Question

Case study

Rachael Tomkins is 55 years old and is a certified practising accountant. She works part time and lives with her husband Paul, aged 64 and daughter Marie, aged 17. Her grandmother Jean aged 90, lives in a small flat at the back of their house and her mother Mary, aged 72 lives in an Over 55s housing unit nearby. In her early 20s Rachael’s father, a Vietnam Veteran, committed suicide. Rachael is described by her family as reliable and caring. She has a small group of friends from her local parish church. Rachael has regular contact with her GP to manage her Diabetes Type 2. She is prescribed metformin and has been trying to lose weight. She also sees a psychiatrist Dr Lianne Yu for management of her symptoms of schizophrenia. She is prescribed Olanzapine and Lithium. She was diagnosed with schizophrenia in her early 20’s when she was studying at university. She was hospitalised with acute psychosis several times before her symptoms were stabilised. She was able to complete her university degree and has worked part time. The last time she experienced acute psychosis was 17 years ago, just after the birth of her daughter. Her symptoms stabilised, and she has been maintained in recovery for almost 15 years. This year has been a particularly challenging year for Rachael. Both her husband’s parents passed away within months of each other, her daughter commenced Year 12 and her grandmother had an infection in her middle toe, which resulted in a series of trips to the doctor, hospitalization and finally amputation of the affected toe. Rachael has become irritable with her family, and has developed erratic sleeping patterns, a lack of interest in grooming, and avoided social interactions with her friends or family. She complained to them that her neighbors were spying on her. In the 48 hours before she was admitted to hospital two incidents escalated Rachael’s need for professional help. In the first episode, she yelled and threatened the neighbor across the fence. She accused him of spying on her with a ‘trackamanometer’. Her husband intervened and took her back into the house. In the second incident later that day, Rachael started screaming at her family to evacuate the house because they would be bombed. Rachael insisted the newsreader on the TV was giving her this important information and they must all get out of the house. Rachael ran onto the road. A concerned neighbor called the police, who were able to convince her to accompany them to the hospital. She was met by her psychiatrist Dr. Yu who reports the following -Rachael is disheveled, dressed in a pajama top and track pants, no shoes, she has an exacerbation of auditory hallucinations, with persecutory delusions and disorganized thinking. Rachael agrees to be admitted because she says ‘I’m frightened’. Rachael is admitted for inpatient psychiatric care. Faculty of Health | School of Nursing, Midwifery & Paramedicine In the hospital, Rachael is argumentative and resistive to staff interactions and interventions, and her family are frightened and bewildered by her dramatic deterioration.

Q. Rachael will be admitted to the mental health inpatient unit. Write a nursing care plan based on the nursing diagnosis.

Q. What are the risk factors?  Does Racheal have any protective factors? If so, what are they?

can you please provide answer to these questions from the above case study.

thank you.....

Answer 1

Nursing Care Plan for this patient is -

Nursing Interventions	Rationale
Assess if the medication has reached therapeutic levels.	Many of the positive symptoms of schizophrenia (hallucinations, delusions, racing thoughts) will subside with medications, which will facilitate interactions.
Identify with client symptoms she experiences when she begins to feel anxious around others.	Increased anxiety can intensify agitation, aggressiveness, and suspiciousness.
Keep client in an environment as free of stimuli (loud noises, crowding) as possible.	Client might respond to noises and crowding with agitation, anxiety, and increased inability to concentrate on outside events.
Avoid touching the client.	Touch by an unknown person can be misinterpreted as a sexual or threatening gesture. This particularly true for a paranoid client.
Ensure that the goals set are realistic; whether in the hospital or community.	Avoids pressure on the client and sense of failure on part of nurse/family. This sense of failure can lead to mutual withdrawal
If client is found to be very paranoid, solitary or one-on-one activities that require concentration are appropriate.	Client is free to choose his level of interaction; however, the concentration can help minimize distressing paranoid thoughts or voice.
If client is delusional/hallucinating or is having trouble concentrating at this time, provide very simple concrete activities with client (e.g., looking at a picture or do a painting).	Even simple activities help draw client away from delusional thinking into reality in the environment.
Be alert for signs of increasing fear, anxiety or agitation.	Might herald hallucinatory activity, which can be very frightening to client, and client might act upon command hallucinations (harm self or others)
Interact with clients on the basis of things in the environment. Try to distract client from their delusions by engaging in reality-based activities (e.g., card games, simple arts and crafts projects etc).	When thinking is focused on reality-based activities, the client is free of delusional thinking during that time. Helps focus attention externally.
If client is very withdrawn, one-on-one activities with a “safe” person initially should be planned.	Learn to feel safe with one person, then gradually might participate in a structured group activity.
Try to incorporate the strengths and interests the client had when not as impaired into the activities planned.	Increase likelihood of client’s participation and enjoyment.
Teach client to remove himself briefly when feeling agitated and work on some anxiety relief exercise (e.g., meditations,rhytmic exercise, deep breathing exercise).	Teach client skills in dealing with anxiety and increasing a sense of control.
Useful coping skills that client will need include conversational and assertiveness skills.	These are fundamental skills for dealing with the world, which everyone uses daily with more or less skill.
Remember to give acknowledgment and recognition for positive steps client takes in increasing social skills and appropriate interactions with others.	Recognition and appreciation go a long way to sustaining and increasing a specific behavior.
Provide opportunities for the client to learn adaptive social skills in a non-threatening environment. Initial social skills training could include basic social behaviors (e.g., appropriate distance, maintain good eye contact, calm manner/behavior, moderate voice tone).	Social skills training helps the client adapt and function at a higher level in society, and increases the client’s quality of life.
As the client progresses, provide the client with graded activities according to the level of tolerance e.g., (1) simple games with one “safe” person; (2) slowly add a third person into “safe”.	Gradually the client learns to feel safe and competent with increased social demands.
As the client progresses, Coping Skills Training should be available to him/her (nurse, staff or others). Basically the process: Define the skill to be learned. Model the skill. Rehearse skills in a safe environment, then in the community. Give corrective feedback on the implementation of skills.	Increases client’s ability to derive social support and decrease loneliness. Clients will not give up the substance of abuse unless they have alternative means to facilitate socialization they belong.
Eventually engage other clients and significant others in social interactions and activities with the client (card games, ping pong, sing-a-songs, group sharing activities) at the client’s level.	Client continues to feel safe and competent in a graduated hierarchy of interactions.

Risk Factors are-

• Viral Infections
• Neural Imbalance
• Genetic / family history
• Lead Exposure
• Dense Living Conditions
• Advanced paternal age

Protective factors are-

• Social gathering with church people i.e Social Support
• Family living nearby i. e Familial Support
• Gets to sees her local General Practitioner Regularly
• Steady Employment