Question

--Identify 4 priority interventions used to care for this patient and include rationale for each intervention---

Client is 21-year old male who has a recent diagnosis of schizophrenia, visiting an outpatient mental health clinic for a routine visit to meet with his health care provider. Accompanied by a family member (sister) brings him in. Information provided by his (sister).

Family History: Prior to diagnosis patient was living independently in an apartment and was enrolled full-time at a local University where he was studying accounting. Client’s sister reported a decline in self-care, grades, and a withdrawal from personal relationships. Client soon thereafter quit attending classes.  Currently employed as a stocker at a local warehouse following withdrawal from college. Currently lives independently in an apartment. identifies his older sister as his primary support system. Clients

History of prior mental health treatment: Client admitted to acute mental health facility at time of diagnosis. Referred to outpatient health clinic for follow-up care. No history of previous surgeries, denies medical illnesses except seasonal allergies. Has history of substance abuse, reports he quit smoking cigarettes two years ago, 2 pack-year history. Reports social use of alcohol, also states that he has used cocaine in the past but denies recent use of cocaine or other substances.

• History of Mental Illness: Recent diagnosis of schizophrenia.

Current Medications:

• Acetaminophen 325mg 1-2 PO as needed for general discomfort
• Cetirizine 10 mg PO daily PRN allergies
• Risperidone mg PO twice daily

Vital Signs:

• B/P: 122/72
• HR: 76 bpm
• RR: 16
• Temp: 37 C (98.6 F)

Objective data: Client exhibits auditory hallucinations, delusion, and disorganized speech. Worsening of symptoms with med noncompliance and schizophrenia disorder

Subjective Data: Exhibits change in speech making (loosing associations) shifting from one unrelated thought to another. Client becoming increasing anxious, confused while talking.  Patient admits to med noncompliance, stopped taking med (Risperidone) states “I think the pharmacist is trying to poison me,” exhibiting delusion of persecution. Client states he hears voices, music, and words. Client states, “voices are just mumblings” and “music are just quite songs.” Client admits to occurrence to one “dizzy spell” when he stood up and has trouble swallowing bites of foods. Sister states “client not wanting to do as much with (her) or friends,” seems more restless and anxious lately.

1. Present risk factors

Client admits to med noncompliance (risperidone) that would exacerbate his signs and symptoms of his schizophrenia disorder.  Client exhibits increased anxiety behaviors, can be at a risk for violence. Client is exhibiting positive symptoms of schizophrenia (delusions of persecution) and loose associations. Increased isolation actions noted by family member, auditory hallucination are present with client. Greatest risk for a client experiencing auditory hallucination is the risk of self-or-other- directed harm due to command hallucinations, therefore this assessment is the priority. Care team should continue to asses client to determine exactly what the voices are commanding him to do. Client admits to past history of substance abuse (cocaine) is at risk for cocaine intoxication, cocaine can mimic or worsen the symptoms of schizophrenia, such as with psychosis.

Answer 1

Schizophrenia

It is a serious psychiatric disorder characterized by the person gradually losing contact with reality, often experiencing delusions or hallucinations.

Identify 4 priority interventions used to care for this patient and include rationale for each intervention

1. Nursing intervention for substance abuse

Assist patient to recognise problem exists.discuss caring , nonjudgmental manner how drug abuse has interfered with his life .

Rationale

• Predisposing factors - gender male
• History of alcoholism and smoking
• Use of cocaine

2. Nursing intervention for hallucinations

Observe the behaviour of patient carefully during routine patient care.

Rationale

Close observation is mandatory to protect from self harm .

3. Nursing intervention for violence

Redirect violent behaviour

Rationale

Physical exercise can decrease tension and give focus

4. Nursing intervention for confusion

Work with patient to recognise negative thinking and thoughts. Assist patient to reframe negative thoughts.

Rationale

Negative thoughts add more feeling of hopelessness hence it lead to more confusion.intervening this would be more useful.