Varcarolis: Essentials of Psychiatric Mental Health Nursing, 2nd Edition

Chapter 17: Schizophrenia Spectrum Disorders Case Studies and Nursing Care Plans Disorganized Thinking Martin Taylor, a 36-year-old white, unemployed man, has been referred to the mental health center. He is accompanied by his mother and sister. He had been hospitalized for 3 years in a state hospital with the diagnosis of chronic schizophrenia and was doing well at home until 2 months ago. His only employment was for 5 months as a janitor after high school graduation. Other significant family history includes a twin brother who died of a cerebral aneurysm in his teens. Martin tells the nurse he has used every street drug available, including LSD and intravenous heroin. His mother states that as a teenager, before his substance abuse, he was an excellent athlete who received average grades. At 17 years of age, he had his first psychotic break when taking a variety of street drugs. His behavior became markedly bizarre (e.g., eating cat food, swallowing a rubber-soled shoe that required an emergency laparotomy). Ms. Lamb, a clinical nurse specialist, meets with Martin after speaking with his mother and sister. Martin is unshaven, and his appearance is disheveled. He is wearing a red headband in which he has placed popsicle sticks and scraps of paper. He chain smokes during the interview and frequently gets up and paces back and forth. He tells the nurse that he is Alice from Alice in the Underground and that people from space hurt him with needles. His speech pattern is marked by associative looseness and occasional blocking. For example, he often stops in the middle of a phrase and giggles to himself. At one point, when he starts to giggle, Ms. Lamb asks him what he is thinking about. He stated, You interrupted me. At that point, he began to shake his head while repeating in a sing-song voice Shake them tigers . . . shake them tigers . . . shake them tigers. He denies suicidal or homicidal ideation. Ms. Lamb notes that Martin has a great deal of difficulty accurately perceiving what is going on around him. He has markedly regressed social behaviors. For example, he eats with his hands and picks his nose in public. He has no apparent insight into his problems; he tells Ms. Lamb that his biggest problem is the people in space. Assessment Objective Data Associative looseness Giggles and mumbles to self Poorly and bizarrely dressed Low level of functioning History of bizarre behavior Restless, pacing, and chain smoking Regressed social behaviors Occasional blocking Subjective Data I am Alice from Alice in the Underground.
All Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.

People from space hurt me with needles. You interrupted me, in response to being asked what he was thinking. Denies suicidal or homicidal impulses. My biggest problems are the people from space.

Self-Assessment Working with a patient who has limited potential for relating, poorly defined ego boundaries, and limited social skills and who demonstrates regressed bizarre behavior requires a great deal of skill, patience, and peer support. In the presence of delusions, bizarre behaviors, and regressed social skills, health care workers can experience helplessness, can feel overwhelmed, and can become anxious. Some anxiety may be caused by empathizing or acknowledging the patients deeply repressed feelings of inferiority, fear, and anger. At times, nurses may have similar repressed feelings that they have difficulty dealing with; these feelings may cause them to withdraw from the patient in an attempt to minimize their awareness of uncomfortable feelings. Often, the more withdrawn and regressed the patient is, the more taxing he or she is to health care workers. Diagnosis Ms. Lamb identifies Martins deterioration of functioning as a priority for intervention. Ms. Lambs first diagnosis is Ineffective individual coping related to confused thought processes and lack of motivation to respond, as evidenced by inability to meet basic needs: Regressed social behaviors Poor and bizarre dress Low level of functioning Frequent looseness of association Outcomes Identification Ms. Lamb identifies Martin as a candidate for skills training and makes arrangements for him to live in a halfway house. She also encourages the family to participate in a multifamily psychoeducational group. Nursing Diagnosis Ineffective individual coping related to confused thought processes and lack of motivation, as evidenced by inability to meet basic needs Outcome Criteria Martin will be able to perform three skills in daily living within 2 months. Short-Term Goals a. Martin will be able to bathe independently in 1 month. b. Martin will make his bed in 3 weeks. c. Martin will be able to make a sandwich with supervision in 5 weeks.

Implementation Martin is placed in a group home, where skills training will be conducted. Because Martin has a chronic history of deterioration, concrete goals are set. A trial daily checklist for activities of daily living is devised and will be periodically reviewed. It includes such items as the following: Makes bed Brushes teeth

Case Studies and Nursing Care Plans Combs hair Shaves Showers Makes two sandwiches a week Wears clean clothing

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Evaluation Martin gradually adapts to the group home, where skills training continues. The group home is helping Martin relearn self-care needs. After 3 months, Martin is able to carry out basic activities of daily living when constant reminders are given. He is able to bathe, shave, comb his hair, and dress more appropriately when given simple instructions and encouragement. The goal of making a sandwich or fixing a simple lunch has not yet been met; Martin starts to eat the food before the task of finishing the sandwich is completed. Martin and his family have been attending meetings of a multiple-family psychoeducational group, and the stress on Martin and his family has been greatly reduced. Plans are for Martin to return home in the near future.

All Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.