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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
Risperidone (Risperdal) 2 mg bid then
Axis II None
titrate to 3 mg bid if needed
Axis III None
Lorazepam (Activan) 2 mg PO or IM PRN
Axis IV Educational problems (failing)
IM for agitation
Social problems (withdrawn from social
contacts)
Axis V GAF Current = 25
Potential = ?
Nursing Diagnosis 1: Disturbed Thought Processes
Defining Characteristics
Related Factors
Inaccurate interpretation of stimuli (people
Uncompensated alterations in brain
thinking his thoughts, trying to take
activity.
information from his brain).
Cognitive dysfunction, including memory
deficits, difficulty in problem solving and
abstraction.
Suspiciousness
Hallucinations
Confusion/disorientation
Impulsivity
Inappropriate social behavior
Outcomes
Initial
1. Recognize changes in thinking and
behavior.
2. Learn coping strategies to deal
effectively with hallucinations and
delusions.
Discharge
6. 6. Use coping strategies to deal with
hallucinations and delusions.
7. 7. Communicate clearly with others.
8. 8. Agree to take antipsychotic medication
as prescribed.
3. Express delusional material less
9. 9. Maintain reality orientation.
frequently.
4. Take Risperdal as prescribed orally.
5. Participate in unit activities according to
treatment plan.
Interventions
Interventions
Rationale
Ongoing Assessment
Initiate a nurse-patient
A therapeutic relationship
Determine whether or not
relationship by
will provide JB support
JB can engage in a
demonstrating an
as he develops an
relationship.
acceptance of JB as a
awareness of
worthwhile human being
schizophrenia and the
through the use of
implications of the
nonjudgmental statements
disorder.
and behavior. Approach
in a calm, nurturing
manner. Be patient
(patient’s brain is not
processing data normally)
and nurturing.
Assist JB in differentiating
Initially, JB will be unable
Determine if JB is
between his own thoughts
to determine whether or
convinced that his
and reality. Validate the
not his hallucinations are
perceptual experiences
presence of
reality based. Because
are hallucinations.
hallucinations. Identify
hallucinations tend to be
them as a part of the
repeated, the patient
disorder and explain that
learns that recurring
they are present because
perceptual experiences
of the metabolic changes
that are not confirmed by
that are occurring in his
others are hallucinations.
brain. Focus on reality-
The patient can learn to
oriented aspects of the
focus on reality and
communication.
ignore the perceptual
experience.
Teach JB about his
Helping JB understand his
Assess whether or not JB
disorder. Assure him that
disorder will give him a
can process the
the symptoms can be
sense of control over his
information. Has the
improved and that he can
disorder and give him
confusion been
manage the disorder.
the information he needs
alleviated?
to manage the
symptoms.
Administer Risperdal as
Risperdal is a
Observe for relief of
prescribed. Teach about
monoaminergic
positive symptoms and
the action, side effects,
antagonist of D2 and 5-
assess for side effects,
and dosage of medication.
HT2 postsynaptic. It is
especially extrapyramidal
Emphasize the importance
indicated for the
symptoms (specifically
of taking medication after
management of the
acute dystonic reactions,
discharge, even if
manifestations of
akathisia,
symptoms go away
psychotic disorders.
pseudoparkinsonism).
completely. Ask patient
Observe for orthostatic
for a commitment to take
hypotension.
the medication.
When patient is
By refocusing JB’s
Determine whether or not
hallucinating, determine
attention from
the hallucination is
the significance to the
hallucinations to reality,
frightening to the patient
patient (what are the
he will begin to develop
or giving patient
voices telling him?), then
coping skills to control
command, especially to
try to reassure JB that he
the perceptual
harm self or others.
is not alone and then
experience. It is
Assess patient’s response
redirect him to the here-
important for the nurse
to the hallucination.
and-now.
to understand the context
Assess his ability to be
of the hallucination to
redirected to the here-
provide the appropriate
and-now.
supportive intervention.
When patient is making
Delusions, by definition, are Assess the meaning of the
delusional statements,
fixed false beliefs. They
delusion to the patient.
assess the significance of
cannot be changed
Determine if the patient
the delusion to the patient
through logical
can be redirected.
(it is frightening), support
argument. Because the
patient if necessary, and
patient is convinced of
redirect to the here-and-
the truth of the delusion,
now. Do not try to
the individual should be
convince JB that the
supported if the delusion
delusion is false.
is upsetting to him.
Assist patient in
Patients with schizophrenia
Determine situations that
communicating
typically have problems
cause JB the most
effectively. Encourage
because of the disordered
problem in
patient to attend
thought process.
communicating.
communication groups.
Improving
communication skills
will help the patient cope
with the disorder.
Assess ability for self-care
The negative symptoms of
Monitor patient’s actual
activities. Identify areas
schizophrenia can
ability to complete self-
of physical care for which
interfere with the
care activities. Assist
the patient needs
patient’s ability to
when necessary.
assistance. Note level of
complete daily living
motivation and interest in
activities.
appearance.
Assess sleep and rest
JB was unable to sleep
patterns. If problems with
before admission. The
sleep continue after
prescribed medications
initiation of medication,
are sedating and may
explore techniques that
reverse the insomnia.
Observe patient’s sleep
cycle.
may promote sleep.
Structure times for sleep,
rest, and diversional
activities.
Evaluation
Outcomes
Revised Outcomes
Interventions
Within the safety of the
Continue to learn about
Refer to symptom
nurse-patient
relationship, JB
acknowledges that his
thinking and behavior
have changed from the
schizophrenia.
management group at the
mental health center.
beginning of school
until now. He is
perplexed by the
change.
JB continues to have
Use strategies to reduce
Encourage JB to practice
hallucinations and
hallucinations and
strategies that reduce
delusional thinking. He
delusions. Structure daily
hallucinations and
is beginning to develop
activities to avoid
delusions. Discuss the
strategies for dealing
isolation, withdrawal,
development of a daily
with the unusual
and negative symptoms.
routine with JB and his
perceptual experiences.
parents.
He is also having
problems with being
motivated to complete
daily activities.
JB understood that he had a
disorder called
Continue to learn about
Refer to case manager and
schizophrenia.
recommend individual
schizophrenia, but was
supportive therapy at the
not sure what it meant.
mental health clinic.
The medication has
Continue to take medication Refer to medication group
decreased the intensity
as prescribed.
at the mental health
of the hallucinations and
center.
the frequency of
delusional thoughts. He
agrees to take the
Risperdal as prescribed.
Through attending the unit
Develop communication
Discuss the possibility of a
activities, JB was able
skills to interact with
day treatment program
to improve his
others.
for JB that will help him
communication skills
improve his
and maintain reality
communication skills.
orientation.
Nursing Diagnosis 2: Risk for Violence
Defining Characteristics
Related Factors
Assaultive toward others, self, and
Frightened, secondary to auditory
environment
hallucination and delusional thinking
Presence of pathophysiologic risk factors:
delusional thinking
Excessive activity and explosive agitated
comments (catatonic excitement)
Poor impulse control
Dysfunctional communication patterns
Outcomes
Initial
Discharge
1. Avoid hurting self or assaulting other
3. Control behavior with assistance from
patients or staff, with assistance from
staff and parents.
staff.
2. Decrease agitation and aggression.
Interventions
Interventions
Rationale
Ongoing Assessment
Acknowledge patient’s fear,
Hallucinations and
Determine if patient is able
hallucinations, and
delusions change an
to hear you. Assess his
delusions. Be genuine and
individual’s perception of
response to your
empathetic. Assure patient
environmental stimuli.
comments and his ability
that you will help him
Patient is truly frightened
to concentrate on what is
control behavior and keep
and is responding out of
being said.
him safe. Begin to
his need to preserve his
establish a trusting
own safety.
relationship.
Offer patient choices of
By giving patient choices,
Listen for his response to
maintaining safety:
he will begin to develop a
choices. Is he able to
staying in the seclusion
sense of control over his
make choices at this
room, medications to help
behavior. Seclusion and
time? Is he starting to
him relax. Avoid
restraint are options only
engage in the nurse-
mechanical restraints and
for persons exhibiting
patient relationship?
a show of force by having
serious, persistent
several persons
aggression. The person’s
approaching him at once.
safety must be protected at
all times.
Administer Ativan 2 mg.
Offer oral medication
The exact mechanisms of
action are not understood,
Observe for relief of
agitation and side effects:
first. If IM necessary, give
but the medication is
drowsiness, dizziness,
injections deep into
believed to potentiate the
constipation, diarrhea, dry
muscle mass; monitor
inhibitory neurotransmitter
mouth, nausea.
injection sites.
γ–aminobutyric acid. It
relieves anxiety and
produces a sedative effect.
Ativan is rapidly absorbed,
thus produces desired
effects quickly.
Evaluation
Outcomes
Revised Outcomes
Interventions
JB was placed in seclusion
Demonstrate control of
Teach JB about the effects
with constant observation.
behavior by resisting
of hallucinations and
Ativan decreased his
hallucinations and
delusions. Problem-solve
agitation and was
delusions.
with him ways of
administered three times.
controlling auditory
After 2 days he was less
hallucinations if they
agitated and less
continue.
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 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
Refusal to eat because of delusional
recommended daily requirement.
thinking: He has “the Power.”
Outcomes
Initial
Discharge
1. Food intake will match energy
3. Weight will be between 160 and 174 lb.
expenditures (roughly 2,000-3,000
4. JB will be able to describe the food
calories)
pyramid and identify foods he likes and
2. JB will eat at least 3 meals per day, with
amounts for each section.
snacks in late afternoon and late evening.
Interventions
Interventions
Rationale
Ongoing Assessment
Offer small frequent meals.
For someone who has not
Intake and output and a
been eating well, small
calorie count until fluid
meals are easier to
intake is adequate and
tolerate.
calorie intake is 2,500 to
3,000 cal.
Suggest parents bring meals
Familiar foods are more
Intake and output when
that JB likes when they
likely to be eaten.
family members present.
visit; encourage family to
Observe family interaction.
visit at mealtimes
occasionally.
Allow JB to eat alone
Being comfortable when
Observe JB’s interaction
initially; gradually allow
eating is important. A
with others to know when
him to eat with increasing
patient who is
he should be encouraged to
numbers of patients at
uncomfortable with
eat with others.
mealtimes.
others may not eat in
front of other people.
After medications have
JB will not be able to retain
Assess cognitive
improved JB’s attention
information while
functioning to determine
span, teach him about
confused and
when teaching can be
nutritious food selection
disoriented.
implemented.
and the food pyramid.
Evaluation
Outcomes
Revised Outcomes
Interventions
JB is eating all meals and
Maintain adequate nutrition. Explore the need to
snacks with other patients.
continue nutritional
He has a healthy appetite
education based on plans
and has been consuming
for JB and his family
at least 3,000 calories a
after discharge.
day. He weighs 158 lb.
JB can identify the foods in
the food pyramid but
states his mother knows
what foods to boy.
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 his medication (Risperdal 4 mg od). No side effects are evident. He is
reclusive at home, staying in his room most of the time. Refuses to contact old friends.
He is eating well, but his parents report that he is not sleeping well at night. They hear
him pacing and mumbling to himself. He then naps during the day. He has agreed to
attend the day treatment program with eventual reintegration into society.
Nursing Diagnosis 1: Disturbed Sleep Pattern
Defining Characteristics
Related Factors
Difficulty falling or remaining asleep
Excessive hyperactivity secondary to
Dozing during the day
catatonic excitement
Excessive daytime sleeping
Inadequate daytime activities
Outcomes
Initial
Discharge
1. JB will sleep between 5 and 8 hours each 3. JB will sleep 7-8 hours each 24-hour
24-hour period.
period between the hours of 10 PM and
2. Describe factors that prevent or inhibit
sleep.
7:30 AM.
4. Identify techniques to induce sleep.
5. Report an optimal balance of rest and
activity.
Interventions
Interventions
Rationale
Ongoing Assessment
Assess JB’s sleep cycle.
A thorough understanding
Determine if JB has trouble
Report time he goes to
of sleep cycle is important
falling asleep or if he
bed, ability to fall to
to develop strategies that
wakes up in the middle of
sleep, waking up in the
will improve sleep
the night. Do his voices
middle of the night.
hygiene.
and thoughts wake him?
Is there any evidence of
nightmares?
Increase activities by
Increasing activities during
Monitor JB’s ability to stay
attending day treatment
the day will help readjust
alert and active at the day
program daily. Encourage
sleep cycle.
treatment center.
JB to resist urge to sleep
during the day. Establish a
daily routine for getting
up and going to bed.
Plan with patient how to
increase physical exercise.
Regular physical exercise
improves sleep hygiene.
Determine if JB is willing
to exercise and can
develop a realistic
exercise plan.
Evaluation
Outcomes
Revised Outcomes
Interventions
After JB began attending
None.
None.
day treatment program, he
and his family reported
that he slept all night.
Nursing Diagnosis 2: Impaired Social Interactions
Defining Characteristics
Related Factors
Inability to establish and maintain stable
Embarrassment about mental illness
relationship
Communication barriers secondary to
Dissatisfied with social network
schizophrenia
Avoidance of others
Alienation from others secondary to
Interpersonal difficulties
hallucinations, delusions, disorganized
Social isolation
thinking
Lack of social skills
Outcomes
Initial
Discharge
1. Establish a therapeutic relationship with
3. Describe strategies to promote effective
the nurse.
socialization.
2. Identify barriers in interpersonal
4. Practice new social interaction skills.
relationships that interfere with
socialization.
Interventions
Interventions
Rationale
Ongoing Assessment
Initiate a nurse-patient
Through a nurse-patient
Determine whether or not
relationship with JB.
relationship, the patient
JB can engage in a
Establish a time each day
can learn about his
relationship.
to meet with him to
strengths and limitations.
support him as he learns
to cope with his disorder.
Provide supportive group
The negative symptoms of
therapy to focus on the
schizophrenia can make
here-and-now, establish
it difficult to
group norms that
automatically recall
discourage inappropriate
appropriate social
social behavior, and
behavior. Reinforcing
encourage testing of new
appropriate behavior in a
social behavior.
group can help the
patient add new skills to
a limited repertoire of
behaviors.
Assess JB’s ability to
interact in the group.
Role-play certain accepted
Through practicing social
Assess JB’s willingness to
social behaviors. Foster
interaction, the patient
participate with others.
development of
can become comfortable
Assess the availability of
relationships among
in social situations.
people who are his age
group members through
and have similar interests.
self-disclosure and
genuineness. Encourage
members to validate their
perception with others.
Monitor adherence to
Patients may not be aware
Assess for nonverbal cues
medication regimen.
that symptoms are
that symptoms are
Encourage JB to attend
erupting. By specifically
present. Monitor for
medication group. Ask
asking about symptoms
evidence of relapse.
patient about specific side
and medication side
effects and symptom
effects, patients can
exacerbations. Encourage
focus on specific
JB to attend the evening
experiences that
symptom management
represent
group.
symptomatology.
Identify the environment in
Different social skills are
Assess for readiness to
which social interactions
needed in different
return to learning and
are impaired (living,
situations.
working environment.
learning, working,
leisure).
Role-play aspects of social
By practicing specific skills, Assess for ability to engage
interactions such as
patients will be able to
initiating/terminating a
use them in specific
conversation, refusing a
situations. It is then
request, asking for
possible to assign a
something, interviewing
patient to practice a
for a job, asking someone
specific social skill. Too
to participate in an
much feedback adds
activity (going to a
confusion and increases
movie). Give positive
anxiety.
feedback. Focus on no
more than three
in social interactions.
behavioral connections at
a time.
Assist family and
Family members are often
community members in
the patient’s main source
understanding and
of support. The family
providing support. With
needs help and support
JB’s permission, develop
in dealing with the care
an alliance with the
of a person with a long-
family. Encourage them
term mental illness.
Assess family interaction.
to attend a support group.
Evaluation
Outcomes
Revised Outcomes
Interventions
JB was able to establish a
Continue to develop social
Continue on a part-time
therapeutic relationship
interaction skills. Discuss
basis with the day
with one of the nurses.
with the group the
treatment center.
Through the relationship
everyday problems
and the group, JB
encountered outside the
identified barriers in his
day treatment
interpersonal
environment.
relationships. He was
afraid of telling his
friends about the mental
disorder.
JB was able to practice
Continue to practice
Monitor medication
various communication
communication strategies.
adherence and ability to
strategies and eventually
Maintain medication
communicate.
was able to contact his old
adherence.
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.
Enroll in community
college for one course.
Teach patient about dealing
with stress and relapse
prevention techniques.