RUNNING HEAD: Depression and schizoaffective disorder

Kaitlin North

Mental Health Nursing

Case Study: Depression and Schizoaffective Disorder

November 9, 2016
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Abstract

While on the psychiatric unit of St. Elizabeths hospital, I took care of a patient with

depression and schizoaffective disorder. In this case study, I will present objective data that

describes the patient, their psychiatric diagnoses, admission and date of care, treatment,

medications, and safety measures employed on the unit. I will describe depression and

schizoaffective disorder, as well as their other diagnoses, and identify the stressors leading up to

their psychiatric commitment, as well as the behaviors they presented with on the unit. I will

present nursing interventions and outcomes for their nursing care, as well as their plans for

discharge. I will analyze any potential cultural, spiritual, or ethnic influences on the patient. I will

also present a prioritized list of nursing diagnoses for the patient, and provide potential

diagnoses.
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Objective Data

My patient was a 48 year old female in a long term relationship with their boyfriend.

They do not work and receive Social Security, and they were recently moved into a nursing

home by their sister. She was admitted on November 7, 2016; the patient called 911 from the

nursing home due to fear of the staff and other residents. The nursing home reports that the

patient was threatening to harm their self and others, was behaving aggressively, pretending to

have seizures, and was behaving inappropriately towards other residents while accusing them of

abusing her. I took care of the patient on November 9, 2016 and interviewed her in the common

room of the unit. Before, during, and after the interview I made sure to observe her behavior. The

patient seemed to be social with the other patients and very open with them and the staff. During

the interview the patient was cooperative and willing to provide information. Their body

language was fidgety but still open, they maintained intermittent eye contact, and their facial

expression was appropriate for the topics discussed. At the end of the interview the patient had a

pseudoseizure, where they sat in their chair upright and appeared to shake their body with their

eyes closed (they did not roll back into their head). I will discuss pseudoseizures more in depth

later in this case study.

Upon admission, a risk assessment and interview were performed. The risk assessment

involves asking about suicidal/homicidal ideations and assessing the seriousness of what they say

(even if the patient does not seem serious, the staff still considers them when planning their

care). The patient made both suicidal and homicidal threats before admission, but did deny any

suicidal/homicidal ideations on the day I took care of them.

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Axis I of the DSM involves psychological diagnoses. This patients axis I included

depression, schizoaffective disorder (bipolar type), and chronic post traumatic stress disorder

(PTSD). Axis II involves personality disorders and developmental disabilities. This patients axis

II included history of auditory and visual hallucinations. Axis III involves any general medical

problems the patient has. This patients axis III included type 2 diabetes mellitus, hypertension,

emphysema, asthma, peripheral neuropathy, and pseudoseizures. Axis IV involves stressors or

precipitating events leading to hospitalization. This patients axis IV included their recent move

to a nursing home and their tense relations with their family as a result of that move. Axis V

involves the Global Assessment of Functioning (GAF) scale, which assesses the patients level of

function in different areas, such as social, occupational, and school functioning. This axis is

something the doctor assesses and it was not noted in this patients chart.

Summary of Psychiatric Diagnoses

This patient was diagnosed with depression, schizoaffective disorder (bipolar type), and

was suffering from chronic post traumatic stress disorder (PTSD). As a result of having multiple

psychiatric diagnoses, this patient was unable to function and maintain normal life processes,

which resulted in their hospitalization. In this area of the case study I will discuss these

diagnoses in detail.

Depression is characterized by an alteration in mood that is expressed by feelings of

sadness, despair, and pessimism. There is a loss of interest in usual activities, and somatic

symptoms may be evident. Changes in appetite and sleep patterns are common, (Townsend,

2015, p. 459). The signs and symptoms of depression can be similar to hypothyroidism, so it is
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important to monitor their TSH and T3 levels to ensure that the diagnosis is correct. This patient

did have their thyroid levels drawn, and came back with normal results.

Schizoaffective disorder is similar to schizophrenia, but it also has the symptoms of a

mood disorder as well as the symptoms of schizophrenia. The signs and symptoms of

schizoaffective disorder include psychomotor retardation, suicidal ideation, euphoria,

grandiosity, hyperactivity, and depressed mood, (Townsend, 2015, p. 428-429). In order for a

patient to be diagnosed with schizoaffective disorder, the patient must exhibit

delusions/hallucinations for at least 2 weeks, and there must be absence of a mood episode

during those 2 weeks (Townsend, 2015, p. 429). In my patients case, their schizoaffective

disorder has characteristics of schizophrenia and bipolar disorder.

Post traumatic stress disorder (PTSD) is a reaction to the distress caused by a traumatic

experience. The symptoms revolve around the traumatic event, and include reexperiencing the

traumatic event, a sustained high level or anxiety or arousal, or a general numbing of

responsiveness, (Townsend, 2015, p. 560). Patients often experience nightmares about the

event, or may even completely block out the memories of the event. My patient has a history of

sexual assault, but did not talk about the assault. When looking in the chart, it became apparent

that the patient did not have a clear memory of the event and may have blocked it out.

Identify Precipitating Stressors and Behaviors

The patient was moved into a nursing home 3 weeks prior to hospitalization by their

sister. Before the move into the nursing home, they were discharged from another hospital, where

guardianship of the patient was attempting to be arranged. This seems to be the precipitating

stressor, and while at the nursing home they were very aggressive towards staff and other
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residents, accusing both of abusing her while exhibiting inappropriate behaviors (such as

flashing her privates to another resident). The patient describes the events leading up to

hospitalization, including describing feeling very afraid for their life, hating their living situation,

and contempt for their family and claiming that they steal her money. She also describes how her

family attempted to break her and her boyfriend of 18 years up. While at the nursing home, she

called 911 and said that she would kill everyone there and burn the place down, which lead to her

going to the hospital and being involuntarily admitted to the psychiatric unit from the emergency

department.

The patient claimed to have a seizure disorder, and while I interview they appeared to

have a seizure. However, they sat perfectly upright in the chair during this seizure, their eyes did

not role back into their head, and after the seizure they were not confused or disoriented. While

this seizure was occurring, the staff on the unit did not react to it. All of this indicated that it was

a pseudoseizure, meaning that it was not a true seizure and may have been a means for attention,

or a delusion.

Patient and Family History of Mental Illness

The patient has been admitted to multiple hospitals over the years for different psychiatric

visits. Their most recent hospitalization was 3 weeks prior to this one, and during that

hospitalization they were looking to get guardianship established over the patient due to inability

to care for oneself. The patient also stated that they have tried to kill themselves previously by

overdose, although they cannot remember when. The patient also stated that they had been raped

years ago (which lead to the PTSD), but again they cannot remember when or the details of the

incident. Currently the patient states that they are being sexually harassed and abused at the
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nursing home, and has preoccupied thoughts of sexual activities occurring at the nursing home.

The patient does not have good relations with their family and refuses to talk in depth about

them, and instead only talks of their actions against her and her boyfriend. The chart does not

allude to any family history of mental illness.

Psychiatric Evidence Based Practice

Nursing care on the psychiatric unit includes milieu therapy, where specific structuring of

the environment is meant to facilitate psychological improvement (Townsend, 2015). The milieu

is meant to be an environment where everything they experience during the hospitalization is

therapeutic. It is also meant to be a setting in which the patient can learn how to effectively

function, and have opportunities to adapt their behaviors to cope with whatever may causing

them distress (Vatne & Hoem, 2008). An important part of milieu therapy has to do with

interpersonal relationships, especially the nurse-patient relationship, and on the unit I noticed that

the nurses put a lot of emphasis on reminding the patients to go to them if anything is wrong.

Many of these patients have issues in their personal relationships, so learning how to form a

positive relationship with others is an important part of their hospitalization (Vatne & Hoem,

2008).

It also includes maintaining a safe environment for the patients. When the patient is first

admitted, they are checked for any objects that they can potentially harm themselves with, such

as a metal nail file, any possible weapons, or a pill stash to prevent overdose. Some more safety

measures on the unit include the way the unit was built. The doors are slanted to prevent patients

from hanging themselves, and they have sensors on the top of the non-slanted doors in case

anything gets put on top of the door. The mirrors are made of reflective steel so that the patients
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cannot break them to cut themselves. The silverware is plastic, and the staff check the trays on

return to ensure the patients are not hoarding any silverware to make a weapon. The staff also

perform head counts every 15 minutes to account for every patients whereabouts.

Ethnic, Spiritual, and Cultural Influences

Consideration of a patients ethnic, spiritual, and cultural beliefs and influences on

their life are important when assessing the patient and how they view mental health. In order to

assess the patients views, the nurse must first evaluate their own personal views and beliefs.

They also need to ask the patient about their views in order to care for them, because a holistic

approach to nursing is involves the nurse [maintaining] an open attitude and uses skills and

interventions that are culturally appropriate, (Wilson, 2008, p. 716). My patient was a white

female that did not identify with any specific ethnic group. Due to their troubled life, they felt

that God did not care about them and the patient no longer believed in God. My patient did

identify with the biker lifestyle, and for them this was their culture. When asked about their life

as a motorcycle rider, they became visibly happy and excited to talk about it.

Evaluate Patient Outcomes

Outcomes for the patient are meant to be realistic, and in order to make outcomes you

must first assess the patient and what they would realistically be able to achieve, while helping

the patient return to normal functioning. The first goal for the patient was decreased suicidal and

homicidal ideations, because while at the nursing home they were continually threatening to

harm their self and the staff. The goal for suicidal ideation was achieved, as they stated in the

interview that they no longer wanted to harm them self. The goal for homicidal ideation was not

met yet, because they were still adamant on not liking the staff of the nursing home if they went
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back there, and while they did not directly say that they would harm the staff, the patient still

held animosity towards them. Another goal for the patient was decreased frequency of

hallucinations, and during the interview they reported not having hallucinations that day. An

important goal for this patient was to implement an improved support system, because they have

a lot of tense personal relationships. Going along with that goal was having the patient attend

family therapy in order to improve upon those relationships.

Summarize Discharge Plans

Similar to any hospital stay, discharge planning is started when the patient is first

admitted. An important part of discharge planning for this patient was medication compliance.

This patient was on a long list of medications for various reasons, including antidepressants,

antipsychotics, and anticonvulsants. The patient is taking sertraline (Zoloft) for depression,

topiramate (Topomax) and zonisamide (Zonegran) for their seizures (although they have

pseudoseizures), risperidone (Risperdal) for schizoaffective disorder, and haloperidol (Haldol)

and hydroxyzine (Vistaril) for anxiety and agitation, as well as an antidiabetic and

antihypertensive. Many psychiatric patients have problems with medication compliance for a

variety of reasons, including financial issues, addiction due to self medicating, lack of

transportation to appointments to refill the prescriptions, as well as many other reasons. This

pattern of medication discontinuation has ramifications, given that non-adherence has been

associated with increased rates of relapse, rehospitalization and self-harm, (Stomski, Morrison,

& Meehan, 2016, p. 370). Because they are on an antipsychotic and antidepressant, it is

important to monitor for side effects and adverse reactions, such as increased energy leading to

increased ability to commit suicide (also teaching lag time). It is especially important to monitor

for tardive dyskinesia since it is irreversible and chronic.

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Another important for this patients discharge planning was setting up outpatient

counseling for when they leave the unit, and especially family counseling since their family

relations are tense at this point in time. The patient has poor insight and judgment, as well as

unrealistic goals for them self so outpatient counseling will be very beneficial in facilitating them

to set more realistic goals for their life.

Prioritized List of Actual Nursing Diagnoses

1. Anxiety r/t change in home environment AEB feelings of fear and helplessness
2. Ineffective coping r/t inadequate family support AEB destructive behavior

towards self and others

3. Dysfunctional family processes r/t lack of problem solving skills AEB anger,

chronic family problems, pattern of rejection, and impaired communication

4. Fear r/t separation from support system in new home environment AEB increased

tension, dread, attack behaviors, and narrowed focus on the source of fear

(preoccupied thoughts on sexual harassment)

List of Potential Nursing Diagnoses

1. Risk for suicide r/t disturbed interpersonal relationships, inadequate coping,

hallucinations, feelings of depression, and previous suicide attempt

2. Risk for poisoning r/t suicide attempt by overdose, emotional instability, and

ineffective coping
3. Risk for disturbed personal identity r/t dysfunctional family processes,

schizoaffective disorder and depression, and situational crisis (moved into nursing

home)
4. Risk for acute confusion r/t use of psychoactive drugs (current tobacco user,

former user of cocaine, LSD, and marijuana) and use of multiple medications
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References
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Stomski, N. J., Morrison, P., & Meehan, T. (2016). Mental health nurses views about

antipsychotic medication side effects. Journal Of Psychiatric & Mental Health

Nursing, 23(6-7), 369-377.

Townsend, M.C. (2015). Psychiatric mental health nursing: Concepts of care in evidence-based

practice (8th ed.). Philadelphia, PA: F.A. Davis

Vatne, S., & Hoem, E. (2008). Acknowledging communication: a milieu-therapeutic approach in

mental health care. Journal of Advanced Nursing, 61(6), 690-698. doi:10.1111/J.1365-

2648.2007.04565.X

Wilson, D. W. (2010). Culturally competent psychiatric nursing care. Journal of Psychiatric and

Mental Health Nursing, 17(8), 715-724. doi:10.1111/J.1365-2850.2010.01586.X