Running head: Psychiatric Case Study Project

Psychiatric Case Study Project

Sabrina Nichols

Youngstown State University

Teresa Peck, MSN, RN

Running head: Psychiatric Case Study Project

Abstract

This case study analyzes a patient on the psychiatric unit of Trumbull Memorial

Hospital, who is diagnosed mainly with paranoid schizophrenia disorder. I analyze his behavior

in accordance with the disorder. Sections analyzed include objective data on the day of care, all

psychiatric diagnoses and common behaviors related to it, stressors and behaviors prior to

admission, patient and family history of mental illness, psychiatric evidence-based nursing care

provided and milieu activities attended, analyzing ethnic/spiritual/cultural influences, evaluating

patient outcomes, summarizing the plans for the patient’s discharge, prioritizing a list of all

actual diagnoses, and listing potential nursing diagnoses. In this paper, I also analyze nursing

components, such as medications the patient is on, interventions used, and nursing diagnoses

with intended outcomes.

Running head: Psychiatric Case Study Project

Objective Data

K.F. is a 52-year-old caucasian male diagnosed with paranoid schizophrenia, along with

depression, delusional disorders, and tobacco dependency (smoking addiction). On the unit, his

facial expression was very angry, fixed and concerned. He was very tense, and paced around the

unit constantly. Physically, his dress was careless, and his hair, nor beard, was maintained. As

far as his motor activity, the patient had extreme restlessness, as mentioned, he walked around

the floor non-stop, rarely sitting down. The precipitating events leading to K.F.’s arrival to the

psychiatric unit are as follows. He had been living at the Warren Family Mission since July of

2019, and during his stay here, he spent his time compiling information he deemed important,

and deemed as national secrets, that he needed desperately to report. He decided after calling

many numbers to get in touch with the FBI, that he would bring the “national secrets” to the

government in some way, by himself. He brought what he termed a “packet of intel” to the

Vienna Air Force Base in Vienna, Ohio; and tried to get into the facility. The police were called,

and due to his delusions and potential harm to others and himself, he was brought to the hospital

emergency room. He is currently involuntary, and refused to sign in.

Upon his arrival, he denied any delusions or suicidal thoughts. All of the patient’s labs that

we needed to look at (WBC, RBC, HGB, HCT, AST, ALT, Glucose, TSH, and T4) were within

normal limits, and his drug screen was negative. Despite this, the patient does have a history of

cocaine abuse spanning about 30 years, ending in 2007, as well as a history of marijuana and

cigarette smoking.

The patient is currently prescribed benzotropine mesylate (Cogentin) at 0.5 mg IM BID

PRN, and 0.5 mg PO q12h for the treatment of extrapyramidal side effects that occur with

antipsychotic drug therapies, haloperidol (Haldol) at 5 mg PO q6h PRN for acute psychotic
Running head: Psychiatric Case Study Project

behavior, and 5 mg IM q6h PRN for severe psychotic behavior, Hydroxizine (Atarax/Vistaril) at

50 mg PO q6h PRN for anxiety and 50 mg IM q6h PRN for severe agitation, palliperidone

(Invega) 3 mg PO daily and 6 mg PO qhs for treatment of symptoms related to schizophrenia,

palliperidone palmitate (Invega Sustenna) 156 mg q30d for the same, and trazadone HCl 50 mg

PO qhs PRN for insomnia. The patient has a penicillin allergy. The patient is currently OPC

(Order of Protective Custody) with forced medications. This patient is a perfect candidate for

long-acting injections, that are becoming more and more available in the world. The benefits are

numerous and include ensuring stable blood levels, better tolerance, marked reduction in

rehospitalization and relapse, and less side effects (Brissos, Veguilla, Taylor, & Balanza-

Martinez, 2015).

I interacted with the patient on October 1st. At first, he refused to speak to a student, but

later on in the day I casually asked him to sit down with me and tell me his story. He is

extremely suspicious of all nurses and caregivers, potentially why he did not agree to speak with

me in the first place. He agreed and we sat and talked for over 30 minutes, and he reiterated the

fact that everyone on the unit was against him, and he has told his story to many people, but no

one will believe him. In desperation, he was eager to report his story to anyone who would listen

at this point, and gave me the details from top to bottom. The three words reiterated through-out

the conversation were: fraud, kidnap, and murder. He claimed that the entire hospital was a

fraud, and that I needed to call the FBI because he does not need to be injected with medications

for “paranoid schizophrenia, which I do not have!” He also said, “They are holding me against

my will, this is kidnapping!” I asked him if he was on duty at the moment in the military that he

spoke of, in which he told me he was currently “active/inactive,” although no one could know
Running head: Psychiatric Case Study Project

this because it was classified information. When speaking of his son and daughter, he reiterated

the fact that he needs to get out to raise his children.

He most likely would have told his story to anyone, due to the desperate fact that he just

wanted to get in contact with the FBI. Everything he said to me matched up with the data in his

chart. He had ample eye contact when I was conversing with him. At the end of the discussion,

he basically asked me to help him get out of here, and contact the FBI.

Summarize the Psychiatric Diagnoses

The man psychiatric diagnosis for this patient is schizophrenia (paranoid). This disorder

causes “disturbances in thought process, perception, and affect invariably result in a severe

deterioration of social and occupational functioning” (Townsend & Morgan, p. 341).

Schizophrenia may also be characterized by delusions, hallucinations, disorganized speech,

grossly disorganized or catatonic behavior, or negative symptoms [diminished emotional

expression] (Townsend & Morgan, p. 342). The patient must have at least two of those during a

1-month period. Work, social and occupational functioning, and self-care also diminish. There

are periods of exacerbation and remission. The paranoia is an extreme suspiciousness of others

and of their intentions.

Another diagnosis the patient has is delusional disorder. This disorder is where the patient

has experienced delusions for over one month. The patient has grandeur (believing he possesses

important government information that needs to be reported) and persecutory delusions

(believing that everyone, especially authority figures, are against him). Grandiose delusions

have the patient believing they are of some importance, like in the government. Persecutory

delusions have the patient believing they are being plotted against essentially (Townsend &
Running head: Psychiatric Case Study Project

Morgan p. 347). This is evidenced by the patient believing he was kidnapped by the hospital

staff, and is being held hostage.

Identify the stressors and behaviors prior to admission

The patient had been living at the Warren Family Mission. On August 28th, he brought his

work to the Vienna Air Force Base, trying to get in to the facility. This being after he tried

calling the Air Force Base hundreds of times. Following this incident, the police were called to

the scene, and he was brought to the emergency room, then placed in the psychiatric into of

Trumbull Memorial Hospital.

Discuss patient and family history of mental illness

This patient has no immediate family history of mental illness that is known. Although, his

mental health history stems back many years. The patient lived in Austintown until age 5, then

Pennsylvania until age 14, and Boardman since. He lived in a hotel periodically from 2003 –

2005. The patient had participated in valley counseling around thirteen years ago. The patient

had three psychiatric admissions in 2000, with two admissions at Trumbull Regional Medical

Center and one at North Side Hospital. This is around when he was diagnosed with his

psychiatric diagnoses. The patient says that he received laced marijuana in 2000, and that is

what caused him to develop his mental disorders. During this time is when he served jail time,

due to domestic violence related to marijuana use. He had a second charge in 2013 for domestic

violence against his son, where he served four months in Colorado. After this, his son put a

restraining order against him.

Both of the patient’s parents are deceased. He has a brother in North Carolina, a daughter

in Akron, and as mentioned, a son in Colorado, where he claims he lived for many years. His
Running head: Psychiatric Case Study Project

son is in the Air Force in Colorado and he needed to reconnect with his son to get rid of the

cancer that he has. 

This cancer is termed in a few different ways throughout the charts of previous statements

and from the patient’s own words directly to me. It is either called, “Light-bulb Cancer” or

“New Lifal Debilital Cancer.” He claims that no one will admit him for diagnosis. He stated,

“this is an adult pediatric cancer that you get from doing nothing, and therefore your metabolism

slows down.” It is cured by getting back with your family or getting a new life, or you will die.

He claims that the air in Colorado can cure the cancer and when he was there he was in

remission. He diagnosed himself in 2013 with this.  He went to the hospital six times while in

Colorado, and claimed to me that the wristband he currently had on was from one of those stays!

Regarding his psychiatric diagnoses, he claimed that he only has that label on him because

the police forced him to sign a piece of paper, saying he has these mental illnesses, in order to be

released from jail. The National Alliance of Mental Illness [NAMI] uses the term anosognia for

patients (especially with schizophrenia diagnoses), to describe the symptom in which the patient

us unaware of their condition or cannot perceive it (2019). This is incredibly common, and it

makes the illness even more frustrating to the patient, and subsequently the families.

Describe Psychiatric Evidence-Based Nursing Care Provided and Milieu Activities Attended

Every patient at Trumbull Memorial Hospital is put on suicide/self-harm precautions, and

have unit restrictions. This is due to the fact that they cannot be a danger to themselves, or to

others on the unit. At this particular hospital, some precautions are as follows: velcro-attached

soft doors on the bathrooms, along with steel mirrors to prevent glass breakage, no long phone

cords or call light cords, break-away shower curtains to prevent a patient from hanging

themselves, locked and sturdy windows with a barrier to prevent jumping, and even paper trash
Running head: Psychiatric Case Study Project

bags. Other things the unit does is look through all of the patient belongings upon arrival,

confiscating all shoe strings to prevent self-harming, using no writing utensils (such as pens or

pencils) besides markers, and patient checks every 15 minutes (at least).

The patient had very little interest in attending group, but was encouraged by staff and

students to do so, and did so fairly regularly. That being said, he did not participate in any

activities, or answer any questions in games on the day I was there. When asked if he would like

to share his answer to a question asked in group, he replied, “I can’t answer anything right now

because I am on active duty.” The patient spent his time generally pacing the floor. He did write

two letters addressed to the FBI that I had the opportunity to read, describing his predicament of

being essentially jailed in the hospital. One letter was seventeen pages long, and one may

consider this slightly therapeutic to the patient, since he was able to express his frustrations and

ideas on paper, be them real or delusional. These letters basically reiterated all the things he said

to me. It is known that this patient also frequently plays chess with himself, moving from seat to

seat, and saying no to anyone who offers to play with him.

Other than establishing a therapeutic relationship with the patient for the benefit of the

patient, interventions nurses used for this patient include acknowledging the patient’s delusions

but not agreeing with them, decreasing environmental stimuli, involving the client in therapy and

reality-based activities, administer medications as ordered, monitoring behavior, providing

redirection, explaining all procedures to the patient to enhance compliance and reduce paranoia,

avoid touching the client, reorient the patient, teach coping skills not usually utilized, and using

one-on-one activities.
Running head: Psychiatric Case Study Project

Analyze ethnic, spiritual, and cultural influences

There were no spiritual influences on this patient, and he had no mention of any higher

power. He was truly infatuated with the United States government, though. The patient has his

GED and is currently on disability services, although he says he was denied. The patient has no

rational judgment, due to his total preoccupation of thoughts. He is currently unemployed, and,

unfortunately, he probably would not be able to hold a job due to the nature of his psychiatric

illness.

Evaluate the patient outcomes

There are many goals we wish for this patient to eventually be able to accomplish. During

his stay at Trumbull Hospital, he was generally unwilling to comply with medicines and

therapies, believing he had nothing wrong with him at all. The biggest outcome beneficial to the

patient to achieve would be that the patient will remain safe. The patient will remain free from

any injury in the ideal long-term situation. Outcomes would be the patient will remain free of

dangerous levels of hyperactive motor behavior with the aid of medications. One such

medication is Cogentin. Cogentin is an inti-parkinsonian drug, that is often used with patients on

antipsychotic medications. There are benefits and even other effects that can come from using

anti-parkinsonian drugs on these patient’s.  According to a study done at St. Mariana University

School of Medicine (2014), “on this neurochemical basis, all antipsychotics are dopamine D-

receptor antagonists. By blocking dopaminergic neurotransmission in subcortical areas, they are

capable of producing extrapyramidal side-effects (EPS), such as parkinsonism (tremor, akinesia,

and rigidity), akathisia, dystonia, and tardive dyskinesia (TD), occurring acutely or during

chronic treatment” (p. 37).

Running head: Psychiatric Case Study Project

We could also eventually hope to see his anxiety relieved, and paranoia go down. We

would like to use medications for this such as Invega, and help the patient find coping

mechanisms and distractions that work for him. So, outcomes would be: patient will

demonstrate at least one coping skill to alleviate anxiety and patient will discuss feelings of

anxiety with a nurse.

Other goals for this patient, eventually, could include: patient explains three realistic

things in the environment not relating to their delusions, patient will react with others

appropriately, patient will maintain medical compliance, patient will identify one coping

mechanism, patient will demonstrate an increased ability to concentrate, patient will maintain

interaction with another client while doing an activity, or patient will attend three group therapy

sessions per day.

Summarize Plans for Discharge

There are currently no plans for discharge. When it does happen, his potential plan is to

be discharged to River Bend Center. This would be excellent for the patient, as there are mental

health professionals on site to evaluate the patient and can give him the best treatment possible

for the difficult diagnosis. They will be able to give him medicine, a safe place to stay,

counseling, and multiple types of therapies. The end goal would be to improve the patient’s

physical and mental health to an optimal level of functioning. We would also hope to instill

functional coping mechanisms to the client that he can understand to use in times of stress and

turmoil. Medication teaching is standard upon all discharges from the hospital, but, in this

patient’s case he does not believe he has any disorder, so compliance level would be low.

Medication compliance would be easier when other people oversee it, as K. F. may not
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remember, want to, or care to take his prescribed medications upon discharge; another reason

why a facility such as River Bend is a clarifying option for him.

Prioritized List of All Actual Diagnoses

At risk for self-directed violence related to impulsivity as evidenced by conflict with

authority and delusional beliefs of power and importance.

At risk for other directed violence related to delusional thinking and paranoid thoughts as

evidenced by believing everyone is against him or out to get him.

Disturbed thought process related to psychiatric disorder as evidenced by paranoid

delusions.

Defensive coping related to suspiciousness of others motives as evidenced by denial of

delusional thoughts and false beliefs that he is being kidnapped and held against his will.

Ineffective coping related to disturbed thought process as evidenced by total

preoccupation of thoughts and focus on one thing.

Anxiety related to conflict with reality as evidenced by pacing the floor.

Impaired social interaction related to feeling threatened in social situations as evidenced

by not speaking in group and telling people he cannot answer questions due to delusions of being

on active duty.

Social Isolation related to lack of trust, fear, and delusional thoughts as evidenced by not

speaking to others on the unit, participating in group, and playing chess by himself.

Fear related to altered contact with reality as evidenced by trying to get help to get out of

the hospital or to contact the FBI from everyone he encounters

List of Potential Nursing Diagnoses

Self-care deficit related to loss of contact with reality.

Running head: Psychiatric Case Study Project

Self-neglect related to psychosis.

Disturbed personal identity related to psychiatric disorder.

Ineffective activity planning related to compromised ability to process information.

Impaired verbal communication related to inaccurate perception of the world and

delusional thoughts.

Deficient diversional activity related to social isolation.

Risk for suicide related to psychiatric illness.

Risk-prone health behavior related to intense emotional state.

Interrupted family processes related to inability to express feelings.

Impaired memory related to psychosocial condition.

Risk for loneliness related to inability to interact.

Running head: Psychiatric Case Study Project

References

Anosognosia – NAMI (2019). Retrieved from https://www.nami.org/learn-more/mental-health-

conditions/related-conditions/anosognosia

Brissos, S., Veguilla, M., Taylor, D., & Balanza-Martinez, V. (2014). The role of long-acting

injectable antipsychotics in schizophrenia: a critical appraisal. Therapeutic Advances in

Psychopharmacology, 4(5), 198-219. doi: 10.1177/2045125314540297

Ogino, S., Miyamoto, S., Miyake, N., & Yamaguchi, N. (2014). Benefits and limits of

anticholinergic use in schizophrenia: Focusing on its effect on cognitive function. St.

Mariana School of Medicine - Psychiatry and Clinical Neurosciences, 68, 37–49. doi:

10.1111/pcn.12088

Townsend, M. & Morgan, K. (2017). Essentials of psychiatric mental health nursing.

Philadelphia, PA: F. A. Davis Company.