The client with schizophrenia

Recovery focused nursing care plan

Case Study 2: The client with schizophrenia

Schizophrenia is typified by disturbances – for at least a period of six months – in sense of self, affect, thought content and form, social activity, psychomotor behaviour, perception, interpersonal relationships, language, and volition (Marder, 2011; Kopelowicz, 2012). In the case study, the 25-year-old Bernard who has a diagnosis of schizophrenia (295.9) has paranoid schizophrenia. The Recovery Focused Care Plan for him is as follows:    

Consumers priorityIdentified goals /issuesConsumer’s strengths to address these issuesConsumer and nursing interventionsPersons responsibleTime frame for next review
Hallucinations or delusions – the client reported increased paranoid ideation during the previous 4/52 and he stated that they are talking about him, following him and watching him. When the client is asked what he means by they, he is reluctant to identify them and states that they will also come to you. In addition, this client was initially diagnosed with schizophrenia when he was 22 years old. He stated that during this time, he was hearing voices of a commentary nature and was also experiencing paranoid ideation. Working as a labourer at a building site, he reported that he felt somewhat paranoid regarding his fellow labourers and started suspecting that they were making plans to harm him or his family. The client has some lingering paranoia ideas evident with regard to his previous workmates at the building site. However, these paranoia ideas are short-lived in their nature and whenever they occur they happen to be less disturbing. Client exhibited suicidal ideation.  Reduce hallucinations and delusionsClient can attend counselling sessions for hallucinations / delusions.     Bernard can take anti-psychotic medications.Prevent self-harm through continuous assessment of suicide potential.Maintain a safe environment. Stay with the client when he starts to hallucinate, and direct him to tell the voices he is hearing to go away. Do not argue with him about his delusions or hallucinations (Edwards et al., 2011).Tell the client that the delusions or hallucinations are symptoms of a psychiatric disorder.Acknowledge fear or feelingsTry to keep the client engagedDo not express approvalKeep communication non-judgmental and open (Köhler et al., 2013).Encourage client to practice some techniques of relaxationAssist the client to control delusions or hallucinations by focusing on reality and taking necessary medications as prescribed.Be tactful in approachUtilize distractions, hobbies, exercising, saying stop (Davis et al., 2016).Maintain consistencyEncourage and reassure the clientListen to the client and respect his feelingsClearly explain what you are doing and the reason as to why.Assist him in identifying the needs which may underlie the hallucinations. What other ways could those needs be satisfied? Hallucinations could reflect needs for sexuality, self-esteem, power and anger (Beck, 2014).Do not touch Bernard without first informing him exactly what you are trying to do. Do not tease or joke with Bernard. Assist Bernard to differentiate between reality and his own thoughts. Confirm the presence of delusions or hallucinations. Identify hallucinations or delusions as being symptoms of the disorder and tell him that hallucinations or delusions are present due to the metabolic changes taking place inside his brain. Centre on the reality-oriented facets of the communication (Fleury et al., 2013).Administer antipsychotics agents such as Risperdal, Zyprexa and Gedon, as prescribed. Inform Bernard about the side effects of the medicine, as well as dose of medication. Give emphasis to the significance of taking medicines following discharge, even when the symptoms have totally gone away. Ask Bernard to be committed in taking the medicine (Yamasaki et al., 2016).The nurse will provide pharmacotherapy intervention.    Psychiatrist will provide non  pharmacotherapy  intervention3 months
Activities of daily living – the client is socially isolated and withdrawn as he has become more and more insular and avoids social contact, inclining to avoid family and friends. He described few activities or interests outside the home. He has not been able to establish a new social circle since he left university. He experiences difficulties to sleep and often lies in bed worrying about his future and his life. Since he restarted medication, his appetite has increased as he consumes large meals and adds snacks on top of the meals. He does not feel like doing any household chores like he used to do previously before he relapsed.   Improve the client’s activities of daily livingBernard can adhere to treatment regimen aimed at improving his activities of daily livingInvolve the client in group and/or individual interactions within the hospital unit. This would reduce the client’s isolation and promote a sense of self-worth.Assess the ability of the client to conduct activities of daily living and pay special attention to his nutritional status (Loebel, Lieberman & Alvir, 2013).Provide supportive group therapy that focuses on the here-and-now, create group norms which discourage improper social behaviour, and encourage the client to test new social behaviour.Role-play particular established social behaviours. Promote growth of relationships amongst group members by means of self-disclosure and realness. Encourage the members of the group to confirm their perceptions with other people (Oya, Kishi & Iwata, 2014).Monitor patient’s compliance with medication routine. Encourage the client to be present at medication group. Ask the client about particular symptom exacerbations and side effects. Encourage the client to go to regular symptom management groups.Recognize the environments wherein social interactions are impaired such as leisure, living, working, and learning.Role-play different facets of social interactions like asking for something, starting or terminating a conversation, asking somebody to take part in a certain activity such as going to watch a movie, refusing a request, or even interviewing for a job (Wai Tong et al., 2016). Give Bernard positive feedback. Focus at most on 3 behavioural connections at a time.Assist community members and client’s family to understand Bernard and give him necessary support. With the permission of the client, form an alliance with the family. Encourage members of his family to attend a support group (Chow 2012).The nurse will provide pharmacotherapy intervention.    Psychiatrist will provide non  pharmacotherapy  intervention   Family members and community members will be understanding to Bernard and give him support3 months
Problems with occupation and activities – client has problems at the workplace as he does not relate well with his workmates. Working as a labourer at a building site, he reported that he felt somewhat paranoid regarding his fellow labourers and started suspecting that they were making plans to harm him or his family. Some workmates were making fun of him and this made him to become more and more stressed, and consequently had disorganized actions and thoughts.   Reduce client’s problems with occupation and activitiesBernard can adhere to treatment regimen aimed at reducing his problems with occupation and activitiesTeach Bernard coping skills which minimize problems with occupation and activities such as talking to a trusted friend at the workplace, going to the gym, and phoning a helpline (Loebel, Lieberman & Alvir, 2013).Encourage the client to observe healthy habits that will help to optimize functioning such as working well with others at the building site, maintaining a regular pattern of sleep, and maintaining medication regimen. These are helpful in keeping the patient in remission (Kopelowicz, 2012).Engage patient in reality-oriented activities involving human contact such as outpatient day care, sheltered workshops, and inpatient social skills training groups.Reward positive behaviour to assist Bernard improve his functioning level (Edwards et al., 2011).The nurse will provide pharmacotherapy intervention.    Psychiatrist will provide non  pharmacotherapy  intervention   Family members and community members will be understanding to Bernard and give him support3 months
Depressed mood, anxiety and cognitive problems – When he worked for his uncle as a labourer at a building site, Bernard pointed out that other labourers in the same site began making fun of him and this made him to feel more and more stressed and increasingly disorganized in his actions and thoughts. The client described themes of hopeless, helplessness and worthlessness. The client described his mood as being variable; he reported of uncertainty for the future, anxiety, and sadness. Bernard experienced escalating stress levels, disorganized thinking and behaviour. He has also demonstrated mildly depressed mood, and decreased concentration.Reduce client’s mood and anxietyClient can comply with anti-depressant medication.   Bernard can stick to the treatment regimeWork with Bernard to find the activities that are helpful in reducing anxiety and depressed mood and distract him from hallucinatory material. Practice with him new skills. If Bernard’s stress and depression trigger hallucinatory activity, he may be more motivated to find ways of removing himself from stressful environments or attempt distraction techniques (Steele, 2011).Be alert for signs of growing agitation, anxiety or fear. May be indication of hallucinatory activity that could be really frightening to Bernard, and he may act upon command hallucinations for instance by harming others or himself (Kohler et al., 2013).Intervene with seclusion, one-on-one or pharmacological/ medication treatments for depression and stress. Also use psychotherapeutic and somatic interventions and psychoeducation.Intervene before the anxiety starts to increase. If Bernard is already out of control, utilize physical or chemical restraints following unit protocols (Davis et al., 2016).The nurse will provide pharmacotherapy intervention.    Psychiatrist will provide non  pharmacotherapy  intervention3 months

References

Beck, J. (2014). Nursing process in psychiatric. Psychiatric Rehabilitation Skills, 42(6): 245-256

Chow, S. (2012). Schizophrenia interventions. J Clin Psychiatry, 31(67): 90-112

Davis, K. N., Tao, R., Li, C., Gao, Y., Gondré-Lewis, M. C., Lipska, B. K., & … Hyde, T. M. (2016). GAD2 Alternative Transcripts in the Human Prefrontal Cortex, and in Schizophrenia and Affective Disorders. Plos ONE, 11(2), 1-15. doi:10.1371/journal.pone.0148558

Edwards, J., Maude, D., McGorry, P. D., Harrigan, S. M., Cocks, J. T. (2011). Prolonged recovery in first-episode psychosis. Brit J Psychiatry, 172(33): 107-116 

Fleury, M., Grenier, G., Bamvita, J., & Tremblay, J. (2013). Typology of persons with severe mental disorders. BMC Psychiatry, 13(1), 1-10. doi:10.1186/1471-244X-13-137

Köhler, S., Hoffmann, S., Unger, T., Steinacher, B., Dierstein, N., & Fydrich, T. (2013). Effectiveness of Cognitive-Behavioural Therapy Plus Pharmacotherapy in Inpatient Treatment of Depressive Disorders. Clinical Psychology & Psychotherapy, 20(2), 97-106. doi:10.1002/cpp.795

Kopelowicz, A. (2012). Recovery from schizophrenia. Psycholog Med, 123(24): 135-146

Loebel, A. D., Lieberman, J. A., & Alvir, J. (2013). Duration of psychosis and outcome in first-episode schizophrenia. AM J Psychiatry, 2(4): 43-60  

Marder, S. R. (2011). Facilitating compliance with antipsychotic medication. J Clin Psychiatry, 51(98): 277-311

Oya, K., Kishi, T., & Iwata, N. (2014). Efficacy and tolerability of minocycline augmentation therapy in schizophrenia: a systematic review and meta-analysis of randomized controlled trials. Human Psychopharmacology: Clinical & Experimental, 29(5), 483-491.

Sarin, F., Wallin, L., & Widerlööv, B. (2011). Cognitive behavior therapy for schizophrenia: A meta-analytical review of randomized controlled trials. Nordic Journal Of Psychiatry, 65(3), 162-174.

Steele, K. (2011). The day the voices stopped. Albany, NY: Basic Books.

Wai Tong, C., Jolene, M., Gray, R., & Eric, C. (2016). Adherence therapy versus routine psychiatric care for people with schizophrenia spectrum disorders: a randomised controlled trial. BMC Psychiatry, 161-14. doi:10.1186/s12888-016-0744-6

Yamasaki, S., Ando, S., Shimodera, S., Endo, K., Okazaki, Y., Asukai, N., & … Sasaki, T. (2016). The Recognition of Mental Illness, Schizophrenia Identification, and Help-Seeking from Friends in Late Adolescence. Plos ONE, 11(3), 1-8.

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