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Case Study
Case Study
Angela Babcock
Teresa Peck
Abstract
The issue with medication compliance in those with mental illness is well known. This
case study examines R.S., who is a paranoid schizophrenic patient with bipolar. Her issues with
medication compliance are explained as well as the issues of maintaining relationships due to her
delusions of religion, persecution, and grandeur. Her issues with noncompliance lead to her
Objective Data
R.S. is a 50-year-old female with no known allergies, full code, admitted on Oct. 30.
During her admission she was on self-harm precautions, elopement risk, and high and low risk
protocols. These are measures used keep the patient safe. The elopement risk is given when a
patient is at risk for trying to leave the lock down unit. Self-harm protocols are measures taken to
prevent suicide while on the psych unit, such as beds low to the floor, paper bags instead of
plastic in the trash cans, unbreakable bathroom mirrors, windows with screws that can’t be used
for self-harm, plastic silverware, and short dull pencils. Patients are visually checked every 15
minutes to prevent self harm. R.S. was diagnosed with bipolar, paranoid schizophrenia, diabetes,
fibromyalgia, and hypothyroidism. On admission she arrived to the ER, pink slipped, following
an argument with her ex-husband of wanting to get her gun from him. When he refused, she
became very irritable and homicidal. During ER admission patient stated, “I want to light the ER
physician on fire with my lighter.” She denies suicidal ideation but not homicidal ideation.
On Nov.8, I observed and talked to her before dinner. We had a nursing group therapy
about dealing problem solving, which she participated in. She described what it was like having
auditory hallucinations and how the first step to dealing with them is realizing that they aren’t
real and that others aren’t seeing them. During this group, I witnessed her being very labile. She
would laugh one minute and started crying when talking about the mental health stigma in our
society. During my interview with her after group, she was relaxed and neatly dressed.
Whenever talking about her doctor or family, she became very tensed and irritable. She said her
reason for being admitted was the she was admitted under false pretenses because someone
She was having persecutory delusions, that her doctor is out to get her and trying to mess
with her medications. She stated, “he is pumping me full of meds, enough to tranquilize a horse.”
She stated, “I want to snap his neck in half like a pencil.” She also believes that her parents are
stealing food from her apartment. R.S. was also having religious delusions. These including her
stating that she was married to the antichrist and that he was going to come for her parents. She
also stated that she used to be prostitute in New York City. I believe this to be religious delusion
because her parents are Christian, and she is very against their religion. Having a delusion that
she was a prostitute would be a stab at her parents. She also stated that Chick Publications, which
is a Christian book company, are protestant right wing horror tracts that show exorcisms. She
During my interview with her on Nov. 8, she had inappropriate affect. When talking
about how her ex husband raped her, she laughed and said he was an asshole. She also had
unpleasant affects in showing agitation and aggression towards her ex. husband and family. In
her thinking, she showed some circumstantiality. She would get off topic and pause. I had to
remind her what she was talking about and then she would get to the point. She was oriented in
her memory but impaired in her judgment. When the nurses tried to explain that the doctor was
titrating her medication, she only believed that titration means going from a high to low dose.
She became very irritable because the doctor is slowly increasing her medications and she
doesn’t believe that is titration. She was dictating her medications, refusing certain ones and if
two doses were required each day, she would only take the one dose.
I also interviewed her on Nov. 15, a week after my first interview. The night before she
had only slept 1.5 hours and was angry that they were keeping her over the weekend. She didn’t
recognize me from the week prior. Her reason for admission this time was that she was playing
RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 5
her music too loud, so the cops came and took her here. When she talked about her parents and
ex-husband, she was still agitated and angry. She stated, “As soon as I get out of here, I’m
getting a retraining order for all of them.” She believes that her ex-husband lied to her about
everything but his name. She stated that he called pretending to be her father. Since my last visit,
she had court hearing. The court ordered that she could only be held here for 90 days and was
OPC per probate court to take long acting aristada injections every 30 days and follow treatments
and medications. OPC is court ordered treatment (including medication) for individuals who
need ongoing behavioral health care to prevent relapse, rehospitalization, and/or dangerous
behavior and who have difficulty following treatment. This can help increase patient’s long-term
compliance and reduce caregiver stress. She was having grandiose delusions. She told me that
she can’t take Zyprexa because she received a 90,000 settlement the she can’t talk about and has
a class action lawsuit against Zyprexa. She was still having persecutory delusions about her
parents stealing her food and her doctor being out of get her. Her speech was very slow that day
and she kept zoning out in the middle of our conversation. She would stop talking and stare off
into the distance. Compared to the week before, she looked exhausted. She had difficulty
carrying out conversation. When asked if she was having hallucinations, she denied ever having
them, even though the week before she described hers and said that voices told her to eat a bowl
full of pills. The nurses on shift reported that they observed her talking to unseen others in her
room on 11/15.
On Nov. 8, the medications she was on were divalproex DR bid 750mg to treat bipolar,
aripiprazole 20mg to treat schizophrenia, duloxetine 60mg to treat fibromyalgia, haloperidol 5mg
to treat agitation, hydroxyzine 50mg for anxiety, trazodone 150mg for sleep, and Aripiprazole
On Nov.15, R.S. was on Haldol 5mg for agitation, hydroxyzine 50mg for anxiety,
1000mg bid for bipolar, and zolpidem tartrate 10mg for insomnia.
Her lab values on admission were WBC 10.8H, RBC 4.69, Hgb 13.4, Hct 39.9, MCV
85.1, MCH 28.6, MCHC 33.6, RDW 14.5H, PLT count 366, MPV 8.0, TSH 2.00, T4 0.99, both
Summarize
To be diagnosed with schizophrenia, patient must exhibit two or more of following: delusions,
symptoms during a 1-month period. For a significant portion of time since onset of disturbance,
level of functioning in on or more major areas is markedly below level achieved the level
achieved prior to onset. Patient must have continuous signs of the disturbance persist for at least
6 months. Schizoaffective disorder and depressive or bipolar disorder with psychotic features
have been ruled out. The disturbance must not be attributable to physiological effects of
substance (Townsend, M.C., Morgan, K.I. 2017 p.342-343). Some positive symptoms that you
may see with schizophrenia are delusions of persecution, delusions of grandeur, delusions of
thinking, associative looseness, neologisms, concrete thinking, clang associations, word salad,
illusions, echolalia, echopraxia, depersonalization ( Townsend, M.C., Morgan, K.I. 2017 p.350-
352). Some negative symptoms that may be present include inappropriate affect, flat affect,
apathy, volition, deteriorated appearance, impaired social interaction, social isolation, lack of
RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 7
insight, anergia, waxy flexibility, pacing and rocking, anhedonia, and regression (Townsend,
Morgan, K.I. 2017 p.419). During the manic episode, mood is elevated, expansive or irritable.
Mood is subject to change from irritable and anger or even sadness and crying. Patient may
exhibit flight of ideas, pressured speech, disorganized speech, distractibility, impulsive spending
Identify
The stressors and behaviors that precipitated the current hospitalization of R.S. include recent
separation with husband, disturbed relationship with parents, pattern of schizophrenia, and non-
Parashos, I.A., Xiromeritis, K., Zombau, V., Stamouli, S., & Theodotou, R. (2000)
examined the reason behind noncompliance in patients with schizophrenia and their relatives.
According to their study, the most important cause for non-compliance, according to patients’
and relatives’ opinions, was the lack of knowledge concerning the illness (natural course and
Compliance is found to be improved by 30% after a series of psychoeducation sessions and also
by the provision of knowledge specifically about medication (Parashos, I.A. et al. 2000). Lack
of insight, social pressure and side-effects are also mentioned in the literature as reasons for non-
compliance. Of special interest is our finding that 50% (10/20) of the reasons mentioned in our
study were related directly (side-effects) or indirectly (lack of knowledge about treatment
methods, including efficacy and safety of drugs) to the use of drugs for treatment. This relatively
RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 8
high percentage shows the importance of accurate and extensive discussion of the issue of
pharmacotherapy with the patients ( Parashos, I.A. et al 2000). On Nov. 3, R.S. Depakote level
was 28.6. This proves that there was noncompliance in her medication adherence. On Nov. 13,
her valproic acid level 57.7, which is within the therapeutic range.
Due to disturbed family relationship, no one was there to ensure that R.S. was taking her
medications. With the pattern of schizophrenia and the periods of remission and exacerbation, it
is important to have a strong support system. According to R.S., she didn’t have a strong family
relationship for a while, so her husband appeared to be her support system. With the recent
Discuss
Family has no history of mental illness. Patient has minimal contact with brothers and
parents. R.S. was admitted in 1992 to Weston State Hospital in Washington, where she was
diagnosed with schizophrenia at age 24. She spent 5 years there. Was going to counseling at
Genesis Counseling for 11 years and seeing Dr. Fikter there, but per collateral hasn’t been there
for a year. Last fall, R.S. was at Highland Springs. She was at Mercy Health Toledo 1 week prior
Describe
I sat next to R.S. in a group therapy about problem solving. When hallucinations were
bought up, she participated in the discussion, describing what her auditory hallucinations were
like and that she had to realize they weren’t real. She stated that in the past voices told her to eat
a bowl full of pills. Nursing care for this patient would be providing a safe and therapeutic
environment. Pinho, Lara Guedes de, et al. (2017) states “when caring for a patient with
RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 9
delusions, it is important not to discuss or deny belief so as not to risk compromising trust.
Reasonable doubt must therefore be used as a therapeutic technique. For example, “I understand
that you believe this to be true, but I do not think the same.” The nurse should also be attentive
during feeding and taking medication, since the delirium of poisoning may be present, and the
patient may believe that the food or medication is to poison him. Thus, it may be necessary to
confirm whether the patient has taken the medication (Pinho, Lara Guedes de, et al. 2017).
Nurses should also monitor the patient for symptoms of schizophrenia. The nurses witnessed
Analyze
R.S. stated that she recently converted to Catholic 6 years ago. Her parents are Christian,
and she was raised Christian. Patient stated that her priest came to visit her, which was very
important to her. Her and her parents’ religious differences seem to be the main cause for her
religious delusions about her being married to the antichrist and her delusions about Christian
faith and her seeing exorcisms as a child. In a way, it seems as though she is showing a bit of
regression. When interviewing her it seemed she was regressing back to her teenage years and
being rebellious towards her parents. She kept claiming that they are always in her business and
wouldn’t get off her back, even though they are around 80 years old. The chart also stated that
she has minimal contact with them, however she claims they are always butting in her life.
Evaluate
R.S. is a very intelligent individual. She is well read on psychology and medications.
When attempting to be educated on her medications and titration, she became very agitated with
the nurses. They tried explaining to her that they were titrating her from low to high doses and in
RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 10
her mind, titration only means high to low. An issue that affects her care are also her delusions.
She believes that her doctor is out to get her and purposefully messing with her medications and
delaying her disability process. Her persecutory delusions make it hard to treat her. A study done
by Kilicaslan, E. E., Acar, G., Eksioglu, S., Kesebir, S., & Tezcan, E. 2016, examined the
relationship between the type of delusion and the treatment in patients with schizophrenia. In our
study, the analysis of the correlation between delusion types and response to therapy showed that
in patients with religious and grandiose delusions, the duration of hospitalization was statistically
significantly longer than in other patients (p=0.013, p=0.008). A study assessing first-episode
schizophrenia patients came to a result consistent with our study, finding that sexual, religious,
and grandiose delusions are strong determinants for poor response (Kilicaslan, E. E. et al 2016).
Summarize
R.S. was previously followed by Coleman. She will be discharge back to Coleman.
Coleman offers behavioral health services, family, individual, and group counseling, and
community housing. Social work will do a duty to warn ex-husband and family. OPC per probate
court mandated that R.S. take medications and follow treatment. Patient will be starting long-
acting aristada injections at the end of the month. Hopefully she will be able to get housing at
major problem, and can lead to poorer clinical outcomes and higher treatment costs
with extended dosing intervals have been developed to provide an alternative for patients who
RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 11
antipsychotics are recommended for patients with recurrent relapses related to nonadherence to
oral preparations and for those who prefer this mode of administration (Frampton, J. 2017).
Aripiprazole lauroxil LAI can be administered once-monthly (q4w), every 6 weeks (q6w) or
every 2 months (q8w), depending on the dose strength . This makes compliance more likely
due to less doctor visits and need to remember to take your medication, especially with those
suffering from schizophrenia. R.S. will benefit from this type of medication administration due
Prioritized
List
Risk for violence r/t suspiciousness of doctors, agitation aeb verbalization of wanting to snap
doctors neck
Impaired social interaction r/t absence of significant others, disturbed thought process aeb
Social isolation r/t altered state of wellness, inability to engage in satisfying personal
Insomnia r/t short periods of sleep, paranoia, preoccupation of thoughts aeb observed changes in
Disturbed thought processes r/t hallucinations, inability to trust aeb hostility towards doctor,
delusional thinking
RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 12
Risk for noncompliance r/t disturbed thought process aeb refusal to take medication, persecutory
delusions
Risk for suicide r/t wanting her gun aeb involuntary admission, showing up to ex-husbands
wanting gun
Dysfunctional family processes r/t conflict with family aeb agitation, anger, and hostility towards
family
In conclusion, caring and interviewing R.S. showed me a lot about how schizophrenia
can negatively impact your life. Due to her delusions, she pushed her family and husband away.
She developed persecutory delusions about her parents and as a result is at risk for social
isolation and issues with treatment and care. She doesn’t have a support system to ensure that she
is caring for herself and following her medication treatment. I hope that after being discharged
her OPC per probate and long-acting injections will help increase her medication compliance to
prevent exacerbations. Community mental health services such as Coleman, will hopefully work
to increase her compliance and do follow ups with her. Mental illness is a challenging issue in
References
2056. https://doi.org/10.1007/s40265-017-0848-4
Kilicaslan, E. E., Acar, G., Eksioglu, S., Kesebir, S., & Tezcan, E. (2016). The Effect of
Disorder. Dusunen Adam: Journal of Psychiatry & Neurological Sciences, 29(1), 29–35.
https://doi.org/10.5350/DAJPN2016290103
Parashos, I. A., Xiromeritis, K., Zoumbou, V., Stamouli, S., & Theodotou, R. (2000). The
study. International Journal of Psychiatry in Clinical Practice, 4(2), 147–150. Retrieved from
https://eps.cc.ysu.edu:8443/login?url=https://search.ebscohost.com/login.aspx?direct=true&Auth
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Pinho, Lara Guedes de, et al. (2017) “Nursing Interventions in Schizophrenia: The Importance of
http://medcraveonline.com/NCOAJ/NCOAJ-03-00090
Townsend, M., Morgan, K. (2017). Essentials of Psychiatric Mental Health Nursing: Concepts of
Care in Evidence Based Practice Ed.7. Philadelphia, PA: F.A. Davis Company