Nursing Case Study: Patient with Drug and Alcohol Induced Paranoid Schizophrenia

This essay will focus on a patient encountered while on placement. The patient was 64-year-old male named Jim who was diagnosed with drug and alcohol induced paranoid schizophrenia thirty years previously.

Jim is an excessive smoker of cigarettes. This has resulted in Jim having a diagnosis of Chronic Obstructive Pulmonary Disorder (COPD) and this presented as being Jim’s main nursing problem because without treatment symptoms can deteriorate quickly and become life threatening. (Brooker et al 2013) Jim is presenting with breathlessness, a chesty cough and ongoing wheezing. The main nursing problem therefore involved interventions being put in place to ensure Jim’s breathing problems were stabilised and that his safety was ensured. The secondary nursing problem that was evident when caring for Jim related to his dysphagia which caused Jim significant difficulties with swallowing certain foods.

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The rationale for the choice of this patient was made due to the extent and range of Jim’s support needs. It also gave the nurse the chance to research Chronic Obstructive Pulmonary Disorder and how this impacted on the patient and what nursing interventions were used to ensure high quality care. The additional care needs related to dysphagia provided the opportunity for the nurse to gain insight into specific nursing interventions that were used. A further rationale is that both nursing problems impacted significantly on Jim’s quality of day to day life. Jim’s nursing problems will therefore be based on the FOCs focusing on Jim’s breathing problems FOC 7 and 3, and Jim’s eating and drinking issues (FOC 9)

These symptoms clearly link to the Fundamentals of Care (FOC) that were introduced by the Welsh Assembly Government. (WAG 2003). The FOC consist of 12 principles which are as follows:  1) Communication and information, 2), respecting people, 3). Ensuring safety, 4) Promoting independence, 5).Relationships,  6) Rest and sleep, 7) Ensuring comfort, alleviating pain, 8) Personal hygiene, appearance and foot care, 9) Eating and drinking, 10) Oral health and hygiene, 11) Toilet needs, 12) Preventing pressure sores.

These principles were introduced across Wales to ensure equality of provision and to provided patients in different settings with information about the quality of care which they could expect to receive. (WAG 2003)

The FOC will be used in conjunction with the nursing process.  The nursing process has been introduced as a system that consists of 4 key stages assessment, planning, implementation and evaluation. (Hamilton and Price 2013).  The purpose of this framework is to ensure that patients receive the highest quality of care at all times, and that this is evaluated.  Kozier et al (2012) state  that the use of the nursing process is the  most effective way for identifying the needs of patients, which will then enable nurses to recommend the most appropriate nursing interventions.  The nursing process is of paramount importance in keeping patients safe and can be used to ensure patients receive the best quality nursing care. (Alfaro- Le Fevre 2006). Furthermore, Howatson-Jones, Standing & Roberts (2015) claim that critical thinking is central to the nursing process in order for care and treatment plans to be put in place and reviewed.  This continual process of evaluation will allow nurses to improve the quality of care they give and also learn from reflective practice.

This assignment will therefore apply both the nursing process and FOC to Jim’s condition focusing mainly on the main and secondary nursing problem. The main focus will be on the assessment and implementation stages of the nursing interventions that were used.   The assessment tools will include Care and Treatment Plans, Medication plans, risk assessments, news charts etc. These frameworks will enable a more comprehensive assessment of patient outcomes and will also allow any risks to be highlighted when using the nursing process.

In accordance with the Nursing and Midwifery Council (NMC 2018) to maintain confidentiality all names used within this essay will be pseudonyms and locations have been changed.

PEN PICTURE

Jim is a 64 year old patient with a diagnosis of schizophrenia. He has resided in a nursing home for seven years and has been diagnosed with Chronic Obstructive Pulmonary Disorder and has dysphagia. Jim also has difficulties communicating. He has a history of alcohol and drug abuse, and also smoking which have contributed to his condition. Jim also has a soft diet in place due to difficulties with swallowing. Jim receives few visitors and has no meaningful contact with his family. His condition significantly impacted on the quality of his day to day life, which is linked to the Fundamentals of Care FOC 3, 7 and 10. (WAG) (2003)

Assessment stage of nursing process.

The first stage in the nursing process is assessment. During this stage it is essential to gather information from the perspective of the patient and any other previous support plans, For example in the case of Jim, he already a risk assessment and also care and treatment plan for when he was experiencing difficulties associated with his Chronic Obstructive Pulmonary Disorder This plan outlined the nursing interventions that were recommended to be used in order to safeguard the wellbeing of Jim in regards to his breathing problems These assessment tools are vital to ensure that Jim had access to effective and safe care ( Barret et al 2012)

Pathophysiology of COPD

Chronic obstructive pulmonary disease (COPD) is a condition that causes serious breathing difficulties that is related to lung function. (Dougherty and Lister 2015)  Symptoms include coughing and wheezing due to damage to the lining of the lungs. Smoking increases the risk of contracting COPD and is responsible for it in 90% of cases. (www.nhsdirect.wales.nhs.uk )

The News chart is an important tool used within the assessment stage of the nursing process and is used to identify acutely ill patients. The National Early Warning Score (NEWS) is a tool developed by the Royal college of Physicians. The purpose of the tool is to provide a standardised system to monitor early warning signs of acute illness and has been introduced across the NHS to help nurses to quickly identify a deteriorating patient/ condition. This was intended to improve patient safety and standards of care by allowing nursing interventions to be tailored to the specific needs of the patient (Hughes 2013). It will provide the nurse with up to date information on respiration rate, oxygen saturation rates, and systolic blood pressure, pulse rate, level of consciousness and temperature. (Kelly 2018) The NEWS chart is an essential part of patient assessment as it provides an indication of the degree of care that is required, it also monitors any deterioration and improvements with the patient’s symptoms. (Abbott et al 2015). Furthermore, the NEWS chart enables the nurse to identify the level of risk to the patient through numeric assessment. (0-2 no risk, 3-5 threat of acute illness, 6-8 likely to deteriorate quickly, 9 the patient has an immediate life threatening condition) http://www.1000livesplus.wales.nhs.uk

In the case of Jim the News chart indicated the following that his respiratory rate was 22 beats per minute which scored 2 points on the NEWS chart. Jim’s temperature was 37 degrees which scored zero points as this is within the normal parameters. Jim’s pulse rate was recorded as being 43 beats per minute which scores one point on NEWS chart, Jim’s systolic blood pressure was assessed as being 111 which again scored one point on the NEWS chart. Jim AVPU score was zero as Jim was fully alert and responsive during observations of the nurse. Therefore, in this instance, the overall score documented within the NEWS chart was 6 indicating that he was likely to deteriorate quickly.

Pathophysiology of related dysphagia

Every patient within the NHS has a legal right to have a care and treatment plan. The care and treatment plans are an individualised plan to provide holistic care. (Barret et al 2012) It is formulated by a multidisciplinary team and includes nurses, social workers, patient and can also include the patient’s family.  It is particularly important where possible to involve the patient involving their health in line with FOC principles as this ensures that the patient is treated with dignity, respect, it promotes inclusion which enhances independence ( FOC 1,2,4) Jim’s care and treatment plan stated that his main care needs were breathing (due to his COPD) and dietary. The care and treatment plan indicated that Jim had been diagnosed with dysphagia. Dysphagia is a condition which affects a patient’s ability to swallow. (Dougherty and Lister 2015) This condition is often linked to COPD and can affect the mouth, throat and oesophagus. Dougherty, L., Lister, S., & West-Oram, A. (2015). However, in the case of Jim it was limited to his throat meaning he was at high risk of choking.  (FOC 3, 7, 9)  Jim had been assessed on the malnutrition universal screening tool (MUST) which indicated that he was at serious risk of malnutrition due to scoring 2 which indicated a weight loss  and that there were risks to his health unless support was planned and implemented.  (Scott 2008)

Planning stage of nursing process

The second stage in the nursing process is the planning of nursing care. This uses a problem-solving cycle to meet the patients’ needs in a person centred manner.  (Hall & Ritchie 2013, p 87).  Ballantyne (2016) stresses that this stage is vital in allowing nurses to plan care interventions and affords them the chance to discuss these with the patients. This planning often relies on the care and treatment plan which allows the nurse to provide holistic care and to discuss the ongoing treatments with the patient, their family, and the multidisciplinary team.

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In the case of Jim, the nurse had spent considerable time establishing a therapeutic relationship. This was important as it enabled the nurse to communicate effectively with Jim regarding his condition which is essential within the assessment stage of the nursing process as it allows the nurse the chance to assess and react to patients’ physical, social and psychological needs, which ensures that the needs of patients are prioritised as outlined by the Nursing and Midwifery Council (NMC).  (Feo et al 2014) Furthermore, a good therapeutic relationship will allow the patient to develop trust and will result in the patient being more likely to open up about their support needs. This will enable the nurse to better understand the patient and also to implement effective nursing interventions more quickly to improve patient outcomes. (Kourkouta, L., & Papathanasiou 2014). A therapeutic relationship was essential to promote patient autonomy and independence and ensure respect at all times during care and treatment. (NMC 2018)  This also ensures that patient’s needs are individualised, it also promotes professionalism and trust and ensures that information can be recorded in detail so that safe interventions can be offered. (NMC 2018)

Mansel and Bradley-Adams (2017) support the mnemonic The Mental State examination (MSE ‘I AM A STAR’.) They stress that this method is an excellent and effective tool that can be used when assessing the holistic needs of patients. The MSE can be used by the nurse to present an overall assessment relating to the patient’s current presentation, which will allow the nurse the opportunity pass on information where appropriate if any concerns arise and commence a risk assessment if necessary.

The two main risks related to Jim’s condition are his COPD and his dysphagia as these are both potentially life threatening conditions, it is therefore essential that these are prioritised within the planning stage of the nursing process. (FOC 3) Risk assessments were therefore necessary with regards to both his breathing and eating and drinking and risk of choking due to swallowing difficulties. This process of assessing immediate risks is vital to ensure a patient safety. Dougherty, Lister and West-Oram (2015) it was important for Jim that risk assessment was part of his care and treatment as he was susceptible to infection based on finding on the NEWS chart. . It was also important because it was deemed that Jim was a deteriorating patient (NEWS chart) and therefore he required control measures such as inhaler to improve his breathing.

Regarding his COPD the nurse will need to be aware of the risks of infection, heart problems, collapsed lung (Pneumothorax) and rapid deterioration Dougherty and Lister (2015). The main risk associated with his dysphagia is choking and putting interventions in place to ensure that he has enough nutrients within his diet as recommended within his care and treatment plan.

Implementation stage of nursing process

The third stage of the nursing process involves the nurse putting into action the care and treatment plans and recommended interventions that have been formulated within these plans. (Hall and Ritchie 2013)  Peate and Wild (2018) suggest that it is important at this stage to ensure that the patient is involved in their treatment so that they feel they have some control and are autonomous regarding their health and wellbeing.  This will impact positively on patient outcomes because it will result in the patent feeling more respected and promotes independence as indicated in the principles of FOC 1, 2, 4)( Barrett et al 2012). Displaying positive body language was very important as this encouraged Jim to engage and reassured him that the Nurse was there to help. It was important to show patience and compassion especially when he was experiencing symptoms relating to his mental health that hindered his ability to rationalise, and communicate effectively.  Related to FOC 1. (McCabe & Timmins 2013). Maintaining this relationship whilst focusing on the main nursing problems was important as it enabled the nurse to assess Jim’s support needs  better and gain a better understanding of Jim’s needs in order to provide person centred care in a holistic way. (Koizer 2008).

Jim’ care and treatment plan advised that in order to treat him effectively he required medication. Including inhalers, the nurse will therefore need to work with Jim on the use of these devices to ensure safety and effectiveness of treatment.  The nurse will also need to liaise with Occupational health with regards to breathing exercises and techniques that can clear the airways and ensure that Jim practices these where required to improve his breathing if required. Lister, S., & Dougherty, L. (2015) Additionally, because he is deteriorating the Doctors have prescribed Jim with Theophylline tablets. These tablets will also require regular blood test to monitor the volume of medication within bloodstream. It will be essential to closely monitor Jim to observe for possible side effects, which could include insomnia and or irregular heartbeats which may require additional nursing interventions. (Jilani & Sharma 2018) Based on Jim’s COPD the nurse will need to ensure that Jim has enough fluid intake as dehydration can lead to a decrease in blood pressure and an increase in heart rate which could lead to organ failure. (Sumnall 2007) It was therefore important to commence a fluid balance chart immediately and monitor the colour of his urine because monitoring urine output is an indicator of infection and can be used to measure whether Jim was having sufficient fluids. (Lupi 2018). Furthermore, the observations needed to be increased and the nurse in charge needs to be informed of any changes in heart rate, respiratory rate, systolic blood pressure, level of consciousness, oxygen saturation, temperature, which could be triggers to potential sepsis and other critical health conditions.

The care and treatment and risk assessment plans therefore advised that Jim should be given feeding and drinking aids to ensure his safety. It was also advised that Jim’s food and fluid consumption should be recorded due to the risk of malnutrition. It was also pinpointed within the care and treatment plan that treating Jim’s dysphagia was essential to reduce the risk of him aspirating and to ensure that he had focused support to maintain a high level of nutrition safely. (Potter and Perry 2016) As Jim had serious problems linked to his dysphagia such as difficulties swallowing, chewing foods, it was strongly recommended that his diet was modified to reduce the risk of choking, this involved a recommendation that Jim was to only be fed in an upright position. Furthermore, Jim’s care plan clearly specified that Jim was to only be given a soft diet. This was to ensure Jim’s safety in eating and drinking.  (FOC 3 and 9.)  The nurse’s role will therefore involve supervising his eating ensuring that he is fed in an upright position and liaising with the cook and dieticians to make sure he has a nutritional diet that is safe to eat according to the recommendations of the dietician. One advantage of this was that the dietician had extensive knowledge and skills that could be used to ensure that Jim’s nutritional needs were met. For example, one of the side effects of some medication is a loss of appetite, this was observed in the case of Jim,  the nurse recommend a medication review and the dietician was liaised with who then  modified  Jim’s diet to ensure he had sufficient nutrients after  (Leaker 2013). This ensured Jim was safeguarded from risks of malnutrition as much as possible.

It will be important for the nurse to put in place fluid and food charts to record fluid and nutritional intake. In this instance, the all wales food chart was used. This food chart is essential so that all nursing staff are aware of the needs and potential risks of the patient and so that patients can monitor quickly any deterioration with the patient such as unexpected weight loss.  (Leaker 2013). The nurse must communicate with dieticians when required to ensure the patient’s diet incorporates enough protein and micronutrients, as this would more likely result in pressure ulcers not forming which would ensure that the nurse can adhere to (FOC 12). Furthermore, ensuring enough micronutrients are available within a diet would also improve the chances of a wound healing. (Leaker 2013)

The nurse will need to employ initially feeding aids such as cutlery and nosey cups. It will be important to ensure that food and drinks are not left for too long as thickener that is used within drinks will become adversely affected. It will also help if the Jim is fed when he is not tired and that he is not distracted while eating as his poses a further risk of choking. The dietician had advised three particular nutritional drinks for Jim that were chosen by Jim. These drinks were chosen to avoid potential calorie deficit.   (Schneyder, 2014), recommends that nutritional drinks are a useful part of managing nutrition in older patient’s because it safeguards them from malnutrition. On issue hat confronted the nurse was the fact that some of the meals appeared unappetising which   meant that Jim was reluctant to eat them. This required the nurse to encourage Jim which was often time consuming but was essential to his recovery and wellbeing.

Evaluation stage of nursing process

The fourth stage of the nursing process is evaluation. At this stage the nurse has to evaluate whether the care and treatment plans have been effective in meeting the needs of the patient. (Hamilton and Price 2013).  This process of evaluation needs to be ongoing as the patient’s condition and needs can change day to day and is important that the nurse bases the care on the nursing process and fundamental of care. Hall and Richie (2013). As Jim was a patient encountered on placement it was impossible to evaluate the effectiveness of interventions. However, if Jim improved significantly it would be important for the nursing staff to address lifestyle changes such as stopping smoking, breathing techniques, eating healthier diet and exercising. It would be important at this stage to involve the multi-disciplinary team and continue to adhere to and update risk assessments and care and treatment plans.

Conclusion

In conclusion, this essay has enabled the student nurse to gain considerable insight into two common medical conditions.  The primary condition was COPD and frequently related to this condition is dysphagia. It was interesting that both the main condition and the secondary condition were potentially life threatening unless interventions were put in place to address the adverse effects of both conditions.  The nursing process became essential in implementing a person centred and systematic approach to planning Jim’s care and implementing nursing interventions. The NMC (2018) support that the nursing process this is an important facet of nursing care.  It provided the cornerstone to provide safe and effective care to serious medical conditions.   Hall and Ritchie (2013), Hall and Ritchie further state that this process ensures high standards of patient care when applied appropriately.

The importance of the assessment stage became apparent when caring for Jim in order to gather information so that a care and treatment plan could be drawn up which was essential for the planning and implementation stages of nursing process. It also enabled a plan which included the fundamentals of care to provide holistic care for Jim. (WAG 2003) A holistic nursing process is essential to make sure the needs of patients are met in the best way possible, as assessments involving a multi-disciplinary team approach are intended to ensure that all areas of a patient’s care are explored in detail to result in better health outcomes for the patients. (NMC 2018) This was particularly important for Jim as he had two potentially life threatening conditions and there was an overlap in his care. FOR example fluid intake monitoring was essential for both COPD and eating and drinking issues. Although not the main focus of this essay the fundamentals of care became important in the treatment of his underlying condition of schizophrenia.

This emphasises the importance of the fundamentals of care and of taking a more holistic approach rather treating conditions in isolation. This case study has also highlighted the importance of the assessment tools and the necessity for nurses to gain information about their use. In Jim’s case one essential tool was the care and treatment plan which is an ongoing framework that used to meet the varied support needs of Jim. From the nurse’s perspective it is an essential guide for daily nursing care.  Additional tools included fluid and food intake charts, risk assessments, medications, multi-disciplinary input, it was interesting to use Jim as a case study as it was insightful to learn about the range of nursing tools involved when caring for a critically ill patient.

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