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Nursing Care Plan Multiple Setting Nursing Care Plan for a Patient With Schizophrenia
JB is a 19-year-old African American man exhibiting symptoms of schizophrenia for the first time. His parents brought him to the hospital after he was brought home for spring break. He is a freshman at college and is attending on an academic scholarship. He is the oldest child of three and is the first in his family to go to college. His father is a foreman at the local auto plant, and his mother is a receptionist for a physician. His father’s insurance plan allows for a 15-day stay for mental health services. JB has always been a quiet, hard worker with a small circle of friends. His first semester was a lonely one, with disappointing grades. Although he was not at risk to fail out of school, he was at risk of losing his scholarship. At Christmas time, JB was quieter than usual but participated in family activities without prodding. When grandparents, aunts, and uncles asked him about school he was distracted and answered simply that it was fine. His parents returned him to school with some anxiety but thought it was just a difficult adjustment being away from home for the first time. When his parents picked him up for spring break he was disheveled and had not bathed. His side of the dorm room was covered with small pieces of taped paper with single words on them. The words made no sense but JB stated that he put them there “to organize (his) thoughts.” His roommate informed his parents that this behavior started about the same time JB began staying in the room and skipping classes and meals. JB agreed to leave with his parents only after they agreed to take everything home with them. As they packed his belongings, JB sat in the corner of his bed listening to his compact disk player. When his parents asked him what was happening, he merely said, “I have the power.” On the way home JB responded to their questions by saying his professors were trying to take away what he knew. He sat huddled in the back seat of the car with his coat over his head. He laughed and mumbled in response to nothing his parents could hear.
SETTING: INTENSIVE CARE PSYCHIATRIC UNIT/GENERAL HOSPITAL BASELINE ASSESSMENT: This is the first admission for JB, a 19-year-old single African American college student who has not slept for 4 days and is frightened with wide-eyed hypervigilance, pacing, and periods of extended immobility. Is vague about past drug use. Parents do not believe he has used drugs. He appears to be hallucinating, conversing as if someone is in the room. At times he says he is receiving instructions from “the power.” He is unable to write, speak, or think coherently. He is disoriented to time and place and is confused. JB is 6’1”, 155 lb, thin in appearance, but normally developed. Lab values are within normal limits except Hgb, 10.2 and Hct, 32. He has not eaten for several days. Associated Psychiatric Diagnosis Medications Axis I Schizophrenia, catatonic type Axis II None Axis III None Axis IV Educational problems (failing) Social problems (withdrawn from social contacts) Axis V GAF Current = 25 Potential =?
Risperidone (Risperdal) 2 mg bid then titrate to 3 mg bid if needed Lorazepam (Activan) 2 mg PO or IM PRN IM for agitation
Nursing Diagnosis 1: Disturbed Thought Processes Defining Characteristics Related Factors Inaccurate interpretation of stimuli (people thinking his thoughts, trying to take information from his brain). Cognitive dysfunction, including memory deficits, difficulty in problem solving and abstraction. Suspiciousness Hallucinations Confusion/disorientation Impulsivity Inappropriate social behavior
Uncompensated alterations in brain activity.
Outcomes Initial Discharge
- Recognize changes in thinking and behavior.
- Learn coping strategies to deal effectively with
- Use coping strategies to deal with hallucinations and delusions.
hallucinations and delusions.
- Express delusional material less frequently.
- Take Risperdal as prescribed orally.
- Participate in unit activities according to treatment plan.
- Communicate clearly with others.
- Agree to take antipsychotic medication as prescribed.
- Maintain reality orientation.
Interventions Interventions Rationale Ongoing Assessment Initiate a nurse-patient relationship by demonstrating an acceptance of JB as a worthwhile human being through the use of nonjudgmental statements and behavior. Approach in a calm, nurturing manner. Be patient (patient’s brain is not processing data normally) and nurturing. Assist JB in differentiating between his own thoughts and reality. Validate the presence of hallucinations. Identify them as a part of the disorder and explain that they are present because of the metabolic changes that are occurring in his brain. Focus on reality-oriented aspects of the communication.
Teach JB about his disorder. Assure him that the symptoms can be improved and that he can manage the disorder.
Administer Risperdal as prescribed. Teach about the action, side effects, and dosage of medication. Emphasize the importance of taking medication after discharge, even if symptoms go away completely. Ask patient for a commitment to take the medication. When patient is hallucinating, determine the significance to the patient (what are the voices telling him?), then try to reassure JB that he is not alone and then redirect him to the here-and-now.
When patient is making delusional statements, assess the significance of the delusion to the patient (it is frightening), support patient if necessary, and redirect to the here- and-now. Do not try to convince JB
A therapeutic relationship will provide JB support as he develops an awareness of schizophrenia and the implications of the disorder.
Initially, JB will be unable to determine whether or not his hallucinations are reality based. Because hallucinations tend to be repeated, the patient learns that recurring perceptual experiences that are not confirmed by others are hallucinations. The patient can learn to focus on reality and ignore the perceptual experience. Helping JB understand his disorder will give him a sense of control over his disorder and give him the information he needs to manage the symptoms. Risperdal is a monoaminergic antagonist of D 2 and 5-HT 2 postsynaptic. It is indicated for the management of the manifestations of psychotic disorders.
By refocusing JB’s attention from hallucinations to reality, he will begin to develop coping skills to control the perceptual experience. It is important for the nurse to understand the context of the hallucination to provide the appropriate supportive intervention. Delusions, by definition, are fixed false beliefs. They cannot be changed through logical argument. Because the patient is convinced of the truth of the delusion, the
Determine whether or not JB can engage in a relationship.
Determine if JB is convinced that his perceptual experiences are hallucinations.
Assess whether or not JB can process the information. Has the confusion been alleviated?
Observe for relief of positive symptoms and assess for side effects, especially extrapyramidal symptoms (specifically acute dystonic reactions, akathisia, pseudoparkinsonism). Observe for orthostatic hypotension.
Determine whether or not the hallucination is frightening to the patient or giving patient command, especially to harm self or others. Assess patient’s response to the hallucination. Assess his ability to be redirected to the here-and-now.
Assess the meaning of the delusion to the patient. Determine if the patient
interact with others.
Nursing Diagnosis 2: Risk for Violence Defining Characteristics Related Factors Assaultive toward others, self, and environment Presence of pathophysiologic risk factors: delusional thinking
Frightened, secondary to auditory hallucination and delusional thinking Excessive activity and explosive agitated comments (catatonic excitement) Poor impulse control Dysfunctional communication patterns
Outcomes Initial Discharge
- Avoid hurting self or assaulting other patients or staff, with assistance from staff.
- Decrease agitation and aggression.
- Control behavior with assistance from staff and parents.
Interventions Interventions Rationale Ongoing Assessment Acknowledge patient’s fear, hallucinations, and delusions. Be genuine and empathetic. Assure patient that you will help him control behavior and keep him safe. Begin to establish a trusting relationship. Offer patient choices of maintaining safety: staying in the seclusion room, medications to help him relax. Avoid mechanical restraints and a show of force by having several persons approaching him at once.
Administer Ativan 2 mg. Offer oral medication first. If IM necessary, give injections deep into muscle mass; monitor injection sites.
Hallucinations and delusions change an individual’s perception of environmental stimuli. Patient is truly frightened and is responding out of his need to preserve his own safety.
By giving patient choices, he will begin to develop a sense of control over his behavior. Seclusion and restraint are options only for persons exhibiting serious, persistent aggression. The person’s safety must be protected at all times. The exact mechanisms of action are not understood, but the medication is believed to potentiate the inhibitory neurotransmitter γ–aminobutyric acid. It relieves anxiety and produces a sedative effect. Ativan is rapidly absorbed, thus produces desired effects quickly.
Determine if patient is able to hear you. Assess his response to your comments and his ability to concentrate on what is being said.
Listen for his response to choices. Is he able to make choices at this time? Is he starting to engage in the nurse-patient relationship?
Observe for relief of agitation and side effects: drowsiness, dizziness, constipation, diarrhea, dry mouth, nausea.
Evaluation Outcomes Revised Outcomes Interventions JB was placed in seclusion with constant observation. Ativan decreased his agitation and was administered three times. After 2 days he was less agitated and less aggressive. On his third day in the hospital, he was able to come out of the seclusion room for brief periods of time. At these times he would stand in one spot for as long as 20 minutes without moving except to
Demonstrate control of behavior by resisting hallucinations and delusions.
Teach JB about the effects of hallucinations and delusions. Problem-solve with him ways of controlling auditory hallucinations if they continue.
shake his head once in a while.
Nursing Diagnosis 3: Imbalanced Nutrition: Less than Body Requirements Defining Characteristics Related Factors Inadequate food intake less than recommended daily requirement.
Refusal to eat because of delusional thinking: He has “the Power.”
Outcomes Initial Discharge
- Food intake will match energy expenditures (roughly 2,000-3,000 calories)
- JB will eat at least 3 meals per day, with snacks in late afternoon and late evening. 3. Weight will be between 160 and 174 lb. 4. JB will be able to describe the food pyramid and identify foods he likes and amounts for each section.
Interventions Interventions Rationale Ongoing Assessment Offer small frequent meals.
Suggest parents bring meals that JB likes when they visit; encourage family to visit at mealtimes occasionally. Allow JB to eat alone initially; gradually allow him to eat with increasing numbers of patients at mealtimes.
After medications have improved JB’s attention span, teach him about nutritious food selection and the food pyramid.
For someone who has not been eating well, small meals are easier to tolerate.
Familiar foods are more likely to be eaten.
Being comfortable when eating is important. A patient who is uncomfortable with others may not eat in front of other people. JB will not be able to retain information while confused and disoriented.
Intake and output and a calorie count until fluid intake is adequate and calorie intake is 2,500 to 3,000 cal. Intake and output when family members present. Observe family interaction.
Observe JB’s interaction with others to know when he should be encouraged to eat with others.
Assess cognitive functioning to determine when teaching can be implemented.
Evaluation Outcomes Revised Outcomes Interventions JB is eating all meals and snacks with other patients. He has a healthy appetite and has been consuming at least 3,000 calories a day. He weighs 158 lb. JB can identify the foods in the food pyramid but states his mother knows what foods to boy.
Maintain adequate nutrition. Explore the need to continue nutritional education based on plans for JB and his family after discharge.
SUMMARY OF INPATIENT TREATMENT: JB was discharged 2 weeks after admission. He was no longer agitated or aggressive. He reluctantly participated in the group activities, but willingly met with his primary nurse. The discharge plan included JB returning home with his parents and beginning outpatient treatment at the community mental health center. JB adhered to his medication regimen. JB is to participate in the day treatment program.
SETTING: DAY TREATMENT CENTER AT THE COMMUNITY MENTAL HEALTH CENTER CMHC ASSESSMENT: JB is a 19-year-old with a diagnosis of schizophrenia, catatonic type, discharged from an inpatient unit. Hears voices (telling him “you have the power”) and has some delusional thinking (believes people are stealing his thoughts). He is oriented, coherent, and able to complete basic mathematical calculations. He has been faithfully taking
- Identify barriers in interpersonal relationships that interfere with socialization. 4. Practice new social interaction skills.
Interventions Interventions Rationale Ongoing Assessment Initiate a nurse-patient relationship with JB. Establish a time each day to meet with him to support him as he learns to cope with his disorder. Provide supportive group therapy to focus on the here-and-now, establish group norms that discourage inappropriate social behavior, and encourage testing of new social behavior.
Role-play certain accepted social behaviors. Foster development of relationships among group members through self-disclosure and genuineness. Encourage members to validate their perception with others. Monitor adherence to medication regimen. Encourage JB to attend medication group. Ask patient about specific side effects and symptom exacerbations. Encourage JB to attend the evening symptom management group. Identify the environment in which social interactions are impaired (living, learning, working, leisure). Role-play aspects of social interactions such as initiating/terminating a conversation, refusing a request, asking for something, interviewing for a job, asking someone to participate in an activity (going to a movie). Give positive feedback. Focus on no more than three behavioral connections at a time. Assist family and community members in understanding and providing support. With JB’s permission, develop an alliance with the family. Encourage them to attend a support group.
Through a nurse-patient relationship, the patient can learn about his strengths and limitations.
The negative symptoms of schizophrenia can make it difficult to automatically recall appropriate social behavior. Reinforcing appropriate behavior in a group can help the patient add new skills to a limited repertoire of behaviors. Through practicing social interaction, the patient can become comfortable in social situations.
Patients may not be aware that symptoms are erupting. By specifically asking about symptoms and medication side effects, patients can focus on specific experiences that represent symptomatology. Different social skills are needed in different situations.
By practicing specific skills, patients will be able to use them in specific situations. It is then possible to assign a patient to practice a specific social skill. Too much feedback adds confusion and increases anxiety.
Family members are often the patient’s main source of support. The family needs help and support in dealing with the care of a person with a long-term mental illness.
Determine whether or not JB can engage in a relationship.
Assess JB’s ability to interact in the group.
Assess JB’s willingness to participate with others. Assess the availability of people who are his age and have similar interests.
Assess for nonverbal cues that symptoms are present. Monitor for evidence of relapse.
Assess for readiness to return to learning and working environment.
Assess for ability to engage in social interactions.
Assess family interaction.
Evaluation Outcomes Revised Outcomes Interventions JB was able to establish a therapeutic relationship with one of the nurses. Through the relationship and the group, JB identified barriers in his interpersonal relationships. He was afraid of telling his friends about the mental disorder. JB was able to practice various communication strategies and eventually was able to contact his old friends. He also developed some new ones and started sharing leisure activities with them. JB would like to return to school and live at home.
Continue to develop social interaction skills. Discuss with the group the everyday problems encountered outside the day treatment environment.
Continue to practice communication strategies. Maintain medication adherence.
Enroll in community college for one course.
Continue on a part-time basis with the day treatment center.
Monitor medication adherence and ability to communicate.
Teach patient about dealing with stress and relapse prevention techniques.
