Psychiatric Mental Health Comprehensive Case Study

Hayley Socha

Youngstown State University

NURS 4842L

Phyllis Jean Defiore-Golden

Nov 18, 2021

Abstract

The following paper is a case study on a schizophrenic patient. The patient’s behaviors

were observed and patient data will be provided in the paper. The psychiatric disorder of

schizophrenia is summarized as well as the expected or common behaviors of a patient with

schizophrenia. The paper provides information on the patient’s history including family history

of mental illness and past medical history. Stressors and behaviors that led to the patient’s

admission were further looked at and explained in the paper. Each patient has ethnic, spiritual,

and cultural influences that impact them so these are also talked about in the case study. Another

thing the case study includes is an evaluation of patient outcomes related to care. Discharge plans

are summarized in the end of the paper as well as actual and potential nursing diagnoses.
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Objective Data

The reviewed patient is a 45 year old female with a diagnosis of schizophrenia.

The patient’s blood pressure was 140/94, her pulse was 70 beats per minute, her respiratory rate

was 18 breaths per minute, and her temperature was 97.9 degrees fahrenheit. Her general

appearance was very flat with no facial expression, not talking much, and staring off. The patient

appears withdrawn as she had poor intake at breakfast and refused to go to two group therapy

sessions.

The patient had shown two positive symptoms of schizophrenia- the delusion that

someone else controls what she does or how she acts, and the persecutory delusion that she was

going to be hurt or poisoned by the staff. A few negative symptoms of schizophrenia that were

noted include the patient exhibited catatonia or less movement, had a very flat affect with a blank

stare, and didn’t speak a lot. There were no signs of hallucinations on the day of care. The patient

also demonstrated a lot of anxiety, asking multiple times when the interview would be over.

Summarize the Psychiatric Diagnoses

The patient has a diagnosis of schizophrenia. This disorder has periods of exacerbations

and remissions. Patients are usually diagnosed after their first psychotic break that usually

happens in the late teens to late twenties. It is difficult for someone with schizophrenia to cope in

the real world because there is severe deterioration of social and occupational functioning. Most

people with schizophrenia are not able to hold a job or may drop out of school.

The trademark criteria for a diagnosis of schizophrenia is psychosis, or a loss of reality. A

schizophrenic patient will have delusions, hallucinations, or disorganized thinking and speech

such as repeating movements (echopraxia), and words (echolalia) with the purpose of identifying
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with the person they are speaking to. The cause of schizophrenia is not exact but one thing that is

seen is an excess of dopamine in the brain.

Another thing that is common with schizophrenic patients is risky sexual behavior. In

2018, a study was done by Biruk Negash, Bethlehem Asmamewu, and Wondale Getinet Alemu.

Their study states, “The odds of having risky sexual behavior was five times higher among

clients ages 18–24... Possible reasons could be use of substance, psychiatric disorders and risky

sexual behaviors both peak in young adulthood”(p. 5). This age group is the same age group

where the schizophrenic patient has their first psychotic break. Another thing that is common in

this age group as well as someone with a psychiatric disorder is the lack of self esteem which is

also known to cause people to engage in risky sexual behavior.

Identify Stressors and Behaviors

There are a few things that lead to the hospitalization of the patient. The patient

mentioned in an interview that her mother says she should behave in public. Schizophrenia

usually involves poor social functioning and the patient likely feels stressed in public situations

which triggers her to behave abnormally. The weekend prior to hospitalization, the patient had

fallen asleep on the grass at the lake and demonstrated the symptom of somatic delusion when

she believed a snake crawled into her stomach during this time and has been chewing her insides

ever since. The mother of the patient explains that leading up to hospitalization the patient

stopped taking her medication and didn’t make sense at times when she talked. The patient also

had a job loss recent to hospitalization. After the job loss and prior to hospitalization the patient

was lacking self care, hygiene and sleeping excessively. Individuals with schizophrenia have an
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impairment in work and social relations so they tend to not be able to hold a job. The loss of the

job could have precipitated the current state of the patient.

Discuss Patient and Family History of Mental Illness

Patient and family history is a very important thing to look at when it comes to any

mental illness. Schizophrenia does tend to run in families. When we are aware of the patient’s

past history or family history of mental illness we can use that information to predict behaviors.

A 2021 study in the Indian Journal of Psychiatry explains that “significant contributors to

suicidal behavior in schizophrenia include a long period of untreated psychosis, multiple

hospitalizations, the immediate post discharge period, a previous attempt, presence of positive

symptoms and depressive symptoms, and a family history of psychiatric illness and

suicide”(Santanu, p. 2). All of these contributors should be assessed and reviewed by the nurse.

At the age of 22, the patient was in nursing school when she had her first psychotic

break. She never completed the program. The patient requires hospitalization several times a

year for psychotic relapses. In past hospitalizations the patient had auditory delusions of a voice

telling her she is worthless.

The patient also has a history of the grandiose delusion that she is the president of the

world. She gets upset when her family and friends don’t believe her. The patient has a history of

the paranoid delusion that the staff is out to get her and that they have eyes and ears everywhere

as well as a history of somatic delusions. The patient lives with her mother who has no history of

mental illness. The patient’s maternal grandma had a history of schizophrenia and psychotic

breaks. When the patient was ten years old, her father who was an abusive alcoholic left the

family.
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Describe the Psychiatric Evidence Based Nursing Care Provided

A schizophrenic patient usually requires a lifelong need for medications and other

therapies. Medication compliance is important to control psychosis. Medication regimen usually

includes antipsychotics and anti-tremor medications. Since paranoia is likely with schizophrenia,

it is important for the nurse to make sure the patient hasn’t pocketed any of their pills.

On the day of care, all prescribed medications were administered to the patient.

Ziprazidone is an atypical antipsychotic given to the patient twice a day by oral route. Atypical

antipsychotics treat both positive and negative symptoms of schizophrenia. They improve mood,

behavior, and thinking by blocking dopamine and increasing serotonin and norepinephrine.

Venlafaxine is an SSNRI antidepressant given to the patient once a day by oral route.

Antidepressants can improve symptoms in schizophrenic patients by increasing dopamine,

serotonin, and norepinephrine.

Haldol is a first generation antipsychotic given to the patient every four hours as needed

for agitation by oral route. First generation antipsychotics treat only the positive symptoms of

schizophrenia. Haldol works for agitation by blocking dopamine. Schizophrenic patients usually

have sleep disturbances and will either sleep all the time or not sleep at all. For anxiety and

trouble sleeping, Lorazepam is a sedative given to the patient every eight hours as needed for

oral route.

Other nursing care done included vital signs every four hours. Suicide precautions were

continued on the day of care as ordered. The most important thing as the nurse is to keep the

patient and others safe. Other nursing care provided on the day of care was providing pre
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packaged food trays and high calorie finger foods during mania. The patient refused to attend

two group therapy sessions on the day of care.

Analyze Ethnic, Spiritual, and Cultural Influences that Impact the Patient

The 45 year old patient diagnosed with schizophrenia is African American. A 2017

Ethnicity & Health study reveals that there are higher rates of schizophrenia spectrum disorder

amongst African Americans and other minorities. It is known that mental illness is more likely in

areas of poverty. The article states, “Given the high rates of poverty among many African

American communities, it is likely that African Americans experience socioeconomic pressures,

including discrimination, that potentially impact psychological functioning”(Peltier. p. 2). All of

these things the patient has dealt with as a minority impact her.

Culture also has an impact on the patient. The patient’s mother expressed that the patient

did not want to seek help when she was in the prodromal phase because she didn’t want to be

looked at as “crazy” like her grandmother. Because of the stigma there is on schizophrenia she

was afraid to seek help because of how others would view her. The patient does claim to believe

in God, but does not attend church. It is a positive thing that the patient says she believes in God

because religion and spirituality can instill hope in a person.

Evaluate the Patient Outcomes Related to Care

The priority to consider when caring for a schizophrenic patient is to keep the patient and

those around them safe. The safety of others is important to consider because of the paranoia

associated with schizophrenia. The patient was also on suicide precautions on the day of care. On

the day of care the patient and others remained free of harm.
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Another important thing when caring for a schizophrenic patient is to provide adequate

nutrition. The patient was provided with prepackaged food trays. Breakfast intake was 0%,

Lunch intake was 25%, and dinner intake was 25%. The patient has had poor intake since

admission, but is improving with positive reinforcement and by providing high calorie finger

foods throughout the day.

Before admission, the patient was lacking self care and hygiene. Towards the beginning

of admission the patient was refusing showers. On the day of care, encouragement was given to

the patient and she showered and took care of personal hygiene. Positive reinforcement was

given so that the patient will be more likely to continue self care in the future.

Summarize the Plans for Discharge

The first step in planning discharge of the patient is evaluation of the patient’s condition.

It is important to evaluate the patient’s condition upon discharge as compared to admission. The

patient is currently still showing positive and negative symptoms of schizophrenia, a flat affect

and grandiose delusions on the day of care. The patient’s nutrition is improving but still not ideal.

Self care and hygiene were not being done by the patient prior to admission.The patient has been

demonstrating self care and hygiene with positive reinforcement. Nursing goals and outcomes

will continue to be evaluated.

The next step in discharge planning is to have a discussion with the patient and the

mother regarding discharge. The mother is concerned about how the patient will react to

discussion about where she goes after discharge, but it is important that the patient is involved in

all aspects of care. It would be important to have this discussion with the patient when she isn’t

showing signs of agitation and after medication has been given.

An important part of discharge planning includes family and patient education. It is

important to teach the family that this is very real for the patient. The patient should be educated

on schizophrenia so she can better understand and cope with her illness. Another thing that is

included is medication education. The patient should be taught the correct dose, time, purpose,

and side effects of the medications as well as given the information in written format to refer to.

The patient is on two antipsychotic medications. The patient should be aware of the

chance of extrapyramidal symptoms related to antipsychotics and the need to report these

symptoms to their physician. Extrapyramidal symptoms include pseudoparkinsonism

(involuntary tremors), akinesia (absence of movement), akathisia (restlessness and muscle

cramping), dystonia (involuntary muscle contractions that cause repetitive movements), and

oculogyric crisis (affecting the eye). For both typical and atypical antipsychotics, the patient

should be taught the side effects of major weight gain, sexual side effects, neuroleptic malignant

syndrome, dry mouth, and tardive dyskinesia which is irreversible and from long term use.

The patient is on one typical antipsychotic, Haldol. She should be taught the importance

of fluids and fiber as urinary retention and constipation are common. The patient will also be

taught that this medication can cause blurred vision. It is important for a patient taking Haldol or

any antipsychotic to change positions slowly because of the side effect of orthostatic

hypotension. The patient should also be taught that photophobia is a common symptom and that

she should wear protective clothing, sunscreen, and sunglasses when outside.

The patient is on one atypical antipsychotic, Ziprasidone. This medication causes the

highest risk for prolonged interval time so the patient should be taught that it can not be used

with cardiac issues. She should also be taught that common side effects of atypical antipsychotics
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include increased blood sugar, increased cholesterol, and increased triglycerides so follow up

appointments are important to monitor WBC, A1C, and cholesterol.

Serotonin syndrome and neuroleptic malignant syndrome are two very serious side

effects the patient should be aware of. With serotonin syndrome some signs to teach the patient

are a fever under 102 fahrenheit as well as muscle tremors, rigidity, sweating, restlessness, high

blood pressure and tachycardia. Signs of neuroleptic syndrome should be taken very seriously as

the patient could end up in the ICU. The patient should be taught that these signs include a fever

over 102 fahrenheit, shortness of breath, sweating, stove pipe rigidity, and altered mental status.

It is important that the patient knows she should stop taking the medication immediately if she

notices any of these signs. The next step in discharge planning includes working with the case

manager to refer the patient to group homes. Lastly, arranging follow up appointments and tests

is essential for a patient with schizophrenia.

Prioritized List of all Nursing Diagnoses

I. Imbalanced nutrition: less than body requirements r/t disinterest toward food a.e.b.

skipping meals and poor intake.

II. Self care deficit r/t impairment of perception a.e.b. mother as primary caregiver and lack

of personal hygiene

III. Disturbed personal identity r/t psychiatric disorder a.e.b. grandiose delusion that the

patient is the president of the world.

IV. Impaired social interaction r/t impaired thought process a.e.b. somatic, grandiose, and

paranoid delusions.
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V. Impaired verbal communication r/t altered perception aeb disorganized thinking and flat

affect.

VI. Deficient diversional activity r/t social isolation a.e.b. refusing group activities and

self-isolation.

List of Potential Nursing Diagnoses

I. Risk for suicide r/t psychiatric illness

II. Risk for powerlessness r/r intrusive, distorted thinking

III. Risk for self and other-directed violence r/t hallucinations and delusional thinking.

IV. Risk for loneliness r/t inability to interact socially.

V. Risk for caregiver role strain r/t chronicity of condition.

Conclusion

To sum up the information gathered on the patient, she is a 45 year old African American

female with a diagnosis of schizophrenia. The patient has a past history of hospitalizations and

psychosis. There are multiple things that cause someone to be more likely to have schizophrenia

disorder. The patient has a family history of mental illness as her maternal grandmother was

schizophrenic and her father was an alcoholic. Other things that have impacted the patient are

cultural and ethnic influences. The patient has demonstrated multiple symptoms of

schizophrenia. Some of these include a flat affect, the grandiose delusion that she is the

president of the world, the somatic delusion that a snake crawled into her stomach and is eating

her from the inside out, and the paranoid delusion that people are out to get her. The patient is on

both atypical and atypical antipsychotics and medication education is a part of discharge
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planning. It is also important that a patient who is taking antipsychotics is taught the signs of

both neuroleptic malignant syndrome and serotonin syndrome. As the patient’s mother ages and

her sister is moving away, it is necessary to assist the family in making a decision about living

arrangements and referring to a group home.

References

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

planning care. Mosby Elsevier.

Nath, S., Kalita, K. N., Baruah, A., Saraf, A. S., Mukherjee, D., & Singh, P. K. (2021). Suicidal

ideation in schizophrenia: A cross-sectional study in a tertiary mental hospital in

North-East India. Indian Journal of Psychiatry, 63(2), 179–183.

https://doi-org.eps.cc.ysu.edu/10.4103/psychiatry.IndianJPsychiatry_130_19

Negash, B., Asmamewu, B., & Alemu, W. G. (2019). Risky sexual behaviors of schizophrenic

patients: a single center study in Ethiopia, 2018. BMC Research Notes, 12(1), N.PAG.

https://doi-org.eps.cc.ysu.edu/10.1186/s13104-019-4673-6

Peltier, M. R., Cosgrove, S. J., Ohayagha, K., Crapanzano, K. A., & Jones, G. N. (2017). Do they

see dead people? Cultural factors and sensitivity in screening for schizophrenia spectrum

disorders. Ethnicity & Health, 22(2), 119–129.

https://doi-org.eps.cc.ysu.edu/10.1080/13557858.2016.1196650
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