I am presently completing my clinical placement with a very busy team who are responsible for clients’ assessment before decisions for admissions are made. I will be referring to my client herein as Andrew (pseudonym NMC 2009). Andrew was brought in by an ambulance following a psychotic episode. It was reported that Andrew had formal thought disorder and delusions. He was preoccupied with thoughts of being in the news and this has made him very paranoid. Andrew was seen and assessed by my mentor and myself.
I had the privilege to introduce myself as a student nurse and explained my role to Andrew. Although due to his presentation at the time he did not understand my role as he was pre-occupied with thoughts of me being a news agent. Andrew appeared frightened, suspicious and guarded. I noted that he had a great sense of humour even though he was anxious. I began to initiate a conversation with him. His speech was incoherent and non-spontaneous as he made fleeting eye contact. I offered Andrew a cup of water which he initially declined to have but later did. Then I began to establish a rapport with Andrew during which he became talkative as the conversation went on. He made tangent points, some of which was not relevant to the questions asked. I nodded my head and maintained a good rapport with him throughout the time to validate his narrative accordingly.
I noted he has become uncommunicative and un-cooperative with his treatment regime. I asked him a few questions pertaining to his wellbeing and he explained that he was suspicious of his partner giving out his information. He then stated that he has stopped taking his psychotropic medication as prescribed, as he was concerned about the side effect he was experiencing and this was in relation to his weight gain. I asked Andrew to share with me his experience of this recent development. Andrew noted that the Clozapine medication had helped in maintaining stability.
He had been under clozapine medication to help reduce the symptoms of schizophrenia. Clozapine can also be used in management of bipolar disorder. It also seems to reduce suicidal feelings in people who presents with negative or positive symptoms, (Esstroff 1989). I advised him that I will inform and discuss with the doctor if this could be reviewed. I paraphrased and summarized information he had shared with me to make sure I understood him. I did not elicit any other pending need or risk from Andrew.
Subjective, Medical, and alternative perspectives on the situation
‘I fear that something bad will happen…I feel my information is being shared everywhere in the news and very soon I fear I will be dead’ I want to be able to live a normal life’.
Andrew is a 41 year old white British He experienced his first episode of paranoia at the age of 19 years. On account of his condition, Andrew did not complete his university education. Typically, some people experience these symptoms in early adulthood between the age of 15 and 25 years. His condition is characterized by delusional persecutory ideation and hearing of voices (Zarit et al 2006). Whenever the phone rang, he became nervous and anxious. It was reported that his sleep and appetite has decreased in the last three days. Although he shows some insight to his illness but has refused medication and therapeutic activities offered.
In the past Andrew has reported that he had benefitted from the use of medication in helping combat the level of paranoia he experiences (Ekeland 2008). But on the other hand the side effects seem a concern for him due to excessive weight gained.
Schizophrenia has affected Andrew’s psychology and the manner of his thinking. He is delusionary and thinks that there are some people who are out to harm him. Andrew has disorganized speech showing the disorganized manner of his thinking. For example, he is concerned that if he shares information about himself then this information could be used against him. This is a belief that is not true but which Andrew holds very dear to him. Andrew does not want these thoughts to be removed from him and he gets very upset when he feels that an external force is trying to make him act in a certain way. The disorganized thinking can also be seen in his disorganized behavior. For example, Andrew looks confused and in most cases he does not understand what he is doing. While interacting with him, it is seen that he has reduced ability to work. Schizophrenia has altered Andrew’s perception of the world around him (Kendall, 2012). With such a vision of the world, he was preoccupied with thoughts of harm (Schulze et al 2003). Andrew also showed difficult to negotiate the different activities of daily life. Andrew also showed some withdrawal symptoms. For example, he says that every time he gets unwell, the sickness affects his relationship with other people as he becomes suspicious of them. This makes him be isolated from the people making delusionary symptoms.
The healthcare institution should create a good environment to help in the effective recovery for Andrew. This will help in reducing instances when Andrew would engage in violence and aggressive behavior and pose legal challenges to him. Andrew has a medical right to treatment and mental health examination. These tests and screening should be done to help detect dangerous behavior like suicide. The tests and screening will help in identifying symptoms and initiate interventions that will stabilize the symptoms. The health care institution should have a crisis intervention team to help support Andrew. The team will help in preventing violence.
Alternative perspectives on the situation
Previously, people with schizophrenia were either ill or well. However, over the years this has changed and there are different degrees of illness and wellness. Andrew will be able to experience small improvements as he recovers from the symptoms of schizophrenia. Although the disease is stressful for Andrew, with good management he can be able to lead a happy life. This will result in Andrew getting back to his normal social life (White & Hardy, 2010).
How my illness has affected my life and how my life has affected my illness
‘Every time I become unwell, it deters my relationship with people as I begin to feel suspicious of them. This in turn affect my social life as I then begin to isolate myself from everyone otherwise, I am preoccupied with thoughts to harm’
Schizophrenia has made Andrew to have negative social relationships. Some of these traits include the fact that he does not have an interest in social activities, and is flat emotionally. In addition, Andrew has a reduced ability to complete assigned tasks (Schulze et al 2003) .
In the case of Andrew, the disease has affected his relationship with other people. This is because every time he becomes ill, he becomes very suspicious of people. He does not feel that the people can provide him with the best care that he deserves. This has made him isolate himself from the other people in the society. The disease has made Andrew not to accept treatment as he has stopped his own medication. However, Andrew has not shown any signs of being a threat to his life. Andrew believes that he does not have enough support system within the family and at the healthcare institution. Through this, his emotional needs have not been met in most cases.
How it affects lifestyle and self-actualisation
Schizophrenia has affected Andrew’s motivation to look after himself and has made his psychology to be dominated by anxiety. For example, he is very anxious about his relationship with others and whether he will achieve his objectives in life. This has made Andrew to be very unsafe of his environment. In addition, Andrew feels that many people consider him lazy (Hooley, 2010).
Maximising recovery minimising loss
‘For me to be able to recognise and prevent relapse I will need support to help me understand early warning signs and triggers and also I would like more information on how to identify and avoid these triggers’.
This means that Andrew should be involved in the treatment process so that recovery can be maximized (Jibson, Glick & Tandon, 2004). Through involvement of Andrew in the treatment process, he can be taught of the symptoms. The involvement also helps in developing support systems that will help Andrew to make healthy lifestyle choices to ensure that he sticks to the treatment plans.
From his perspective, Andrew will need to develop a close relationship with family and friends. When the family and friends will be involved in treatment, Andrew will get the independence required to reduce the relapse of the condition (Jibson, Glick & Tandon, 2004). The support systems will help Andrew integrate Andrew the pharmacological treatments with other therapies that will be administered. This may include lifestyle choices and behavioural therapies that will be administered to Andrew (Jibson, Glick & Tandon, 2004).
Due to the depression that he is suffering from, Andrew is having some sleep problems. This has made him have irregular sleep hours and sleeping patterns may change. The problem of sleep can be solved by using medication like melatonin (Shamir et al., 2000).
Baseline measurements, timeframes and goals
|Physical health||• diagnosis and management schizophrenia|
|• positive outcomes and recovery|
|• getting help in a crisis|
|The choice of antipsychotic medication||Clozapine medication|
|Treatment options||• Oral antipsychotic medication|
|• psychological interventions|
|Needs identified||§ “I rarely had bath or change my|
|§ “I slept for long hours and I never had|
|the desire to sleep”.|
|§ “’I hate medications and therapists”|
Short term goals: Frequent clinical visits to help establish any warning signs of symptoms like agitation, anxiety and hallucinations and diligently report to staff with the aim of getting assistance.
Long term goals: The client will not harm himself in an attempt to commit suicide and continue with medication and get involved with physical activity and exercise as well as take care of his personal life. In addition, the client will continue to use his prescribed medication.
“I want to live a normal life in a society where I am not judged because of my mental illness”.
An optimistic point of view is essential in ensuring that a person recovers his personal health and their quality of life is improved (Ekeland 2008). One of the major interventions for mental illness is the peer-led, mental illness education intervention program which is referred to as the Building Recovery of Individual Dreams and Goals through Education and Support (BRIDGES), which can be described as a self-help program that gives education and support to adults with mental health disorders (Cook et al. 2012). In this context, the BRIDGES plan is to play a major role in ensuring that setbacks are eliminated and optimism is achieved. This can be achieved through the use of the Seligman’s ABCDE system (adversity, belief, consequence, dispute, and energize). For example Andrew can be optimistic that the identified needs can be resolved by believing that his condition is manageable. In addition cognitive skills acquired during the BRIDGES support group can help fight negative thoughts and feelings and when he finds himself down, he will always take action like taking his medication and participating in support group.
- Identify the indicators of recovery of relapse
Under this, the absence or increase of these indicators will be checked namely: delusions or hallucinations, forgetfulness, disorganization, social withdrawal, suspicious of other people, overall psychological functioning and willingness to participate in practical activities and take a bath. Physical observation and emotional check-ups by the caregiver are the best ways to identify indicators of recovery of relapse.
- Early warning signs of relapses will also be monitored.
Early warning signs such as change in emotional behaviour, decreased participation in physical exercises, not willing to take baths, and high levels of anxiety and paranoia which were all experienced by Andrew on the onset of his relapse.
- Identify possible needs
Some of the identifiable needs based on the session with Andrew are medical attention, personal hygiene, engagement to prevent isolation and sleeping for long hours.
- Implementation, Action, Intervention,
The patient will be interviewed at baseline and assigned to BRIDGES. For a period of 8 weeks, two-and-one-half hour classes will be taught on symptoms of schizophrenia, better ways to minimize the symptoms. This is to be carried out by certified BRIDGES instructors. After the
education intervention, the subject is to be followed-up at close post-intervention and 6-months later. The patient will also be advised to be attending to support groups for the same period time where he will work with other individuals with schizophrenia so as to empowered with the realities of living with schizophrenia as well as strengthen coping skills.
The success of this intervention program is supported by a research by Cook et al. (2012), research study which showed that peer-led mental illness education has the ability to improve patient’s self-perceived recovery as well as hopefulness over time. BRIDGES has been chosen because of its ability to empower people with mental health disorders such as paranoid schizophrenia to take an active as well as an informed role in their treatment and to have meaning on their lives. It has been chosen because it provides the emotional “glue” which according to Cook et al. (2012) enables people to ease feelings of hopelessness, helplessness, or guilt. Some of principles used during the intervention process are the principles “Emotional Stages of Recovery” and that of “Support”. These principles provide the patient with the bases for developing and maintaining a healthy, happy life. Andrew believed on the effectiveness of BRIDGES because it had helped him ease feelings of hopelessness and helplessness.
To ensure recovery, this essay has highlighted the importance of both autonomy and sustainability. Autonomy is where the wishes and desires of the patient are considered while designing the treatment plan. This is a form of person0-centred care that can help improve and sustain the benefits obtained during the recovery process. To promote sustainability, Andrew should write down psychiatric advance directives, which can later be used to predetermine future outcomes like medication to be given, acute symptoms, and needs which should be addressed (Peralta et al. (2003). The patient can also be encouraged to engage his family, support him to manage his medication and maintain his physical well-being (Schulze 2003). Andrew should also be encouraged to stick to the care plan that has been provided for him. This will help in ensuring that he benefits fully from the gains of treatment.
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Care Plan for Paranoia
Psychotic episode (delusion preoccupied with thoughts of being in the news which makes him paranoid), formal thought disorder, appears frightened, suspicious and guarded).
STRENGTH (great sense of humour even though he was anxious, his speech was incoherent and non spontaneous as he makes fleeting eye contact.
Relapse symptoms Less sleep and appetite
Some insight into illness but refused medication and therapeutic activities offered Suspicious of his partner
Andrew just relapsed three days ago from psychotic illness( formal thought disorder, delusions, less sleep, loss of appetite, appears frightened, preoccupied with thoughts of being in the news which makes him paranoid.
For Andrew to manage his symptoms effectively until he is healed
- His sleep needs to be resolve through short medication intervention like Zopiclone or promethiazine depending on the effect of these medications on each other.
- We must involve the family but his wish must be recognised
- Regular mental state assessment must be done
- There must be a psycho-education of the family on the illness and how to recognise when to call for help.
- Relapse indication, will be less sleep, non compliance, less appetite, increase anxiety and paranoia. Talking more with family can help to know more of his relapse indications.
- Create a rapport with Andrew to minimise his suspicion
- Seek to improve his compliance with medication by putting in place a rigid management of his blood test, physical illness as patient is prone to infection as clozapine suppresses his immune system)
- To assess suicidal risk regularly