MENTAL HEALTH COMPREHENSIVE CASE STUDY 1

Mental Health Comprehensive Case Study

Alli Giambattista

December 1, 2021

Mrs. Teresa Peck, MSN, RN

NURS 4842L Mental Health Nursing Laboratory

Youngstown State University

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Abstract

The following case study discusses the case of a schizophrenic patient and her plan of care. The

study is focused on JW, a 45-year-old female, that was brought to the emergency room by her

mother because of medication noncompliance and increased paranoia. JW has a psychiatric

diagnosis of schizophrenia with a history of paranoia, delusions, and hallucinations. She was

admitted to the inpatient psychiatric unit and was put on suicide and unit precautions. During her

hospital stay, JW’s medication regimen included antidepressants, antipsychotics, and sedative

agents. Nursing care included a combination of therapy and pharmacologic methods.

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Objective Data

Patient identifier: JW

Age: 45

Sex Female

Date of admission: November 21, 2021

Date of care: December 1, 2021

Psychiatric diagnosis: Schizophrenia

Other diagnoses: Possible hypertension

Behaviors on admission: JW presented to the emergency room accompanied by her mother.

Mother states that the patient has stopped taking her medications and has been less motivated

and more paranoid. On admission, JW was experiencing catatonia, associative looseness, flat

affect, and concrete thinking.

Behaviors on day of care: JW stayed in her room and refused to participate in group therapy.

She ate none of her breakfast and only 25% of her lunch. During lunch, she demonstrated

paranoia and claimed that staff is “trying to poison her.” She believes that staff is trying to hurt

her. When JW was interviewed today, she was experiencing grandiose delusions and claiming to

be the “president of all the countries.” In contrast to her behavior on admission, JW had a normal

affect and appeared to have more energy.

Safety and security measures: Since JW was admitted to an inpatient psychiatric unit, normal

unit precautions were put into place. These include visual checks every 15 minutes, removal of

dangerous/hazardous items, and restricted phone access. Other safety features of the inpatient

unit include slanted door corners, no shower curtains, two locked doors at entrance/exit of unit,

paper trash bags, no bed rails, and no visible plumbing. In addition to these precautions, another
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security measure that is taken on the unit is the procedure of medication administration. The

nurse verifies all medications and makes sure that they are swallowed.

Laboratory Results

Potassium 3.9

Sodium 140

Glucose 92

Blood Urea Nitrogen 18

Creatinine 0.7

Hemoglobin/Hematocrit 15.5/43

White Blood Cells 7

TSH/T4 WNL

Drug Toxicology Negative

UA Alcohol Level <0.03

QTC 404  512

Psychiatric Medications

Generic Name Trade Name Dose Route/Frequency Classification Reason pt

receiving
Ziprasidone Geodon 40mg PO BID Antipsychotic Schizophrenia

Venlafaxine XR Effexor 75mg PO daily SSNRI Increase mood

Haloperidol Haldol 5mg PO Q4hr PRN Antipsychotic Agitation

Haloperidol Haldol 5mg IM Q4hr PRN Antipsychotic Agitation

Lorazepam Ativan 2mg PO Q8hr PRN Sedative Anxiety

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Summary of Psychiatric Diagnosis

Schizophrenia is chronic brain disorder that includes a variety of symptoms. This disorder is

rarely seen in children. The usual diagnosis is during late adolescence and early adulthood.

According to the American Psychiatric Association, less than one percent of the United States

population is affected by schizophrenia. In the past, schizophrenia has been misunderstood. The

complexity of the disorder causes misconceptions, but “most people with schizophrenia are not

any more dangerous or violent than people in the general population” (Torres 2020). There is

more research available now that can help people have a better understanding of the brain

disorder. There is no single cause for schizophrenia, it is a mix of different factors including

genetics, neurochemicals and neuroanatomy.

This disorder causes distorted perception, emotions, movements, behaviors, and bizarre

thoughts. The symptoms that these people experience are divided into two categories, positive

and negative. The positive symptoms can be defined as the presence of unhealthy behaviors.

Examples of these include delusions, hallucinations, disorganized thinking, and bizarre behavior.

The negative symptoms can be defined as absence of healthy behaviors. Examples of these

include alogia, anhedonia, flat affect, catatonia, and avolition.

In order to be diagnosed with schizophrenia, a doctor needs to perform a complete

medical history and physical examination. The criteria for this diagnosis would be met when

"two or more of the following, each present for a significant portion of time during a 1-month

period: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic

behavior, or negative symptoms (affective flattening, alogia, or avolition)” (Tandon et al., 2013).

Treatment options for patients with schizophrenia include therapy and

psychopharmacology. The medication of choice is antipsychotics. Both typical and atypical

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antipsychotics are used for this disorder, and they treat the positive and negative symptoms that

the patients experience.

Identification of stressors and behaviors precipitating current hospitalization

JW’s history of mental illness began at 22 years old when she had her first psychotic

break. After that, she has had relapses into psychosis several times each year that required

hospitalization. She has a history of auditory hallucinations and delusions but has denied having

any on this admission; however, staff has reported that she has been gesturing and talking to an

empty room. She lives with her mother, who is her legal guardian. Her mother brought JW into

the emergency department because she was displaying increased paranoia and was becoming less

motivated. She has been lacking hygiene, sleeping a lot, and not always making sense when she

speaks. Her mother believes that JW has stopped taking her medications. JW did not state that

she has issues living with her mother, but during her interview she acted annoyed with her

mother which could mean potential disagreements. Noncompliance with her psychiatric

medications has been JW’s greatest issue.

Patient and family history of mental illness

JW had her first psychotic break when she was 22 years old. She has a history of

delusions and auditory hallucinations. The auditory hallucination that she experiences was

described as a “mean female voice telling me she is worthless.” There is no recorded history of

mental illness in JW’s mother. Her father, who left when she was 10 years old, is reported to be

an alcoholic. JW’s living situation is currently at home with her mother and sister.
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Psychiatric evidence-based nursing care provided

During JW’s inpatient stay, safety is the priority. Paranoia and suspicions can cause a

patient to act out against the hospital staff. It is important to make JW feel safe during her stay.

Staff can do this by giving plenty of personal space, giving prepackaged food and drinks, and

being observant for any increase in agitation or aggression. In addition to safety, it is important

for the nurses to form a trust between them and the patient. Clear and direct communication

along with active listening can be helpful for this. If JW is experiencing a delusion or

hallucination, reorientation and distraction should be used.

Other ways that the nurses provide care for JW is being aware of the side effects that her

antipsychotics may cause and teaching self-care. JW was having issues with personal hygiene

upon admission, so it is important to encourage showering, changing clothes, and proper

nutrition. JW might also have issues with social skills, so the hospital staff could work with her

to improve that. Through the use of role modeling, practice, and education JW can become less

socially isolated.

Another significant item of care for JW is the teaching of medication compliance. Upon

admission, she was having issues with complying. Medication noncompliance is a huge issue

with schizophrenic patients. There are many reasons a patient may not adhere to their

medication regimen, so the nurse should work to determine the barriers for JW.

Lastly, it could be very helpful for patients with schizophrenia to follow a schedule.

While staying on the inpatient psychiatric unit, JW will be following the daily schedule that is

posted on the wall each morning. This schedule includes the times for mealtimes, personal care,

group sessions, and other activities.

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Ethnic, spiritual and cultural influences

JW is a 45-year-old Caucasian, single woman. She has never been married and has no

children. She graduated from high school and began college for nursing. However, she

experienced her first psychotic break at 22 years-old and never completed nursing school. Over

the years, she has held down part-time jobs. She was most recently employed at Walmart as a

shelf-stocker but was has been laid off. She currently lives at home with her mother and sister.

Her mother is her legal guardian and controls her finances. JW claims that she believes in God,

but does not actively attend church.

Evaluation of patient outcomes

The outcomes for schizophrenic patients can vary based on what phase they are in. If they are

experiencing an acute psychotic episode, it is likely that they will need hospitalization. A few

examples of outcomes for patients during this time can include:

 The patient will participate in prescribed therapeutic interventions.

 The patient will establish contact with reality.

 The patient will not injure themselves or others.

 The patient will participate in self-care activities.

During her stay, it is important that JW reaches these outcomes. She has already started

showering again with encouragement, so it is hopeful she continues to move in the right

direction.

Other outcomes for the continued care of schizophrenic patients after stabilization can

include:

 The patient will seek assistance when indicated.

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 The patient will demonstrate independence in self-care activities.

 The patient will participate in the prescribed treatment plan.

Overall, JW has already started working towards these goals, but it is important for her to keep

working. She used to be able to hold a job down, so with compliance of treatment, she might be

able to start working again.

Plans for discharge

There is currently not a set plan for JW’s discharge, but it has been discussed with her

mother. Once medications are adjusted and she becomes stable again, her mother states that she

can move back home. Also, since mom is getting older and sister is moving out soon, she stated

that she would be interested in learning more about the group home setting and how it works.

Education will be provided, and social work will be consulted to discuss all discharge options.

Priority Nursing Diagnoses

1. Disturbed thought processes related to mental illness as evidenced by delusions and

paranoia.

2. Disturbed sensory perception related to altered sensory perception as evidenced by

hallucinations and altered communication pattern.

3. Ineffective health maintenance related to loss of reality as evidenced by noncompliance

with medications.

4. Defensive coping related to suspicions of the motives of others as evidenced by hostility.

5. Risk for violence related to delusions and hallucinations.

6. Risk for self-harm related to delusions and hallucinations.

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Other Potential Nursing Diagnoses

1. Self-care deficit

2. Interrupted family process

3. Impaired social interaction

4. Anxiety

5. Ineffective coping

6. Ineffective activity planning

7. Impaired verbal communication

8. Fear

9. Hopelessness

10. Impaired memory

11. Social isolation

Conclusion

Schizophrenia is a chronic illness that will require life-long management. Throughout the

course of this illness, the patient will experience exacerbations and remissions. It is important to

keep safety as the priority of these patients, especially during exacerbations because they can

become a danger to themselves and others.

The use of different supportive treatments can significantly improve these patients’

quality of life. The different options can include individual psychotherapy, group therapy,

behavior therapy, social skills training, milieu therapy, and family therapy. Group and individual

therapy sessions can give the patient a chance to socially interact and form relationships with

other people. Social skills training can include working on eye contact, voice tone, and role-
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playing situations. With the use of psychopharmacology and therapy, it is hopeful that JW will

stay compliant with this medication regimen and continue to make progress towards normal

functioning.
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References

Tandon, R. (2013). Definition and description of schizophrenia in the DSM-5. Schizophrenia

Research. Retrieved December 1, 2021.
https://cpb-us-w2.wpmucdn.com/sites.wustl.edu/dist/1/1008/files/2017/10/2013_defdes-
2510lj0.pdf. 

Torres, F. (n.d.). Schizophrenia. American Psychiatric Association. Retrieved December 1, 2021.

https://www.psychiatry.org/patients-families/schizophrenia/what-is-schizophrenia.