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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

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.

OUT LINE :

-Introduction-statistics

-Client Historya) 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

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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

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OUT LINE :

-MEDICATION -Prognosis

-Summary

-References

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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

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-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;

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-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

STATISTICS:

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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

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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.

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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;

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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.

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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;

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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;

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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;

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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;

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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;

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

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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)

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

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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)

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;

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PARANOID SCHIZOPHRENIA

PARANOID schizophrenia (f20)

Extreme suspiciousness Persecutory delusions Paranoid delusions Auditory hallucinations Labile affect Uses PROJECTION.

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FAMOUS WITH SCHIZOPHRENIA

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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

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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.

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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)

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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.

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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

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 weaknessAnd un pleasant feeling

-She refused to take medications then she worsened again and Un complete remission.

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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.

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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

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FAMILY HISTORY:

Positive family history of psychiatric illness without details in file.

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ASSESSMENT :

A. MENTAL STATUS EXAMINATION (MSE):

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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

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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.

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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 )

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V. MOOD (SUBJECTIVE) AND AFFECT (OBJECTIVE):

A) Inappropriate –

Relevance to situation and thought congruent.

b) Unpleasurable affect- depression

c) Other affects- fear  .

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:PERCEPTION DISORDERS

Hallucination -:

Type:

-She has auditory hallucination.

Example:

-She hear that her brother called her

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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

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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 HospitalWho is accompanied with you? MY Brother MX

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C-MEMORY

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MEMORY1 -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 .

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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 .

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Judgment:The client has poor judgment to other and to society .

Insight:She has awareness of being sick attribute it to external physical factor .

PHYSICAL ASSESSMENT

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

CONT…

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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)

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

Pulse: 120 bpm Respiration: 20 bpmTemperature: 37°c Blood Pressure: 110/80 mmhg Height: 154 cm Weight: 42 kgSo , her BMI is 17.71 she is under weight

Vital signs

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Side effect Contraindication Indication Dose / 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 MAOinhibitor

To treat major. depression

200mg\tabODPO

Chemical class: PiperazinoazepineTherapeutic class: AntidepressantPregnancy category: C

GENERIC NAME: MirtazapineRemeron BRAND NAME:

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NURSING CONSIDERATIONS •Administer mirtazapine before bedtime.

•Expect disintegrating tablet to dissolve onpatient’s tongue within 30 seconds.

•If patient takes drug for depression, watch closely for suicidal tendencies, especiallywhen 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 thesesigns occur, notify prescriber and expect tostop drug.

•Expect mirtazapine therapy to last 6 months or longer

for acute depression.

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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.

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Side effect Contraindication Indication Dose / rout freq..

Classification

Aggressiveness, agitation, akathisia,anxiety, asthenia, confusion, Cough, dyspnea, sleep apnea, upperrespiratory tract infection, Abdominal pain, anorexia, constipation, diarrheanausea, 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 monotherapyor as adjunct to lithium or valproate therapy To treat irritability associated withautistic disorder

2mg/tabBIDPO

Chemical class: Benzisoxazole derivativeTherapeutic class: AntipsychoticPregnancy category: C

GENERIC NAME: risperidoneBRAND NAME: Risperdal

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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

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 ofits additive CNS effects.

•Caution diabetic patient to monitor bloodglucose level closely because risperidone may increase it.

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Side effect Contraindication Indication Dose / 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; hypersensitivityto carbamazepine, tricyclic compounds,or their components; MAOinhibitor or nefazodone therapy

To treat epilepsy To treat acute manic and mixed episodesin bipolar disorder To relieve pain in trigeminal neuralgia

200mg\tabODPO

Chemical class: Tricyclic iminostilbenederivativeTherapeutic class: Analgesic, anticonvulsantPregnancy category: C

GENERIC NAME: carbamazepineBRAND NAME: Tegretol

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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

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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

rationale Technique used

Nurse verbal and non verbal communication

Pts, verbal and non verbal

communication

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 self I will stay with you today OK

To encourage pts to discuss

that to me

Stating the observed

S.X you appear Angry.

I have a headache

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rationale Technique used Nurse verbal and non verbal communication

Pts, verbal and non verbal communication

To encourage the pts to repeat this good action daily

Feed back I notice you have brushed your teeth

YES , I do that daily

To help the pts to identify her

feeling.

reflection you 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.

Exploring Can you tell me more?.

I don’t like my brother

NURSING CARE PLAN:

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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

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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

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Objective data Subjective data Behavior : PreoccupiedMood and affect : fearAwareness: good Thought processes : neologism, Pressure of speech , persecutory delusion of referenceAppearance : isolatedActivity : stereotyping Judgment : impaired Pulse : 120 bpm Respiration : 20 bpmT :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 hospitalSomatic complain : none The complain of the patient none

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Goal Nursing diagnosis:

After one weak of nursing intervention the patient weight will increase 2 kg .

IMBALANCED NUTRITION, LESS THAN BODY REQUIREMENTS R/T Loss of appetiteevidenced by Loss of weight

First nursing diagnosis

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evaluation Rational Nursing 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 toeat 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.

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Rational Nursing 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, includinga 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.

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2NDNURSING CARE PLAN ..

goal Nursing diagnosis

Short-term Goal:Client will verbalize a desire to perform ADLs by end of1 week.Long-term Goal:By time of discharge from treatment, client will be able toperform ADLs in an independent manner and demonstrate awillingness to do so.

SELF-CARE DEFICIT RALATED TO Withdrawal INTO THE SELF

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Evaluation Rationale Intervention

1. Client feeds self without assistance.2. Client selects appropriate clothing, dresses, and grooms selfdaily without assistance.3. Client maintains optimal level of personal hygiene by bathingdaily and carrying out essential toileting procedures withoutassistance.

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 levelof ability..

2. Encourage independence, but intervene when client is unable to perform..

3. Offer recognition and positive reinforcement for independentaccomplishments. (Example: “Ms. S.X, I see you have put on a clean dress and combed your hair.”)

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Rationale Intervention

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.

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3RD NURSING CARE PLAN

Goal Nursing diagnosis:

Short-term GoalClient will willingly attend therapy activities accompanied bytrusted staff member within 1 week.Long-term GoalClient will voluntarily spend time with other clients and staff members in group activities.

SOCIAL ISOLATION related to Delusional thinking

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evaluation Rational Nursing 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 beliefin the client as a worthwhile human being..

3- The presence of a trusted individual provides emotional security for theclient.

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.

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Rational Nursing intervention:

5- to put client in reality

6- a suspicious client may perceive touch as a threatening gesture

7- Positive reinforcement enhancesself-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 voluntaryinteractions with others

4TH NURSING DIAGNOSIS

Goal Nursing diagnosis

Short-term GoalClient will demonstrate ability to remain on one topic, usingappropriate, intermittent eye contact for 5 minutes with nurseor therapist.Long-term GoalBy time of discharge from treatment, client will demonstrateability to carry on a verbal communication in a socially acceptable manner with staff and peers

IMPAIRED VERBALCOMMUNICATION R/T Unrealistic thinking evidenced by Neologism AND Mutism

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Evaluation Rationale Intervention

Short-term Goal

After my nursing interventionShe 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 techniquesreveal 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 andcommunication

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 alienateothers.

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Rationale Nursing intervention

4. This may help to convey empathy, develop trust, and eventuallyencourage client to discuss painful issues.

5- Client comfort and safety arenursing priorities.

6. to control s\s 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 verydifficult for you when....”)

5. Anticipate and fulfill client’s needs until satisfactory communication patterns return.

6- administer medication as order and checked after administering

RECOMMENDATION

Comprehensive services provisionAll 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 carersWhen 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 treatmentprovide information about local carer and family support groups and voluntary organizations, and help carers to access thesenegotiate confidentiality and information sharing between the service user and their carers, if appropriate

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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.

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CONCLUSION

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

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

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Thank you