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Mental Health Case Study: Schizophrenia

Kaelyn Snyder

Youngstown State University

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Abstract

In this case study, the nursing care provided to a patient with schizophrenia will be

discussed, as well as outcome, medical diagnosis, nursing diagnosis, and summary for discharge.

By using evidence based practice and nursing interventions, the patient was discharged from the

unit to receive care from another facility, and following that a rehabilitation center. This case

study will also compare the relationship between schizophrenia and twins.

Mental Health Case Study: Schizophrenia

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1. Objective Data:

Patient was a thirty year old African American female with schizophrenia paranoid type

with an acute on chronic exacerbation admitted on November 9, 2018, and date of care was

November 15, 2018. Upon admission the patient had a urinary tract infection as well as

trichomoniasis which were treated appropriately with antibiotics. According to the DSM IV-TR,

a diagnosis of schizophrenia must meet the following criteria,

“…delusions, hallucinations, disorganized speech, grossly disorganized or catatonic

behavior, negative symptoms, i.e., affective flattening, alogia, or avolition…

Social/occupational dysfunction: For a significant portion of the time since the onset of

the disturbance, one or more major areas of functioning, such as work, interpersonal

relations, or self-care, are markedly below the level achieved prior to the onset (or when

the onset is in childhood or adolescence, failure to achieve expected level of

interpersonal, academic, or occupational achievement)…Duration: Continuous signs of

the disturbance persist for at least 6 months. This 6-month period must include at least 1

month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-

phase symptoms) and may include periods of prodromal or residual symptoms. During

these prodromal or residual periods, the signs of the disturbance may be manifested by

only negative symptoms or by two or more symptoms listed…present in an attenuated

form (e.g., odd beliefs, unusual perceptual experiences)…Schizoaffective and major

mood disorder exclusion. Schizoaffective disorder and depressive or bipolar disorder with

psychotic features have been ruled out…Substance/general medical condition exclusion:

The disturbance is not attributed to the direct physiological effects of a substance (e.g., a

drug of abuse, a medication) or another medical condition…If there is a history of autism

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spectrum disorder, 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).” (Tandon et al., 2013, p. 3)

Upon admission to the emergency department the patient was having auditory

hallucinations and talking to unseen others stating that, “the tornado was blowing everyone

away, they are going to cut my skin off, and there is a hole in my head with my brain falling

out.” On the day of care the patient reported anxiety as a 10/10 on a zero to ten scale, and was

maintaining good eye contact and had rapid pressured speech with some circumstantiality. The

patients appearance was animated, relaxed, neat, friendly, and affect was pleasurable; however,

the patients legs were not shaved and had acne scars. Disturbance in thought content was

experienced by having somatic delusions about a hole in the patients head, and persecutory

delusions about the patient’s sister stealing the patient’s cat before admission, as well as a cousin

whom is a nurse wanting to fist fight the patient. On day of care the patient denied having any

somatic delusions, and the patient reported before, “I am embarrassed I thought there were holes

in my head.” Preoccupations of thoughts were present about the patient’s mind “snapping,”

father, and cat. The patient also demonstrated akathisia and restlessness, and was negative for

unpleasant and inappropriate affect, akinesia, tardive dyskinesia, and acute dystonic reactions.

The patient was negative for tangentiality, flight of ideas, perseveration, blocking, and loose

associations. The patient did not quite remember how the circumstances were surrounding the

initial visit to the hospital, and depersonalization was reported as experienced in the police

station before the hospitalization occurred. The patient demonstrates poor judgment on the day

of care. Labs were unremarkable other than a positive cocaine screen, elevated white blood cells

of 12.9 due to the UTI and trichomoniasis, and high glucose of 106 due to stress and infection.
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Urine bacteria was positive, hemoglobin was 15.2, liver function tests were normal, and vitamin

B12 was high of 1039.

On the unit, the patient was prescribed an antipsychotic paliperidone (Invega) three

milligrams twice a day orally for schizophrenia to decrease positive symptoms, an antiparkinson

medication benztropine (Cogentin) 0.5 milligrams twice a day orally to decrease reported

extrapyramidal side effects (EPS), an anxiolytic hydroxyzine (Atarax) 50 milligrams every six

hours orally to decrease anxiety. As needed, a standing order of an antipsychotic haloperidol

(Haldol) five milligrams orally was available for agitation. The patient was also scheduled to

receive monthly injections of long acting paliperidone palmitate (Invega Sustenna) 234

milligrams due to compliance issues with oral medication at home, mainly due to the side effects.

Since the patient had the Cogentin to help with the EPS, and the once a month injections the

patient reported much more likelihood of being compliant with the medication. The patient

attended group therapy and learned different coping techniques to use when dealing with a

stressor such as breathing, petting the cat, painting nails, and taking walks. Standard safety

precautions were taken such as a locked unit, short pencils with dull tips, fifteen minute checks

on the patient, alarms on tops of doors, and no hoodie strings or shoe laces allowed.

2. Summarized psychiatric diagnosis and expected/common behaviors:

Schizophrenia has four phases. The first phase is the premorbid phase where we start to

see antisocial behavior, social maladjustment, and poor peer relationships. The second phase is

the prodromal phase and can last from weeks to a few years. This phase is where mood changes

begin, sleep disturbances are present, negative symptoms may develop, and substantial

functional impairment is seen. The third phase is schizophrenia, and the fourth phase is the

residual phase. During the schizophrenia phase the patient will have delusions, hallucinations,
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and impairment in work, social interactions, and self-care. The residual phase occurs after the

schizophrenia phase is under control and the hallucinations and delusions stop. This is where we

see a lot of negative symptoms. Hallucinations, neologisms, and delusions are positive

symptoms of schizophrenia. Some of the negative symptoms of schizophrenia are flat affect,

anhedonia, catatonia, reduced social interaction, avolition, and alogia. There have not been a lot

of medications to help with the negative side effects of schizophrenia until recently the newer

atypical antipsychotics have helped with both positive and negative. A lot of schizophrenia

medications have unwanted side effects such as EPS, tardive dyskinesia, agranulocytosis,

gynecomastia, weight gain, decreased libido, neuroleptic malignant syndrome, orthostatic

hypotension, dizziness, constipation, urinary retention, blurred vision, increased cholesterol,

photophobia, type two diabetes, and prolonged QT intervals. The side effects are a reason why

some patients do not want to take their medications, including this patient.

3. Identify stressors that precipitated event:

The patient had not been taking the prescribed medications, and the parents had been

fighting a lot which was upsetting. It was stated that the patient went to a party the night before.

There the patient self medicated with cocaine, and someone saw then told the parents. When the

patient woke up, the cat that the patient was very attached to was missing, so in a panic, the

patient started looking for the cat. The patient assumed the sister put it outside or stole it, and

started to wander the streets and came to a police station, became disoriented confused and asked

them to call 9-1-1, and was then transported to the emergency department by ambulance.

4. Discuss patient and family history of mental illness:

The patient has a twin sister who also has schizophrenia, and many studies have been

done to examine the relationship between twins and mental illness. Hilker et al., (2011) stated
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that there is a great importance and need for studies done on twins with this illess, and stated

that, “The risk of developing schizophrenia is influenced by both genetic and environmental

factors. Twin studies have provided important insight, with several reports indicating a strong

genetic risk.” According to Castellani et al. (2017),

“Two specific pathway defects, glutamate receptor signaling and dopamine feedback in

cAMP signaling pathways, were uniquely affected in the two patients representing two

unrelated families…The results support the proposition that each schizophrenia patient

may be unique and heterogeneous somatic de novo events may contribute to

schizophrenia threshold and discordance of the disease in monozygotic twins.”

It was found that there are specific neurotransmitters affected in the brain that propose evidence

for heredity of schizophrenia in families and twins. Another study was done by Castellani et al.

(2015) that showed,

“The results are compatible with the suggestion that DNA methylation may contribute to

the discordance of monozygotic twins for schizophrenia. Also, this may be accomplished

by the direct effect of gene specific methylation changes on specific biological networks

rather than individual genes. It supports the extensive genetic, epigenetic and phenotypic

heterogeneity implicated in schizophrenia.”

This evidence supports that schizophrenia has an organic cause, and that the mental illness is

genetic.

5. Describe the psychiatric evidence based nursing care provided and milieu activities attended:

The patient attended group therapy and learned different coping techniques to use when

dealing with a stressor such as breathing, petting the cat, painting nails, and taking walks. When

the patient would report delusions or hallucinations, the nurse would deny seeing or hearing
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anything and then reorient and distract the patient. Interventions provided were to establish a

therapeutic relationship with the patient and the patient’s family, decrease external stimuli, teach

new coping and relaxation techniques, teach new social skills, monitor labs, check the patient

every fifteen minutes, assure the clients safety in a therapeutic milieu, and administer prescribed

medications.

6. Analyze ethnic, spiritual, and cultural influences that impact the patient:

The patient is a high school graduate, currently unemployed, single, and lives with

mother and father, twin sister, and three young nephews. The patient receives Social Security

benefits and Medicare parts A and B, and is chronically mentally ill with multiple

hospitalizations to the unit before. The patient reported that church had not been attended

recently, but a desire to go back was stated. The patient also reported a desire to move out of the

parent’s home and into an apartment alone with the cat. It was stated that the parents are very

hard on the patient, and they did not have a tolerance for drug use.

7. Evaluate the patient outcomes related to care:

The patient outcomes that were met are as follows: on day of care the patient will attend

group therapy, on day of care patient will participate in group therapy, on day of care patient will

perceive self realistically, on day of care patient will perceive the environment correctly, on day

of care patient will use appropriate verbal communication when interacting with others, on day

of care patient will demonstrate an ability to trust others. On day of care patient will maintain

anxiety at a manageable level, this outcome was not met due to anxiety 10/10 on zero to ten

scale, and medications were given to assist in decreasing anxiety, as well as relaxation

techniques.

8. Summarize the plans for discharge:

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Although there were no plans for discharge set in stone at the time, the patient wanted to

be transferred to Riverbend after the stay on the unit. Afterwards the patient discussed wanted to

go to rehab in New York that the father volunteered to pay for. At the time, the patient was not

ready to leave the unit.

9. Prioritized list of nursing diagnosis:

The patient had a nursing diagnosis of altered thought process due to delusions as

evidenced by somatic and persecutory symptoms, stating a hole in her head with brain falling

out, and that the sister took the cat. Altered sensory perception due to hallucinations as

evidenced by hearing voices and talking to unseen others. Anxiety due to unknown location of

pet as evidenced by verbally stating anxiety is present, as well as restlessness and preoccupied

thoughts of pet. Impaired communication due to exaggerated responses to alerting stimuli as

evidenced by inappropriate emotional response. Ineffective coping due to self medicating as

evidenced by positive cocaine screen. Self care deficit due to severe anxiety as evidenced by

unkempt hygiene.

10. Potential nursing diagnosis:

Considering in the past that the patient had been employed and lived alone, the

downward drift theory that mental illness causes poverty is applicable to this patient. The patient

started out with a job and lived in an apartment alone, but as the mental illness progressed, the

patient is now unemployed and living with parents. The patient could have also been at risk for

violence due to the panic of losing a pet, or could have gotten hurt wandering the streets not

realizing the location or vehicles on the road which would be risk for injury. The patients family

may have a diagnosis of interrupted family process due to a mental disorder of a family member

as evidenced by an inability to meet the needs of the family.

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11. Conclusion:

Considering that there are many different pharmacological treatments available for

schizophrenia, it would be tough to argue which one could be best. With the newer medications

out there, there are less harmful side effects with just as good or even better outcomes for

patients with schizophrenia, and now that there are mandatory long acting injections available

compliance is increasing. Professional counseling, a solid support system, pharmacological

treatment, and a schedule and routine has been shown to have the best results or this mental

illness. Many patients think that once they have routinely taken their medications, and the

negative symptoms of schizophrenia subside, that they are cured and stop taking their

medications; however, that is not the case, which is why we see re-hospitalization. Many

patients also have a lack of resources to obtain their mediations, or they do not like the side

effects of the medication they are prescribed. In order for patients with this mental illness to get

the help that they need, it is important to stress before discharge the importance of taking their

medications for the rest of their life to prevent rebound hospitalizations, as well as being an

advocate for patient needs as a heath care professional.

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References

Castellani, C. A., Laufer, B. I., Melka, M. G., Diehl, E. J., O’Reilly, R. L., & Singh, S. M.

(2015). DNA methylation differences in monozygotic twin pairs discordant for

schizophrenia identifies psychosis related genes and networks. BMC Medical Genomics,

8(1), 1–12. https://doi.org/10.1186/s12920-015-0093-1

Castellani, C., Melka, M., Gui, J., Gallo, A., O’Reilly, R., & Singh, S. (2017). Post-zygotic

genomic changes in glutamate and dopamine pathway genes may explain discordance of

monozygotic twins for schizophrenia. Clinical & Translational Medicine, 6(1), 1–22.

https://doi.org/10.1186/s40169-017-0174-1

Hilker, R., Helenius, D., Fagerlund, B., Skytthe, A., Christensen, K., Werge, T. M., Nordentoft,

M., & Glenthøj, B. (2018). Heritability of schizophrenia and schizophrenia spectrum

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based on the nationwide danish twin register. Biological Psychiatry, 83(6), 492–498.

https://doi.org/10.1016/j.biopsych.2017.08.017

Tandon, R., Gaebel, W., Barch, D. M., Bustillo, J., Gur, R. E., Heckers, S., Malaspina, D., Owen,

M. J., Schultz, S., Tsuang, M., Van Os, J., & Carpenter, W. (2013). Definition and

description of schizophrenia in the DSM-5. Elsevier, 1-8.

http://dx.doi.org/10.1016/j.schres.2013.05.028