Individual Process Recording Schizophrenia Case Study
Pedro Perez
Individual Process Recording
Date: Sep 11, 2010 Diagnosis: Schizophrenia Chronic Paranoid Client initials: A.G.
Location:
The conversation takes place in the Psychic geriatric living room in Larkin Hospital. The room is very spacious with several recliners, tables and chairs. Upon entering the room, you will find several recliner chairs up against the wall and several tables directly in front of you surrounded by chairs. There is a small is a TV to view for the patients entertainment While conducting my IPR there is twelve clients and three employees in the room. My client is at the corner of one of the tables by her self watching the TV. I walked over to my client and introduced myself, and asked permission …show more content…
to conduct my IPR.
Appearance and motor activity:
The client is a fifty six –year old Hispanic woman. She is sitting by herself in the corner of the table. She seems very anxious and nervous. She may be experiencing either visual or auditory hallucinations due to that fact the she is mumbling to herself. She is currently dressed sandals black sweat pants and white t-shirt. Her weight is 177 lbs and her height is 5’4’’. The clients overall appearance is low kept. She is not well groomed. The client has episodes where she abruptly stops mumbling and begins to stare at the TV. The client may be suffering from delusion of reference, because she states the TV commercial is trying to tell her something. The client acknowledges my presences in a friend manner and is very receptive to me, and she agrees to conduct the IPR.
Interaction:
Clients Student Comments | 1. Hello, Mrs. AG My name is Pedro Perez I am a nursing student from MDC. I will be here every SAT –SUB from 7:00 to 4:00 if you would like to talk about anything I am here to listen. | I explain to the client the process and purpose of the IPR | 2. The client acknowledges my presence and consents to participate in the IPR. | | Pt seem anxious. Her anxiety level rose once the interview began as evidence by fidgeting and her rocking in her chair. Her particular comment about a suspicious commercial is indicative symptoms of paranoid schizophrenia. Stage of development is Erikson’s Mistrust. | | 3.
I ask the patient directly about her delusions of reference and what they are trying to tell her. | The client elaborates about her delusions of reference by stating that Fidel Castro’s secrete police have been after her for years. | 4. The client states I am an anti revolutionist. I have been trying to assassinate Fidel Castro and his government agents for years. The Cuban agents have been after me for years to try and stop me. | | Pt exhibited paranoid schizophrenia ideation and delusional thoughts of refernce. This is evidence that she has impaired reality testing and thought process. | | 5. I try to re-orient the client by telling her that she is in Miami, FL at Larking hospital. | The client fails to acknowledge my statement, and continues explaining to me about the conspiracy against her. | 6. The client states, I had to leave Cuba because there were trying to kill me. The clients state they new about her plan to kill Fidel Castro. The client believe some of the staff of the hospital are involved in the conspiracy against her. | | Pt continues to elaborate on her delusion. Major defense mechanism is denialSuspiciousness- Erickson’s Mistrust. …show more content…
| | 6. I ask the patient if she is aware of her mental illness. | The client explains to me when the illness began and that she can control it. | 7. The patient states, I am tried of talking I want to go to my room. | | Patient stands from her chair and leaves. | | 7. I thank the client for her time and let her know that I will be here whenever she wants to continue talking. | |
Evaluation The patient strongly exhibits signs of paranoia and delusional thoughts of reference. She clearly is psychotic, lacks the ability to re-orient her self to reality. The patient suffers from a disturbed thought processes. It is clear to understand that these paranoid delusional thoughts of reference can interfere with her re-orientation to reality and the ability to perform her ALDs. I also think that the patient might be experiencing auditory and maybe visual hallucinations, because when I entered the room, she was was mumbling to herself. The client is a 57 y/o having difficulties with the trust vs mistrust.
The first stage of Erik Erikson's theory centers around the infant's basic needs being met by the parents. The infant depends on the parents, especially the mother, for food, sustenance, and comfort. The child's relative understanding of world and society come from the parents and their interaction with the child. If the parents expose the child to warmth, regularity, and dependable affection, the infant's view of the world will be one of trust. Should the parents fail to provide a secure environment and to meet the child's basic need a sense of mistrust will
result.
I would say base on this interaction, that the patient’s primary nursing diagnosis is alteration in reality testing related to chronic paranoid schizophrenia as evidence by delusions thoughts of reference and hallucinations. A long term goal for her would be that she would be able to function without interference of delusions and hallucination. Short term goal: The client will approach the staff when she is experiencing hallucinations or paranoia.
I now truly understand that a delusional patient REALLY believes her delusions she/he has created. There is no convincing her that his belief about being a special agent is untrue.
I believe I performed at a safe level. I may not have immediately help the patient, but I feel that I built good rapport and trust with the patient. I didn’t say anything that greatly increased the patient’s anxiety. I am now able to identify some particular S/S of PSCT clients which I was not able to.
Individual Process Recording
Date: Sep 11, 2010 Diagnosis: Schizophrenia Chronic Paranoid Client initials: A.G.
Location:
The conversation takes place in the Psychic geriatric living room in Larkin Hospital. The room is very spacious with several recliners, tables and chairs. Upon entering the room, you will find several recliner chairs up against the wall and several tables directly in front of you surrounded by chairs. There is a small is a TV to view for the patients entertainment While conducting my IPR there is twelve clients and three employees in the room. My client is at the corner of one of the tables by her self watching the TV. I walked over to my client and introduced myself, and asked permission …show more content…
to conduct my IPR.
Appearance and motor activity:
The client is a fifty six –year old Hispanic woman. She is sitting by herself in the corner of the table. She seems very anxious and nervous. She may be experiencing either visual or auditory hallucinations due to that fact the she is mumbling to herself. She is currently dressed sandals black sweat pants and white t-shirt. Her weight is 177 lbs and her height is 5’4’’. The clients overall appearance is low kept. She is not well groomed. The client has episodes where she abruptly stops mumbling and begins to stare at the TV. The client may be suffering from delusion of reference, because she states the TV commercial is trying to tell her something. The client acknowledges my presences in a friend manner and is very receptive to me, and she agrees to conduct the IPR.
Interaction:
Clients Student Comments | 1. Hello, Mrs. AG My name is Pedro Perez I am a nursing student from MDC. I will be here every SAT –SUB from 7:00 to 4:00 if you would like to talk about anything I am here to listen. | I explain to the client the process and purpose of the IPR | 2. The client acknowledges my presence and consents to participate in the IPR. | | Pt seem anxious. Her anxiety level rose once the interview began as evidence by fidgeting and her rocking in her chair. Her particular comment about a suspicious commercial is indicative symptoms of paranoid schizophrenia. Stage of development is Erikson’s Mistrust. | | 3.
I ask the patient directly about her delusions of reference and what they are trying to tell her. | The client elaborates about her delusions of reference by stating that Fidel Castro’s secrete police have been after her for years. | 4. The client states I am an anti revolutionist. I have been trying to assassinate Fidel Castro and his government agents for years. The Cuban agents have been after me for years to try and stop me. | | Pt exhibited paranoid schizophrenia ideation and delusional thoughts of refernce. This is evidence that she has impaired reality testing and thought process. | | 5. I try to re-orient the client by telling her that she is in Miami, FL at Larking hospital. | The client fails to acknowledge my statement, and continues explaining to me about the conspiracy against her. | 6. The client states, I had to leave Cuba because there were trying to kill me. The clients state they new about her plan to kill Fidel Castro. The client believe some of the staff of the hospital are involved in the conspiracy against her. | | Pt continues to elaborate on her delusion. Major defense mechanism is denialSuspiciousness- Erickson’s Mistrust. …show more content…
| | 6. I ask the patient if she is aware of her mental illness. | The client explains to me when the illness began and that she can control it. | 7. The patient states, I am tried of talking I want to go to my room. | | Patient stands from her chair and leaves. | | 7. I thank the client for her time and let her know that I will be here whenever she wants to continue talking. | |
Evaluation The patient strongly exhibits signs of paranoia and delusional thoughts of reference. She clearly is psychotic, lacks the ability to re-orient her self to reality. The patient suffers from a disturbed thought processes. It is clear to understand that these paranoid delusional thoughts of reference can interfere with her re-orientation to reality and the ability to perform her ALDs. I also think that the patient might be experiencing auditory and maybe visual hallucinations, because when I entered the room, she was was mumbling to herself. The client is a 57 y/o having difficulties with the trust vs mistrust.
The first stage of Erik Erikson's theory centers around the infant's basic needs being met by the parents. The infant depends on the parents, especially the mother, for food, sustenance, and comfort. The child's relative understanding of world and society come from the parents and their interaction with the child. If the parents expose the child to warmth, regularity, and dependable affection, the infant's view of the world will be one of trust. Should the parents fail to provide a secure environment and to meet the child's basic need a sense of mistrust will
result.
I would say base on this interaction, that the patient’s primary nursing diagnosis is alteration in reality testing related to chronic paranoid schizophrenia as evidence by delusions thoughts of reference and hallucinations. A long term goal for her would be that she would be able to function without interference of delusions and hallucination. Short term goal: The client will approach the staff when she is experiencing hallucinations or paranoia.
I now truly understand that a delusional patient REALLY believes her delusions she/he has created. There is no convincing her that his belief about being a special agent is untrue.
I believe I performed at a safe level. I may not have immediately help the patient, but I feel that I built good rapport and trust with the patient. I didn’t say anything that greatly increased the patient’s anxiety. I am now able to identify some particular S/S of PSCT clients which I was not able to.