Case study schezophrenia

1. 1
Universty of tabuk
Faculty of Applied Medical sciences
Department of nursing
Done by :
-Asma mohammed Alshehri.
-Nada Atallah Alhwiti.
-Shroog meflh Albalawi.
-Khlood Ebrahim Hakami.
-Layla Ali Akam.
-Asma mohammed Alzahrani.
-Jawaher nafe Alharbi.
-Rawan faiz Almarwani.
-Nura Almasaudi.
Supervision by:
Dr.Jeneth Gutierrez
Schizophrenia F20

2. 2
.

3. OUT LINE :
-Introduction
-statistics
-Client History
a) Socio-Demographic Profile
b) Chief Complaint
c) Past psychiatric history
-Personal history
A) behavior during childhood
B) illness during childhood
C) schooling
D)occupational history
3

4. OUT LINE :
-Family history
-Assessment
-MENTAL STATUS EXAMINATION
I. General appearance and behaviour (GAAB)
II. Psychomotor Activity and speech
IV. Thought
V. Mood (subjective) and Affect (objective)
-Cognitive function
-Nursing diagnoses for schizophrenia
-Planning and goal for schizophrenia Nursing --
implementation for schizophrenia
-Evaluation for schizophrenia
4

5. OUT LINE :
-MEDICATION
-Prognosis
-Summary
-References
5

6. INTRODUCTION
Our Case presentation is about schizophrenia
F20
(paranoid schizophrenia )
Our client S.X is referred from Alhawra hospital of
Omlej with known case of schizophrenia with
positive symptom of psychiatric illness
She is divorced without children because she
cant be pregnant
6

7. -Most commonly diagnosed thought disorder;
-Interferes with a person's ability to think clearly, to
distinguish reality from fantasy, to manage emotions,
make decisions, and relate to others;
-A person with schizophrenia does not have a "split
personality” (DISORGANIZED PERSONALITY)
-Char by disturbances hallucinations in thought and
sensory perception (and delusions), thought disorders,
and by deterioration in psychosocial functioning;
-Usually appears in LATE ADOLESCENT OR EARLY
ADULTHOOD (15-25 Y/O), and affects men and women
almost equally;
7

8. 8
-MOREL described schizophrenia before as dementia
praecox (precocious senility);
-BLEULER later coined the term schizophrenia which
means “split mind” (not split personality);
-95% of clients with schizophrenia have a lifetime
disease;
-70% of clients will have a partial response to treatment;
-50% will experience severe side effects to your anti-
psychotics;
-SUICIDE is the most common cause of premature death
of these clients

9. STATISTICS:
9
By age and gender:
 Each year, one in 10,000 people age 12 to 60 develops schizophrenia. It is
diagnosed 1.4 times more frequently in males than females and typically
appears earlier in men—the peak ages of onset are 20–28 years for males
and 26–32 years for females. Onset in childhood is much rarer,[9] as is
onset in middle- or old age.
 Generally, the mean age of first admission for schizophrenics is between
25 and 35.
 It is generally accepted that women tend to present with schizophrenia
anywhere between 4-10 years after their male counterparts.
 This additional post-menopausal peak of late-onset schizophrenia in
women calls into question the etiology of the disease and raises a debate
about "subtypes" of schizophrenia, with men and women being
susceptible to different types

10. 10
By country:
 In 2000, the World Health Organization found the prevalence and
incidence of schizophrenia to be roughly similar around the world,
with age-standardized prevalence per 100,000 ranging from 343 in
Africa to 544 in Japan and Oceania for men and from 378 in Africa to
527 in Southeastern Europe for women.
 DALY rate in saudi Arabia is 270.202
 In 2010, there were approximately 397,200 hospitalizations for
schizophrenia in the United States. About 88,600 (22.3%) were
readmitted within 30 days.

11. 11

12. Theoretical Perspective
A. Biological Theories
1- Biochemical Theory (Dopaminergic Hypotheses)
 Excessive dopaminergic activity in cortical areas causes
acute positive symptoms of schizophrenia.
 Excessive dopamine could be a result of increased
dopamine synthesis, increase dopamine release, or
increase activity of dopamine receptors;
 Increase administration of artificial dopamine can cause
psychotic manifestations;
12

13. 13

14. 2. Neurostructural Theory
-Patients with schizophrenia have four structural changes in the
brain:
 Cerebral ventricular enlargement.
 Cerebral atrophy
 Hypoplasia of the medial (limbic) temporal structures.
 Decreased cerebral blood flow specially in the prefrontal
cortex.
14

15. 15
3. Genetic Theory
 Higher incidence of schizophrenia in patients with a
diagnosed psychotic relative;
 Monozygotic twins have a higher incident rate
compared to ordinary individuals;
 Identical twins have 50% risk;
 Fraternal twins have 15% risk;

16. 16
B. Developmental Theory
 The “first stage (trust vs mistrust) is very important in
the development of interpersonal relationship.”
 A child deprived of nurturing, loving environment,
neglected or rejected, is very vulnerable to mental
disturbances;
 Therapeutic intervention focuses on the
reestablishment of trust thru consistent, anxiety-free
relationship;

17. 17
 Absence of warm, nurturing attention during
the early years blocks the same expressions
in the later years;
 Persons will exhibit disordered social
interactions thereby avoiding interpersonal
interactions which will lead to pain and
shame;

18. 18
C. Family Theory
 Lack of a loving and nurturing primary caregiver,
inconsistent family behaviors and faulty
communication patterns are thought to cause mental
problems in later life;
D. Vulnerability-Stress Model
 This model recognizes that both biological and
psychodynamic predispositions plus stressful life
events can precipitate a schizophrenic process;

19. 19
BLEULER’S Four A’s
1-Affective Disturbances
 Inappropriate – affective response doe not match the
circumstances;
 Blunted – the response to certain circumstances is weakly
appropriate;
 Flat – inability to generate any affective response;
 Labile – emotional tone changes quickly;
 Latent – the response of the client is delayed;

20. 2- Mutism – preoccupation with the self with little
concern for external reality;
3- Ambivalence – simultaneous opposite feelings;
4- Associative looseness – the stringing together of
unrelated topics with vague connections;
 Auditory hallucination
20

21. 21
Positive vs Negative Symptoms
of Schizophrenia
1-Positive Symptoms (type I)
 believed to be caused by an increase in the amount
of dopamine affecting the cortical areas;
 Symptoms are additional of abnormal cognition
and perception;
 Targeted by typical anti-psychotics (Haldol,
Thorazine)

22. Examples of Positive Symptoms:
A- HALLUCINATIONS – a false sensory perception
unrelated to external stimuli;
 AUDITORY – most common;
 Somatic – part of the body is abnormal.
 Tactile – touch.
 Olfactory – smell.
 Gustatory – taste.
 Visual
 Kinesthetic – false perception that the body is
moving.
 Cinesthetic – client can feel body organ function.22

23. 23
2. Negative Symptoms (type II)
 Symptoms are essentially an absence or diminution
of what should be ( lack of affect, lack of energy)
anergia, alogia
 May be related to:
 decrease amount of dopamine
 cerebral atrophy
 decreased cerebral blood flow
 increase serotonin;
 Targeted by ATYPICAL anti-psychotics (Clozapine,
Olanzapine)

24. Examples of Negative Symptoms:
 Alogia – poverty of content; lack of meaning on what the
CLIENT is talking;
 Anhedonia
 Apathy, lack of feeling, concern, or interest
 Asocial behavior
 Attention deficit
 A volition – lack of motivation;
 Blunted or flat affectCommunication difficulties (echolalia,
neologism, word salad, etc)
 Difficulty with abstraction;
24

25. 25
PARANOID SCHIZOPHRENIA

26. PARANOID schizophrenia (f20)
 Extreme suspiciousness
 Persecutory delusions
 Paranoid delusions
 Auditory hallucinations
 Labile affect
 Uses PROJECTION.
26

27. FAMOUS WITH SCHIZOPHRENIA
27

28. Demographic data:
Patient name is s.x, she is 30 years old , she
is Saudi , female , she is muslim , devporse
with no kids > she was Living with her
brother in Ummljj
Admission data:
Entered the hospital in 30/2/1434H ,
Diagnostic paranoid schizophrenia
disorder
Under the supervision of Dr rasha
abood
28

29. Chief Complain:
(ana maabe arjaa albeet lean akoy ykrhny wykleeny aaked
dawa wana mo mareedha )
She said I do not want to go back to home because my
brother hates me and makes me take medication and am
not sick )
From file :
patient referred from Alhawra hospital of Ummlujj . She is
a known case of schizophrenia ,with positive family history
of psychiatric illness she referred because she is tried to
running out from the home and she is not compliant to her
medications which is queliepine and benztropine then her
family refused to received her from hospital. 29

30. PAST PSYCHIATRIC HISTORY:
There is no information in file about past psychiatric
history because the patient referred from ummlujj
hospital but we seek some information from the
nurses which known the family . the symptoms was
appear at 20 years old when she divorced which are
(bizarre behavior , Suspiciousness ideas of references
and moderatory conceptual disorganized isolated
and she is hitting other and running out from home
she did not want to interact with other and she was
always isolated and she sleep for along time and
does not want to eat because she thought that
some thing will harm her)
30

31. S-X SAID:
- I want to be alone .
- I hate my brother.
- I didn't want to talk or eat.
- I Don't need medication .
31

32. Precipitating factor:
-S .x life stressor affect her psychological
condition , her parent died and she
divorsed and his brother blame her
-these are the major challenges that
faced her
Periods of high stress : when she married
she known that she well not be pregnant.
32

33. PREVIOUS TREATMENT WAS:
-These medications was prescribed in ummllaj hospital
(queliepine and benztropine ) she was taken these
medication and her state slightly improved then she
neglected them because its makes her worsen and
harm her With these complaint
-headache
-She feel drowsiness all the time
-Nervousness
-Vomiting and nausea and she feel weakness
And un pleasant feeling
-She refused to take medications then she worsened
again and Un complete remission.
33

34. PERSONAL HISTORY :
Behavior during childhood .
-She went to school, she was good in her study , she
like her friend and spend time with them , she had good
relationship with others.
-she didn't have episode temper , she have normal
feeding habits about three meals a day , she didn't
have neurotic symptoms and pica , she was play with
her friends .
Illness during childhood :
-she didn't have CNS infectious epilepsy or any neurotic
disorders
Schooling :
-began her study at the age of 6 years and she have a good
relationship with teachers and his friends and she didn't have
any learning disability and no attention deficient .
34

35. Occupational history:
She continue her education until the 5rd
grade and she discontinued studding at
that time because her parents died and
she was neglected and she spend the
time with her big pothers which they
were suffering from low socio-
economic state
35

36. FAMILY HISTORY:
Positive family history of
psychiatricillness without
details in file.
36

37. ASSESSMENT:
A. MENTAL STATUS
EXAMINATION (MSE):
37

38. I. GENERAL APPEARANCE AND
BEHAVIOUR (GAAB)
At the time of examination, the client was conscious
with appropriate grooming and dressing. she had
stooped Posture and stereotyping Mannerisms,also
stereotyping psychomotor activity.
For the appearance, she looks older, there is blunted
facial expression. During our conversation with the
client : the rapport was built with difficulty , eye to
eye contact did not maintain And the client was
preoccupied . And there is no desire to talk .
She appeared isolated
38

39. II. PSYCHOMOTOR ACTIVITY AND
SPEECH:
The patient articulated clearly. she answered
questions inappropriately with (incoherent
speech) , decrease in rate and speed. she spoke
in soft volume and low pitch tone throughout the
conversation, particularly when we asked her
about her life before .
Generally she has stereotyping psychomotor
activity.
39

40. IV. THOUGHT
The patient administered with some thought
disorder :
-not understandable thought
- Neologism
-pressure of speech
-persecutory delusion of reference .
-ex (when I gave her cake she refuse to take it ,
she think there is some thing in the cake will
harm her )
40

41. V. MOOD (SUBJECTIVE) AND AFFECT
(OBJECTIVE):
A) Inappropriate –
Relevance to situation and thought
congruent.
b) Unpleasurable affect- depression
c) Other affects- fear.
41

42. :PERCEPTION DISORDERS
Hallucination :-
Type :
-She has auditory hallucination.
Example :
-She hear that her brother called her
42

43. COGNITIVE FUNCTION
A) attention and concentration :
We test S.x about listing the months of the
year
She knows that there are 12 months/year
but in general she cannot say it
accurately in true order even forward or
backward .
We test Sx about Serial subtraction and
her answer :
*100-5 = ??? No answer
43

44. COGNITIVE FUNCTIONS :
B ) Orientation :
we ask the patient those question :
What time is it ?
the time is 11 am
Where are you now ?
I am In Mental Health Hospital
Who is accompanied with you ?
MY Brother MX
44

45. C-MEMORY
45

46. MEMORY
1- To examine her recent memory , we asked her about
our names that we told her during the last meeting she
did not remember that . So ,her recent memory is very
weak .
2- I asked her about her birth day , she does not answer ,
So her remote memory is very poor .
3-To examine her Short-term memory I told her before 5
minutes that today is Tuesday and I asked her after 5
minute then she answered correctly . So, her Short-term
memory is good .
46

47. CONT …
-She can differentiate between things
and also the similarity between things
like pens and papers .
-she has difficulties to understand what
the people say and what they mean .
47

48. 48
Judgment:
The client has poor judgment to other
and to society .
Insight:
She has awareness of being sick
attribute it to external physical factor .

49. PHYSICAL ASSESSMENT
49
The client is physically well she does not
complain of any diseases his health is well,
all physical findings are normal .

50. CONT…
50
Head:
-Hair- normal texture.
Scalp- no ( lesion-tenderness) .-
-Eyes: Sclera- white .
-Conjunctiva- pink.
-Teeth: Present ,Tongue: no lesions .
ABDOMEN:
-Observation: there is abd steria . Due to loss in WT
-Palpation: Superficial- no tenderness, masses.
-Deep- no (tenderness, masses)

51. CON..
EXTREMITIES:
-Upper: Nails-no cyanosis, clubbing
-Palms- normal color, texture .
Joints (including ROM):
-normal ROM , no deformities .
-Lower: Nails- normal (no cyanosis, clubbing).
-Joints (including ROM) :
Ankle- dorsiflexion, plantar flexion, eversion,
inversion.
Knee- flexion.
Hip- flexion ,internal rotation, external rotation.
51

52. Pulse: 120 bpm
Respiration: 20 bpm
Temperature: 37°c
Blood Pressure: 110/80 mmhg
Height: 154 cm
Weight: 42 kg
So , her BMI is 17.71 she is under weight
Vital signs
52

53. 53

54. Side effectContraindicationIndicationDose /
rout/fre
Classification
Agitation, amnesia,
anxiety, apathy,
asthenia, ataxia,
cerebral ischemia,
delirium,chills ,
confusion, Angina,
bradycardia, edema,
hypercholesterolemia,
hypertension , dry
mouth, earache,
epistaxis,eye pain,
Abdominal distention
and pain, Asthma,
bronchitis, cough,
dyspnea,pneumonia
Hypersensitivity
to mirtazapine
or its
components,
use within 14
days of an MAO
inhibitor
To treat major.
depression
200mg
tab
OD
PO
Chemical
class:
Piperazinoaze
pine
Therapeutic
class:
Antidepressan
t
Pregnancy
category: C
GENERIC NAME: Mirtazapine
RemeronBRAND NAME:
54

55. NURSING CONSIDERATIONS
• Administer mirtazapine before bedtime.
• Expect disintegrating tablet to dissolve on
patient’s tongue within 30 seconds.
• If patient takes drug for depression, watch
closely for suicidal tendencies, especially
when therapy starts or dosage changes,
because depression may briefly worsen.
•Monitor patient closely for infection
(fever, pharyngitis, stomatitis), which may
be linked to a low WBC count. If these
signs occur, notify prescriber and expect to
stop drug.
• Expect mirtazapine therapy to last 6 months or longer
for acute depression.
55

56. PATIENT TEACHING
• Instruct patient not to swallow disintegrating tablet. Tell him
to
hold tablet on tongue and let it dissolve. Inform him that
tablet will
dissolve within 30 seconds.
• Instruct patient to avoid alcohol and other CNS depressants
during
therapy and for up to 7 days after drug is discontinued.
• Advise patient to avoid hazardous activities until drug’s CNS
effects are known.
• Direct patient to change position slowly to minimize the
effects of
orthostatic hypotension.
• Instruct patient to notify prescriber at once about chills,
fever,
Mouth irritation,sore throat, and other signs of infection.
• Encourage patient to visit prescriber regularly during therapy
to
monitor progress. 56

57. Side effectContraindicationIndicationDose / rout
freq..
Classification
Aggressiveness,
agitation, akathisia,
anxiety, asthenia,
confusion, Cough,
dyspnea, sleep
apnea, upper
respiratory tract
infection,
Abdominal pain,
anorexia,
constipation,
diarrhea
nausea, vomiting
hyperglycemia,
Diaphoresis, dry
skin,leukopenia,
Hypersensitivity
to risperidone or
its components
To manage
psychotic
disorders .
To treat bipolar
mania.
To treat bipolar
mania as
monotherapy
or as adjunct to
lithium or
valproate
therapy
To treat
irritability
associated with
autistic disorder
2mg/tab
BID
PO
Chemical class:
Benzisoxazole
derivative
Therapeutic
class:
Antipsychotic
Pregnancy
category: C
GENERIC NAME: risperidone
BRAND NAME: Risperdal
57

58. NURSING CONSIDERATIONS
• Use risperidone cautiously in debilitated patients, elderly
patients, and patients with hepatic or renal dysfunction or
hypotension because of their increased sensitivity to drug.
Also use risperidone cautiously in patients with a history of
seizures.
• Monitor for orthostatic hypotension, especially in patients with
cardiac or cerebrovascular Disease.
Monitor patient’s blood glucose and lipid levels as ordered
because
drug Increases the risk of hyperglycemia and
hypercholesterolemia
• Monitor patient’s CBC, as ordered, because serious adverse
hematologic Reactions may occur, such as agranulocytosis,
leukopenia, or neutropenia.
58

59. PATIENT TEACHING
• instruct patient to dilute risperidone oral solution with water, coffee,
orange juice, or low-fat milk but not with cola or tea.
• Tell patient prescribed orally disintegrating tablets to break open the
blister
unit with dry hands by peeling the foil back to expose the tablet. Stress
the
importance of not pushing tablet through the foil because this could
damage
the tablet. Once patient has removed tablet, she should place
immediately
on her tongue, where it will dissolve within seconds. Tell patient not to
chew
orally disintegrating tablet or attempt to spit it out of her mouth.
• Urge patient to avoid alcohol because of
its additive CNS effects.
• Caution diabetic patient to monitor blood
glucose level closely because risperidone may increase it.
59

60. Side effectContraindicationIndicationDose / dosage
rout frequency
Classification
Chills, confusion,
dizziness,
drowsiness,
fatigue, fever,
headache, visual
hallucinations,
Abdominal pain,
anorexia,
constipation,
diarrhea,
dyspepsia, Acute
urine retention,
albuminuria,
azotemia,
glycosuria, leg
cramps,
thrombocytopenia
History of bone
marrow
depression;
hypersensitivity
to
carbamazepine,
tricyclic
compounds,
or their
components;
MAO
inhibitor or
nefazodone
therapy
To treat
epilepsy
To treat acute
manic and mixed
episodes
in bipolar
disorder
To relieve pain
in trigeminal
neuralgia
200mgtab
OD
PO
Chemical class:
Tricyclic
iminostilbene
derivative
Therapeutic
class: Analgesic,
anticonvulsant
Pregnancy
category: C
GENERIC NAME: carbamazepine
BRAND NAME: Tegretol
60

61. NURSING CONSIDERATIONS
• Avoid using carbamazepine in patients with a history of
hepatic porphyria because it may prompt an acute attack.
• Use carbamazepine cautiously in patients with impaired
hepatic function Because it’s mainly metabolized in the liver.
Monitor liver function tests, as directed.
•Monitor patient closely for adverse reactions because
many are serious.
• Periodically monitor blood carbamazepine level to assess
for therapeutic and Toxic levels; a blood level of 6 to
12 mcg/ml is optimal for anticonvulsant effects
•Monitor patient closely for evidence of suicidal thinking
or behavior, especially when therapy starts or dosage changes.
•Withdraw carbamazepine gradually to minimize risk of seizures
61

62. PATIENT TEACHING
•Tell patient to take carbamazepine with food (except the oral
suspension
form,which shouldn’t be taken with other liquid drugs or diluents).
•Warn patient about possible dizziness, blurred vision, and unsteadiness.
• Advise patient not to crush or chew capsules or tablets. If he
can’t swallow capsules whole, have him open them and sprinkle
contents
on food.
• Urge patient to wear sunscreen and protective clothing to reduce
photosensitivity.
• Tell patient to report unusual bleeding or bruising, fever, rash, or mouth
ulcers Instruct caregivers to watch patient closely for evidence of
suicidal
tendencies, Especially when therapy starts or dosage changes,
and to report such tendencies to prescriber immediately.
62

63. rationaleTechnique
used
Nurse verbal and non verbal
communication
Pts, verbal and
non verbal
communicatio
n
Giving
information to
pts about me
to start the
conversation
Giving
information
hello, I am monera , Im a student
nurse
Hello, monera
Its for making
self available
and showing
interest and
concern.
Offering selfI will stay with you todayOK
To encourage
pts to discuss
that to me
Stating the
observed
S.X you appear
Angry.
I have a
headache
63

64. 64
rationaleTechnique usedNurse verbal and
non verbal
communication
Pts, verbal and non
verbal
communication
To encourage the
pts to repeat this
good action daily
Feed backI notice you have
brushed your teeth
YES , I do that daily
To help the pts to
identify her feeling
.
reflectionyou don’t want to
go to your home?
I dont want to go
back my home
Because I want to
know the causes of
that.
ExploringCan you tell me
more .?
I don’t like my
brother

65. NURSING CARE PLAN :
65

66. SUBJECTIVE ASSESSMENT
-There is no understandable thought
-Neologism
-pressure of speech
-Persecutory delusion of reference
ex (when I gave her cake she refuse to take
it , she think there is some thing in the cake
will harm her )
-Auditory hallucination
66

67. OBJECTIVE ASSESSMENT
Stereotyping psychomotor activity.
She has stooped Posture and
stereotyping Mannerisms.
She spoke in soft volume and low pitch
tone throughout the conversation,
Decrease in rate and speed she is
always looks Mutism
67

68. Objective dataSubjective data
Behavior : Preoccupied
Mood and affect : fear
Awareness: good
Thought processes :
neologism,
Pressure of speech ,
persecutory delusion of reference
Appearance : isolated
Activity : stereotyping
Judgment : impaired
Pulse : 120 bpm Respiration : 20 bpm
T :37°c Blood Pressure :110/80
mmgh Height :154 cm Weight :42 kg
So , her BMI is 17.71 she is under
weight
Name : S,X, age: 30 yrs/old
Marital status: Divorced
Education level : educated
until 5th grade
Date of admission to hospital
: 30/2/1434H
Reason for referral :
patient referred from Alhawra
hospital of Ummlujj . With a known
case of schizophrenia she referred
because she is tried to running out
from the home and she is not
compliant to her medications then
her family refused to received her
from hospital
Somatic complain : none
The complain of the patient
none 68

69. GoalNursing diagnosis:
After one weak of
nursing intervention the
patient weight will
increase 2 kg .
IMBALANCED NUTRITION, LESS
THAN BODY REQUIREMENTS
R/T Loss of appetite
evidenced by Loss of weight
First nursing diagnosis
69

70. evaluationRationalNursing interventions:
After one weak of
nursing
intervention the
patient
successfully gained
2 kg.
1- to provide nutrition that
well help to increase pts
weight
2- This information is
necessary to make an accurate
nutritional assessment and
maintain client safety.
3- Weight loss or gain is
important assessment
information.
4- Client is more likely to
eat foods that he or she
particularly enjoys
1- Consult with dietitian,
determine number of calories
required to provide adequate
nutrition and realistic
(according to body structure
and height) weight gain.
2- Keep strict documentation
of intake, output, and calorie
count.
3- Weigh client daily.
4- Determine client’s likes and
dislikes, and collaborate with
dietitian to provide favorite
foods.
70

71. RationalNursing interventions:
5- Large amounts of food may be
objectionable, or even intolerable,
to the client.
6- It enhance the increasing of the
pts weight
7- Laboratory values provide
objective data regarding
nutritional status.
8- Client may have inadequate or
inaccurate knowledge regarding
the contribution of good nutrition
to overall wellness.
5- Ensure that client receives small,
frequent feedings, including
a bedtime snack, rather than three larger
meals.
6. Administer vitamin and mineral
supplements, as ordered by physician.
7- Monitor laboratory values, and report
significant changes to physician.
8. Explain the importance of adequate
nutrition and fluid intake.
71

72. 2NDNURSING CARE PLAN ..
goalNursing diagnosis
Short-term Goal:
Client will verbalize a desire to
perform ADLs by end of
1 week.
Long-term Goal:
By time of discharge from treatment,
client will be able to
perform ADLs in an independent
manner and demonstrate a
willingness to do so.
SELF-CARE DEFICIT
RALATED TO
Withdrawal INTO
THE SELF
72

73. EvaluationRationaleIntervention
1. Client feeds self
without assistance.
2. Client selects
appropriate
clothing, dresses,
and grooms self
daily without
assistance.
3. Client maintains
optimal level of
personal hygiene
by bathing
daily and carrying
out essential
toileting
procedures without
assistance.
1.Successful performance of
independent activities
enhances self-esteem
2.Client comfort and safety
are nursing priorities
3.Positive reinforcement
enhances self-esteem and
encourages repetition of
desirable behaviors.
1. Encourage client to perform
normal ADLs to his or her level
of ability..
2. Encourage independence,
but intervene when client is
unable to perform..
3. Offer recognition and
positive reinforcement for
independent
accomplishments. (Example:
“Ms. S.X, I see you have put on
a clean dress and combed your
hair.”)
73

74. RationaleIntervention
4.Because he need some explanation
5.This information is necessary to
acquire an accurate nutritional
assessment
4. Show client, how to perform activities
with which he or she is having difficulty.
(Example: showing her how to brush her
teeth )
5. Keep strict records of food and fluid
intake.
6- If client is soiling self, establish
routine schedule for toileting needs.
Assist client to bathroom on hourly or
bi-hourly schedule, as need is
determined, until he or she is able to
fulfill this need without assistance.
74

75. 3RD NURSING CARE PLAN
GoalNursing diagnosis:
Short-term Goal
Client will willingly attend therapy
activities accompanied by
trusted staff member within 1 week.
Long-term Goal
Client will voluntarily spend time with
other clients and staff members in
group activities.
SOCIAL ISOLATION
related to
Delusional thinking
75

76. evaluationRationalNursing interventions:
1. Client
demonstrates
willingness and
desire to socialize
with others.
2. Client voluntarily
attends group
activities.
3. Client approaches
others in
appropriate manner
for one -to-one
interaction.
1- An accepting attitude
increases feelings of self-
worth and facilitates trust.
2- This conveys your belief
in the client as a worthwhile
human being..
3- The presence of a trusted
individual provides emotional
security for the
client.
4- Honesty and dependability
promote a trusting
relationship.
1- Convey an accepting
attitude by making brief,
frequent contacts.
2. Show unconditional
positive regard. This conveys
your belief in the client as a
worthwhile human being.
3. Be with the client to offer
support during group
activities that may be
frightening or difficult for
him or her.
4. Be honest and keep all
promises.
76

77. 77
RationalNursing intervention:
5- to put client in reality
6- a suspicious client may perceive
touch as a threatening gesture
7- Positive reinforcement enhances
self-esteem and encourages
repetition of acceptable behaviors
5. Orient client to time, person, and place,
as necessary.
6. Be cautious with touch. Allow client
extra space and an avenue for exit if he or
she becomes too anxious.
7. Give recognition and positive
reinforcement for client’s voluntary
interactions with others

78. 4TH NURSING DIAGNOSIS
GoalNursing diagnosis
Short-term Goal
Client will demonstrate ability to remain on
one topic, using
appropriate, intermittent eye contact for 5
minutes with nurse
or therapist.
Long-term Goal
By time of discharge from treatment, client
will demonstrate
ability to carry on a verbal communication
in a socially acceptable manner with staff
and peers
IMPAIRED VERBAL
COMMUNICATION R/T
Unrealistic thinking
evidenced by
Neologism AND
Mutism
78

79. EvaluationRationaleIntervention
Short-term Goal
After my nursing
intervention
She demonstrated
the ability to remain
on our topic using
appropriate
intermittent eye
contact for about 5
min .
Long-term Goal
We did not have
enough time to
reach this goal
So the goal is
partially met
1.These techniques
reveal to the client how
he or she is being
perceived by others,
and the responsibility for
not understanding is
accepted by the nurse.
2. to facilitate trust and
the ability to understand
client’s actions and
communication
1.Use the techniques of
consensual validation and seeking
clarification to decode
communication patterns.
(Examples: “Is that you mean...?”
or “I don’t understand what you
mean by that. Would you please
explain it to me?”)
2. Maintain consistency of staff
assignment over time
3. In a nonthreatening manner,
explain to client how his or her
behavior and verbalizations are
viewed by and may alienate
others.
79

80. 80
RationaleNursing intervention
4. This may help to convey empathy, develop
trust, and eventually
encourage client to discuss painful issues.
5- Client comfort and safety are
nursing priorities.
6. to control ss of adverse reaction and to
verify that the client swallowed the
medication
4. If client is unable or unwilling
to speak (mutism), use of the
technique of verbalizing the
implied is therapeutic. (Example:
“That must have been very
difficult for you when....”)
5. Anticipate and fulfill client’s
needs until satisfactory
communication patterns return.
6- administer medication as order
and checked after administering

81. RECOMMENDATION
Comprehensive services provision
All teams providing services for people with schizophrenia
should offer social, group and physical activities to people
with schizophrenia (including in inpatient settings) and record
arrangements in their care plan.
Working in partnership with carers
When working with carers of people with schizophrenia:
provide written and verbal information on schizophrenia and its
management, including how families and carers can help through
all phases of treatment
provide information about local carer and family support groups and
voluntary organizations, and help carers to access these
negotiate confidentiality and information sharing between the
service user and their carers, if appropriate
81

82. PROGNOSIS:
X.S hospitalization for 12 months there is remission
in some symptoms , she was buzzer behavior ..
Aggressive hitting other and running out from the
house , and refuse medication and auditory
hallucination and she referred from ummllaj
hospital to Mental Health Hospital in tabuke but
after hospitalization no more these behaviors , she
still need supervision ,treatment and behavior
monitoring.
82

83. 83
CONCLUSION

84. SS: sleep disturbance,neolgisme ,,
persecutory delusion of reference
,Auditory hallucination ,
depression,isolated,poor judgement.
DD: 30/2/1434H
Treatment: Mirtazapine ,
carbamazepine ,
risperidone.
Prognosis :X.S hospitalization for 12 months there is remission in some
symptoms , she was buzzer behavior .. Aggressive hitting other and running out
from the house , and refuse medication and auditory hallucination and she
referred from ummllaj hospital to Mental Health Hospital in tabuke but after
hospitalization no more these behaviors , she still need supervision ,treatment
and behavior monitoring. 84

85. REFERENCES:
-Zaretsky, H.H., Richter, E.F., & Eisenberg, M.G.
(Eds.) (2005). Medical Aspects of Disability (3rd
ed.). New York: Springer Publishing.
-Smith, S., & Jones, T. (2001). The impact of
authoritative supervisors on job retention. Journal
of Applied Rehabilitation Counseling, 12(2), 110-
112. Retrieved October 13, 2001, from
http://jarc.org/articles
85

86. 86
Thank you 