Help me with the patient care essay

Daytonite, BSN, RN · Aug 25, 2009

although you are being asked to write this out as an essay, you are being asked to write a care plan on this case scenario. to do that you organize by incorporating and using the steps of the nursing process which is the process solving tool that we use. a care plan is a determination of a person's nursing problems and nursing diagnoses are merely another name for their nursing problems.

look up the drug he is taking. it is given for schizophrenia. if people stop taking their medication for schizophrenia they get the signs and symptoms of the disorder: delusions, hallucinations, disorganized speech and behavior, the inability to make decisions and mood swings and disorders.

step #1 - assessment - pull out all the abnormal data from the case scenario that was given to you. that will provide all the assessment data you need.

25 year old with a history of several psychiatric admissions over the past ten years, one admission was for a brief psychotic episode after using marijuana
has been living with his parents and two younger brothers and been unable to keep regular employment as a clerk in the public service
admitted this time because "he went crazy and threatened to kill us [parents]"
prior to admission he often ceases to take his medication, olanzapine 5mgs bd - did that happen this time?
pt states that he has been drinking alcohol and smoking marijuana on an increasingly regular basis because "it helps me to deal with the terrible situation i am in" - is this "terrible situation" real or a delusion?
he has asked for your help "in making a better go of living and to re-establish relationships with my family" - does this indicate he is thinking clearer?

step #2 - determine the nursing problem (nursing diagnosis) based on the signs and symptoms that are present (see list above)

ineffective health maintenance r/t impaired judgment aeb failing to take his olanzapine and having a psychotic episode as well as asking for help to improve his living and relationship with his family
defensive coping r/t substance abuse aeb patient statement that he has been drinking alcohol and smoking marijuana on an increasingly regular basis because "it helps me to deal with the terrible situation i am in".

- - - - - - - - - - - - - - -

the two priority problems that i think are the fact that he is at risk of harm his family or other people and he has been drinking and smoking marijuana on an increasingly regular basis. am i on the right track??

you are on the right track with the drinking and smoking of marijuana. they are coping mechanisms and he's told you that-->"it helps me to deal with the terrible situation i am in". we don't know what that terrible situation is, but i would sit and explore that with him. what terrible situation has him increasing his substance abuse? is that normal thinking? he also may have stopped taking his olanzapine which is for schizophrenia. and although the scenario doesn't confirm this, it gave a history of him doing it. if he has stopped taking it, he could have been experiencing symptoms of schizophrenia and this business of the "terrible situation" may be delusional and part of his psychotic behavior.

i did not list risk of harm to family or others (the correct diagnosis is

risk for other-directed violence r/t history of substance abuse, failure to take medication, history of violent behavior and psychotic behavior

) because it is an anticipated problem and not an actual one. it would be sequenced last.

wjddnjs · Aug 25, 2009

Thank you very much for the reply. I really appriciated that :)

I really need more practice on the critical thinking and planning nursing care for patients.

However, Im just wondering, the risk of harm to family or others can be the one of the priority problems although it is an anticipated problem, no?? cuz my tutor said if there is any risk of harm to himself of others, that would be the priority problem, anything that is associated with harming anyone.

Also, could you please explain me how to collaborate with the consumer, the family and the community nurse to address the two problems and facilitate continuity of care after his discharg.

I think the most important thing is to educate the patient and the family to enhance the family supports. the education can include the information about the drugs and the side effects and how to deal with his abnormal behaviours and what to do in emergency situations. Am I right? :confused:

wjddnjs · Aug 25, 2009

Daytonite Thank you very much for your help but I think I need to change the case scenario as I found the previous one so hard. :yldhdbng: I'm sorry..

Please help me again with this.. that would be very much appriciated!

I hope this one is easier than the other one.

Case Scenario

Jack Jones is a 42 year old man who has had several psychiatric admissions, his first when he was 18 and in his first year at university. Over the past 9 years he has been declining in his ability to live in the community. After a 10-day admission, Jack is almost ready for discharge from the psychiatic unit in which you are working. Prior to Jack's admissions to hospital he has had a pattern of similar experiences. That is, he often ceases to take his medication, stating that he stops the medication because of the extra-pyramidal side-effects, dry mouth and blurred vision, that are "unbearable, and I'd have to say, they are worse than the psychotic symptoms". Shortly following this, he begins to believe that he is being talked about on the radio (derogatively) and hears voices telling him that the government is monitoring his every move via a tracking device. When Jack is ill, he believes this device was implanted during his first admission. Just before this admission he went to the police to ask them to "find out who put it there and to lock them up in prison". Jack lives in a large hostel in the community supervised by an unqualified home care assistant. "I like it because it is cheap, I can spend my money on what I want, and they don't hassle me". He has recently been unable to keep regular employment as a labourer on building sites, and is hesitant to apply for any job for fear of being rejected or eventually sacked. Jack also believes that he should have a girlfriend but often expresses feelings of intimidation and anxiety when approaching women. He has a highly ambivalent relationship with his family, whom he says "shout and argue all the time". They live in a remote country town and keep asking me "when am I going to find a nice girl and get married, and have someone to look after me". Following a team meeting, the Psychiatric Registrar has ordered that he be recommenced on Flupenthixol Decanoate 20 mgs 2nd weekly and Cogentin 2mg mane

Briefly describe the problems that Jack is experiencing that impact on his health and well-being. Then, identify two priority problems and state them as nursing diagnoses, briefly outlining your rationale for each diagnosis. Discuss how you as a registered nurse would collaborate with the consumer, the family and the community mental health nurse to address the two identified priority problems and facilitate continuity of care, after Jack's discharge.

the problems that I have found include;

-the fact that he often ceases to take his medication

-he believes that he is being talked about on the radio (delusion)

-and hears voices (hallucinations)

-he is unable to keep regular employment as a labourer on building sites

-he often expresses feelings of intimidation and anxiety when approaching women

I though the priority problems can be the fact that he often ceases the medication and the being intimidated and anxious when approaching as these feelings can be the source of harm people especially women.

I think it is more likely to be a psychologists' or a doctor's responsibilities than nurses' to deal with the schizophrenic symptoms like delusion and hallucination. Am I right?

Daytonite, BSN, RN · Aug 25, 2009

step #1 - assessment - pull out all the abnormal data from the case scenario that was given to you. that will provide all the assessment data you need.

jack's history: 42 year old man who has had several psychiatric admissions over the past 9 years and he has been declining in his ability to live in the community
- his pattern of psychiatric admission is that he often ceases to take his medication stating that the extra-pyramidal side-effects (parkinsonism), dry mouth and blurred vision are "unbearable, and i'd have to say, they are worse than the psychotic symptoms". - hint: he is psychotic and aware of it and the side effects of his medications are a problem for him
- he began to believe that he was being derogatively talked about on the radio and hears voices telling him that the government is monitoring his every move via a tracking device. when jack is ill, he believes this device was implanted during his first admission. he went to the police to ask them to "find out who put it there and to lock them up in prison". - and here are the psychotic symptoms of his schizophrenia
[*]the fallout as a result of the psychosis and resulting behavior
- unable to keep regular employment as a labourer on building sites
- hesitant to apply for any job for fear of being rejected or eventually sacked
- believes that he should have a girlfriend but often expresses feelings of intimidation and anxiety when approaching women
- has a highly ambivalent relationship with his family, whom he says "shout and argue all the time" and keep asking me "when am i going to find a nice girl and get married, and have someone to look after me"
[*]medical treatment: ordered that he be recommenced on flupenthixol decanoate 20 mgs 2nd weekly and cogentin 2mg mane
- flupenthixol decanoate - given for schizophrenia
- cogentin (benzotropine) - given for parkinsonism

step #2 - determine the nursing problem (nursing diagnosis) based on the signs and symptoms that are present (see list above)

briefly describe the problems that jack is experiencing that impact on his health and well-being.

the problems that i have found include;

-the fact that he often ceases to take his medication - yes

-he believes that he is being talked about on the radio (delusion) - when symptomatic, but if he takes his medication this should not happen

-and hears voices (hallucinations) - when symptomatic, but if he takes his medication this should not happen

-he is unable to keep regular employment as a labourer on building sites

low self esteem in the ability to maintain independence

-he often expresses feelings of intimidation and anxiety when approaching women

pressure by family to conform to a societal norm to have a relationship with someone of the opposite sex. it seems there is concern about who will look out for jack and that ultimately the parents have been doing this. they must be at least in their 60s since jack is 42, so what might be going on there? are the parents worried about what will happen to jack when they are gone? is that the reason for the shouting and arguing and them wanting him to find someone to look after him? maybe they are just tired of parenting a 42 year old man. however, this care plan is about jack and not the parents, so keep the focus on jack. he wants to please his family, but because he is unable to do so because of his illness he feels intimidated and becomes anxious.

then, identify two priority problems and state them as nursing diagnoses, briefly outlining your rationale for each diagnosis.

i thought the priority problems can be the fact that he often ceases the medication and the being intimidated and anxious when approaching as these feelings can be the source of harm people especially women.

i believe this is correct. the diagnoses for these are

ineffective health maintenance

(inability to identify, manage, and/or seek out help to maintain health)

and

ineffective coping

(inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources).

he needs help and strategies in dealing with his parent's demands. however, i do not think there is any worry for him to harm anyone. there was no mention of him harming anyone in the scenario or of him being a harm to himself. schizophrenia does not mean people are going to do harm to themselves or others.

i think it is more likely to be a psychologists' or a doctor's responsibilities than nurses' to deal with the schizophrenic symptoms like delusion and hallucination. am i right?

no. we both deal with the symptoms. physicians can order medications. nurses treat how the patient deals with the delusions and hallucinations. nursing is about helping people dealing with their responses to their medical diseases and delusions and hallucinations are jack's responses to his schizophrenia. we also help them achieve their adls (activities of daily living).

nursing interventions for psychotic behavior (delusions and hallucinations) from page 58-9 of

psychiatric principles and applications for general patient care

, 4th edition, by bonnie fossett and marlene nadler-moodie:

establish rapport and a trusting relationship by
- making brief but frequent contacts with the patient
- approach the patient with acceptance and a nonthreatening manner
  - rationale: these measures provide support and reassurance
[*]provide a safe environment (this may not apply to this patient)
- check the patient's potential for self-harm or harm to others
- observe the patient often
- command hallucinations, voices that tell a person to harm himself or herself, are extremely dangerous to the patient's safety.
- persons who are delusional and feel persecuted may act out violently, irrationally, and impulsively toward others
  - rationale: psychotic patients can be distraught enough to attempt suicide or may assault others.
[*]decrease stimulation
- rationale: if the patient is overly excited or responding to a great deal of anxiety, creating a more relaxing, restful, and calming atmosphere may decrease the entire episode or the intensity of the psychosis.
[*]do not argue with psychotic patients
- let them know you believe they are in fact reporting the truth as they know it
- tell them the reality from your prospective
- remind them of time, place and person
- you may want to say, "i know you are fearful of being harmed by aliens, but there is no evidence of their presence here now," or "i don't see any spiders. i believe that you do. let us talk about how we can help you feel safe."
  - rationale: these approaches provide reality orientation and a sense of safety.
[*]make sure you understand what the patient means.
- ask questions
- summarize what you think has been said
  - rationale: misinterpretation can occur easily.
[*]help patients determine when and why they become anxious.
- use problem solving with them to find ways to cope with anxiety.
- do this before or after, not during, a psychotic episode.
  - rationale: anxiety can stimulate signs and symptoms of psychosis.
[*]use physical contact cautiously.
- rationale: patients who believe they are being persecuted or who are irrational may misinterpret physical contact and overreact.
[*]communicate your assessments to the physician.
- rationale: the physician most likely will order an antipsychotic medication to alleviate the signs and symptoms of psychosis.
[*]administer psychopharmacologic medications when necessary as directed by a physician
- rationale: these medications are used to manage the symptoms of schizophrenia and psychosis.

you can find other information and nursing interventions for these 2 nursing diagnoses on these webpages:

ineffective health maintenance

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=27

- ineffective health maintenance

ineffective coping

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=15

- ineffective coping

discuss how you as a registered nurse would collaborate with the consumer, the family and the community mental health nurse to address the two identified priority problems and facilitate continuity of care, after jack's discharge.

i think your instructors are specifically looking for you to come up with nursing interventions that will involve the patient, his family and community resources that address his problems that you have identified and are treating. because i don't live in your area i do not know what those are. when i was in school we had to do this also and were expected to find out what kinds of local resources were available. this family of jack's needs some education about jack's disease and they need to be educated to stop pressuring jack to have girlfriends because it creates anxiety in the poor guy and the anxiety is a potential trigger to bring on his symptoms, you see? if they can't be included, then jack needs be encouraged to keep his contacts with family to a minimum although that is hard to tell someone because they are his family. that is a tricky problem. sometimes you just want to hit people that make matters worse because of their ignorance. so, obviously, jack's care is a priority--to the family.

wjddnjs · Aug 28, 2009

Daytonite thanks very much for your posting. It really helps! :wink2:

but I still have got few questions,

in the case study, it doesn't tell us about that Jack is anxious because of the pressure by his family wanting him to get married or he wants to please his family or anything like that.

When we determine the nursing problems, is that ok to make an assumption because we don't have enough information??

Also, for the nursing diagnosis, I have difficulties finding the evidences of the nursing diagnosis from the case scenario.

I tried write nursing diagnoses, could you please check it and tell me anything to add into or take from?

Ineffective coping related to inadequate coping method, personal vulnerability, poor self-esteem, inadequate social support as evidenced by inability to keep regular employment, hesitancy of applying for a job for fear of being rejected or eventually sacked, expressing feelings of intimidation and anxiety when approaching women and the symptoms of Schiziophrenia like delusion and hallucinations.

Ineffective health maintenance related to lack of ability to make deliberate and thoughful judgments, perceptual or cognitive impairment, ineffective coping, ineffective family coping, inability to seek out help to maintain healthlack of material resources as evidenced by frequent stopping of medication because of the side effects, having ambivalent relationship with his family.

The rationales that you have given me were great, but I also have some rationales from the Nursing diagnosis handbook. Can you please check these are right?

Ineffective Health Maintenance:

-assess for family patterns, economic issues, and cultural patterns that influence compliance with a given medical regimen

-identify support groups related to the disease process

-assist the client in reducing stress

-refer the client to community agencies for appropriate follow-up care

-provide the family with information about the client's disease

Ineffective Coping:

-assess the risk of the client's harming self or others and intervene appropriately

-use empathetic communicatoin and encourage the client and family to verberlize fears, express emotions

-refer for counseling as needed

-provide the client and the family with needed information regarding the condition and treatment

-work closely with the client to develop appropriate educational tools that address individualized needs

-teach the client about available community resources

What is difference between rationale and the nursing interventions? are they the same? cuz the rationales that I have listed are like interventions.. :confused:

Last question!

Im still not sure about those nursing diagnosis are the priority problems.. bcuz my tutor said the priority is anything that is threat the patient's safety.

Is there any other problem that is more urgent than those two?

Once again thanks for your help. I really appriciate that!:)

Daytonite, BSN, RN · Aug 29, 2009

in the case study, it doesn't tell us about that jack is anxious because of the pressure by his family wanting him to get married or he wants to please his family or anything like that.

the scenario tells you: jack also believes that he should have a girlfriend but often

expresses feelings of intimidation and anxiety

when approaching women. that is evidence that he has anxiety.

when we determine the nursing problems, is that ok to make an assumption because we don't have enough information??

never assume anything. always rely on facts.

also, for the nursing diagnosis, i have difficulties finding the evidences of the nursing diagnosis from the case scenario. i tried write nursing diagnoses, could you please check it and tell me anything to add into or take from?

the nursing diagnoses i gave you were based upon evidence in the scenario. i listed it just above in the

step #1 assessment

area. i wanted you to try to do some of the connection yourself. this isn't much different from the first scenario that you decided to abandon. a nursing diagnosis reference will also have some of this information. you need to review the pathophysiology and the signs and symptoms of the patient's medical conditions (schizophrenia) as well as the historical data in the scenario. i gave you weblinks to both nursing diagnoses that have nursing diagnosis reference information on them (related factors and defining characteristics) so you could do this.

the diagnoses in priority order are:

ineffective coping r/t poor problem solving skills, low self-esteem and threat to his place with other family members aeb inablity to keep regular employment as a labourer on building sites, hesitancy to apply for any job for fear of being rejected or eventually sacked, belief that he should have a girlfriend, and ambivalent relationship with his family that results in shouting and arguing all the time.
ineffective coping r/t poor problem solving skills and threat to his self esteem aeb inability to keep regular employment as a labourer on building sites, hesitancy to apply for any job for fear of being rejected or eventually sacked, belief that he should have a girlfriend, and ambivalent relationship with his family that results in shouting and arguing all the time.

what is difference between rationale and the nursing interventions? are they the same? cuz the rationales that i have listed are like interventions..

rationales have to do with

why

a

nursing intervention

in being done.

the rationales that you have given me were great, but i also have some rationales from the nursing diagnosis handbook. can you please check these are right?

i dumped all your rationales. i had no idea what you were doing with them or what nursing interventions they applied to.

nursing interventions are done for the

evidence

you have for a nursing diagnosis.

for

ineffective health maintenance r/t impaired judgment aeb failing to take medication because extra-pyramidal side-effects (parkinsonism) of dry mouth and blurred vision are "unbearable, and i'd have to say, they are worse than the psychotic symptoms".

your nursing interventions would target

failing to take medication

interventions would be teaching the patient about what his medications are for and the importance of taking them on a regular basis. you can find these in a nursing reference book.

for

ineffective coping r/t poor problem solving skills and threat to his self esteem aeb inability to keep regular employment as a labourer on building sites, hesitancy to apply for any job for fear of being rejected or eventually sacked, belief that he should have a girlfriend, and ambivalent relationship with his family that results in shouting and arguing all the time

your nursing interventions would target

poor problem solving skills (which resulted in this evidence of the problem)
- inablity to keep regular employment as a labourer on building sites
- hesitancy to apply for any job for fear of being rejected or eventually sacked
- belief that he should have a girlfriend
- ambivalent relationship with his family that results in shouting and arguing all the time

interventions include things like:

explain the flight or flight response and the relaxation response
- rationale: understanding the physiologic aspect of anxiety helps people realize that they have some control over their actions as well as hope.
[*]teach breathing techniques to help him deal with anxious situations
- rationale: breathing techniques can prevent anxiety from escalating.
[*]teach new coping skills to substitute for ineffective ones.
- rationale: different skills gives the patient other options.
[*]a relaxation technique that can be taught to the patient to help him calm down is visualization
- rationale: calming down gives the patient control of their own behavior.
[*]role play different potential stressful situations and how the patient can prepare to handle them
- rationale: developing effective new coping strategies as well as practicing them increases the patient's success with using them.

you need to learn the steps of the nursing process:

assessment - finding the evidence of abnormal data
diagnosis - determination of the problems
planning

goals
nursing intervention (and rationale, or reason for doing the intervention)

[*]implementation

[*]evaluation

wjddnjs · Sep 2, 2009

I'm sorry to bother you so much..but I have one more question.

When the question asks how the nurse collaborate with the consumer, the family and the community mental health urse to address the problem, the nurse definitely need to educate the consumer and the family, rite??

but Jack's family live in a remote country town and Jack lives in a hostel in the community, so I thought the nurse can provide the family information about Jack's medical conditions and how to manage and things like that by calling them or writing a letter or sending an email. Is that ok?

also, since they are not living together, the family wouldn't be able to help and support and take care of Jack effectively, would they? So I decided to focus on collaboration with the community nurses more as they can support Jack better than the family do. Am I right?

Then, what can I do as a resistered nurse to collaborate with the community mental health nurse?

all I can think of is that RN provides information about Jack to the community nurse and suggest or discuss any community support services that would be needed by Jack. is there anything else??

thanks for your reply. I really appreciate that :)