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UNIT 3 ■ Care of Patients With Psychiatric Disorders
Smoking Cessation Smoking cigarettes has long been identified as a particular health risk for clients with schizophrenia because the prevalence is three times that of the gen- eral population; it is estimated that as many as 88% of those with schizophrenia and 70% of those with bipo- lar disorder are smokers (Kranjac, 2016). Some clients report increased ability to concentrate when smoking tobacco, which has led to clinical trials of drugs that increase nicotine levels. However, to date, these drugs have not been proven to be effective. In addition to the obvious health risks of chronic lung diseases and cancers, smoking decreases the effectiveness of some
psychotropic medications. Varenicline (Chantix), a nicotine agonist used as a smoking deterrent, was once thought to increase symptoms and even suicide risk in those with serious mental illness. However, a recent meta-analysis (Wu et al., 2016) concluded that varenicline is effective for assisting with smoking ces- sation in this population and that “there was no clear evidence of neuropsychiatric or other adverse events compared with placebo” (p. 1554). In any scenario, assessing the client’s motivation to stop smoking and exploring viable treatment options, including psy- chological interventions, are important components of treatment.
CASE STUDY AND SAMPLE CARE PLAN
NURSING HISTORY AND ASSESSMENT Frank is 22 years old. He joined the Marines just out of high school at age 18 for a 3-year enlistment. His final year was spent in Afghanistan. When his 3-year enlistment was up, he returned to his hometown and married a young woman who had been a high school classmate. Frank has always been quiet and somewhat withdrawn, and he had very few friends. He was the only child of a single mom who never married, and he does not know his father. His mother was killed in an automobile accident the spring before he enlisted in the Marines. During the past year, he has become increasingly iso- lated and withdrawn. He is without regular employment but finds work as a day laborer when he can. His wife, Suzanne, works as a secretary and is the primary wage earner. Lately, Frank has become very suspicious of her and sometimes follows her to work. He also drops in on her at work and accuses her of having affairs with some of the men in the office. Last evening, when Suzanne got home from work, Frank was hiding in the closet. She didn’t know he was home. When she started to undress, he jumped out of the closet holding a large kitchen knife and threatened to kill her “for being unfaithful.” Suzanne managed to flee their home and ran to the neighbor’s house and called the police. Frank told the police that he received a message over the radio from his Marine commanding officer telling him that he couldn’t allow his wife to continue to commit adul- tery, and the only way he could stop it was to kill her. The police took Frank to the emergency department of the VA hospital, where he was admitted to the psychiatric unit. Suzanne is helping with the admission history. Suzanne tells the nurse that she has never been unfaith- ful to Frank, and she doesn’t know why he believes that she
has. Frank tells the nurse that he has been “taking orders from my commanding officer through my car radio ever since I got back from Afghanistan.” He survived a helicopter crash in Afghanistan in which all were killed except Frank and one other man. Frank says, “I have to follow my CO’s orders. God saved me to annihilate the impure.” Following an evaluation, the psychiatrist diagnoses Frank with Schizophrenia and orders olanzapine 10 mg PO to be given daily and olanzapine 10 mg IM q6h prn for agitation. NURSING DIAGNOSES AND OUTCOME IDENTIFICATION From the assessment data, the nurse develops the follow- ing nursing diagnoses for Frank: 1. Risk for self-directed or other-directed violence related to unresolved grief over loss of mother; survivor’s guilt associated with helicopter crash; command halluci- nations; and history of violence a. Short-Term Goals: • Frank will seek out staff when anxiety and agitation start to increase. • Frank will not harm self or others. b. Long-Term Goal: Frank will not harm self or others. 2. Disturbed sensory perception: Auditory related to increased anxiety and agitation, withdrawal into self, and stress of sufficient intensity to threaten an already weak ego a. Short-Term Goals: • Frank will discuss the content of the hallucinations with the nurse. • Frank will maintain anxiety at a manageable level. b. Long-Term Goal: Frank will be able to define and test reality, reducing or eliminating the occurrence of hallucinations.
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