Caring for the Client with Schizophrenia

7/30/2019 Caring for the Client with Schizophrenia

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Table of Content

Contents Page

Introduction 1

/Purpose/Aim of Study 2

Literature Review 3

Patients profile

Past Medical History

History of Present Illness

Past Surgical History

Sexual History

Family History

Family Psychiatric History

Psychiatric History

Education History

Description of patients community

Behaviour on Admission

Medical management

Nursing management

Physical Assessment

Mental Status Assessment

Summary of Care

Family Involvement in care

Community Involvement in care

Patients Outlook for the future

Nursing Care Plan

Conclusion

Recommendations

References


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Appendices

Introduction

This Care Study looks at a client currently admitted to ward five (5) at the Bellevue

Hospital. We shall refer to him as S.F, he was admitted on the seventh (7) 0f October

2008 (and diagnosed with schizophrenia) after he was brought in by mental health

officers with a history of exposing and denuding himself on the compounds of a school

on which he worked as the caretaker.

This Care study will also look at the nursing and medical management of Mr. S.F. as

well as all the related therapies, these include; group therapy, one to one therapy,

pharmacotherapy, and occupational therapy.

A profile of the clients community, his outcome/prognosis as well as his familys

involvement in his care will also be looked at.


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Purpose of this study

This Care Study is being done in partial fulfilment of the course Post Basic Psychiatric

Nursing. Its intent is to provide this student with the requisite skill and knowledge to

manage the client with the above named diagnosis as well as others with similar mental

health challenges.


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Literature Review

Schizophrenia is a severe mental illness that usually strikes between the ages of

seventeen (17) and twenty five (25) years of age. (Ignatavicius, 2004). It is one of the

large groups of severe mental disorders typified by gross distortion of reality,

disturbance in language and breakdown of thought processes, perceptions and

emotions. Delusions and hallucinations are usual as are apathy, confusion,

incontinence, and strange behaviour. No single cause is known but genetic factors,

chemical imbalance, structural brain abnormalities, and stressful events are probably

important. (Frisch, Frisch, 2005)

TheDSM-1V-TR list five subtypes: (1) Paranoid - this is where theres presence of

hallucination and delusional thinking, but fairly organized speech and behaviour; may

show some range in affect. (2) Disorganized - theres dominant manifestations of

disorganized speech and behaviour, with flat or inappropriate affect; may also have

hallucinations and delusions. (3) Catatonic theres the presence of bizarre motor

activity, either excessive and purposeless or immobilized as if in a stupor; may be mute

or show incoherent speech. (4) Undifferentiated theres the presence of two or more

of the following signs and symptoms, but theres no marked feature as in the previously

named subtypes: hallucinations, delusions, disorganized speech/behaviour and

flattening of the affect. (5) Residual behaviours do not manifest obvious


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hallucinations, delusions, or disorganization, but theres an alteration in the range of

affect and thought patterns. (Black 2005).

In all cases, theres a profound deficit in an individuals ability to think and to

communicate. Signs and symptoms are generally classified as either positive or

negative symptoms or both. Positive signs and symptoms include the following:

auditory/visual hallucinations, delusions, disorganized thinking and speech, which are

all obvious signs of psychosis. Negative signs and symptoms include: blunted affect,

avoidance of social contact, lack of attention to hygiene, and a decrease in speech, these

are all lack of usual emotional/social responses.

The cause of schizophrenia is unknown, but several theories have been

propagated, among these are: The genetic, psychoanalytic, organic, and

neurotransmitter theories.

The genetic theory posits, that for the general population the chance of an individual

becoming schizophrenic is 1%, while the individual with two parents stands a 40-50%

chance of becoming ill with the condition, other family relations is also a risk factor.

Of all the genetic permutations, studies have shown that monozygous twins stands the

greatest chance of being affected with schizophrenia. (Frisch 2005).

The Psychoanalytic view states that childhood situations, such as, temper tantrums and

unresolved aggression might ultimately lead to psychosis. Another view posits, that


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inadequate maternal nuturance in early infancy could lead to psychosis. Further

psychoanalytical research have evaluated a wide range of developmental,

environmental and psychological factors, but those studies have not proved to be very

definitive. ( Frisch et al., 2005)

The Organic theory, suggests that there is something physically and structurally wrong

with the brain of the schizophrenic individual. Studies done, have shown (with the CT

scanner) that there is an abnormality in the structure of the ventricles of the brain of

male clients. Despite this finding, it is not clear that ventricular abnormality is the

cause of schizophrenia, however, it has been shown that ventricular enlargement may

occur in the schizophrenic client and may lead to cerebral atrophy. Studies have also

shown that the hippocampus in the brain is larger in the schizophrenic client. (Delisi,

2000).

It must be noted that while these findings are speculative, they could result in the view

that schizophrenia is a neurologic degenerative disease.

The Neurotransmitter theory states that, brain chemicals, particularly dopamine is the

major culprit. Dopamine is produced in the brain and serves as a signalling molecule or

neurotransmitter, an excess or hyperactivity could be the cause of schizophrenia. Drugs

effective in the control of positive symptoms in schizophrenia all seem to have a

dopamine blocking action, that is, these drugs seem to work because they reduce the

effect of the individuals own dopamine on his brain. It should be noted that while

dopamine is speculated to be the major cause of schizophrenia, other neurotransmitters


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such as GABA, and the neuropeptides cholecystokinin and somatostatin are also

decreased. (Freeman, 2003).

Positive manifestations of schizophrenia are usually managed by both typical

(Chlorpromazine, Haloperidol) and atypical (Resperidone, Clozapine ) psychotropic

medications, but the negative manifestations are managed better by atypical

medications and supportive therapy. (Black 2005). Antipsychotics have been in use

since the 1950s, and several classes have evolved over time in an effort to reduce

unpleasant side effects brought about by the older antipsychotics. ( Example

Chlorpromazine). (Frisch, Frisch 2004). These antipsychotic are usually required to be

taken over a lifetime to control the manifestations of schizophrenia, with medication

some client report an absence of hallucinations, but for others internal voices become

an unpleasant permanent experience. (Black 2005).

A major concern for most clients is the presence of side effects related to sedation and

abnormal movements. Antipsychotics particularly, typicals, affect dopamine receptors

and result in side effects known as extrapyramidal syndrome (EPS). Some of these side

effects are: stiffness, tremors of the arms and legs, extreme restlessness with subjective

discomfort, drooling and acute muscle spasm of the face, neck and tongue. These side

effects are usually short termed and can be reversed with an anticholinergic

(Benztropine). ( )


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However, it should be noted that there is one long term side effect called tardive

dyskinesia, which manifests itself with the following: involuntary movements of the

tongue, face, hands or legs and occurs after long term antipsychotic use, usually it is

irreversible. Treatment options include, changing the current medication to a less

potent one or to one of the atypicals (these have a better side effect profile).

Neuroleptic malignant syndrome (NMS) is a rare, but serious, life threatening side

effect that occurs from long-term use of antipsychotics, this manifest it self in the

following ways: extreme muscle rigidity, hyperpyrexia, diaphoresis, high blood

pressure and extreme fluctuation in conscious levels. Treatment option include,

supportive therapy, to decrease temperature and keeping t with cool as well as

monitoring clients vital signs and stopping the medication immediately. (Black, 2005).

Treatment options for impaired functioning include long term supportive therapy and

psycho rehabilitation. Social withdrawal and lack of interest in school or work often

signal the onset of the illness and may persist throughout treatment. For the

schizophrenic client there is a need for development and maintenance of maximal

functioning, individual counselling and support, psycho education and organized

rehabilitation and family therapy.

The client experiencing schizophrenia has many remissions and exacerbations,

exacerbations are compounded by medication non-compliance, denial of illness, stress

life events, these will usually result in multiple admissions over a life time. With


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consistent support of family and community resources, many clients can progress

toward higher levels of independence. (Black, 2005) (Frisch, 2005).

Description of clients community

Hope Road is one of the sub communities in the community located in Barbican in the

parish of Saint Andrew. It is described as being moderately populated and is border by

Halfway Tree to the left, and Liguanea to the right. It is one of the more affluent

communities in Jamaica, and features mainly middle to upper class individuals. It has

all the physical amenities such as light, water and sewer system, an adequate garbage

disposal and telephone system as well as fine roads.

Some of the facilities available in that community include:

Entertainment center (Ronald Williams, Police Officers Club)

Shops, Variety stores, Supermarkets, Shopping centers (Thank God its Friday,

Baskin Robins, Devon House)

Playing ground (Police Officers Club)

Schools (including Basic, Primary and high)

Churches (Seven Day Adventist, Pocomania, Faith of Light ,Church of God)

The nearest Hospital is the Andrew Memorial Hospital (Private)

The nearest Police Station is the Police Officers Club and Matildas corner

Post Office is located in the shopping centre.

The people in the community of Hope Road are largely from middle to (lower) upper

class socio-economic background. However, there are a few working class individuals


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that include skilled workers who, work on construction sites and in the public and

private sector. (These include professionals). Others are self employed which range

from the vending of food to the keeping of shops and supermarkets.

The individuals of Hope Road are described as co-operative and friendly. Crime is not

very prevalent in comparison to other parts of Jamaica.

Patients profile

Name: S.F.

Age: 31yrs.

Gender: Male

Religion: Church of God

Marital Status: Single

Medical Diagnosis: Schizophrenia

Address: Mount Airy District Saint Thomas

Next of Kin: Aunt, E.A.

Occupation: worked as a caretaker and welder

Height: Approximately 6ft.

Weight: - 1781bs


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History of present Illness

Chief Complaint: According to docket and patient, he was brought to Bellevue hospital

on the seventh (7th) of October 2008 by mental health officers, after they were called to

say that he was on the compound of the Ardene preparatory school masturbating and

denuding him in public view of the students.

History of present complaint: Client was picked up on the compound of the Ardene

preparatory school on the seventh (7) of October 2008 at approximately 4:55pm.

Mental health officers reported that Reverend Mr. Angling called them to lodge the

complaint; he (Mr. Angling) stated that the clients parents had died about (4) four

years ago. Previous to their death they had worked as caretaker at the same school, after

they died he took their position. He lived in a home next door which belonged to his

mother, but he burned it down in 2006, because he felt that that someone had bugged it,

subsequently, he went to live on the school compound in early 2008.

About 3/52 ago he began to neglect his personal hygiene, 2/52 he stated that, he started

to hear voices in his head telling him to do various things, including throwing things at

people and approximately 1/52 he began to denude himself as well as masturbate in

front of all the school children. Parents and community members became quite

concerned about the behaviour; subsequently he was brought to Emergency Room,

Bellevue hospital, where he was admitted on the seventh (7) of October 2008. On

examination: Young adult male sitting on chair, relatively calm and cooperative.


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Temperature-97.7, Pulse rate-84 beats per minutes, Respiratory rate-20 breaths per

minutes. Mucus membrane: pink, anicteric, acyanotic.

DSM IV Classification

Axis I- R/O Psychotic disorder, Substance disorder, Depressive disorder, later

diagnosed as Schizophrenia.

Axis II- Nil

Axis III- Nil

Axis IV- Currently unemployed and has very little social support

Social/ developmental/Family History

Client grew up with mother and father in a home that had all the physical amenities,

such as electricity, piped water and adequate garbage disposal system. Mother had two

(2) children, him and a younger female sibling, who is one year, his junior, she

currently resides in England, but they are not in touch right now. According to client,

home was a relatively happy place most of the time, with few squabbles between his

sibling and himself.

Past Medical History

Nil

Past Surgical History

Nil


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Psychosexual History

Has no children and is currently not in any relationship, however, he said that he had

about three relationships in the past, but they did not last very long because he was not

working most of the time. His last relationship, which broke up about three years ago

lasted for about six months and ended due to frequent quarrels, especially as it related

to finances.

Past Psychiatric History

Has never been treated for a psychiatric condition before.

Educational History

Attended three primary schools, but he cannot remember their names or why he had to

be moving from school to school. He looked a bit sad as he reflected on the fact that he

did not do his common entrance exams. Clients docket stated that he attended

Pembroke Hall, Ardene day and Extension as well as the Saint Josephs high schools

however; he stated that he only attended the Saint Josephs High school where he sat 5

CXCs, and was successful in two, namely Accounts and Principle of Business. When

client was spoken to again, he confirmed the high schools as stated in the dockets.


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Employment History

Worked as a welder for six years in Vineyard Town and as a Caretaker for the Ardene

Preparatory School at 59 Hope Road. He went on to say that the last time he worked as

a welder was three years ago. He left because business became very slow.

Forensic History

Client was arrested for eight years, but cannot remember much about the incident.

Mental status examination

Appearance: Clean and well put together, dressing appropriate for setting, age,

climate and time of the day. Hair quite kempt and feet shod.

Mood: Euthymic

Affect: blunted/restricted (negative symptom)

Speech: Low toned, clear and mainly rational

Though form/process: No abnormalities detected

Thought content: No delusions, paranoid ideations, however, expressed

decreased self worth, as he feels that he has not maximized his full potential.

Perception: Admitted to auditory hallucinations, (positive symptom) stated that

he has heard voices speaking in his head from time to time, sometimes the

voices tells him to throw things at staff as well as fellow patients.

Orientation: Fully oriented in all spheres, time, place and person

Behaviour: Very cooperative, answer questions asked,


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Abstract/Cognition: Intact; was able to explain the idiomatic expressions, One,

one coco full basket and Every tub must stand on its own bottom.

Memory: Recent, and remote memory are intact, he could recall events in his

early childhood and could state currents events, such as the prime ministers of

the recent past and the present.

Judgement: This is very good, when asked what he would do if he was locked

in a room burning, he replied, that he would shout for help or try to break the

window pane.

Insight: Client knows that something is wrong with him, but stated that he is not

sure, but suggested that maybe something is wrong with his mind and could

have resulted from his financial and social situation.

Summary of the care of A.F.

Week One: 29.06. - 05.07.09

Mr. A.F. was met sitting quietly beside his bed by himself, when approached he was

quiet reluctant to talk, however, after I introduced myself and what I wanted to do, he

became more receptive and was quite willing to share his situation with me.

A.F. does not socialize much with the other clients, he generally takes his morning

baths then sits by himself and wait for medication and breakfast to be served, at other

times he may sit in the group sessions if he so inclined, then he comes back on the

inside where he sits until its time for the afternoon meal and baths.


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He said that most times when he is sitting by himself he hears a voice speaking in his

head, this voice tells him many things, including throwing water on the staff and his

fellow clients.

Mr. A.F. was encouraged to speak to at least one person each day, to attend and

participate in the group therapy sessions, to assist in doing minimal ward chores, to

watch television, to take his medications, and to try and not listen to the voices. In

addition to these the client would, be engaged in a one to one conversation each day

with yours truly.

So far the client has been very complaint with all the measures/therapies identified. He

has sat in the group meetings for all the days so far and has actively participated; he has

tried to speak to client N.T. who sleeps beside him.

The other aspect of his care such as hygienic needs, are done very early in the morning

and in the afternoon, these the client usually accomplish by himself without any

supervision.

Week Two: 06.07.2009-10.07.2009

Client received locked in seclusion room on the 06.07.2009. He reportedly threw

Water at staff the previous day. When questioned why he threw the water, he gave no

response but a blank stare.


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Mr. A.F. was nursed in the seclusion room on a request made by the nurses from the

doctor. The intent of this method was to provide behaviour modification for the client

and to provide protection for him (from other patients, who wanted to beat him for the

incident) for the other clients and staff. He was reviewed by the ward doctor and a

decision is yet to be made concerning a change in his current medical management.

Client was allowed out of seclusion room each morning under close supervision for

baths, meals, medication, and group therapy as well as one to one interaction with yours

truly.

On Friday client stated that he felt bad that he threw water at the staff, and that he

would try very hard not to listen to the voice when it tells him to do things. (See

nursing care plan for interventions).

Patients behaviour at admission

On admission at the emergency Room, Young, tall, slimly built gentleman, sat very

quietly and calmly in chair, was cooperative and spoke mainly rationally. He was able

to indicate that the house that he lived in got burned down, and that he denuded himself

because he wanted to take a bath, and not because he wanted to expose himself to the

children or anybody.


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Stated that he eats and sleeps very well, smokes cigarettes and smoked cocaine in the

past. He also admitted to hearing voices in his head telling to do various things,

however, he did not elaborate.

Medical Management

Medication Frequency Mechanism of

action

Side effects Nursing

Responsibility

Resperidol 4mg b/d (Twice

daily)

Cogentin 5mg b/d (Twice

daily)

Chlorpromazine

100mg

Fluphenazine

Decanoate 1cc

Nocte

Monthly

Physical Status Examination

Done: 10. 07.2009


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General appearance: Client appeared alert, conscious and calm, sat by himself and

seemed preoccupied with his own thoughts. Had no obvious signs of pulmonary or

painful discomfort. Well nourished and appropriately dressed for setting, age, gender

time of day and for season. Hair was well kempt and feet shod, however, posture was

somewhat slouched and eye contact, intermittent.

Vital signs: T 37 deg. C; P-88bpm; R-20bpm; B/P-120/70

Growth (weight and height): Weight 178lbs.

Height 6ft. 2 inches

Skin (hair, nails): Skin colour was quite uniformed, no patches seen; same was

smooth, moist with good skin turgor. No skin lesion or abrasions noted, warm to the

touch. Hair was kempt and clean with adequate distribution, quantity, texture and

colour. Nails were a bit long and dirty, same firmly attached to nail beds. Capillary

refill of nails occurred in less than three seconds.

Lymph nodes: None felt

Head: Normal, proportional to body size, skull contour smooth, no sign of trauma

swelling, tenderness, nodules or lesions was seen.

Neck: Symmetrical, skin intact, had no visible signs of abnormal pulsation, masses,

swelling or venous distention. Thyroid gland non palpable, client was able to move

neck through the entire range of motion, had no difficulty when swallowing. Trachea


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remained in midline position.

Eyes: Symmetrical, no lacrimal drainage or swelling was noted. Equal distance

apart, outer cantus in line with the ears. Pupils were equally round, had no tenderness

on palpation, mucus membrane pink and moist.

Ears: Non tender touch, warm on palpation. No signs of hyper/hypo pigmentation,

in line with the eyes, no signs of drainage nor swelling, no ceruman was seen on

inspection.

Nose: Colour uniformed, no signs of nasal drainage or discharge seen, no lesions or

evidence of flaring. The sinus area was non tender on palpation and had no sign of

swelling.

Mouth and Throat: Lips were symmetrical, no swelling, same were moist, gum and

mucus membranes were pink and moist, and no lesions were seen. Teeth were in line,

no evidence of dental carries were noted. Tongue was pink and clean, no sign of

swelling or lesions observed.

Lungs: Chest expansion equal bilaterally, no abnormality was noted to chest wall,

same was non- tender to touch. No flaring observed from the nares, breath sounds

normal and vesicular. Client had no signs of respiratory distress/discomfort.

Heart: Heart sounds were normal, S1 and S2 heard on auscultation. No obvious signs

of cardiac distress detected, capillary refill was within three seconds.

Chest/Thorax: Normal bilaterally, two nipples present, no hyper/hypo pigmentation

or any other abnormality observed.


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Abdomen/Gastrointestinal: Abdomen soft, flat and non-tender when touched, no

signs of lumps bulges or masses felt or observed. Normal bowel sounds heard on

auscultation, no obvious signs of abnormality were detected.

Genitourinary: Made no complaint about genitalia, stated that he passed urine on a

regular basis, No abnormality observed.

Back and Extremities: Both sides were symmetrical, with uniformity in colour,

spinal cord straight, no signs of scoliosis, kyphosis or lordosis observed. Arms and

legs appeared to be of equal size, no deformities noted, however had very mild

intermittent tremors of the hands. Range of motion, colour and sensation present in

all four extremities.

Neuromuscular: Reflex was good, range of motion to all four limbs good, although

client appears sluggish at times, with intermittent tremors of the hands. Voiced no

complaints of pain or tenderness on examination.

Laboratory Test: Test for cocaine, marijuana and opoids was done, same was

positive for cocaine.

Familys attitude towards client

A.F. father is reportedly living in Portmore, but cannot be located at this time, he has

not visited client since he has been admitted in hospital. Client has a sister who resides

in United States, but they are not in contact with each other. There is an aunt A.F. who

also lives in Greater Portmore she has visited A.F. once, but stated that she is unable to


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accommodate him as there are three other persons who are mentally challenged living

with her.

In terms of family support, there is no one to assist A.F. should he be discharged from

the hospital; however, he stated that is just a small challenge he can over come.

Communitys attitude towards client

Community was always receptive of client, but when he started to denude himself in

front of the children, they became quite upset and intolerant of him and demanded that

he should be treated. It should be noted that the church is quite willing to take him

back as long as his condition improves. (so says Pastor Angling, the church pastor at 59

Hope Road)

Clients outlook for the future/prognosis

A.E. has a very positive outlook for the future, he stated that the wants to go back to

school and finish up his education so that he could provide for him, he also wants to

continue working as a welder. He stated he knows that he will have challenges, but

those can be overcome.

Prognosis: Client will be able to live a functional life once he takes his medication, is

gainfully employed, (his job at the church was given to someone else, prior to his

admission), keeps his appointments at the clinic/health centre and stop the use of hard

drugs.


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Medical Diagnosis: Initially Psychosis, later, Schizophrenia

Nursing Diagnosis: (1) Altered Sensory Perception (auditory) related to alteration in

brain/neuro chemicals, (2) Risk for violence, directed against others related to auditory

hallucination, (3) Social Isolation related to altered state of wellness/decreased self

worth

Plan of care: Medicate with antipsychotic, CPZ, 100mg. B/d, Resperidol 4mg. PO,

Fluphenazine IM, 2cc, monthly, Benztropine 5mg, BD, PO, same to be finalized by

doctor, Reality orientation, Group therapy, one to one and observation. Refer to

Psychotherapy, Social worker and Occupational therapy when psychotic symptoms

subside.

Health education

Evaluate level of education

Identify what client knows about medication

Educate about drug therapy including the name of the drug and dosage

The length of time it takes to achieve therapeutic results

The side effects of the drugs

Report any unusual side effects

Not to alter regime of the drug without first informing the doctor

Encourage client to keep appointment at clinic/doctor

Educate on taking sedative medication at nights

Ensure that a balanced diet is consumed


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Nursing Care Plan


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ASSESSMENT

1. Client stated that he

heard voices telling him

to do things, including

throwing water at

people.

2. Client stated that he

felt that he did not

achieve as much as he

could have, feels sad at

times.

3. Client sits by himself

most of the times, does

not initiate conversation

with fellow clients or

staff.

DIAGNOSIS

1. Altered sensory

perception (auditory)

related to disturbed

thought process

secondary to an

imbalance in

neurotransmitter.

PATIENTS

OBJECT.

1. Client will

report/exhibit a decrease in

auditory hallucinations

following nursing and

collaborative intervention

throughout the next two

weeks.

INTERVENTIONS

1.

Establish one to one, for

therapeutic relationship.

Medicate with Risperdol

and Chlorpromazine to

decrease psychotic

symptoms.

Do not validate

hallucination, to allow

client to realize that they

are not real.

Allow client to take part

in ward chores, to take

mind from off the

hallucinations.

Allow client to attend

group therapy session this

will allow peers to

evaluate condition and

may help client to

EVALUATION

Objective was

not achieved at

the time I left the

ward, client is

still actively

having

hallucinations.


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Documents

Caring for the Client with Schizophrenia