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Varcarolis: Essentials of Psychiatric Mental Health Nursing

Chapter 14: The Schizophrenias Case Study and Nursing Care Plan Paranoid Schizophrenia Tom, a 32-year-old man, is an inpatient at a Veterans Administration hospital. He has been separated from his wife and four children for 3 years. His records state that he has been in and out of hospitals for 13 years. Tom is a former Marine who first heard !oices" at 1# years of a$e while he was ser!in$ in the %ulf &ar. He subse'uently recei!ed a medical dischar$e. The hospitali(ation was precipitated by an e)acerbation of auditory hallucinations. * thou$ht people were followin$ me. * hear !oices, usually a woman+s !oice, and she+s tormentin$ me. ,eople say that it happens because * don+t ta-e my medications. The medications ma-e me tired and * can+t ha!e se)." Tom also uses mari.uana, which he -nows increases his paranoia. *t ma-es me feel $ood, and not much else does." Tom finished 11 years of school but did not $raduate. He says that he has no close friends. He was in prison for / years for manslau$hter and was abusin$ alcohol and dru$s at the time. Ms. 0ally is Tom+s nurse. Tom is dressed in pa.amas and a bathrobe, his hy$iene is $ood, and he is well nourished. He reports that he does not sleep much because the !oices $et worse at ni$ht." Ms. 0ally notes in Tom+s medical record that he has had two episodes of suicidal ideation, durin$ which the !oices were tellin$ him to .ump off rooftops" and in front of trains." 1urin$ the first inter!iew, Tom rarely ma-es eye contact and spea-s in a low monotone. At times, he $lances about the room as if distracted, mumbles to himself, and appears upset. Nurse: Tom, my name is Ms. 0ally. * will be your nurse in the hospital. *f it is o- with you, we will meet e!ery day for 32 minutes at 12 AM. &e can tal- about areas of concern to you. To : &ell . . . don+t belie!e what they say about me. * want to start . . . Are you married3 Nurse: This time is for you to tal- about your concerns. To : 4h . . . 5looks furtively around the room, then lowers his eyes6 * thin- someone is tryin$ to -ill me. Nurse: 7ou seem to be focusin$ on somethin$ other than our con!ersation. To : The !oices tell me thin$s . . . * can+t say. Nurse: * don+t hear any !oices e)cept yours and mine. * will stay with you. Tell me what is happenin$, and * will try to help you. To : The !oices tell me bad thin$s. Ms. 0ally stays with Tom and encoura$es him to communicate with her. As Tom focuses more on the con!ersation, his an)iety appears to lessen. His thou$hts become more connected, he is able to concentrate more, and he mumbles to himself less. !ssess ent

8ase 9tudy and :ursin$ 8are ,lan Objective Data 9pea-s in low monotone Ma-es poor eye contact &ei$ht appropriate for hei$ht 8lean, bathed, clothes match *mpaired reality testin$ Has a history of dru$ abuse 5cocaine and mari.uana6, which appears to contribute to relapses Has no close friends, separated from wife and children &as first hospitali(ed at 1# years of a$e and has not wor-ed since that time Has had suicidal impulses twice, both associated with command hallucinations &as imprisoned for / years for !iolence 5manslau$hter6 and assaulted a peer in the hospital Thou$hts scattered when an)ious Subjective Data * hear !oices." 9omeone is tryin$ to -ill me, * thin-." * don+t ta-e my medications. The medications ma-e me tired and * can+t ha!e se)." The !oices $et worse at ni$ht, and * can+t sleep." 51ru$s6 ma-e me feel $ood . . . not much else does." Voices ha!e told him to .ump off rooftops" and in front of trains".

Self-Assessment 4n the first day of admission, Tom assaults another male patient, statin$ that the patient accused him of bein$ a homose)ual and touched him on the buttoc-s. After assessin$ the incident, the staff a$rees that Tom+s pro!ocation came more from his own pro.ections 5Tom+s se)ual attraction to the other patient6 than from anythin$ the other patient did or said. Tom+s difficulty with impulse control fri$htens Ms. 0ally. 9he has concerns re$ardin$ Tom+s ability to curb his impulses and the possibility of Tom stri-in$ out at her, especially when Tom is hallucinatin$ and hi$hly delusional. Ms. 0ally mentions her concerns to the nursin$ coordinator, who su$$ests that Ms. 0ally meet with Tom in the day room until he demonstrates more control and less suspicion of others. After / days, Tom is less e)citable, and the sessions are mo!ed to a room set aside for patient inter!iews. Ms. 0ally also spea-s with a senior staff nurse re$ardin$ her fears. ;y tal-in$ to the senior nurse and understandin$ more clearly her own fear, Ms. 0ally is able to mana$e her fear and identify inter!entions to help Tom re$ain a better sense of control. "iagnosis 1. Disturbed thought processes related to alteration in neurolo$ic function, as e!idenced by persecutory hallucinations and paranoia< Voices ha!e told him to .ump off rooftops" and in front of trains." 9omeone is tryin$ to -ill me, * thin-." Abuses cocaine and mari.uana, althou$h these increase paranoia, because they ma-e me feel $ood." 2. Nonadherence to medication re$imen related to side effects of therapy, as e!idenced by !erbali(ation of noncompliance and persistence of symptoms< =ailure to ta-e prescribed medications because they ma-e me tired and * can+t ha!e se)"
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8ase 9tudy and :ursin$ 8are ,lan 8hronic history of relapse of symptoms #utco es $dentification 1. Tom consistently refrains from actin$ upon his !oices" and suspicions. 2. Tom consistently adheres to treatment re$imen. Planning The nurse plans inter!ention that will 516 help Tom deal with his disturbin$ thou$hts and 526 minimi(e dru$ abuse and ad!erse effects of medication to increase adherence and decrease the potential for relapse and !iolence. $ ple entation Nursing Diagnosis 1isturbed thou$ht processes @AT schi(ophrenia A?; patient statin$ !oices are scarin$ me" Outcome Criteria Tom consistently refrains from actin$ upon his !oices" and suspicions when they occur. Short-Term oal 1% ;y the end of the first wee-, Tom will reco$ni(e the presence of hallucinations and identify one or more contributin$ factors, as e!idenced by tellin$ his nurse when they occur and what preceded them. !ntervention a% Meet with Tom each day for 32 minutes to establish trust and rapport. . "ationale a% 9hort, consistent meetin$s help decrease an)iety and establish trust.

#valuation &#!' MET ;y the end of the first wee-, Tom tells the nurse that he is e)periencin$ hallucinations.

(% ?)plore those times that !oices are the most threatenin$ and disturbin$, notin$ the circumstances that precede them. c% ,ro!ide noncompetiti!e acti!ities that focus on the present )% ;y the end of the first wee-, Tom will reco$ni(e hallucinations as not a% ?)plore content of hallucinations with Tom. ways to determine if

(% *dentifies e!ents that increase an)iety and tri$$er !oices"B by learnin$ to mana$e tri$$ers, hallucinations can be reduced. c% *ncreased time spent in reality-based acti!ities decreases focus on hallucinations. a% *dentifies suicidal or a$$ressi!e themes or command hallucinations.

&#!' MET Tom identifies that the !oices tell him he is a loser and he needs to

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8ase 9tudy and :ursin$ 8are ,lan real" and ascribe them to his illness. !oices" are real. (% ?ducate Tom about the nature of hallucinations and (% *mpro!es Tom+s reality testin$ and helps him be$in to attribute his e)periences to schi(ophrenia.

D be careful because someone is after me." He identifies that the !oices are worse at ni$ht. He notes that others do not seem to hear what he hears and also states that smo-in$ mari.uana and ta-in$ cocaine produce threatenin$ !oices. &#!' MET Tom states that he is hearin$ !oices less and they are less threatenin$ to him. Tom identifies that if he whistles or sin$s he stays calm and can control the !oices.

*% ;y dischar$e, Tom will consistently report a decrease in hallucinations.

?)plore with Tom possible actions that can minimi(e an)iety andAor reduce hallucinations, such as whistlin$ or readin$ aloud.

4ffers alternati!es while an)iety le!el is relati!ely low.

Nursing Diagnosis :onadherence Outcome Criteria Tom consistently adheres to medication re$imen. Short-Term oal 1% ;y the end of wee1, Tom will discuss his concerns about medication with staff. !ntervention a% ?!aluate medication response and side effect issues. "ationale a% *dentifies dru$s and dosa$es that ha!e increased therapeutic !alue and decreased side effects. (% 4lan(apine causes no -nown se)ual difficulties. #valuation &#!' MET Tom identifies the reasons for stoppin$ his medicationB he a$rees to try olan(apine because he trusts staff+s assurances that the side effects will be reduced. Tom states that he sleeps better at ni$ht but is still tired durin$ the day.

(% *nitiate medication chan$ed to olan(apine 5Cypre)a6. A lar$e dose is ta-en at bedtime to increase sleep, and a small dose is ta-en durin$ the day to decrease fati$ue. c% ?ducate Tom re$ardin$ side effects

c% 8an $i!e increased sense of control o!er

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8ase 9tudy and :ursin$ 8are ,lan Ehow lon$ they last and what actions can be ta-en. 8onnect Tom with the local :AM* support $roup. symptoms. ,ro!ides peer support and a chance to hear from others further alon$ in reco!ery how medications can be helpful, side effects can be mana$ed, and su$$estions for dealin$ with his loneliness and other problems.

)% ;y the end of wee2, Tom will describe two ways to reduce or cope with side effects and two ways the medications help him meet his $oals 5e.$. of a!oidin$ .ail and reducin$ fear6.

&#!' MET +ee, 1: Tom attends meetin$. +ee, ): He spea-s in the $roup about not feelin$ $ood." 9e!eral $roup members say that they understand and try to help him fi$ure out why he is not feelin$ $ood. ,eers say how ta-in$ medication has helped them feel better.

E-aluation ;y dischar$e, Tom e)presses hope that the medicines will help him feel better and a!oid problems li-e .ail. He has a better understandin$ of his medications and what to do for side effects. He -nows that mari.uana and cocaine increase his symptoms and e)plains that when he $ets lonely, he now has ideas of thin$s he can do other than dru$s to feel $ood." Tom continues with the support $roup and outpatient counselin$, statin$ that it+s because Ms. 0ally really cared about himB this made him want to $et better and led him to trust what staff told him. He reports sleepin$ much better and says that he has more ener$y durin$ the day.

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