Capstone Project Focus: Paranoid Schizophrenia

BRANDI ANASTACIO, N360 PMH PROF. CHAT AUGUSTIN

What is Paranoid Schizophrenia?

Schizophrenia: Group of psychotic disorders that affect thinking, behavior, emotions and perception of reality. Usually diagnosed during the late teens and early twenties. Paranoid Schizophrenia is a subtype that is characterized by suspicion of others, hallucinations and/or delusions. This subtype is less likely to experience neurologic and cognitive impairment, resulting in a better prognosis.

DSM-lV-TR: Schizophrenia
Criterion A: Two or more symptoms, each present for a significant portion of time during a 1 month period

Delusions, Hallucinations, Disorganized speech, Grossly disorganized or catatonic behavior, Negative symptoms

Criterion B: Social/occupational dysfunction Criterion C: Duration. Continuous signs of disturbance persist for at least 6 months

Schizophrenia Subtypes

PARANOID TYPE

Preoccupation with one or more delusions or frequent auditory hallucinations None of the following are present: disorganized speech, disorganized or catatonic behavior, flat or inappropriate affect

Case Study: Refer to Concept Map

50 y/o male, diagnosed with paranoid schizophrenia at the age of 24 y/o. Graduated high school and college with a degree in Sociology. Up until a few years ago, he lived in a condo with his mother until she moved to Chicago to be with his sister. He currently lives alone and is unemployed, with hopes to receive social security. Denys any close friends or interpersonal relationships. Schizophrenia has been managed with Haldol. Current admission due to auditory hallucinations that began a few months ago. Client states this is the first episode. He stopped his medications because he thought they were causing the voices. The voices became worse and began to chant. He then sought emergency medical attention due to suicidal ideation. Client states he had a plan to go to a power plant, where he could dissolve himself.

FBS: 90 mg/dL Metformin Lisinopril Hypertension Lives alone in a Condo College Graduate Sociology Major No Religious Preference Diabetes Mellitus

Dx age of 24 Haldol Two previous episodes of AH in the 90s

Paranoid Schizophrenia

Hyperlipidemia

Pravastatin

DSM IV TR:
+AH resulting in social/occupational dysfunction Hx of multiple episodes >1 month duration in a 6 month period

AXIS:
I: Paranoid Schizophrenia III: Diabetes Mellitus, Hypertension and Hyperlipidemia IV: Lives alone, unemployed V: GAF 31-40

Mother and Sister live in Chicago

Unemployed Assessment Per Client

I have a mental illness. Its difficult. It started when I was young, but this has never happened before with voices in my head. The voices are kind of like chanting and they manipulate things, like the TV.

Asst Tool: Suicide Risk Score: 2, No risk

Limitations:
Per Client: Im forgetful. Per Observation: Clients affect is blunted and appears to be experiencing poverty of speech. Per Staff: Although client is able to perform ADLs, he requires frequent reminders to perform hygienic self-care.

Strengths:
Per client: I am independent. Per Observation: Client actively participates in group activities and is appropriate with peers and staff. Per Staff: Client is pleasant within the milieu and approachable; nonimpulsive. Client is able to verbalize needs.

MSE:
Behavior: Calm and appropriate with staff and peers. Affect: Blunted Sensorium: +Auditory Hallucinations Imagery: Disheveled, unkempt Cognition: Inhibited with poverty of thought

gths

Case Study in relation to DSM-lV-TR

Diagnosed at the age of 24 years old

Experiencing auditory hallucinations. Although client states no previous history of hallucinations. Medical chart states two previous episodes, 1991 & 1996, that required hospitalization and an adjustment in medications. Suicidal Ideation and dysfunction in social/occupational aspects of lifestyle

Client presents with blunted affect and slowed speech, not flat affect or disorganized speech.

Evidenced Based Nursing Practice:

Managing Suicide Risk in Patients with Schizophrenia

RE: Safety

Compared with the general population, these patients [with schizophrenia] have an 8.5-fold greater risk of suicide. (Kasckow et al., 2011) 80% of patients with schizophrenia who committed suicide did so while in the hospital or within 6 months of discharge. (Kasckow et al., 2011)

RE: Isolation

It is also important for staff to realize that a more withdrawn or paranoid patient should be regarded as one having an increased risk of suicide. (Kasckow et al., 2011)

An integrated biomedical/psychosocial treatment with standard pharmacotherapy and case management in patients with recent-onset schizophrenia, has also supported the use of integrated care as a way to improve outcomes, including positive and negative symptom outcomes. (Kasckow et al., 2011)

Four Priority Needs and Concerns with Interventions

1. P: Safety E: Verbalization of suicidal ideation upon admission in relation to auditory hallucinations. S: Assess for suicide risk, plan and intent. Establish rapport, encourage client to express feelings and contract for safety at the start of each shift. Reassess as needed. 2. P: Isolation E: Client sits disengaged in the milieu. Client verbalizes the desire to participate. S: Use of therapeutic communication techniques to engage client in group and recreational therapy. 3. P: Coping skills in reducing anxiety related to auditory hallucinations E: Client states the sounds of the TV can make the chanting louder and they manipulate the TV. S: Explore coping skills, i.e. quiet area, distraction and communication of thoughts and feelings. 4. P: Hygiene E: Client appears disheveled, unkempt and is malodorous with greasy hair. S: Remind client of the importance of hygiene, especially in relation to diabetes, and direct client to perform self-care by assisting client in obtaining supplies and guiding to facilities with staff.

Priority # 1 Nursing Diagnosis: Risk for self-directed violence P: Safety E: Verbalization of suicidal ideation upon admission related to auditory hallucinations. S: Assess for suicide risk, plan and intent. Establish rapport, encourage client to express feelings and contract for safety at shift. Reassess as needed. LT goal: Client will not harm himself by discharge. ST goal: Client will not harm himself by the end of the shift.
Intervention & Frequency Interview the patient to assess potential for self-harm at the beginning of each shift. Scientific Rationale People who are suicidal remain ambivalent about wanting to end their lives. Patients may view suicide as the only way to relieve severe, persistent, or recurrent emotional pain. (Gulanick & Meyers, 2011, p.476) The degree of supervision is defined by the degree of risk. (Gulanick & Meyers, 2011, p.477) Evaluation

CARE PLAN

the start of each

With use of suicide risk assessment, score of 4: no risk. Client states I do not feel like hurting myself since the voices have quieted down.

Provide close patient supervision by maintaining observation or awareness of the patient at all times, with random checks.

Performed 1:1 with client. Client did not display an attempt to perform self-harm.

Develop a verbal or written contract stating that the patient will not act on impulse to do self-harm. Review and update the contract as needed or at least every shift.

The patient benefits from talking about suicide ideation with trusted staff. A written or verbal agreement establishes permission to discuss the subject, makes a commitment not to act on impulse, and defines a plan of action in case impulse occurs. (Gulanick & Meyers, 2011, p.477)
Depressed patients need the opportunity to discuss negative thoughts and intentions to harm themselves. Verbalization of these feelings may lessen their intensity. Patients also need to see that staff can tolerate discussion of suicide ideation. (Gulanick & Meyers, 2011, p.477)

Client verbally contracted for safety for the duration of the shift. Client stated I will let staff know if the voices are bad enough for me to want to hurt myself.

Encourage verbalization of negative feelings within appropriate limits, periodically or at least every two hours, assess for this need.

Client reassessed periodically for thoughts of SI and increasing auditory hallucinations resulting in negative thoughts. Client denies thoughts of SI and any negative thoughts.

Reference Gulanick, M., & Myers, J. (2011). Nursing care plans: diagnoses interventions, and outcomes. (7th ed ed.). PA: Mosby

Implications of Care

Legal

Moral

Ethical

Confidentiality Patients Rights

Right to Refuse Right to fair treatment Right to informed consent

This is less complicating with this client because he is admitted voluntarily under an MH-5

Self-Awareness and the ability to morally provide care to all clients and separate ones discriminations in order to provide an equal and the highest quality of care to all clients. Regardless of ethnicity, gender and diagnosis.

This is intertwined with morality and the ability to perform ethically to do good, to do no harm and still allow the client to perform with autonomy in his plan of care. This can be especially difficult in the mental health setting when clients may not be able to make decisions regarding their care or their actions are harming themselves and/or others.

Resources
Fortinash, K. M., & Holoday Worret, P. A. (2012). Psychiatric mental health nursing (5th ed.). St. Louis, MO: Elsevier. Kasckow, J., Felmet, K., & Zisook, S. (2011). Managing suicide risk in patients with schizophrenia. CNS Drugs, 25(2), 129-143. doi:10.2165/11586450-000000000-00000 Kotowski, A. (2012). Case study: a young male with auditory hallucinations in paranoid schizophrenia.

International Journal Of Nursing Knowledge, 23(1), 41-44.