RUNNING

HEAD: SCHIZOPHRENIA CASE STUDY 1

Schizophrenia Case Study Psychiatric Mental Health

Nicole Rodomsky

Youngstown State University

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Abstract

This psychiatric mental health comprehensive case study investigates the case of a 34-

year-old Caucasian male, B.B., diagnosed and hospitalized on an acute psychiatric unit with

schizophrenia. The purpose of this mental health case study is to discuss, describe, analyze, and

evaluate the patient’s psychiatric condition and the care being provided on the psychiatric unit

to return the patient to pre-admission baseline status. Objective and subjective data of the

patient was gathered on the date of care and additional research was done to write this

comprehensive case study. Actual nursing diagnoses, as well as a list of potential nursing

diagnoses for this patient is included. The date of care took place 6 days after the date of

admission.

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Objective Data

B.B. is a 34-year-old Caucasian male who was brought into the emergency department

by the police on February 27, 2019. The patient stated to medical personnel that he was tired

and unable to concentrate. He denied suicidal and homicidal ideations, hallucinations, and

hearing voices. He was positive for cannabis upon admission. The patient has a main diagnosis

of schizophrenia (since age 23), and is also diagnosed with schizoaffective disorder and bipolar

type. B.B. has no comorbid medical diagnoses along with his psychiatric diagnoses.

The patient had not taken his home medications to manage his mental illness for the

previous four days before admission. As the patient decompensates on his medications, he

starts wandering and traveling. This current admission, B.B. was hitch hiking to Cleveland from

his home in Pittsburgh, in hopes to find work. Local police found him and brought him to the ED

where he was pink slipped. B.B. was placed on unit restrictions, patient self-harm precautions,

and a specific protocol of cheeking precautions due to taking pills without water. He has no

history of assault, suicidal behavior, sexual abuse, or physical abuse. On March 3, 2019, the

patient signed in voluntary to the unit.

At home, B.B. is on clozapine (Clozaril), an atypical antipsychotic to treat severe

schizophrenia, aripiprazole (Abilify), another atypical antipsychotic to treat schizophrenia,

lithium carbonate (Eskalith), an antimanic to treat and prevent episodes of mania, and

lorazepam (Ativan), a benzodiazepine to relieve symptoms of anxiety. The patient was set up

with an ACT team who monitors his medication and comes daily to his house to give the patient

his medications. Upon admission, the patient was also prescribed haloperidol (Haldol) for

agitation, haloperidol lactate (Haldol injection) for harmful agitation, hydroxyzine HCl (Atarax
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and Vistaril) for anxiety, nicotine polacrilex (Nicorelief) for nicotine withdrawal, and trazadone

HCl as a sleep aid. B.B. was not on lorazepam (Ativan) in the hospital. Patient has been taking

prescribed medications throughout stay. Significant lab values of B.B. include WBC 11.3

cells/mcL and lithium <0.2 mmol/L. WBC lab value is monitored for clozapine (Clozaril) to

prevent the side effect of agranulocytosis. Lithium lab value is monitored for lithium carbonate

(Eskalith) to prevent lithium toxicity.

On date of care, March 5, 2019, B.B. had a friendly reaction to the nurses. He presented

a flat affect, relaxed posture, fixed facial expression, poor eye contact, and slow to process

information during one-on-one communication. The patient had little emotion and would fall

into blank stares often during the conversation. The patient was alert and oriented during all

one-on-one time with him. He was aware that he was hitch hiking to Cleveland and the police

got him, and where he was at currently. However, he did not think he was doing anything

wrong or unsafe, a symptom of schizophrenia (compulsive behavior). He also did not know that

he did not take his meds or the details to what had happened. He stated that the police were

involved in his life a lot due to him being a frequent missing person. He went to morning group,

but did not participate. He described his mood as “not bad” in relation to the news that he

would be getting discharged near the end of the week.

Summarize

B.B. is diagnosed with schizophrenia, schizoaffective disorder, and bipolar type. The

National Alliance on Mental Illness (NAMI) defined schizophrenia as “a serious mental illness

that interferes with a person’s ability to think clearly, manage emotions, make decisions, and

relate to others” (NAMI, 2015, p.1). According to Townsend & Morgan (2017) authors of
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Essentials of psychiatric mental health nursing, this mental illness cannot be cured, only

managed. Symptoms of the disease include delusions, hallucinations, disorganized speech,

catatonic behavior, and negative symptoms such as blunt affect, lack of interest, and lack of

emotion. However, not all of these symptoms need to be present to confirm the diagnosis.

These symptoms can result in a major worsening of functioning for the diagnosed individual, as

well as affecting the lives of their family and friends (Townsend & Morgan, 2017). Treatment

includes antipsychotic medication, psychotherapy, and psychosocial treatments (NAMI, 2015).

Schizoaffective disorder is schizophrenia with the additional symptoms of mood

disorder. The patient diagnosed with this mental illness stays in a depressed or manic phase

while still having the sign and symptoms of schizophrenia. Additional symptoms the patient

may experience are depression with suicidal ideation or euphoria, hyperactivity, and

grandiosity (Townsend & Morgan, 2017). Bipolar type was the third mental illness B.B. was

diagnosed with. It is now known what type of bipolar the patient has.

Identify

The patient’s behavior of noncompliance with his home prescribed medications is what

precipitated the current psychiatric hospitalization. B.B. has had multiple previous psychiatric

hospitalizations in his hometown of Pittsburgh. Decompensation of medications is what leads

to these hospitalizations. Pt decompensates on medications, starts to wander and travel,

becomes a missing person, found by local police wherever he is at who call his mother, and

then his mother picks him up or has him taken to a psych department by the police. Normally,

this decompensation happens once a year, particularly in June. Patient is aware of traveling and

hitch hiking, and has a specific purpose to do so, but does not realize the consequences of his
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actions. Patient could not also state how he specifically got to the hospital this admission or

previous admissions. B.B. has not taken his medications in the past since his diagnosis and hitch

hiked to Atlanta, New York, Texas, West Virginia, other places in Pennsylvania, and was a

missing person for 2 months in Vermont.

Discuss

B.B. was diagnosed with schizophrenia at the age of 23. He described his childhood as

normal. He got along with both of his parents well, even when they got divorced when he was

18-20. The divorce did not affect him because he felt that they were both still in his life just as

much as they were when they were married. He has two brothers, 4 and 5 years older than

him, that he was close with and still is to this day. He seems to have a good familial support

system.

He stated to have had many friends growing up and throughout school. He describes his

friends currently as he has them but doesn’t see them much because they are on different

paths in life. B.B. enjoyed playing basketball and soccer recreationally throughout his childhood

and adolescent years. He went to college after graduation from high school for general studies

and dropped out after 3 years when symptoms started to develop. Shortly after leaving college,

he was diagnosed with schizophrenia. He was in and out of jobs, including food services and

landscaping. His most previous job was landscaping, but his boss had just fired him. During

conversation with B.B., he showed motivation to get discharged from this psychiatric unit and

go home and find work.

B.B. was very understanding of his diagnosis. He knew what he had and what

medications he was on. He understood that he needed help taking care of himself. He noted a
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story about his cat he used to have. His dad was getting rid of the cat and B.B. wanted to take

the cat to his apartment and take care of it, but stated “I can’t take care of myself sometimes,

so I wouldn’t be able to take care of this cat.” He seemed accepting with his diagnosis.

The patient has no family history of mental illness noted. He had no history of abuse.

B.B. recognized nothing significant in his childhood that could have precipitated this diagnosis

of schizophrenia. Schizophrenia is most commonly diagnosed in late adolescence through early

adulthood, when symptoms begin to appear. Biological, psychological, and environmental

factors can all be predisposing factors (Townsend & Morgan, p. 341-347, 2017). Schizophrenia

causes and predisposing factors are still be studied.

B.B. was diagnosed as a cannabis abuser as well. It is unknown how long he has used

cannabis, as this information was not disclosed by the patient. However, there is research that

connects cannabis use throughout adolescence, a time when the brain is still developing, to the

development of schizophrenia later in life. According to Bossong & Niesink (2010) in their

research article “Adolescent brain maturation, the endogenous cannabinoid system and the

neurobiology of cannabis-induced schizophrenia,” it is known that the use of high-dose

cannabis can cause an acute psychosis state on an individual, that can eventually lead to a

diagnosis of schizophrenia. Cannabis users who are diagnosed with schizophrenia frequently

have higher relapse statistics that place them into an acute psychiatric facility more often than

non-cannabis users. The underlying neurobiological processes that occur are unknown, but

research is being conducted. Is it suspected that THC, the neurotoxic agent in cannabis,

interacts with the CB1 receptor in the brain which controls the release of GABA and glutamine.

This interaction can interfere with neural synapses and when this happens at the right place
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and right time, can cause symptoms that lead to the lifelong psychiatric diagnosis of

schizophrenia on the cannabis user. There is a spontaneous relationship between schizophrenia

and cannabis use, as more research is to be completed on this topic (Bossong & Niesink, 2010).

Cannabis use has now become added to the list of risk factors for the development of

schizophrenia.

Describe

The psychiatric unit the patient was admitted into had a milieu environment. The

priority of safety was maintained for each patient. Group attendance and participation was

encouraged. B.B. attended morning group, however, he did not participate. He sat there with a

blank stare, looking inattentive to the group leader and the other patients. It was documented

that B.B. had been attending day groups. Social interaction was also encouraged, especially for

this patient. During shift, B.B. did not make any interaction with other patients. However, the

previous days to the date of care, he did attempt social interaction with other patients. The

nurses documented his social interaction and verbal communication with other patients as a

“childlike demeanor.” The patient was administered his daily medications at prescribed times

as part of his care provided.

The evidenced based nursing care provided towards an individual in an acute psychiatric

unit can be very helpful for a long duration. Jeste, Palmer, and Saks (2017), researchers at the

Department of Psychiatry at the University of California, determined that the evidence based

practice of positive psychiatry can benefit longer remissions without psychiatric admittance in

schizophrenia patients. In their research article, “Why we need positive psychiatry for

Schizophrenia and other psychotic disorders” (2017), they defined positive psychiatry as “the
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science and practice of psychiatry that focuses on study and promotion of mental health and

well-being through enhancement of positive psychosocial factors” (Jeste, Palmer, & Saks p.

227). It is designed that positive implementations during a psychiatric admission will produce

positive results. Some factors that contribute to positive psychiatry that can be implemented in

practice are intelligence, optimism, hope, and resilience (Jeste, Palmer, & Saks, 2017). Positive

psychiatry should be implemented on psychiatric units by the interdisciplinary team as

evidenced based practice due to the improved results and long term outcomes that can benefit

our patients.

Analyze

B.B. is a Northern European American. He stated no ethnic, cultural, or spiritual

influences that would impact him. However, the nurse should still be aware of his ethnicity and

cultural norms when caring for this patient. Within this culture, personal space is valued from

18 inches to 3 feet. This culture is future-oriented who strive to the completion of set goals.

Work ethic, efficiency, and punctuality have a high significance. The value of religion in this

culture seems to be diminishing. This is due to lack of confidence in the church and religion and

having busy lives (Townsend & Morgan, 2017). Spirituality should be assessed and discussed

further with the patient due to one’s spiritual needs.

Evaluate

Time in an acute psychiatric unit, whether it be days, weeks, or months, is meant to help

return the patient back their pre-admission baseline. B.B. described his time on this psychiatric

unit as helpful to him, as he was going to be discharged a few days after the date of care. The

goal of any psychiatric unit for every patient is to return the patient back to their baseline. For
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this patient, his return to baseline was occurring as he started taking his medications again,

after not taking them for four days before admission. The patient was motivated to get back to

his home and his life. He had talked about the goal of getting and keeping a job after he

returned home. Care, which involved correct medication regimen, was effective for this patient.

Care also involved increased social interaction. Although he had impaired verbal

communication when interacting with other patients, he did show increased social interaction

throughout his stay in the facility.

Summarize

B.B. has plans to get discharged 2-3 days after the date of care. The nurses and doctors

on the unit have seen him improve, as he started taking his medications again, which led to the

decision of discharge soon. He will go back home to his mom’s house in Pittsburgh. The ACT

team will visit him daily to continue to monitor his medications. On his medications, B.B. can

function adequately. Only when he decompensates from his medications does there seem to

be a problem. The interdisciplinary team has suggested that he begin receiving Abilify

injections, instead of the PO medication. This modification in his medication regimen is to

improve his compliance. The patient will still take Clozaril, Lithium, and Ativan at home.

Education needs to be reinforced to client about medication compliance, as well as, the safety

of the patient related to medication decompensation. Education should also be completed on

the negative effects of nicotine and cannabis on the body.

The client also needs to be educated on positive coping strategies. B.B. did not state

many coping techniques when asked. He states he likes to watch tv, specifically “The Price is

Right,” every morning at 1100 and enjoys reading a good book, if he can find one. He did not
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state any other coping techniques. While reading his chart, it stated that the patient smokes 1

pack of cigarettes a day and is a cannabis abuser. These are negative coping skills. According to

Holubova et al., faculty at the department of psychiatry at multiple universities in the Czech

Republic, individuals diagnosed with schizophrenia are highly susceptible to precipitating

stressors that increase their chance for a relapse (2016). These people have maladaptive coping

techniques. A study performed by Holubova et al. (2016) revealed that people diagnosed with

schizophrenia may have negative coping techniques due to there never being a resolution to

their situation. It was also found that the more severe the mental illness is prevalent in an

induvial, the less positive coping techniques that individual will use (Holubova et al., 2016).

Before discharge, the patient should identify 2 new positive coping strategies for when he gets

home.

Prioritized

List of actual diagnoses include:

• risk for suicide related to psychiatric illness as evidenced by psychological

diagnosis and cannabis abuse

• impaired social interaction related to impaired communication patterns and

disturbed thought processes as evidenced by little communication with others

and a childlike demeanor when communicating with other

• impaired verbal communication related to biochemical alterations in the brain as

evidenced by difficulty communicating thoughts verbally

• ineffective coping related to inadequate coping skills as evidenced by poor

concentration and risk taking (Ackley & Ladwig, 2014)

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List

Potential nursing diagnoses include:

• ineffective activity planning related to compromised ability to process

information as evidenced by lack of sequential organization and impaired social

interaction

• anxiety related to unconscious conflict with reality as evidenced by diminished

productivity and poor eye contact

• deficient diversional activity related to social isolation as evidenced by

psychiatric unit environment

• risk for interrupted family processes related to inability to express feelings

• risk for ineffective health maintenance related to cognitive impairment

• hopelessness related to long-term stress from chronic illness as evidenced by flat

affect and lack of initiative

• risk for disturbed personal identity related to schizophrenia diagnosis

• risk for chronic sorrow related to schizophrenia diagnosis

• spiritual distress as related to social alienation as evidenced by ineffective coping

and expresses lack of hope

• risk for impaired religiosity related to ineffective coping (Ackley & Ladwig, 2014)

Conclusion

B.B. was diagnosed with schizophrenia at the age of 23. He was admitted to this

psychiatric unit after being found by the police away from home and hitchhiking to another

city. His decompensation of his daily medications for four days had caused this relapse.
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Noncompliance with his medications has caused many previous psychiatric hospitalizations.

Throughout his stay, his normal daily medication regimen was regained, as well as improved

social interaction. Discharge instructions need to include education on the importance of

medication compliance, the risk of safety associated with medication decompensation, positive

coping skills, and the negative effects of nicotine and cannabis. This psychiatric mental health

comprehensive case study on a patient with schizophrenia is concluded.

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References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: an evidence-based guide to

planning care. Tenth edition. Maryland Heights, Missouri: Mosby Elsevier.

Bossong, M. G., & Niesink, R. J. M. (2010). Adolescent brain maturation, the endogenous

cannabinoid system and the neurobiology of cannabis-induced schizophrenia. Progress

in Neurobiology, 92(3), 370–385. https://doi.org/10.1016/j.pneurobio.2010.06.010

Holubova, M., Prasko, J., Hruby, R., Latalova, K., Kamaradova, D., Marackova, M., … Gubova, T.

(2016). Coping strategies and self-stigma in patients with schizophrenia-spectrum

disorders. Patient Preference & Adherence, 10, 1151–1158.

https://doi.org/10.2147/PPA.S106437

Jeste, D., Palmer, B., & Saks, E. (2017) Why we need positive psychiatry for Schizophrenia and

other psychotic disorders. Schizophrenia bulletin vol. 43(2): 227-229.

doi:10.1093/schbul/sbw184

National Alliance on Mental Illness. (March 2015). Schizophrenia. Retrieved from

https://www.nami.org/NAMI/media/NAMI-Media/Images/FactSheets/Schizophrenia-

FS.pdf

Townsend, M. and Morgan, K. (2017). Essentials of psychiatric mental health nursing: Concepts of

care in evidence-based practice (7th ed). Philadelphia, PA: F.A. Davis.

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