Case Study 1

In the process of being updated...

Phyllis M. Connolly PhD, RN, CS, Professor
School of Nursing, College of Applied Sciences and Arts
San Jose State University, San Jose, CA 95192-0057

INFORMATION OBTAINED DURING A VISIT/ENCOUNTER:

The psychiatric home care nurse is visiting a 62 year old female, African American. She was diagnosed with Schizophrenia, chronic undifferentiated; and is also receiving care for a chronic respiratory disease and cardiovascular disease.

She has been living in a licensed board and care facility for the past two years in an urban area. The Administrator is concerned because the resident has been given a warning and faces a possible eviction because of her decreasing personal hygiene.

The Administrator tells the nurse that he is concerned that her psychiatric medications are not controlling her symptoms. The nurse is taken to the resident’s room and the resident agrees to talk to the nurse.

The resident’s clothes are wrinkled, and soiled with food, her hair is matted, finger nails long and dirty and the room is cluttered with piles of dirty clothing, plastic bags, and broken pocket books. The resident is looking through her bags as if she was searching for something.

She moved about the room frequently, picking things up then looking distracted and moving to the next item. She frequently stopped and argued with herself. Her mood shifted rapidly during the visit. The resident asks the nurse "Are you my new conservator? You look like one, they are all after my money, and they try to keep me from my family, as soon as my boyfriend gets a new job, we are going to get out of this place. They want to throw me out anyway."

The nurse explains who she is and asks permission to talk with the resident. The nurse notices pictures on a cluttered dresser and asks the resident about the people, the resident stops and tells her they are her grandchildren, that they don't live near by so she doesn't get to see them very often, sometimes she got to play with them and she really misses them.

The nurse asks if she knows why she has come to see her.  The resident says no but since she has not been able to take a shower because people are always in the bathroom that she suspects that the other residents are complaining about her. "You know it's one of the rules and they said they could even throw me out,...but it's not my fault."

The nurse validates her understanding that her personal hygiene does seem to have become a problem and is there any way she the nurse might help her with that problem. The resident says that she tries to take a shower but she has a hard time concentrating on getting everything together for the shower and that sometimes the voices start shouting at her when she is in the shower.  "I'm not sure when I showered last."

She also reported that a new resident keeps banging on the bathroom door and demanding that she get out. The nurse asks if the resident would be willing to take a shower with the help of the mental health worker who could help her assemble what she needed and keep the other resident from interrupting her during the shower.  She agreed she would try.

The nurse asks if the resident could use some help with her laundry. The resident responds that if she could just remember what she needed to do each time and where she left the soap and which clothes should be washed together that she could probably do that herself.

During the visit the resident began to cry and said, "I used to have a beautiful little apartment and everything was clean and very neat before I got sick, my grandchildren could visit me then." The nurse asks the resident if she knows what types of medications she is taking and if she thinks they are working for her.

The resident is able to name each of her medications and adds that sometimes the doctor has to change them, " they keep telling me not to drink so much coffee and coke and to stop smoking-something about the medications"

The nurse asks if she has ever tried decaffeinated coffee and cokes, the resident says "no." The nurse asks if she could come back and visit again in a few days and if it would be all right to talk with the Administrator to get some help for her with her shower, and her laundry, and to see if decaffeinated coffee and coke are available, as well as making an appointment to have her medications evaluated, the resident agrees.

APPLICATION OF THE OMAHA SYSTEM

PROBLEM CLASSIFICATION SCHEME

Domain II. Psychosocial

Problem #12: Emotional Stability.

Modifiers:
Individual
Impairment

Signs & Symptoms:
03. loss of interest/involvement in activities/self-care
04. narrowed perceptual focus
05. scattering of attention
07. irritable/agitated
08. purposeless activity

PROBLEM RATING SCALE FOR OUTCOMES

Knowledge:  2 minimal knowledge (persistent hallucinations and delusions interfere with reality)
Behavior:  2 rarely appropriate (willing to talk with nurse about her situation)
Status: 2 severe signs and symptoms (pacing, unable to complete ADLs)

INTERVENTION SCHEME:

Category I: Health Care Teaching/Guidance/Counseling

Targets and Client specific information/details:

28. Interaction, (Began to establish a therapeutic relationship)

37. Nutrition (Discussed caffeine intake which interferes with effectiveness of psychotropic medication with Board and Care Administrator)

Category III.Case Management

12. Day Care/respite (Discussed with Care Administrator to need to make an appointment with physician for primary health care including medications evaluation)

Category IV. Surveillance

49. Signs/symptoms—mental/emotional: (Observed and monitored moods shifts, hallucinations, and delusions)

PROBLEM CLASSIFICATION SCHEME

Domain IV, Health Related Behaviors

Problem #38, Personal Hygiene

Modifiers:
Individual
Impairment

Signs & Symptoms:
01. inadequate laundering of clothing
02. inadequate bathing
03. body odor
04. inadequate shampooing/combing of hair
inadequate bushing/flossing/mouth care

PROBLEM RATING SCALE FOR OUTCOMES

Knowledge: 2 Minimal knowledge ("I know I need to shower, but it's not my fault")
Behavior: 1 Not appropriate: ("I don't know when I showered last")
Status: 1 Extreme signs/symptoms: (body and clothing unclean)

INTERVENTION SCHEME:

Category III. Case Management

41. Personal care (Contacted mental health worker in board and care to assist client with shower and laundering)