PROBLEM:

A 40- year-old woman with a history of multiple admissions is

admitted to the floor. Emma Rice was found wandering downtown
incoherent and dishevelled. During the assessment interview,
Emma is noted to have a flat affect and is withdrawn. She
reports not seeing her family for five years and cannot remember
when she last held a job. There is no history of hallucinatory
or delusional thought content in this recent occurrence. The
staff knows Emma and knows that during past admissions, she has
responded to the less expensive haloperidol. After admission,
Emma says, “Let me go. Go on, onward, backward (pause) Emma
hide, died.” When asked where she lives, Emma slowly responds,
“Over there, somewhere, anywhere, nowhere.” Emma’s board and
care operator knows her well and has indicated that a bed is
being held for Emma.

DIAGNOSIS: Schizophrenia

Schizophrenia affects thought processes and content,

perception, emotion, behaviour and social functioning; however,
it affects each individual differently. The degree of impairment
in both the acute or psychotic phase and the chronic or long
term phase varies greatly; thus, so do the needs of and the
nursing interventions for each affected client. The nurse must
not make assumptions about the client’s abilities or limitations
based solely on the medical diagnosis of schizophrenia.

ASSESSMENTS:

Name: Emma Rice

Age: 40 years old

Areas of strength:

• No history of hallucinatory or delusional thought content

in the current occurrence
• Responds in less expensive Haloperidol during past
admissions

Problems of the patient/ signs and symptoms:

• She cannot remember when she last held a job

• Incoherent and dishevelled
• Clang association
• Flat affect and withdrawn
NURSING DIAGNOSIS:

1. Risk for suicide

Nursing interventions:

• Assess the client for previous suicide

attempts by asking questions such as “ Have
you ever attempted suicide?” or “ Have you
ever heard voices telling you to hurt
yourself?”
• Assess history of aggressive behaviour by
asking questions such as “What do you do
when you are angry, frustrated, upset, or
scared?”
• Note behaviours indicative of intent
• Develop therapeutic nurse-client
relationship. Promotes sense of trust
• Encourage expression of feelings and make
time to listen to concerns
• Maintain observations of client and check
environment for hazards that could be used
to commit suicide, to increase client safety.

2.Self-care Deficit
Nursing interventions:
• Identify degree of patient impairment or function
level
• Develop plan of care appropriate to patient’s
situation
• Assist with rehabilitation program
• Determine age or developmental issues affecting
ability of individual to participate in own care

3. Ineffective health maintenance

 • Determine whether impairment is an acute or
sudden onset situation, a progressive illness or
long term health problem.
• Ascertain changes in life style
• Note desire or level of ability to meet health
maintenance needs, as well as self-care ADL’s
• Assess communication skills
• Provide anticipatory guidance

4. Ineffective therapeutic regimen management

• Ascertain clients knowledge or understanding and

treatment needs so that he she can make informed
decisions about managing self-care.
• Identify individual perceptions and expectations
of treatment regimen
• Use therapeutic communication skills to assist
client to problem solve solutions
• Explore client involvement in or lack of mutual
goal setting
• Refer to counselling or therapy as indicated

5. Disturbed thought processes

• Assess attentions span or distractibility and

ability to make decisions or problem solving
• Test ability to receive, send, and appropriately
interpret communications
• Note behaviour that may be indicative of
potential for violence and take appropriate
actions
• Provide safety measures as indicated
• Maintain a pleasant, quite environment and
approach client in a slow, calm manner
• Give simple directions, using short words and
simple sentences