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Case Presentation

Background Information

Nursing Care Plan

Evaluation of Outcomes

Implementation Plan

  • Evaluate patient’s knowledge and understanding of the importance of medication compliance, as well as level of compliance with drug regimen.
  • Evaluate presence/severity of any side effects and their effect on patient.
  • Evaluate core symptom clusters using the Moller-Murphy Symptom Management Assessment Tool.
  • Evaluate patient’s ability to recognize and describe the behaviors associated with the onset of relapse.
  • Evaluate the burden of illness and whether it has been decreased by enhanced adaptive and functional skills and minimizing family burden.

  • Impaired social interaction related to thought disorder and paranoia, as evidenced by belief that he is being poisoned.

“Vulnerability-stress models propose that social stress triggers psychotic episodes in high risk individuals.” It is shown that stress as well as low self esteem can trigger these delusions and hallucination. “As evidence for causal conclusions has not been provided yet, the present study assessed the direct impact of social stress on paranoid beliefs using an experimental design and considered a decrease in self-esteem as a mediator and the proneness to psychosis and paranoia as moderators of the effect" (Kesting, 2012).

Desired Outcomes

  • Risk for suicide related to perceptual disturbance, as evidenced by past history of self-injury (stabbing oneself with a knife)

Suicide is one that can be prevented with early diagnosis and vigilance. In the case of this patient if it were possible to reach him before he stabbed himself, this harm could have been avoided. However in his current case and with this past history of inflicting self-harm due to these hallucinations and delusions it can be prevented in the future. It is important that the health care provider works collectively with his team to prevent such harm. Unfortunately in certain cases this is difficult and the early warning signs are not seen. “Emphasizing distal preventive interventions, strategies must focus on people and places-and on related interpersonal factors and social contexts--to alter the life trajectories of people before they become suicidal. Attention also must be paid to those in the middle years--the age with the greatest overall burden” (Caine, 2013).

Recovery Model

  • “Putting recovery into action means focusing care on supporting recovery and building the resilience of people with mental health problems, not just on treating or managing their symptoms” (Mental Health Foundation, 2013)
  • Patient will be able to acknowledge signs of onset of suicidal thoughts in the future. The patient will use his familial resources from his brother.
  • Patient will be able to rationalize his thoughts of delusions and hallucinations. He will attempt to secure a better living environment, which do not provoke such thoughts. In the case of this delusions and hallucinations it is never wise to believe in them. However it can be effective to listen to them and make them see what is impaired in their judgment. He will start to better cope with his adversities and stressors.

The 10 fundamental components are:

  •  Self-direction
  •  Individualized and person-centered care
  • Empowerment
  •  Holistic nature
  • Non-linear care
  • Strength-based treatment
  • Peer support
  •  Respect
  •  Responsibility
  • Hope

  •  Mental health care is to be consumer and family driven.
  •  Care must focus on increasing consumers’ ability to successfully cope with life’s challenges, on facilitating recovery, and on building resilience, and not just managing symptoms.
  •  An individualized plan of care is to be at the core of consumer-centered, recovery-oriented services that allow consumers to realize improved mental health and quality of life.
  •  Consumers must be partners in decision making in all aspects of care
  • 64 yr. old male
  • Dx: Schizo-affective Bipolar type
  • Voluntary admission
  • KROL status for 15+ years
  • Present problem
  • Chief complaint: “I wasn’t feeling right”
  • Attempted to stab himself to death in order to go to heaven
  • Religiously preoccupied, discontinuation of medication precipitates negative feelings

By

Rachna Desai

Helen Kim

Heather Bloom King

Samya Senan

DSM IV Diagnosis

Assessment of Client’s Behavior and Health Status

Mental Health Exam

AXIS I: Bipolar Affective

AXIS II: None

AXIS III: Diabetes type II

AXIS IV: Death of a family member, living alone

AXIS V: Global Assessment of Functioning (GAF) = 21-30

Behavior considerably influenced by delusions or hallucinations OR inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends) (MacArthur Study, 1992).

Appearance

Mental Health Exam

Manner of Approach

  • 64 year old white male
  • Alert, awake, and oriented x3
  • Patient of average built for age and weight
  • Hair kempt
  • Missing teeth
  • Appropriate demeanor
  • Dressed appropriately for current weather conditions
  • Steady gait
  • No evidence of repetitive gestures or mannerisms
  • Speech was clear

Mental Health Exam

  • Patient extremely cooperative and open to talking and when asked he stated “I am not feeling so good.”
  • Showed signs of trust in the nurse patient relationship. However further into the conversation he showed signs of being frightened and highly alert of his surroundings.
  • There were moments when the patient needed soothing and positive reinforcement that the environment was safe and free from harm
  • Speech was well within range
  • Patient had great command and proper use of language
  • Maintained adequate eye contact through the interview process
  • Receptive language was normal and patient was able to comprehend questions asked during interview process
  • Upon evaluation of memory and recall, patient presented with the ability to recall pertinent information, such as a current personality nun on Eternal World Television Network.

Orientation, Alertness, and Thought Processes

  • Signs of delusions and hallucinations were prominent
  • Flight of ideas, illogical thinking, magical thinking, obsessions, and even mild signs of depersonalization as evidenced by his statements: “Mother Angelica was communicating with me telepathically about how I should go to heaven.” He then stabbed himself in the chest and was surrendering to death. This however led to great confusion for the patient as he could not comprehend how he was being told to go to heaven, but he was not being taken.
  • Currently, delusions and obsessions revolve around that fact that there are the devil’s minions tainting his water.
  • Hallucinations consist of seeing mist/fog from the ceiling of the attic and that these residents are spilling dust onto his clothing.
  • Patient denies use of alcohol or drugs. He states that his brother encourages him to take his medication, and the patient does so. Patient denies suicide and does not consider himself a suicidal person.

Nursing Diagnoses

Nursing Diagnoses

  • Disturbed thought processes related to hallucinations and delusions, as evidenced by belief that
  • Impaired religiosity related to religious delusions and hallucinations in which he “spoke” to Mother Angelica who told him God “wants everyone to go to Heaven”
  • Risk for self-directed violence related to perceptual disturbance, as evidenced by past history of self-injury (stabbing oneself with a knife)
  • Risk for suicide related to perceptual disturbance, as evidenced by past history of self-injury (stabbing oneself with a knife)
  • Risk for other-directed violence related to perceptual disturbance, as evidenced by past history of killing his father
  • Impaired social interaction related to thought disorder and paranoia, as evidenced by belief that he is being poisoned

Nursing Interventions

References

Interventions

  • Assess for symptoms of hallucinations, including duration, intensity and frequency
  • Determine impact of patient’s symptoms on activities of daily living
  • Help patient learn to identify symptom triggers and early symptoms of relapse
  • Identify symptom management techniques such as distraction and relaxation
  • Help patient recognize symptoms of hallucination so that he can distinguish between reality and fantasy
  • Identify family and community resources available to the patient
  • Monitor medications for compliance as well as potential side effects
  • Encourage client to participate in other evidence-based treatments, including skills training/supported employment, supportive housing, CBT, social learning, and family psychoeducation
  • Educate patient about medications, including expected side effects and symptoms to report, as well as importance of compliance with treatment regimen.

Caine, E. D. (2013). Forging an Agenda for Suicide Prevention in the United States. American Journal Of Public Health, 103(5), e1-e8. doi:10.2105/AJPH.2012.301078

Levinson, D.F., Umapathy, C. and Musthaq, Mohamado (1999).  Treatment of Schizoaffective Disorders and Schizophrenia with Mood Symptoms.  American Journal of Psychiatry, 156:1138-1148.

“Lithium.” (2013) Retrieved from Micromedex Application for Android.

MacArthur Study. (1992). Dsm-iii-r axis v: Global assessment of function scale. Retrieved from http://macarthur.virginia.edu/Data/Pdf/gaf.pdf

Kesting, M., Bredenpohl, M., Klenke, J., Westermann, S., Lincoln, T.M. The impact of social stress on self-esteem and paranoid ideation, Journal of Behavior Therapy and Experimental Psychiatry, Volume 44, Issue 1, March 2013, Pages 122-128, ISSN 0005-7916, http://dx.doi.org/10.1016/j.jbtep.2012.07.010. Retrieved from http://www.sciencedirect.com/science/article/pii/S0005791612000699

Mental Health Foundation. (2013). Recovery model. Retrieved from http://www.mentalhealth.org.uk/help-information/mental-health-a-z/R/recovery/

“Navane.” (2013) Retrieved from Micromedex Application for Android.

Recovery model. Mental Health Foundation. http://www.mentalhealth.org.uk/help-information/mental-health-a-z/R/recovery/

Stuart, Gail.  Principles and Practice of Psychiatric Nursing, 10th edition. Mosby, 2013.

Swearingen, Pamela L. All-in-One Care Planning Resource, 2nd edition.  Mosby, 2008.

Medications

Past Psychiatric & Relevant Medical History

Navane

Classification

Anti-psychotic

Therapeutic Use

Schizophrenia

Psychotic disorder

Client Education

•Patient should avoid activities requiring mental alertness or coordination until drug effects are realized, as drug may cause dizziness or somnolence

•Instruct patient to rise slowly from a sitting/supine position, as drug may cause orthostatic hypotension

•Drug may impair heat or cold regulation. Advise patient to use caution with activities leading to an increased core temperature, such as strenuous exercise, exposure to extreme heat, or dehydration. Also advise patient to wear appropriate clothing in colder weather

•This drug may cause anticholinergic effects, akathisia, dystonia, extrapyrimidal disease, epithetial keratopathy, retinitis pigmentosa, or nasal congestion

•Tell patient to report signs/symptoms of arrhythmia, myelosuppression, or tardive dyskinesia (jerky muscle movements, tongue thrusting, facial grimacing/ticks, random movements of extremities)

•Patient should take with food to minimize gastric irritation

•Advise patient against sudden discontinuation of drug

•Patient should avoid drinking alcohol while taking this drug.

Possible disturbed body image

Thiothixene

(Navane)

Onset: 28 years old on vacation – sudden paranoia

continuous psychiatric evaluations + KROL status

Lost 60 lbs prior to trip in a short amount of time

  • Stopped taking medication after a few years: common mistake!

Prescribed antipsychotic medication

Lithium

(Eskalith, Lithobid)

Currently believes there are demons living in his home and feels tormented

Classification

Anti-manic

Lithium

Therapeutic Use

Bipolar disorder: maintenance therapy

Bipolar disorder: manic episodes

Client Education

•Advise patient to avoid activities requiring mental alertness or coordination until drug effects are realized, as drug may cause dizziness, somnolence, and vision changes.

•Drug may cause diarrhea, nausea, ataxia, hand tremor, muscle irritability or weakness, polyuria, oliguria, dehydration, cardiac arrhythmias, hypotension, seizures, alopecia, or xerostomia.

•Instruct patient to discontinue therapy and immediately report signs/symptoms of toxicity, which may include diarrhea, vomiting, tremor, ataxia, drowsiness, muscle weakness, lack of coordination, giddiness, blurred vision, tinnitus, or large volumes of dilute urine.

•Counsel patient to seek emergency assistance with development of unexplained syncope, lightheadedness, palpitations, or shortness of breath, as these may be symptoms of Brugada syndrome.

•Advise patient to maintain adequate fluid intake, salt intake, and a normal diet, especially during stabilization period.

•Advise patient there are multiple significant drug-drug interactions for this drug. Consult healthcare professional prior to new drug use, including over-the-counter and herbal drugs.

"The accident"

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