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Beata, a 29 year old lady I was assigned to during my placement in the Great Western Hospital was admitted to the psychiatric ward by her parents. She was admitted with episodes of low moods and complaints of tiredness. Beata is known to suffer from schizophrenia, a diagnosis she had had since she was 16 years old. She had been on clozapine treatment to help with her moods and behavior but had stopped without her doctor’s orders due to the side effects she experienced from taking the drug. Schizophrenia is defined by Stepnicki et al. (2018) as a mental illness that affects a person’s behavioral and cognitive activities. The illness affects approximately 20 million people worldwide according to the National Health Service (2019) and about 14.5 in 1000 people are affected by the illness in the United Kingdom. The precise cause of schizophrenia is unknown but mostly occurs due to genetic defects, environmental factors like puberty and psychological triggers such as death of loved one according to Kuipers et al. (2014).
The three major types of schizophrenia include paranoid schizophrenia where the patient hears and sees things that others do not. The patient becomes fearful of their surroundings and people making them withdrawn from social interactions. Catatonic schizophrenia is a type of schizophrenia in which the patient mentally, physically and emotionally shuts down. The patient loses drive to perform basic activities of daily living such as eating and grooming. The other type of schizophrenia is disorganized schizophrenia where the patient presents with altered speech, behavioral disturbance and altered emotional expression (American Psychiatric Association, 2013).
The symptoms of schizophrenia are classified as cognitive, psychotic and negative. Negative symptoms include lack of interest in activities of daily living such as hygiene practices while psychotic symptoms are presented by patient experiencing paranoia and hallucinations. Cognitive symptoms of schizophrenia entail poor decision making and reduced attention span (McCutcheon, 2020).
Episode of care, according to Kuipers et al. (2014) is the total care provided to a patient based on their condition during a set period in a health facility. The intervention methods taken were to aid in reducing and eliminating Beata’s diagnoses of having low moods and difficulty sleeping.
During patient assessment, the nurse collects all necessary information that will guide the patient’s care plan. The patient’s health history is collected using interviewing method and from hospital records from prior visits to health facilities. Therapeutic communications methods such as the use of silence to encourage patient to talk, paraphrasing to clarify what the patient has said and exploring to garner more in depth information are some of the ways mental assessments are done (Williams and Wilkins, 2013). The mental health act of 1983 acted as our guide when handling Beata during the assessment period. The mental health act protects people with mental illnesses from harming themselves as well as others. Their rights include right to information pertaining their care, the right to a guardian who’ll help in decision making, right to privacy and confidentiality, right to give consent before any procedure is done and the right to equal, fair treatment (NHS, 2021). The interview that was conducted was carried out in a quiet office which eliminated unauthorized persons from accessing her information. Consent was also sought before the interview process to ensure that she was comfortable divulging any information to the nursing team. Beata was also accompanied by her guardian, her mother, who she had indicated as her guardian and could therefore be present in the interviewing room and could also participate in decision making on matters affecting her care.
The nursing care plan is a tool made to assess, diagnose, plan, implement and evaluate the care that is provided to patients. Care plans are tailored to fit each individual since each patient wish is unique. They ensure that the patients participate in their care and that the same level of care is received regardless of who the health care provider is, as stated by Capriotti (2013). The care plan developed for Beata is outlined in appendix 1.
The Roper-Logan-Tierney’s model of nursing was used as a checklist to determine Beata’s level of independence ranging from complete independence to complete dependence. This model has five main factors; the biological, environmental, politico economical, biological and socio cultural. The Roper model is used to measure how efficiently the patient s is able to carry out the activities of daily living. Roper (2008) outlined the 12 activities of daily living as managing body temperature, grooming, communication, breathing, feeding and drinking, ambulating, maintaining safe environment, elimination, death, sleep, expressing sexuality and working and playing. The Roper-Logan-Tierney model was inspired by Dorothea Orem’s theory where all persons are capable of performing their own care. In Orem’s theory, the nurse ensures patient independence and patient initiative in performing activities of daily living and only steps in to assist the patient in areas where the patient is unable to. In both Roper’s model and Orem’s theory, the nurse has to conduct an assessment, diagnose, plan for the patient care, implement the set strategies and finally evaluate the goals to see if they were met (Kumar, 2007).
The abrupt discontinuation of Clozapine by Beata is among the causes of difficulty in falling asleep as studies by Kluge et al., (2014) showed that clozapine has high sedative properties which promotes sleep and stabilizes moods. Staff nurse Anne and I resumed the clozapine administration and closely monitored to see if there would be any changes in Beata’s sleeping patterns and moods. Patient education on the importance of adhering to the medication prescribed is important in ensuring that the therapeutic effect of the drug is achieved. Compliance to treatment ensures patient care continues and eliminates illness related complications and ensures that the care provided is patient centered (Dibonaventura, 2012). Patient education on the expected side effects of medication such as nausea and headaches in the case of Beata prepares the patient thus ensuring continuity in treatment. Educating the patient on the effects of abruptly ceasing treatment also encouraged compliance to the treatment. Nurses are also expected to monitor the expected therapeutic effects of the drug and consult the physician if no changes are experienced by the patient. The patient’s physician should then review and prescribe new medications to achieve the expected results.
Beata was advised to seek support from close family and friends when feeling down in order to avoid low mood episodes. Her mother was advised by the counselor to ensure that family members around Beata constantly kept in touch with her to avoid her feeling lonely hence develop low moods. According to the Mind website (Mind, 2021), the community is able to access information about mental health and how to support people suffering from mental health issues. Beata’s family members were educated more about Schizophrenia, the symptoms that Beata might present and how they should handle her during her episodes of low moods. Peter et al. (2015) emphasizes on the importance of educating a patient’s family about her diagnosis and condition. Family members being knowledgeable about the patient’s condition guarantees better treatment adherence by patients as they’ll encourage and support patients during their treatment. Other than medication, a patient’s family assists them in their activities of daily living which might at times prove difficult. Close family members also act as support systems during periods when the patient feels low. In addition to offering support in adherence to medication and treatment, providing sources of information to care givers increases their awareness about schizophrenia due to the emotional toll they might experience due to the condition. Close family are often burdened with the emotional and financial task of caring for schizophrenic patients thus the availability of easy to access information is an invaluable resource to not only them but also to the patients (Brophy et al., 2014).
Support from free online services such as ICOPE, age UK and the listening place which have helplines for people with mood disorders or for persons seeking a listening ear were provided to Beata in case she did not feel comfortable to communicate with those around her. Online counseling services are cheap, convenient and provide anonymity to those seeking the service (Baker and Ray, 2011). Most people seek free online counseling as they had had an initial terrible experience with service provider, fear of being stigmatized against and distrust against health care providers. Peer support also entails the patient offering support to other distressed persons through their own experience and perspective thus improving their self-efficacy. Occupational therapy was included in Beata’s care plan as it is a vital activity in helping regain and develop her ability to perform daily tasks. The occupational therapist evaluates a patient’s needs and abilities then comes up with specific goals together with the patient that the patient hopes to achieve (Lannigan and Noyes, 2019). Activities that are often carried out during occupational therapy aim to improve activities of daily living such as personal grooming and hygiene, social skills such as maintaining eye contact during conversations and group activities like coking and gardening
Socialization according to studies by Troyer (2018) helps to raise one’s mood by decreasing loneliness which leads to depressive feelings. Socialization includes interacting with others either by meeting physically or via communication using social media. Stress levels are reduced when there’s socialization as oxytocin is released improving confidence and one’s ability to deal with stressors in their life. Beata reported to her case manager that she enjoyed the group activities they had during occupational therapy meetings as they were a source of distraction to her.
Beata worked with a psychiatrist to help in determining the core reasons for experiencing periods of low moods. The assigned psychiatrist was working with Beata to identify and change the negative thoughts that she experiences into more positive jovial thoughts. Through cognitive behavioral therapy, patients get to work with therapists to develop healthy and constructive thoughts to avoid dampening their moods. It is during this process where patients learn how to handle negative thoughts without feeling overwhelmed and develop skills that would prevent them from relapsing by managing their triggers (American Psychiatric Association, 2013).
Physical activities such as hiking, swimming and running promote improved mood levels of Schizophrenic patients. Research on the impact of exercise on mood disorders show that exercise boosts release of endorphins that promote a sense of wellness and distracts one from getting worried about life hassles (Xie et al., 2017). Exercising prevents feelings of anxiety and encourages the patient to develop healthy coping mechanism and gain confidence. Schizophrenic patients should also be occupied with activities that keep their minds activities. These might range from dog walking to volunteering in old people’s homes. Indulging patients with activities that require them to care for another person or living thing act as a distraction for the patients hindering them from focusing on their illness and diverting their attention towards the animals and old people (Kuipers et al., 2014). Another way to keep their minds occupied is by signing up for vocational training like cooking classes. Cooking acts as a therapeutic gateway from low moods episodes. This is a long term care intervention that the Beata and her parents agreed to follow up on in order to keep her busy upon discharge from the hospital.
Participating in fun filled leisure activities such as watching funny television programmes or listening to upbeat music helps to avoid feeling low. Humor improves a person’s emotions therefore dissociating the person from any stressful thought that they might be experiencing. Participating in activities like music classes as in the case of Beata, has been shown to improve the quality of life, patient’s cognition and the patient’s mental state. Music therapy according to D’Aurea et al. (2019) not only improves cognitive and emotion stabilization but also communication and social skills.
The interventions done to improve Beata’s sleeping patterns, focus was placed on the environment, diet, day time physical activities and relaxation. Beata was encouraged to practice good sleep hygiene to improve on her sleeping habits. Sleep hygiene practices include maintaining a regular sleep practice, avoiding napping during the day, creating a conducive sleeping environment and partaking in the appropriate diet before bed time. Relaxation activities before bedtime such as reading a book, taking a warm bath or having a massage have been shown to induce sleep. Reading a book induces sleep due to the rapid eye movements made when reading, this causes the muscles to become tired and eventually cause one to fall asleep. Reading a book in bed allows for a person to fall even faster asleep due to the association of the bed to sleep (Gronli et al., 2016). Having a warm bath 90 minutes before bed is ideal in promoting sleep. Having warm baths have been shown by Gooneratne and Vtiello, (2014) to cause a drop in temperature causing faster sleep onset. Massages cause relaxation and stimulate serotonin production which induces sleep. Beata alternated reading books, warm baths and massages daily to prevent boredom with one routine and to help her decide on which of the activities she enjoyed the most and which one actually benefited her sleeping patterns
The ideal sleeping environment is cool, dark and quiet according to Cardick et al. (2018). For quality sleep and fast sleep onset, the environment should be free from noise both coming from people or television, should be dark with curtains drawn and lights switched off and should be free from disruptions. Beata was encouraged to avoid using her mobile phone and the television during bedtime to cut off distractions. The blue light from phones and televisions reduce the production of melatonin which is produced by the body to initiate sleep (Xie et al., 2017).Melatonin released by the pineal gland responsible for the sleep-wake cycle is often highest in the blood at night when it is dark and is inhibited by light exposure. Therefore, setting up a patient with sleeping difficulties in a dark room stimulates melatonin production thus promoting sleep.
Beata’s diet mostly consisted of alcoholic drinks, fatty foods and caffeine rich drinks. These foods and drinks affect a person’s sleeping pattern leading to insomnia and tiredness. Alcohol reduces the rapid eye movement sleep causing poor concentration and drowsiness despite it being abused as a sleep inducer. Dependence on alcohol to stimulate sleep leads to overdependence causing alcoholism. Caffeine and nicotine were reported by Snel and Lorist (2011) to be amongst the most highly abused by schizophrenic patients which highly increased their symptoms. Reducing the amount of caffeine consumed by using decaffeinated coffee or reducing amount consumed a day to prevent alertness especially before bed time since caffeine is a stimulant and increases brain activity thus reducing sleep onset. Avoiding heavy meals during dinner also promote better sleep as heavy meals interferes with digestion therefore slowing down the body’s preparation for sleep. Having too much liquid as well leads to sleep interruptions as a person will have to frequently wake up to void their bladder (Snel and Loris, 2011).
Consuming foods such as milk, nuts and bananas that are rich in L-tryptophan just before bed promote sleep as the L-tryptophan s converted into serotonin which promotes sleep. Milk also contains melatonin which is responsible for the sleep- wake cycle which ensures a person knows what time to sleep and what time to wake up. Beata met with a nutritionist to discuss her dietary plan to ensure her daily dietary requirements are met. She was advised to eat small amounts of food at frequent intervals as opposed to large meals spaced out throughout the day to stimulate her appetite as she had experienced loss of appetite before. Herbal teas such as chamomile were provided as substitute for milk to prevent monotony in the diet. Chamomile tea contains apigenin which reduces stress and promotes sleep according to a study carried out by Adib and Mousavi, (2017) which reported respondents who took chamomile tea slept better compared to those who did not.
Liaising with the patient care coordinator to ensure that the patient is well managed, educated about their care process and that all professionals involved with the patient’s care are kept up to date about the progress of the patient promotes a well-rounded and successful patient care. A patient care coordinator also checks in on patients to ascertain that the treatment plan that they are on are effective and works as an intermediary between patients and service providers (Brophy et al, 2014). The coordinators are also vital in evaluation of patient progress and in the identification of new intervention measures where the goals set are not attained in the stipulated time.
Besides the two major issues of low moods and lack of sleep experienced by Beata, other physical, mental, behavioral and cognitive problems experienced by patients suffering from schizophrenia should be managed to avoid their health from deteriorating. Managing physical conditions of schizophrenia such as diabetes and obesity can be done by encouraging proper diet intake to avoid risk of complications that might develop from the conditions like diabetes and high blood pressure. For their mental well- being, being physically active and interacting with others will improve their mental status (Troyer, 2018). Poor cognitive ability on the other hand is achievable through cognitive behavioral therapy where negative behavior is identified and interventions made to make these thoughts more realistic (Stepnicki et al, 2018). Finally behavioral issues experienced by schizophrenics such as withdrawal and emotional flatness can be improved by encouraging stimulating activities to the patient. These activities include group therapy activities like cooking or music classes where the patient’s mind is stimulated and thus prevents feelings of loneliness.
After the intervention measures taken to manage Beata’s low moods and lack of sleep, an evaluation was done to find out if the set goals set for her had been met. With support from the nurses, group therapy and family members, Beata’s moods had noticeably been elevated as well as her sleeping patterns changed. She no longer appeared tired and sad on further observation. She maintained taking her medication diligently since the side effects of the medication were also being treated.
Creating a care plan with the patient promoted patient centred care where care is individualized based on an individual and not on the condition. When patients participate in their care plans, they are more likely to adhere to the designed care which promotes faster recovery and shorter hospital stay. Support from close family , friends and health care providers was noted to have a positive effect on managing the patient’s symptoms such as low moods and adhering to their treatment regimen.
Education was a key factor in ensuring continuity of treatment by Beata and her family go to understand her condition and ways in which that could help her but at the same time maintain her independence when performing her day to day activities.
NURSING CARE PLAN
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