Download Schizophrenia Patient Case Study: Assessment, Medication, and Plan of Care and more Study notes Nursing in PDF only on Docsity!
Room Patient/Age/Sex N.E 47 Female
Date of evaluation 2/18/
Allergies NKA
Admit date 02/01/
Diagnosis Schizophrenia
Legal status State Conserved
Chief complaint/concern (CC) (quoted: “In the patient’s words) Patient stated “I came here voluntarily, and asked to be placed in conservatorship”
Past psychiatric history The patient was diagnosed with schizophrenia.
History of Present Illness (HPI) Patient's has a history of hypertension.
Alcohol/Tobacco/Drug history : Alcohol Barbiturates Tobacco Cocaine Marijuana Heroin Vaping Inhalants Other: LSD Methamphetamines PCP IV Opioids
Medical history
Schizophrenia
Diet
Patient has a regular diet.
Family history Family history unable to be obtained.
Social history Educational level:
High School drop out (11th)
Employment history: Unemployed
Interpersonal relationships/support system:
Constitutional review Temp: 100.4 Height: unable to obtain
HR: 98 Weight: unable to obtain
BP & MAP: 128/
Resp rate: 16
The patient has 1 brother, 1 sister, mom and dad but has no family support. Patient states they don’t visit him and want nothing to do with him until he gets better.
Musculoskeletal Examination
Muscle tone No impairment Dystonia Hypertonic/myoclonus Rigidity Flaccid
Gait Grossly normal Antalgic Limping In wheelchair Wide-based (walker)
Station Grossly normal Unsteady In wheelchair
Abnormal/Involuntary movements None Tremors Spasms Tics
Strength Greater than antigravity (>3/5) in all extremities Weakness:
Appearance Well-groomed Casual Disheveled Other:
Psychomotor behavior WNL Agitation Retardation EPS/tremors Involuntary movements Hyperactivity
Speech Spontaneous Slow Loud Rapid Other:
Attitude Cooperative Guarded Irritable Withdrawn Other:
Intelligence Average Above Below
Insight WNL Impaire
Mood Euthymic Depressed Anxious Irritable Other:
Affect Full (agitated) Constricted (no change) Flat (no emotion) Labile (mood fluctuates) Other:
Orientation Time Person Place Situation
Perception WNL Delusions Obsessions Phobias Other:
Memory test (3 Items) 3 2 1 0 out of 3 in 3 min
Judgement WNL Impaire
with lithium or valproate). ^ Pruritus Rash
blurred vision
Hyperglycemia
hyperprolactinemia
Plan of Care (Clinical Judgment Plan) Priority problem #1 [hypothesis]:
Anxiety as evidence by his grandiouse goal of saving the world pt. stated ”I feel like it all up to me and that’s too much pressure.
S.M.A.R.T. goal/outcome #1 [solution]:
The goal is to have patient express the grandiose ideas and teach him new coping mechanisms to relive the pressure he may feel from those ideations.
Interventions with frequency & rationale [actions]: Assess/monitor: Assess if the patients current mood through out my shift so we can prevent his grandiose deations from being triggered or causing anxiety.
Manage: Implement and work with the patient on areas that need improvement to help promote a higher evel of self-soothing coping mechanism techniques.
Priority problem #2 [hypothesis]:
Medication education as evidence by his statement “He states the government creates a lot of medications that aren’t helpful and just poison people”
S.M.A.R.T. goal/outcome #2 [solution]: Patient will be washed while taking his medications, nurse will assess that he swallowed all med before the end of the shift.
Interventions with frequency & rationale [actions]: Assess/monitor: Assess that the patient knows why he is taking the meds, and make sure he is in-fact swallowing the medications when given to him.
Manage: I the nurse will work with the patient to identify cognitive distortions that may trigger her loss in interest to adhere to medications.
Educate: The nurser will educate the patient on the importance of medication adherence for his medical diagnosis.
Patient strengths
Steady employment, financial stability Housing Stability Able to vocalize needs Motivation, ready for change Knowledge of medications Awareness of substance issues Other:
Patient limitations
Medication non-compliance Intellectual impairment Lack of social supports Pathological/unsupported environment Complicated medical illness No interests Legal issues Other:
Pertinent assessment data [cues]:
Pertinent assessment data [cues]:
Mental Status Examination (MSE)
Educate: The patient will be educated on how she can manage his anxiety that comes from the. Pressure he feels with his grandiose ideations of saving the world; as well as medication and the importance of medication adherence to help maintain her mood stabilized, hallucinations minimized, and anxiety under control.
Evaluation [evaluate]: Met / Not met Recommendations (If goal/outcome not met):
Goal was met patient was able to practice positive reinforcement of his Mui Tai patient stated “ when I practice my Mui Tai I feel much better” utilizing that as a soothing coping mechanism technique during my shift.
Evaluation [evaluate]: Met / Not met Recommendations (If goal/outcome not met): Goal was met patient was given their scheduled medications throughout my shift and patient showed he had swallowed all medications at med pass time during my shift.
