Objective Data

On 11/13/17 a 41 year-old female was admitted to the psychiatric unit at Trumbull

Memorial Hospital for treatment for her paranoid delusions and major depression. She presented

on the unit involuntarily, her family members called the police stating “she has had many years

of erotic behavior, and it has gotten worse.” Her family also states she has had paranoid behavior

that men are out to get her, she is making sexual advances toward men, she was not taking care

of her self, she had suicidal ideations and lastly stating she wants her son’s friend dead. She

presented on the unit denying all accusations, but admitted she has been depressed lately.

I provided care to this patient on 11/14/17. She appeared her age, had long hair in a

ponytail, wearing a hospital shirt and pants. She had showered that morning, she seemed well-

kept and clean. She appeared nervous and tense, she sat straight up with her hands folded in her

lap when I was speaking with her. She spoke very quietly and did not maintain eye contact when

she was answering my questions.

Psychiatric nursing diagnosis for this patient using the DSM IV-TR axes I through V are

as follows: Axis I depression, schizophrenia, Axis II none stated, Axis III none stated, Axis IV

problems with access to health care services, primary support group Axis V GAF is not listed.

This patient has a history of major depression. She has no previous hospitalizations. She

stated she was on antidepressants years ago but stopped taking them around five years ago. Since

then she has been taking St. Johns Wort about 6-8 tablets a day, it is an herb that is used to help

depression. “Extracts of Hypericum perforatum (St John's wort) are widely used to treat

depression. Systematic reviews published between 1996 and 2000 concluded that such extracts

are more effective than placebo and are comparable with older antidepressants in the treatment of
mild to moderate depression” (Linde et al, 1996; Volz, 1997; Linde & Mulrow, 1998; Josey &

Tacket, 1999; Gaster & Holroyd, 2000; Williams et al, 2000). This patient is Amish and does
believe in natural cures to illness. She does state this herb has been helping her depression. On

her current admission she is prescribed Aripiprazole (Aristada) 662mg every 30 days and

Aripiprazole (Abilify) 20mg daily Both medications are antipsychotics and used in the treatment

of schizophrenia.

This patient was admitted due to her delusional thinking, paranoia, possible homicidal

ideation, and major depression. She remained safe during the shift. The milieu on the unit was

calm and quiet, there was just one outburst that was handled in a swift manner and was over in a

few minutes. She was not in seclusion and did not need any restraints.

Summarize

This patient was diagnosed with major depression and schizoaffective disorder.

Schizoaffective disorder diagnosis is based on the presence of hallucinations and/or delusions

that occur for at least 2 weeks in the absence of a major mood disorder. (APA, 2013) The

disorder is manifested by schizophrenic behaviors, with a strong element of symptomatology

associated with the mood disorders. The expected behaviors would be appearing depressed with

psychomotor retardation and suicidal ideation, or symptoms that include euphoria, grandiosity,

and hyperactivity. Major depression is characterized by depressed mood or loss of interest or

pleasure in usual activities. Evidence will show impaired social and occupational functioning

that has existed for more than 2 weeks, no history of manic behavior and symptoms that cannot

be attributed to use of substances or a general medical condition. (Townsend)

Identify

There were many events that lead up to the current hospitalization. The patient was

involuntarily admitted on 11/13/17 by her family. The patient believes it was her siblings that
had
called the police on her and believes her husband had nothing to do with it, but in fact her

husband was the one who called the police. He and other family members stated the patient was

experiencing visual and auditory hallucinations. They visual hallucinations included a man that

would appear at night that wore all white and had no head that she believed to be an angel. The

family said she has had erotic behavior for years now and it has gotten worse in the few weeks.

They stated she was paranoid about men, thinking they were making advances at her, but she

also would make inappropriate advances toward them. She did not like her son’s friend for an

unknown reason and had told her family she wanted him dead. Unfortunately the patient did not

discuss any of this in detail with me and this was all information from the chart. The patient

believed her husband had nothing to do with her admission to the hospital. She believed her

family called the police because they were worried about her and her depression. She stated she

was hearing and seeing things but would not discuss her hallucinations and stated she went

through that years ago and had no recent hallucinations. The patient discussed how she had a

history of depression but had stopped taking her meds five years ago. She stated she was feeling

sad lately and did have suicidal thoughts with no plan. During the discussion the patient seemed

vey uncomfortable and answered questions very directly and did not want to go into detail. She

did mention she had 6 children and is a homemaker which could be causing her extra stress

lately. This patient is also Amish which could have been a reason for not seeking healthcare

sooner. The Amish culture believes in natural remedies and prayer to heal illness. (Weyer, 2003)

Discuss

This patient states she has had history of previous mental illness. She does not remember

when her depression started but says it was many years ago. The patient has a history of visual

and auditory hallucinations but states she hasn't had any for awhile. The patient says her father
also suffered from mental illness. She did not know specifically what mental illness he had. She

says her uncle also suffered from mental illness and also does not remember what he was

diagnosed with.

Describe

The priority nursing care being proved would be maintaining a safe environment. This

includes this patIent and the others on the floor. The goal would to keep the patient from harm,

harming herself or harming others. Another priority would be assessing the patent for suicidal or

homicidal ideation. The patient did not feel suicidal or homicidal on the day of

care. The patients mood was also assessed, she stated feeling fine that day and wanted to go

home. She was upset with her family members for sending her to the hospital and she did not

think she had that big of a problem. Other nursing care included providing her medications,

Aristada and Abilify. On the day of care she attended group. The group therapy focused on

identifying feelings and how to cope with them. The patient was very quiet during group but did

participate in answering a few questions. She also expressed interest in going to the spiritual

group being offered later that morning.

Analyze

The cultural influences the patient would have is being Amish. This would impact the

patient greatly. First the Amish culture do not often go to the hospital right away. Many will try

home remedies and often prayer to help an ill person in their community. The hospital is seen as

a last resort for them. Another problem would just be the access to a hospital or health care in

general. My patient lives in the country like other people in the Amish community. It is not as

easy to get to as someone who lives closer by. Also, the Amish do not drive. So getting to any

doctor appointments or refilling prescriptions would be much more difficult for them. The Amish
may have a harder time understanding the importance of health care. “The Amish formal

education system includes grades one through eight, taught by one or two Amish teachers who

are picked by the school board. The school board is made up of parents of the Amish children.

Teachers do not have formal education beyond the eighth grade and are not required to have

certification. They are selected by the school board based on their ability to uphold and teach

Amish values to the children.” (Weyer, 2003) Their education focuses more on their values and

basic concepts. It may be hard for them to understand the importance of getting to a doctor and

getting care when sick because of the lack of understanding of the disease process. The often

wait until their remedies do not work or the person is very ill to get medical attention. A part of

being Amish is being religious. A characteristic that distinguishes the Amish from many other

denominations is that they conduct their church service in members’ homes. They also believe

that “those who worship God, obey the church, provide for family and community will enjoy

salvation” (O’Neil, 1997). My patient says church is a huge part of her life. She says her family

gets together and reads the bible. It is much more intimate and personal than a regular church

service. She states having these spiritual beliefs do help her cope. Lastly, it is not uncommon for

the Amish to drink alcohol. My patient states she drinks 1-2 glasses of wine a night. She says it

helps calm her down and relax. She states she could cut back on how many days a week she does

drink but does not see it as a problem and does not feel like she needs alcohol to function.

Evaluate

The patient remained safe throughout the shift. She took her medication and attended group. She

expressed feeling better. She did not quite understand why she had to be admitted. She denied

having recent auditory or visual hallucinations. She did admit to feeling “a little depressed

lately.” She was not talkative but did participate in group. She rated several times wanting to go
bake home.

Summarize

A main priority for discharge would be for the patient to have a session with her husband.

It is important for the patient to know before she goes home her husband was a part of her

getting help. This was a main priority so the patient does not find out after she is discharged and

causes stress on her. Another plan for discharge would be to be compliant with medications.

Taking them everyday, finding the means to get the shot every 30 days, and finding a way to

refill her other medications. Medication noncompliance was significantly associated with an

increased risk of rehospitalization, emergency room visits, homelessness, and symptom

exacerbation. Compared with the compliant group, the noncompliant group was significantly

more likely to have a history of medication noncompliance, substance abuse or dependence, and

difficulty recognizing their own symptoms. (Olfson, Mechanic, Hansell) We discussed the

importance of being compliant with mediations, and taking them even when she feels normal

again. Cutting back on alcohol would also be advised prior to discharge. Encouraging the patient

to use spiritual means as a coping skill would be very beneficial to her well being.

Prioritize

Nursing Diagnoses: 1) Risk for suicide relate to verbal threats, helplessness and

hopelessness (Ackely, 780). 2) Risk for harm to others related to verbal threats (Ackley, 711)

3) Self- care deficit related to not having the will or energy to take care of ones self (Ackley,

677) 4) Ineffective coping related to depression, unable to cope with stressors (Ackley, 262)

5) Knowledge deficit related to noncompliance as evidenced by not taking prescribed

medications (Ackley, 504) 6) Sleep deprivation related to intrusive thoughts, paranoia (Ackley,

740) 7) Risk for caregiver role strain related to schizophrenia as evidenced by getting the client
admitted (Ackley, 191)

List

Potential nursing diagnoses include fatigue, ineffective health maintenance, sexual

dysfunction, social isolation, risk for constipation, imbalanced nutrition, ineffective home

maintenance, impaired memory, fear, spiritual distress, risk for powerlessness, impaired social

interaction, and chronic sorrow.

References

Ackley, Betty J., Ladwig, Gail B. 2014 Nursing Diagnosis Handbook. Mosby Elsevier, Mosby
Inc. St. Louis Missouri.

Journal of Transcultural Nursing . (2010, January 3). Retrieved November 26, 2017, from
https://s3.amazonaws.com/academia.edu.documents/43016915/A_look_into_the_Amish_culture
_what_shoul20160224-15736-rnyd67.pdf?

Linde, K., Berner, M., Egger, M., & Mulrow, C. (2005, February 01). St John's wort for
depression. Retrieved November 26, 2017, from http://bjp.rcpsych.org/content/186/2/99.full

Predicting Medication Noncompliance After Hospital Discharge Among Patients With

Mary C. Townsend. Psychiatric Mental Health Nursing. F.A. Davis. Philadelphia, PA