Comprehensive Health History and Holistic Plan of Care

Schizophrenia is a mental illness that is difficult to diagnose. In the prodromal period people exhibit suspicion and withdrawal along with an increase of unusual thoughts. The exact causes of the disease are unknown, but genetics, brain chemistry, and a variety of environmental factors are thought to be contributing factors. Stress, malnutrition, and viruses are environmental factors that may play a part in the development of disease (National Institute of Mental Health, n.d.). The patient is a 40 year old female who has experienced a schizophrenic episode including psychotic symptoms, (see psycho-social history) and was recently released from the psychiatric ward of a hospital in Detroit, Michigan. She is temporarily living with her mother. The patient has no history of mental health illness, and it is unclear how long she has been having psychotic symptoms. The patient’s mother reports that she was informed by the patient’s husband that the delusions have been going on for about six months. She is no longer delusional, and is refusing medication. She currently presents with a slight vitamin B12 deficiency and exhibits negative characteristics of schizophrenia, as well as exhibiting lethargy and anhedonia, which are symptoms of mental illness, and vitamin deficiency. I have used the data assessment tools of a comprehensive health history, a psychiatric nursing interview, and the brief psychiatric rating scale (BPRS), as well as a short psycho-social interview with information obtained mainly from the patient’s mother. The patient has recently been released from the hospital, and is staying with her mother until she is able to get a job and begin to support herself. She has no support system, other than her mother who works full time. She has three living children who live in Hawaii. The patient denies mental illness, and is non-compliant with her medication, stating that: “the doctors are trying to make me fat and ugly, and I don’t need medicine, I am fine.” The main concerns in this case include the fact that the patient is non-compliant with her medication, and that relapse is possible. Another concern is that the patient does not admit illness, and is hostile and suspicious of healthcare professionals, making treatment difficult. Due to the patient’s continuing negative symptoms, paranoia, flat affect, and lack of motivation, she is having difficulty in social situations, as well as in obtaining and keeping employment. Ann has a history of eating mainly junk food, and her nutritional health is poor, which may be a cause of her low energy level. The priorities for this patient are nutritional support, development of a trusting therapeutic relationship that focuses on continuity of care, and the prevention of a relapse of positive schizophrenic symptoms, which in the past has led to dangerous impulsivity, and impaired judgement in the patient. The patient’s major strength is her high level of intelligence. A supportive relationship with an assertive outreach team who understand the social stigma of being labeled schizophrenic will help to boost the patient’s self- esteem, without making her feel “disabled”. The patient is very aware of the stigma that accompanies a diagnosis of schizophrenia, and she is resistant to treatment due to embarrassment, and denial. The patient’s weaknesses are impulsive behavior, lack of a strong support system, paranoia, and her secretive nature. These traits are inherent in many schizophrenic patients, but with consistent support it is possible to maintain a normal life. The top three problems that I have identified are related to nutrition, non-compliance with medical advice, and denial of mental illness. I chose knowledge deficit related to nutrition as my first nursing diagnosis, because it is the most urgent problem under Maslow’s hierarchy. A study published in the Journal of Research in Medical Sciences found that: “cobalamin and folate deficiencies may contribute to the pathogenesis of neuropsychiatric disorders such as mental confusion, memory changes, cognitive slowing, mood disorder, violent behavior, fatigue, delirium and paranoid psychosis” (Saedisomeolia et al., 2011).
Interventions:
1. Determine nutritional knowledge and motivation about health and eating.
This first step will help to determine what the client knows, and what she needs to learn. 2. Obtain a dietary consult to assist the client in selecting appealing foods that meet nutritional needs that the client can use as a guide after discharge.
By encouraging the client to eat things that she likes that are also healthy, there will be a better chance of compliance with the healthy eating plan. 3. Encourage family members to offer client reinforcement about healthy food every-day.
Due to the clients mental illness, and lack of energy, support may be necessary to get her on the right track.
Outcome: Client will recognize inappropriate behaviors and consequences related to improper nutrition.

The second nursing diagnosis that I chose is ineffective denial related to anger and frustration. This patient had no history of mental illness until the age of 40, and although she has had negative schizophrenic symptoms for years, she has led a normal life up until recently.
Patrick Corrigan PsyD (2005) is quoted in the American Psychological Association Journal as saying: “The toxic effects of stigma are well-documented. People with mental illness often internalize society’s beliefs about them- that they are incompetent, irrational and untrustworthy-and that can lead to distress that’s sometimes worse than the mental illness itself” (as cited in Dingfelder, 2009 p. 65).
Interventions:
1. Mobilize community resources to provide a support system for client to reduce the vulnerability to stress while client is a part of the community.
Being involved in community groups will help the client to understand her illness and build confidence. 2. Encourage verbalization of fear and anxiety and provide feedback while client is under my care.
Verbalization of fears and anxiety helps the patient to confront her feelings so that she may better understand them. 3. Assist client to identify stressors and ways to cope with them in the future.
Identifying stressors will help to prevent relapse.

Outcome: Client will experience a reduction in fear and anxiety as evidenced by normal perceptual ability and interaction with others while living in the community.

The third nursing diagnoses, Ineffective management of therapeutic regimen related to the lack of understanding of the implications of not following the prescribed treatment plan, addresses the continued level of support that this client will still need when she returns to the community. Continuity of care is an important factor in this client’s wellness plan because the schizophrenic patient cannot fully comprehend her illness. Bustillo et al. (2001) speaks of the importance of a strong support system for the schizophrenic patient to improve: “Assertive community training programs ought to be offered to patients with frequent relapses and hospitalizations, especially if they have limited family support. Patients with schizophrenia can clearly improve their social competence with social skills training which may translate into a more adaptive functioning in the community” (para. 4). 1. Refer client to a behavioral therapist who has experience dealing with schizophrenic patients. Cognitive behavioral therapy will help the patient to develop social skills and prevent a relapse. 2. Implement measures to promote effective management of the therapeutic regimen: Encourage the patient to take part in community programs every week that assist with stress reduction and encourage socialization. Lowering stress and participating in 3. Develop a contract with the client to maintain motivation for changes in behavior.
Developing a contract is a way to keep track of progress. 4. Continue teaching the concept that mental illness happens on a continuum and that with adherence to prescribed regimes, the patient will progress on the continuum towards a more healthy life, and reinforce the teaching until the patient is capable of total self- care with little chance of relapse. The concept that mental illness is part of a continuum will help the patient understand that she is not alone, and that recovery is possible.
Outcome: The client will demonstrate the probability of effective management of the therapeutic regimen as evidenced by: 1. Willingness to learn about and participate in treatment plan and care. 2. Statements reflecting ways to modify personal habits and integrate treatments into lifestyle. 3. Statements reflecting an understanding of the implications of not following the prescribed treatment plan. In addition to these diagnoses, it is important to avoid confronting the person on the use of denial and provide positive reinforcement for any expressions of insight.
Conclusion
With proper treatment, the schizophrenic patient can control symptoms, prevent relapse and live an independent life. It is possible that the fear and stigma that is attached to the diagnosis of schizophrenia can affect the patient more than the illness itself, especially during remission. Helping the patient to understand the health-illness continuum and identify stressors will help him to understand how to deal with his illness. There are many mentally ill people who do not receive treatment and end up living on the outskirts of society. Promoting inclusion and understanding, as well as community support systems will help these people to heal.

References
Saedisommeolia, A., Dialali, M., Moghadam, A., Ramezankhani,O., Najmi,L. (2011) Folate and Vitamin B12 Status in Schizophrenic Patients. Journal of Research in Medical Sciences .16(Suppl): s37-s441. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3252772/

Bustillo, J., Lauriello, J., Horan, W., Keith, S. (2001). The Psychosocial Treatment of Schizophrenia: An Update. The American Journal of Psychiatry, 2001, 158(2): 163-175. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11156795
Carpenito-Moyet, L. (2004). Handbook of Nursing Diagnosis. Philadelphia: Lippincott, Williams, and Wilkins.
Corrigan, P. (2005). On the Stigma of Mental Illness: Practical Strategies for Research and Social Change. American Psychological Association, xv 343 doi: 10.1037/10887-000 .
Dingfelder, S. (2009). Stigma: Alive and Well. Monitor on Psychology, 40, 56. Retrieved from http://www.apa.org/monitor/2009/06/stigma.aspx
National Institute of Mental Health. (n.d.). What is schizophrenia? Retrieved from http://www.nimh.nih.gov/health/publications/schizophrenia/index.shtml

[Title Here, up to 12 Words, on One to Two Lines]