respectively, of a house, a tree, and a person. Each drawing is done on a separate piece of paper and the test taker is asked to draw as accurately as possible. drawings, Upon test completion takers are of the asked

questions about the drawings. There are a total of 60 questions that examiners can ask. Examiners can also create their own questions or ask unscripted followup questions. For example, with reference to the house, the test creator wrote questions such as, "Is it a happy house?" and "What is the house made

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of?"

Regarding

the

tree,

questions

include, "About how old is that tree?" and "Is the tree alive?" Concerning the person, questions include, "Is that person happy?" and "How does that person feel?" During the second phase of the test, test takers are asked to draw the same pictures with a pencil. The questions that follow this phase are similar to the ones in the first phase. Some examiners give only one of the two phases, choosing either a crayon, a pencil, or some other writing instrument. One variation of test administration involves asking the individual to draw two separate persons, one of each sex. Another variation is to have test takers Raven’s Matrix put all the drawings on one page. Progressive Raven's Progressive Matrices (often Jan. 4 2005 referred to simply as Raven's Matrices) are multiple choice intelligence tests of abstract reasoning, originally developed by Dr. John C. Raven in 1936. In each test item, the subject is asked to identify the missing item that completes a pattern. Many patterns are presented in the form of a 4x4, 3x3, or 2x2 matrix, giving the test its name. Bender’s Gestalt Visual The Bender Visual Motor Gestalt Test, Jan. 4 2005 Motor test or simply the Bender-Gestalt test, is a psychological test first developed by child neuropsychiatrist Lauretta Bender. The test is used to evaluate "visualmotor maturity", to screen for

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developmental disorders, or to assess neurological function or brain damage. The original test consists of nine figures, each on its own 3 × 5 card. The subject is shown each figure and asked to copy it onto a piece of blank paper. The test typically takes 7-10 minutes, after which the results are scored based on accuracy and other characteristics. Sachs completion test Sentence Sentence completion tests are a class Jan. 6 2005 of semi-structured projective techniques. Sentence completion tests typically provide respondents with beginnings of sentences, referred to as “stems,” and respondents then complete the sentences in ways that are meaningful to them. The responses are believed to provide indications of attitudes, beliefs, motivations, or other mental states. There is debate over whether or not sentence responses completion from tests elicit thought conscious

rather than unconscious states. This debate would affect whether sentence completion tests can be strictly categorized as projective tests. A sentence completion test form may be relatively short, such as those used to assess responses to advertisements, or much longer, such as those used to assess personality. A long sentence completion test is the Forer Sentence Completion Test, which has 100 stems.

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The tests are usually administered in booklet paper. The structures of sentence completion tests vary according to the length and relative generality and wording of the sentence stems. Structured tests have longer stems that lead respondents to more specific types of responses; less structured tests provide shorter stems, which produce a wider variety of responses. form where respondents complete the stems by writing words on

Test result and Interpretation Subject’s intellectual capacity falls within the limited level, which denotes his poor ability to perceive and integrate logical relationships among abstract concepts. Visual-motor coordination is poor with bellow par memory recall. Psychological and Emotional Functioning Subject is seen to be an emotionally immature individual who may lack insight and secure feelings. He shows strong desire to abandon unsatisfactory situations and may respond to the demand of the environment with feelings of inferiority and regression. Diminished capacity of abstraction and organization, maybe reflective of ambivalence and faulty perception as well as lack of contact with reality. Signs of castration fears and feelings of helplessness contributed to psychosexual immaturity or low physical vigor. Traumatic experience in his life maybe contributory to inner feelings of conflict. Interpersonal relationships Shows withdrawal characteristics and tends to be evasive about the functional mastery of interpersonal relationships. He attempts to b cautious but may have the ability controlling aggressive drive. ________ attitudes and hostile feelings are also present. These may result in conflicting authority figure and difficulty in social interaction Psychosexual Sexual identity is directed towards same sex.

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Diagnostic Impression Schizophrenia paranoid tendencies should be addressed. Thinking disorders, perceptual and deviance are manageable. Subject is recommended to undergo progressive therapy and treatment to address inner conflict and disturbances in personality.

Therapies
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Medications Medicatons work successfully to control symptoms in the majority of patients (approximately 70% of patients will improve to some degree, according to research - but we've also seen research that suggests the chances of any one drug working for a person may be only 50% or so. People frequently have to try more than one drug to partially or completely control the positive symptoms - hallucinations, delusions, paranoia, racing thoughts, etc). They are not as effective in controlling negative symptoms, and may cause side-effects of their own. However, second-generation antipsychotics (also called atypical antipsychotics) have shown more success with some patient population in treating negative and cognitive symptoms. There are also a wealth of new, and hopefully better,schizophrenia medications currently in development. Many patients and their families choose supplemental therapies (these can include psychosocial or cognitive therapy, rehabilitation day programs, peer support groups, nutritional supplements, etc) to use in conjunction with their medications. In certain severe cases, some patients also respond to electroconvulsive therapy (which has been shown to be safe and effective) or transcranial magnetic stimulation (TMS). These additional treatments can be essential for a full recovery - although medications are the best tool right now for controlling symptoms (particularly positive ones), other treatments and therapies are what can help a person manage depression, social interactions, school, work, and the components for a full life. The most promising complementary treatments to try in conjunction with medication that we have seen thus far, based on scientific literature and patient experiences, include personal therapy (there are many types), certain amino acids and antioxidant vitamins such as glycine or sarcosine supplements, and a healthy diet. Personal Therapy Personal Therapy is a psychosocial intervention designed to help patients with schizophrenia recognize and respond appropriately to arousing stimuli improves function and reduces relapse. Personal therapy, as it is called, aims to create a therapeutic umbrella to protect the patients from; undue personal stress. Recent studies have suggested that over the long haul, individual psychotherapy tailored to strengthen

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interpersonal skills and control social stress markedly helps many people suffering from the disorder. This new form of schizophrenia treatment has resulted in lower relapse rates and progressively better social functioning over 3 years, at least for people able to live with family members and meet basic survival needs, contend social worker Gerard E. Hogarty of the University of Pittsburgh School of Medicine and his colleagues. ECT (Electro-Convulsive Therapy) Research suggests that Electroconvulsive therapy (ECT) has a modest but definite role to play in the treatment of schizophrenia despite the adverse publicity it has received. . In European countries it has been used more widely for the treatment of schizophrenia than in the United States. Antioxidant Vitamins Researchers have found a positive correlation between superoxide generation and the negative symptoms of schizophrenia, indicating a possible role for oxidative stress in the development of the disease (and the potential for antioxidants to help in decreasing the risk or severity of the disease). "There are several lines of evidence to support the contribution of oxygen free radicals in schizophrenia, including increased lipid peroxidation, fatty acids, and alterations in blood levels of antioxidant enzymes," note Pinkhas Sirota (Tel Aviv University, Israel) and colleagues, in a recent research paper. Higher than normal intake of foods known to have a high content of antioxidants, as well as supplements of high antioxidant vitamins (Alpha Lipoic Acid, Vitamin E, Vitamin C) may have some beneficial impact on the incidence and progression of the disease anecdotal evidence suggests as much as 5% to 10% improvement for some individuals. Foods high in antioxidants include blue berries (frozen or fresh), dried plums, spinach and strawberries. Group Therapy A number of studies on the efficacy of group therapy in the treatment of schizophrenia have reported meagre but positive results, particularly with outpatients and when combined with drug treatment. Group therapy in patient settings is less productive. Inpatient treatment usually occurs when symptomatology and social

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disorganization are at their most intense. At this time, the least amount of stimuli possible is most beneficial for the client. Because group therapy is, in fact, a multistimuli situatuin frequently high in intensity, it may be counterproductive early treatment. Group therapy for schizophrenia has been most useful over the long-term course of the illness. Groups led in a supportive manner, rather than in an interpretative way, appear to be most helpful for schizophrenic clients. Animal-Assisted Therapy Research has shown that pets (dogs and cats) may offer a low cost, yet helpful type of therapy for people with schizophrenia. What the researchers call "Animalassisted Therapy" has been shown to encourage mobility, interpersonal contact, and communication and reinforced activities of daily living, including personal hygiene and independent self-care. Music Therapy Music therapy is a type of psychotherapy in which the patient is encouraged to utilize music to improve interpersonal and communication skills in ways that regular dialogue is limited. Forms of music therapy generally are based around cognitive/behavioral, humanistic or psychoanalytic frameworks or a mixture of approaches. There are usually both active and receptive parts of the therapy, meaning that at times music is listened to and at other times there is the use of musical improvisation or creation. There have not been many studies on music therapy and schizophrenia, but the Cochrane review looked at the data available for a recent review. Acupuncture Acupuncture has been used to treat mental health disorders, including schizophrenia, for more than 2000 years. However, in an analysis by the Cochrane Review (the leading medical review publisher) in early 2006 it was determined that there is: "insufficient evidence to recommend the use of acupuncture for people with schizophrenia. The numbers of participants and the blinding of acupuncture were both inadequate, and more comprehensive and better designed studies are needed to determine the effects of acupuncture for schizophrenia." Source: Cochrane Review: Acupuncture for schizophrenia

A Case Analysis | 30

Art Therapy for Schizophrenia The Cochrane Review (a leading medical review publication) has this to say about Art Therapy for Schizophrenia.

"The British Association of Art Therapists definition of Art Therapy is "the use of art materials for self-expression and reflection in the presence of a trained art therapist. Clients who are referred to art therapy need not have previous experience or skill in art, the art therapist is not primarily concerned with making an aesthetic or diagnostic assessment of the client's image. The overall aim of its practitioners is to enable a client to effect change and growth on a personal level through the use of art materials in a safe and facilitating environment." It has proved to be difficult to estimate how widely this intervention is available. However, there are descriptions of its use with people with schizophrenia, individually and in groups, in inpatient and outpatient settings as well as in the private sector. Unfortunately we only found two randomised controlled trials that studied the use of art therapy for people with schizophrenia. Both studies did not include enough participants to make the results meaningful and we were unable to draw clear conclusions regarding the benefits or harms of art therapy from these studies. More research is needed to determine the value of art therapy in this population." Source: The Cochrane Review: Art therapy for schizophrenia or schizophrenia-like illnesses Psychotherapy: One-fifth to one-third of all patients with schizophrenia do not respond adequately to drug treatment. Many patients who have been successfully treated with medications experience the "awakenings" phenomena, which are painful reactions that are manifested as inner emotions and the recognition of real losses. The effects of the disease, in any case, are profoundly emotional. As a result, psychological therapies can be helpful for many patients. Cognitive-Behavioral and Other Psychosocial Therapies The use of cognitive-behavioral therapy is showing particular promise for improvement in both positive and negative symptoms in some patients, and the benefits

A Case Analysis | 31

may persist after treatment has stopped. This approach attempts to strengthen the patient's capacity for normal thinking, using mental exercises and self-observation. More evidence is showing that improving patients' ability to learn, remember, and pay attention allows them to better cope with ongoing positive symptoms and lead independent lives. Patients with schizophrenia are taught to critically analyze hallucinations and examine underlying beliefs in them. Family Therapy Some therapists treat schizophrenia as an illness not of the client alone, but of the entire family. Even when families appear to cope well, there is a notable impact on the mental health status of relatives when a family member has the illness. The importance of the expanded role of family in the aftercare of relatives with schizophrenia has been recognized, thereby stimulating interest in family intervention programs designed to support the family system, prevent delay relapse, and help maintain the client in the community. The psychoeducational programs treat the family as a resource rather than a stressor, with the focus on concrete problem solving and specific helping behaviors for coping with stress. By providing the family with information about the illness and suggestions for effective coping, psychoeducational programs the likelihood of the client’s relapse and the possible emergence of mental illness in preiously nonaffected relatives. Goals for family therapy: 1. Increase family members’ understanding of the illness. 2. Reduce family stress. 3. Enhance social networks for family interaction. 4. Diminish long-term issues contributing to family stress. Strategies: 1. Connection with, and introduction to, the family. 2. Teaching survival skills for living with a person with schizophrenia. 3. Monitoring the application of these skills. 4. Continued treatment or disengagement.

A Case Analysis | 32

Drug Studies
Generic Name: Losartan potasium + Hydrochlorothiazide Brand Name: combizar Date ordered: September 10, 2010 Classification: diuretic Suggested dose: Usual Initial and Maintenance Adult Dose: 1 tablet of Losartan 50mg + HCTZ 12.5mg FDC once daily. Ordered dose: 50 mg/12.5 mg 1 tab OD Indication: hypertension Contraindications: hypersensitivity to any component of the product , Hypersensitivity to sulfonamide-derived drugs, Pregnancy, Patients with anuria, severe renal impairment Mode of Action: -Mechanism of Losartan potasium : a selective, competitive Angiotensin II receptor type1 (AT1) receptor antagonist, simply it inhibits indirectly some substances occur naturally in ur body that are responsible for body water retention. Thus by decreasing body water volume, the blood volume will decrease then the lowering blood pressure will occur. -Mechanism of Hydrochlorothiazide: acting on the kidneys to reduce sodium (Na) reabsorption in the distal convoluted tubule. This increases the osmolarity in the lumen of the kidneys, causing less water to be reabsorbed by the collecting ducts. This leads to increased urinary output---->decreasing body water volume -----> decreasing blood volume----> lowering blood pressure. Side effects: Body as a Whole: chest pain, facial edema, fever, orthostatic effects, syncope Cardiovascular: angina pectoris, arrhythmias including atrial fibrillation, sinus bradycardia, tachycardia, ventricular tachycardia and ventricular fibrillation, CVA,hypotension, myocardial infarction, second degree AV block Digestive: anorexia, constipation, dental pain, dry mouth, dyspepsia, flatulence,gastritis, vomiting General disorders and administration site conditions: malaise Hematologic: anemia Metabolic: gout Musculoskeletal: arm pain, arthralgia, arthritis, fibromyalgia, hip pain, joint swelling, knee pain, leg pain, muscle cramps, muscle weakness, musculoskeletal pain, myalgia, shoulder pain, stiffnes Nervous System/Psychiatric: anxiety, anxiety disorder, ataxia, confusion,depression, dream abnormality, hypesthesia, insomnia, libido decreased, memory impairment, migraine, nervousness, panic disorder, paresthesia, peripheral neuropathy, sleep disorder, somnolence, tremor, vertigo Respiratory: dyspnea, epistaxis, nasal congestion, pharyngeal discomfort, respiratory congestion, rhinitis, sinus disorder Skin: alopecia, dermatitis, dry skin, ecchymosis, erythema, flushing,photosensitivity, pruritus, sweating, urticaria Special Senses: blurred vision, burning/stinging in the eye, conjunctivitis, decrease in visual acuity, taste perversion, tinnitus

A Case Analysis | 33

Urogenital: impotence, nocturia, urinary frequency, urinary tract infection. Hydrochlorothiazide Other adverse experiences that have been reported with hydrochlorothiazide, without regard to causality, are listed below: Body as a Whole: weakness Digestive: pancreatitis, jaundice (intrahepatic cholestatic jaundice), sialadenitis, cramping, gastric irritation Hematologic: aplastic anemia, agranulocytosis, leukopenia, hemolytic anemia,thrombocytopenia Hypersensitivity: purpura, photosensitivity, urticaria, necrotizing angiitis (vasculitis and cutaneous vasculitis), fever, respiratory distress including pneumonitis and pulmonary edema; Metabolic: hyperglycemia, glycosuria, hyperuricemia Musculoskeletal: muscle spasm Nervous System/Psychiatric: restlessness Renal: renal failure, renal dysfunction, interstitial nephritis Skin: erythema multiforme including Stevens-Johnson syndrome, exfoliative dermatitis including toxic epidermal necrolysis Special Senses: transient blurred vision, xanthopsia. Interactions: Lithium: lithium excretion will be reduced Anti-diabetic drug: adjustment to the dose is recomended Nursing Responsibilities: 1. Assess blood pressure when lying, sitting, and standing, and pulse periodically during therapy. 2. Assess for signs of angioedema such as dyspnea and facial swelling. 3. Monitor daily weight and assess patient routinely for resolution of fluid overload such as peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention. 4. Monitor renal function and electrolyte levels periodically. Serum potassium, BUN, and serum creatinine may be increased. 5. May be administered without regard to meals. 6. Emphasize the importance of continuing to take as directed, even if feeling well. 7. Caution patient to avoid sudden changes in position to decrease orthostatic hypotension. 8. Caution patient to avoid activities requiring alertness until response to medication is known. This drug causes dizziness. 9. Instruct patient to notify health care professional of swelling of face, eyes, lips, or tongue occurs, or if difficulty swallowing or breathing occurs. 10. Emphasize the importance of follow-up exams to evaluate effectiveness of medication. 11. Encourage patient to comply with additional interventions for hypertension like weight reduction, low-sodium diet, moderation of alcohol consumption, discontinuation of smoking, regular exercise, and stress management. 12. Instruct patient and family on proper technique for monitoring blood pressure. Advise them to check blood pressure at least weekly and to report significant changes. 13. Encourage to monitor fluid input and output.

A Case Analysis | 34

Nursing Care Plans

A Case Analysis | 35

Date

Cues

Need

Nursing Diagnosis Disturbed Thought Processes r/t presence of grandeur and paranoid delusional thinking ® Delusions are fixed false beliefs that cannot be changed by logical persuasion. They are not based on reality. It is a core feature of psychotic disorders. Cognitive processes include those mental processes by which knowledge is acquired. These mental processes include reality orientation, comprehension, awareness, and judgment. A

Goal of Care

Intervention Plan

Evaluation

12/1 1/10 @ 7 am

Subjective: ““Si Jaworski ang nagtudlo sa ako ug basketball. Narciso. Kaila ka ana niya? Sa Bachelor pud na siya naga-trabaho, sa may Finance. Mangayo unta ko ug tabang sa iya para makasulod sa Bachelor. Gusto pud ko sa may Finance banda,” he stated. “Naa sila dira sa gawas nagahulat,” he also said. Objective: -paranoid delusion -looks around oftenly -sharp eye contact -suspicious -does not open up or express feelings and thoughts

C O G N I T I V E P E R C E P T U A L P A T T E R N

Within 3 weeks of exposure in NDRC, our client will be able to demonstrate satisfying relationships with real people, specifically:

a. talk about
concrete happenings in the environment without talking about delusions for 2-3 minutes; b. initiate conversation with other nurses and clients and: c. participate with activities

1. Utilize safety measures to protect clients and others, if client believes he needs to protect himself against a specific person. Precautions are needed. ® Client’s delusional thinking might dictate to them that they might have to hurt others or self in order to be safe. External controls might be needed. 2. Attempt to understand the significance of these beliefs to the client at the time of their presentation. ® Important clues to underlying fears and issues can be found in the client’s seemingly illogical fantasies. 3. Be aware that the client’s delusions represent the way that he experiences reality. ® Identifying the client’s experience allows the nurse to understand the client’s feelings. 4. Assess attention span/distractibility and ability to

“Goal Partially Met” @ January 8, 2011 5 pm My client was able to demonstrate satisfying relationships with real people, specifically:

a. talk about his
experience with balloon making such as, “Kabalo man ko ani kay atong una nagabuhat man mi ani, pero lahi ra nga design,” and; b. participate with activities

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readily -constant changing of position -grandiose delusion -smiles and laughs when talking about his Jaworski and his basketball career -gives so much interest in basketball -claimed that he can do well in free throws, and 2 and 3-point field goals. -confidently shares ideas about basketball

disruption in these mental processes may lead to inaccurate interpretations of the environment and may result in an inability to evaluate reality accurately. Disturbed thought process is a state in which an individual experiences a disruption in cognitive operations and activities. Keltner, N.L., et al. (2007) Psychiatric Nursing. (5th Ed.) Singapore. Elsevier Inc. pg. 347 http://nursingcarep lan.blogspot.com/2 009/01/ncpdisturbed-thoughtprocesses.html

make decisions or problem solve. ® Determines ability to participate in planning/executing care. 5. Do not argue with client’s beliefs or try to correct his false beliefs using facts. ® Arguing will only increase client’s defensive position, therefore reinforcing false beliefs. This will result in client feeling even more isolated and misunderstood. 6. Do not touch the client; use gestures carefully. ® A psychotic person might misinterpret touch as either aggressive or sexual in nature and might interpret gestures as aggressive moves. People who are psychotic need a lot of personal space. 7. Interact with the client on the basis of things in the environment. Try to distract the client from his delusion or hallucination by engaging in reality-based like cards, board games, arts and crafts projects, and cooking. ® When thinking is focused on reality-based activities, the client

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is free from delusional thinking or hallucinations. It also helps focus attention externally. 8. Teach client coping skills that minimize “worrying” thoughts. Coping skills include: ● Talking to a trusted friend ● Singing ● Thought-stopping techniques ® When client is ready, teach strategies that client can do alone. 9. Encourage healthy habits to optimize functioning. ● Maintain regular sleep pattern. ● Maintain self-care. ● Maintain medication regimen. ® All are vital to help client in remission.

Date

Cues

Need

Nursing Diagnosis

Goal of Care

Intervention Plan

Evaluation

38

12/1 1/10 @ 7 am

Subjective: “Unsa man ni sila uie… mga buang dyud…nagaexerciseexercise…” patient said as he was caught murmuring to himself. “Sagdai lang na sila,” he whispers to himself. Objective: - murmurs - talks to self alone - laughs - less social interaction - fair attention span - looks around often

C O G N I T I V E P E R C E P T U A L P A T T E R N

Disturbed Sensory Perception r/t audio and visual hallucinatory activites ® Altered perception includes hallucination. Hallucinations are false sensory perceptions and can be auditory, visual, olfactory, tactile, gustatory or somatic. Auditory hallucinations are the most common in schizophrenia and often take the form of accusations or commands. Visual hallucinations are not as common in schizophrenia as auditory. Disturbed or altered sensory perception is a state in which as

Within 3 weeks of exposure in NDRC, our client will be able to improve social interaction with real people, particularly: a. manifest less auditory hallucinatory activities; b. initiate conversation with other nurses and residents; c. participate in activities and; d. increase attention span as evidenced by being able to finish task

1. Clearly document what client says and, if he is a threat to others, document who was contacted and notified. 2. Decrease environmental stimuli when possible like low noise and minimal activity. ® Decrease potential for anxiety that might trigger hallucinations. It’ll also help calm client. 3. Accept the fact that voices are real to the client, but explain that you do not hear voices. ® Validating that your reality does not include voices can help client cast “doubt” on the validity of his or her voices. 4. Stay with the client when he is starting to hallucinate, and direct him to tell the “voices he hears” to go away. Repeat often in a manner-of-fact manner. ® Client can sometimes learn to push voice aside when given repeated instruction, especially within the framework of a trusting relationship. 5. Keep to simple, basic, realitybased topics of conversation.

Goal Partially Met @ January 8, 2011 5 PM My client was able to improve social interaction with real people, particularly:

a.
nifesting less auditory hallucinatory activities;

ma

b. par ticipate in activities and; c. inc rease attention span as evidenced by being able to finish task such as balloon twisting and card making.

39

individual experiences a change in the amount or patterning of oncoming stimuli (either internally or externally initiated) accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli. Keltner, N.L., et al. (2007) Psychiatric Nursing. (5th Ed.) Singapore. Elsevier Inc. pg. 345 http://www.testand calc.com/Richard/r esources/Teachin g_Resource_Ment al_Status_Examin ation.pdf

Help client to focus on one topic at a time. ® Client’s thinking might be confused and disorganized; this intervention helps client focus and comprehend reality-based issues. 6. Explore how hallucinations are experienced by the client. ® Exploring the hallucination and sharing the experience can help give the person a sense of power that he may be able to manage the hallucinatory voices. 7. Help the client to identify the needs that might underlie the hallucination ® Hallucination might reflect needs for: a. Power b. Self-Esteem c. Anger d. Sexuality 8. Help client identify times when hallucinations are most prevalent and frightening. ® Helps both nurse and client identify situations and times that might be most anxiety-producing and threatening to the client.

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9. Engage client in simple physical activities or tasks that channel energy such as writing, drawing, crafts, noncompetitive sports, and exercise. ® Redirecting client’s energies to acceptable activities can decrease the possibility of acting on hallucinations and help distract from voices. 10. Work with the client to find which activities help reduce anxiety and distract the client from hallucinatory material. Practice new skills with the client. ® If client’s stress triggers hallucinatory activity, they might be more motivated to find ways to remove themselves from a stressful environment or try distraction techniques. 11. Be alert for signs of increasing anxiety, agitation, and fear. ® Might herald hallucinatory activity, which can be frightening to client, and client might act upon command hallucinations.

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Date

Cues

Need

Nursing Diagnosis

Goal of Care

Intervention Plan

Evaluation

42

12/1 1/10 @ 7 am

Subjective: “Gusto nako muuli… Sina Gambon, Kambaryo ug Velasco, sa opisina man na sila… Pasahero sa Bachelor, mag-abot mi sa Butuan, unya sa Cagayan… Ang Mintal, sa Cagayan man na diba?” Objective: -loose association of ideas or ideas - difficulty expressing thoughts verbally -deliberate stream of talk -incomprehensible ideas -incoherent speech -poor eye contact

R O L E R E L A T I O N S H I P P A T T E R N

Impaired Social Communication r/t communication barriers as evidenced by loose association of words ® Loose association is a pattern of speech in which a person’s ideas slip off one track onto another that is completely unrelated or only slightly related. Interpersonal communication becomes inadequate and might be inappropriate, This compromises their ability to engage in meaningful social interaction or communication. Impaired social interaction is state in which there is insufficient or

Within 3 weeks of exposure in NDRC, our client will be able to communicate thoughts and feelings in a coherent, goal-directed manner (to client’s best ability) specifically: a. speak in a manner that can be understood by others; b. establish good eye contact; c. spending time with one or two other people in structured activity involving neutral topics

1. Identify how long the client has been on anti-psychotic medication. ® Therapeutic levels of antipsychotic help clear thinking and diminish looseness of association (LOA). 2. Plan short, frequent periods with the client throughout the day. ® Short periods are less stressful, and periodic meetings give client a chance to develop familiarity and safety. 3. Tell patient that he or she may understand events and interactions different from others. ® So that client will not feel bad when the nurse couldn’t respond appropriately or if their ideas collide. 4. Provide praise and reinforcement when patient communicates directly and openly about needs and concerns. ® This encourages client to express more despite the communication barrier. 5. Use simple words and keep

Goal Met @ January 8, 2011 5 PM My client was able to communicate thoughts and feelings in coherent, goaldirected manner (to client’s best ability) specifically: a. speak in a manner that can be understood by others; b. establish good eye contact and; c. spend time with two student nurses conversing about his hobbies and knowledge on the Ilonggo

43

excessive quantity or ineffective quality social exchange. Keltner, N.L., et al. (2007) Psychiatric Nursing. (5th Ed.) Singapore. Elsevier Inc. pg. 345

directions simple. ® Client might have difficulty processing even simple sentences. 6. Keep voice low and speak slowly. ® High pitched/loud tone of voice can raise anxiety levels; slow speaking aids understanding. 7. Look for themes in what is said, even though spoken words appear incoherent. ® Often client’s choice of words is symbolic of feelings 8. When you do not understand him, let him know that you are having difficulty understanding him. ® Pretending to understand (when you do not) limits your credibility in the eyes of your client, and lessens the potential for trust. 9. Use therapeutic techniques to try to understand the client’s concerns. ® Even if the words are hard to understand, try getting to the feelings behind them.

dialect..

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10. Use simple, concrete, and literal explanations. ® Minimizes misunderstanding and/or incorporating those misunderstandings into delusional systems 11. When client is ready, introduce tactics that lower anxiety can lower anxiety and minimize voices and “worrying” thoughts. Teach client to do the following: ● Read aloud to self. ● Seek out staff, family, or other supportive person. ● Listen to music. ● Perform deep breathing exercises. ® Helping client to use tactics to lower anxiety can help enhance functional speech.

Date

Cues

Need

Nursing Diagnosis Social Isolation r/t low self-worth

Goal of Care

Intervention Plan

Evaluation

12/1 1/10

Subjective: “Naa man… Sila ra

R O

Within 3 weeks of exposure in NDRC, our

1. Avoid touching the client. ® Touch by a “stranger” can be

Goal Partially Met

45

@ 7 am

gud…” he answered when asked who his friends are. “Ay dili lang… Unya na…” he answered when asked to showcase talent. Objective: - looks down at his feet - deliberate answers or response - chose to sit at the very end or edge of the semicircle - doesn’t interact with co-residents that much - flat affect - auditory and visual hallucination s deliberate speech - loose association of words

L E R E L A T I O N S H I P P A T T E R N

® Social isolation is a condition of aloneness experienced by the individual and perceived as imposed by others and as a negative or threatened state. Selfesteem is a term used in psychology to reflect a person's overall evaluation or appraisal of his or her own worth. Self-esteem encompasses beliefs and emotions such as triumph, despair, pride and shame. People with low self worth or self esteem lack the skills and confidence that are necessary in social interactions. In order to protect themselves from anticipated

client will be able to improve self worth, specifically:

misinterpreted as a sexual or threatening gesture. 2. If client is unable to respond verbally or in a coherent manner, spend short, frequent periods with the client. ® An interested presence can provide a sense of being worthwhile. 3. Structure times each day to include planned times for brief interactions and activities with the client on a one-on-one basis. ® Helps client develop a sense of safety in a nonthreatening environment. 4. If the client is hallucinating or having trouble concentrating, provide very simple concrete activities with the client like looking on a picture book, drawing or painting, ® Even simple activities can help draw client away from delusional thinking or hallucinations onto reality in the environment. 5. Structure activities that work at the client’s pace and ability. ® Client can lose interest in activities that are too ambitious,

@ January 8, 2011 5 PM My client partially engaged in social interactions in goaldirected manner, specifically:

a. engage in one or
two activities with minimal encouragement from nurse;

b. maintain an
interaction with another client while doing an activity; c. establish eye contact with the nurse and; d. sit in the middle of the sitting arrangement or in between nurses or residents

a. engaged in
activities with minimal encourageme nt from nurse as evidenced by volunteering to share a song for 2 straight days; b. establish eye contact with the nurse and; c. sit in the middle of the sitting arrangement or in between nurses during the program

46

-

-

frequent changing of sitting position (anxious) suspicious stooping position

criticism or ridicule, they withdraw from other people. This avoidance of interaction tends to isolate them from meaningful relationships, and serves to reinforce their nervousness and awkwardness in social situations. http://www.minddis orders.com/ABr/Avoidantpersonalitydisorder.html#ixzz 1BO4xMOEa

which can increase a sense of failure. 6. Try to incorporate the strengths and interests the client had when not as impaired into the activities planned. ® Increases likelihood of client’s participation and enjoyment. 7. As client progresses, provide him with graded activities according to the level of tolerance like simple games with 1 safe person, slowly add third person into safe activity, and groups in which clients participate more. ® Client continues to feel safe and competent in a graduated hierarchy of interactions. 8. Identify with the client the symptoms he experiences when he begins to feel anxious around others. ® Increased anxiety can intensify agitation, aggressiveness and suspiciousness. 9. Provide opportunities for the client to learn adaptive social skills in a nonthreatening environment. Initial social skills training could include basic social

47

behaviors (e.g. maintain good eye contact, appropriate distance, calm demeanor, moderate voice tone) ® Social skills training help client adapt and function at a higher level in society, and increases client’s quality of life. These simple skills might take time for clients with schizophrenia, but can increase self-confidence as well as more positive responses from others. 10. As client progresses, coping skills training should be available to him. Basically the process is: a.) Define the skill to be learned. b.)Model the skill. c.) Rehearse the skills in a safe environment, then in the community. d.) Give corrective feedback on the implementation of skills ® Increases client’s ability to derive social support and decreases loneliness 11. Remember to give acknowledgment and recognition for positive steps client takes in increasing social skills and appropriate interactions with others.

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® Recognition and appreciation go a long way to sustaining and increasing a specific behavior.

Date

Cues

Need

Nursing Diagnosis

Goal of Care

Intervention Plan

Evaluation

D E

Objective: Active

S E

Risk for violence: directed towards

Within 3 weeks of nursing intervention the

Goal Partially Met

49

C E M B E R 11 2010 @

hallucinations Looking at others suspiciously History of violence against his mother

7:00 am

L F P E R C E P T I O N S E L F C O N C E P T P A T T E R N

others related to history of violence

client will not harm others as evidenced by: a. Maintain good interpersonal relationship with coresidents and staff and; b. client will seek out staff member when hostile feelings occur towards other.

@

1. Observe client’s behavior
frequently. Do this through routine activities and interactions; avoid appearing watchful and suspicious. Close observation is required so that intervention can occur if required to ensure client's (and others') safety. 2. Obtain verbal or written contract from client agreeing not to harm self and to seek out staff in the event that suicidal ideation occurs. Discussion of suicidal feelings with a trusted individual provides some relief to client. A contract gets the subject out in the open and places some of the responsibility for his or her safety with client. An attitude of acceptance of client as a worthwhile individual is conveyed. 3. Remove all dangerous objects from client’s environment (e.g., sharp items, belts, ties, straps, breakable items, smoking

Jan 8,2010 5:00pm Within 3 weeks or nursing intervention the client did not harm others as evidenced by: a. Maintained good interpersonal relationship with co-residents and staff

50

materials). Client safety is a nursing priority. 4. Try to redirect violent behavior by means of physical outlets for client’s anxiety (e.g., punching bag, jogging).Physical exercise is a safe and effective way of relieving pent-up tension. 5. Be available to stay with client as anxiety level and tensions begin to rise. Presence of a trusted individual provides a feeling of security and may help to prevent rapid escalation of anxiety. 6. Staff should maintain and convey a calm attitude to client. Anxiety is contagious and can be transmitted from staff members to client. 7. Administer tranquilizing medications as ordered by physician, or obtain an order if necessary. Monitor client response for effectiveness of the medication and for adverse side effects. Shortterm use of tranquilizing medications such as

51

anxiolytics or antipsychotics can induce a calming effect on the client and may prevent aggressive behaviors. 8. Use of mechanical restraints or isolation room may be required if less restrictive interventions are unsuccessful. Follow policy and procedure prescribed by the institution in executing this intervention. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that the physician reevaluate and issue a new order for restraints every 4 hours for adults age 18 years and older. If client has previously refused medication, administer after restraints have been applied. Most states consider this intervention appropriate in emergency situations or in the event that a client would likely harm self or others. 9. Observe client in restraints every 15 minutes. Ensure that circulation to extremities is not compromised (check

52

temperature, color, pulses). Assist client with needs related to nutrition, hydration, and elimination. Position client so that comfort is facilitated and aspiration can be prevented. Client safety is a nursing priority.

10.

As agitation decreases, assess client’s readiness for restraint removal or reduction. Remove one restraint at a time while assessing client’s response. This minimizes risk of injury to the client and staff.

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Bibliography

Kaplan, H.I., et. al (2002) Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry. (8th Ed) Baltimore. Williams and Wilkins Keltner, N.L., et. al (2007) Psychiatric Nursing (5th Ed) Singapore. Elsevier Motir, W.K. (2006) Psychiatric –Mental Health Nursing (6th Ed.) Philadelphia, USA. Lippincott-Raven Publishers Schmidt, L.A. (2002) Individual Differences in Childhood Shyness: Origins, Malleability, and Developmental Course. New York. Guilford Press. Taylor, C.M. (1990) Essentials of Psychiatric Nursing (13th Ed) USA. C.V. Mosby Company American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000. http://nursingcareplan.blogspot.com/2006/12/ncp-schizophrenia.html http://nursingcrib.com/case-study/schizophrenia-case-study/ http://www.medicinenet.com/schizophrenia/article.htm

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