Case Study Report

Paranoid schizophrenia including continuous treatment resistance

By

Peeyachat Kamjanghan 6313290

Submitted to

A. Chaowarit Ngernthaisong

This case study submitted in partial fulfilment of requirement of

NS 2427 Mental Health and Psychiatric Nursing Practicum

Bernadette de Lourdes School of Nursing Science Assumption

 University of Thailand

Preface

I practiced at the Buddharaksa Public Health Center for 9 days, from April 4, 2022 to April 20,

2022, from 7:00 AM to 4:00 PM, to gain work experience and take care of psychiatric patients.

This case study aims to describe the theory, medical, and nursing management about the with

paranoid schizophrenia including continuous treatment resistance. The later part of the case

study discusses in the detail about my patient condition throughout my day of practice at

Puttaruksa Public Health Center, medications nursing assessment, nursing care plans set up for

this case. Finally, the conclusion of this case study.

 Table of Contents

Content page

1. Theory of disease 5

2. Personal history and Family history. 17

3. Review physical and mental assessment. 24

4. Medical diagnosis and nursing opinion 25

5. Medical treatment. 30

6. Analysis of the cause of present mental illness 36

7. Nursing management 36

8. Conclusion and suggestion 54

9. References 56
 Introduction

The patient is a Thai female aged 69 years old with diagnosis of paranoid schizophrenia

including continuous treatment resistance. On the 4-12 April 2022 that visited the patient feel

concerned about their condition and worry about their caregivers. Patients were able to

immediately answer some questions, and some were unable to answer them. Sometimes the

patient is slow to respond to questions. The patient might forget some information when

communicate with her.

This case study aims to describe the theory, medical, and nursing management about the

with paranoid schizophrenia including continuous treatment resistance, with patient has

underlying disease with Diabetes mellitus and Hyperlipidemia. The later part of the case study

discusses in the detail about my patient condition throughout my day of practice at Puttaruksa

community, medications nursing assessment, nursing care plans set up for this case. Finally, the

conclusion of this case study.

Sincerely

Peeyachat K.
1. Theory of disease

1.1 Definition of disease Schizophrenia is a serious mental disorder in which people

interpret reality abnormally. Schizophrenia may result in some combination of

hallucinations, delusions, and extremely disordered thinking and behavior that impairs

daily functioning, and can be disabling.

1.1.1 Types of Schizophrenia

There are five types of schizophrenia (discussed in the following slides). They are categorized by

the types of symptoms the person exhibits when they are assessed:

 Paranoid schizophrenia

 Disorganized schizophrenia

 Catatonic schizophrenia
  Undifferentiated schizophrenia

 Residual schizophrenia

Paranoid Schizophrenia

Paranoid-type schizophrenia is distinguished by paranoid behavior, including delusions and

auditory hallucinations. Paranoid behavior is exhibited by feelings of persecution, of being

watched, or sometimes this behavior is associated with a famous or noteworthy person a

celebrity or politician, or an entity such as a corporation. People with paranoid-type

schizophrenia may display anger, anxiety, and hostility. The person usually has relatively normal

intellectual functioning and expression of affect.

Pathophysiology

There are three main hypotheses regarding the development of schizophrenia. The

neurochemical abnormality hypothesis argues that an imbalance of dopamine, serotonin,

glutamate, and GABA results in the psychiatric manifestations of the disease. It postulates that

four main dopaminergic pathways are involved in the development of schizophrenia. This

dopamine hypothesis attributes the positive symptoms of the illness to excessive activation of D2

receptors via the mesolimbic pathway, while low levels of dopamine in the nigrostriatal pathway

are theorized to cause motor symptoms through their effect on the extrapyramidal system. Low

mesocortical dopamine levels resulting from the mesocortical pathway are thought to elicit the

negative symptoms of the disease. Other symptoms such as amenorrhea and decreased libido

may be caused by elevated prolactin levels due to decreased availability of tuber infundibular

dopamine as a result of blockage of the tuberoinfundibular pathway. Evidence showing

exacerbation of positive and negative symptoms in schizophrenia by NMDA receptor antagonists

insinuates the potential role of glutaminergic hypoactivity while serotonergic hyperactivity has

also been shown to play a role in schizophrenia development.

1.2 Etiology

The exact cause of schizophrenia isn’t known. But like cancer and diabetes, schizophrenia is

a real illness with a biological basis. Researchers have uncovered a number of things that

appear to make someone more likely to get schizophrenia, including:

 Genetics (heredity): Schizophrenia can run in families, which means a greater likelihood

to have schizophrenia may be passed on from parents to their children.

 Brain chemistry and circuits: People with schizophrenia may not be able to regulate brain

chemicals called neurotransmitters that control certain pathways, or "circuits," of nerve

cells that affect thinking and behavior.

 Brain abnormality: Research has found abnormal brain structure in people with

schizophrenia. But this doesn’t apply to all people with schizophrenia. It can affect

people without the disease.

 Environment: Things like viral infections, exposure to toxins like marijuana, or highly

stressful situations may trigger schizophrenia in people whose genes make them more

likely to get the disorder. Schizophrenia more often surfaces when the body is having

hormonal and physical changes, like those that happen during the teen and young adult

years.
 1.3 Risk factors

Although the precise cause of schizophrenia isn't known, certain factors seem to increase the risk

of developing or triggering schizophrenia, including:

 Having a family history of schizophrenia

 Some pregnancy and birth complications, such as malnutrition or exposure to toxins or

viruses that may impact brain development.

 Taking mind-altering (psychoactive or psychotropic) drugs during teen years and young

adulthood.

 Abnormal fetal development and low birth weight

 Gestational diabetes

 Preeclampsia

 Emergency cesarean section and other birthing complications

 Maternal malnutrition and vitamin D deficiency

 Winter births - associated with a 10% higher relative risk

 Urban residence - increases the risk of developing schizophrenia by 2 to 4%

Complications

Left untreated, schizophrenia can result in severe problems that affect every area of life.

Complications that schizophrenia may cause or be associated with include:

 Suicide, suicide attempts and thoughts of suicide

 Anxiety disorders and obsessive-compulsive disorder (OCD)

 Depression

 self-injury

 Abuse of alcohol or other drugs, including nicotine

  Inability to work or attend school

 Financial problems and homelessness

 Social isolation

 Health and medical problems

 Being victimized

 Aggressive behavior, although it's uncommon

1.4 Clinical manifestations

Clinical manifestation related to DSM -V criteria.

Schizophrenia

Symptom

Positive (More Overtly Psychotic)

Symptoms

The "positive," or overtly psychotic,

symptoms are symptoms not seen in

healthy people, include:

 Delusions Patient has have had hallucinations that

 Hallucinations
  Disorganized speech or behavior
hearing things that don't exist.
 Dysfunctional thinking

 Catatonia or other movement Patient has dysfunctional thinking

disorders sometime. Patient answers to questions

may be partially.

Negative (Deficit) Symptoms

"Negative" symptoms disrupt normal

emotions and behaviors and include:

 Social withdrawal
Patient is social withdrawal. Patient love
 "Flat affect," dull or monotonous
isolation.
speech, and lack of facial

expression

 Difficulty expressing emotions

 Lack of self-care

 Inability to feel pleasure

(anhedonia)

Cognitive Symptoms

Cognitive symptoms may be most

difficult to detect and these include:

  Inability to process information

and make decisions

Sometimes patients can't make their own
 Difficulty focusing or paying
decisions.
attention

 Problems with memory or

learning new tasks

Patient cannot remember something.

Affective (or Mood) Symptoms

Affective symptoms refer to those which Patient has had suicidal thoughts 1 year

affect mood. Patients with schizophrenia ago.

often have overlapping depression and

may have suicidal thoughts or behaviors.

Diabetes Mellitus

Signs and Symptoms

 Frequent urination.

 Excessive thirst.
  Unexplained weight loss.
Patient has tingling at hands.

 Extreme hunger.

 Sudden vision changes.

 Tingling or numbness in the hands

or feet.

 Feeling very tired much of the

time.

 Very dry skin.

Hyperlipidemia

 Chest pain or pressure (angina)

 Blockage of blood vessels in brain

and heart

 High blood pressure

 Heart attack

 Stroke

1.5 Diagnostic Test

If symptoms are present, the doctor will perform a complete medical history and physical

examination. Although there are no laboratory tests to specifically diagnose schizophrenia, the
doctor might use various diagnostic tests such as MRI or CT scans or blood tests to rule out

physical illness as the cause of your symptoms.

The doctor or therapist then determines if the person’s symptoms point to a specific disorder as

outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is

published by the American Psychiatric Association and is the standard reference book for

recognized mental illnesses.

1.6. DSM-V

Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5)

Two or more of the following symptoms must be present for a significant portion of time during

a one-month period:

 Delusions

 Hallucinations

 Disorganized speech

 Grossly disorganized or catatonic behavior

 Negative symptoms.

1.7 Medical treatment

The goal of schizophrenia treatment is to ease the symptoms and to cut the chances of a relapse

or return of symptoms. Treatment for schizophrenia may include:

 Medications: The primary medications used to treat schizophrenia are called

antipsychotics. These drugs don’t cure schizophrenia but help relieve the most troubling

symptoms, including delusions, hallucinations, and thinking problems.

 Antipsychotics drugs. Antipsychotics are usually recommended as the initial treatment

for the symptoms of an acute schizophrenic episode. They work by blocking the effect of

the chemical dopamine on the brain.

Antipsychotics can usually reduce feelings of anxiety or aggression within a few hours of

use but may take several days or weeks to reduce other symptoms, such as hallucinations

or delusional thoughts.

Typical (First-Generationer conventional Antipsychotic Drugs). ¡The medications block a

brain chemical “dopamine “and effectively control the hallucinations, delusions, and

confusion Cheaper than second-generation antipsychotics.

These first-generation antipsychotics have frequent and potentially significant

neurological side effects, including the possibility of developing a movement disorder

extrapyramidal symptom (EPS) and galactorrhea.

Anticholinergic effect: Tachycardia, tremor, insomnia, postural hypotension.

Atypical (second generation, the newer, novel antipsychotic Drugs)

They’re newer than the first-generation drugs. These medications might work on both

serotonin and dopamine receptors. Lower risk of serious side effects than first-generation

antipsychotics.
 Rehabilitation, which focuses on social skills and job training to help people with

schizophrenia function in the community and live as independently as possible.

 Cognitive behavior therapy (CBT). This can help the person change their thinking and

behavior. A therapist will show them ways to deal with voices and hallucinations. With a

combination of CBT sessions and medication, they can eventually tell what triggers their

psychotic episodes (times when hallucinations or delusions flare up) and how to reduce

or stop them.

 Individual psychotherapy, which can help the person better understand their illness, and

learn coping and problem-solving skills.

 Family therapy, which can help families deal with a loved one who has schizophrenia,

enabling them to better help their loved one

 Group therapy/support groups, which can provide continuing mutual support

 Hospitalization: Many people with schizophrenia may be treated as outpatients. But

hospitalization may be the best option for people:

1. With severe symptoms

2. Who might harm themselves or others.

3. Who can’t take care of themselves at home.

 Electroconvulsive therapy (ECT): The application of metal electrodes to the brain,

through which an electric current is delivered. ECT is an effective intervention in the

treatment of severe depression, although it remains a controversial.

 Indication. Not respond to medication used Present several adverse drug effects First

treatment before using medication Patients who were diagnosed with:

 Schizophrenia

 Affective and mood disorders

 manic episode

 depressive episode

 Major Depressive Disorder (MDD)

 present suicidal idea

Contraindication

 Severe hypertension

 Cardiac disease / myocardial infarction (MI)

 Space-occupying lesion

 Retinal detachment

 Osteoporosis

 Having plate and screw

 Pregnancy women (first trimester)

 Increase intra-cranial pressure (IICP)O

 Organic brain and related disposers.

Pre-ECT care

 Provide inform consent

  Interpret laboratory result

 Provide NPO 6-8 hours prior to ECT

 Review the medication used of each patient

 Tell the patient to take a bath, hair shampoo and dry

 Keep all personal accessories and denture

During ECT care

 Approach the patient

 Adjust patient position: supine position

 Support the small pillow at neck and waist

 Monitor V/S

 Provide the electrodes placement

 Provide mouth gag

 Support the patient at shoulder, wrist, hip, and knees areas

Post-ECT care

 Monitor V/S; post operative care

 Adjust patient position: comfortable position

 Provide food and drink when the patient is full recovery

 Observe and monitor the adverse effects

 Encourage patient to participate the group activity after day 1 of ECT

 2. Personal history and Family history.

2.1 Personal history and social history regarding the developmental psychology theory.

Generativity versus stagnation is the seventh of eight stages of Erik Erikson's theory of

psychosocial development. This stage takes place during middle adulthood (ages 40 to 65 yrs)

This patient is in the stage of stagnation because she is a dependent person, she cannot support

her grandchildren. She has no child. She has no job that mean she has no social position.

Present illness: Paranoid schizophrenia including continuous treatment resistance.

Past illness. She did not smoke and did not drink alcohol. She did not allergy to drug.

She has no operation history. Her underlying diseases are DM and hyperlipidemia.

Sociocultural Orientation

 Social structure: She is Thai, born in Thailand. She did not work.

 Customs: She speaks Thai. she has no social role in the village.

 Values: She speaks Thai. she has no social role in the village.

 Beliefs: She believes that praying can help her to recover from disease.

2.2 Family history.

Family system factor

 Composition and stage of development: She is the older sister.

 Member’s role and tasks: She is older sister in the house.

 Condition of living: She has Two-storey house, upstairs in wood, downstairs cement. The

village closes to city. Her house has less tree.

 Patterns of living: She only stays at home and watching TV. She acts as house

keeper. She is friendly person when talk to her. She loves isolation.
 Health care system Factors: She has Universal Health Coverage. She got treatment of

psychiatric at Samutprakarn hospital. She got treatment of DM and high cholesterol at

public Health center. When she has small symptom, she will take medication by herself.

 Relevant Life experiences: When she stresses, she will be annoyed. She will cope by take

medication and watch TV or she will drink nectar.

2.3 Present history of mental illness and chief complaint.

Present illness: Paranoid schizophrenia including continuous treatment resistance

2.4 Past history

2.4.1 Obstetrical history

Patient has no child

2.4.2 Developmental history

Developmental state

 Psychosocial development: The patient is in the aging state.

According to the Erikson’s theory of psychosocial development. Patient age is 64 years

old. This patient is the stagnation stage. She is a dependent person; she cannot support

her grandchildren. She has no child. She has no job that mean she has no social position.

 Physical development: Height = 155 cm, Body weight = 50, BMI is 20.81, which is

healthy. Her fine is working as she can grab her stuff. Her gross motor is working. As she

can walk normally. Her fine and cross motor is coordinate.

 Cognitive: She graduated from grade 4. She can communicate and response to some

question correctly.

2.4.3 Education history

 She graduated from grade 4.

2.4.4 Past physical illness

U/D: Diabetes mellitus, high cholesterol.

Operation history: None

Smoke: None

Alcohol: None

Allergy history: seafood

Foundation Capabilities and Disposition

Sensation & Perception: Her sensation is normal, including smell, taste, hearing, touch, and

vision.

Memory: She can remember about some story such as her family but some she cannot.

Capability: She can perform ADLs by herself. She can do chore.

Attention & Interest: She pays attention when asking the question.

Self-awareness: She knows about her disease.

Self-acceptance: She accept about her diseases.

Self-concern: She concern about her condition.

Habits: She only stays at home and watching TV. She loves isolation.

Power Components of Self Care Agency

Ability to maintain attention and vigilance related to self-internal ana external conditions.

- She can pay attention when nursing is asking question to her.

Controlled use of the physical energy sufficient for self-care

- She cannot control the physical energy for self-care well because sometime if she not hungry,

she does not eat.

Ability to control the position of the body and body part in movement for self-care.

- She cannot control the position of the body and body part in movement for self-care well

because she has knee and back pain that make, she unable to walk stable.

Ability to reason within self-care frame of reference.

- She knew the result of exercise that will help her to be healthy.

Motivation

- She is happy when watching TV, it will help her

Ability to make and operationalize decisions

- She can make decision by herself such as when she want to eat something, she will order it

by herself.

Ability to acquire, retain and operationalize technical knowledge about self-care

- She has ability to retain technical knowledges about Self-care such as doing activity daily

living.

Possession of cognitive, manipulative, communication, and interpersonal skill for self-care

- Patient speaks Thai, has eye contact when talking with nursing student.

He noticed that the toiletries were out of stock. she will tell relatives ใ

bought it for her.

- Ability to priorities self-care actions to achieve goals.

She has ability to priorities action to archive goals such as cleaning the house, do the laundry.
- Ability to consistently perform self-care and integrate it into daily life.

She has ability to priorities action to archive goals such as cleaning the house, do the laundry.

Therapeutic Self-care Demand

A. Universal Self-care requisites

1.Maintenance of sufficient intake of:

 Air: She can breathe by herself in the room air.

 Water: She drink water 2 liter per day.

 Food: She eat food 5 meal per day but small meal.

2. Provision of care for eliminations.

- Her urine output is yellow which is normal and normal range of amount.

3. Maintenance of balance between activity and rest.

 Exercise: She do exercise as she is doing housework.

 Activities/recreation: She can perform ADLs by herself.

 Relaxation: Watching TV and pray.

 Sleep pattern: She has deep sleep at night.

B. Development Self-care requites

1. Maturation: (progress toward higher level of maturation)

 - She has maturation.

2. Situation: (Prevention of deleterious effects rate to)

- She tries to follow her treatment

USCR continue:

5. Prevention of hazards:

Accident prevention: (In home/motor vehicle/other)

- She needs to prevent from suicidal attempt relative say that the client has the suicidal ideas.

Substance abuse: (medication/alcohol/tobacco/others)

- She did not use alcohol, tobacco use, and substance abuse.

Protection from communicable disease

- She got COVID-19 Vaccines 3 dose and 1 dose of influenza vaccine.

6. Promotion of normal in function and development

- She promotes normal function and development

C. Health deviation self-care requisites

1. Seeking and scouring appropriate medical assistance

- She seeks the medical assistance by herself.

2. Being aware of and taking care of effects of pathological condition

- She aware of and taking care of her condition.

3. Effectively carrying out prescribed diagnostic or rehabilitative measures.

- She follows treatment such as she always takes the medication as doctor prescribed.

4.Being aware of and taking care of side effects of medical care measures.

- She knows the side effect of medication

5. Modifying self-concept and self-image, accepting health state and need for health care.

- She knows how tom take care herself and how to cope with moody.

6. Learning to live with the effects of pathological conditions and medical care measures.

- She is learning to live with her illness.

2.4.5 Past psychological illness

The patient has had this disease for 25 years. During the first 10 years, the patient

took medicine from the clinic. And after that, the patient stopped taking medicine for 10
 years and had just come to take medicine continuously for 5 years after at Samut Prakan

Hospital.

3. Review physical and mental assessment.

3.1 Physical assessment

Health Assessment: Physical assessment

Patient is a 64 years-old Thai female. She has a good conscious. She can answer the question.

Skin & Nail: Her skin is moist and no redness and lesion. Her nail is short, and the color is pink

HEET: Her head is symmetry and normal shape and size, no mass, no lesion and no tenderness

and swollen. Her hair is gray and short and has a good hygiene. Her ears are symmetrical.

Nose: Her nose is symmetrical and in the midline. There is some discharge from the nose.

Throat, mouth and oral: She has 8 teeth left. Her mouth has not wound/bleeding, and no

swelling.

Musculoskeletal: She can perform ADLs and Rom well

Neurological: She has a good conscious.

3.2 Mental assessment

From depression screening form 2 question (2Q)

The result is normal or not depressed

From depression screening form 9 question (9Q)

The result is there are no symptoms of depression or there are very few symptoms

of depression.

MMSE – Thai 2002

The result is that she is normal elderly that have attended primary school.

Patient
 4. Medical diagnosis and nursing opinion of the diagnosis including the supportive data.

Medically, the patient is diagnosed with Paranoid schizophrenia including continuous

treatment resistance.

Nursing opinion of the diagnosis related to DSM-V

I. Compare theory and the client

TOPIC THEORY CLIENT

DSM -V DSM-V diagnostic criteria for schizophrenia The patient has auditory

A. Two (or more) of the following hallucination that she heard the

symptoms people telling her to do

present for one month, at least one of these somethings.

must be (1), (2), or (3): The patient had history of

1.Delusions suicidal thoughts 1 year ago.

2.hailucinations Patient is social withdrawal.

3.disorganized speech

4.grossly disorganized or catatonic behavior

5.negative symptoms

B. Decline in social and/or occupationally

functioning since the onset of illness

C. Continuous signs of illness for at least

six months with at least one month of

active symptoms.

D. Schizoaffective disorder and mood

disorder with psychotic features have

 been excluded.

E. The disturbance is not due to substance

abuse or a medical condition.

Symptoms The symptoms of schizophrenia are usually

classified into:

 Positive symptoms–any change in

behavior or thoughts.

(Delusion, Hallucination, disorganized

speech)

 Negative symptoms–where people

appear to withdraw from the world

around then, take no interest in

everyday social interactions, and often

appear emotionless and flat.

Lack of emotion expression-blunted

affect

Alogia –decrease verbal

communication

Avolition-having no drive to do

anything (Neglect of activities of daily

living)

Decrease interest in social interaction-

withdrawal, poor rapport

 Diminish ability for abstract thinking

Treatment - Medicine Medicine

modality  Antipsychotic Drugs Patient take the medication such

-Medicine  first-generation antipsychotics as risperidone, lorazepam and

-Group activity  Chlorpromazine(Thorazine), Fluoxetine.

-Psychotherapy Fluphenazine (Proxlixin), Haloperidol

(Haldol), Loxapine (Loxitane),

Perphenazine(Trilafon),

Pimozide(Orap),

Thioridazine(Mellaril),

Thiothixene(Navane),

Trifluoperazine(Stelazine).

 second generation

 Lurasidone (Latuda),

Olanzapine(Zyprexa),

Paliperidone(Invega),

Pimavanserin(Nuplazid),

Quetiapine(Seroquel),

Risperidone(Risperdal),

Ziprasidone(Geodon).

-Family therapy

 Family therapy is a type of counselling

that help family members improve

 communication and resolve the

conflict. To facilitate and change in

family by helping the client improve

trouble relationship with family

members.

-Psychotherapy therapy

 Psychological therapies refer to a range

of interventions, based on

psychological concepts and theory,

which are designed to help people

understand and make changes to their

thinking, behavior and relationships in

order to relieve distress and to improve

functioning

-Milieu therapy

 It is one of activity therapy which

involves the environment in the

treatment process, the participation of

patients and staff indecision making,

the use of multidisplinaryteam, open

communication and individualized

goal setting with patients.

- Cognitive therapy
  Cognitive behavioral therapy is a short-

term, problem-focused approach with

the goal of teaching people who have

schizophrenia a variety of coping skills

to help them manage difficult

situations. This type of therapy is

typically given for one hour a week

during 12 to 16 weeks.

Rehabilitation Psychiatric rehabilitation for schizophrenia

involves utilizing psychosocial interventions to Brain training

assist persons with the illness to attain their

highest level of independent functioning,

strongest level of symptom control, and

greatest level of subjective life satisfaction.

Yes, the patient has schizophrenia by her behavior and mental such as social withdrawal,

memory loss sometimes. The patient hallucinated before. The patient hears people telling her to

do somethings. The patient had suicidal thoughts, but during the past month the patient's

symptoms have improved significantly due to continued medication and in the past month, the

patient has no hallucinations and can hear the sound.

5. Medical treatment. (identify in details including result and side effects, complication of each

treatment)
Nursing and Medical Treatment & Therapies

Order date Drug Dose/Route/Frequency Rational

Everyday Risperidone 2 mg 2tab oral hs. Therapeutic class:

atypical antipsychotics

Indications/Uses:

Risperidone is used to

treat schizophrenia,

bipolar disorder, or

irritability associated

with autistic disorder.

This medicine should

not be used to treat

behavioral problems in

older adults who have

dementia. This medicine

is available only with

your doctor's

prescription

Side effects:

 nausea.

 vomiting.
  diarrhea.

 constipation.

 heartburn.

 dry mouth.

 increased saliva.

 increased

appetite.

Trihexyphenide 5 mg 1 tab oral hs. and Therapeutic class:

2 mg 1 tab oral pc antimuscarinics

breakfast Indications/Uses:

Trihexyphenidyl is used

alone or together with

other medicines (e.g.,

levodopa) to treat

Parkinson's disease. By

improving muscle

control and reducing

stiffness, this medicine

allows more normal

movements of the body

as the disease symptoms

are reduced.

Side effects:
  dizziness or

blurred vision.

 dry mouth.

 upset stomach.

 vomiting.

 constipation.

 headache.

 difficulty

urinating.

Lorazepam 0.5 mg 1 tab oral OD Therapeutic class:

pc After breakfast benzodiazepines

Indications/Uses:

Ativan (lorazepam) is

indicated for the

management of anxiety

disorders or for the

short-term relief of the

symptoms of anxiety or

anxiety associated with

depressive symptoms.

Anxiety or tension

associated with the

 stress of everyday life

usually does not require

treatment with an

anxiolytic.

Side effects:

 drowsiness.

 dizziness.

 tiredness.

 weakness.

 dry mouth.

 diarrhea.

 nausea.

 changes in

appetite

Fluoxetine 20 mg 2 tab pc OD Therapeutic class:

After breakfast selective serotonin

reuptake inhibitors

(SSRIs)

Indications/Uses:

Fluoxetine is FDA-

approved for major

depressive disorder (age

eight and older),

obsessive-compulsive

disorder, panic disorder,

bulimia, binge eating

disorder, premenstrual

dysphoric disorder, and

bipolar depression, as

well as treatment-

resistant depression

when used in

combination with

olanzapine.

Side effects:

 nervousness.

 anxiety.

 difficulty falling

asleep or staying

asleep.

 nausea.

 diarrhea.

 dry mouth.

 heartburn.
  yawning.

6. Analysis of the cause of present mental illness concerning predisposing factors,

precipitating factors, and defense mechanisms.

Factor Predisposing Preciptating Perpetuating Protective factor

factor

Biological

Psychological Conflict with hus Younger sister

band (husband us

e substance)

Social Lack of pees Government

allowance.

6.3 Defense mechanisms

None

7. Nursing management

Therapeutic self-care demand

1. The patient needs to reduce Irritability.

 2. The patient needs to reduce memory loss.

3. The patient needs to reduce anxiety.

4. The patient needs to reduce depressive mood.

5. The patient needs to improve social interaction.

6. The patient needs to promote knowledge.

7. The patient needs to promote skin integrity.

07/04/2022

Nursing Care Plan Day3

Nursing diagnosis Nursing action Rational Evaluation

Irritability related to 1. Maintain low level of 1. The Irritability - Patient stayed at

unstable mood. stimuli in client’s can stimulate by low stimuli

environment (low the environment. environment.

light, few people, 2. To… - patient do not

simple decor, low harm self and

noise level. 3. To ensure other.

2. Nurses must maintain client (and - She try to cope

and convey a calm others’) safety. with unstable

attitude toward patient. mood.

3. Suggest the relative to -Patients take

take care the client’s 4. To reduce medication as

 behavior frequently (at unstable provided.

least 2 hours). Do this

when carrying out 4. To promote

routine activities. relaxation and

4. Encourage the patient relieve client’s

to ventilate her feeling. tension also,

promote
5. Encourage the client to
excretion of
do physical exercise.
endorphin

 Provide medication

risperidone as

prescribe and monitor

side effect such as

nausea.

 vomiting.

 diarrhea.

 constipation.

 heartburn.

 dry mouth.

 increased saliva.

 increased appetite

 aggressive behavior.

 agitation.
Subjective data: The

patient said that in

the morning

sometimes she has

irritable or moody.

Objective data:

Nursing goal: To

prevent harm to self

or others.

Expected outcome:

The Patient will not

 harm self or others.

05/04/2022

Nursing Care Plan Day2

Nursing diagnosis Nursing action Rational Evaluation

Cognitive impairment 1. Interact with the client 1. Helps focus -Patients pay

related to discontinue in clam environment attention attention to

as evidenced by 2. Approach the client externally. nursing students.

memory loss with respected, 2 To promote - Patient feel

acceptance, and relationship and relax to talk

empathic built trust. when showing

understanding. 3.To build empathy to her.

3. Use sample relationship -Patients

explanations and face- with the client. maintain takings

to-face interaction 4. To make the medication.

when communicating patient - Patients have a

with the client. understand. good sleep.

4. Replete the sentence -Patient can cope

again if the patient does with worrying

 not understand or present thought.

suspicious to the nursing

student.

5. Frequently orient client To assess the

to time, place, and person and conscious and

surroundings. memory of the

patient.

6. Arrange the milieu To help client

therapy for the client. learn healthier

ways of

thinking,

interacting, and

behaving in a

larger society.

1. Set the schedule for the To promote

client to do activity recall memory.

Subjective data: 2. Create the activity such To maintain

as matching card. brain

functioning

Patient said that she 3. Give positive To make the

has often forgotten. reinforcement for patient have the

patient when she encouragement

continues to take the to continue

 medicine. treatment.

Objective data:

Patient cannot

remember that how

many members live in

her house.

Nursing goal: To

reduce memory loss.

Expected outcome:

Patient can remember

how many persons in

her house.

12/04/2022
 Nursing Care Plan Day6

Nursing diagnosis Nursing action Rational

Anxiety related to imbalance 1. Assess the anxiety level of the 1. To establish a

neurotransmitter. patient, anxiety triggers and baseline observation of

symptoms by asking open-ended the anxiety level of the

questions. patient.

2. Ensure to speak in a calm and 3. To establish

non-threatening manner to the interested when patient

patient including respect and speaks.

acceptance. 4. To promote

3. Maintain eye contact when relaxation and reduce

communicating with him/her. acxiety levels.

4. Maintain the personal space of

the client but sit not too far from

her.

5. Teach the patient to perform

relaxation techniques such as

deep breathing exercises, guided

imagery, meditation, and

progressive muscle relaxation.

Subjective data: Patient said that

she worries about care giver might

be worried about her that care giver

could not so some activity outside

house.

Objective data:

The patient expression worry face

when taking about her concern with

wrinkle eyebrow.

Nursing goal: To reduce anxiety.

Expected outcome: Patient

verbalized that she could cope with

anxiety

08/04/2022

Nursing care plan 4

 Nursing diagnosis Nursing action Rational Evaluation

Depressive mood 1. Assessment of 1. To planed - Patients look

related to loss of depression mood. nursing happy when

husband 2. Encourage patient to intervention. taking.

identify and verbalize 2.The process of - Patient do not

feelings and identifying talk about her

perceptions. feelings that feeling.

3. Encourage patient to underlie and -Patients take a

review relationship drive behavior responsibility for

with her husband and allows the self-care.

the nursing student patient to take

support her. control of her

4. If indicated, share life.

stories of how others 3.Helping

have coped with patients set

similar situations. realistic goals

5. Help the patient to increases sense

solve her feeling by of control and

discussion and identify satisfaction.

coping strategies. 4.It gives the

Provide medication as impression that

prescribed such as Fluoxetine. the problem is

 Side effects: manageable.

 nervousness. 5. To reduce

 anxiety. depressive mood.

 difficulty falling asleep

or staying asleep.

Subjective data: The

patient said that her

husband passed

away 10 years ago.

The patient's relative

said that the patient

was mourning when

she was alone.

Objective data: -

Nursing goal: To
reduce depressive

mood

Expected outcome:

Patients can discuss

the strategy to cope

with depression.

Nursing Care Plan Day 1.

Nursing diagnosis Nursing action Rational Evaluation

Impaired social 4. Assess medicine in 1. To plan the - Patients always

interaction related to take and behavior of intervention for take medicines as

annoyed. isolation related to patient correctly. prescribed by the

annoy feeling 2. To reduce doctor.

5. Structure times each agitation and - Patients feel

day to include annoyed. comfortable when

planned times for 3. To helps client environment free

Subjective data: The brief interactions and to reduce stimuli of stimuli.

patient said that she activities with the of annoyed. - Patient do not

did not like to go out client on one-on-one 6. Teach client feel or trust

and was only at basis. skills in dealing nursing student

home. 6. Approach patient with social yet.

The patient's relatives one-on-one activities withdrawal.

said that the patient with a “safe” person 6. To find the

rarely talked to initially. cause of annoyed

anyone because she 7. Encourage patient to and solve the

was annoyed. ventilate when problem.

feeling agitated and

annoyed.

8. Provide mediation as

prescribed.

Risperidone can

reduce.

9. Help the patient to

identify the cause of

annoyed.
Objective:

Nursing goal: To

reduce social

interaction

Expected outcome:

Patient will improve

social interaction by

beginning with the

nursing student,

family, friends, and

neighbors.
12/04/2022

Nursing Care Plan Day 7

Nursing diagnosis Nursing action Patient action Evaluation

Inappropriate behavior 1. Assess ability to 1. To 1. Patient has

related to knowledge learn or perform acknowledge willing to learn.

deficit brain exercise. patient about 2.Patient

2. Assess motivation incorrect understand how

and willingness of brain to do brain

patient to learn. exercise. boosting.

3. Discuss about 2. To

inappropriate acknowledge

behavior of brain the

training. motivation of

4. Encourage patient patient.

to do brain exercise 3. To tach the

follow the method. patient that if

5. Arrange the she has a

activity to practice. inappropriate

behavior of

brain training.

4. To promote
 knowledge of

brain

exercise.

Subjective data:

Patient said that

shaking the head is the

way to stimulate the

brain.

Objective data: Patient

misunderstanding

about brain

stimulation.

Nursing goal: To

promote knowledge
Expected outcome:

Patient can do the

brain exercise.

18/04/2022

Nursing Care Plan

Day 8

Nursing diagnosis Nursing action Rational Evaluation

Impaired skin integrity 1. Assessment Rationale 1. Assessment of the 1. Patient has

related to allergic to Assess the overall condition of the skin redness skin on

weather. condition of the skin. provides baseline forehead.

2. Assess patient’s data for possible 2. Patient has

nutritional status. interventions. healthy BMI.

3. Assess the skin for: 2. To indicating 3. Patient is

Pruritus (itching) or severe protein itching at the

mechanical trauma. depletion and at skin.

 4. Clean, dry, and high-risk of skin 4. Patient clean

moisturize skin, breakdown. and dry the

particularly bony 3. Itching or skin.

prominences, twice daily mechanical traumas 5. Patient eat 5

or as indicated by can result in group of food.

incontinence or sweating. disruptions to skin

5. Encourage patient to eat integrity and reduce

protein rich foods. its barrier function.

4. Smooth, supple

skin is more resistant

to injury

5. To promote skin

integrity.

Subjective data:

Patient said that she

itches on body parts

Objective data: Patient

has redness skin on

forehead.

Nursing goal: To

prevent scraped skin

Expected outcome:

Patient has normal

skin.

7.8 Ethical consideration

Beneficence – Doing good and the right thing for the patient. The patient must be well taken

care of.

Justice – The patient must be treated fairly.

 Confidentiality – The patient's right to privacy. Patient information should not be published,

and while being cared for, it is imperative to take care of the patient's privacy.

8. Conclusion concerning prognosis and suggestion.

The patient is a Thai female aged 64 years old with diagnosis of paranoid schizophrenia

including continuous treatment resistance. On the 4-12 April 2022 that visited the patient was

nervous to talk to nursing student. The patient was able to immediately answer some questions,

and some were unable to answer them. Sometimes the patient is slow to respond to questions.

The patient might forget some information when communicate with her. In the following days I

talked to the patient. The patient feels more trusting and comfortable to talk to. In conclude, the

patient has memory problems. The patient has problem is social withdrawal and self-isolation

because of fear of strangers. The patient may be concerned about having her sister take care of

her. The patient still has some irritability, but the patient can solve the problem by herself. The

problem in the future that may arise is that patients may be at risk of memory loss as the patient

gets older and the patient's lifestyle is not use a lot of thought. Therefore, there is a risk of

forgetfulness, so patients should be trained regularly to reduce the risk of memory loss.
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