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Chart Data: In-Patient Psychosocial Rehabilitation Unit Client

Chart Data: In-Patient Psychosocial Rehabilitation Unit
Client: Marie Perault
Date of Admission: 21 days ago
Reason for Admission: Paranoid delusions, risk of harm to others related to schizophrenia
Case Manager: David Shaw MRP: Dr. Taylor, Psychiatrist
Surrogate Decision-Maker: None
Age: 53 years old Sex: Female Gender: Female
Race: White Culture: French, Acadian
Social History:
Social Network: Lives alone, estranged from 2 adult sons, few acquaintances at
Community Clubhouse
Education: University, Teaching Certificate
Employment: Previously employed as a high school science & mathematics teacher,
currently unemployed receiving social assistance for disability
Income: < $25,000 per year
Housing: Subsidized housing, urban apartment
Transportation: Walks, bikes, public transportation, driver’s license revoked
Food Security: Meals on Wheels x 3 times per week, accesses food bank 1-2x per month
Medical History:
– Schizophrenia diagnosed at 29 years old
– Hospitalizations x 12 occasions related to uncontrolled behaviours, disturbed thoughts
– Positive symptoms: paranoid delusions, auditory hallucinations, agitation
– Negative symptoms: avolition, social withdrawal, poverty of speech
Prior Treatment Plan:
– Case Manager appointment for monitoring 1x per month @ out-patient clinic
– Psychiatrist appointment for monitoring 1x every 3 months
– Community Clubhouse Program, community meeting 1-2x per week
– Olanzepine 5mg BID PO, Benztropine 1-2mg TID PO


Current Admission: Mental Health Assessment
– paranoid delusions (neighbour spying on her)
– auditory hallucinations (voices stating her sons are in danger)
– disorganized behaviour (threats to others)
– sleep/wake disturbance (insomnia)
– agitated, difficulty sitting still
– difficulty concentrating
– difficulty retaining information
Nursing Diagnoses:
1) *Disturbed thinking related to uncompensated alterations in brain activity as evidenced
by auditory hallucinations and delusions that neighbours are tampering with her
2) Self-care challenges related to inability to make thoughtful judgments as evidenced by
MP does not remember when she last took her medications
2) Anxiety related to delusional ideas as evidenced by patient expressing they are unsafe.
Discharge Plan:
– Discharge home in 7-14 days
– Community Clubhouse Program 5 days per week x 2 weeks, reassess prior to tapering to
3 days per week
– Follow-up appt with Dr. Taylor in community within 7 days of discharge
– Follow-up appt with Case Manager on day 2 of discharge
– Case Manager to be alerted if patient does not attend Clubhouse x 1 day
– F.U with community mental health nurse in 28 days
– Olanzepine 5mg PO BID
– Benztropin Mesylate (Congentin) 1-2mg TID PRN (max 6mg per day)
– Lorazepam 1-2mg PO TID PRN (max 6mg per day)
– Invega Sustenna 78mg IM Injection Q28D

Discharge Teaching Plan questions;
Purpose: Why  providing the teaching
Goal: Broad overall goal for teaching
Client’s Developmental Stage/Characteristics: State the client’s developmental
stage (i.e., age, adult/child) and characteristics that may influence their learning.
Create 3 learning outcomes: *Must have 1 for cognitive, behavioural &

Content Outline: headings of the topics covered
(e.g., medication action, schedule).
Methods of Instruction: activities use d for teaching
Methods of Evaluation: Ways you will assess if the client has achieved the
learning outcomes
Select teaching methods/interventions based on evidence for effectiveness

Teaching Method/Intervention Summary:
  summarize and explanation for one teaching method
used in discharge teaching plan with references to support this choice