567922748-schizophrenia-case-study.docx

psy

1. Running head: SCHIZOPHRENIA: CASE STUDY 1
Schizophrenia: Case Study



Ashley C Graf
Centofanti School of Nursing: Youngstown State University
NURS 4842: Mental Health Nursing
Mrs. Teresa Peck
November 26, 2021

2. SCHIZOPHRENIA: CASE STUDY 2
Abstract
Schizophrenia is a common, severe mental illness that many clinicians will encounter during
their practice. Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions,
movements, and behaviors. Schizophrenia is often diagnosed in between the age of 15-25 years
of age for men and 25 to 25 years if age for women (Videbeck, 2020). Schizophrenia can be
defined as having positive or negative symptoms. Positive symptoms are the presence of
hallucinations, delusions, or disorganized speech, thought, or behavior. Negative symptoms are
the lack of symptoms such as flat affect, avolition, and social withdrawal or discomfort. Typical
and atypical antipsychotics are the drug of choice for treatment; however, these drugs do not
come without side effects.

3. SCHIZOPHRENIA: CASE STUDY 3
Schizophrenia: Case Study
Objective Data
Client is a 45-year-old female who presented to Emergency Room 10 days ago
accompanied by her mother with whom the client lives with. Mother is concerned that client has
stopped taking her medications, has been displaying paranoia, and has had decreased motivation.
Mother also states client has not been showering, has been sleeping a lot, and not making sense
when talking. Client recently lost her job as a shelf stocker at Walmart. Client lives with her
mother and sister. Mother is legal guardian and controls clients’ finances. Client has a past
medical history of schizophrenia with multiple relapses over the years requiring hospitalization.
On day of care, client presented for interview and is sitting in chair across from
interviewer. Client appears to have recently showered and is wearing clean clothing that is
appropriate for the season. Hair is neatly groomed and pulled back in a ponytail. Client appears
stated age. Height and weight are within normal limits. Client maintained good eye contact
throughout interview. Client shows no signs of tremors, rigidity, tics, or extra movements.
Client’s gait is within normal limits. Client is cooperative in answering questions but suspicious
and defensive. During the interview client blocked questioning and stated, “I have to go, I have
lots to do”. Client has a broad affect and appears confident in her answers. Client appears to be
having grandiose delusions as she believes she is the president of all countries and that she was
appointed yesterday. Client appears irritable and feels she is unappreciated and that nobody
cares. Client denies hallucinations but client has been noted talking and gesturing to self while on
the unit. Client denies suicidal and homicidal ideation.

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Laboratory studies were obtained on admission to the Emergency Room including basic
metabolic panel, complete blood count, TSH/T4 level, urine drug screen, alcohol level, and 12-
lead EKG. All labs within normal limits. QTc at 404ms.
Client is currently prescribed Ziprasidone (Geodon) 40 mg orally twice a day for
psychosis. 12-lead EKG must be checked 3 days after starting to check for QTc prolongation.
Clients repeat EKG showed an increase in QTc to 512 and Ziprasidone was held. Client is
prescribed Venlafaxine XR (Effexor XR) 75 mg orally daily for depression. Client is prescribed
Haloperidol (Haldol) 5 mg orally or IM every 4 hours PRN for agitation along with Lorazepam
(Ativan) 2 mg orally every 8 hours PRN for anxiety while on the unit.
Safety on the psychiatric floor includes removing all personal property from the client,
clients may have some personal clothing if they do not have strings, belts, shoelaces or bows.
Clients are not allowed to have pens, pencils, scissors, knifes, razors, or anything sharp. Plastic
utensils are provided for meals and counted upon return. Clients are visually assessed client
every 15minutes. Client rooms have a box bed made from wood that is bolted to the ground. All
rooms have shelves and no closest with doors or a place to hang clothing. Call lights are either
buttons or have a very short cord to prevent strangulation. Shower doors and rooms are locked
and must be unlocked by a staff member. Showers do not have curtains. Automatic plumbing is
installed in bathrooms and no plumbing is visible. The bathroom mirrors are polished steel. Tash
bags are made of paper to prevent suffocation. All areas within the unit are video monitored
except for bedrooms, showers, and bathrooms. Windows are made of bullet proof plastic and
screwed into the frames with special bolts. To enter the unit there are two locked doors to
prevent elopement. The entrance to the unit has a window so you can see what is ahead. When

5. SCHIZOPHRENIA: CASE STUDY 5
entering the unit, you must face forward and when leaving you must leave with your back
against the door to watch for clients attempting to leave.
For personal safety, do not get trapped in a room alone, if you are alone, you should keep
a leg length away and always be between the client and the door. Know what your escape route
is if something were to happen. All interactions with clients should take place in a public area
and not in patient rooms. Take another staff member with you or let another staff member know
where you will be. Identification badges should be on a clip and not a reel. Do not reveal last
name or personal details, and do not accept social media requests or invites to social events.

Summary of Psychiatric Diagnoses
The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American
Psychiatric Association, 2013) is the most widely accepted nomenclature used by clinicians and
researchers for the classification of mental disorders.
The DSM-5 Diagnosis Criteria for Schizophrenia states, under criterion A, that the client
must procession two (or more) of the following symptoms, delusions, hallucinations,
disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms. Each of
these symptoms must be present for significant portion of time during a 1-month period (or less
if successfully treated). At least one of symptoms must be delusions, hallucinations, or
disorganized speech.
Under Criterion B, for a significant portion of the time since the onset of the disturbance,
the level of functioning on one or more major areas, such as work, interpersonal relationships, or
self-care, is markedly below the level achieved prior to the onset.

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Under Criterion C, there must be continuous signs of the disturbance persisted for at least
6 months. This 6-month period must include at least one 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 in Criterion A present in an attenuated form (e.g., off beliefs, unusual perceptual
experiences).
Under Criterion D, Schizoaffective disorder and depressive or bipolar disorder with
psychotic features have been ruled out because either (1) no major depressive or manic episodes
have occurred concurrently with the active-phase symptoms or (2) if mood episodes have
occurred during active-phase symptoms, they have been present for a minority of the total
duration of the active and residual periods of the illness.
Under criterion E, the disturbance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication), or other medical condition.
Under Criterion F, if there is a history of autism spectrum disorder or a communication
disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent
delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also
present for at least 1 month (or less if successfully treated).
Unusual speech patterns associated with Schizophrenia include clang association,
neologism, verbigeration, echolalia, stilted language, perseveration, and word salad. Clang
associations are the ideas that are related to one another based on sound or rhyming rather than
meaning. Neologisms are words invented by the client and have no meaning to anyone but the
client. Verbigerations is the stereotyped repetition of words or phrases that may or may not have

7. SCHIZOPHRENIA: CASE STUDY 7
meaning to the listener. Echolalia is the client’s imitation or repetition of what the nurse says.
Stilted language is the use of words or phrases that are flowery, excessive, and pompous.
Perseveration is the persistent adherence to a single idea or topic and verbal repetition of
sentence, phrase, or word, even when another person attempts to change the topic. Word salad is
a combination of jumbled words and phrases that are disconnected or incoherent and make no
sense to the listener (Videbeck & Miller, 2020).
Delusions can be classed into categories to include persecutory/paranoid, grandiose,
religious, somatic, sexual, nihilistic, or referential. Persecutory/paranoid delusions involve the
client’s belief that “others” are planning to harm him or her or are spying, following, ridiculing,
or belittling the client in some way. Grandiose delusions are characterized by the client’s clam to
association with famous people or celebrities, or the client’s belief that he or she is famous or
capable of great feats. Religious delusions often center arounds the second coming of Christ or
another significant religious figure or prophet. These religious delusions appear suddenly as part
of the client’s psychosis and are not part of his or her religious faith or that of others. Somatic
delusions are generally vague and unrealistic beliefs about the client’s health or bodily functions.
Factual information or diagnostic testing does not change these beliefs. Sexual delusions involve
the client’s belief that his or her sexual behavior is known to others; that the client is a rapist,
prostitute, or pedophile or is pregnant; or that his or her excessive masturbation has led to
insanity. Nihilistic delusions are the client’s belief that his or her organs aren’t functioning or are
rotting away, or that some best part or feature is horribly disfigured or misshapen. Referential
delusions or ideas of reference involve the client’s belief that television broadcasts, music, or
newspaper articles have special meaning for him or her (Videbeck & Miller, 2020).

8. SCHIZOPHRENIA: CASE STUDY 8
Stressors and behaviors
Client recently lost her job as a self-stocker at Walmart. Client’s mother believes she has
stopped taking her medications. Client has recently been displaying increased paranoia, and
decreased motivation. Client has been sleeping more, not showering, and not making sense when
she talks.

Patient and family history
Client graduated from high school and started college to become a nurse. Client had her
first psychotic break at 22 years old and never completed her college program. Client has a
history of relapses into psychosis several times each year that have required hospitalization.
Client has a history of auditory hallucinations of a mean female voice telling her she is
worthless. Client has a history of somatic, grandiose, and paranoid delusions.
Family history includes a father who was a mean alcoholic who left when the client was
10 years old.

Describe the psychiatric evidence-based nursing care provided
Client refused to attend 2 group sessions and ate none of her breakfast. Client is concerned that
the staff is trying to poison her. Client also believes the staff are trying to hurt her. Client has
displayed both positive and negative symptoms of Schizophrenia.
Client has showered with encouragement. Client slept for 10 hours the previous night and
has been taking naps during the day. Client care is to provide prepackaged meals to encourage
nutritional intake, encourage medication compliance, reduced the need for naps, and increase
social interaction.

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Analyze ethnic, spiritual, and cultural influences
Client states she believes in God but does not attend Church. Client spiritual and cultural
influences were not discussed.

Evaluate the patient outcomes
Client has shown positive steps by showering with encouragement. Client will continue
to shower daily with encouragement, progressing to needing no encouragement.
Client did not eat her breakfast and ate 25% of her lunch. Client will need to increase
nutritional intake to meet daily nutritional requirements. Prepackage meals to be provided to
deter thinking that staff is trying to poison her.
Client refused to attend two group sessions and preferred to stay in her room. Client
needs to start to show interest in attending group and interacting with other clients to increase
socialization.
Client will continue medication regimen and understand the need for medication, side
effects of medication, and schedule of medication.
Client is sleeping 10 hours a night and taking naps throughout the day. Client needs to be
encouraged to be out of her room during the day and engaging in care plan of attending groups,
eating meals, and interacting with others.

Plans for discharge
Planning for discharge is to include finding somewhere for client to stay. Mother has
expressed interest in a group home setting due to her age and other daughter getting married.

10. SCHIZOPHRENIA: CASE STUDY 10
Client is to understand medications and need for compliance with medications to prevent
recurrence of symptoms. Client will increase socialization and attend two group sessions daily
for a week. Client will display positive coping skills and social interactions. Client will meet
with social worker to start application for a new job to provide income and way to socialize.

Prioritized list of all actual diagnoses
Risk for other-directed violence due to paranoia as evidenced by paranoid delusions
Risk for self-directed violence due to delusions/hallucinations as evidenced by female voice
telling client she is worthless.
Risk for suicide due to internal stimulation as evidenced by female voice telling client she is
worthless.
Disturbed thought processes due to paranoia as evidenced by client believing public messages
are for her.
Disturbed thought processes due to referential delusions as evidenced by client believing public
messages are for her.
Disturbed personal identity due grandiose delusion as evidenced by client believing she is the
president of all countries.
Risk for deficient nutritional intake due to paranoia as evidenced by not eating because client
believes food is poisoned.
Social isolation due to lack of trust as evidenced by increased sleep, staying in room, and not
eating.
Self-care deficits due decreased hygiene care as evidenced by not showering.

11. SCHIZOPHRENIA: CASE STUDY 11
Care giver role strain due to family dynamics as evidenced by aging mother/caretaker and sister
getting married.

List of potential nursing diagnoses
Ineffective activity planning due to compromised ability to process information.
Anxiety due to unconscious conflict with reality.
Impaired verbal communication due to psychosis and delusions.
Ineffective coping due to unrealistic perceptions, inadequate coping, and disturbed thought
processes.
Deficient diversional activity due to social isolation.
Interrupted family processes due to impaired communication.
Fear due to altered perception of reality.
Ineffective health maintenance due to cognitive impairment.
Impaired home maintenance due to paranoid delusions.
Ineffective family health management due to chronicity and unpredictability of condition.
Hopelessness due to long-term stress from chronic mental illness.
Disturbed personal identity due to psychiatric disorder.
Impaired memory due to psychosocial condition.
Sleep deprivation due to intrusive thoughts.
Spiritual distress due to loneliness.
Readiness for enhanced hope expressed by desire to problem-solve to meet goals.
Readiness for enhanced power expressed by willingness to enhance participation in choices for
daily living and health.

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Conclusion
Schizophrenia is conceptualized as a psychotic disorder with delusions, hallucinations,
and disorganized speech being the core “positive symptoms” diagnosed (Tandon et al., 2013).
These positive symptoms are often the reason the patient presents to the clinician. However, the
disorder is also associated with negative symptoms, such as amotivation and social withdrawal,
and cognitive symptoms, including deficits in working memory, executive function, and
processing speed (McCutcheon et al., 2020).
Schizophrenia typically appears in early adulthood. It has a lifetime prevalence of about
1% and accounts for a huge health care burden, with annual associated costs in the United States
estimated to be more than %150 billion (McCutcheon et al., 2020). Such high costs are attributed
to the early onset of the disease along with the long-term impairments in social and occupational
function (McCutcheon et al., 2020).
Overall, someone diagnosed with schizophrenia has a mean life expectancy of 15 years
shorter than the general population and a 5% to 10% lifetime risk of death by suicide
(McCutcheon et al., 2020).
When it comes to treatment, antipsychotics are the first line drug of choice. In the past,
typical antipsychotics were the choice as they were effective for the positive symptoms for most
patients but have little benefit for negative and cognitive symptoms (McCutcheon et al., 2020).
More recently, the development of atypical antipsychotic has become the leader in drug choice.
This is because they have a reduced risk of EPS, generally improved tolerability, and good
efficacy (Perkins, 2002).

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For many patients’ compliance is an issue. Patient compliance is defined as the extent to
which a person’s behavior coincides with the medical advice he or she has received (Perkins,
2002). Poor compliance or noncompliance with treatment is one of the most important factors
affecting treatment of schizophrenia. Many times, poor compliance or noncompliance is strongly
associated with an increase in relapse, greater likelihood of hospital admission, and a longer
duration of hospitalization once admitted (Perkins, 2002).
Medication side effects are also a reason for reduced compliance. Typical and atypical
antipsychotics, like all medications, have side effects, some less desirable than others. Side
effects associated with atypical antipsychotics include weight gain (and related risks of
cardiovascular disease, osteoarthritis, diabetes, social consequences), endocrine abnormalities
(e.g., hyperglycemia, hyperlipidemia, diabetes, hyperprolactinemia), and cardiovascular side
effects (Perkins, 2002). Research suggests that extrapyramidal side effects (EPS) and the related
phenomena of neuroleptic dysphoria, sedation, weight gain, and sexual dysfunction are the side
effects most likely to have negative effects on compliance with antipsychotic medication
(Perkins, 2002).
The appearance of EPS is a frequent reason for noncompliance. EPS can be divided into
4 groups: akinesia or rigidity (Parkinsonism), akathisia (an intense subjective feeling of
restlessness, often manifested as relentless physical activity such as pacing or marching on the
spot), dystonia (abnormal muscle tone or muscle spasms), and dyskinesia (abnormal involuntary
movements) (Perkins, 2002). While the risk of EPS is reduced with the use of atypical
antipsychotics, there is still the chance of development.

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References
American Psychiatric Association. (2013) Diagnostics and statistical manual of mental disorders
(5
th
ed). https://doi.org/10.1176/appi.books.9780890425596

McCutcheon RA, Reis Marques T, Howes OD. Schizophrenia—An Overview. JAMA
Psychiatry. 2020;77(2):201–210. doi:10.1001/jamapsychiatry.2019.3360

Perkins, D. O. (2002). Predictors of noncompliance in patients with schizophrenia. The Journal
of Clinical Psychiatry, 63(12), 1121–1128. https://doi.org/10.4088/jcp.v63n1206

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. Schizophrenia Research, 150(1), 3–10.
https://doi.org/10.1016/j.schres.2013.05.028

Videbeck, S. L., & Miller, C. J. (2020). Psychiatric-Mental Health Nursing (8th ed.). Wolters
Kluwer.