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Transcript
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.