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MENTAL HEALTH CASE STUDY

Psychiatric Mental Health Case Study

Alexa Lynch

NURS 4842L Mental Health Nursing Laboratory

Mrs. Teresa Peck, MSN, RN

Youngstown State University

December 3, 2021
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MENTAL HEALTH CASE STUDY

Abstract

S.W. is a 45-year-old female patient with a diagnosis of schizophrenia and experiences delusions

and auditory hallucinations. S.W. presented in the ER 10 days ago. S.W. is reportedly off her

medications according to her mother. The patient is currently on antipsychotics, antianxiety, and

SNRI medications. S.W.’s plan of care will consist of managing symptoms, presenting reality,

and establishing a medication regimen. Building a therapeutic and trusting relationship with the

patient will also be included in her plan of care due to the patient’s paranoia.
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Objective Data

Patient Identifier: S.W.

Age: 45

Date of admission: September 20, 2021

Date of care: September 30, 2021

Psychiatric diagnosis: Schizophrenia

Other diagnoses: Psychosis

Behaviors on admission: S.W. had stopped taking her medications according to her mother. The

patient displayed signs of paranoia, was becoming increasingly less unmotivated, and was not

making a lot of sense when talking. S.W. was showing signs of catatonia and had a very flat

affect. She displayed concrete thinking when asked a proverb. S.W. shows poor judgment and

insight and was very slow to answer questions during the interview.

Behaviors on day of care: The patient did not eat breakfast and only ate prepackaged food items

during lunch. S.W. stated that the nursing staff is “trying to poison her”. She slept for 10 hours

and would take naps during the day. The patient also refused to go to 2 group therapy sessions

and stayed in her room during them. During S.W.’s interview, she was showing signs of

grandiose delusions when she stated that she “is the president”. S.W. was also showing signs of

paranoia and became very defensive during the interview. Patient is no longer catatonic as she

was on the day of admission and is talking a lot more.

Safety and security measures: The patient is on a lockdown psychiatric unit. There are many

safety measures that psychiatric floors make sure to follow through on. Every 15 minutes nurses

perform a head check to make sure patients are okay on the floor. Patients on the floor are not

allowed to have cellphones on the floor and instead are allowed to use the phones provided to
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them on the floor until 10 pm. Patients are not allowed to have shoelaces, belts, jewelry, any

cords, drawstring clothing, or any sharp items such as razors or glass items. The psychiatric floor

has call lights with shortened cords, mirrors that are polished steel, doors that are cut at an angle,

shelves in the rooms.

Laboratory results:

Lab Value Result

Sodium 140

Potassium 3.9

Platelets 185

Glucose 92

TSH WNL

T4 WNL

Hgb/Hct 15.5/43

WBC 6.2

BUN/Creatinine 18/0.7

QTc 404

Toxicology Negative

UA Alcohol <0.03

The laboratory values that are shown above are necessary to evaluate for that patients that

are new to the psychiatric floor. For this patient in particular, monitoring her QTc and blood

sugar levels would be important due to the antipsychotic medications she is on which increase

blood sugar and prolong the QT interval. A normal QT interval is 410 or less which means that
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S.W. is in the normal range. If S.W.’s QT interval is greater than 440 then that would be a

concern. A prolonged QT interval can put the patient at risk for torsades de pointes. Torsades de

points is a type of ventricular tachycardia. It is also very important to monitor S.W.’s WBC

count due to the fact that Haldol or Haloperidol can lower WBCs which can increase the

patient’s risk of getting an infection.

Generic Name Trade Name Dose/Route/Frequency Classification Reasoning

Ziprasidone Geodon 40mg/PO/BID Atypical Schizophrenia

Antipsychotic

Venlafaxine XR Effexor 75mg/PO/Daily SNRI Mood

Antidepressant stabilization

Haloperidol Haldol 5mg/PO/Q4H/PRN Typical Agitation

Antipsychotic

Haloperidol Haldol 5mg/IM/Q4H/PRN Typical Agitation

Antipsychotic

Lorazepam Ativan 2mg/PO/Q8H/PRN Benzodiazepine Anxiety

Antianxiety

When the patient presented in the ER, the patient’s mother claimed she thinks the patient

was not taking her medications. A medication regimen that is followed will help S.W.

significantly. S.W. is prescribed Geodon which is atypical antipsychotic. Geodon can increase

blood sugar levels, increase lipids, and prolong the QT interval. We want to make sure to check

QTc and EKG on this patient. S.W. is also on Effexor which is an SNRI. This medication can

increase blood pressure, so it is necessary to monitor heart rate and blood pressure. The patient is
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on Haldol both PO and IM. Haldol is an antipsychotic so it can prolong the QT interval and

lower WBC count. Lastly, S.W. is on Ativan which is a benzodiazepine antianxiety medication.

Ativan may change the patient’s appetite, make her feel nauseous or may have the patient

experience dizziness.

Summary of Psychiatric Diagnosis

Schizophrenia can be defined as a disorder that causes distorted and bizarre thoughts,

perceptions, emotions, movements, and behavior (Videbeck, 2016). Schizophrenia is typically

diagnosed in late adolescence or early on in adulthood. Schizophrenia affects about 1% of the

United States population and needs consistent treatment and medication to decrease the risk of

the patient relapsing (Mahone, Maphis, & Snow, 2016). Treatment for schizophrenia is usually a

lifelong treatment and includes a variety of medications and psychotherapy. The exact

pathophysiology of schizophrenia is unknown but may be related to genetic or environmental

factors.

There are positive and negative symptoms of schizophrenia. Positive symptoms of

schizophrenia are delusions, hallucinations and disorganized thinking, and bizarre behaviors.

Auditory hallucinations are the first most common hallucination in schizophrenia and visual

hallucinations are the second most common type of hallucinations. Other positive symptoms are

echolalia and echopraxia. With echolalia and echopraxia, the person is trying to connect and

identify with you. The positive symptoms of schizophrenia can be treated with typical

antipsychotics that help block dopamine. The positive symptoms are much easier to treat than the

negative symptoms are.

The positive symptoms that S.W. has displayed include delusions, hallucinations, and

paranoia. S.W. has had auditory hallucinations in the past of a “mean female voice telling her she
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is worthless”. She also has grandiose delusions when she stated that she is the president of all of

the countries. When asked in the interview of how she became the president, the patient

answered by saying “it just happened”. S.W. also showed signs of somatic delusions. The patient

stated that her stomach hurt because of a snake in her stomach.

The negative symptoms that are associated with schizophrenia are a flat affect, and

emotional or social withdrawal. Other negative symptoms are anhedonia, alogia, and catatonia.

Patients who exhibit negative symptoms may also show signs of impaired interpersonal

functioning. Other patient may have volition. Negative symptoms are very common with patients

who have schizophrenia. The symptoms usually start showing in the prodromal phase and before

the patient’s first acute psychotic episode (Correll & Schooler, 2020). Negative symptoms can be

treated with the help of atypical antipsychotics. Atypical antipsychotics help by blocking

dopamine and increase norepinephrine and serotonin.

The negative symptoms that S.W. displayed during her stay on the psychiatric floor were

a flat affect, catatonia, and concrete answers. On admission, the patient did not display any

emotion. S.W. was very slow to answer questions and talked monotone. The patient would

barely move during the interview. S.W. is prescribed Geodon which will help with these

negative symptoms of schizophrenia since it is an atypical antipsychotic medication.

Identification of Stressors and Behaviors Precipitating Current Hospitalization

Upon S.W.’s admission, the patient’s mother brought her into the ER and stated she

thinks her daughter stopped taking her medications. S.W. was showing signs of paranoia and was

becoming increasingly less motivated. The patient has not been keeping up with hygiene,

sleeping for long periods of time, and speaking in ways that no one could understand. S.W. also
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has lost her job recently at Walmart where she is a shelf-stocker. The patient lost her job due to

not showing up to work even when her mother encouraged her to go.

Patient and Family History of Mental Illness

S.W. has a history of auditory hallucinations and claims she hears voices saying

she is worthless. S.W. also has a history of somatic, grandiose, and paranoid delusions. The

patient shows signs of having a delusional disorder. S.W> is currently on disability. The patient

suffered from her first psychotic break at 22 years old and was never able to complete her

college program. S.W. also has a history of psychosis many times each year which requires her

to be hospitalized.

The patient stated that her father was a “mean alcoholic” who ran out on her family when

the patient was only 10 years old. S.W.’s mother is the patient’s legal guardian and is in charge

of the patient’s finances. The patient has never been married and has no children.

Psychiatric Evidence-Based Nursing Care Provided

During S.W.’s stay on the psychiatric floor, her belongings were searched to make sure

items were within the safety limits that are placed on the floor. The nurse assigned to S.W. is in

charge of completing an initial assessment on the patient and developing a plan of care that will

benefit the patient. The nurse should advocate for the patient and use the nursing process to

provide optimal care.

S.W. will receive her medications from the nurse at the proper time that they are

supposed to be administered. Medication education should be taught to evaluate the patient’s

understanding. S.W. is currently on Geodon, Effexor, Haldol, and Ativan. The nurse knows to

check the patient’s labs and to administer the medications properly. For the Geodon, it is

important that nurse checks the patient’s QT interval and blood sugar level. Geodon is known to
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prolong the QT interval and raise blood sugar levels. For Haldol, the nurse should make sure to

check S.W.’s QT interval and WBC count. Haldol can prolong the QT interval and can

temporarily lower the patient’s WBC count. It is important to monitor the patient’s WBC count

weekly and teach the patient to report any signs of infection such as fever, sore throat, or flu.

Ethnic, Spiritual, and Cultural Influences

S.W. is a Caucasian single female who lives with her mother and her sister. The patient’s

mother is S.W.’s legal guardian and handles all of her finances. S.W. has never been married and

has had no children. The patient stated that she believes in God, but she does not go to church.

S.W. was working at Walmart as a shelf-stocker until recently losing her job due to not showing

up to work.

Evaluation of Patient Outcomes

During S.W.’s stay on the psychiatric floor, the nurses have given her daily medications

and monitored her progress throughout her stay. It is important to provide S.W. with medication

education and to stress the importance of medication compliance. S.W. has remained somewhat

paranoid and continues to have delusions of grandeur with the belief that she is the president of

the United States. It is important to distract and reorient the patient when she is showing signs of

delusions.

The patient has not displayed signs of catatonia like she did in her first interview. S.W. is

now talking much more to people around the floor. S.W. will only eat prepackaged meals due to

her paranoia and lack of trust in the nursing staff. The patient has started to shower with

encouragement. A priority goal for S.W. would be for her to be able to complete her self-care

each day. It is important to include the patient in the plan of care and to have her participate in

the decisions of her treatment to further improve her outcomes. Encouraging the patient to attend
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regular group therapy sessions would also be very beneficial to S.W.’s care. Other outcomes for

this patient still have yet to be met.

Plans for Discharge

As of now, there is no discharge planning for the patient yet. The patient’s mother said

S.W. is able to move back in her home once her medications are adjusted accordingly. The

patient’s mother had also mentioned she would like to consider placement options for the patient

since the mother is getting older. The mother would like to find out more information about

group homes. The mother showed concern to how the patient would handle this information

when brought to the patient’s attention. Patient education on medications should be provided

before discharge to ensure S.W. understands the side-effects of the medications and how to take

them properly. Side effects such as increased blood sugar levels, increase lipids, and prolonged

QT interval will be discussed with S.W. prior to discharge.

Prioritized Nursing Diagnoses

The following are prioritized nursing diagnoses for S.W.:

1. Altered/impaired thought process related to paranoia and persecutory and grandiose

delusions as evidenced by patient thinking people are watching her.

2. Risk for imbalanced nutrition related to paranoia of delusions as evidenced by patient

thinking people are poisoning her food.

3. Risk of disturbed thought processes related to inadequate support systems as evidenced

by delusions.

4. Anxiety related to patient discharge as evidenced by patient’s mother considering

placement options.
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5. Risk of violence related to paranoia and delusions as evidenced by patient saying

everyone is spying on her.

Potential Nursing Diagnoses

1. Ineffective health maintenance

2. Impaired social interaction

3. Defensive coping

4. Interrupted family process

5. Risk for social isolation

6. Impaired memory function

7. Risk for acute confusion

8. Risk for impaired attachment

9. Fear

10. Risk of infection

11. Risk for loneliness

12. Self-care deficit

13. Risk for hopelessness

Conclusion

S.W. has displayed negative symptoms of schizophrenia as well as paranoia and

delusions of grandeur. S.W. has experienced auditory hallucinations in the past claiming she

heard a voice saying she is worthless. The patient also has a history of somatic delusions.

Patients with schizophrenia have trouble complying to a medication regimen which increase the

risk of relapse (Mahone, Maphis, & Snow, 2016). It is important for S.W. to develop a

medication regimen and to understand the importance of taking her medications. S.W. should
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continue regular treatment to monitor her labs closely and the progress of her condition. Patient

education is necessary for S.W. prior to discharge.

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References

Correll, C. U., & Schooler, N. R. (2020, February 21). Negative symptoms in schizophrenia: A

review and Clinical Guide for recognition, assessment, and treatment. Neuropsychiatric

disease and treatment. Retrieved December 11, 2021, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7041437/.

Mahone, I. H., Maphis, C. F., & Snow, D. E. (2016, May). Effective strategies for nurses

empowering clients with schizophrenia: Medication use as a tool in recovery. Issues in

mental health nursing. Retrieved December 11, 2021, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4898146/.

U.S. Department of Health and Human Services. (n.d.). Schizophrenia. National Institute of

Mental Health. Retrieved December 3, 2021, from

https://www.nimh.nih.gov/health/topics/schizophrenia.

Videbeck, S. L. (2016). Psychiatric - Mental Health Nursing. Lippincott Williams & Wilkins.
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Case Study Comment Sheet 4842 (Turn in with Case Study)

Student Name_____________________________________
Pt Identifier______________
Date(s) of Care_____________

__________ Objective Data presentation the patient, treatments, medications

_ _________ Discuss patient / family history of mental illness

___________ Identify stressors and behaviors that precipitated current hospitalization

___________ Summarize the psychiatric nursing interventions with rationales

___________ Evaluate patient outcomes for nursing care provided

___________ Analyze ethnic, spiritual and cultural influences that impact care of the patient

__________ Summarize discharge plans and community care

__________ Actual nursing diagnoses, prioritized, using R/T and a.e.b.

___________ List of potential nursing diagnoses

___________ Conclusion paragraph

____________ Style, spelling, grammar, clarity, organization, APA format