Nursing Care Plan

Multiple Setting Nursing Care Plan for a Patient With

Schizophrenia
JB is a 19-year-old African American man exhibiting symptoms of schizophrenia for the
first time. His parents brought him to the hospital after he was brought home for spring
break. He is a freshman at college and is attending on an academic scholarship. He is the
oldest child of three and is the first in his family to go to college. His father is a foreman
at the local auto plant, and his mother is a receptionist for a physician. His fathers
insurance plan allows for a 15-day stay for mental health services.
JB has always been a quiet, hard worker with a small circle of friends. His first
semester was a lonely one, with disappointing grades. Although he was not at risk to fail
out of school, he was at risk of losing his scholarship. At Christmas time, JB was quieter
than usual but participated in family activities without prodding. When grandparents,
aunts, and uncles asked him about school he was distracted and answered simply that it
was fine. His parents returned him to school with some anxiety but thought it was just a
difficult adjustment being away from home for the first time.
When his parents picked him up for spring break he was disheveled and had not
bathed. His side of the dorm room was covered with small pieces of taped paper with
single words on them. The words made no sense but JB stated that he put them there to
organize (his) thoughts. His roommate informed his parents that this behavior started
about the same time JB began staying in the room and skipping classes and meals.
JB agreed to leave with his parents only after they agreed to take everything home
with them. As they packed his belongings, JB sat in the corner of his bed listening to his
compact disk player. When his parents asked him what was happening, he merely said, I
have the power. On the way home JB responded to their questions by saying his
professors were trying to take away what he knew. He sat huddled in the back seat of the
car with his coat over his head. He laughed and mumbled in response to nothing his
parents could hear.
SETTING: INTENSIVE CARE PSYCHIATRIC UNIT/GENERAL HOSPITAL
BASELINE ASSESSMENT: This is the first admission for JB, a 19-year-old single
African American college student who has not slept for 4 days and is frightened with
wide-eyed hypervigilance, pacing, and periods of extended immobility. Is vague about
past drug use. Parents do not believe he has used drugs. He appears to be hallucinating,

conversing as if someone is in the room. At times he says he is receiving instructions

from the power. He is unable to write, speak, or think coherently. He is disoriented to
time and place and is confused. JB is 61, 155 lb, thin in appearance, but normally
developed. Lab values are within normal limits except Hgb, 10.2 and Hct, 32. He has not
eaten for several days.
Associated Psychiatric Diagnosis
Axis I Schizophrenia, catatonic type

Medications
Risperidone (Risperdal) 2 mg bid then

Axis II None

titrate to 3 mg bid if needed

Axis III None

Lorazepam (Activan) 2 mg PO or IM PRN

Axis IV Educational problems (failing)

IM for agitation

Social problems (withdrawn from social

contacts)
Axis V GAF Current = 25
Potential = ?
Nursing Diagnosis 1: Disturbed Thought Processes
Defining Characteristics
Inaccurate interpretation of stimuli (people
thinking his thoughts, trying to take

Related Factors
Uncompensated alterations in brain
activity.

information from his brain).

Cognitive dysfunction, including memory
deficits, difficulty in problem solving and
abstraction.
Suspiciousness
Hallucinations
Confusion/disorientation
Impulsivity
Inappropriate social behavior
Outcomes
Initial
1. Recognize changes in thinking and
behavior.
2. Learn coping strategies to deal
effectively with hallucinations and
delusions.
3. Express delusional material less
frequently.

Discharge
6. 6. Use coping strategies to deal with
hallucinations and delusions.
7. 7. Communicate clearly with others.
8. 8. Agree to take antipsychotic medication
as prescribed.
9. 9. Maintain reality orientation.

4. Take Risperdal as prescribed orally.

5. Participate in unit activities according to
treatment plan.
Interventions
Interventions
Initiate a nurse-patient

Rationale
A therapeutic relationship

Ongoing Assessment
Determine whether or not

relationship by

will provide JB support

JB can engage in a

demonstrating an

as he develops an

relationship.

acceptance of JB as a

awareness of

worthwhile human being

schizophrenia and the

through the use of

implications of the

nonjudgmental statements

disorder.

and behavior. Approach in

a calm, nurturing manner.
Be patient (patients brain
is not processing data
normally) and nurturing.
Assist JB in differentiating
between his own thoughts

Initially, JB will be unable

Determine if JB is

and reality. Validate the

to determine whether or

convinced that his

presence of

not his hallucinations are

perceptual experiences

hallucinations. Identify

reality based. Because

are hallucinations.

them as a part of the

hallucinations tend to be

disorder and explain that

repeated, the patient

they are present because

learns that recurring

of the metabolic changes

perceptual experiences

that are occurring in his

that are not confirmed by

brain. Focus on reality-

others are hallucinations.

oriented aspects of the

The patient can learn to

communication.

focus on reality and

ignore the perceptual

Teach JB about his disorder.

Assure him that the

experience.
Helping JB understand his

Assess whether or not JB

symptoms can be

disorder will give him a

can process the

improved and that he can

sense of control over his

information. Has the

manage the disorder.

disorder and give him

confusion been

the information he needs

alleviated?

to manage the
Administer Risperdal as
prescribed. Teach about

symptoms.
Risperdal is a

Observe for relief of

the action, side effects,

monoaminergic

positive symptoms and

and dosage of medication.

antagonist of D2 and 5-

assess for side effects,

Emphasize the importance

HT2 postsynaptic. It is

especially extrapyramidal

of taking medication after

indicated for the

symptoms (specifically

discharge, even if

management of the

acute dystonic reactions,

symptoms go away

manifestations of

akathisia,

completely. Ask patient

psychotic disorders.

pseudoparkinsonism).

for a commitment to take

Observe for orthostatic

the medication.

hypotension.

When patient is
hallucinating, determine

By refocusing JBs attention Determine whether or not

the significance to the

from hallucinations to

the hallucination is

patient (what are the

reality, he will begin to

frightening to the patient

voices telling him?), then

develop coping skills to

or giving patient

try to reassure JB that he

control the perceptual

command, especially to

is not alone and then

experience. It is

harm self or others.

redirect him to the here-

important for the nurse

Assess patients response

and-now.

to understand the context

to the hallucination.

of the hallucination to

Assess his ability to be

provide the appropriate

redirected to the here-

supportive intervention.

and-now.

When patient is making

Delusions, by definition, are

delusional statements,

fixed false beliefs. They

assess the significance of

cannot be changed

delusion to the patient.

the delusion to the patient

through logical

Determine if the patient

(it is frightening), support

argument. Because the

can be redirected.

patient if necessary, and

patient is convinced of

redirect to the here-and-

the truth of the delusion,

now. Do not try to

the individual should be

convince JB that the

supported if the delusion

delusion is false.

is upsetting to him.

Assist patient in
communicating

Assess the meaning of the

Patients with schizophrenia

typically have problems

Determine situations that

effectively. Encourage

because of the disordered

cause JB the most

patient to attend

thought process.

problem in

communication groups.

Improving

communicating.

communication skills
will help the patient cope
with the disorder.
Assess ability for self-care

The negative symptoms of

activities. Identify areas

schizophrenia can

Monitor patients actual

of physical care for which

interfere with the

ability to complete self-

the patient needs

patients ability to

care activities. Assist

assistance. Note level of

complete daily living

when necessary.

motivation and interest in

activities.

appearance.
Assess sleep and rest

JB was unable to sleep

patterns. If problems with

before admission. The

sleep continue after

prescribed medications

initiation of medication,

are sedating and may

explore techniques that

reverse the insomnia.

Observe patients sleep

cycle.

may promote sleep.

Structure times for sleep,
rest, and diversional
activities.
Evaluation
Outcomes
Within the safety of the
nurse-patient

Revised Outcomes
Continue to learn about
schizophrenia.

relationship, JB

Interventions
Refer to symptom
management group at the
mental health center.

acknowledges that his

thinking and behavior
have changed from the
beginning of school
until now. He is
perplexed by the
change.
JB continues to have
hallucinations and

Use strategies to reduce

Encourage JB to practice

hallucinations and

strategies that reduce

delusional thinking. He

delusions. Structure daily

hallucinations and

is beginning to develop

activities to avoid

delusions. Discuss the

strategies for dealing

isolation, withdrawal,

development of a daily

with the unusual

and negative symptoms.

routine with JB and his

perceptual experiences.

parents.

He is also having
problems with being
motivated to complete
daily activities.
JB understood that he had a
disorder called

Continue to learn about

schizophrenia.

Refer to case manager and

recommend individual

schizophrenia, but was

supportive therapy at the

not sure what it meant.

mental health clinic.

The medication has

Continue to take medication

decreased the intensity

as prescribed.

Refer to medication group

at the mental health

of the hallucinations and

center.

the frequency of
delusional thoughts. He
agrees to take the
Risperdal as prescribed.
Through attending the unit

Develop communication

Discuss the possibility of a

activities, JB was able

skills to interact with

day treatment program for

to improve his

others.

JB that will help him

communication skills

improve his

and maintain reality

communication skills.

orientation.
Nursing Diagnosis 2: Risk for Violence
Defining Characteristics
Assaultive toward others, self, and

Related Factors
Frightened, secondary to auditory

environment

hallucination and delusional thinking

Presence of pathophysiologic risk factors:

delusional thinking

Excessive activity and explosive agitated

comments (catatonic excitement)
Poor impulse control
Dysfunctional communication patterns

Outcomes
Initial

Discharge

1. Avoid hurting self or assaulting other

3. Control behavior with assistance from

patients or staff, with assistance from

staff and parents.

staff.
2. Decrease agitation and aggression.
Interventions
Interventions
Acknowledge patients fear,

Rationale
Hallucinations and

Ongoing Assessment
Determine if patient is able

hallucinations, and

delusions change an

to hear you. Assess his

delusions. Be genuine and

individuals perception of

response to your

empathetic. Assure patient

environmental stimuli.

comments and his ability

that you will help him

Patient is truly frightened

to concentrate on what is

control behavior and keep

and is responding out of

being said.

him safe. Begin to

his need to preserve his

establish a trusting

own safety.

relationship.
Offer patient choices of

By giving patient choices,

Listen for his response to

maintaining safety:

he will begin to develop a

choices. Is he able to

staying in the seclusion

sense of control over his

make choices at this

room, medications to help

behavior. Seclusion and

time? Is he starting to

him relax. Avoid

restraint are options only

engage in the nurse-

mechanical restraints and

for persons exhibiting

patient relationship?

a show of force by having

serious, persistent

several persons

aggression. The persons

approaching him at once.

safety must be protected at

all times.

Administer Ativan 2 mg.

The exact mechanisms of

Observe for relief of

Offer oral medication

action are not understood,

agitation and side effects:

first. If IM necessary, give

but the medication is

drowsiness, dizziness,

injections deep into

believed to potentiate the

constipation, diarrhea, dry

muscle mass; monitor

inhibitory neurotransmitter

mouth, nausea.

injection sites.

aminobutyric acid. It
relieves anxiety and
produces a sedative effect.
Ativan is rapidly absorbed,
thus produces desired
effects quickly.

Evaluation
Outcomes
JB was placed in seclusion

Revised Outcomes
Demonstrate control of

Interventions
Teach JB about the effects

with constant observation.

behavior by resisting

of hallucinations and

Ativan decreased his

hallucinations and

delusions. Problem-solve

agitation and was

delusions.

with him ways of

administered three times.

controlling auditory

After 2 days he was less

hallucinations if they

agitated and less

continue.

aggressive. On his third

day in the hospital, he was
able to come out of the
seclusion room for brief
periods of time. At these
times he would stand in
one spot for as long as 20
minutes without moving
except to shake his head
once in a while.
Nursing Diagnosis 3: Imbalanced Nutrition: Less than Body Requirements
Defining Characteristics
Inadequate food intake less than

Related Factors
Refusal to eat because of delusional

recommended daily requirement.

thinking: He has the Power.

Outcomes

Initial
1. Food intake will match energy

Discharge
3. Weight will be between 160 and 174 lb.

expenditures (roughly 2,000-3,000

4. JB will be able to describe the food

calories)

pyramid and identify foods he likes and

2. JB will eat at least 3 meals per day, with

amounts for each section.

snacks in late afternoon and late evening.

Interventions
Interventions
Offer small frequent meals.

Rationale
For someone who has not

Ongoing Assessment
Intake and output and a

been eating well, small

calorie count until fluid

meals are easier to

intake is adequate and

tolerate.

calorie intake is 2,500 to

3,000 cal.
Suggest parents bring meals

Familiar foods are more

Intake and output when

that JB likes when they

likely to be eaten.

family members present.

visit; encourage family to

Observe family interaction.

visit at mealtimes
occasionally.
Allow JB to eat alone

Being comfortable when

Observe JBs interaction

initially; gradually allow

eating is important. A

with others to know when

him to eat with increasing

patient who is

he should be encouraged to

numbers of patients at

uncomfortable with

eat with others.

mealtimes.

others may not eat in

front of other people.

After medications have

JB will not be able to retain

Assess cognitive

improved JBs attention

information while

functioning to determine

span, teach him about

confused and

when teaching can be

nutritious food selection

disoriented.

implemented.

and the food pyramid.

Evaluation
Outcomes
JB is eating all meals and

Revised Outcomes
Interventions
Maintain adequate nutrition. Explore the need to

snacks with other patients.

continue nutritional

He has a healthy appetite

education based on plans

and has been consuming

for JB and his family after

at least 3,000 calories a

discharge.

day. He weighs 158 lb.

JB can identify the foods in
the food pyramid but
states his mother knows
what foods to boy.
SUMMARY OF INPATIENT TREATMENT: JB was discharged 2 weeks after
admission. He was no longer agitated or aggressive. He reluctantly participated in the
group activities, but willingly met with his primary nurse. The discharge plan included JB
returning home with his parents and beginning outpatient treatment at the community
mental health center. JB adhered to his medication regimen. JB is to participate in the day
treatment program.

SETTING: DAY TREATMENT CENTER AT THE COMMUNITY MENTAL

HEALTH CENTER
CMHC ASSESSMENT: JB is a 19-year-old with a diagnosis of schizophrenia, catatonic
type, discharged from an inpatient unit. Hears voices (telling him you have the power)
and has some delusional thinking (believes people are stealing his thoughts). He is
oriented, coherent, and able to complete basic mathematical calculations. He has been
faithfully taking his medication (Risperdal 4 mg od). No side effects are evident. He is
reclusive at home, staying in his room most of the time. Refuses to contact old friends.
He is eating well, but his parents report that he is not sleeping well at night. They hear
him pacing and mumbling to himself. He then naps during the day. He has agreed to
attend the day treatment program with eventual reintegration into society.
Nursing Diagnosis 1: Disturbed Sleep Pattern
Defining Characteristics
Difficulty falling or remaining asleep

Related Factors
Excessive hyperactivity secondary to

Dozing during the day

catatonic excitement
Excessive daytime sleeping
Inadequate daytime activities
Outcomes

Initial
Discharge
1. JB will sleep between 5 and 8 hours each 3. JB will sleep 7-8 hours each 24-hour
24-hour period.

period between the hours of 10 PM and

2. Describe factors that prevent or inhibit

sleep.

7:30 AM.
4. Identify techniques to induce sleep.
5. Report an optimal balance of rest and
activity.

Interventions
Interventions
Assess JBs sleep cycle.

Rationale
A thorough understanding

Ongoing Assessment
Determine if JB has trouble

Report time he goes to

of sleep cycle is important

falling asleep or if he

bed, ability to fall to

to develop strategies that

wakes up in the middle of

sleep, waking up in the

will improve sleep

the night. Do his voices

middle of the night.

hygiene.

and thoughts wake him?

Is there any evidence of
nightmares?

Increase activities by

Increasing activities during

Monitor JBs ability to stay

attending day treatment

the day will help readjust

alert and active at the day

program daily. Encourage

sleep cycle.

treatment center.

JB to resist urge to sleep

during the day. Establish a
daily routine for getting
up and going to bed.
Plan with patient how to
increase physical exercise.

Regular physical exercise

Determine if JB is willing to

improves sleep hygiene.

exercise and can develop

a realistic exercise plan.

Evaluation
Outcomes
After JB began attending

Revised Outcomes
None.

Interventions
None.

day treatment program, he

and his family reported
that he slept all night.
Nursing Diagnosis 2: Impaired Social Interactions
Defining Characteristics
Inability to establish and maintain stable
relationship

Related Factors
Embarrassment about mental illness
Communication barriers secondary to

Dissatisfied with social network

schizophrenia

Avoidance of others

Alienation from others secondary to

Interpersonal difficulties

hallucinations, delusions, disorganized

Social isolation

thinking
Lack of social skills
Outcomes

Initial
1. Establish a therapeutic relationship with
the nurse.

Discharge
3. Describe strategies to promote effective
socialization.

2. Identify barriers in interpersonal

4. Practice new social interaction skills.

relationships that interfere with

socialization.
Interventions
Interventions
Initiate a nurse-patient

Rationale
Through a nurse-patient

Ongoing Assessment
Determine whether or not

relationship with JB.

relationship, the patient

JB can engage in a

Establish a time each day

can learn about his

relationship.

to meet with him to

strengths and limitations.

support him as he learns

to cope with his disorder.
Provide supportive group

The negative symptoms of

therapy to focus on the

schizophrenia can make

here-and-now, establish

it difficult to

group norms that

automatically recall

discourage inappropriate

appropriate social

social behavior, and

behavior. Reinforcing

encourage testing of new

appropriate behavior in a

social behavior.

group can help the

Assess JBs ability to

interact in the group.

patient add new skills to

a limited repertoire of
behaviors.
Role-play certain accepted

Through practicing social

Assess JBs willingness to

social behaviors. Foster

interaction, the patient

participate with others.

development of

can become comfortable

Assess the availability of

relationships among

in social situations.

people who are his age

group members through

and have similar interests.

self-disclosure and
genuineness. Encourage
members to validate their
perception with others.
Monitor adherence to

Patients may not be aware

Assess for nonverbal cues

medication regimen.

that symptoms are

that symptoms are

Encourage JB to attend

erupting. By specifically

present. Monitor for

medication group. Ask

asking about symptoms

evidence of relapse.

patient about specific side

and medication side

effects and symptom

effects, patients can

exacerbations. Encourage

focus on specific

JB to attend the evening

experiences that

symptom management

represent

group.

symptomatology.

Identify the environment in

Different social skills are

which social interactions

needed in different

Assess for readiness to

return to learning and

are impaired (living,

situations.

working environment.

learning, working,
leisure).
Role-play aspects of social

By practicing specific skills, Assess for ability to engage

interactions such as

patients will be able to

initiating/terminating a

use them in specific

conversation, refusing a

situations. It is then

request, asking for

possible to assign a

something, interviewing

patient to practice a

for a job, asking someone

specific social skill. Too

to participate in an

much feedback adds

activity (going to a

confusion and increases

movie). Give positive

anxiety.

in social interactions.

feedback. Focus on no
more than three
behavioral connections at
a time.
Assist family and

Family members are often

community members in

the patients main source

understanding and

of support. The family

providing support. With

needs help and support

JBs permission, develop

in dealing with the care

an alliance with the

of a person with a long-

family. Encourage them to

term mental illness.

Assess family interaction.

attend a support group.

Evaluation
Outcomes
JB was able to establish a

Revised Outcomes
Continue to develop social

Interventions
Continue on a part-time

therapeutic relationship

interaction skills. Discuss

basis with the day

with one of the nurses.

with the group the

treatment center.

Through the relationship

everyday problems

and the group, JB

encountered outside the

identified barriers in his

day treatment

interpersonal

environment.

relationships. He was
afraid of telling his

friends about the mental

disorder.
JB was able to practice

Continue to practice

Monitor medication

various communication

communication strategies.

adherence and ability to

strategies and eventually

Maintain medication

communicate.

was able to contact his old

adherence.

friends. He also
developed some new ones
and started sharing leisure
activities with them.
JB would like to return to
school and live at home.

Enroll in community
college for one course.

Teach patient about dealing

with stress and relapse
prevention techniques.