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Case Study

Schizophrenia with Acute Psychosis

By: Marissa Buchenic

Youngstown State University

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Abstract

During my shift on psychiatric unit at Trumbull Memorial Hospital, I took care of a patient who

was diagnosed with paranoid schizophrenia with acute psychosis. Throughout this paper, I will

identify objective data which describes my patient’s date of admission, date of care, psychiatric

diagnosis, behaviors on admission and day of care, medical conditions and treatments, safety and

security measures maintained and prescribed by psychiatric medications. Next, I will summarize

paranoid schizophrenia , identify stressors and behaviors that precipitated his hospitalization,

discuss patient and family history of mental illness, describe psychiatric evidence based nursing

care provided to this patient on the day of care, analyze ethnic, spiritual, and cultural influences

that impact my patient, evaluate the patient outcomes related to care, summarize the plans for

discharge, prioritize a list of actual diagnosis using individualized NANDA format and list

potential nursing diagnosis for my patient.

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Objective Data

My patient RH, was a 40 year old, white, unemployed, single male. He doesn’t have any

children and lives alone. He was admitted on Wednesday, September 12, 2018. He was

readmitted in less than 30 days from discharge on 8-31-18. I took care of him on Tuesday,

September 18, 2018. Patient was pink slipped, acutely psychotic. Patient is paranoid, talking to

unseen others, and reports hearing voices. Patient’s mother reports patient has not been taking his

medications. His diagnosis is (paranoid) schizophrenia- chronic condition with acute

exacerbation. Some medical diagnoses are acute psychosis, chronic schizophrenia, hypokalemia,

Diabetes Mellitus type 2, hyperglycemia, acute kidney injury (nontraumatic), and morbid

obesity. A risk assessment is to be performed during the interview with the patient which

includes asking the patient if he has any suicidal or homicidal ideations. Upon admission is was

noted that he had poor self care, wasn’t sleeping well, and had some medication issues.

On the day of care, my patient was dressed in clothing offered by the hospital. He did not

have any intention of trying to commit suicide or homicide. He appeared unkept and he had a flat

affect. He seemed pretty relaxed while talking with him and his dress was very careless.A

physical characteristic that I noticed, was excessive yawning. He stated that he slept pretty good

last night, although he seemed to be overly tired. He seemed to open up as the conversation went

on. Patient talked about how he would forget to take his medications. He said he lives alone in

Warren. He also told a story about how on his birthday, he went out somewhere, downtown

Warren, and he happened to drink a lot. His ideas were all over the place and he was a little

hesitant on all the details, possibly because he couldn’t remember it all. He told me how knew it

wasn’t a good idea to consume alcohol while on his medications, but he said he wanted to
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celebrate his birthday and was willing to deal with what was to come. It seemed as if he drank

excessively on that day of his birthday. As he continued on with his story, he kept talking about

how he picked up this huge chain that was the size of the room. The chain was outside of the bar

he was at. He had no problem picking it up and swung it around. He said, “the voices were

telling me to.” He talked about how he was glad he didn’t hurt anyone. But he did mention how

he got arrested. It seemed as if things got out of hand and he was experiencing some command

hallucinations due to the experience and alcohol consumption. His thought content was

delusional. He was cognitively alert, awake, oriented for the most part, but his concentration,

insight, and judgement were all impaired.

He was participating actively in group therapy. This put him out of his comfort zone

since he seemed to not like to participate in group activities, but he knows he needs to learn new

skills to get healthier and that is taught at group. He was not completely honest with why he was

admitted. He stated that he was forgetting to take his medications, but his mom said that he

stopped taking them. I wasn’t able to build that super close bond, but was open to talking.

He shared a story with me, but I’m sure if I had more time with him I would have been able to

develop that trusting relationship and he could feel like he could tell me anything without

judgment.

Safety and security measures were maintained throughout the day of care. Interventions

to maintain this include; encouraging showering, independent of activities of daily living,

facilitate daily and PRN dental hygiene, vital signs one time a day and PRN if needed. Safety

checks were conducted every 15 minutes, but the entire time I spent with the patient we were in

either group or the common room. He was compliant with his medication, even though he was
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apprehensive about it because he did not like taking pills, but he knew they would help him so he

was willing to be compliant. It was our priority to make sure he is taking his medications, he is

aware of what is medications are for, why he is taking them, and why he is in the hospital. There

were no signs of agitation, anxiety, or depression that I witnessed during the day of care.

My patient’s scheduled medications for his schizophrenia diagnosis included

Aripiprazole (Abilify) 15 mg PO daily- Antimanic. Benztropine Mesylate (Cogentin) 1 mg PO

twice a day- Antiparkinsonian. Divalproex Sodium (Depakote) 750 mg PO twice a day-

Antimanic. Haloperidol (Haldol) 10 mg PO every 12 hours- Antipsychotic. Insulin Human

Lispro (Humalog) 0 unit SC TIDAC/ QHS- for diabetes. Metformin HCL (Glucophage) 500 mg

PO twice a day with meals ​to control high blood sugar.

Summarize

“​Schizophrenia is a serious mental disorder in which people interpret reality abnormally.

Schizophrenia may result in some combination of hallucinations, delusions, and

extremely disordered thinking and behavior that impairs daily functioning, and can be

disabling. People with schizophrenia require lifelong treatment. Early treatment may help

get symptoms under control before serious complications develop and may help improve

the long-term outlook” (Mayo Clinic, 2018).

Schizophrenia- losing touch with reality and being unaware of behaviors. The patient has

these episodes of delusions and hallucinations. People with this illness create their own

world in their head.

“Paranoid schizophrenia is a subtype of schizophrenia. A defining characteristic of

paranoid schizophrenia is the presence of hallucinations or delusional thoughts. ​People with

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paranoid delusions are unreasonably suspicious of others. This can make it hard for them to hold

a job, run errands, have friendships, and even go to the doctor. Paranoid Symptoms include

delusions that are fixed beliefs that seem real to you, even when there's strong evidence they

aren't. Paranoid delusions, also called delusions of persecution, reflect profound fear and ​anxiety

along with the loss of the ability to tell what's real and what's not real. These beliefs can cause

trouble in your ​relationships​. And if you think that strangers are going to hurt you, you may feel

like staying inside or being alone. People with schizophrenia aren't usually violent. But

sometimes, paranoid delusions can make them feel threatened and angry. If someone is pushed

over the edge, their actions usually focus on family members, not the public, and it happens at

home. You could also have related ​hallucinations​, in which your senses aren’t working right. For

example, you may hear voices that make fun of you or insult you. They might also tell you to do

harmful things. Or you might see things that aren’t really there” ​(WebMD).

My patient experienced delusional thoughts, that I know of. He believed that he was

hearing a voice that told him to pick up a huge chain out when he was partying while intoxicated.

Identify

My patient is a single, 40 year old male, who presents with schizophrenia and acute

psychosis. He claims to have a support system and his mom keeps in touch with him. She seems

to be his only form of support. He is currently unemployed and stated that he lives alone. During

group therapy, he made a list of healthy and unhealthy coping skills. Some ineffective skills he

claimed to use were over-eating, over-sleeping, and aggression. Some effective skills are seeking

medical help and listening to music.

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Discuss

RH was born and currently lives in Warren, Ohio. He doesn't have the best support

system, and it seemed that he only hears from his mom. The patient has been in and out of this

facility many times due to being pink slipped, acutely psychotic. When noncompliant with his

medications, he is seen as paranoid, talking to unseen others, and reports hearing voices. Also,

when off his meds, he has trouble sleeping, and continues to have poor self care. At first, while

talking with him, his affect seemed flat and he looked very exhausted. As I continued to

communicate with him, he seemed to feel more comfortable and his mood got a little better. He

used the paper of healthy vs unhealthy coping strategies to highlight what he used in life. He

began to understand the difference and became interested in more healthy strategies.

Describe

In order to have the best outcome for this client, the nursing staff had to individualize their plan

of care to fit his needs. This included spending time with the patient 1:1 to establish trust and to

identify needs at least three times a shift, helping the patient achieve control of symptoms as they

occur through each group interaction, monitoring desired and problematic symptoms effects of

prescribed medication at least 2 times per shift, provide medication education prior to initiation

of therapy and as needed during continuation of same at time of each administration, educate the

patient regarding his disease process 3 times as needed, and assess signs and symptoms of

delusional thinking each encounter. My patient attended two group therapies during my shift and

talked to me for an hour.

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Evaluate

There are many short-term goals in which the nursing staff believes the patient should be

able to accomplish within the amount of time that he is at the facility. The first goal is RH will

not refuse medication, food, or fluids more than 2 times in 5 days. Next is DH will attend group

therapy at least one time a day. Thirdly RH will state he is not hearing voices to harm others or

him. During my shift, RH did not refuse his medication. He attended three group therapies the

day of care. When given his medication he stated that he was not feeling suicidal or wanting to

harm other. He did not have episodes of auditory hallucination, agitation, depression, or thoughts

of harm to self or others.

Summarize

The patient has been admitted to an inpatient psychiatric unite for treatment, safety and

stabilization. His plan for discharge includes continuing to seek counseling and going to group

therapies for anger. He plans on looking for a job and education on the importance of complying

with medication is key. Patient education is imperative for discharge. Education on his new

medication, new diagnosis, coping skills, and community resources are needed. He needs to have

continuing care to try to stabilize his mood, needs to have follow up care, and physician

appointments to prevent readmissions.

Prioritized

1. Risk for other – directed violence related to diagnosis of schizophrenia disorder AEB

hyper vigilance

2. Risk of other – directed violence related to diagnosis of schizophrenia disorder AEB

voices telling him to harm others

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3. Anxiety related to diagnosis of schizophrenia AEB suspiciousness

4. Anxiety related to diagnosis of schizophrenia AEB new medications

5. Disturbed sensory perception related to diagnosis of schizophrenia AEB poor judgement

with delusions

List

1. Anxiety

2. Bathing or hygiene self-care deficit

3. Disturbed thought process

4. Disturbed personal identity

5. Disturbed sleep pattern

6. Dressing or grooming self-care deficit

7. Fear

8. Imbalanced nutrition: More than body requirements

9. Impaired social interaction

10. Impaired verbal communication

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Works Cited

Mayo Clinic. (2018). ​Schizophrenia - Symptoms and causes​. [online] Available at:

https://www.mayoclinic.org/diseases-conditions/schizophrenia/symptoms-causes/syc-20354443

What is Schizophrenia With Paranoia? (n.d.). Retrieved from

https://www.webmd.com/schizophrenia/guide/schizophrenia-paranoia#1