Graham Uy

Instructor Rodney
Aquino
Kapi olani
Community
College
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Capstone
Presentation
NURSING 360 PSYCHIATRIC MENTAL HEALTH KAHI
MOHALA ROTATION

Assessment Data

Patient information:
Age: 49 y/o

Gender: male

Ethnicity: Asian; native to Vietnam

Current Legal Status: 704-411 (1)(a)

(Acquit and commit)

Language preference: English*

Admission date: 11/25/15

Spiritual: Buddhist

Expected LOS: 2-3 mo

Marital status: single

Reason: Transferred from

OCCCHSH(10/26/15)Kahi
Mohala as 704-406 unfit to proceed

Occupation: unemployed
Living condition: homeless
Primary insurance: DOH Adult Mental
Health
Secondary insurance: Aloha Care Quest

Legal charges: sitting/lying on

sidewalk; criminal littering;
urinating/defecating in public;
situation of a shopping cart;
*Assault in the 3rd degree

DSM-V Diagnosis: Schizophrenia Spectrum

Disorder
DSM-V Diagnostic Criteria
A. Two or more:
1.

Delusions

2.

Hallucinations

3.

Disorganized speech

4.

Grossly disorganized or catatonic behavior

5.

Negative symptoms (i.e., diminished emotional

expression or avolition)

B. Level of functioning in one or more major areas is

markedly below the level achieved prior to the onset
C. Disturbances persist 6 mo period in which 1 mo
of Criterion A symptoms occurs

Patients Presenting Symptoms

(approx. 10-12 year history)
Positive symptoms:

+AH +VH.

Delusional thought content

Aggression**

Negative symptoms:
Diminished emotional expression

D. Schizoaffective d/o, depressive and Bipolar d/o with

psychotic features have been ruled out

Avolition (dec motivation for self-initiated

purposeful activities)

E. Disturbances not attributable to substances

Alogia (dec speech output)

F.

Anhedonia (dec ability to experience

pleasure)

If there is a history of autism spectrum disorder or

other communication disorder of childhood onset,
the additional diagnosis of schizophrenia is made
only if prominent delusions or hallucinations are also
present for at least 1 month (or less if successfully
treated)

Asociality

DSM IV-TR Diagnosis and Additional Health

Concerns
Axis I: Schizophrenia, Paranoid Type
Axis II: Deferred
**Axis III: Diabetes Mellitus Type II; Rash on face and scalp;
history of heart murmur
Axis IV: Stressors have been lack of social support,
homelessness, and legal issues
Axis V: Current GAF = 40. Highest in past year: 45

Hospital Treatment Plan and Discharge

Disposition
Treatment Plan
1. Stabilize psychiatric
symptoms
2. Legal fitness
3. Psychosocial Rehabilitation

Current Discharge Plan

Safe for lower level care;
Suitable for group home

Discharge Needs
Stable housing
Benefits

Patients own discharge criteria:

Clothing/housing/benefits

Resources and Support

Case manager
Community Mental Health Center such
as the Kalihi-Palama Health Center
(instant access to behavioral health
services)
Crisis Line: (808) 832-3100
SNAP: food stamps

Pharmacotherapy
Scheduled Meds

PRN meds
1. ibuprophen: Pain
2. Tylenol: Fever

1. Risperidone (ATAP)

3. Mag/Alum/Simethicone:
dyspepsia

2. Benztropine (Anti-Ach)
3. Sertraline hydrochloride (SSRi)
4. Metformin ER (Antidiabetic)

4. Sennosides: constipation
5. Epipen: anaphylactic reaction

5. Pravastatin (antilipemic)
6. Metamucil (bulk lax)
7. Lactulose (lax)

**No known drug allergies

Mental Status Examination

49 y/o Asian male. Well developed and appears older than
stated age. Patient neatly dressed in own clothing with no foul
body odors noted. Patient approachable and cooperative. Able
to maintain good eye contact. Speech clear, coherent, and nonpressured. Mild thought blocking. Patient presents with
constricted affect. His mood he describes as lazy. Alert and
oriented x 3 person, place , time. Positive AH and VH. Poor
remote memory. Working memory intact AEB 3 word recall.
Paucity of understanding of reasons for current hospitalization.
Patient unable to provide meaningful description of his
illnesses. He states, I have mental illness; they [doctors] told
me I have.

Diagnostic Laboratory Data

History of Ordered Labs

Abnormal Values

BMP:
Basic Metabolic Panel

BUN: 23 H

Liver Function Tests

Gluc: 146 H

Lipid Panel
Urine Specimen

LFTs:
Total Bili: 1.5 H

HbA1c: 7.6 H

Strengths, Limitations, and Developmental

Considerations
Strengths
Patient is compliant with
medication therapies (Feel more
rested.)
Able to recognize his perceptual
disturbances as abnormal
(describes his auditory
hallucinations as opposite from
reality)
Limitations
Does not appear to have the
requisite skills that would allow him
to make and maintain meaningful
employment or to establish lengthy
interpersonal relations

Content at Kahi Mohala (Nurses and

doctors here.)

Maslows Hierarchy of Needs

1.
2.
3.
4.
5.

Physiologic needs
Safety needs
Love and belonging
Esteem
Self-actualization (highest
potential)

Erikson (Psychosocial)
.
.

.
.

failure to resolve several

psychosocial conflicts:
*As far back as adolescent
Identity vs role confusion: Unable
to identify appropriate roles in
life
Intimacy vs Isolation: no close
friendships or history of spouse
or offspring
Generativity vs Stagnation:
trivialization of ones activities

Nursing Process
PLANNING, IMPLEMENTATION, AND EVALUATION

Highest Priorities
1. Safety: Assaultive and
aggressive behaviors

*Safety is always the top

priority!

2. Psychosocial Stressors:
a) Housing
b) Primary supports
c) Legal issues

3. Psychiatric: Disturbances
in thought content and
sensory perception

Failure to address
psychosocial stressors will
hinder expected patient
outcomes, and would
increase the likelihood for
readmission

Care Plan
1. Risk for self- and other-directed violence related to poor selfesteem, history of aggressive behaviors, and hallucinations telling
him to attack the Japanese military.
Short term goal: Patient will demonstrate an absence of suicidal
behaviors or violent behaviors toward others during my 8 hour shift.
Long term goal: Patient will demonstrate an absence of suicidal
behaviors or violent behaviors toward others within a six-month
duration following discharge.
Interventions: Continuously monitor for safety. Use distractions and
redirection. Minimize environmental stimuli. Keep all appointments
with patient.

Care Plan
2. Social isolation related to alterations in mental status (Schizophrenia)
and inability to engage in satisfying interpersonal relationships (avoids
social situations) as evidenced by persistent physical isolation to room for
many hours during the day, and self-isolation when in the milieu.
Short term goal: On my shift, patient will socialize with writer and
participate in one daily community discussion.
Long term goal: Upon day of discharge, patient will have demonstrated
ability to initiate socialization with peers and staff and participate in all
groups.
Interventions: Role model positive social behaviors in interactions.
Engage in non challenging interactions. Accompany patient to group
activities

Care Plan
3. Disturbed sensory perception and thought processes related to biochemical
imbalance resulting from mental illness (Schizophrenia Spectrum Disorder) as
evidenced by hallucinations telling him to attack the Japanese army, visual
hallucinations of black shadows, and grandiose delusions of working for the White
House and Swiss government.
Short term goal: On my 8 hr shift, the patient will demonstrate reality-based thinking
and behaviors.
Long term goal: At the first follow up appointment subsequent to discharge, the
patient will verbalize a significant reduction in hallucinations and delusions for a period
of at least 6 months.

Interventions: Attempt to determine factors that worsen hallucinatory experiences

Positively reinforce reality based perception

Relevance and Critical

Thinking
THE BIGGER PICTURE

So
Barriers to improvement?
Thoughts, feelings, behaviors
How will the patient improve?

Thank you