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MENTAL HEALTH CASE STUDY

Mental Health Case Study

Emmalee Rich

Youngstown State University

NURS 4842 Mental Health Nursing

Bill Church

April 14, 2020

Mental illnesses are complex by nature and have a multitude of potential etiologies.

Schizophrenia is no exception due to its complexity and unfortunate characteristics. This disease

is characterized by periods of exacerbations and remissions. There is no cure, and each

individual patient is different. This disease is unfortunately incurable. In this particular case

study, J.W. experiences many stressors and triggers that potentially lead to her inability to

remain in remission. She has the support of her mother and her sister. This case study will

outline her lifestyle and analyze past and present hospitalizations. It will also include the

importance of patient treatment adherence, the symptoms that many schizophrenics experience,

and her future goals. I have also included three research articles to give a further understanding

of each topic from various medical professionals.

J.W. is a 45-year-old female admitted for rule out schizophrenia who has been

demonstrating negative symptoms. She was admitted on April 4, 2020 and date of care is April

14, 2020. Upon observation and interview, I have observed that she is very slow to react with a

flat affect. She would answer each question to the best of her ability, but she did not have any

emotion in her responses. She was slower than average to state her name and come up with

answers. The interviewer asked J.W. if she had ever heard the Proverb: “People who live in glass

houses should not throw stones.” She stated that she had not ever heard it. The interviewer

proceeded to ask her to explain what she thinks it means. As expected, her response was slow.

She stated in slow mumbled words: “People throw something.” The interviewer moved on to ask

her a situational question. He asked her to state what she would do if she was in a movie theater

that caught on fire. She stated: “I would step on it and put it out.” He then proceeded to ask J.W.

to state what she would do if she could not see the fire and only smelled it. She responded by

saying “Then I couldn’t find it. Is that wrong?” She often asked: “Is that wrong?” after her

slowed responses to which the interviewer would respond: “No, that’s fine.” He proceeded with

the interview and asked J.W. if she ever heard things that were not there. He also asked her if she

ever saw things that were not there or had thoughts that other people do not have. She answered

no to all of these questions. The interviewer then asked if she felt that she had superhuman

powers. She responded: “No, I like Spiderman. That would be funny.” She had a quick moment

of laughter after she made this comment. This day of interviews finished with J.W. stating that

her mother says she should behave while she’s with the doctor and in public. The interviewer

responded: “That’s good.”

by some friends. The interviewer began by asking how she was. She responded: “Okay.”

Although she had the same flat affect, she seemed more irritable and uncomfortable than the

previous set of interviews. The interviewer asked J.W. to state why she had been admitted to the

emergency department. She responded: “My friends brought me.” The interviewer then asked

her if she knew why her friends brought her. She stated: “You can ask them.” She was more

reluctant to answer questions and did not want to participate in the interview for long.

The next set of interviews are where we can begin to see J.W.’s paranoia. When the

interviewer asked how she was, she responded: “You’re with them. I know that you are. She

won’t tell me. People like you never will.” When the interviewer asks her to explain, she makes

additional statements such as: “You have eyes and ears everywhere.” When asked if she felt safe

in the hospital, she replied “There is nowhere that is safe. Don’t pretend like there is.”

Based on these interviews, it is clear to the viewer that J.W. is a frequent flyer in the

emergency department. This visit, J.W. was brought in by her mother due to stated stomach pain

after a visit to the lake. She is experiencing a somatic delusion and states that she believes that a

snake is causing her stomach pain. She explains that she fell asleep in the grass and the snake

entered her stomach.

In addition to experiencing paranoia and somatic delusions, J.W. also expresses grandiose

delusions. She felt unappreciated because she is supposed to be the president. She became the

president yesterday according to her interview.

The observations made from these interviews are essential in planning care for this

patient and determining prognoses. In addition to these observations, it is crucial to observe lab

values and rule out all possibilities causing the symptoms before making an ultimate diagnosis.
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MENTAL HEALTH CASE STUDY
The TSH and T4 were “within normal range” according to the patient’s chart. She had a WBC of

6.2 which is also in the normal range. Her drug screen was negative and her alcohol level on

admit was <0.03. All of these findings rule out the possibility of a thyroid issue, infection, and

substance abuse.

Safety precautions were incorporated upon J.W.’s admission. She is on suicide

precautions and is restricted to the unit. Her activity is as tolerated, and she is on a regular diet.

She is also getting her vital signs taken every 4 hours and as needed. Her medications include

ziprasidone 40 mg orally twice a day (started 3 days ago), venlafaxine XR 75 mg orally daily,

Haldol 5 mg orally every 4 hours PRN for agitation, Haldol 5 mg intramuscularly every 4 hours

PRN for agitation, and lorazepam 2 mg orally every 8 hours PRN for anxiety. Ziprasidone is an

antipsychotic prescribed to treat schizophrenia. This medication also has the ability to increase

the QT interval which can lead to cardiac dysrhythmias. J.W.’s QT increased from 400 to 478.

The goal of schizophrenia medication is not to cure the disease but to control and maintain the

symptoms so the individual can be a safe member of society. Venlafaxine is an antidepressant

that can treat depression, nerve pain, and social anxiety disorder. Haldol is an old school

antipsychotic that treats the positive symptoms of schizophrenia. Lorazepam is a sedative that is

prescribed for anxiety as stated above.

Summarize the psychiatric diagnoses:

Schizophrenia is a very desolate disease that affects both the patient and all who care for

that patient. It is often diagnosed between the ages of 17-25 and more often seen in men. This

disease is characterized by multiple remissions and exacerbations accompanied by lengthy

hospital stays. Many people who develop schizophrenia have a high IQ. Many research studies
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have shown that schizophrenia is caused by an excess of dopamine in the body. The body has an

excess either from making too much, having extra sensitive receptors, or having too many

dopamine receptors. This excess of dopamine then causes disturbances in thought processes as

evidenced by disorganized thinking, word salad, delusions of grandeur, and more. Perceptions

are often affected. Paranoia is a large sign of this disease. Many schizophrenic patients have a

change in affect/emotion. They become very unmotivated and depressed. In addition to these

detrimental symptoms, psychosis is another characteristic of schizophrenia. This includes a loss

of reality, disorganization of the personality, deterioration in social functioning, delusions, and

hallucinations. These symptoms can be categorized as negative or positive symptoms. A

statement from the nursing journal, Caring for the Patient With Schizophrenia, is as follows:

“...schizophrenia is characterized by positive symptoms that reflect an excess or distortion of

normal functions, and negative symptoms that reflect a loss of normal functions” (Iannaco, 2011,

p. 2).

Schizophrenia is not often discovered in an individual until after that individual’s first

psychotic break. This disease process can be broken up into four phases. The first phase is

known as the premorbid phase. This phase occurs before the first psychotic break and is

characterized by social maladjustment, antagonistic behaviors, and antisocial behavior. Peers

may have noticed the individual become shy and withdrawn. The second phase is the prodromal

phase. This phase is also before the first psychotic break and can last a few weeks up to a few

years. This phase is where family and friends really start to see a change. There is a deterioration

in role functioning and social withdrawal. The individual may also experience ideas of reference,

i.e. believing that secret messages are coming through the mass media and specifically directed

towards he/she. There is also substantial functional impairment that might be seen as a decrease
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in hygiene. Phase 3 is when the individual has his/her first psychotic break. This phase is

characterized by delusions, hallucinations, impairment in all social aspects, etc. The goal of this

stage is to treat the individual and have him/her transition to phase 4. The fourth phase is the

residual phase. The symptoms of this phase are similar to the prodromal phase. Individuals often

have exacerbations and remissions between phases 3 & 4. More often than not, phase 4 is

characterized by many negative symptoms such as apathy, flat affect, and anhedonia.

Unfortunately, there is no cure for schizophrenia. Antipsychotics and other treatments usually

have the ability to control many of the side effects and enable a diagnosed schizophrenic to be an

active member of society.

Identify the stressors and behaviors:

From the time J.W. was 22 years old after her first psychotic break, she has experienced

exacerbations and remissions of schizophrenia. A major stressor in her life at the time was

nursing school. The pressure to succeed and the overly abundant workload could have induced

stress. J.W. also has had to endure the stress that no one believes her including those closest to

her. She adamantly struggles to convince others that she is the president. This exhausting feat

causes on stress which led to her most recent admission. In addition to these stressors, J.W. has

only had one parental figure in her life from the time she was 10 years old. This missing father

figure could have potentially caused stress and led to unsuitable behaviors. On this current

admission, J.W. denied any type of hallucination. In her history, she had experienced auditory

hallucinations. Medical professionals had stated that they have seen her motioning and talking

quietly to unseen others on this current admission. J.W. stressors have become very abundant

and potentially led to her inability to show up for her Wal-Mart job.
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Discuss the patient and family history of mental illness:

The patient lives with her mother and sister, Lyndsay. J.W.’s mother is in charge of her

finances and is her legal guardian. The patient’s father was a “mean” alcoholic and left the

patient when she was only 10 years old. J.W. graduated high school and soon after began nursing

school. Her first psychotic break was when she was 22 years old. She did not complete her

nursing program. She has had a history of relapses into psychosis several times each year that

have required hospitalization. J.W. has a history of auditory hallucinations, but she has denied

them this hospital stay. Previously, these auditory hallucinations have been a “mean female voice

telling her she is worthless.” The staff on the unit have reported that J.W. has been talking and

gesturing at unseen others at times. She is on disability and has held down part-time jobs in the

past. She recently lost her job at Walmart because she was not going to work. Her mother had

encouraged her to go to work and continue with medication, but she has stopped both. J.W. has

never been married or had any children.

Analyze ethnic, spiritual and cultural influences:

According to new research, ethnic, spiritual, and cultural factors have a strong influence

on the development of psychiatric disorders, specifically schizophrenia. The patient is a middle-

aged Caucasian woman who believes in God, but she does not attend church. A study about the

correlation between culture and major mental disorders states: “...current understanding is that

culture has multiple roles to play in the expressions of psychopathology” (Viswanath &

Chaturvedi, 2012, p. 1) This article also described the prevalence and incidence of schizophrenia

in under-developed and developed countries. The prevalence of schizophrenia is significantly

due to underreporting (Viswanath & Chaturvedi, 2012, p. 2).

Evaluate the patient outcomes:

In order for J.W. to have successful outcomes, she must comply to all treatment regimen.

She would have to attend all group sessions on the unit and truly do her best to work toward

remaining in remission. Establishing a trusting therapeutic relationship with the patient leads to

better patient outcomes. Above all, this strict compliance is ideal in managing schizophrenia. In

addition to group therapy, medication compliance is essential. An article from the Journal of

Nursing Education and Practice states: “Psychotropic drugs decrease the positive symptoms of

schizophrenia and inhibit deterioration” (El-Azzab & Abu-Salem, 2018). This article states many

interesting statistical data about the exacerbation of schizophrenia, i.e.:

“Nearly three-quarters of clients relapse through one year as if psychotropic drugs are

stopped. The noncompliance with medication occurs the following discharge, for that

reason, follow-up is essential for inhibiting noncompliance with antipsychotic drug and

early identification of signs and symptoms of deterioration” (El-Azzab & Abu-Salem,

2018).

The patient did quickly become irritated during her follow-up interviews. Her hygiene had

improved. She was often brought to the hospital because she did not comply with her medication

regimen. Following this strict regimen leads a schizophrenic patient to attain the ability to

function as a safe member of society.

No discharge planning has been determined yet. The patient’s mother had stated that she

would like more information about group home settings. She is getting old and her other

daughter is about to get married and move out. The mother is hesitant about announcing this

possibility to the client, because she is concerned about the client’s reaction. The priority of this

discharge is client safety. The ultimate goal is to ensure that this patient’s symptoms are

controlled. As a nurse, a possible consult with social work may be initiated to give the mother

more information about group homes. When a home is decided for this patient, the staff should

be prepared for an adverse reaction to this news.

Prioritized list of all actual discharge:

It is of utmost importance that this patient is handled with care, and safety is a priority.

This particular patient may be reluctant to join a group home facility. It is the duty of everyone

involved to ensure this transition to flow as smoothly as possible. Medication regimes must be

followed strictly. A patient may believe that they do not need the medication because their

symptoms are not as evident as they were without the medication. This does not mean the patient

should stop taking the medication. This simply means that the medications are working as

prescribed and should be continued to avoid any exacerbations. An article written by Dodi

Iannaco DNP, RN, APN-BC states: “Caring for a patient with schizophrenia includes ensuring

that prescribed medications are administered as directed. You’ll also monitor for adverse drug

reactions...” (Iannaco, 2011, p. 2). Following each of these precautions leads to a safe outcome

for the patient and all people involved.

Potential nursing diagnosis for this patient include disturbed thought process related to

schizophrenia diagnosis as evidenced by seclusion, grandiose, and persecutory delusions.

Another nursing diagnosis is social isolation related to schizophrenia as evidenced by paranoia

and persecutory delusions. She is also at risk for violence, self-directed or other directed, related

to schizophrenia as evidenced by a history of auditory hallucinations and paranoia. Above all, it

is essential to maintain the safety of the client and other people in the client’s surroundings.

Conclusion:

Schizophrenia is an extremely unfortunate disease that is characterized by exacerbations

and remissions. J.W. had a flat affect with delusions, hallucinations, and many symptoms of this

disease. She had an alcoholic, “mean” father who abandoned the family when J.W. was 10 years

old. She was a nursing student and had her first psychotic break at 22 years old. This disease is

very sad for both the patient and all who care for that patient. Schizophrenia is not curable. The

highest level of functioning is in the fourth phase, and in this phase, patients still experience

negative symptoms.
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References

El-Azzab, S., & Abu-Salem, E. (2018). Effective strategies for nurses empowering the life

quality and antipsychotic adherence of patients with schizophrenia. Journal of Nursing

Education and Practice, 8(10). doi: https://doi.org/10.5430/jnep.v8n10p106

Iannaco, Dodi DNP, RN, APN-BC Caring for the patient with schizophrenia, Nursing Critical

Care: September 2011 - Volume 6 - Issue 5 - p 20-22 doi:

10.1097/01.CCN.0000403405.34359.30

Viswanath, B., & Chaturvedi, S. K. (2012). Cultural aspects of major mental disorders: a critical

review from an Indian perspective. Indian journal of psychological medicine, 34(4), 306–

312. https://doi.org/10.4103/0253-7176.108193