Faculty of Health Sciences
Department of nursing
Tripoli Campus
Psychiatric and mental health
NURS 419
Case Report #3
Prepared By: Razan Nasereddine
ID: 201803107
Dr’s Name: Maha Dankar
Date: 2/12/2019
Outline:
1) Patient initial and habits.
2) Cause of admission/history of present illness.
3) Past medical and surgical history and blood tests
4) Symptoms reported by the patient.
5) Medical and nursing management provided to the patient.
1.A) Patient initial:
o Patient’s name : Terez Skaf
o Age : 37 years old
o Date of birth: 16/2/1983
o Marital status : single
o Patient’s weight: 61kg height:163cm
o Living : lives with her mother after her dad died
o Address : beirut
o Occupation : knitting
o Education : 4th grade
o Patient has two brothers
o Patient’s family doesn’t visit her
o Patient’s father died and she doesn’t admit his death
o Patient was her father’s girl-friend
o Patient has no allergy
o Patient’s financial status is average
o Absence of medication intolerance
o Family history: there is no history of mental problems in patient’s family
o Patient’s parents got divorced when she was 18 years and she had so many problems
with her mom. Patient used to love her dad more than a father and he used to love her
back and they were both okay with it
B) Patient habits:
o Patient has hypersomnia
o Eats well and alone ( three meals/day)
o Doesn’t drink alcohol but she smokes about half packet/day
o Normal elimination
o Hygiene with help
o Takes shower every 2/3 days
o watch TV
o she doesn’t do any activity
o patient has an abnormal acts that se do in her mouth as if there is something in her
mouth
2) Cause of admission:
Patient admitted to Dar AL Salib Hospital in 5/2/2019 at 10:00am through the
admission door with her brother and mother under the psychologist doctor name Dr
Mirna Maawad
Chief complaint: affective Schizophrenia relapse
Medical observation on entry: visual and auditory hallucinations
Differential diagnosis: psychotic relapse with no suicidal thoughts
History of present illness:
Antecedent: mania episode and schizophrenia since the age of 16 years
Last admission to the hospital was 4 months ago from the new admission where her
brother said that she was unstable and this is the 6th relapse
Her dad died at age 56 when she was 30 years and she denies his death and she has an
uncontrolled responses till today
She used to go out with so many boys but they used to break up with her which made
her mental health even worse
3) Past medical and surgical history and blood tests:
Patient has no surgical history
Patient has no medical history except mental illness having schizophrenia since she
was 16 years old
Patient’s vital signs at admission were :
blood pressure: 100/70mmhg
pulse:118beats/min
temperature: 36.5 degrees
oxygen saturation: 96%
Patient had an ECT scan 6 episodes, ECGand radiothorax they all showed normal
results
Patient also had some biological tests: FNS,urea,creatinine,TSH,serologic VIA level.
patient evaluation on scale DSM-IV-TR showed:
i. axis 1: schizophrenia
ii. axis 2: no personality disorder/mental retardation
iii. axis 3 : no medical/organic disease present
iv. axis 4: negative family history,middle class socioeconomic status,parent’s
devorce
v. axis 5: 21/100 :
Behavior is considerably influences by delusions or hallucinations OR serious
impairment in communication or judgment (eg. Sometimes incoherent, acts grossly
inappropriately, suicidal preoccupation) OR inability to function in almost all areas
( eg. Stays in bed all day, no job, home, or friends).
Patient’s medications at hospital:
Medication Dosage Frequency
Depakin 500mg 1-0-2
Zyprex 10mg ½ -0-1
Valium 5mg 1-1-1
Clopixol 3mg 1amp IM/week
Benzhxol 5mg 1-1-1
Maldol 10mg 1-1-2
Chlorpinazin 100mg 0-0-1
note that patient can’t take medications on her own
4) Symptoms reported by the patient:
Actual symptoms: visual and auditory hallucinations
No substance abuse
Patient laughs with no reason
Hyperactive
Irritable
Agitated
Delirium of parentage
Fugue
Clinical exam on admission: Physical exam was normal and patient was conscious and
oriented
5) Medical and nursing management provided to the patient:
Nursing management for disturbed sensory perception: auditory/visual
Accept the fact that the voices are real to the client, but explain that you do not hear
the voices. Refer to the voices as “your voices” or “voices that you hear”.
Be alert for signs of increasing fear, anxiety or agitation.
Explore how the hallucinations are experienced by the client.
Help the client to identify the needs that might underlie the hallucination. What other
ways can these needs be met?
Help client to identify times that the hallucinations are most prevalent and
frightening.
Stay with clients when they are starting to hallucinate, and direct them to tell the
“voices they hear” to go away. Repeat often in a matter-of-fact manner.
Medical management: Intervene with one-on-one, seclusion, or PRN medication
(As ordered) when appropriate.
Nursing management for decreasing irritability and agitation (nonpharmacological)
Music therapy (listening), aromatherapy, bright light therapy, multisensory
stimulation.
Dancing, exercise, social interaction, music therapy (playing, singing), art therapy,
outdoor walks
Aromatherapy, reflexology, acupuncture, acupressure, massage, Reiki
Validation therapy, reality orientation, reminiscence therapy, support groups
Medical management: administer for the patient aripiprazole (Abilify), haloperidol
(Haldol), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), and
ziprasidone (Geodon) if prescribed
Nursing management for delirium:
Assess level of anxiety. Assess client’s level of anxiety and behaviors that indicate
the anxiety is increasing; recognizing these behaviors, nurse may be able to intervene
before violence occurs.
Provide an appropriate environment. Maintain a low level of stimuli in client’s
environment (low lighting, few people, simple decor, low noise level) because
anxiety increases in a highly stimulating environment.
Promote patient’s safety. Remove all potentially dangerous objects from client’s
environment; in a disoriented, confused state, clients may use objects to harm self or
others.
Ask assistance from others when needed. Have sufficient staff available to execute a
physical confrontation, if necessary; assistance may be required from others to
provide for physical safety of client or primary nurse or both.
Stay calm and reassure patient. Maintain a calm manner with the client; attempt to
prevent frightening client unnecessarily; Provide continual reassurance and support.
Interrupt periods of unreality and reorient; client safety is jeopardized during periods
of disorientation; correcting misinterpretations of reality enhances client’s feelings of
self-worth and personal dignity.
Medicate or restrain patient as prescribed. Use tranquilizing medications and soft
restraints, as prescribed by physician, for protection of client and other during periods
of elevated anxiety.
Observe suicide precautions. Sit with client and provide one-to-one observation if
assessed to be actively suicidal; client safety is a nursing priority, and one-to-one
observation may be necessary to prevent a suicidal attempt.
Teach relaxation exercises to intervene in times of increasing anxiety.
Teach prospective caregivers to recognize client behaviors that indicate anxiety is
increasing and ways to intervene before violence occurs.
Medical management: administer antipsychotic drugs as prescribed
