This descriptive case study illustrates the experience of Mr. Velasquez, who is a twenty-two-year-old Colombian diagnosed with schizophrenia and mild intellectual disability. Born of teenage parents who later got divorced, forcing the client to live with his maternal grandparents. The mother later emigrated to the United States. When he was ten, the rest of the family also emigrated. Immediately, the client became ill, though they did not seek any medical assistance. The client has a 14-year-old sister who has washed and dressed him. He seems to be hallucinating, thinking he is in a space shuttle with frequent loud outbursts. He has been referred by his clinic to benefit from structured family therapy.
Clinical features of restlessness, hallucination, poor self-care, poor socio-occupational functioning and excessive masturbation were reported. Not married. Dropped out of school at the age of sixteen, never had the opportunity to complete high school unemployed. No aggressive behavior. During most current illnesses, reported self-care neglect, poor attention and concentration, decreased sleeplessness and loss of appetite. Personnel history during schooling only a few friends, no substance use, alcohol habit, no aggressive behavior present. Socio-occupational functioning is moderate. Medical history: became ill at the age of 10 but did not seek medical assistance. Later visited an outpatient clinic where the clinician stabilized him on benztropine haloperidol. The client has visited a psychiatrist, where he had a medication change to Risperdal.
The client was subjected to the Allen Cognitive Level Screening test, which assesses the patient’s ability to function and further remain at normal cognitive levels. The identification helps in easing stress through reduction of behaviors they are dealing. The Running Stitch indicates the abilities one has in doing the activities of daily living. The Whip Stitch is used in determining a person’s ability to solve the problem. The test is used to evaluate how the patient can respond to emergencies. The Cordovan Stitch shows an individual’s ability to process information. After the test, the client was found to average a cognitive level of four, where he completed the two whip stitches and then two running stitches though he could not finish the single cordovan stitch.
Assessment
Objective: Mr. Vasquez develops a trusting relationship with the OTA within a given period.
Diagnosis
The patient shows Impairment in Social Interaction related to a lack of available significant others and peers. This is evidenced through dysfunctional interactions with others.
Planning
Encourage the client to express his feelings honestly due to the loss of his prior level of functioning. Acknowledge the pain of neglect, especially by close family members.
Encourage the client when he attempts to communicate. If words are not understandable, express to the client possibly what he intended to say. Frequently reorienting the client.
Intervention
Spend time with the client by just sitting around them, even if in silence for a lengthy period.
Try to develop a therapeutic nurse-client relationship. Achievable through frequent contact and showing unconditional positive regard at all times.
Positively reinforce the client’s interactions with others, especially when he does it voluntarily, and show assertiveness techniques.
Rationale
My presence may help by improving the client’s perception of self as a worthwhile individual.
Presence and acceptance, together with the transmission of positive repute, improve the client’s feelings of self-respect.
Positively reinforcing enhances self-esteem, which encourages the patient to repeat the desirable behaviors.
Assertive techniques and knowledge improve the client’s relationships with the surroundings.
Evaluation
The client demonstrated the desire and willingness to socialize.
The client voluntarily attended the group activities and participated actively.
As an OTA, I majorly implement assessments delegated by the OT and provide reports of the client’s ability and observations made during my stay with the patient. Further providing inputs to the client’s intervention plans based on his needs. As an OTA, one must be knowledgeable about the therapy goals of the client and the outcomes the OT is targeting the client. It will also be necessary to provide clients with achievements. An OTA is also responsible for ensuring the required discharge resources to the client.
The client is found to possess poor self-care, poor occupational performance, reduced social interaction as he only sees members of his family and poor self-concept. On observation, this is a result of the Allen Cognitive Level Screening test.
General appearance moderately thin build, Self-care, moderate in grooming and dressed, not shaving correctly, psychomotor hyperactivity, a Social smile present.
On Examination
Cognitive skills: The patient is fairly oriented well, as he was able to attend to the task and listen to the therapist, though he could not attempt the tasks on the second attempt. Hence, no sustaining of attention and frustration tolerance is fair during the work. Factors affecting occupational functioning’s highly irritable mood, restlessness, and not following instructions.
As an OTA I understand there are various tools at my disposal in the evaluation of a client. Orthopedic devices like braces and slings. Patients may need the training to use a stick held in the mouth for pointing or performing a given task. Heavy webbing belt tied around a patient’s waist aiding during transfers or exercises. An OTA helps a patient achieve independence and, therefore, at all times, tries to help the patient learn basic grooming skills. The OT heavily depends on the OTA to provide feedback about the patient’s progress and the recommendations made on whether to change the treatment plan based on the recent patient’s performance and capabilities. OTA further documents the patient’s activities on the chart or computers.
The treatment plan is normally built based on the problems the patient is bringing into the treatment. The OT is in-charge of the evaluation of the client. A treatment plan gives the therapeutic interventions. Mr. Velasquez is to develop a program of recovery and develop positive sobriety. The patient will develop a healthy diet, which will help him gain normal weight. With the help of the OT, we ensure the patient shares positive feelings towards others. Together, we help the patient come up with a list of essential skills that will be necessary for his recovery process. The patient will also be advised to keep an assertiveness log, and daily share the log with a family member or a counselor.
Electroconvulsive therapy may be considered in the event the client’s response to drug therapy is poor, especially when depression persists. The procedure is done under general anesthesia, where a small electric current is usually passed through the brain, which triggers a seizure. This will, in turn, change the brain chemistry, reversing the typical symptoms. ECT is to be conducted in the event other treatments are unsuccessful and the full treatment course has been completed.
Medication is essential for patients with schizophrenia. The patient can be put on antipsychotic drugs, which control symptoms affecting brain neurotransmission. Other medications that can help include anti-anxiety drugs or antidepressants. The drugs can be administered through injection in the event the patient becomes reluctant to take the medication orally.
CBT helps to identify the irrational thoughts a patient may have and change them further, Helping patients to make sense of how the hallucinations impact feelings and their behavior.
Family therapy is also necessary as it helps a patient recover, enabling him to stay well through altering communication and relationship patterns to a lower expressed emotion.
Once the patient’s psychosis recedes, medication should be continued. Additionally, psychosocial interventions are essential to ensure the patient leads a healthy life. These may include:
• Individual therapy. Introducing the patient to psychotherapy may help normalize his thought patterns. The treatment further aids in learning to manage stress and further in the identification of warning signs early enough of relapse to help patients with schizophrenia manage their illness efficiently.
• Social skills training to improve social interaction and communication hence enabling the patient to participate in the daily activities effectively.
• Family therapy. It is necessary as this provides support and education to families dealing with schizophrenia on how to handle the patient and, further identify warning signs, help in medication uptake.
Vocational rehabilitation, together with supported employment programs, focuses on helping schizophrenic patients prepare for jobs and even makes it easier for them to find and keep jobs. Patients with schizophrenia would like to work to improve their income and elevate their self-esteem and social status in society. However, people with the disorder are, in most cases, unable to maintain competitive employment. Supported employment programs are the most active.
Cognitive remediation would be useful in enhancing the client’s safety. The treatment is derived from neuropsychological rehabilitation principles. The brain has plasticity, and exercising it encourages neuron growth, thus developing neuro-circuitry, which underlies most mental activities. The remediation works best when the patient is stable.
Counseling is also recommended as this will assist the patient to explore his problems and deal with them effectively.
Schizophrenia is found to affect the patient’s family. The response a patient gets affects the course of the patient’s illness. Relapses have been observed where hostile and intrusive families are reported. Family therapy and interventions prevent relapse, which reduces regular admission to the hospital and improves compliance with medication. The family should be present at most times to ensure the patient is taking their medication and further assist in the daily grooming. Reminding the patient regularly to undertake the medicine and live positively encourages the patient. Psycho-education helps those around a patient how to manage him effectively.
Patients with schizophrenia have mild cognitive deficits affecting their ability to function alone. Most tend to have problems with planning, decision, decision making and short-term memory. Essential activities of life skills and cognitive remedial therapy can help in reducing such occurrences. Psychiatric symptoms result in patient neglecting their physical health. Follow-up care is, therefore, necessary, such as eye, dental and ear care.
Most patients with schizophrenia are found to smoke. This is a result of the previous antipsychotic treatment. The patient should, therefore closely monitored, especially by the caregiver, to avoid boredom usually associated with hospitalization. Making a routine schedule for the patient would be necessary to ensure he abides by some personal grooming. Integration into a healthy social life is also necessary, and this is done by encouraging the patient to accept his condition and freely interact with others without any fear. Having appropriate residence gives the patient support to remain within the community, hence avoiding revolving-door syndrome as a result of recurrent admissions to the hospital.
It would be necessary to address behavior manifestations present by incorporating the therapeutic use of self. Promoting consonance among the three selves of the patient: the ideal person, the perceived self and the acting self. At the end of the evaluation, the patient performance is put to comparison to average data to determine the severity of the deficit.
As time goes on, the patient’s behavior changes, and he is now capable of taking on tasks independently. Behavioral therapy worked, and he rarely masturbates. There is reduced hallucination.
The environment has a significant influence on occupational therapy if better utilized. When the patient is comfortable in a given environment, they may adapt positively, which will aid in the healing process. For instance, for Mr. Vasquez would be necessary to stay at a rehabilitation center. A well-designed rehab center helps the client achieve their therapy goals. The younger siblings would not effectively act as caregivers, and hence, well-trained caregivers are recommended to look after the patient and those who understand how to handle the patient appropriately.
Monitoring a patient’s modification can be essential for continuity of care. Referrals to the rehab center are an option. A patient may also be enrolled in different home programming to support their professional performance. Mr. Vasquez can be enrolled in a residential crisis program where he will live in a home-care facility. The homes, just like hospitals, have healthcare workers, and it is a good program. In the event the client develops a relapse, the workers can assist appropriately. Additionally, he can be enrolled for a partial care program where he will be attending group therapy at average 5 to 6 hours a day at an interval of 3 to 5 days a week; helping the client to control symptoms hence avoiding occurrence of relapse.
Before leaving the hospital, the client is informed of the basics of recognizing signs. Assistance in getting transportation to and from appointments will be necessary. The patient and the caregiver are to be involved fully in the plan. Documentation should be completed and signed. The cognitive intactness of the patient should be noted. Medication and follow-up plans are necessary to share with the family to limit the possibility of relapses. Family members are also shown how to identify symptoms and the intervention required to take in the event relapse occurs.
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